Health Service

I beg to move

That this Assembly urges the Minister of Health, Social Services and Public Safety to take urgent action to tackle the current crisis in the Health Service, particularly in view of impending additional winter pressures.

3.30 pm

I look forward to a constructive debate on the future of our Health Service. Members share many concerns about the Health Service, and we also share a desire to help provide the best treatment and service. Today, we have an opportunity to explore ways of tackling the all-too-evident problems.

Every day seems to bring more bad news about our health and social services, and we appear to lurch from crisis to crisis. Sometimes, the Minister, her Department and the Committee for Health, Social Services and Public Safety appear to be overwhelmed by the multitude and complexity of the problems. However, we must know where we want to go and how to get there. That is the essence of a strategic vision. We want to achieve a real Health Service, not one for the inadequate treatment of bad health, but one that promotes a positive and coherent vision of healthy living and tries to anticipate our problems.

I support the amendment, but I must say that resources are only half the picture. A blank cheque is not the solution, and spending must be planned. The amendment may be a distraction from the constructive thrust of my motion.

Last week, the Department issued statistics on hospital waiting lists for the quarter ending 30 September 2001. Those statistics give added relevance to the motion, especially as waiting lists appear to be spiralling out of control even before the full impact of additional winter pressures is felt.

I hope that the debate will focus on the necessity for a shared strategic vision for the future of the National Health Service. There are 56,700 people on waiting lists. That is a disturbing statistic, and, more importantly, the annualised rate of increase is now approaching 14% - an increase of more than half on the annualised rate of increase only three months ago.

Waiting lists are one way to measure the pressures on the National Health Service, but I am worried that health professionals acknowledge that waiting lists alone are inappropriate to measure the effectiveness of acute hospital performance. The only foolproof qualitative criterion to determine a patient's treatment is an assessment of clinical need. The pressures on acute hospitals to meet targets has placed undue emphasis on the performance of routine operations for more easily treatable conditions at the expense of patients who need longer, more complex and, ultimately, more necessary procedures. What concerns me most is that the waiting lists include many of the most difficult cases, and there is less of a mix than in the past. The resources required to reduce that bald statistic - 56,700 - may be enormous.

I have asked for an audit of waiting lists. I ask for it again. For example, the framework for action on waiting lists was supposed to reduce our waiting list to 48,000. The Department received £8 million accordingly. What were the findings of that framework? Where exactly did that £8 million go? Why did the problem get worse rather than better? Those are hard questions, and the answers may sometimes be embarrassing or awkward. However, we need to hear them.

At times, we appear to be rudderless and out of control. In such a situation, to simply call for more resources without knowing what they are to be applied to and what value that expenditure will add is missing the point. Since devolution, we have spent more than 40% of the block grant on health and social services - almost half of our Budget. In the first year, the finance allocated was £2·178 billion. For the current year, 2001-02, the allocation was £2·366 billion. Next year's allocation from the Minister of Finance and Personnel will be £2·5 billion.

In the three years since devolution, the amount of money going to the Department of Health, Social Services and Public Safety has increased considerably and has been in excess of the rate of inflation. Despite those extra resources the position of the National Health Service in the North has declined. That is a substantial sum of money. Even though the vast bulk of it is committed beforehand, the Minister of Finance and Personnel has rightly noted that the Minister of Health, Social Services and Public Safety was successful with more than half her bids for discretionary initiatives that she wanted to undertake. In other words, resources are a problem, but they form only part of the bigger picture.

Waiting lists are an indicator of pressures in the acute sector. However, the unpalatable fact is that we in the North already spend a higher amount per capita, and a higher percentage of our total health budget, on acute healthcare than the Irish Republic or anywhere in England. However, our waiting lists are by far the worst of any UK region and are worsening all the time.

Those issues are being debated in the legislatures of every Western democracy. They are all faced with ageing populations and a seemingly limitless demand for health and social services. The questions that people in Northern Ireland must address regarding our Health Service are not unique. Some of them may be, but most are not.

I ask the Minister how we can match the finite resources available with an apparently ever-expanding need? How do we optimise the use of available financial and manpower resources? How do we plan strategically for the future use of trained and competent doctors, nurses, and other professions allied to medicine, as well as Health Service managers and appropriate medical facilities?

How do we lift ourselves off the bottom of the UK regional league table of performance indicators for long waiting lists, cancelled clinics, chronic heart disease, cancer rates and inappropriate lifestyles, as represented by excessive alcohol and tobacco consumption? How soon can we slim down and rationalise the Health Service structures between health boards and trusts? It must be done sooner rather than later. How do we restore public confidence in the bright shining vision of a National Health Service - as first articulated by Aneurin Bevan - as a universal, excellent healthcare system available to all and free at the point of delivery?

As someone who has worked in the National Health Service for decades, I want to make a difference, and I want to play my part. I am sure that every Member of the Assembly who is interested in health matters wants to do the same. Devolution means local people sorting out local problems with the maximum amount of democratic input. I am sure that the people who elected me to the Assembly would expect me to take my opportunity to be involved in that vision. One thing that Tony Benn said that always struck a chord with me was that the most socialist and popular act that any British Government ever carried out was to establish the National Health Service.

The types of healthcare procedures needed most urgently in this demand-led service, and the types of drugs and procedures now available, were largely unknown at the inception of the National Health Service in 1948. The service is a product of a different era and a different set of expectations. We can still preserve the integrity of the founding vision of the National Health Service, but we need to make hard choices to do so.

We have had the reviews and the consultations, now we must have an audit of performance. We must cost the decisions to be made in terms of people, manpower and resources, prioritise them and then make hard choices. As a member of the Health Committee, I have to express my frustration at the inertia and lack of decisions that emanate from the Department of Health, Social Services and Public Safety. The Minister has inherited an admittedly difficult, challenging and complex brief. She has had to cope with decades of underfunding, the postponement of hard decisions and the lack of political leadership. However, she is now in her third year of office and we seem to be going backwards rather than forwards.

At the same time, there appears to be a lack of imagination, leadership and vision in the Department. The Department's role should be as a balancing act in the formulation of policy, advising the Minister and introducing legislation. Alongside that, in the hospitals and community care sector, we need the best possible Health Service managers with the appropriate knowledge and skills. That means that the Department must ensure that central priorities are met, while allowing the maximum possible scope for local initiative. It is easy to get bogged down in firefighting from day to day. However, if the Department is purely reactive we shall never break the vicious cycles and replace them with virtuous cycles. We shall never get anywhere.

The National Health Service is supposed to be a seamless, integrated and interdependent service that combines acute hospital and community care. However, we hear mostly about pressures on acute hospitals. We must never lose sight of the fact that more than 80% of healthcare takes place in the community. Healthcare is very much the Cinderella of the National Health Service.

The statistics on the uptake of flu jabs show that targets have not been met. Only around 50% of the elderly population have had the jab, yet I hope that that figure reaches 70%. If there is a flu epidemic, a winter crisis or a cold snap with an increase in fractures among older people, and staff in hospitals going down with flu, how will we cope? Will the perennial problem of the delayed discharge of patients be made worse because the community care facilities are not available? Will other patients who need acute procedures be unable to receive them because the beds for their planned treatments are occupied? And so the cycle continues.

We need to debate whether the current models of health and social services are appropriate and whether they have the capacity to address the complex issues of chronic sickness in an ageing population. There is clear evidence that the most chronic disabling conditions increase rapidly in incidence and prevalence with advancing age. In the next quarter of a century, the number of people aged 80 and over is expected to increase by almost 50%, and the number of those aged over 90 is expected to double. Those age groups have the greatest take-up of health and social services.

Now that the statutory sector no longer provides nursing and residential care for older people, we rely more on the private sector. Last week, we learned of a major private nursing home provider in Northern Ireland in financial difficulties, and we must ask why. Delayed discharges are symptoms of the gap in the total healthcare system in the interface between the acute sector and the primary and community care sector. Neither sector is equipped with the resources to deal with the needs of those with chronic health problems who require intermittent periods of treatment, rehabilitation, health monitoring and long-term care.

As a member of the Health Committee, I have learnt a lot by listening and talking to people about the National Health Service, whether they be patients, orderlies, ancillaries, nurses or doctors. The vast majority of health professionals want to deliver a patient-centred healthcare system, but they become frustrated by silly things like incompatible information and communication technology (ICT) systems. A properly functioning person- centred information system can reduce duplication, speed up the process and be very cost effective.

I wish to refer to the excellence of some of our local practitioners. At the top of their profession and esteemed internationally, they are harassed by having to cope with day-to-day pressures. Specialists with established international reputations return to the North, but they are disheartened by the chaos, the disorganisation and the lack of decision-making that confronts them.

The Department must audit practice. Where it is bad, it must be discontinued and where it is excellent, it must be replicated. We need a centre for clinical excellence here that will combine efficacy and efficiency, and recognise that current services vary unacceptably between different hospitals and trusts. With such a small population, 1·67 million, models and standards of practice need to be set so that unacceptable variations between hospitals are eliminated as quickly as possible. The best people in the Health Service, whether they be doctors, nurses, professionals allied to medicine, or managers, all need to have time to think strategically and to contribute to the vision of which I spoke earlier.

How can we expect to get the best from our staff if we do not facilitate professional development and allow them the time to think creatively to solve problems? Is it any wonder that the National Health Service is losing nurses to the private sector, which is costing us more than twice what it should, when working practices are so inflexible and family unfriendly?

The SDLP is the party of public services, but it is also the party of the competent management of public resources. The Committee for Health, Social Services and Public Safety and the Executive have demonstrated their commitment to the Health Service and their desire to work in partnership with the Minister to achieve a well resourced and properly managed service. We are here to help. We share the objective of prioritising health for all, but we need the Minister to meet us half way. She must acknowledge that finance is not the only issue and that receipt of more than 40% of the budget carries significant managerial responsibility.

I have received one amendment to the motion, which is on the Marshalled List of amendments.

I beg to move the following amendment: At the end add

"and calls on the Executive to make the necessary resources available to alleviate pressures throughout the Health Service."

Go raibh maith agat, a LeasCheann Comhairle. The amendment is not a distraction, as Ms Carmel Hanna suggests. It is an attempt to expand on her motion in order to make it more inclusive.

We agree with the sentiments of the motion, but it does not go far enough. The motion tends to curse the darkness, rather than light a candle of hope. I hope that all of us want to point to a beacon of light in the despair that engulfs the Health Service.

I hope that we shall have a constructive debate. However, health is an emotive issue. It is an issue that makes people angry and play games. We hope that no political games are being played with the health of the people of this part of the island.

"The scale of the problem should be acknowledged, as well as the resources and the time that will be required to address it".

That is a quote from an SDLP document, not a Sinn Féin document. Financial resources, whatever Ms Carmel Hanna says, are at the heart of the health crisis that we face, and if we harp on about mismanagement in the service we shall discourage investment in it. Members are here in an attempt to encourage investment in the Health Service.

The practitioners - the people at the coalface - know the reasons for the crisis. They know exactly where funding is required, and we who have spoken to them in the past year also know. Those people told the Health Committee how the Health Service should be managed, where it should be managed and what finances are required to manage it. There is no mystery about where the money is going in many cases. There may be a degree of rationalisation required in the trusts and boards. However, that is separate from the critical issue about which we talk today - the crisis at the centre of the Health Service.

The Committee for Health, Social Services and Public Safety, as Ms Hanna will be aware, invited the First Minister and the Deputy First Minister to discuss the financial crisis in the Health Service. The Committee has yet to receive a reply even though the Health Minister has stated that she welcomes its support in that matter.

The ability to provide the financial structures to meet the urgent needs of the crisis in the Health Service is a challenge to the collective responsibility of the Executive. The failure to provide those financial structures is a collective failure of the Executive, not of the Minister, in managing the Department. Events in the other part of Ireland prove that. Charlie McCreevy has provided the resources to finance a 10-year programme of health in the Twenty-six Counties. Gordon Brown is embarking on a similar strategic financial plan to assist in implementing health services in England, Scotland and Wales.

The Health Committee believes that health is the number one priority and, as such, supports the Minister's assessment of an additional £122 million as the minimum needs for 2002-03. The Committee believes that those additional resources are required to deliver an acceptable level of healthcare, otherwise further pressures will be heaped on a sector operating at times under intolerable conditions. The Health Committee is saying that funding is required to the tune of £122 million, and in the current year that is £50 million short. Given all the moneys that have come from the Department of Finance and Personnel, that is still £50 million short.

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Junior doctors recently passed a resolution that expressed grave concern at the progressive deterioration in services for patients due to delay in clarifying policy and adequately resourcing the Health Service. They believe that the Assembly needs to take up the issue of funding and ensure that health and social care is given higher priority. That is what the junior doctors say, not the Health Committee. Those at the coalface are saying that at the centre of the crisis is a lack of funding. That is where we are coming from and where we should be coming from - we should express our concern about the lack of funding that afflicts and affects the Health Service. That is what the Health Committee, junior doctors and the SDLP document has stated.

A consultant to whom I spoke recently compared the provision of financial services to the Health Service to putting money into a bottomless pit. He said that the answer did not lie in throwing resources into that pit but in finding a floor to that pit. Members realise that good money could be thrown after bad, and no one is asking that more good money be thrown after bad. However, Members must realise that there is a bottomless pit and the trick is finding the floor to it. Only then will it be possible to deliver, as the consultant said, an equitable Health Service to a greater number of the sick.

Again, the core question is funding. Sinn Féin would support a financially structured 10-year plan that is consultative as it develops, and which has at its centre the collaborative participation of those at the coalface - health consultants, surgeons and junior doctors.

We know from our meetings with clinicians, consultants, nurses and midwives, who work on the floor of the Health Service, that a collaborative approach is needed. It is not good enough that one discipline should compete with another. Given that this Assembly acts collaboratively, medical care providers should be asked to collaborate as a profession. Cardiac departments should not be fighting with orthopaedics or obstetrics departments; every element of the profession should collaborate to point the way forward for service provision.

Last week, during the day, it took me just six-and- a-half minutes to travel from Belfast City Hospital to the Royal Victoria Hospital. Those two major hospitals are situated minutes apart in the centre of Belfast, yet they operate differently and under different boards. The Health Service would benefit a great deal if those hospitals collaborated to provide the services that are needed in Greater Belfast. That is one example of an area in which an integrated approach should be taken. Again, the motion calls for urgent action to tackle the current crisis.

Does Ms Hanna refer to the £12·9 million allocation for extra community services, the £12·4 million for additional hospital services, the £2 million for additional children's services, or the additional £8 million that will be made available in the current year to make a start? Alternatively, does she refer to the bid by the Minister for Health, Social Services and Public Safety for £50 million, which the Minister for Finance and Personnel did not provide?

The primary obligation of a civilised society with any notion of its responsibility to its citizens is to provide for the sick and to find a cohesive and collaborative way to attack the problem. That should not be done disparately, or simply through targeting a Minister or even the Executive; providers should come together to heal the sickness in our society.

The people's health is the central responsibility of Government. Their success can be measured according to the quality of life of its people. For too long, sections of our community have died younger, suffered increasing ill health longer and battled daily. They exist rather than live. The public and hospital staff are disillusioned by the uncertainty of the crisis management of the Health Service. They are ready for a change, and they demand change. The end to crisis management requires funding that addresses realistically the crisis, not crisis funding.

I call on the Executive to make the health of our people their number one priority and to finance in full the bids made by the Minister. Failure to act now will result in a greater crisis of confidence that will further undermine the crumbling foundation of our Health Service.

Members will be aware that there is much interest in the debate and that many Members wish to contribute. The Business Committee has allocated three hours for the debate. Therefore, in this first round, I urge Members to restrict the length of their contribution to eight minutes and in the second round I shall recalculate.

As the Chairperson of the Health Committee and after - I hate to say it - 40 years of experience in primary health care, this is a subject about which I know, and about which I feel strongly. I welcome the motion put forward by Ms Carmel Hanna, and I welcome the amendment also.

In his amendment Mr Kelly uses the word "alleviate" and thus accepts that money itself cannot reverse the situation, despite gross underfunding of the Health Service over many years. There are problems as well as financial constraints.

There is a major crisis in the Health Service every day, and it still has to face the difficulties of winter. Direct rule Minister, Mr McFall, introduced two documents in 1999, 'Putting it Right', which related to acute hospitals, and 'Fit for the Future', a new approach to future primary care. Massive consultation was carried out, and both documents were prepared for the Assembly. I appreciate that they are mentioned from time to time, but generally they have been pushed to one side, and we have review document after review document for consultation.

There is a crisis in cardiac surgery services - we read about people being sent to Germany and other places for operations. Last year 18 people died while on the waiting list for cardiac surgery. We have had reviews of that. A cardiac surgeon's job was not advertised although it was known for a year that he would be retiring. I do not know what happened about that post.

The fracture service is available only in Belfast and Derry. The level of staffing and facilities available for trauma and orthopaedic services is the lowest of any National Health Service region. The waiting times for treatment of fractures are appallingly long. The average time between admission and surgery for hip fracture patients in the Royal is between five and six days. As a medical student I was taught that a fracture to the neck of the femur should be dealt with within 24 hours, because a patient's condition deteriorates after that, and, if he does not die, his quality of life is reduced. In Scotland the waiting time is two days, whereas here it can be up to five or six days.

There is gross inequity for patients, with injuries, who go to hospitals outside Belfast or Derry - for example, to Craigavon and Antrim. If an elderly lady is admitted to Antrim or Craigavon with a fracture to the neck of the femur, which happens frequently, she will probably have to wait five or six days for a bed in the main trauma hospital. The elective orthopaedic facility in Musgrave Park is bursting at the seams. I could go on, but time is insufficient.

In all hospitals within 20 miles of Belfast, the situation is the same in the accident and emergency departments. Recently, Monica McWilliams and I visited the Ulster Hospital, where the situation is horrific. People were waiting on trolleys and chairs. A nursing sister was in tears when she told us of one poor man who had been in a chair but was so concerned about the welfare of the staff that he did not want to call them and so soiled himself.

We visited the Royal and the City hospitals recently where the situation is the same. Dr K E Dowey, the senior accident and emergency surgeon in the City, wrote to the Chief Medical Officer and said that the situation with acute beds was critical and that the staff were on "take in" daily. She said that lying in an accident and emergency corridor for up to 24 hours was totally unacceptable for patients, who sometimes have to be nursed all night there. The stress and strain on the staff is intolerable, and morale is at an all-time low. Young doctors cannot be attracted to accident and emergency work, and young nurses are leaving almost weekly.

Dr Ian Carson sent a letter to every doctor in Northern Ireland in primary care about the regional neurosurgery service in the Royal Victoria Hospital. It said

"The net effect of the problems are that our surgical capacity is limited almost completely to emergency and clinically urgent cases and consequently very few, if any, elective patients are being admitted."

Where is the seamless transition in primary care where 90% of all patients are treated? Last January, the Committee for Health, Social Services and Public Safety tabled an amendment on fundholding, the purpose of which was to allow seamless transition. I welcome the Minister's decision on the new primary care groups, but I do not see the seamless transition that is to take place between now and 1 April.

The sad thing is that the people of Northern Ireland deserve the best. Last January I said that we would not have another opportunity to get primary care right for several years. I still believe that we have a chance to do that. If we do not get primary care right, we will not get acute hospitals or other secondary services right either.

Nine per cent of all outpatient clinics are cancelled. Some are cancelled for good reasons, others for not so good reasons. Waiting lists were referred to. The latest figure quoted was 56,000 people on waiting lists, and the number is rising. The Executive and the Minister of Finance and Personnel seem to have got the message, judging by their statements and the recent allocations to the Health Service. For example, Mr Durkan revealed an increase of £205 million in allocation for 2002-03 to health and social services. That is an increase of 8·9% over the 2001-02 allocation, giving a total of over £2·5 billion. Substantial increases in funding have been made, but it is still not enough.

On 3 December, the Minister of Finance and Personnel told the House:

"It is not enough simply to put money into the Health Service. Many people rightly ask how the resources that have already been provided have been used. .As with all public services, there are problems with management and efficiency which must be addressed. The way in which the services are organised begs many questions. Hard choices must be made which will affect the standard of care and the nature of hospital provision in the region." - [Official Report, Bound Volume 13, p.190]

Ms Hanna referred to the audit. Recently, some colleagues and I met with the Auditor General of Northern Ireland. He informed us that he has responsibility for the supervision of all Departments, excluding the Department of Health, Social Services and Public Safety. I do not pretend to understand the historic reasons behind that, but the situation must be corrected.

The Committee wants to work in partnership with the Minister of Health, Social Services and Public Safety. We worked together on the new cancer centre. The Committee tried to be as helpful as it could, and it believes that the funding will be found. I agree with what Ms Hanna said about the overall strategy for the Health Service. We want to work with the Minister in the spirit of public service, but the Minister must meet the Committee halfway. Finance is important but it is not the only issue.

The Member's time is up.

I thank Ms Hanna for proposing the motion. Ultimately, it concerns every home and every person in the country. The subject has given the Assembly much to think about in the past. In particular, the Committee for Health, Social Services and Public Safety has looked in frustration at so much that seems to be wrong in the Health Service. We have heard many speeches about the things that are wrong.

Three issues in the Health Service must be examined. First, there is the structure of the service. There is no need for a huge Department, four boards, 19 trusts and countless agencies. In England, one board controls areas that have a population exactly the same as ours.

Duplication in administration has been mentioned. When one examines the salary scales of the senior officers in trusts and boards, one sees immediately where the haemorrhaging begins in departmental funds. In the present structure, the perception that is given of wasting finance is such that it casts despair into the hearts and minds of patients waiting for operations, who read in the local papers that an officer is being given a rise of £25,000 per year. The whole structure of the service needs to be examined.

We have been inundated with consultancy documents and bombarded with review documents. However, ultimately it seems that very few decisions are made. It is not a question of tinkering with individual sections of the Health Service: the entire structure needs to be examined, reviewed, and changed.

As the Assembly reviews the problems in the Health Service, the second matter that should be examined is its strategy - or the lack of it. One is tempted to ask, "What is the strategy of the Department of Finance and Personnel?" When we begin to enquire about the audit trails within the Health Service we run up against a brick wall. Money is given to the boards; the boards give it to the trusts; the trusts dispense it. As I remarked to the Minister of Finance and Personnel during the Budget debate, money becomes confetti currency within the Health Service. It is impossible to even begin looking at the audit trails never mind trying to follow them.

One is tempted to ask questions about the bonus system for managers. Comparing the salaries of nurses who are on the wards with those of managers who sit in offices, the perception is that the service is being run for the latter. It is not being run for patients, or for the nurses who are dispensing the service. The service is being structured by a strategy that deals only with finance.

I suggest that when communities find funds to provide equipment, the Minister and the Department should match that funding - pound for pound. There would then not only be accountability for community funding; the communities themselves would share in the accountability for the funds they would be given by the Department.

I mentioned the Health Service structure earlier. What is the strategy behind a structure in which one trust covers a fifth of the entire population of Northern Ireland? There is something wrong when only one out of 19 trusts is tasked with the community care of the people of Northern Ireland to that extent.

There is no question that there has been competition in the Health Service, and that is a huge drain on funds. Is it the Department's strategy to continue competitiveness among various areas of the Health Service? The Chairperson of the Committee for Health, Social Services and Public Safety has already mentioned this point. Everyone should be working together. The strategy should be clear, and everyone should know exactly where he or she is going. Where are the "care trails" within our Health Service? When a patient asks how he or she will be treated how often can that patient be told the trail that they will follow back to health?

There are three distinct sectors within the Health Service in Northern Ireland - acute care, community care, and primary care. We have discussed accident and emergency units associated with the acute sector, and we have seen the difficulties there. It is not acceptable when an ambulance is left sitting for 45 minutes because the stretcher has been taken from it for a patient to lie on in an accident and emergency unit.

Staff are leaving the Health Service to work abroad. Is that because the grading system needs to be changed? At the last conference of the Royal College of Nursing, that issue was brought to the fore. Until there is a situation where services are patient-driven and not finance-driven and where all of us - the Minister, the Department, nurses and consultants - are working together, we will not be able to make any change to the service. I support the motion.

I commend the proposer of the motion. It is one in a long line of motions on the Health Service, although it is important to highlight the serious problems within it and how best to deal with them.

The state of the Health Service has become synonymous with the words "crisis", "disaster" and "despair". Newspaper articles on the Health Service since January this year all describe bed crises, cancer crises, staff crises, fracture crises and casualty crises. Sadly, the list goes on.

In November last year, the Chairperson of the Health Committee, Dr Joe Hendron, expressed concern about the crises in the Health Service. In October and November of this year, he again expressed shock at those crises. In other words, nothing has improved at all. Health is among the most frequently debated matters in the House. That in itself demonstrates the widespread perception across the House that things are not only bad but that there is no sign of any improvement. In March last year, the Minister said that waiting lists were a top priority, yet they are still a major problem this year. No improvement has taken place, and things are getting worse.

Complaints over cancer services continue unabated. There is to be another consultation, which should silence those complaints for another six months - that is the perception, and it is the line that the Department is taking.

We can all highlight different areas to portray the shambles and demoralisation in the Health Service. Problems facing junior doctors is one area that emphasises, in a very real way, how widespread the rot is. The lack of cover, combined with a general shortage of doctors, simply means longer hours for those who are available to work.

The Health Committee recently met the British Medical Association and the spokespersons for junior doctors. One junior doctor told the Committee that, on one day, he worked 21·5 hours solid because there was no one on duty after him. That is hardly something to recommend, considering the risk to both patients and staff, as well as the strain upon the doctor in question.

The junior doctors' spokesman, Dr Peter Maguire, recently highlighted the problems. His concerns must be carefully listened to and heeded. He said that problems are continuing to amount at a worrying rate, that the situation is threatening to spiral out of control and that the Health Service is heading for meltdown and the winter crisis has not even begun.

He went on to say that waiting lists and the numbers of patients waiting on trolleys are increasing because there are no spare beds in hospitals. Something must be done soon to sort that problem out. Winter is approaching. If there is a flu epidemic, people will die. Dr Maguire said that we are currently on the road to nowhere, that the Health Service is in tatters and that we must get our act together. Time after time we have raised the same concerns in the Chamber.

This situation is not acceptable. Do we want to hear it all again next year, the following year and the years to come? At a time when waiting lists are already at an all-time high, non-emergency operations have been cancelled in hospitals throughout the Province. The number of patients who have been waiting for up to two years just for a scan has not been reduced, and the problem continues.

Extra money is essential if we are to deal with the crisis. Recently, the chief executive of the Southern Health and Social Services Board said that local services were suffering. He went on to say:

"We simply do not receive the amount of money we need to provide an adequate service.The lack of investment has resulted in little better than Third World standards in parts of the system."

Besides the extra money, there is another essential ingredient. Management, from the top down and across the spectrum, is an area that is easily overlooked. We should consider again the language used by Dr Maguire about our Health Service: he talked of meltdown and said that the Health Service was

"currently on the road to nowhere"

and "in tatters".

That underscores the role of management. There is a question mark over the current management of the Health Service. There are new initiatives of one sort or another, and reviews of all kinds of things are announced; it seems that any kind of activity is the goal, whereas overall, managed delivery is irrelevant. The situation lacks focus and perspective.

I welcome the money that will go towards providing free care for the elderly. There is, however, a wider perspective. If private nursing and residential homes continue to close because the fees paid are inadequate, how much better off is our Health Service? If the elderly are kept in hospitals because there is no money for care in the community and there are no beds in the private sector, how are we better off? I know of two homes in my own area where relatives are asked to pay £15 more per week because the fees do not cover the cost of care. An overall perspective would take all the relevant issues into consideration at the same time. That does not happen with the current piecemeal approach.

When the Department of Health, Social Services and Public Safety issues a press release about a new initiative or extra money, it takes its cut, and the remainder is passed on to the trusts, even though it is not enough to allow them to carry out their task. No time is taken to check on progress or establish what improvements are needed, before yet another initiative is announced or a press release issued. There is a widespread perception that neither the Minister nor her Department is seriously interested in solving the crisis and that they exist simply to produce new rules, initiatives and procedures - in other words, red tape. The actual delivery of services, which is grossly underfunded, is ignored.

The motion calls on the Department of Health, Social Services and Public Safety to take urgent action to tackle the crisis. Meanwhile, cancer services, cardiology services, orthopaedics and staff morale deteriorate. The maternity service is lost in a maze of consultations. Our Health Service is not being managed.

The Department of Health, Social Services and Public Safety has no overall strategy to resolve the crisis. Management has no will to succeed, and the trusts do not have the resources to deliver the service. Until all those matters are resolved, the current shambles will remain. I commend the nurses, doctors and the professionals in the service.

Go raibh maith agat, a LeasCheann Comhairle. I listened carefully to the points that have been made, and I welcome the chance to discuss this vital area. Morale in the Health Service is very low.

Our doctors and nurses work in a system that has been underfunded for many years. Successive British Ministers travelled in and out, making decisions that affected all of us. Some of those decisions were good, but very many of them were bad. They knew that those decisions would never cost them a single vote. For the first time in my life, directly accountable, locally elected representatives can make such decisions, but they must live with the legacy of a lack of resources and accountability, and there is much work to be done to bring the Health Service up to the standard required by the Minister.

The Health Service is still a sick organisation with insufficient staff, poor facilities and too few beds. Those problems, combined with a lack of community consultation and a policy of papering over the cracks, mean that there is a mountain to climb. As a result, money has been taken out of children's services and community care and put into the bottomless pit of acute services - without adequate planning.

The imagination and confidence to think "outside the box" are needed. I welcome good projects such as the breast milk bank; they should be encouraged. However, social issues such as fuel poverty should also be addressed as a matter of urgency to cut down on hospital stays, inhaler and antibiotic use and absenteeism from either school or work.

We should all work to tackle poverty and the social and economic conditions that impact on the health of our constituents. Fermanagh and South Tyrone has one of the highest rates of heart disease and cancer in Ireland, and it is no coincidence that it also has less economic investment, fewer public service jobs and some of the worst housing conditions in the Six Counties. It is little wonder that the health of my constituents is bad, but it will take more than investment in the Health Service to rectify that. A holistic and integrated approach is essential, and every Minister must take responsibility for that.

I welcome the Minister and the Executive's initiative to provide over 1,000 community care packages to free up acute service beds. I have raised that issue with the Minister; it is a direct reversal of previous policy, and as a result, the Health Service and the Executive are targeting an area that was starved of resources by previous Administrations.

However, the Minister cannot magic doctors, nurses and consultants out of a hat. She needs the time and resources to turn round 30 years of rundown in the Health Service, and that cannot be done overnight. The service that she inherited had become so debilitated in the years before her tenure that she has had to try to halt the systematic closure and rundown of our local hospitals by the people who we trusted to run them.

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