Thursday, 7 March 2002
Dáil Eireann Debate
–deplores the appalling situation that has been allowed to develop by the Government in accident and emergency services in many hospitals, which in recent weeks has seen hundreds of people forced to endure long waits on hospital trolleys and, in at least one case, a hospital forced to turn away ambulances;
–acknowledges that it is largely due to the heroic work put in by staff in accident and emergency services that a total breakdown in services has been prevented and believes that the industrial action now being planned by members of SIPTU and the INO reflects the level of frustration they feel at the deteriorating situation;
–calls on the Minister for Health and Children to take immediate action to ensure that the threatened industrial action can be averted and that the needs of patients requiring treatment at accident and emergency services are addressed through:
The Labour Party has tabled this motion as a demonstration of its concern for the perilous state of accident and emergency departments. Patients often have to wait for hours to be seen and days may pass before they are given a bed. A recent report showed that hundreds of patients are on trolleys in accident and emergency departments at any given time.
When asked in the House for a response to the recent crisis when Beaumont Hospital was forced to turn away ambulances, the Taoiseach tried to play down its seriousness by pointing out that it was not an unusual occurrence. It is tragically true that the crisis in accident and emergency departments is not new, but it has deepened in  the past five years. The Taoiseach should not be using these facts as an excuse, as they are an indictment of a Government which cannot, or will not, live up to its responsibilities. It is clear the Taoiseach's priorities are focused elsewhere. If the Government had tried to solve the problems in the health service in as dedicated a manner as it approached yesterday's abortion referendum, the sick and the elderly may have seen a real and significant improvement in their health. The nightmare in accident and emergency wards continues, however. The prolonged nature and scale of this crisis is hard evidence that after five years in office the Government has failed abysmally to provide quality health care for patients and a fair deal for staff.
When the Government took office, it undertook to tackle waiting lists in hospitals. Money has been dedicated to that end, but we have not seen the desired results. Commitments have been made by the Minister for Health and Children, Deputy Martin, and his predecessor, Deputy Cowen, but waiting lists are as long as ever. They increased under this Administration at first and have since been reduced, but their overall profile has not changed significantly, despite the additional funds. About 70 review groups of different kinds have been set up by the Government in its five years in office, but basic hospital services are over stretched
Ms McManus: I cannot keep up. With a general election looming, the Government has pinned its hopes on an overblown health strategy, but it has failed to provide the funding needed if the plan is to live up to its hype. The Taoiseach said at the launch of the strategy last November that he was resolved to focus on long-term solutions rather than quick fixes, but we have not seen any evidence of such an approach. It was clear within days of the announcement of the strategy that the Government had not made any funding commitments beyond the end of the current year. The practical application of the health strategy means that people on low incomes who are just above the medical card limit will be offered no help or support. The Government insists on concentrating the provision of medical cards on those over 70, even though we know those in that age group who are in the top 20% of earners will receive the benefits. I have no problem with extending the medical card scheme, but I believe all people should get free GP care at the point of delivery. The Government made a deliberate decision in favour of wealthier people over 70 and against poorer low income families who are just above medical card limits. The health strategy is meaningless to the latter group as it has nothing to offer them.
According to the Minister for Health and Children, much needed measures to deal with prob lems in accident and emergency departments in acute hospitals can only be introduced if the cost of such initiatives can be met within current resources. Any reasonable person would take that as an indication that improvements in accident and emergency wards will mean a withdrawal of funding from, and less improvement in, other health services. The struggle between competing needs is most acute in emergency wards. The solution to overcrowding is often to cancel elective procedures, but the knock-on effect is that patients on waiting lists for treatment are pushed further down the line to make way for emergency cases. This happens to an increasing number of people and the solution must be to meet both needs. We should endeavour to manage and resource the health service to provide for those who need emergency care, without denying those who are entitled to other forms of care.
The stark comments of Dr. Patrick Plunkett, an accident and emergency consultant at St. James's Hospital, sum up the Government's failure. He explained at a recent press conference that he resigned from the hospital's board of management because he could not accept that poor, sick and aged people who are too sick to be sent home should have to lie on trolleys in public corridors for hours or days because elective admissions are given precedence. Last Monday, 22 patients were on trolleys in the accident and emergency department of the hospital, waiting for beds in wards. Dr. Plunkett said that one such patient had been waiting for an emergency bed in a psychiatric hospital since the previous Friday. The fact that a new generation of doctors is learning to examine patients on busy thoroughfares in full view of other patients and passers-by is, according to Dr. Plunkett, a sad deterioration in professional standards. This may be acceptable after an earthquake has levelled a hospital, but in Ireland in the 21st century it is a cause of shame.
One of the factors regarding the health service from which we have always taken solace and a certain amount of comfort is the high professional standards of medical and nursing staff. However, in conditions such as those described by Dr. Plunkett it is impossible for those high professional standards to be maintained. The point he makes is that it is unsustainable to expect that high level of professionalism to pertain in such a poor environment and in such working conditions.
Even more shameful is the evidence given by nurses working at the coal face on a daily basis who are struggling to cope with a deepening crisis. In SIPTU's submission published recently the experience of one nurse is truly harrowing. This nurse spent one night watching over an accident victim so she could claim the bed when the time came for another patient in her care. The victim was a young, 28 year old man who she knew was about to die. This nurse stated that all she wished to do was to care for this patient in  his last moments. She did not wish to watch over him in order to claim his bed.
Another psychiatric nurse brought an elderly patient from a psychiatric hospital to an accident and emergency unit because the patient needed urgent attention. The nurse was severely rebuked by a doctor on duty because the unit was already overcrowded and she had to leave in tears. For these nurses who already work in a stressful environment, fears for their safety have become a growing issue. SIPTU and the INO are calling for proper security provisions to make accident and emergency departments safe places in which to work. A key demand is the immediate introduction of measures to enhance security within these departments, including, where required, improved lighting, closed circuit television, security doors and the presence of security personnel 24 hours a day, seven days a week. These demands tell us all we need to know about the circumstances in which professionally trained people are trying to deal with emergency cases which come into over loaded departments. Is it any wonder that nurses have decided to take industrial action given the overcrowded conditions in which patients sleep on trolleys and in which nurses are constantly under pressure and often face aggression. More than 90% of nurses balloted voted to take this action. Striking is not something they set out to do. There has been only one nurses' strike which was taken under equally difficult conditions. It is significant that, in this case, the issue is not about pay or conditions, but the needs of patients and the capability and capacity of the hospital service to meet those needs.
It is vital that this threatened industrial action is prevented and pre-empted by the Minister for Health and Children. He must seize the opportunity which the nurses have given him by delaying their action until 13 March. He has time to implement a clear set of measures to tackle the fundamental deficiencies in the accident and emergency service which he has so far failed to address.
An analysis carried out by Geraldine Regan and published in an accident and emergency nursing publication two years ago outlined the main reasons delays in these departments were so lengthy. In her research interviewees saw the main cause as the high proportion of inexperienced junior medical staff. The crisis in hospitals is only added to where junior staff in accident and emergency departments are ill-equipped or insufficiently trained to cope. Patients must be assured that they have access to consultant care when needed.
Another problem which was clearly identified, and which is still unresolved despite the Minister's announcements, is the shortage of beds. We have to ask why, after five years of economic buoyancy in which health spending doubled, people are still forced to wait, often in pain and distress, in accident and emergency departments before they can see a doctor. People often have  to wait to get into a cubicle, then wait again to be admitted or forwarded to another department or hospital.
An article in today's edition of The Mirror highlights the case of a young Kerryman who was kicked unconscious on the streets of Killarney and who was taken to Tralee General Hospital. On arrival it was discovered that he had severe head injuries and was soaked in blood. However, because there was no head trauma specialist available, he was forced to wait on a trolley in the accident and emergency department corridor for 15 hours, from 5 a.m. until 9 p.m. During this time he continued to remain soaked in blood and in much pain.
Will the Minister for Health and Children tell the House if this is the kind of health service over which he stands? Why was this young man – an innocent victim of a brutal attack – left to suffer even further because this Government has failed to upgrade, resource and where necessary, redesign accident and emergency services? The requirements have been set out by the INO and SIPTU and have been itemised by medical practitioners working in the field who have continually pointed out what needs to be done, and where, to improve accident and emergency services. We need more consultants, anaesthetic facilities, endoscopy services, facilities for minor surgery and general practitioner services. However, in addition there is a clear direction in terms of better management which must be spearheaded by the Minister who is ultimately responsible. He can transfer blame and responsibility to the health boards, hospital management and so on, but at the end of the day the buck lands on his desk. He has to take a real and effective initiative in this regard.
The chief executive officers of hospitals with accident and emergency departments must be central to whatever management changes and reorganisations are required. Long before now we should have seen the implementation of measures such as the restructuring of the role of nurses, the greater use of nurse practitioners, a more efficient admission and discharge policy in accident and emergency units and improved liaison measures between hospital and community services.
This issue has not arisen out of nowhere and this crisis should not come as a surprise to anyone. The Government is almost five years in office. We have just come through what I imagine has been a painful experience for many women, particularly those who experienced crisis pregnancies and who went to Britain for abortions. That experience demanded a great deal of resources, time and energy from the Minister to whom I pay tribute as he did not shirk his duty. He was willing to debate the issue on any occasion. Unfortunately, the Taoiseach was not as willing to do likewise. Considerable resources and energies were put into this issue by the Minister and his officials to try and drive through an  abortion referendum which was unnecessary and unnecessarily divisive. That energy and those resources should have gone into dealing with the crisis in our accident and emergency departments which are affecting patients – the born of this country, the elderly and the sick.
One of the main reasons what is happening in accident and emergency departments is not forgotten is because it does not matter whether one is rich or poor, if one needs that kind of care one goes to such a department. Even Charlie Haughey ended up availing of such a department. If we had private departments we probably would not know half of what is going on. However, we do not have private accident and emergency departments so everyone goes to a public hospital when necessary. Most people who attend such departments point out that the nurses and medical staff are great, but that they are overworked and the conditions are often appalling. There is genuine shock that at a time when this country is so financially secure that we have a Taoiseach dreaming about national stadia and changing the Constitution in totally unnecessary ways, we cannot get the floors of our accident and emergency departments swept clean or have units upgraded and staffed to meet the needs of poor, sick and vulnerable people. Those people need the Minister's attention but, so far, have not got it.
Mr. Rabbitte: I am more typical of the Members of the House than Deputy McManus in approaching this debate. She is something of an expert in the area whereas I am merely the recipient in clinics and elsewhere of heart-rending complaints from those who have direct experience of the accident and emergency service. It is difficult to understand how, after seven years of unprecedented boom, the accident and emergency services are as Deputy McManus described them.
The staff frustration is perfectly understandable. I hope the dispute in this area is resolved but I understand why staff of all categories working in these circumstances would wish to express their frustration in this way as a final resort. Recently I wrote to the Minister about a case from the midlands, where the person ended up in the accident and emergency unit of St. James's Hospital on a Friday night. It might be because the person concerned was from the midlands, but he was absolutely appalled by the environment in which he found himself. I do not understand how nurses and other staff can cope with these circumstances in a major acute hospital in cities at the weekend. After waiting for five hours, the person concerned discharged himself, if that is the correct word, because he despaired of being attended. He feared for his safety because of the fights and arguments taking place in the accident and emergency department at that hour between people who were drunk or addicted to drugs, worsening the already excruciating situation for those queuing for attention.
The fact that Beaumont Hospital had to issue a protection warning two weeks ago that it was  unable to cope with further admissions is extraordinary. Some 59 patients were already waiting for attention – more than three times the capacity. Ambulances had to circle as a flight would have to circle Dublin Airport if air traffic control required it. Tallaght Hospital is developing a fine reputation but the problem for people on the street is that, while it is a fine hospital, they cannot get into it for a variety of reasons.
One third of patients who get into accident and emergency units wait longer than six hours. Are there no remedial measures the Minister can take to deal with this problem? Why can he not put GPs into accident and emergency departments? Different categories of complaint cause people to present at accident and emergency departments.
Deputy McManus dealt with the implications of the health card and people using the accident and emergency service because they cannot afford to see their GP. The old system of the triage nurse defining the gravity of the category would allow a situation where minor categories could be referred to a GP doing sessions in the accident and emergency departments of our major city hospitals, while more serious categories could be referred to a surgeon or physician. Management of non-emergency cases is critical in gaining respite. That happened with some success in St. James's Hospital but this phenomenon in accident and emergency departments is predominantly city based.
Some GPs have come to rely on the accident and emergency services or the radio doctor to an extent. That clearly contributes to the situation where the throughput in the accident and emergency departments cannot be attended to. The whole question of the accident and emergency service supporting primary care will have to be examined by the Minister. He must talk to the GPs about it.
In provincial areas, the opposite is the case. There is no accident and emergency consultant in the hospital in Ennis. In such a situation, highly trained, professionally qualified, non-national doctors, who are not necessarily specialists in the area, have to deal with patients. This gives rise to an issue with paediatrics that must be addressed separately. There can be a very highly qualified doctor, a specialist in his own area, on duty who is not comfortable with a child presenting with what could be a serious problem. I do not understand why the consultants the Minister has announced for accident and emergency departments are temporary.
Mr. Rabbitte: Perhaps we devolved too many statutory powers and not enough accountability. I was disturbed yesterday to meet a manager who told me that she was recently an applicant for a post in an agency. Someone at the top of the agency came to the conclusion that a professional manager was required, rather than a physician, and advertised accordingly. This person is satisfied that the only reason she did not get the post was that she did not come from inside. Some chap who came up through the system concluded she would not be able to talk to consultants.
There must be a problem with management in the health services. I do not understand why, while financial investment in the health services is doubled, the problems also double. There must be a problem with the calibre and quality of the management. It would be desirable for the Minister to encourage a system where managers from the private sector are brought in to shake up some of the habits within the system.
I do not understand why the Minister does not require private hospitals to provide an accident and emergency facility. Insurers of private cover, whether it be BUPA, the VHI or whoever, should be required to make the necessary investment to ensure the Blackrock Clinic and other private hospitals provide an accident and emergency service. It is intolerable for working class people and others to be obliged to queue for attention in accident and emergency departments. The Minister must address the problem with a greater degree of urgency. He says his proposals offer a great deal of promise but he must produce more imaginative solutions.
Ms O'Sullivan: I thank Deputy McManus for sharing time with me. It is shameful that nurses have been driven to call strike action to draw attention to the crisis in accident and emergency departments. If it was not for their dedication, nursing and medical staff would be leaving the service in droves. It is old fashioned to refer to vocations but nurses have a genuine vocation. They are so committed to their chosen careers to look after the sick they are willing to put up with a great deal of hard work and difficulty. However, they have been driven by frustration to take their present action. While he may not say it publicly, I believe the Minister would agree with Deputy McManus when she said he would have been much better using his time over the past few months addressing these issues rather than dealing with the divisive abortion referendum.
There is a crisis in accident and emergency departments of hospitals. Sick patients must wait  for hours on trolleys. Deputy McManus outlined specific cases that illustrate the depth of the crisis. It is frightening enough to be sick and in hospital without having to wait in uncomfortable accident and emergency departments in the absence of adequate diagnosis and not knowing when and where treatment will commence. Given the state of the public finances, it is shameful that this situation persists.
We must address the basic problems, which are clearly outlined in the motion. These include the provision of additional staff and resources, the opening of additional community beds to ease the pressure on accident and emergency departments and the introduction of improved management procedures and enhanced protocols for hospital management and patient care. They will not be addressed by endless long-term reports and so on. They must be tackled now. If the Minister spoke to the front line staff in accident and emergency departments—
One of the problems is that to access the acute hospitals, virtually all patients must first go through the accident and emergency departments where they are filtered to the different departments. The system covers a spectrum of patients, from those involved in acute road accidents, those with minor cuts and suspected fractures, a growing number of suicidal young people, those with suspected heart trouble to the chronic elderly referred by GPs because they have become too sick to stay at home. That leads to bad management and it is surprising it has not been previously addressed. These patients are often seen at a time when senior management and consultants have gone home. It means they are being dealt with by relatively inexperienced hospital staff with the result that often difficulties arise in making management decisions. A different type of admissions system is required to ensure that patients can be referred directly to the part of the hospital where they will get treatment.
There is also a need for a more interactive system with GPs. I live in the same house as a GP and I have often heard the telephone calls in the middle of night. Even where a GP refers a patient he knows very well, the patient must queue in the accident and emergency system as if he or she had arrived without referral That does not amount to a proper use of the GP service.
There is a need for more consultants, although I take the point about Comhairle na nOspidéal. There is a very low ratio of accident and emergency consultants. Many more nurses are also required. There is also a need to break down the management hierarchies in hospitals. At present there can be management structures covering administrators, doctors and nurses who tend not to interact. It is an ineffective system.
More needs to be done to keep patients out and move patients on who do not need to be in acute hospitals. This will involve closer co-operation with GPs. There is a need for move-on facilities to help patients who are ready to move to step-down facilities. The shortage of long-stay beds for the elderly is scandalous. We have known for a long time about the growth in the population of the elderly and the Ombudsman reported on the state of nursing homes over a year ago. St. Camillus's hospital has closed long-stay beds in recent years in an attempt to balance resources. Such decisions should not be forced on health boards. If space is to be made available in acute hospitals there must be a system to ensure that those who do not need to be there can move on in a simple way. Rather than oblige people to seek unaffordable nursing homes, public long-stay beds should be made available.
The health system continues to be under resourced. We have one of the lowest number of beds per capita of all EU countries and our GDP expenditure on health places us in the lower half of member states. The Minister acknowledges that we have not reached the levels of expenditure in other EU countries.
Ms O'Sullivan: A large number of young school students want to be nurses, physiotherapists, occupational therapists, speech therapists and many of the other classes of expertise required by hospitals but many of them cannot access third level courses. Last year a mother of a leaving certificate student told me her daughter only wanted to be a nurse but she had not got the necessary qualifying points. At the same time there are shortages in nursing which would be even more acute if nurses were not so dedicated. There are many easier and better paid careers for them. We have been very slow to integrate the educational system with the needs of the health care system. A minimum of 500 points in the leaving certificate is required to access courses in physiotherapy, occupational therapy or speech therapy. While it is the intention to introduce new courses next year it is a much too delayed response to current needs.
Spending on the elderly is still too low at a time when we know the dependent elderly population is growing. The Minister may have heard about a lot of these issues before, but what is needed is a genuine response to the practical problems which have been identified by nurses. The welfare of sick people is paramount. If major structural changes in the management systems are needed, if it means getting more funding from the Department of Finance for resources, if it means banging heads together in third level institutions to ensure we train appropriate numbers of staff or if it means recruiting from outside the country in the short-term, then we will have to do those things. We cannot stand over a system where patients are coming in their droves into accident and  emergency departments which cannot cope. Nurses will leave if this is not addressed and we will have a much bigger crisis than that which already exists if numbers in nursing staff are reduced further.
There is no time to look to the medium term, although the Minister must do so, as there are immediate crisis situations which need to be addressed. I hope this motion receives an urgent response from the Minister.
–endorses the Government's commitment to the continued development of hospital services, including accident and emergency, A&E, services, as outlined in the health strategy – Quality and Fairness – A Health System for you;
–commends the Government on its decision to increase hospital capacity by 3,000 beds up to 2011 and for providing additional funding of €65 million to fund the commissioning of 709 of these extra beds over the next 12 months, measures which will benefit all patients awaiting admission to acute hospitals, including those attending A&E departments;
–acknowledges the measures being taken by the Minister for Health and Children to address the difficulties being experienced in A&E departments, including the establishment by him of an A&E forum in partnership with all other relevant stakeholders; and
–endorses the request by the Minister for Health and Children to the Nursing Alliance to recognise the efforts being made by health service employers to alleviate the difficulties in A&E departments and to defer its proposed industrial action in the best interests of quality patient care.
 I thank Deputy McManus and the Labour Party for tabling a motion relating to health for one of this Dail's final Private Members' debates. A core objective for our health services must be the development of accident and emergency services which are of the highest quality and are relieved of the unreasonable pressures their staff often face. Achieving this objective will take a wide series of initiatives, involving primary care, staffing, new facilities and many other areas.
The blueprint for this series of initiatives is in place and action is under way. All my discussions with the groups responsible for implementation have been very constructive. In contrast, being constructive is unfortunately one the qualities generally absent from the Opposition's approach to these issues. I particularly welcome this debate because it gives another opportunity to show the contrast between the empty rhetoric of some politicians concerned only with an ever more desperate and distant hope of getting into power and the substance of a programme of investment and reform which will deliver the quality and fairness which our people so rightly demand of their health service.
During the two and a half years I have had the honour of serving in the Department of Health and Children, the approach of the Opposition parties has been absolutely consistent. They publish their motions a few days beforehand and sometimes get their denunciations in early through media appearances. On every occasion the debate is opened with a carefully choreographed series of attacks, many of which fail to mention any positive proposal whatsoever. One particularly creative part of the Opposition's ritual on these occasions involves anyone who dares to reply directly to their attacks, or to question their vague and undetailed proposals being accused of a wide range of ever more grievous sins. These new champions of the interests of patients always manage to leave one thing out of their lengthy contributions – they never explain and never apologise for their abject record. The Opposition's concern for health is something which materialised from nowhere a couple of years ago, faster than you could say “opinion poll”. Since then everything has been driven by the same motivation.
In preparation for this evening's debate, I asked to see a copy of what the Labour Party's extensive policy documents have to say about accident and emergency services. The House will recall that the Labour Party has spent a lot of time praising itself for producing what it claims is a blueprint to cure our ills. Two years ago, Deputy McManus published the first document promising to follow it up with legislation and detailed costings. Late last year we saw the second instalment, which was billed as a more detailed contribution. This managed the almost impossible task of having less detail and containing more basic contradictions than the first. We still await with bated breath how the Deputy will explain the promise to keep all facilities fully  operational, yet require all facilities to compete for their funding from insurers.
In relation to accident and emergency, the area which the Labour Party has shown so much concern for tonight, this was completely absent from its first “comprehensive” policy. Last year's Labour Party document “Our Good Health” gave us a brave new vision for accident and emergency. The policy amounts to one proposal, worth quoting in full: Accident and emergency departments will be strengthened where necessary.
Our accident and emergency departments are often the place where key shortcomings in the rest of our health system come together. The lack of effective primary care teams in much of the country, the lack of capacity for elective admissions and an historic failure to invest in facilities and personnel all combine to impact on accident and emergency departments. The fact that 70% of all admissions now come through accident and emergency departments is the most dramatic demonstration that major investment and reform is required. Dealing with these issues does not require a single initiative – a series of interrelated initiatives are required, together with a sustained period of investment and that is what we are delivering.
A key step in lifting the pressure from accident and emergency is to develop the capacity of our acute hospital system. The Government has recognised this and is taking action. The health strategy, “Quality and Fairness – A Health System for you”, which we published last year outlines a programme of investment and reform of the health services starting immediately which will stretch over the next decade. As part of the preparation work for the strategy, we conducted the first comprehensive review of acute hospital bed capacity needs for many years. The last health strategy in 1994 had no such bed capacity review or plan. This is the first health strategy to focus on that key issue.
On foot of that review, “Acute Hospital Bed Capacity – A National Review”, which I published in early January, the Government has put in place a programme to provide an additional 3,000 beds in acute hospitals over the next ten years. This will be the largest bed capacity expansion in the history of our health services.
I announced on 16 January this year a €65 million investment package in the current year for the commissioning of 709 of these 3,000 beds in acute hospitals and these will come on stream within the next 12 months. There are 55 in Deputy O'Sullivan's constituency.
Mr. Martin: I am confident that once these beds are put in place there will be a significant improvement in the accident and emergency services. The provision of these extra beds will increase the capacity of the hospitals to facilitate the admission of patients awaiting admission through accident and emergency departments and will also help to facilitate reductions in waiting times for these patients.
In the wider non-acute setting the Government is committed in the strategy to major investment in services which will relieve pressures currently faced by our accident and emergency departments. A major re-focus on primary care services marked by the introduction of a new model of care involving a core inter-disciplinary primary care team, which will work with a wider network of health and social care professionals and which will offer 24 hour cover to patients, will help to reduce demand from and treat appropriately patients who would otherwise have to attend at an accident and emergency department. This sector will therefore take on a pivotal role in helping to reduce pressures in accident and emergency departments.
Our vision for primary care is a bold one which will represent a dramatic improvement both in the quality of care available and in the effective utilisation of vital health professionals. It will provide a more stable and supportive working environment and maximise the impact of early intervention and preventative work. We will also push on with a major programme of developing community care facilities, ensuring that people who often have no alternative to hospital can be cared for in more appropriate and effective facilities.
The lack of sufficient capacity and primary care have a particular impact during the winter period when patients often have to wait for long periods before being admitted to an available bed. I will outline to the House a range of important initiatives which are being supported by the Government to improve service in accident and emergency departments. Among these initiatives was the provision last year of a €40 million investment package aimed at alleviating service pressures and maintaining services to patients over the winter period. This investment package was targeted at a number of areas, including approval to recruit 29 additional accident and emergency consultants as well as additional anaesthetists. There are 12 in place and there is funding for an additional 13. Reference was made to their temporary nature but that was due to the fact that Comhairle, which has the statutory authority to sanction consultant appointments, wanted to do a review before making the posts permanent. When I receive that review, those posts will automatically become permanent and will be advertised as such. That was the largest ever appointment of any one category of consultant in any specialty in any one year; that is the kind of immediate priorities we identified.
Funding was also provided for the contracting of additional private nursing home places by the  Eastern Regional Authority and the health boards. These places are for patients whose acute phase of treatment has been completed but who require continuing care in an alternative setting. The ERHA and the health boards succeeded in contracting more than 700 beds under the initiative and this has helped to free up acute beds for patients awaiting admission to hospital. Deputy Rabbitte talked about alleviating pressures immediately; we did so and the winter initiative was one such initiative. We did not wait to build them but moved immediately. What would the situation be today if we had not provided funding for those additional 700 beds? It helped to significantly alleviate pressures right across the system.
Mr. Martin: That level of funding was repeated over the winter period October 2001 to March 2002 and has been of significant benefit. There is no question about that. Everyone acknowledges that the initiative I took then was of significant benefit to health agencies in responding to the high level of demand for hospital beds over the winter period.
Each of the health boards and voluntary hospitals recognised the priority attaching to investment in accident and emergency service provision and has responded accordingly. By way of example, I would like to outline for the House the initiatives taken by them to alleviate pressures in accident and emergency departments. These include the provision of additional long-stay beds which have become available in the catchment area served by Beaumont Hospital and a new 50-bed unit in Lusk which was opened by the Northern Area Health Board in November 2001. It will be fully operational shortly and will increase the number of public extended-care beds in the area. Initiatives such as this will allow for earlier discharge of patients, mainly elderly, who have completed the acute phase of their illness and who require a level of care more appropriate to their needs. They will also free up acute hospital beds for acute admissions. We purchased St. Joseph's, Raheny, for £11 million within weeks of being alerted to the possibility by the ERHA.
A new project between the Northern Area Health Board and Beaumont Hospital was initiated and funded by the ERHA in 2001. Called the Home First project, it is designed to allow elderly patients to return to their homes after hospitalisation with the necessary support services being provided in their homes. I will continue to support this initiative as we evaluate its success.
Other examples include the provision of additional funding to the ERHA and the health boards to support the following: the development of accident and emergency facilities at St. James's Hospital; the provision of minor injuries units in Beaumont, the Mater, James Connolly Memorial,  St. James's and Tallaght hospitals; development of the accident and emergency department at the Mater Hospital; extension to the accident and emergency department at St. Columcille's Hospital; provision of a chest pain service at St. James's Hospital; the recruitment of discharge planners and patient liaison personnel at accident and emergency sites in the Eastern region; development of new accident and emergency departments at St. Vincent's Hospital, Elm Park, and The Children's Hospital, Temple Street; planning of a new accident and emergency department for Cork University Hospital; development of the accident and emergency department at Galway University Hospital, Castlebar General Hospital and Tullamore General Hospital; development of a new accident and emergency department at Portlaoise General Hospital; the appointment of a design team for the development of a new accident and emergency department at Roscommon County Hospital; and the upgrading of accident and emergency facilities at Our Lady of Lourdes Hospital, Drogheda, Monaghan General Hospital and Our Lady's Hospital, Navan. Additional security measures in accident and emergency departments and further initiatives in this area are under review.
In the health strategy we have also identified additional initiatives which will directly impact on improving accident and emergency service provision. These include the establishment of 24-hour GP co-operatives which will help reduce demand from, and treat appropriately, patients who would otherwise attend accident and emergency departments. A sum of €17 million is being invested in the development of this service in 2002.
Mr. Martin: The sum of €17 million means that every health board area will be able to develop a major GP co-operative which will give 24-hour cover. We are committed to that in the health strategy and it will be a significant development. The South Dock covers west Cork, north Cork and Kerry and is very successful.
Mr. Martin: Another initiative is the establishment of more minor injury units to ensure appropriate treatment and management of non-urgent cases. Earlier this year I saw the St. John's minor injury clinic at work and it is the kind of model that will make a difference.
Mr. Martin: Other initiatives are, such as the use of chest pain clinics, respiratory clinics and in-house specialist teams to fast-track patients as appropriate; the reorganisation of diagnostic services to ensure increased access to, and availability of, services at busy times in accident and emergency departments; the appointment of advanced nurse practitioners, ANPs – emergency – in acute hospitals; the use of admission protocols to ensure that emergency patients are prioritised in terms of admission to hospital through accident and emergency departments; the appointment of additional personnel to liaise with patients while they await diagnosis and treatment at accident and emergency departments; and the introduction of information systems that record comprehensive, comparable and reliable data on activity in accident and emergency departments. Such information will provide staff with a valuable tool in structuring services to meet the needs of patients.
Many of these initiatives are under way and they combine to represent a comprehensive response to the needs of accident and emergency departments. The key to making sure that these initiatives have the desired effect is to ensure that all partner groups work together and that effective strategic plans are in place to guide implementation. The development of accident and emergency services will be further informed by a major review of the structure, operation and staffing of accident and emergency services and departments with a view to improving the provision of patient care. This major review is being undertaken by Comhairle na nOspidéal, the statutory body which, inter alia, regulates the number and type of appointments of consultant medical staff. When we announced funding for an additional 25 accident and emergency consult ants, this statutory body wanted to do the major review. That review will inform and take an in-depth look at how we can move forward in terms of the organisation of the accident and emergency service within the overall context of hospitals.
Mr. Martin: This major review has involved extensive consultation with the Eastern Regional Health Authority, each health board, relevant voluntary hospitals, appropriate professional bodies and other interested parties. The review has also involved an extensive examination of best practice models of accident and emergency services in Britain, Europe, the US, Canada and Australia. I understand that this work is at an advanced stage and I look forward to assessing its findings in the near future.
I am confident that the initiatives which I have outlined above will contribute significantly to the improvement of service provision in accident and emergency departments for all personnel working in these departments and for the patients receiving these services. However, I acknowledge that these improvements, which are needed because of the failure of the Opposition parties to give this matter priority attention while in office, will not be made overnight.
Mr. Martin: Many of the new developments are being built as we speak. It takes time to build them, but that is being done. A lot of work has gone into the redesign of a range of hospital sites as I outlined earlier.
I would like to comment on the proposed industrial action to be taken by nursing staff in accident and emergency departments. I had the opportunity to meet representatives of the nurses on 21 February last. In response to Deputy O'Sullivan, I have been to accident and emergency departments across the country. I have met nurses and spoken to them about the pressures under which they work because of historic issues, buildings built in the 1970s, and because more people are attending hospital today than ever before. Some 90,000 more people attended hospital this year than last year.
We had a constructive meeting on 21 February. It was acknowledged that difficulties can exist in accident and emergency departments from time to time because of the uncertainty surrounding the volume and complexity of cases presenting for care and treatment. I pay tribute to the nursing staff and doctors who work in our accident and emergency departments. Because of the issues I have outlined, they are under a lot of pressure.
During the meeting we identified a number of measures to be taken to address the problems. It was indicated that further measures must be  taken and there should be a demonstration of earnestness at local level in terms of more interim measures to alleviate immediate pressures. We are responding to that. Following the meeting, I wrote to chief executive officers of voluntary hospitals and of the health boards asking them to engage with the Nursing Alliance in each accident and emergency department with the aim of addressing current difficulties. I am happy to advise the House that there has been positive dialogue between nursing staff and health services management on ways in which improvements can be effected, and these discussions are continuing.
In addition, the Health Services Employers Agency, HSEA, and the Nursing Alliance met on Thursday, 28 February to discuss the proposed industrial action. I understand that this was a constructive meeting at which a range of proposed initiatives aimed at further alleviating service pressures were discussed in some detail. All parties agreed to meet again tomorrow, 8 March. I remain absolutely committed to doing all I can to help management and staff at a local level move forward in the implementation of major improvements.
I am also determined that implementation and future policy will be guided by policies informed by all key groups. Partnership is absolutely essential to effective policy development and implementation, in this as much as other areas. That is why I think it is important to convene a national accident and emergency forum in response to a request from the Nursing Alliance. This forum will identify urgent measures which can be taken to enhance accident and emergency services and is consistent with the commitment in the health strategy in this regard. The forum will be chaired by Dr. Danny O'Hare, former President of Dublin City University. Participants will include relevant stakeholders, hospital management, members of the medical and nursing professions, para-medical and non-nursing personnel, staff representative associations and unions, patient advocacy groups and other interested parties.
Mr. Martin: Deputy Allen will be represented on it as he is a member of the health board. He will be a key player. Workable solutions may be reached, with dialogue and sharing of views, which will assist in alleviating the existing problems in parallel with the implementation on a regional basis of the initiative I described earlier. I am satisfied the range of initiatives I have outlined will contribute to a significant improvement in service to patients attending accident and emergency departments and represent tangible evidence of this Government's commitment to the development of the service.
We would be much further along this road if we had not been required to make up for the lack of funding and planning which we inherited. I have no doubt we will hear this evening and over the next few months the old refrain from the  Opposition that its record has nothing to do with anything. While the Opposition did little, it has everything to do with whether its lightly-given promises and repetitive denunciations should be believed.
Mr. Martin: In case I do not get the opportunity of doing so again, I repeat my congratulations to Deputy McManus on her comment to the effect that trying to compare this Government's record with that of its predecessor is like trying to compare the 21st century with the 18th – a comment with many levels of irony obviously not intended by the author. In case he feels left out, I also congratulate Deputy Mitchell on his use of statistics.
Mr. Martin: He tries to blame us for the record increases in waiting lists, but what about the intention of the Labour Party's leader, Deputy Quinn, to cut waiting list funding? This Government is fully committed to the development of a modern health service capable of responding to the needs of the people. We have begun the work of rectifying the problems of the past through unprecedented increases in both capital and revenue.
Mr. Martin: We have done more to invest in the health services than any previous Government and we will continue to do that. The largest programme of development in the history of the Irish health services is under way and the benefits are being felt throughout the system. More patients than ever are receiving the care and treatment they need. They have a right to access services and it is incumbent on us to ensure that these are provided without delay. Patients also have a right to a well co-ordinated hospital service including an accident and emergency service which is capable of responding to their needs and which is integrated with other elements of health care provision.
This Government will continue to invest in the development of a high-quality, equitable and accessible hospital service. Much has been achieved to date but much still remains to be done and this Government is committed to doing it in a far more structured and comprehensive way than any previous Government.
Mr. Martin: I am proud of what this Government has achieved and I am confident we are well  on the way to ensuring that we are delivering the level and quality of service which the people have come to expect and which they deserve.
Dr. Moffatt: I thank the Labour Party for tabling this motion. I appreciate any excuse to outline our progress to date on the job of health reform. I was handed the Labour Party motion yesterday and as I read it I noted the lack of a single policy proposal.
Dr. Moffatt: There is a list of aspirations, but nothing else. In short, Labour condemns and denounces while offering no alternatives. Today's debate reminds me of last November, when Labour tabled a motion on medical card eligibility. Only days before it had launched its pre-budget submission which contained a broad list of proposals for social welfare and health expenditure but absolutely nothing regarding medical card eligibility.
Dr. Moffatt: Labour has become stale and reactive. This week as it senses problems in the area of accident and emergency treatment it seeks to make political capital, despite the fact that it has no real policy on the issue. In November it sought to make political capital from the issue of medical card eligibility despite having no policy stance on medical card eligibility.
Dr. Moffatt: It is one thing to lament the state of the health service over a cappuccino or to compare WHO statistics across the table at a dinner-party but it is quite another thing to deal with the reality of 70 years of under funding in the Irish health services.
Dr. Moffatt: Tuigim anois. Every single person in this room knows and will, I presume, admit it privately that it takes time to build new wards, train new nurses and put new programmes into place. It is not enough to stand in this great House affecting anger and concern at Government inaction when we all know that more has been done to bring about reform over the past five years than ever before in the history of the State, in accident and emergency departments as much as the rest of the health services.
Dr. Moffatt: Examples include the new accident and emergency departments in Portlaoise and Castlebar, the upgrading of facilities at Our Lady of Lourdes, Drogheda, Monaghan General Hospital and Our Lady's General Hospital in Navan, the further development of accident and emergency facilities at St. James's and the Mater, the planning of a new accident and emergency department for Cork University Hospital and more, as has been illustrated by Deputy Martin. All of us know how much has been done. However, we also know that had Deputies Quinn and Noonan, the Ministers for Health and Finance in the rainbow coalition, begun the work of reform two and a half years earlier when they had the money but lacked the political will, we would have more nurses, more wards, more screenings, more treatments and better accident and emergency services in our hospitals.
Dr. Moffatt: There is real anger on this side of the House because Fine Gael and Labour, in the last few months of rainbow government, cut funding on waiting lists reduction by 20% when those same waiting lists had actually risen by 27%. Waiting lists would be far shorter today if Labour and Fine Gael had governed responsibly. There is anger on this side of the House because the massive programme of investment – the 125% increase in health spending since 1997 – was not begun earlier. There would be more wards, more clinics, more screenings today if Labour and Fine Gael had governed properly at that time. There is anger on this side of the House because funding for substantial increases in nursing training places was not put in place before 1997. There would be more nurses working in our wards right now had Labour and Fine Gael done something about that. There is anger and frustration about the state of the health services on this side of the House but there is also a drive to reform which is absent from the parties opposite. We are determined to invest, to reform, to provide the poorest of our citizens with the best medical assistance in the minimum time.
In my area, the health of older people, much has been done in the past five years. We came into office at a time when less than €13 million was being spent on the development of services for older people. That sum has risen to almost €100 million this year. While we are working in partnership with Comhairle na nOspidéal to review the structure, operation and staffing of accident and emergency services and other departments. We have asked chief executive officers of the health boards and voluntary hospitals to engage with the Nursing Alliance in every accident and emergency department in order to address the present undeniable difficulties. The Minister has also announced his intention to establish an accident and emergency forum, made up of all health stake holders working in this area. Since 1997 we have reformed, invested and championed a partnership approach to deal the very real problems which exist in our health services. We have set out a solid policy basis for reform and negotiated with stakeholders. We have picked up the pieces from decades of under investment and a lack of political will to reform and invest on the part of the parties opposite.
Mr. G. Mitchell: It is very difficult to listen to a Minister who has set up 104 different reviews, forums, committees, inquiries and examinations and today tells us that he is setting up yet another forum. I recall the film 101 Dalmations, which was not half as spotty as the Minister's approach to running the health services. This Minister will not take decisions, which is what he is paid for and elected to do, and this contributes to the mess the services are in. That is the real reason we are in this mess.
The Minister made much of the fact that he had set up Comhairle na nOspidéal and announced 25 additional consultants for accident and emergency. However, these were delayed and only 14 or 15 posts were filled on a temporary basis by Comhairle na nOspidéal because it is carrying out another review.
Mr. G. Mitchell: When it is finished its review, it will report to the Minister and the Minister has said that he will assess that review. Is that not what has been happening for the past five years  on 104 different committees. I misled this House for a long time because I thought that there were only 74 or 75 of them. However, I found out last week in a parliamentary reply that there are 104. The Minister gets up here and has the brass neck to talk about more forums and another review group. It is absolutely pathetic.
I have put forward proposals and I notice that the Minister in his contribution did not take on any of the detailed proposals put forward by Fine Gael. It has put forward proposals for separate accident and emergency departments in hospitals, for the fast-tracking of senior citizens along the lines of the pilot scheme in Limerick and for elective beds or perhaps even an elective hospital. That could, for example, be in Cherry Orchard in west Dublin where there is no accident and emergency unit.
People are clustering the accident and emergency wards because they cannot get into elective beds. That is the problem and I have not seen one pastoral letter, one bishop wringing his hands, one Church of Ireland primate or Catholic bishop, or one Muslim or Jewish leader hitting out at the apartheid in the health services in Ireland. That apartheid was wilfully and deliberately extended on the eve of a by-election last year by the Minister for Health and Children.
Members know that apartheid has operated and continues to operate in secondary care hospitals. However, last year, on the eve of a by-election, the Minister extended medical cards to those aged 70 and older. I have no difficulty with that. The Minister accuses me of wanting to give the card to 65 year olds.
Mr. G. Mitchell: I will tell the House what my proposals are in a minute, and they are comprehensive. What did the Minister do? When the average payment to IMO members such as doctors and GPs was in the order of £50, which is probably a reasonable average, he gave them almost £250 to settle, and not to take on those on lower incomes but to take on senior citizens aged 70 and upwards. That was simply because those people vote. There is now a situation where retired bank managers, chief executives of State companies, doctors and Ministers—
Mr. G. Mitchell: —qualify for a medical card at enormous expense while people living on £101 or €128 per week, alone in poverty, misery and in the cold, have been left without a card. Not one bishop has put out a pastoral letter about it. Where have our priorities gone wrong? This is an outrage and is apartheid in every sense of that word.
In the deep south of the United States, there were two waiting rooms, one for the blacks and one for the whites. That is the way it is here  except that the “whites” are the rich while the poor, be they black or white, are left waiting in the other room. The poor are the people who clutter up the accident and emergency wards, those on £101—
Mr. G. Mitchell: —or €128 per week, living alone and denied the medical card. The agreement with the IMO is that up to 40% of the population can be covered. When the rainbow Government was in office, 37% of the population was covered but that figure has fallen to 29% because poor people have been left out.
Mr. G. Mitchell: —the death rate among the wealthiest classes is about ten or 11 per 1,000. In the medium classes, that figure is about 23 per 1,000 but among the poorest classes the figure is about 31 or 32 per 1,000. In other words, the death rate is three times as high for poor people of that age group. The Minister of State, as a doctor, knows this is true.
I will tell the House my proposals because the Minister did not address any of the comprehensive policies that I have put forward. I want to double the income limit for medical cards to bring it up to 40%. Even if that limit is at £10,000, it is not a lot to write home about, but it would bring the rate up to the 40% limit agreed with the IMO. A husband and wife with two children could earn £19,600 under the proposals that I have put forward. I have also said that I would give a free GP service to children up to the age of 18, and beyond that to the lowest paid 60% of the population in full-time education, and to those aged 65 and over as part of the same package.
Mr. G. Mitchell: The Government wilfully left out poor people and wilfully extended this. The poor are the people who end up in bad health and in hospital. They are the ones who have to go to accident and emergency units and who cannot afford private medicine. There is not a word  about that from the people gathered outside this House today. It is apartheid and it has made a major contribution to unfairness and injustice. The Minister has a brass neck to publish a so-called health policy with the word “fairness” contained in it.
Unless we target resources along the lines I have suggested, we will not come to terms with the issue. We must invest in primary care in a targeted way and then invest in secondary care. Deloitte & Touche, which wrote the Value for Money report on the health services for the Government recently, when questioned by me at the Joint Committee on Health and Children, agreed that it is better to have a targeted approach in primary care along the lines I propose. There must be total reform of the way hospitals are run, with citizen based hospital boards and a hospital management where managers have to apply for their jobs every seven years in the same way that city managers, Secretaries General of Departments and the Garda Commissioner do. If that is not the case, we will not ensure the accountability we need in the system to end the carry-on there at present.
Of the 104 reviews that I mentioned, many cater for the vested interests running the services. Patients' interests come about fifth in the queue, and that is the problem. It is the reason I want a covenant of rights and responsibilities for patients. That is not just a charter to be stuck up on a wall but a covenant signed by a patient and an identifiable person in the hospital, overseen by an independent health ombudsman and with a surgeon general reporting directly to this House, no matter who is on the Government side of the House. This will ensure that Members of this House, who provide endless money to incompetent Ministers who cannot run an efficient service, will have an independent report on precisely how the money is being spent.
Mr. Ring: I will come to a matter relating to the Minister of State's constituency later, but first I tell him that last Sunday a constituent of his rang a Dublin hospital. She arrived in Dublin on Sunday night, brought by her family, and was prepared for an operation yesterday. She was washed, cleaned, made ready and put into a gown. A nurse then told her that she was sorry, but the operation had been called off. The woman's husband had to leave County Mayo yesterday morning to bring her home. That is the health service we have in this country. I believe that the excuse in that case was shortage of staff. The new excuse is that they have no money because of the winter bug.
In the Minister of State's area of the Western Health Board – he has a lot of good friends in it – 700 jobs were filled in the last number of years but the problem is that they were not medical jobs. There is a crisis in that people cannot get any kind of procedure without going on a waiting list. The latest thing is that one must go on a waiting list to get on a waiting list, yet lo and behold – I would like the officials to listen to this – the Western Health Board spent €70,000 on diaries which it sent to friends and doctors. One would think doctors could not afford them despite all the money they are taking out of the GP scheme. I would not mind if the health board sent five-year diaries to the people waiting for five years for hip, heart and cataract operations and other procedures. It spent €70,000 on diaries even though people are left on trolleys and people in emergency rooms are sent home every day of the week because they cannot be dealt with as we have no money.
The Minister and his Department should bring in the chief executive and the people responsible for this. I have written to the Committee on Procedure and Privileges and have asked the Committee of Public Accounts and the Comptroller and Auditor General to investigate the matter. There is no way that can be justified when there is a crisis in the health service. Somebody can write to me to try to justify it but I will not put up with it and I do not care on whose corns I stand. I do not care what they say about me in the health board because I know they hate me. I know they hate me in the Department of Health and Children but I will represent the people who elect me and will put it on the record every day that people are being treated like second class citizens. There are people who are weak, upset and cannot fight for themselves. When they ring hospitals, they are told to come in and when they do, they are sent home. That is an outrageous scandal.
The Minister is the man for photographs. Huge money has been spent on public relations. I tabled a parliamentary question and found that, I think, £17 million was spent by that Department on advertisements in the last number of years. The Government has spent £300 million on public relations over the past couple of years.
Mr. Ring: It has 85 spin doctors. I would not mind if it spent money on medical doctors but it spends it on spin doctors who were previously employed in RTE, Independent Newspapers. It is no wonder they cannot see anything wrong with this Government because the spin is being spun by its friends. The sick, weak and old who are  awaiting hip and cataract operations are waiting for this Government in the long grass.
Last week a constituent of mine and of the Minister of State applied for the carer's allowance to look after a very sick person. The matter went to the social welfare appeals board. A doctor was sent out although I do not know what sort of doctor he was. He must have been one of the consultants but he was not a medical doctor. Last Monday morning the woman received a letter saying this man was not sick enough for her to get the carer's allowance. The morning she got that letter, she also got a telephone call from the hospital to say the man had died. How sick does the Government want a person to be to consider him or her sick? The carer's allowance meant a lot to that person. She was insulted by the Government, the Departments of Health and Children and Social, Community and Family Affairs and by the caring profession who said this man did not need full-time care. That man does not need full-time care now because he is gone elsewhere. It is a disgrace, shameful and outrageous that people must wait for treatment.
Mr. Allen: In the five minutes I have to speak, it is very difficult to address a very complex issue such as this but I would like to give two examples of the current situation. On 28 December last in the Minister's constituency, a 74 year old woman was removed from a nursing home to a city hospital. She had a problem and remained on a trolley for six hours. She was then transferred to Waterford, had surgery and died. Her immediate family received a telephone call to say she had passed away and was assured she died a happy death. I wrote to the chief executive of the hospital and the reply I received stated that the woman was moved 80 miles to Waterford because there was no surgeon in Cork city, the second city of this country, to carry out necessary life saving surgery on that woman. That is an example of what has happening in our disjointed health service.
I know a 62 year old man who cannot climb the stairs at home and who cannot get on a waiting list to get on a waiting list. He has been told by Cork University Hospital that his situation is not sufficiently serious for him to be put on a list for an out-patient appointment. Some 5,000 young children in the Cork-Kerry region are awaiting orthodontic treatment. We were not told until we looked for it that a further 5,000 children are on a waiting list to get an assessment.
Professor Wiley of the ESRI issued a report some months ago on the private public mix. She said that in the interests of equity, there should be a cap of 20% on the level of private practice in our public hospitals. As a member of the Southern Health Board, I attempted to get an idea of the work mix of each of the consultants in the public hospitals in the Cork-Kerry region. I was denied the information which was effectively blocked by consultants in the Southern Health Board area who were afraid the truth would get  out in relation to the level of private practice in the public hospitals. The Minister also refused to release that information. I was told it would be a breach of the common contract.
As Deputy Mitchell said, there is apartheid in our public hospitals. The rich get quick access and quick treatment but if one is depending on one's medical card or on the public health services, one will wait. Many people have waited until the day of their death to get treatment. The greatest failure of the Government is that it has provided tax breaks for the rich and the wealthy while it has kept the sick and the elderly waiting on trolleys in accident and emergency departments.
I see little sign of the recommendations of the Murphy report on the delivery of acute hospital services which was carried out in Cork being implemented. As Deputy Mitchell said, medical cards are being distributed to the over 70s while some people on social welfare are being denied medical cards because they are €3 over the limit.
Mr. Allen: It is not incorrect. If the Minister of State reads the Irish Medical Times of last week, he will see that the IMO has sent a letter of protest to the Minister because patients are being removed from the medical card list as they are €3.30 over the eligibility limit. If the Minister of State finds that is incorrect, he should take it up with the IMO.
Mr. Allen: The greatest failure of this Government is that it has neglected the sick and the elderly. It has refused to face up to reality. All the Minister has done is create 104 fora and study groups. There are study groups looking at the findings of strategy groups. He will not grasp the nettle on any of the awkward issues. The most awkward issue in the delivery of hospital services is the abuse in our public hospitals, which are funded by the taxpayer, where more than 20% of the recommended cap is being seriously exceeded by some consultants, yet the Minister is refusing to take action and even to provide the information to public representatives and to Dáil Éireann.
Mr. D. Carey: I wish to share one minute of my time with Deputy Deenihan. My constituency, Clare, has been visited a number of times by the current Minister for Health and Children and his Ministers of State. They have seen that accident and emergency services in the county hospital in Ennis are housed in a very cramped area and that they deserve a larger space in which to work. I recall the Leas-Cheann Comhairle visiting Ennis when he was Minister for Health and Children and he set up a review of accident and emergency services in the general hospital. He was followed  by Deputy Woods, who was followed by Deputy Cowen in turn, and both of them contrived to set up a review of accident and emergency services at Ennis. The current Minister promised that Ennis accident and emergency services will be faithfully considered under the national development plan.
Two Ministers have spoken on this motion and despite the promises they made when they visited it, neither of them referred to Ennis general hospital. We heard the harangue of Deputy Killeen who said it was Deputy Noonan who, as Minister for Health and Children, took the money from Ennis and gave it to Limerick. What nonsense.
Mr. D. Carey: —following the mess made by Fianna Fáil Ministers. I have been there and seen it all. Do the people of Clare not need a proper accident and emergency unit? Are they not entitled to that? Is there no dignity or integrity attached to Ennis general hospital? Do the people in the Department not see the necessity to protect the integrity and dignity of the people of Clare? Why is independent Fianna Fáil running a candidate who is fighting for the hospital and accident and emergency services? Is he foolish? Not at all. This is something that the people of Clare deserve. They have pride in themselves and they want these facilities.
I could continue this in another public forum and I intend to follow it up. I am very disappointed that the Minister of State, Deputy Moffatt, who is a Minister from the west, did not even mention Ennis hospital in his speech.
Mr. Deenihan: More than 30,000 patients are seen annually in the accident and emergency department of Tralee general hospital. As we speak, there are ten sick people lying on trolleys in the corridor of the hospital adjacent to the accident and emergency unit. There are four cubicles in the unit and they can accommodate only four people. These people have to be examined by junior medical staff as there is no senior consultant in the unit in Tralee. There are senior consultants in Castlebar and Sligo, three in Cork but none in Tralee because it has been totally neglected by the Southern Health Board and its preponderance of representatives from Cork. Patients are totally degraded. There are only six nurses on duty by day and three by night. They are over worked, stressed and being pushed to their limits.
Patients are referred to the hospital by their GPs and put through the accident and emergency  department. They expect a bed but are put on trolleys. Some of these patients will go home rather than lie on a trolley. People will die as a result. It is up to the Government to do something about it.
Mr. Durkan: This country had no money in the 1980s and there were excuses and valid reasons for not being able to provide the necessary services, particularly health services. That could not be said about the 1990s. After all, the Government has gone on the public record on many occasions eulogising about how well it has run the country. It said we were among the 20 richest countries in the world. One of the key services Government is required to provide, the health service, has been run down due to inadequate funding. The obvious conclusion is that whatever about the availability of money to Government, when the Government set out its priorities it did not think it worthwhile to devote sufficient resources to the health services.
Mr. Durkan: I want to know where the money was spent. I do not know what the Government did with the money it has squandered over the past four years. I do not know how it will account to the people for what it has done with the country's resources over the past four years. I do not know how it will go to people's doors and make excuses about why the country is facing a deficit after four years of so-called good Government and unlimited resources. I do not know how it will explain this to old age pensioners who have been on the receiving end of the poor services in this area.
Mr. Durkan: Deputy Ring mentioned a person who was deemed to be too well to qualify for a carers' allowance but obviously was not well. I do not know how the Minister of State will explain those things.
Mr. Durkan: I feel sorry for the Minister of State because I know he is a caring and compassionate man. It must be a huge embarrassment for him to have to make excuses in this House for the lack of services in those areas. It must be a source of huge embarrassment to the Government in general to have to say that despite all the riches, wealth and resources that we have  enjoyed, it has not been able to provide a health service.
There are 30,000 people on waiting lists for orthodontic services. Parents bring their children to private orthodontists because there is no service. No service has been provided nor will one be. Things are so bad that we in the Opposition are embarrassed making excuses on the Government's behalf. That is all we can do. We are counselling the people who are unable to gain access to services to which they have a statutory right because Government has not been able to focus on the issues in front of it.
When resources are pinched or misdirected, those who pay are always the most vulnerable in society. I would have thought that somebody in the Department of Health of Children would have said he or she knew how to deliver the services. It should be possible to deliver them quickly, economically and efficiently. Obviously it is not. A former Taoiseach once said during a general election campaign that he had not realised things were as bad as they were in the health services.
Mr. Durkan: He found out that there was something seriously wrong with the health services. Can we, as humble members of the Opposition, tell the august members of Government that things are very bad and that they are about to find out how bad very shortly.
Mr. Dennehy: I wish to share time. I wish to put this Labour motion in context. A year ago the leader of the Labour Party, Deputy Quinn admitted that he was warned about impending nursing and medical manpower shortages in our health services. He admitted that he was warned:
especially with regard to the number of people coming into the nursing profession and the availability of well motivated and qualified people in Ireland. I confess I did not listen to those voices at the time as well as I might have, and the problems the Minister for Health and Children now has are, in part, related to that.
Mr. Dennehy: In light of that stark admission, it is bizarre for the Labour Members to table a motion with straight faces calling for, among other things, the provision of additional staff for accident and emergency wards. Given the Labour Party's funding of the health services from 1995 to early 1997, when it told us there were sufficient funds to begin the work of health reforms, it is  bizarre that it expects us to take seriously this motion.
Does the Labour Party believe that by tabling Private Members' motions on health and appearing angry, as Deputy O'Rourke described it, it will erase its shameful neglect of the health service? Listening to the words of the Opposition, with our long memories, we recall the then Minister, Deputy Desmond, starting cuts in mid-1985, and the party is still at it. Does it think this motion will induce amnesia in the electorate or make it believe that Labour is the solution instead of the problem?
Mr. Dennehy: Clearly, it does not. There are no illusions on this side of the House as to the capacity problems in our accident and emergency departments. Fianna Fáil in government has put a range of measures in place. We introduced the winter initiative, which included a €45.6 million investment package to alleviate the pressures, and that worked. We provided €65 million investment for 2002 to commission more than 700 new beds in the public acute hospitals, most of which were closed down by the Opposition parties when they were in Government. More than €17 million is being invested this year in establishing On Call Doc, the 24 hour GP service, which will alleviate the demands on accident and emergency services. It is important that these are noted when individual cases are cited.
Additional measures in the health strategy include the appointment of additional accident and emergency consultants, to which Deputy Deenihan referred. We appointed 12 new consultants in this area last year and funding for an additional 17 was provided. We plan to establish minor injury units to treat patients with non-urgent illnesses who at present opt for accident and emergency service. These are critical and are a feature in other countries. Advance nurse practitioners are being appointed in acute hospitals. Anyone familiar with the health strategy will be aware that I am merely scratching the surface in mentioning these few, but they are part of a costed, implementable partnership health strategy devised by the Government, health professionals, patients and the public, which all participated in the largest public consultation ever conducted in this area.
Mr. Dennehy: I contrast this to the Labour Party's alternative, the insurance company health system, which would increase bureaucracy and shut down small, local hospitals. We kept these open in 1985 and 1986 by battling locally. The Fine Gael alternative is to have no health policy but vague meandering between acceptance and rejection of the Labour Party proposal. If these  two parties are so concerned with the state of accident and emergency services, why did they make no detailed and specific submission on it to the health strategy when it was being formed, with the nurses, doctors, patients and all health professionals?
Mr. Dennehy: The reason was that they have no workable ideas. In Fine Gael's case, there was no policy to submit. Deputy Shatter stated in the Dáil that the insurance company health service was overly bureaucratic, but that it was questionable if the necessary reform could be brought about by the introduction of a universal health system. He said that less, not more, bureaucracy was needed. So much for a coalition.
Mr. Dennehy: Deputy Noonan stated that if Fine Gael announced a universal insurance system, the whole service would end up like the present accident and emergency chaos. Deputy Gay Mitchell said in Ennis last November that his party would introduce such a universal system. That is the recorded alternative. Fine Gael began as a ranchers' party, and there are still a few cowboys in it by all appearances.
Mr. Dennehy: These services need proper funding, policies and partnership between all the stakeholders. The Labour Party's approach is to shout crisis, advance a policy of shutting local hospitals – I was chairman of a health board when the then Deputy Desmond tried to close our hospital – and hope that no one remembers how incompetent the party was on health in various Governments. It is not up to the job.
The Fine Gael approach is to shout crisis, hope that no one remembers that it has no policy and in government it too was incompetent on this issue. It is not up to the job either. The workable alternative is Fianna Fáil in government working with the health professionals to reform and invest in a health strategy which is costed and delivered.
Members make their own points in this debate and most are parochial. It was interesting to hear Deputy Donal Carey boasting of what Deputy Noonan did for Clare, because I now know where the money, that Cork was left short of at that time, went. I join my colleagues in defending the Government's record, particularly that of the Minister, who is a constituency colleague—
Mr. Dennehy: —and is doing an excellent job. He was probably the best Minister in charge  of education since Deputy Donogh O'Malley and is now probably the best Minister in charge of health. I wish him and his Ministers of State, Deputies Moffatt and Hanafin, every success. May they long continue their efforts and move the strategy on.
Cecilia Keaveney: The Labour Party's motion before the House is disappointingly unproductive, which is not unusual as the Labour Party is generally barren in terms of policy and reforming ideas for the health service. The familiar term “a lost opportunity” springs to mind. This is the party whose health record in government will lose them votes in the forthcoming general election as it did in 1997. It expects the electorate to ignore that record and the fact that its present health policy would close our local hospitals.
Declan Bree, on Mid-West Radio, confirmed that Labour in government would abandon our national health strategy, with the long-term planning and the years that went into it, in favour of cheap auction politics by giving medical cards to all irrespective of any criteria.
Cecilia Keaveney: That sounds rather sad as I would prefer a well worked out health strategy that deals with all the people's health needs. How will Labour candidates explain on the doorsteps that they increased the health spend by a meagre €400 million in their term in office, when the Fianna Fáil led Government spent an additional €5 billion, £4 billion, since 1997? How will they keep a straight face when they compare those figures? They can link them to inflation and growth or whatever they like, but the Labour Party, compared to Fianna Fáil in government, raised the health spend by a paltry sum.
Facts and statistics may be dull but they remain facts. How will the Labour Party explain that it allowed waiting lists to rise by 27% when it was in office last? Under this Government the lists have been reduced by 25% since 1997. How will the Labour Party explain that in 1997 it cut the funding to deal with waiting lists by 20%? How could anyone cut funding at such a time? The Ministers as well as backbenchers could ask that question, and we look forward to the reply, which I am sure will be given in summing up the debate.
Cecilia Keaveney: The Labour Party general secretary has admitted that Labour in Government made decisions that would make a social democrat shudder. One need only refer to the  Department of Finance in 1995, 1996 and 1997 when the needs of our health services were ignored time and again. If health is Angola, perhaps it is time for the Labour Party to stop playing UNITA and start rowing in behind the health strategy and the agenda of investment and reform.
Cecilia Keaveney: The Deputies opposite asked for ideas but we must argue on the basis of policy and substance and not ignore the facts and the issues. It is a fact that radical reform of the health system was not seriously considered before 1997. That was excusable before the mid-1990s when we were not wealthy, but what about 1995, 1996 and early 1997 when the money was available? Fine Gael and Labour simply refused to spend it.
It was left to this Government to set about restructuring, reforming and investing in the health services. No one in Fianna Fáil is asserting that all is well or that a 25% cut in the waiting lists is sufficient. We all hold clinics and we know the facts, but we have made definite progress over the past five years and we will build on that solid record over the next five.
I am a member of a health board and I am aware that 4,000 additional doctors and nurses have been appointed nationally; 80,000 additional treatments were carried out last year over the 1997 figure; 3,500 extra residential and respite care places have been made available for those with a disability; and free medical cards were given to those over the age of 70.
Fianna Fáil can point to a solid record of achievement and it has a solid policy basis for further reform through the national health strategy. We can say that a vote for Fianna Fáil will deliver on waiting lists of no longer than 12 months by the end of the year, no longer than six months by the end of 2003 and no longer than three months by the end of 2004. We can also point to 3,000 additional hospital beds over the coming years. More than 700 of those additional beds are already on-stream, many of which are in the north west, but we anticipate many more, with a further 200 contracted from private hospitals. Those new beds will enable us to carry out 30,000 additional treatments this year alone.
Fianna Fáil had a solid record on health reform in the past five years and it has solid, costed, implementable and agreed policies for the next five years and beyond. In my constituency, votes  to establish a Fianna Fáil-led Government resulted in new accident and emergency consultant posts. One consultant took up duty in June 2001 and the report by the health board states: “A considerable improvement in the service has already been realised on many fronts, including speed of response and quality of service.”
Specific to Letterkenny General Hospital, a new medical rehabilitation unit has been built and funding for the hospital has vastly improved on 1997. On the issue of breast care, there has been co-operation with the Altnagelvin Hospital. The list of achievements includes day surgery rates of 52%; 14 new consultant posts in 2001 in the North-Western Health Board; a 60% increase in ICU beds in Letterkenny General Hospital; a 17% increase in renal dialysis services; a 15% increase in respite care admissions; and a 91% reduction in adult ophthalmic waiting lists over six months and a 65% reduction for children waiting over three months. The list of achievements in the North-Western Health Board area under this Fianna Fáil-led Administration is lengthy. A vote for Fianna Fáil is a vote to complete the job of health service reform in Donegal and throughout the State over the next five years and beyond.
As Deputy Dennehy said earlier, the Opposition parties can shout “crisis” at every turn and run away from their own record of Government failure and from their own policies to close local hospitals. They can play auction politics, but I would prefer to have a national health strategy that is well thought out, costed and ready for implementation. The current Ministers and Ministers of State are best placed to take the helm for the next five years of what will be a ten year strategy. I am confident that a Fianna Fáil-led Administration will be in power for the next ten years and will address the issue of the neglect of the health services when Labour was in power. We must not go back to the days of Labour in Government when we had to close hospitals.
Ms M. McGennis: I would like to pay tribute to the doctors, nurses and all the staff of our hospitals for their dedication and commitment to the patients in their care. I thank the Labour Party for affording us the opportunity to discuss the health services. We welcome all such opportunities.
The most salient point emerging from the debate is that while the parties opposite slam all Government proposals and the efforts of Government, in partnership with the health professionals, to reform the health services and improve the A&E service, they lack the workable policies and solutions for the current undeniable problems in the health services. It is not good  enough for the parties opposite to simply slam all proposals and solutions. They are like criers at a wake, with an ochón for every reforming measure of this Government. The Opposition parties failed to increase the health spend, provide for medical manpower shortages and inject much needed funding into capital expenditure.
The search for solutions to the complex problems experienced in accident and emergency departments appears to be confined to this side of the House. I am proud of the fact that the Government has more than doubled investment in the health service. Deputy Durkan said we would be called to explain where the money has gone, but I want to highlight a number of areas in which funding was increased.
The winter initiative announced in 2000 provided more than €40 million to reduce pressure on accident and emergency units. It provided for the recruitment of additional accident and emergency consultants, anaesthetists and the contracting of more than 700 beds by the Eastern Regional Health Authority and the health boards for patients no longer in need of acute care, thus freeing up the much needed acute beds for those awaiting admission to hospitals through the accident and emergency departments.
Where was the money spent? A €65 million investment package to commission more than 700 new beds in the public acute system, 300 of which have been allocated to the Eastern Regional Health Authority, will also reduce demand for accident and emergency services, as will the On Call Doc 24 hour GP service.
For all its rhetoric and public anxiety on the issue, the Labour Party lacks the policies to effect improvement in the health system and the accident and emergency service in particular. Labour Party policy documents are largely silent on the issue of A&E. The measures called for in the motion, which we are happy to support, include more staff, resources and community beds. Those are Government health strategy proposals. Not only does the Labour Party not have any proposals, it is now starting to rob ours.
Ms M. McGennis: Does the Labour Party not want more staff, resources and community beds? There appears to be perplexity and disorder in Fine Gael on the issue of health, as well as a lack of interest. Last October, the Fine Gael spokesperson on Enterprise, Trade and Employment, Deputy Flanagan, publicly urged FÁS to end its overseas recruitment programme which brought much needed nurses, doctors and health professionals into the Irish health system. Only a week before that, the Fine Gael spokesperson on health asserted that the recruitment of highly qualified nurses from overseas is the only thing preventing meltdown in our hospitals. Deputy Flanagan does not want foreign nurses but the  health spokesperson says we will have meltdown if we do not get them.
This perplexity and disorder on the issue permeates the entire Fine Gael Party. The Fine Gael spokesperson on health asserted in this House that the universal health insurance model was overly bureaucratic and that what was needed was less, and not more, bureaucracy. Deputy Noonan agreed with him. He stated in an article in the Irish Independent that it would lead to accident and emergency chaos. My constituency colleague and the Fine Gael spokesperson on health, Deputy Gay Mitchell, said he was committed to steadfastly backing the universal health insurance system, a policy proposed and promoted by the Labour Party spokesperson on health—
Ms M. McGennis: I will share a secret with Deputy Ryan. Before this was proposed by the spokesperson for Deputy Ryan's party, I was in the happy position to be in her company when she was in the company of the First Lady, Hillary Clinton, who had some interest in the scheme. The Deputy asked the First Lady for her views on it and she said – I am paraphrasing – not to go next, nigh or—
As I have only a short time remaining, I will not say what I was going to say, as it would not be palatable to the Opposition. I will finish on a positive note. We were asked where the money was being spent. I will refer specifically to my constituency where St. James's Hospital is benefiting from the Government's commitment to accident and emergency services. Some 75 new acute hospital beds are being put in place this year, a €71 million A&E unit is being developed this year and we also have the appointment of an additional A&E consultant. That is the type of serious approach the Opposition should mimic in its future policies.
Mr. Killeen: The debate on the health services is taking place against the background of an expenditure of €8 billion this year, which is 2.25 times the 1997 budget. The point is made frequently, particularly by Opposition speakers, that  the improvement is not commensurate with the additional spend on the health services. Ultimately, that needs to be refuted because there has been an enormous improvement in the quality and range of services, which were not in place heretofore. There are almost 20,000 extra employees in the health service and some of them are delivering services in areas other than accident and emergency, one of the areas being debated in this motion. The improvement and extra expenditure is taking place in the face of several decades of woeful neglect of the health services. This will result in a period within which the extra expenditure will not result in the kind of response to the problem that people want.
I am greatly concerned that debating this issue at this time is likely to exacerbate industrial relations position and will probably lead to making a resolution more difficult. This is an area where Members cannot afford to act irresponsibly. There are serious issues at stake which need to be resolved through the normal industrial relations machinery. In that regard, I welcome that the Minister has set up the A&E forum to take account of the difficulties and propose resolutions.
A number of speakers – at least one tonight and many others elsewhere – and commentators tend to attack administrative and medical health board employees and seek to scapegoat them. On occasion politicians seek to use them to hide their own inadequacies. We need to remember that important work is done by people who send out notification of appointments, administer the medical card scheme, deal with housing aid for the elderly, catering, maintenance, ambulance personnel and so on. They deserve better than to be denigrated and belittled for cheap political capital.
I wish to refer to Ennis General Hospital in my constituency. The Minister made a day long visit on Friday last, which was unprecedented. He performed a number of positive functions, which is always nice. He opened an acute psychiatric unit, which is a major improvement from the position that pertained for several decades for people in need of medical intervention in that area. It is a wonderful unit which is staffed by, among others, a former colleague of my Labour colleagues, who is delighted to be moving from a Dickensian building to this wonderful new facility.
Besides the improvement in provision for the patients there, the new unit improves the general appearance of the hospital. In some respects, it points up the differences between the 1940s facilities and those which are appropriate to a new century. It also gives people confidence that in the health service there are people who realise we need to move forward in an unfashionable area, namely that of mental health, which we are doing successfully. I commend the Minister, his predecessor, health board officials and Members for their input into moving forward in an area, which traditionally was hidden from public view. The appalling conditions, which in many cases were  the norm in such institutions, got very little public attention or emphasis.
The Minister also opened a cardiac rehabilitation unit, which in a sense reflects the lifestyle changes in modern society, where virtually any of us might be likely to be in need of cardiac rehabilitation rather than a range of other facilities. He also opened a mammography unit. The general point I am making is that many substantial improvements are happening in hospitals throughout the country. The most significant in the case of Ennis is that the Minister agreed last month to approve the appointment of a design team for a major refurbishment of the hospital.
One of the areas in Ennis General Hospital in most urgent need of such refurbishment is the accident and emergency unit. It is probably true that A&E units in all the older hospitals throughout the country are located in areas that are too small and unsuitable and which make it difficult to develop them to cope with the types of pressures they have come under during the past five to ten years. The fact that the Minister announced the appointment of the design team puts an end to uncertainty concerning Ennis hospital going back three decades, since the Fitzgerald report. That uncertainty and concern is only now being addressed. This is something anyone with an interest in health services in Clare welcomes with open arms.
We look forward to the development of the hospital in two phases. One of the areas that will be developed in the first phase is the refurbishment and new layout of the accident and emergency unit. People there worked in difficult conditions. Throughout the county there are people who have reason to be extremely grateful to the staff who worked there and for the level of facilities and expertise that was available to them.
The Minister introduced the winter initiative in 2000 in which he invested in excess of €40 million and provided a substantial role for additional A&E consultants. That is important in terms of the quality of service that can be developed in A&E.
Perhaps even more important is the need to develop primary care. The Minister has done more in a very short time than anybody else to recognise the role of primary care and to set up the on-call 24 hour GP service. In County Clare the GPs came together with their colleagues in north Tipperary, who are ready to roll with this service, and their colleagues in Limerick, and made their proposals to which the Minister responded positively. That service will be up and running by the middle of the year. There is no doubt that far too many people are presenting initially at A&E units who should more properly be presenting to the primary care service, which includes GPs and a range of other health personnel.
Mr. S. Ryan: I am pleased to have the opportunity to speak on this Labour Party motion which deplores the conditions within the accident and emergency services in the general hospitals throughout the country. It saddens me, however, that once again we are required to do so. This in itself is an indictment of the performance of the Government, which has allowed this appalling situation to deteriorate since coming into office nearly five years ago.
During this period I visited the accident and emergency units in Beaumont Hospital and the Mater Hospital, which cater for the catchment areas of my constituents in Dublin North, on numerous occasions. Some of these visits came about as a result of telephone calls from constituents appealing for assistance for their parents and children while others were on my own initiative.
On a recent visit to Beaumont Hospital the scene resembled one from “ER”. The department appears to be full of nurses and doctors running from one patient to another. The centre, the side aisles and cubicles were filled with trolleys occupied by patients. On that particular night, I counted over 30 patients on trolleys in the corridors awaiting a bed in a ward. On my way out, I came across two people consoling an elderly man on a trolley. One of them recognised me, beckoned me over, and said, angrily, “My father here has worked hard all his life to educate his family on a modest income. He has paid all his taxes and PRSI contributions. On the first occasion he requires the assistance of the State, he has had to wait 24 hours on a trolley for a ward bed. What sort of a society is this?” He was right. The current position is scandalous. The Government has failed miserably to deal with those who require this service.
I recall a telephone call from a constituent who waited over eight hours with her mother in the accident and emergency unit in Beaumont Hospital. Apart from the overcrowding, she said there was only one small toilet available for use by patients and their families. Her mother was embarrassed and unwilling to queue for toilet facilities.
How is it that Ireland, one of the richest countries in the world, provides one of the lowest levels of health care in terms of hospital beds and doctors per capita and percentage of GDP? Has it anything to do with the fact that the service in general caters for the poor, the sick and the aged who do not have the financial resources to gain immediate access to private health care facilities? The vast majority of those who have gone though the accident and emergency units, either as patients or as a patient's relative or friend have the highest regard for the doctors, nurses, administrators and general operative staff working in such traumatic and stressful conditions. Could one blame such professionals if they were to give  serious consideration to moving from the public health service to less stressful and more rewarding employment in the private sector? We must not allow this to happen. A properly funded national health service must be provided.
As this may be my last opportunity to raise health issues in this Dáil, I wish to raise with the Minister the scandalous attitude adopted by him in respect of those with an intellectual disability resident in psychiatric hospitals throughout the length and breadth of the country, including St. Ita's Hospital in Portrane. In 1998, St. Ita's complex was promised, but as a result of many delays the planning application stage has not been reached. This is scandalous. People are waiting for TDs and other candidates to arrive at their doors where they will get a clear message about this matter. The Government has forgotten those it should care for, namely, the ordinary people who cannot finance themselves in private care.
Why does a country with one of the strongest economies in Europe have one of the weakest provisions of health care in terms of hospital beds per capita, doctors per capita and percentage of GDP spent on health care provision? I have to assume that this is because there is no profit to be made from health care, in a system such as ours.
Emergency departments the length and breadth of this land are full of patients deemed by their doctors to be in need of immediate hospital care. These cause overcrowding, which is stressful for the patients, for their relatives and for the health care workers trying to care for them. Like an over-full bus, where a newcomer cannot access the single empty seat at the back, or a plane in a holding pattern above a busy airport, the emergency departments are unable to take more patients into cubicles for evaluation and care. They must wait, stacked in the waiting room, until a space becomes available. It does not matter whether there is one doctor or six doctors available to see patients. Until space is freed up, no more patients can be seen.
I do not believe in playing politics with health because health provision is a necessity. If I had the choice of reducing capital gains tax from 40% to 20% for the well off I would rather see some tax revenue, my own included, being spent on health care. One gets only one chance at health.
The position in accident and emergency departments has deteriorated to the point of a real crisis. That is not a political charge; it is a fact. A survey taken some weeks ago disclosed that there were over 100 patients lying on trolleys in accident and emergency departments throughout the country. Hard pressed nursing staff have now reached the end of their tether and have  been forced, reluctantly, to take limited industrial action over the conditions that pertain at their places of work. They are doing so in order to compel the Government and the Minister to improve the conditions for staff and patients alike. That 90% of the members of both SIPTU and the INO voted for industrial action is an indication of their frustration.
There is no point in engaging in the fig-leaf of setting up forums. We are worn out from forums, strategy groups and focus groups on which we could write theses. Action is what is required. The people are sick of death bed conversions by the Minister in an attempt to deflect nurses from taking action. One of the banes of nurses working in accident and emergency departments is the division of responsibility, taking notes, attending to administrative and clerical duties. That division of responsibility, which was recommended by the commission and is still to be implemented would help. There has been an abject failure of hospital management to fully comprehend and deal with the overcrowding and workload problems of recent years.
At a time of unprecedented wealth, how have we arrived at a situation where ambulances can be turned away because of chronic overcrowding in casualty wards? Do we want a society that consigns patients to trolleys in cramped conditions where, as Deputy Ryan said, doctor-patient confidentiality can be compromised?
It is imperative that a proper admission and discharge policy is put in place at individual hospital level. It involves additional personnel charged with that responsibility at executive level in the hospital who would be able to make instant decisions without having to go up the line for guidance. Personnel should be in charge to make the decision on whether a person can be dealt with as an emergency patient. The INO has made a proposal which would considerably improve liaison measures, ensure that all the stakeholders would be fully informed and help minimise problems by focusing on stronger management and improved team work. All of this would complement the provision, where necessary, of additional bed capacity.
In Longford-Westmeath General Hospital, the completion of Phase 2B would help substantially alleviate the situation. Nothing has been done since 1997. The Government can crow all it wishes. It is a scandal that doctors, nurses and attendants working in a hospital can look through a window and see a huge empty building. All stages should be completed to ensure the provision of high quality patient care. That is what has to be achieved but, to date, it has been shamefully neglected.
There are about 30,000 admissions per year or 2,500 per month at Longford-Westmeath General Hospital, approximately 20% of which are people who are called back for review. The overall admissions figure is increasing each year. Large hospitals such as Mullingar Hospital will have to have accident and emergency consultants  appointed, and they should not be bypassed for such appointments as has happened in the past. Two such consultants are needed at Longford-Westmeath General Hospital to ensure 24 hour consultant accident and emergency cover is provided. Innovative solutions to the problem must also be pursued.
Dr. Upton: The accident and emergency department of St. James's Hospital, which is in my constituency of Dublin South-Central, was designed to cater for 30,000 patients per annum, but has to process up to 55,000 people each year instead. Is it any wonder, therefore, that there are constant reports of chaos, including long waiting times of up to 48 hours? People have to lie on trolleys in corridors and they sometimes express real anger and frustration as a result. I emphasise that my criticisms are accompanied by praise for the hard-working, courteous and frequently exhausted or stressed staff in the hospital.
A recent newspaper report highlighted that patients from Dublin travel outside their health board areas for treatment, to bypass the long waiting times in accident and emergency departments in some of Dublin's larger hospitals, including St. James's. According to a consultant, there are problems in accident and emergency wards because there is nowhere to put patients who can be discharged following their recovery from an acute episode, but who need somewhere to convalesce. The entire health care system is in a state of chaos and is near collapse. If people move from their health board areas to look for attention, there are consequential effects throughout the system.
The Eastern Regional Health Authority, which funds the major Dublin hospitals, responded to the recent consultants' value for money report by saying it is working to address the difficulties. It announced plans in February 2001 to address various initiatives to improve access and reduce waiting lists in casualty departments. Such plans are entirely unimportant for patients, however, as their problems have not been eased. Waiting lists are longer, accident and emergency departments are more chaotic and a large number of social welfare recipients are terrified of losing their medical card entitlements.
The view was expressed in the value for money report that there has been little change in the overall management structure of the health system. It appears that some health boards have become overgrown, like a camel with too many humps. Administration and management seem to form a large part of the camel. Doctors, nurses, occupational therapists, physiotherapists and other health care professionals form the substitute team and not the premier league team, as should be the case. We need to examine the size, structure and composition of health boards, as problems in these areas are perceived as having the potential to limit value for money.
Throughout the debate today, the Minister for Health and Children and his Fianna Fáil colleagues have stated that the Labour Party does not have positive suggestions on how matters may be improved. I suggest that a review of health board structures, members and governance would go some way to creating a better outlook for the health services, including accident and emergency departments. It is a great pity that patients continue to suffer while we wait for serious action to improve the health system.
I am not impressed when I hear Fianna Fáil and the Progressive Democrats saying investment in the health service is twice that provided under the last Administration. The coalition partners make great noise about this but it should not be a surprise, given the unprecedented level of resources at the Government's disposal. It is right that health spending should have increased in the past few years, as the economy has been able to support it. The problem is, however, that money has not been spent properly, equally or fairly. The Government assumed that problems could be solved by pumping millions into the health service, but it is now clear that the money has made little or no impact due to the absence of structural or strategic plans to spend it. Expenditure without value for money audits or analysis of where and how it can be spent is not good enough.
The Minister of State, Deputy Moffatt, has said the Government is working to review structures and that it intends to establish an accident and emergency forum. These aspirations sound very good but they are no replacement for action. I do not know what planet Fianna Fáil is living on or why it has insisted on a trip down memory lane this afternoon. It needs to recognise that this is 2002 and to acknowledge that, five years after it came to power, many people are still waiting for action on the health care system. Others have died, unfortunately, and are no longer on waiting lists.
Mr. Gilmore: I support the motion proposed on behalf of the Labour Party by Deputy McManus and the comments made by my colleagues in connection with accident and emergency services throughout the country. I wish to focus on two hospitals in my constituency, St. Michael's in Dún Laoghaire and St. Columcille's in Loughlinstown. I wish to pay tribute to the staff of both hospitals and to convey the appreciation of many of my constituents for the care and attention they have received from the medical, nursing and support units.
A serious problem in relation to accident and emergency care came to my attention late last year when I discovered that an instruction had been issued by the East Coast Area Health Board to ambulance staff in relation to St. Michael's Hospital in Dún Laoghaire. The chief executive of the health board said in a letter that there would be changes in accident and emergency services at the hospital as part of an agreement between the three hospitals in the health board  area which provide accident and emergency services. The effect of these changes from the start of the year was that St. Michael's stopped taking patients between 8 a.m. on Sundays and 8 a.m. on Mondays and each night between 8 p.m. and 8 a.m. In other words, ambulance crews were instructed not to take patients to the hospital during the night or at weekends.
Naturally, I made a public issue of the matter in my constituency. I made representations to the East Coast Area Health Board. The detailed reply I received from the chief executive of the health board stated that changes are being made to provide a new type of accident and emergency service in St. Michael's, St. Columcille's and St. Vincent's. The letter said that additional consultants were being appointed on a temporary basis and that various changes were being made, which I welcome. It is intended, however, according to the chief executive, to introduce clear protocols and procedures to reflect and underpin current practice on the referral of emergency cases. The reply I received stated that it is intended to ensure St. Michael's Hospital is resourced to meet the role it plays in providing treatment for walk-in, self-referral and GP referral cases after 8 p.m. each night. In other words, ambulance cases will not be brought to the hospital.
I object strongly to the removal of the accident and emergency ambulance service from St. Michael's Hospital in Dún Laoghaire, which is a major commercial centre and capital of the Dún Laoghaire-Rathdown administrative area. It has been decided that ambulances will no longer take accident and emergency cases there which, by any standards, represents a downgrading of the hospital. I want the Minister for Health and Children to acknowledge my strong objection to this measure and to take some steps to deal with it. It is not acceptable that people who have accidents in Dún Laoghaire and surrounding areas have to go by ambulance to St. Vincent's Hospital, rather then the one nearby.
I have said in the House on previous occasions that there is no major hospital between St. Columcille's Hospital in Loughlinstown and Wexford town. I do not know of another part of the country without a major hospital as large as the area between north Wexford, through County Wicklow and into south Dublin. Those with serious complaints in County Wicklow and south County Dublin have to go through heavy traffic to reach a city centre hospital in Dublin. I appeal once more to the Minister for Health and Children to take the necessary steps to ensure a new regional hospital is built at Loughlinstown to serve the needs of my constituency and my neighbouring constituency, which is represented by Deputy McManus.
Mr. Wall: I am pleased to speak on this important motion. As a member of the South West Area Health Board and the Eastern Regional Health Authority I have received many complaints regarding problems in accident and  emergency departments in Kildare and Dublin. I visit hospitals regularly and am aware of the problems faced by hospital bed managers due to the lack of respite or nursing care facilities for unfortunate patients recovering from operations and so on. Such people do not have family or others who would enable them to go home. These unfortunate patients have to stay in general hospitals where they occupy much needed beds.
Despite numerous representations we have not advanced this situation one iota. We are not addressing this issue or trying to understand the basic problem in this regard. Many senior citizens recovering from operations or serious illnesses are in hospital and do not have anywhere to go. These people occupy hospital beds when there may be a nursing home in their area where a neighbour or friend could visit them and assist them to return to a normal life. We are not addressing the lack of a second stage of care in the health system to which such patients could be moved. There is a problem with the lack of respite care and nursing home facilities in my health board area and I have no doubt the same is the case in other health board areas.
There are many cases in which people are left on hospital trolleys as has occurred in Naas General Hospital in my constituency. Deputies on all sides commented favourably on the staff and bed managers who work so hard and, in many cases, above and beyond the call of duty to try to facilitate patients. The lack of privacy, particularly for senior citizens, is disgraceful to say the least. The modern trend may be towards mixed wards, but older people are entitled to a little privacy. However, they are being deprived of this entitlement on the many corridors in which they are kept when they arrive in accident and emergency departments. We must do something regarding this issue.
I am pleased to note the expansion programme for Naas General Hospital. The initial investment at the hospital was only going to create 29 or 39 additional beds, but we have examined this situation and a further development will create, I think, 97 beds in all. However, there is a problem in St. Vincent's Hospital where geriatric patients cannot be moved from the accident and emergency wards because of an industrial dispute. This dispute has been going on for a number of weeks yet we do not seem to be able to resolve it. The dispute is preventing us from dealing with the accident and emergency department in Naas General Hospital because the health board does not have the necessary respite care facilities, particularly for senior citizens, who could be moved to Athy as the second stage of their convalescence. This would ensure that they receive the proper treatment before going back to their homes.
I wish to raise the issue of the new systems regarding GPs. I have continually raised with the health board the issue of locums or others acting for GPs. In many cases, the patient's records are not available to the doctor. This issue is creating  problems because doctors are afraid to deal with patients and send them to accident and emergency departments, thereby creating further overcrowding. There is a need to look at respite and nursing home facilities as this is creating many of the problems in accident and emergency departments because these unfortunate people cannot move on.
Mr. Gormley: I thank the Labour Party for giving me time to contribute to this debate. The severe problems in accident and emergency departments are symptomatic of a deeper malaise in our health service. On many occasions I have pointed out that the legacy of the Government is private affluence and public squalor. This is reflected, not just in our health service, but also in education, housing and public transport, or the lack of it.
The Green party will raise standards in our public health service by creating single waiting lists in public hospitals, standardising the cost of health related procedures, phasing out private practice in public hospitals and reassigning funding which is currently going to private practice to the public health service. We will create smaller hospitals and clinics closer to the patients served so that people will be treated as near as possible to where they live.
We will also introduce local multidisciplinary health clinics staffed by GPs, nurses, midwives and specialist and alternative practitioners which will relieve congestion in our casualty departments. A strong emphasis will be placed on outreach services from these clinics, recognising that the preferred place of residence for those in need of care is often at home.
The Green Party will oversee the establishment of an office for an ombudsman dealing specifically with issues relating to health and with powers reinforced by legislation. The ombudsman will deal with matters such as access to health related information, waiting lists and problems regarding communication with medical professionals.
The Green Party will also support the continuing availability to the public of traditional, herbal and homeopathic remedies. We will review the functions and recommendations of the Irish Medicines Board in relation to these remedies and assess the need to establish a separate traditional medicines board. We will introduce a proper system of registration and regulation of alternative health practitioners. In addition, we will support the wider introduction of information technology within the health services to modernise and improve service delivery. A range of health and telemedicine initiatives will be piloted particularly within the primary health care services, including remote Internet consultations with experts for rural GPs, supervised access for patients to up-to-date health information and virtual support groups for patients with specific diagnoses.
As far as the Green Party is concerned, every citizen is entitled to a level of health care appro priate to his or her needs, regardless of age or income. We intend to provide medical cards for all citizens. The scope of the medical card system will be widened to support a greater range of treatments, including some alternative therapies. These measures will be implemented on a phased basis with immediate implementation of medical cards for all children.
We will also ensure adequate consumer representation at all levels of decision-making within the health services especially at health board and hospital board level. Patients' representatives will play a central role in health policy development. These representatives will be elected by the community fora currently operating in conjunction with local authorities.
In the past many of the major improvements in health standards resulted from preventative measures. It is our aim to shift the emphasis within the health services away from high levels of medical intervention and towards empowering people to make decisions regarding their own health care. We will achieve this by providing better health education services and targeting adequate resources towards the promotion of healthy lifestyles.
Health education will start at an early age. We will encourage a regime of regular health check-ups. We will also ensure the proper integration of environmental and health policies so that the food we eat, the water we drink and the air we breathe are of the highest possible standard. We are facing a crisis in the health service. This Government has served us badly and I hope it will be pay back time at the election for the way it has let our public services run down.
Minister of State at the Department of Health and Children (Ms Hanafin): We are all aware that more people are being treated in our hospitals than ever before. A total of 70% of all hospital admissions come through A&E units and seasonal difficulties and strains in the system occur – that is acknowledged by the Government. Everyone should acknowledge, however, that the Government has put in place a solid policy basis for improvement.
At the core of those policies is the health strategy arrived at through negotiation in partnership with the public, nurses, doctors and all the health professionals. Together we agreed solutions to the A&E problems experienced in the health services. These include the establishment of a 24 hour GP co-operative to treat patients who would normally attend A&E departments; the appointment of additional A&E consultants – 12 appointed over the past 12 months with funding for 17 more approved; the establishment of minor injury units to treat non-urgent cases normally treated in A&E wards; and the reorganisation of diagnostic services to ensure increased access to and availability of services at busy times in A&E departments. These policies are costed, specific and detailed. We are satisfied they can be  implemented to improve the situation in accident and emergency units.
As a result of our bed capacity review, we will provide 3,000 more beds over the next decade. By the end of this year, 709 of these will be in place, allowing 30,000 additional treatments, thus alleviating much of the pressure on A&E units. Last year we provided investment of €40 million to alleviate pressures and to improve services in A&E units over the winter months. This included funding for the recruitment of 29 A&E consultants and the contracting of private nursing home places by the ERHA and the health boards. So far, 700 beds have been contracted, freeing urgently needed acute beds.
We have provided huge increases in capital spending to extend, improve and develop A&E units nationwide. In my constituency, the A&E department in St. Colmcille's received funding to be extended and the new A&E in St. Vincent's Hospital is being supported. The co-operation now developing between those two hospitals and St. Michael's Hospital in Dún Laoghaire will lead to an improved service for the people of the area.
In the same way as the problems in accident and emergency did not arise overnight, we will not solve them overnight. Based on the Government's record of investment, however, and on the plans outlined in the health strategy and agreed with the health stakeholders, the A&E situation will improve. Where problems exist, it is imperative that we work in partnership with the hospital management, nurses, doctors and all stakeholders involved in the provision of A&E services. That is the concern of the A&E forum and why the Minister is urging the chief executive officers of voluntary hospitals and health boards to engage with the Nursing Alliance in every A&E unit to improve the present situation. It is the focus of Comhairle na nOspidéal's review of A&E services. All stakeholders are working towards a solution.
A great deal has been achieved through investment, co-operation and new policies. We acknowledge there is much to be done but the partnership approach that has been devised is the way forward – it is the hallmark of this Government and I am confident we will succeed. Any Member can talk about individual cases; we all deal with the public and we are all aware of individual cases but it is important to acknowledge what has been done, what is being done and what will be done. These are not lofty, notional plans but plans that are well funded and based on the spirit of partnership. It is only through those that we can address the difficulties and strains in the system.
Mr. M. Higgins: I wish to express my gratitude and admiration, and that of many thousands of people, including Members from all sides of this House, for the statement by Dr. Patrick Plunkett at the launch of SIPTU's major health campaign. I read his speech more than once; it is one of the great speeches, informed by a powerful ethical,  professional commitment to health and to those in extreme conditions when they arrive in our accident and emergency units.
I admire the speech for another reason – the way in which Dr. Plunkett has placed what is happening in context socially. In the last few years, the heart has been torn out of communities, where both parents no longer exercise the choice to work but where both have to work to fund a speculative housing situation. They are prisoners of mortgages. In addition, they are deeply stressed and this has removed from the community those who previously cared for the elderly and the very ill.
Something else comes through in this speech. Not only does Dr. Plunkett refer to the destruction of community, but also the thinking involved in hospital care. When the doctor was giving a description of the people who arrived in A&E and the circumstances that led to his resignation from the board of management of St. James's Hospital, he pointed to something else, namely the disastrous competition being set between those arriving in A&E needing emergency care and those who need elective procedures in hospitals. He gave an example that will encourage young people to want to go into medicine, not only to deliver a set of procedures within a sickness industry, but to go into the health care industry, with all the connotations of the word “care”.
I have listened to the phraseology and looked at the language of management in different discussions about health. Any concept of rights is missing from that discourse. A country lets itself down if it does not accept a model of citizenship with health care accepted as a right. EUROSTAT describes Ireland as the second richest economy with the fastest growth rate and second highest income in the European Union, but the second lowest provision for social protection. That is an indictment of the kind of society we are.
The market will never deliver the rights or citizenship I have described. It will never do so and any representative of Government who stands, as the minor partners in the present Government do, and says that lower taxes give us economic growth has put his finger on it. I would pay higher taxes to have a decent health service, as would many people. It is an absolute scandal to suggest that it is possible to make changes in A&E without facing up to the fact that a significant proportion of GDP must be spent on our health service. We should be seeking consensus on that matter in this House but no such consensus is being sought.
Leaving aside the question of past performance and concentrating on what is happening currently, why are we on the verge of industrial action by those who have worked heroically at the coal face of the health service? They are taking such action because of the conditions in which they work. They are drawing our attention to weakness in management and consultation. Even when capital expenditure is allocated, are they consulted about the layout of A&E departments?  In Galway Regional University Hospital, many matters have been raised with me.
I will not refer to individual cases, many of which I know. There are also security and design issues, on which they have never been consulted. Other issues include staff structures, from nursing supervision level to the top, and resources. It is not possible to sweep away their concerns by saying fewer people are on trolleys today than a few weeks ago. Nor can these matters be addressed by providing for what may be termed a trolley dispersal strategy, where trolleys are moved from accident and emergency departments to wards.
Dr. Plunkett is right to address another point frequently made that many who attend accident and emergency departments should not do so. Perhaps that is the case for a small number but the vast majority who attend are treated. Some have no homes to go to and, in that regard, we have torn the heart out of our society. For example, we have allowed people to own ten to 20 houses to generate rental income and these same people are invited to invest it in the private sickness industry. The Finance Bill has created a scandal by providing for a reduction in the number of beds required for new private hospitals to operate.
What kind of society can allow that situation? In fairness, I recall Fianna Fáil Party members speaking of the need for a decent health service. However, where is the ethic today? Where is the principle of universal access, of citizenship and the right to be treated? Why have the structures of privilege in the management of the health services not been addressed? There is something degrading about hearing people speak of health in the same terms as they speak of other aspects of the economy, like at the Irish Management Institute's conference in Killarney. It is a dead language.
A definition of care is required. Let us pay our taxes for a decent health service and let us structure it properly in terms of consultants' posts, career structures and so on. When designing new buildings, let us listen to nurses and doctors and those who admit patients. Let us listen to those who, late at night in the different accident and emergency departments, have to call the Garda for security. Let us put an end to privilege and ensure that the State accepts its responsibility. Is anybody seriously suggesting that advertising investment projects in private medicine as a substitute for the State's responsibilities will do anything? It will not.
A long time ago I was a member of a health board for a number of years. In those days the situation was even worse because accident and emergency departments always suffered most in terms of cutbacks as consultants were not directly responsible. That has changed and I welcome the appointments that are to be made.
Many of those who have given their lives to public service, including those in the Department of Health and Children and the health boards,  have been sometimes forced to defend the indefensible. If there is no State policy for universal access and proper care, how can a policy be delivered to those attending at night or as a result of accidents? There is a need for commitment and a policy that says it will be necessary not only to spend money, but to change managerial structures and define a new logic of management in health care. It is not possible to run a hospital or services of care or provide medicine in the same way as running a factory.
Those from Connemara who attend University College Hospital often speak Irish and often have no homes to go to. They live in mobile homes and broken down houses. Many have no relatives. Even in Galway city, in a booming economy where people are paying 200% more than they should for a house, there are no relatives to look after them. All this means that it is time to realise that it is no longer acceptable to have a Government where the major partner calling the shots says it will continue to reduce tax irrespective of the chronic condition of the health service. Let us have a health policy and begin immediate negotiations to avert this industrial dispute and assist those who are heroically providing a public service in the most professional manner possible.
A Dublin hospital was forced to turn away ambulances for over two hours yesterday amid chronic overcrowding in its casualty ward. Shortly after 2.30 p.m. Beaumont hospital issued a protection notice, warning that its emergency unit could not cope with any further admissions. The decision was taken when the number of patients in A&E reached 59, almost three times its official capacity. Ambulances were diverted to the nearby Mater hospital until shortly after 5 p.m.
Patients who did gain admittance to casualty faced a long and uncomfortable wait. Thirty four were treated on trolleys while a further 25 queued in the waiting room. There was only one functioning toilet in the unit. The hospital's chief executive officer, Mr. John Lamont, said the crisis was so severe it could not get any worse.
I was astonished at the Minister's response to the motion. It is gratifying but hardly productive for him to concentrate so much on trying to rubbish Labour Party policy and spend so little time perhaps expressing a mea culpa and explaining why, after five years in Government, he has failed to deal with the heart of the health service, which is the crisis in the accident and emergency departments. This is where spare capacity is essential but far from that, there is an over stretched ser vice unable to meet demand. The crisis is at times so severe it could not get any worse.
On many occasions we have heard about the national health strategy. The Government should not spend five years muddling through, throwing money at the problem and then produce a strategy at the eleventh hour. Government works best when the reverse happens. As it is, there is now a health strategy but there are also various crises in the health service, especially in the accident and emergency departments. We all know that a health strategy will not bandage wounds, put anyone in a bed or take an x-ray. It is people and resources that provide these kinds of services for patients.
Patients need the services that should be available to them but, most of all, they need their dignity. There is nothing more undignified for them than to find themselves in accident and emergency departments, sitting on chairs or lying on trolleys for days. That is not the way to treat people in a civilised country, yet it is the legacy the Government is leaving to its successor to resolve.
I am very interested to ascertain the position regarding accident and emergency consultants. A beds initiative has been announced, but there has been no explanation as to why it has taken so long to fill the posts, especially the permanent ones. It is time the Government came clean on it. The problems are especially acute in the Eastern Regional Health Authority area. Rather than elaborate on suggestions and proposals on health houses for general practices, time would be better  spent resolving the question of out of hours service by general practitioners, whether it be through co-operatives, on-call duty doctors or whatever. Has the Department of Health and Children even carried out an audit of what is available in terms of out of hours cover? It is quite clear that part of the reason there is such pressure on our accident and emergency departments, particularly on the north side of Dublin, may well be related to shortcomings in out of hours GP cover. Do we know if this is the case? I do not think so.
At the end of the day we are presented with a non serviam by the nurses who are at the coalface. The Minister should listen to them and deal with their concerns and anxieties. Let us ensure that accident and emergency departments stay open to provide for patients who desperately need their services. At present there is grave stress on these services and the last thing we need for those departments is any kind of industrial action. From talking to nurses I know their only reason for taking this course of action is because everything else has failed.
I urge support for our motion. It is important that a strong message goes out from this Chamber that we will not tolerate the poor treatment and lack of quality political intervention of which the Government is guilty. We want to see a strong, effective and speedy initiative to resource and provide for good management of our accident and emergency departments.
de Valera, Síle.
Kitt, Michael P.
McGuinness, John J.
Ó Cuív, Éamon.
Power, Seán. Roche, Dick.
Wright, G. V.
Belton, Louis J.
Broughan, Thomas P.
Browne, John (Carlow-Kilkenny).Burke, Liam.
De Rossa, Proinsias.
Ó Caoláin, Caoimhghín.
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