Mr McHugh:

A Cheann Comhairle, I support the motion, and I support Group 22 in its campaign to extend the gas pipeline to areas outside of Belfast, especially to areas west of the Bann, part of which I represent. There are great benefits, especially to rural areas, from a cheaper fuel source. The availability of gas is an issue of equality. We have a right to have the same access to cheaper fuel as people in any other part of the Six Counties, to produce and have energy that can be used to help bring economic benefit to our areas.

There are energy savings to be made. The economic progress of our area depends on access to cheaper fuel in the future. There are also environmental benefits for the future to be considered.

Reducing peripherality is another aspect of our constant fight. We who live west of the Bann have a battle on our hands every week, year in and year out, to defend our areas against job losses and against the continued pressure for jobs to be moved to Belfast and other built-up areas. Quite a lot of this seems to have to do with mindsets.

Mr McCartney spoke of people wallowing in the past. In the last nine years there has been inward investment of only some several million pounds to Fermanagh/South Tyrone out of a total inward investment amount of £379 million.

Recently £87 million was allocated for road structures, restructuring and infrastructure, and Fermanagh got absolutely nothing. I am not speaking of the past. That was our future just a few years ago, and that is now the present. I am stating facts, just as other people state facts about those areas. We are not talking about the past or about hundreds of years ago. We are talking about the present, and we want it to change.

It is important that there is change because that concerns equality, and we want equality on the economic side. There is also the business of political clout. Most Members of the Assembly come from east of the Bann. We shall therefore have an uphill battle on all these fronts. The mindset of the Government and their officials has been to keep inward investment from places like Fermanagh. The facts are staring us in the face; you have only to look. This is not something that we are making up.

Domestic consumers should have a choice of cheaper fuel if it is available. We have to pay the highest price for virtually everything in places like Fermanagh/South Tyrone, where there is a monopoly at work.

There are positive aspects too to increased employment. We hope that we can get new and small industries into our areas and support them. We hope that we can have cheaper fuel to help to attract them.

There is a cross-border dimension as well. There is a whole region on the far side of Fermanagh -Donegal, Leitrim and other areas could be considered when the viability of a gas pipeline is under discussion.

At the margin there is the recent agriculture crisis and we will have the fallout from that over the next 10 years. The future needs of that industry will have to be considered, given that young people will not continue to work in it. There is a need for farm employment to help with future needs, and cheaper fuel could well be the kick-start that is needed for agriculture.

We have to look at the document which could shape our future. Its aims and objectives have been rural regeneration, economic development and a living and working countryside. That is what we want to move towards and we look at the facts and figures and at the aims and objectives of some of these reports, and we wonder how genuine they are. We need to see all of this happening in our areas. We need to know that we are going to be treated differently in the future.

Equality is a political matter, but we also need equality between east and west. Outside Dublin there is the same type of situation: the deprivation in rural areas.

Everything is pushed towards the built-up areas because of the greater population and political clout. I should like to see change, and thus welcome the opportunity to support the aims of the motion, which will benefit rural areas. The issue needs to be re-examined by the Minister, in particular in relation to rural needs and equality.

Mr Birnie:

I welcome the motion. The extension of gas pipelines beyond the Greater Belfast area depends to a large degree on an increase in the capacity of the trans-Irish Sea pipeline from Scotland to Belfast. In the absence of such doubling up, it is doubtful that either a north-west routing of an additional pipeline or a supplementary pipeline through the Lagan Valley will be achieved.

Maximum interconnection between Northern Ireland and the national and European gas networks is of great value.

First, there is security of energy supply because being part of a larger network results in cost economies and lower prices.

Secondly, through the existing interconnection of gas systems and their possible extension, there is greater competition between energy types, thus putting pressure on electricity prices. I see no conflict between proposals for additional gas pipelines and the development of the electricity interconnector. Both will result in greater competition and liberalisation of energy markets.

Thirdly, there is competitive advantage to energy users, especially industry. Electricity prices here are one quarter higher than in Great Britain, though for most manufacturers energy costs amount to only 3% or 4% of company turnover, so the cost benefit which might be achieved through cheaper energy sources should be not exaggerated. However, there will be some benefit.

Fourthly, there is the environmental issue - natural gas is relatively clean energy. Carbon emissions, particularly of carbon dioxide, are lower than those from coal or oil. That is important because Northern Ireland, as part of the United Kingdom, must meet CO₂ reduction limits by 2010.

Mr Doherty recommended a cost-benefit analysis of pipelines, taking wider social benefits into account. Such benefits would be above the bottom lines of companies such as PowerGen, which might be involved in these projects. I agree with him.

However, Members must first consider the cost benefit of doubling up the Scotland-Belfast gas link, and look at the proposed north-west routing of a pipeline - the main subject of the debate - and at the possibility of a pipeline through the Lagan Valley. After all, that region has a population of the same magnitude as the north-west corridor. Both of those potential pipelines will require an element of public subsidy.

This debate has displayed how Northern Ireland, despite being a small region normally regarded as being economically depressed, has in it significant disparities of income and employment.

12.15 pm

The explanations are complex, but, basically, this situation exists because new economic activity tends to be concentrated in areas where there is already substantial economic activity. This is unfortunate for those areas which are left "in the cold", but it is not, necessarily, a sinister development. Contrary to the arguments made by Sinn Fein Members this morning, academic studies of the subject provide little evidence to show that these disparities of income or employment were deliberately created by the Government, either in the pre-1972 Stormont era, or in the period of direct rule which followed.

There are, of course, various ways in which the Government could try to redress these disparities. However, I would caution Members against believing that large-scale, and potentially very expensive, public intervention in the energy industry would necessarily represent the most cost-effective way of achieving greater economic parity across all regions.

It is desirable that every home in Northern Ireland have access to natural gas, but we should not regard this as a fundamental human right. Adam Smith, the eighteenth-century Scottish economist, wrote, somewhat tongue-in-cheek - to borrow an earlier phrase - that it would be desirable to grow wine in the Scottish Highlands.

He went on to say, however, that it would be too costly to build the necessary greenhouses on the slopes of Ben Nevis. In the same way we need to be careful, subject to the full cost-benefit analysis, that we do not commit ourselves to astronomically expensive projects when there are other, less costly, ways of providing economic support to disadvantaged areas of the Province.

As regards the pipeline, given that public finances will, almost certainly, be limited, the Assembly may find itself faced with the difficult choice of whether to extend the pipeline along the north-west corridor, or along the Lagan Valley. Until such times as this kind of decision has to be made, I am happy to support the motion.

Mr Farren:

I welcome the opportunity to participate in this debate. The obvious consensus that has emerged is very significant. In itself, this underlines the urgent need for agreement on the outstanding political issues so that we can concentrate on the kind of issues we are discussing today and make the kind of decisions which are commensurate with our responsibility to ensure the good management of public finances and the provision of the best possible infrastructure for the energy supply industry and for all other related industries. I note and support many of the points that were made by the last Member who spoke.

With regard to the matter of energy supply in Northern Ireland, many commentators have pointed out that the market is too small to allow for significant economies of scale.

There is a need, therefore, to look at wider contexts in which to make such economies of scale possible and to take advantage of the different energy sources available. Such contexts include Scotland, the South and, indeed, the European mainland.

Given the current expectations associated with new North/South opportunities, many people anticipate enhanced co-operation in the area of energy supply. With such large investments required - a point which has been stressed in several Members' contributions - there is a clear imperative to take advantage of the obvious mutual benefit that could be derived from meeting the needs of a market from both parts of the island by co-ordinating the planning of an energy strategy.

A critical objective for Northern Ireland must be the achievement of the lowest possible electricity supply costs. The continuing high cost of electricity is a deterrent to investment and places Northern Ireland at a considerable disadvantage in comparison with the South. In the South, low energy costs, combined with other incentives, add to its advantages when investment decisions are being made.

Central to the consideration of future energy strategy should be the question of gas supply in both parts of the island. Indeed, now that we are moving towards the adoption of a strategy that will lay the basis for energy supply far into the next century - and this is being clearly anticipated by the economic strategy review underway in the Department of Economic Development - we must ensure that the most effective gas network, in terms of both security and value for money, is developed for the whole island.

It is therefore critical that planning for a gas supply be undertaken in the context of the needs of Ireland as a whole, but with respect to the northern half of the island in particular. In my view, a line drawn from Dublin to Galway and northwards would be the immediate context for the development of an appropriate gas-network strategy.

We know that in the South planning is well advanced for the next phase of the gas network. And with additional connections being planned into Scotland's gas network, it is critical that a northern link be included to create an all-island network.

Recent discoveries of viable gas fields in the Corrib exploration area off the west coast of Ireland underline even more pertinently the need for such a provision. Extending a network beyond Belfast to service the north-west, as well as customers along the Belfast to Newry axis, should form part of such a strategy.

We must begin comprehensive negotiations with the appropriate authorities in the South because, in the absence of negotiations, plans could be advanced for additional links to Scotland without any consideration being given to the development of a North-South link.

As part of an overall development, I, like many of my SDLP colleagues and other Assembly Members today, urge that an early decision be taken to build a new gas-generating plant at Coolkeeragh. A new gas-fired generating station there, which would be a significant customer for a north-west gas link, would not only ensure the continuation of generation there and the retention of the expertise involved, but also provide a new and important addition to the area's industrial and commercial infrastructure.

The availability of a natural gas supply along the north-west corridor would make the whole area north-west of Belfast more attractive - towns such as Ballymena, Ballymoney, Coleraine and Limavady where the commercial and industrial sectors are already expressing considerable interest in the availability of gas.

In keeping with the general plans for regional development over the next two or three decades - plans revealed last week place emphasis on growth areas outside the eastern corridor - the needs of the north-west must receive special attention. If this focus is to be meaningful, the provision of energy supplies - particularly via a gas pipeline - deserves special consideration.

Many Members have referred to the economics of developing the gas supply, and we will face hard decisions when we address that issue.

The emergence of public and private partnerships is a notable feature of recent economic planning, particularly with respect to infrastructural initiatives. We have already had some examples of that approach here; the Scottish interconnector could not have been planned without guarantees of public financing.

In terms of the overall need for infrastructural development, as well as of economics, there is an imperative that the motion recognizes. We should call for the papers; we should have an early opportunity to examine the evidence in detail, after which we will probably recommend that this development proceed so that secure, efficient and cheaper forms of energy can be provided in the north-west and south-east.

Mr Neeson:

I welcome this debate. I remember the last time the natural gas issue was debated in an Assembly. I and my party were booed and heckled because we supported the extension of the Kinsale pipeline to Northern Ireland.

Let us have some reality here. Unless we move forward with the formation of the Executive, the Departments and the North-South bodies, this morning's exercise will have been a waste of hot air.

I believe that in this Chamber there is a desire to move forward so that the Assembly can take the decisions that -

Mr R Hutchinson:

This has nothing to do with the debate. If the Member has something constructive to say about the pipeline, let him say it. Let us not bring politics into this issue.

Mr Neeson:

What I am saying has everything to do with the debate. If the Assembly wants to move forward and take decisions on Belfast Harbour or on the natural gas pipeline, then it has to have real powers. Such decisions cannot be taken unless the power to do so is transferred. We must move forward with urgency and develop the Assembly's structures.

I support the resolution. It will bring major benefits to the north-west, however, I greatly resent the Government's decision to go ahead with the interconnector to Scotland while this issue remained unresolved. On Tuesday 17 November I requested a meeting with Mr Ingram on this subject and on 18 November he made his decision on the interconnector. I find that decision despicable.

12.30 pm

A meeting is to be held with the Minister on 6 January. I have written to the other parties, and I hope that, on that occasion, all the parties in the Assembly can unite to try to persuade the Minister to look with some urgency at the development of the north-west pipeline.

This is a bread-and-butter issue, similar to the integrated schools issue. We went to that meeting together - almost united - and the Government responded very positively. Regrettably Ulidia School, which is in my constituency, did not benefit, but we live to fight another day. If we are to move forward, let us get real about powers for this Assembly.

Mr A Doherty:

I thank everyone who participated in this debate, and I am grateful for such widespread support, albeit one or two Members widened the debate considerably to deal with lignite and Belfast Port, both important in their own right, but a little outside the scope of today's debate.

Mr R Hutchinson:

Will the Member give way?

Mr A Doherty:

This is my maiden speech, and there is a tradition that one does not give way in a maiden speech. However, I will be unmaidenly tomorrow and will accept any advances that are made to me.

If anyone is still lukewarm about this issue, may I point out that it is of importance not just to some areas. It is vital to everyone in Northern Ireland, for a country divided against itself cannot prosper.

My initial contribution to the debate, of necessity, painted a fairly bleak picture of the present situation, and a bleak picture of the consequences of further Government inaction.

Perhaps the best way to respond to the many vital points raised today is to concentrate on the positive benefits that would come from the extension of gas provision, and to call for positive Government action in terms of carrying out a comprehensive socio-economic analysis, as well as positive action to ensure that funding is available for a project that will bring great benefit in many fields - the economy, the environment, energy policy and social need.

It is an excellent European Union structural fund project that will facilitate diversification of the local economies and improve industrial competitiveness. It would be a flagship project for this region, and would be in line with many Government and EC objectives. There is already a real and committed private sector interest in this project. Environmental benefits are many. The north and west would be able to contribute their share to the reduction of global warming and the promotion of a clean environment by a significant reduction of emissions of carbon dioxide, sulphur dioxide, black smoke and nitrogen oxide.

The net present value of the reduction in environmental damage costs would be about £20 million over 25 years. In terms of energy policy, the extension of the gas pipeline would fit well with the Government's stated objectives in this area, and would reduce costs to consumers by almost £10 million per annum over 10 years.

Finally, there are no more compelling arguments in favour of the extension of natural gas than those relating to social need. I congratulate the Assembly for its appreciation of this matter and for its support. I beg leave to withdraw the motion.

Motion, by leave, withdrawn.

The sitting was suspended at 12.35 pm.

On resuming -

Hospital Service

TOP

2.01 pm

The Initial Presiding Officer:

We will now move to item 4 on the Order Paper. Members will have received the Government paper entitled 'Putting it Right', a report on Northern Ireland's hospital service. The Minister responsible for health and social services, Mr John McFall, has agreed to present to the Assembly the material outlined in it.

Proceedings will take the form of a take-note debate. The motion in my name does not imply approval or disapproval of the paper, but simply notes it. The Minister will speak to the paper, and a debate will follow under our Initial Standing Orders. At the end of the debate, the Minister may choose to respond.

Motion made:

That this Assembly takes note of the report 'Putting it Right - The Case for Change in Northern Ireland's Hospital Service', as presented by Mr John McFall MP, Minister for Health and Social Services. - [The Initial Presiding Officer]

The Parliamentary Under-Secretary of State (Mr McFall): It is a privilege for me to be here at your invitation to address the paper 'Putting it Right'.

Closing his Richard Dimbleby lecture a fortnight ago, Senator Mitchell talked of his hope one day of coming to a Northern Ireland at peace. He said

"and, on a rainy afternoon, to visit Stormont to watch and listen to Members debating ordinary issues of life in a democratic society - issues such as education and health care."

I am delighted to be here to discuss such a crucial issue, the future development of the Hospital Service in Northern Ireland. Shaping the future of Northern Ireland's Hospital Service is, I believe, one of the early political challenges facing the new Assembly, and I hope to explain why.

I know from my own experience in Scotland just how difficult it is to address the complex issues associated with the Hospital Service. It is not easy to achieve change. Yet change is vital if this great service is to weather the pressures that it now faces and to emerge as a first-class service that all of our people need and rightly demand.

The challenge facing the Assembly is to see beyond the pressures on individual hospitals and local services, and to grasp the strategic picture. It is for the Assembly to develop a coherent and stable Hospital Service for the Northern Ireland of the twenty-first century. To do so, Members must pioneer new and collaborative approaches to hospital provision - in essence, putting patients before facilities.

I well understand the fears of local communities when services are to be apparently "cut" or "downgraded". But I also well understand the need to develop the hospital service strategically if it is to deliver the standard of service that people will have the right to expect in the twenty-first century.

It was specifically to help the Assembly with this task that I produced 'Putting it Right'. It is an important document setting out the most radical approach to Northern Ireland's hospital provision in 40 years - yes, 40 years.

Too often our debate about hospitals centres on bricks and mortar rather than on delivering the best possible care for patients, and patients have a right to receive the right care in the right place at the right time and from the right person - that is what matters.

It is a sad fact that the quality of some of our services is simply not as good in Northern Ireland as it is in other parts of the United Kingdom, and we must address this urgently. We have to do better and ensure that our services are second to none. This means change - we cannot cling to the past.

Let me say clearly and unambiguously that this strategy is not about cutting expenditure; nor is it about closing hospitals. None will close, but all will change - and change for the better.

The Government have already signalled the importance that we attach to building a modern and effective Health Service. Northern Ireland's Health Service has already received an additional £60 million since the Government came into office and will continue to get its fair share of future investment.

Earlier today I gave details of the massive boost for health and social services in Northern Ireland arising from the comprehensive spending review (CSR). As part of our commitment to modernising the service, we have already spent substantial additional funds this year - about £53 million. Over the next three years, an additional £732 million will be available to spend on health and social care.

Detailed decisions on how the extra funds are to be spent will ultimately be for the Assembly, but for the 1999-2000 financial year it is planned that the following programmes will benefit.

Community care will receive an additional £25 million; mental health and learning disability services will receive an additional £5 million on top of the £25 million for community care; childcare services will receive an additional £7·5 million to take forward the implementation of the Children Order and to make improvements in children's homes; cancer services will receive an extra £7 million and renal services an additional £1·5 million to support the continued expansion of the service; the building and maintenance programme will also receive an extra £6 million for the capital programme and last, but by no means least, acute services will be provided with an additional £7·5 million to reduce further the number of in-patients waiting for treatment and to contribute to the meeting of other pressures.

What needs to change in the Hospital Service? Northern Ireland's Hospital Service is facing a crisis. What we have lacked is a clear vision of the way forward and a plan to address urgently a number of critical problems facing the service. Without prompt action there is a growing risk of service breakdown.

All patients should receive the same high-quality care regardless of where they live. That does not always happen at present, and some patients are being admitted to hospitals that are not adequately equipped to provide the support they need.

I have looked at the current services and have found a number of causes for concern. For example, because they work in small hospitals, some doctors are on call for 104 hours week after week. How can these doctors be expected to provide a quality service on that basis?

Some surgeons, without the best training, are performing major operations. How can this guarantee quality service? Services at busy major hospitals are being held back by lack of resources, while smaller units are tying up expert staff to undertake a handful of procedures each day. Does this make sense?

Small hospitals, struggling to meet rising standards, are heavily reliant on a diminishing pool of general surgeons. How can this benefit patients?

Small maternity units do not deliver enough babies to justify employing expert children's doctors to deal with emergencies. How does this secure the safety of mother and baby?

More than half of Northern Ireland's accident and emergency departments lack the expert staff and support necessary to treat serious injuries or illnesses. This can cost lives. The fact that the service has coped until now is a mark of the skill and dedication of staff at every level. But we cannot base future service provision on the continued selflessness of staff.

What needs to be done? I said earlier that patients have the right to receive the right treatment in the right place at the right time, delivered by the right person. To achieve this, hospitals have to be organised to make full use of the considerable skills and talents of professional health staff. Our goal must be to ensure that all patients, no matter where they live, receive an equally high level of quality health care.

In searching for the best answer, I looked at a number of possible ways forward.

First, keeping hospital services as they are. This approach would not guarantee a sustainable Hospital Service of modern standards. Hospitals which serve small populations do not treat enough patients or illnesses to allow their medical staff to acquire or maintain skills. Difficulties in training and recruiting staff mean that the current service cannot be maintained.

Secondly, expanding the services available at all existing hospitals. The problems facing the Hospital Service are not primarily about money. They are more about how hospitals are structured to pool expertise. Spreading scarce resources more thinly would result in equipment being underused in many hospitals and highly trained and motivated staff struggling to maintain their skills. In other words, spending more to buy less.

Thirdly, concentrating services. The British Medical Association and the medical Royal Colleges suggest that a population the size of Northern Ireland should have only three major hospitals. This could improve the quality of care for people with major illnesses but would raise serious issues about access to services for people living in rural areas.

None of the approaches I have outlined guarantees a first-class, accessible Hospital Service.

What we need is a new approach, with all of our hospitals working together in clinical networks to improve patient care. This will allow the hospitals to be mutually supportive and make the best use of staff and other resources.

Future services will be provided in local hospitals and will be strongly linked to area hospitals and directly supported by them. Major illnesses will be treated at area or regional hospitals where patients can be guaranteed expert care and treatment for the most serious conditions.

This will allow the relocation of some existing services, with the presumption that care will be provided close to patients' homes where this is in their interest.

Local hospitals will be Northern Ireland's hospitals of first resort. They will be strongly linked to area hospitals and develop an increasing number of services with them. More and more frequently, patients will go there for investigations, for outpatient clinics and for day treatments, including day surgery.

These hospitals will provide an important base for consultants, many of whom will divide their time between area and local services. They will have specialist diagnostic equipment and the staff necessary to provide a full range of outpatient clinics and day surgery. These operations will be provided locally unless there are good clinical reasons to do otherwise.

To deal with problems of access in the more remote parts of Northern Ireland, three local hospitals will provide a more general acute service to their local population. They will be an integral part of the area network and will be located at Coleraine, Daisy Hill in Newry and in the southern part of the Western Board area.

Patients with the most serious illnesses will be sent to their area hospital. This will provide a wide range of specialties. Area hospitals will be equipped to deliver high-quality specialist in-patient care and to offer a round-the-clock emergency operating service.

The regional Hospital Service will provide patients with access to highly skilled care and treatment, supported by the latest technology such as coronary bypass surgery and kidney transplantation. They will continue to provide patients in Northern Ireland with skilled care and treatment supported by the latest technology. They will be centres of excellence in their own specialties, and they will share knowledge and experience with other hospitals in Northern Ireland's clinical network.

2.15 pm

I appreciate the concern about the future of accident and emergency services. There are 16 departments in Northern Ireland, the majority of which do not meet current standards. We need to develop a strong local service to deal with the majority of minor or straightforward treatments, and some state-of-the-art units to cover the major injuries and life-threatening traumas.

Most patients will be treated in new local accident units in each local hospital. These will be led by nurse practitioners, supported by specialist staff and by services that are based at the nearest area hospital. The specialist accident and emergency departments will be in area hospitals which will be staffed and supported to provide the very best of accident and emergency care and treatment. They will directly admit serious accident cases and people with major illnesses, and will be able to initiate immediate treatment.

In recognition of the problems of people living in rural isolation, the three local hospitals that provide a more general acute service will also provide a range of accident and emergency services which will be networked with the closest area accident and emergency department.

To make this approach work, we must have a first-rate ambulance service, supported by a highly trained ambulance staff. Ambulances must be able to pick up emergency cases quickly, provide instant treatment to stabilise seriously ill patients, have computer links to expert support, and be able to bring a patient from anywhere in Northern Ireland to the right hospital, quickly and safely. This service must be an integral part of any new arrangements.

To make the vision a reality, we need early action to build up the service and enhance the training of ambulance staff. A commitment is also needed to develop a future specialist transport service to transfer seriously ill or injured patients safely between hospitals. That will mean new investment in these vital services.

Our hospital service is too important to be allowed to drift towards crisis. That is why I am opening up the debate on the way forward, and I am offering to make myself available to discuss these matters. There is an urgent need for a new strategic approach to hospital services. Inevitably, the future of hospital services will be one of the first major issues falling to the Assembly. The paper has been prepared to assist the Assembly with that difficult task, and to ensure that the strategic issues underlying any decision are understood and appreciated.

While it will be for the Assembly to decide what must be done, the proposals offer a practical and realistic way forward. They will ensure that patients get the same high-quality care no matter where they live, and that they will be treated by doctors who are not working impossibly long hours, thereby guaranteeing better quality care.

Patients needing major operations can be confident that they will be undertaken by fully trained specialist surgeons working in expert teams with full clinical and technical support, and they can be assured that hospital resources are fully focused on delivering the best patient care rather than propping up declining services.

Mothers-to-be can be confident that the maternity unit they attend has expert staff and that they will be able to choose the type of delivery that they want in a safe environment. Seriously ill patients who attend accident and emergency departments will get the highest possible quality of expert care and treatment.

Local accident units will quickly and effectively treat patients with less serious conditions. Patients needing emergency treatment will receive high-quality care from a rapid response ambulance service, with expert ambulance staff in direct communication with specialist teams in an accident and emergency hospital department.

While the Assembly must take the major decisions on the future of hospital services, there is an urgent need to develop the ambulance service. A modern and highly proficient ambulance service is the key to unlocking the way forward. With that in mind, I recently commissioned a major review of the service which will point the way forward and make the best use of existing resources. More needs to be done. To help build the service that we need, I am prepared to commit £15 million over the next three years.

The overall challenge for the Assembly will be to agree a strategy that will address current pressures and enable our hospitals to deliver the first-class service which patients have the right to expect well into the next century.

In the meantime I will take whatever decisions are necessary to preserve the safety and effectiveness of our hospitals. I would like to think the Assembly will be able to relieve me of the task of setting its future direction. I am convinced that change is needed, and needed soon, if we are to deliver a modern and effective first-class hospital service which can meet the present and future needs of the people of Northern Ireland.

Forty years ago, at the time of the last major hospital review in Northern Ireland, the idea of man setting foot on the moon was sheer fantasy, but since then the world has unimaginably moved on. However, our hospitals have barely changed during that time.

It is time to plan for the next 40 years so that those who serve the Health Service can work together as part of an extended team, and can be proud of their professionalism. They must be practising in an organisation that can exploit their skills, thereby serving the interests of patients throughout Northern Ireland. We need a service which does not cling to the past but looks to the future with confidence and "puts it right" for the twenty-first century.

Mr Foster:

I wish to welcome the Minister to the Assembly. He has kept his promise to meet us. We also welcome the announcement about extra finance.

This is a challenging time for health and personal social services in Northern Ireland, and we are aware of the big issues confronting us. Like the Minister, I am impressed by the skills, commitment and professionalism of the many capable people in the Health Service.

The paper 'Putting it Right' projects the future direction for hospital services in Northern Ireland. It points the way and we make the decisions. The Minister used a double-edged sword when he said "I have not interfered with your democratic right, neither will I allow myself to be your scapegoat."

Perhaps the paper should be called 'Getting it Right', but how do we go about that? The Minister's presentation was concise, and I commend him on his honesty and frankness. He spoke about what needs to be done and said that hospital services were facing a critical time. He said there was a grave risk that services would break down, and mentioned the need to ensure reasonable access to acute services for people in the more remote parts of Northern Ireland. He said that a small number of local hospitals would provide a more general acute service for local populations.

People in rural areas fear for the future of their local hospitals. They feel under threat, and will fight tooth and nail to ensure that there is a hospital in their area. The threat to local hospitals makes people frightened and angry, and they also feel exposed and at risk.

In recent months I spoke to some health-care professionals, and I am aware of their concerns and of the requirements of the Royal Colleges. They are at the coalface, and the community needs the good quality service that they provide.

As I have said, people in rural areas are fearful. My constituency in Fermanagh equates to other rural areas, including south Tyrone and Dungannon. South-west Fermanagh is neglected in many aspects of public provision.

In the golden six scenario, Fermanagh and also west of the Bann are not catered for. Altnagelvin Hospital is in the Western Board area, but it is accessible to people in the south-western part of the board's area only at the cost of travelling many miles. The Sperrin and Lakeland Trust covers a largely rural area in the local government area of Fermanagh, Omagh and the southern part of Strabane. The estimated population in 1995 was 114,000. The low population density creates some special problems in relation to the provision of accessible services. Another difficulty is that Lough Erne divides the County of Fermanagh.

I refer to the 1994 "Social Deprivation" document of the Western Health and Social Services Board. The board looked at the work showing the strong relationship between health and deprivation, which replicated the work of Townsend. Four key measures of material deprivation were identified: unemployment, car ownership, home ownership and overcrowding. On that index, the three district council areas of Fermanagh, Omagh and Strabane are ranked 15th, 19th and 26th out of the 26 district council areas.

Accessibility to services is a major factor that determines how needs can best be met. If people do not find the service accessible, it is a poor quality service. The road network from Enniskillen to Altnagelvin has slow journey times, and that unique situation needs to be taken into account. Concerns about the poor roads infrastructure and the importance of periods such as the golden hour are vital.

Four options for the future hospital provision in Omagh and Enniskillen were referred to in the review. These were: closure of both hospitals; no change; closure of both hospitals and a new building; one service on two sites. The last is the recommendation currently before the Western Health Board.

The Minister referred to the Accident and Emergency Service. Here is one of the most emotive topics when considering the pattern of acute services. This is a core service, and intense pressures would be created if one of the departments were to be wiped out. There is a sizeable demand from tourists at the Erne Hospital, amounting to over 25% of the summer workload.

The advantages of having two sites and one service are that they will maintain local access; they will improve the potential for some specialisation between and within the two hospitals; they will improve the management of clinical volume and workload across the two hospitals, and there will be the potential for economies of scale; and, as the Minister has said, they will be mutually supportive.

In 1996-97 the Erne Hospital admitted almost 11,000 patients, with an average of 168 beds occupied per day; accident and emergency attendances totalled nearly 17,000, and over 34,000 outpatient attendances were also recorded. A hospital of this type is vital to the needs of the dispersed local community.

Vital economic issues also need to be considered. In 1996-97 Health and Social Services generated approximately £57 million in revenue for the Fermanagh economy; the Sperrin and Lakeland Trust employs 1,764 people in county Fermanagh; wages and salaries total £26·5 million, representing 73% of all the income for that sector; and employees of the health and social services contribute £36 million to Fermanagh's purchasing power. Such a contribution is important for any rural area, and if it were to be taken away and not replaced, there would be great deprivation.

In summary, the Minister's document is very general. On what basis are assumptions made to back up the proposed model? The joint council-Sperrin Lakeland Trust approach - a single hospital on two sites - appears to have been discounted - without any serious consideration having been given to it. The Western Health and Social Services Board's review has been rendered useless.

The proposals are another example of applying an urban solution to a rural problem. No account has been taken of the physical infrastructure, as is evident from 'Putting It Right'. The 'Shaping Our Future' strategy also lacks any reference to health issues.

Enniskillen and Omagh are two of only seven urban hubs identified in the 'Shaping Our Future' strategy. Emphasis should be placed on this proposal to ensure that provision is made to take account of this growth of 3,200 households.

The impact on the local economy must be considered fully in any analysis.

Tourism adds to the population that has to be served in that part of the Province.

The cross-border issue must also be considered, though this can and will work both ways.

The continuous erosion of services in rural areas may be exacerbated by this model, in which the local hospital becomes a "super health centre", causing rural GPs to relocate to larger towns in order to provide their service.

An upgraded and vital Ambulance Service needs an appropriate and good road network. Indeed, the Northern Ireland Forum for Political Dialogue presented a very good report on the Ambulance Service. We said that it has been the Cinderella service, but we hoped that that would change.

We need new and innovative thinking on the delivery of services by administrators and especially the medical profession.

Overall, the document appears to have been rushed. There is nothing about consultation or grounded evidence, and it makes many assumptions. Indeed, many specialisations "above and around the head" are not even considered - for example, ear, nose and throat treatment. I am convinced that we need to give services to the patients; not take them away. There is an ethical and moral issue to consider.

2.30 pm

Dr Hendron:

I welcome the Minister, and I would like to thank him for the briefing he gave to the party spokespersons on health, prior to the launch of 'Putting It Right' on 30 November. The document sets out the difficulties facing the Hospital Service - particularly in the smaller hospitals - spells out the realities and emphasises the urgency of the situation.

This document is neither a Green Paper for discussion, nor a White Paper for legislation; the Minister is - quite rightly - leaving all the important decisions for his successor in the Assembly.

In the analysis, however, the Minister spells out the stark realities. In some areas patients are being admitted to hospitals that are not adequately equipped to provide the full range of tests and support they need. I agree with the Minister that continuing inaction could cost lives.

The situation is very serious, and professionals working at the delivery end of the Health Service have warned that an imminent crisis is facing some of the smaller hospitals. Every Member knows in his or her heart that urgent decisions have to be made. That is why I make no apology for stating a powerful political point. Only when the shadow Executive is formed and power is transferred to the Assembly and Executive will Members be able to face up to their responsibilities in respect of health issues.

There are many good and valid reasons for setting up the shadow Executive now. Indeed, it could have been set up last July. But, even at this late stage, Members must not shirk their duties. Health must be at the top of the Assembly's agenda, and I call on the First Minister (Designate) and Deputy First Minister (Designate) to set up the shadow Executive forthwith.

With great advances in medical technology, the 17 acute hospitals in Northern Ireland cannot be expected to have a full range of specialist surgical, medical, paediatric and other services. The Royal Colleges are concerned about staff being adequately trained, and the Royal College of Surgeons has laid down specific criteria for an efficient, high-quality, surgical service. These include an accident and emergency department led by an accident and emergency specialist, round-the-clock availability of high technology equipment with CT scanners, emergency operating theatres and intensive care facilities. Only the Royal Victoria Hospital, the Ulster Hospital and Altnagelvin Hospital comply with those requirements.

An accident and emergency department which does not have a consultant in accident and emergency medicine and which is without access to the full range of support services is not equipped to treat the most seriously ill patients.

It is essential that trainee doctors learn about the conditions and illnesses they will be dealing with. Hands-on experience is both necessary and mandatory, but, unfortunately, some smaller hospitals are not always able to provide the work experience necessary for trainees to develop that expertise and secure training recognition.

Quality of treatment and equality of success in respect of that treatment are essential for all the people. A proper balance must be struck between providing local services and treating complex and life-threatening conditions in major hospitals.

We are told that the focus of health care will remain in the community and that GPs and primary-care teams will be expected to develop and expand the range of services they provide. There is to be more scope for GPs to look after their own patients in local hospitals, providing patients with continuity of care. Nine out of ten patients are already treated in the community.

The Minister emphasises the development of nurse practitioners who can take lead roles in such areas as minor injuries and neonatal care. His vision sets out a new approach in which hospitals and primary-care teams work together. Most people have their needs met in the community or in the local hospital with relatively few requiring area or regional services.

A modernised Ambulance Service with skilled staff, who are to be known as first responders, will use motorbikes - that is certainly an interesting idea - cars, or whatever is necessary to achieve an effective response. The local hospital is to be the cornerstone of the future Hospital Service - although I accept that every hospital cannot offer a full accident and emergency service, and the idea of a local accident unit does make sense.

The Minister's Paper is hard to fault so far as principles are concerned, and, in most respects, it follows successful regional strategies, although it does contain some new points.

Major changes are proposed, but at what point should they be tested by way of public consultation? Will they be subject to policy appraisal and fair treatment analysis? Departments are required to take fair treatment aspects fully into account when developing new policies or reviewing existing ones. Was this done? If so, what was the outcome?

New features include great emphasis on additional services to be provided by GPs, some vague aspirations about networking, a significant dependence on nurse practitioners, the promotion of the three hospitals - Daisy Hill, Coleraine and either Tyrone County or Erne - and the demotion of Lagan Valley and the Mater to local-hospital status.

Has the Minister considered the workload that would arise from extending the services of the primary care team? GPs, nurses and social workers already have heavy loads. Should pseudo-hospital functions be added to already busy lives? The notion of networking is scarcely freshly minted, but what will it mean in reality? What new structures would allow practical additions to existing relationships between professionals? How many nurse practitioners are in the service, and how many will be needed to do what is proposed? Are training arrangements in hand, and how many people are in training?

Most people will welcome the formal recognition of the three hospitals in addition to the golden six. Community services will escalate. It is not a solution to problems in the hospital service to dump them on other hardworking people who are under-resourced.

The major impediment to the Minister's vision is undoubtedly the potential capital cost. For example, in winter, medical emergencies in Belfast can be a nightmare. Beds are like gold dust, and patients queue in accident and emergency departments if not in the corridors of the Royal and the City Hospital.

There is simply no prospect of the two big hospitals functioning in winter if they have to add the in-patients of Lagan Valley and the Mater to their existing load - unless of course there is significant additional capital expenditure.

The proposal to demote the Mater Hospital does not make sense when it seems that the Government have already decided to invest £7 million in a new ward unit. Has this decision been rescinded?

SDLP colleagues and I have had discussions with Dominic Pinto from the Omagh Hospital, Keith Marshall of the Erne, Basil McNamee from Dungannon and Patrick Piper of the Mid-Ulster Hospital. From our discussions it is clear that a major area hospital is essential in the south-west, the territory which stretches from Magherafelt to the distant ends of Fermanagh. The precise location of that hospital will be discussed in the future.

The great killers in Ireland, North and South, are cancer and heart disease. Cancer services for Northern Ireland are to be concentrated in the City Hospital. Senior cancer surgeon Mr Roy Spence and Professor of Oncology Patrick Johnston have joined forces with colleagues in Dublin on the research and development of cancer services for the island as a whole.

Major, expensive technologies have been developed. PET, or positron emission tomography, is a new procedure which allows a physician to examine images of the heart, veins and other organs. Unlike x-rays and CT and MRI scans, which show body structure or anatomy, PET images show the chemical functioning of an organ or tissue. PET technology can have a huge impact on the diagnosis of cancer, brain tumours, heart disease and other disorders.

I strongly support the acquisition of this important technology for use on both sides of the border. It would be too expensive for any one area to purchase, but its use would save many lives. The United States and some European countries have been using PET for some years.

It is for the Assembly to ensure that everyone in Northern Ireland has equal access to a first-class health service. Important decisions must be made sooner rather than later.

Mr Gibson:

I congratulate the Minister on his presentation and on being the first Minister in 40 years to examine regional hospital provision. Forty years ago in an attempt to cure health problems, a series of hospitals were created, but many have closed. I am rather wary about the Government putting matters right, because it seems that the hastily prepared solution omits rather large rafts of provision that are necessary to make an acute service work.

Rather than a long-winded speech, I pose some questions for the Minister. First, does the Minister think that the golden six hospitals are in the right positions?

Is there not a case for a seventh golden hospital? The Minister has heard of the endeavours mentioned by my colleague Mr Foster from Enniskillen, and of the consultations about Omagh. Hospital provision in Fermanagh and Tyrone should be looked at. Tyrone is the larger rural county, with its centre of population in Omagh. Castlederg and Strabane hospitals have been closed, and to ensure equality of provision and availability in Dungannon, Cookstown, Kesh, Enniskillen, the Clogher Valley and Lisnaskea, there should be a golden hospital in the south-west of the Province. There is a reasonable case for the creation of a seventh or for the relocation of the sixth golden hospital.

In considering 'Putting It Right', we should bear in mind that the vast majority of the population does not require acute hospital treatment. Most people go to GPs and treatment rooms. To make acute provision work effectively, account should be taken of the raft of care that should be provided by primary care centres of excellence. Care provision in the south-west should be supported by such centres of excellence and, therefore, the Erne, Omagh and Dungannon hospitals should be retained and improved to guarantee employment and excellence of service.

Some areas of existing provision have given cause for concern in recent years. I think in particular of the hype surrounding community care. We were told how good it would be. Expectations were raised but the provisions were not adequate. Could there be a lessening of the hype and greater clinical objectivity? At times the Assembly is so elevated that even an archangel could not deliver its expectations. We need to be realistic in our deliberations.

Some people have had to travel from the west of the Province to London and to private hospitals in Scotland, as provision there is cheaper and more accessible. Patients and their partners fly out for surgery and a quality of treatment that is not available here, yet we are told that Northern Ireland provides the best service.

A simple hip replacement costs £8,000 in the Royal, £6,000 in Altnagelvin and less than £3,000 in Eglinton private clinic, while elsewhere it costs under £2,000. There is something wrong with the system, and Members welcome the fact that this document defies the boundaries of the boards.

Finally, I wish to make a special appeal for a 49-year-old who cannot speak and is severely mentally and physically handicapped. For 34 years this person has been in Muckamore Abbey and is now being threatened with removal from 24-hour excellent care to community care.

2.45 pm

My Christmas appeal to the Minister is to ask him to consider the case of Pauline, who is 49 years old, and her family, who are not able to care properly for her because they themselves are elderly. He has it in his power to give them a Christmas present which they would very much appreciate.

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