Mr Molloy:

A Chathaoirligh, I would like to welcome the Minister and the discussion document 'Putting It Right'. It is important that we have a document which sets out a vision for the future of health care. This is the first opportunity that we have had to debate this issue. In the past, we have been told about services which are to be taken away, but not given any details of what services are to remain.

I would like to pay tribute to the staff in all the hospitals in the North. These people - doctors, nurses, ancillary staff, cleaning staff - have provided an important service to all of us in very difficult circumstances. They are a credit to their professions and a credit to the community.

We all have to recognise the need for change, although, obviously, no one wants these changes to take place in his or her area. We must move forward. Nonetheless, there are few areas of public policy which are more emotive than the provision of a health service. The document states that the changes are not simply cost-cutting or closures, and I hope that the Minister will be able to reassure us today that the purpose of these changes is to ensure the best possible service for all of the people, wherever they live and whatever service they require.

The area which I represent, Mid Ulster, has suffered a double blow. West of the Bann, over the years, we have been deprived of jobs, investment in infrastructure, and, now, we are to lose two acute hospitals - the Mid-Ulster and South Tyrone hospitals. The perception is that these two hospitals have been reduced to the status of local hospitals, and we need to reassure those communities that these hospitals will continue to provide a proper service. The South Tyrone hospital is situated in the best position to provide a service to Mid Ulster as well as south Tyrone and would be well situated to provide a maternity service for the area, whether in the form of a designated maternity unit or midwifery services.

I welcome the fact that the document sets out the services which will be available at the hospitals and does not simply state which services will be removed. However, I do not feel that the document promises sufficient resources to sustain these hospitals in the future. We need to be sure about the extent of provision for outpatients, day surgery and other services to the community. We should bring together everyone involved in the provision of health care in each area to ensure that the proper resources are available.

I see much common sense in the document and agree that some changes are necessary. I urge all Members to discuss these proposals together, to ensure that we have a proper health service.

We could all demand that our locality be left with all the facilities of an area hospital, but that would be unrealistic. The Assembly will soon have to make some hard choices. We will not be able to blame Ministers in future. It is therefore essential that we create the Executive that will bring about the structures for taking decisions here and implementing them.

Only the best is good enough for the people we represent, and we must aim to provide the best health-care service. I was alarmed to read that services in some hospitals are in danger of breaking down completely. That would be a disaster and demonstrates the urgent need for the Assembly to take decisions on health-care provision. We must provide a modern Health Service which is equipped with the most modern facilities, information and technical back-up in order to deliver care as close as possible to a patient's home.

People will decide with their feet. They will go to where the best services are provided, as they have done in the past. And I am convinced that they will do so in the future when they require specialist treatment.

One area requiring examination is that of preventative medicine. Many operations are carried out on a day-surgery basis, and I am thankful that that has removed much of the disruption and trauma for the patients and their families.

Health care is also about the environment, housing and jobs. Good health does not come from hospitals or doctors' surgeries. As the Ottawa Charter on health promotion states,

"Health is created where people live, love, work, learn and play."

The road to reconstruction requires an attack on want, disease, ignorance, squalor, idleness and prejudice.

In the past I have been critical of the way in which decisions have been made without consultation with the community. People have been very supportive of all their local hospitals, which they want to ensure are not run down or closed. There is considerable fear among people that they will be deprived of a local Health Service. They want a reassurance for the future. It is important that we involve all the community groups in the decision-making process, those who have fund-raised and supported action campaigns, because they can play a crucial role in managing future changes.

What is right for patients is what matters, and that will require change and sensible compromises between local provision and high quality standards of clinical care. Treatment should not cause unnecessary stress to patients or their families.

Finally, can the Minister report on what provision is being made across the North to ensure the highest standard of clinical performance? Can he reassure patients that some of the recent scandals across the water - in particular, the one in Bristol - will not be repeated here, and that the people will receive the best possible standards of health care?

Mr Close:

I too welcome the Minister here today to present his vision for the future of the Health Service. I have read with interest the document 'Putting it Right: The Case for Change in Northern Ireland's Hospital Service'. No one can deny the rationale behind the need for regional hospitals, which will provide specialist services for everyone in Northern Ireland in areas such as neurosurgery, paediatric neurology, heart surgery and cancer. However, I have a difficulty with the split between the area hospitals and the local hospitals and with the proposals for their respective services.

I come from the borough of Lisburn, and I represent the constituency of Lagan Valley, so the Minister will not be surprised to hear me argue strongly for the continuation of the excellent services that that hospital has provided over the years.

The borough of Lisburn is the second-largest in Northern Ireland, with a population of some 110,000 people, and it is one of the fastest growing areas in Northern Ireland. The reason for its rapid growth is simply the excellent range of services provided for the people who live there. One of those excellent services is the Lagan Valley Hospital. The people of Lisburn would take it extremely ill if there were significant proposals to degrade or remove any of the services which are currently provided by that hospital. I am concerned that in the 'Putting it Right' document, the threat of the axe seems to hang over, in particular, obstetrics and maternity services. How could Lagan Valley be

"the cornerstone of the new hospital service" -

the Minister's own words - if the maternity department were removed? How would Lagan Valley be treating more people if over 1,000 expectant mothers were forced to use another hospital? How could that possibly be construed as a change for the better?

I do not think that anyone would consider maternity to be a serious illness. It is a natural progression in the reproduction of life. I accept that difficult births make up only one in 1,000 or fewer of the total. We would be throwing the baby out with the bathwater, so to speak, if we closed down maternity services because of so-called higher standards that have been established by some consultant. Surely Lagan Valley Hospital, with its superb buildings and its proximity to Belfast hospitals, can be supported on an outreach basis to maintain all of its services, including maternity.

Given the Government's emphasis on the environment, and the large and growing population of Lisburn, would it not be more appropriate to maintain a comprehensive range of local services, rather than have this large number of people - over 1,000 per annum - travelling in and out of central Belfast? On obstetrics, one option which I suggest for consideration is a consultant-supported, midwifery-led service. A similar trend is apparent in Lagan Valley Hospital. Midwives would take professional responsibility, but consultants would be based at Lagan Valley to provide the necessary advice and service.

Over the past 20 to 25 years, during which I have been involved in local government and in politics, my colleagues in Lisburn and I fought against Tory efforts to shift the goalposts and run down the services in Lagan Valley Hospital. In future, a Minister from the Ulster Unionist Party, the SDLP, the Democratic Unionist Party or Sinn Fein might take these so-called difficult decisions. Having fought the Tories for a quarter of a century, I will fight any of those parties in order to retain the service to which the people of Lisburn have become accustomed.

3.00 pm

Mr Boyd:

I welcome the Minister. The people of the Northern Board area are being presented with a fait accompli and, as a consequence, alternative patterns of service and service models have not been properly explored. It is now being proposed that Whiteabbey Hospital be downgraded from an acute hospital to a non-acute hospital with adverse implications for the people of Newtownabbey, Carrickfergus and Larne. The Northern Ireland Information Service's press statement of 10 December said

"We have had extensive and unprecedented consultations with Assembly Members, local politicians, councillors, et cetera."

While I appreciate that the Minister has held meetings with us, it is clear that the Northern Health Board and the Health Minister are pursuing their policy before the elected representatives of the Assembly, who live in our community, are able to assess the whole matter of health.

The people of three constituencies - North Belfast, East Antrim and South Antrim - have said, through their representatives, that they do not want their hospitals to be downgraded. Instead they want the coronary care units and accident and emergency services to be retained to deal with their highly populated areas. Like Mr Close's constituency, Newtownabbey is also growing in population. We have an international airport, a university and many factories. We want to see capital investment in Whiteabbey and other local hospitals, not down-grading.

I propose that any service changes should be underpinned by the following principles. All current services identified for future provision from the Whiteabbey site should continue to operate throughout any transitional period.

The Ambulance Service must have sufficient, appropriately equipped vehicles and trained staff to enable swift response and rapid transfer to consultant-led accident and emergency service. Issues related to public transport must be resolved prior to the relocation of any services. Any changes must have the full support of the local general practitioners, some of whom are very vociferous in the campaign to save Whiteabbey Hospital; and finally, the local community must continue to be consulted on any proposed changes.

Last Monday Roger Hutchinson, my Colleague from East Antrim, and I spent three hours in Muckamore Abbey Hospital. To see those staff working night and day, sometimes with only five or six members of staff to cope with over 30 patients was probably one of the most moving experiences I have ever had - they do a tremendous job.

As my Colleague Oliver Gibson has also stated, sometimes patients who have been in hospital for up to 25 years are going to be put back into the community. Their families, who are very loving and caring, are being asked to take on this task of helping to uproot these patients from the environment which they have been used to for a lifetime. The manager of Muckamore Abbey Hospital said that the only way in which they could make ends meet was to close down two wards.

No more hospitals should have to close their wards to make ends meet. I ask the Minister to make arrangements to visit Muckamore Abbey. I endorse my Colleague Oliver Gibson's comment that we should save Muckamore Abbey Hospital and allocate sufficient money to allow it to continue operating.

I will give Members an example that will show them why I feel strongly that the local hospital at Whiteabbey, and others, should not lose their acute status. Twice in five years my mother has, sadly, had a heart attack. On the first occasion she was taken into Whiteabbey, stabilised overnight and transferred to the Royal Victoria Hospital. The second time was in February this year. The GP at Whiteabbey Health Centre arranged for her to be admitted to Whiteabbey Hospital on the Friday for tests. Unexpectedly on the Monday night, she suffered a massive heart attack - and I am thankful - Whiteabbey Hospital was able to save her life. The next day she was sent to the Royal Victoria Hospital for a life-saving operation.

The surgeons in the Royal said that but for Whiteabbey Hospital's coronary care facility she would have died. She is enjoying as good a lifestyle now as she has had for many years. I challenge anybody to tell me that the case for closing the coronary care unit of Whiteabbey Hospital has been made.

Finally, I have no objection to, in fact I would welcome, a regional cancer centre for Northern Ireland but, as someone who has worked in a financial environment for 18 years, I know that "centre of excellence" can sometimes be a fancy term for cost-cutting. I hope and trust that this matter is given full consideration before any decision is reached, and I hope that no decision is made by the Minister before locally elected representatives become responsible for such decisions.

Ms McWilliams:

I would like to welcome the Minister to the Assembly. Members have said "Yes, we are going to have to do something about the hospitals, as long as it is not our hospital. Yes, we are going to have to do something about the Health Service, as long as the Minister gives more money to my constituency." These are political and strategic decisions that cannot be put on the long finger and which Members will have to face.

The reorganisation of the Health Service is going to be one of the most difficult decisions that Assembly Members will have to make. The money is decreasing, not increasing, and certainly not keeping pace with the expenditure that is required for patients and for those in the community.

I once heard the expression "The operation was a success; it is too bad the patient died." One of my concerns about this document is that it is very much led by the Royal College. It is right that we train our doctors in specialist functions and that we have the best clinical effectiveness available. However, hospitals are also about the care of very sick people, not just the specialist treatment of a few. I have concerns that, if the Royal College were to lead the consultation process, all other voices that are so important to the discussion would come much further down on the list of the people to whom you have to listen. The Royal College is a very powerful body.

I am concerned too that we are talking over and over again about acute health services and care. We know that, with better prevention, we might not be having this debate. In this respect, Northern Ireland lags sadly behind the rest of the United Kingdom. Only around 2% of our budget goes on health prevention. We must take this area of health much more seriously.

This brings me to a very important point about community-based services. We have heard from Oliver Gibson, from a Member of the United Kingdom Unionist Party, from Dr Hendron and from others about the importance of community-based services. Figures from the comprehensive spending review were placed in Members pigeon-holes at lunchtime. Was that to remind us of the amount of money? We had not forgotten.

What is very important is that so little of the money is going to community care. We desperately need respite care and continuity care, particularly for the elderly who are being decanted at far too fast a rate out of geriatric units because there are no beds. Nursing homes are closing down because they are not meeting the health and safety regulations. Where are these elderly people going to be cared for?

Clearly the Minister has got to make a decision now on how the cake gets carved up. It seems that the budget has not reached the right places. Attention has been too much focussed upon the provision of acute hospital services. This is an argument which we must get right in order that the people of Northern Ireland have ownership of the decision on where these hospitals are to be located. I share Mr Foster's concern about the west of the Bann. It is right that the area's representatives should raise the issue of the rural community's reaction to this debate. I offer them my support.

It would be remiss of me, as a representative of the Women's Coalition, if I did not say that most of the job losses will be women's. Those who do the catering, cleaning and nursing - including the auxiliary staff - are predominately women.

How are we going to manage the transfer of jobs? Are we, under the Labour Administration, going to face increasing unemployment in the one area of the public sector where the lot of both Catholics and women improved in terms of the number of jobs available? Angels fearing to tread will become angels failing to tread. Again the argument lies around nursing and the remuneration of nursing, which is appalling given the enormous risks that nursing staff take day and daily.

We need to have a much clearer discussion about the Ambulance Service. It is painful for me to recall having seen an example of this at first hand. Two years ago, on a winter night in a rural area on a very lonely country road, my sister had the most appalling road traffic accident. The driver of the other car was killed instantly. My sister survived because a rural ambulance managed to get there.

She was taken to the hospital in Coleraine where a surgeon carried out the almost impossible task of putting her on a life-support system - she had punctured both lungs, which is a life-threatening condition. However, the most important outcome of all of that - I learnt much in those two days around the Health Service - was that she had to be transferred to the Royal Victoria Hospital where she got specialist attention in orthopaedic care.

Northern Ireland has moved very far in the last few years in not just bringing the solution to the problem, but in looking at the continuum of what is then needed to bring the problem to the solution. That night the problem was brought to the local hospital and later to the regional specialist hospital.

We do need to get it right. We must keep up with the rest of the world with our Ambulance Service and experienced paramedics. The coronary care units must be local. What happens if there is a crucial aneurysm that needs specialist attention? That is the kind of attention we need to pay to the Health Service: we need to take the problems to the solutions but also make sure that the solutions are available locally for emergencies that are life-threatening.

Dr Hendron rightly points us to solutions elsewhere - they do not have to be just here in Northern Ireland. I am aware of the dermatological telemedicine centre and of how skin disease can be diagnosed in the Republic of Ireland simply by screening through the services of a doctor in Northern Ireland. That is the kind of service that we should be looking at, Northern Ireland should not be working in isolation but building good communications and good technological services North and South.

Now I want to raise an important issue which concerns me, and that is who the Minister responsible will be. I would like it to be the Minister responsible for health and social services. Recently I was concerned at what I thought was a mistake when I read in the 'Belfast Telegraph' that "housing and social services" were to be a designated departmental body. I would be completely opposed to that. People have come from all round the world - health and social service experts - to study the one unique service that we have here, and that is the integration of health and social services.

Our problems are not always purely physical; they can also be social - it is the integration of that care that has made us one of the foremost bodies in the field. I would like us to continue down that road rather than enter some kind of separate, functional silo by putting health in one department and social services elsewhere. I welcome this report. The Minister's hands have been tied where expenditure has been concerned, and I welcome the increases in the comprehensive spending review.

Could the Minister tell us how Northern Ireland is faring in relation to Scotland, England and Wales in terms of the increase in the budget? A great deal has been made of how the Minister won extra increases for the Health Service, but I remain concerned about new legislation such as the Children's Order and the other problems that I have highlighted. Are we keeping up or are we now falling behind, like the other regions of the United Kingdom?

3.15 pm

Let us not forget the enormous amount of informal community care that people in Northern Ireland have given voluntarily. This needs to be recognised in any debate. My final plea to the Minister is to take on board the problems we have raised here and ensure that the debate is as wide-ranging as possible and not led just by the articulate, elite few.

Mr McGimpsey:

I welcome the Minister here today, and I welcome and support the broad thrust of the document, in particular the recognition of the need for debate and for us to work out a vision for the Health Service in five years', ten years', 20 years' time, analysing where we are now and how we are going to go where we want to go. Strategic thinking is the key to this.

Health-care provision goes to the heart of politics, it goes to the heart of government, and it goes to the very heart of the ethos of the kingdom - namely, cradle-to-the-grave health care free for everybody. That is a basic right of all citizens of the kingdom.

There are some startling admissions that the hospital services are facing a critical time, that there is a risk that some may break down and that standards of care are not as good as they should be. It is for us in the Assembly, all things being equal, to debate and make the decisions on the way forward.

I recognise that the Minister's inheritance is an unenviable one after 19 years of a Conservative Government which took the view that health provision was about working out what funds were available and then ascribing them to the health service rather than working out what the need was and how that need should be addressed. I welcome the abolition of the internal market, fulfilling a promise made by the Labour Government.

There is a need to take an holistic approach Province-wide and also to pay attention to local needs. We cannot say that money does not matter. We have to manage local budgets - for example. Because of the lack of funding in the Eastern Health and Social Services Board area, in October, there were 149 people on the waiting list for community-care packages and 100 people in hospital taking up valuable hospital beds because community care was not available.

As a representative of South Belfast I must ask the Minister about the decision to close the Jubilee maternity unit in the City Hospital. I believe that that is a bad decision. It concerns us in the Assembly, and we will call on reports from experts.

A couple of years ago we got one such report, the McKenna Report, which after wide-ranging consultation decided that the Jubilee maternity unit should stay. This is a knock-on effect from the decision to centralise the cancer unit at the City Hospital. The sale of the Belvoir Hospital site will pay for this move. McKenna made a simple recommendation that Jubilee take over two floors of the tower block because the need in south Belfast demanded that the Jubilee stay. In that area there are 30,000 women of childbearing age. Currently the Jubilee deals with an average of 2,800 births per annum. It has an intensive care unit for 350 to 400 babies per annum.

A new report by Donaldson, without consultation and almost secretly, recommends the closure of this very valuable unit. That was a bad decision. It means that women in south Belfast will have to go to the Royal Victoria Hospital in west Belfast.

The Royal Victoria Hospital is presently working at its full capacity of 3,000 births per annum. Occasionally the hospital has to send expectant mothers to the City Hospital. That is an example of a local decision which defies logic and rationality and it also flies in the face of economic sense. The Jubilee set-up in the City Hospital means that we do not have to spend money on new buildings. We can simply move it into two floors in the Tower block. The staff and equipment are there, and such a move seems sensible, reasonable and rational. It is unfortunate that decisions such as this are being made prior to the Assembly taking over responsibility.

The Minister spoke of putting it right and gave his vision of the future, but it should be left to the Assembly to make those decisions. The Minister should review his decision, or at least defer implementing it until the Assembly becomes responsible for these matters. If that is not done the Royal Victoria Hospital, which is already working at full capacity, will be required to take on a further 2,800 pregnancies. That is an impossible task, and mothers in south Belfast will be forced to go to the Ulster Hospital or to Lagan Valley, should the concerns of Mr Close be borne out.

This is an important document, but it is merely the first stage in what will be important business for the Assembly. Difficult decisions will have to be made by local politicians who will not be able to hide behind a Northern Ireland Office Minister.

Mr McGrady:

I welcome the Minister to the Assembly and I welcome his opening remarks. I should like to put on record the thanks of our community for the additional finance for the Health Service to reduce waiting lists and ease problems in other areas. This document deals only with hospital services, and the Minister says that it represents his vision of the future of hospital services in Northern Ireland. The purpose of the document is to

"offer information, advice and assistance to the Assembly"

and presumably to the wider community.

I shall speak in the context of hospital services, and not on wider aspects of the Health Service, such as community care or ill-health prevention. The document states that it is important that care be delivered close to the patient's home. The document also states that the provision of care is best when there is a sensible balance between accessibility of services and the provision of modern high-quality standards of clinical expertise. We all subscribe to those sentiments and most of us would agree that the Minister, the Department, the boards, the trusts and the practitioners want to provide the best possible health service. What is in dispute is how to achieve that. I do not agree with a great deal of the substance and conclusions of the document because they do not seem to match the vision and aspiration of the opening paragraphs.

In his opening remarks the Minister said that this was not about expenditure, and I accept that it was not about closing hospitals, but I question that, because when an engine is taken out of a motorcar and replaced by a foot pedal, have you still got a motorcar? That is the question. If the engine is taken out of an acute service hospital, is that still a meaningful hospital?

As anticipated for those listed in annex A, the asterisked exceptions, where services, such as general medicine, general surgery, obstetrics, paediatrics, gynaecology and accident and emergency, are taken out, what is left -a glorified GP polytech surgery? That will be the fate of many of the 12 mentioned in appendix A. There is no doubt about that, should the vision, stated in appendices A, B, and C, be put into practice.

Unfortunately, I draw my conclusions from the experience suffered, over the years, by my community at the Downe Hospital. In the Assembly, it is not appropriate to be parochial and simply deal with my home base, but what is happening there could be the blueprint for others. At the beginning of the document there is a paragraph that says

"some of our smaller hospitals are at risk of collapse."

One of the reasons for the risk is the uncertainty with which they have been visited time and again over the past two to three decades.

The confidence and morale of staff and patients have been undermined, and that is something we must put to bed once and for all. The providers of our health care are the Minister, the Department, the health boards, the trusts, the practitioners, specialist or general. Of course, the patients are also the customers. It is the practitioners and the patients who should make decisions.

Unfortunately, the decisions are often made only by the first three - the Department, the boards and the trusts. The experience of those working at the coalface and the recipients are often not taken into account, and that needs to be dealt with.

Two years ago the Department, the Minister, the board, the trust, the local practitioners and the community assessed the requirements for Downe Hospital and were advised to seek private finance. The Department approved the case but, lo and behold, private finance was no longer deemed to be suitable.

Was that judgement made on medical or financial grounds? Nothing had changed except the Department's attitude. The board as the purchasers, the trust as the providers, the practitioners as the deliverers and the patients as the recipients were all still of the same mind. Only "little Johnny", the Department, "was out of step". One must question whether that decision was taken on medical service grounds or whether something else, such as finance - a dirty word - came in to play. That is the only thing that changed. Everyone else, except the Department, said that things were the same. We entered another series of reviews and the Minister's predecessor, Mr Worthington, decided to take a direction not a million miles away from the direction of this particular document.

3.30 pm

The curious thing was that the six options presented by Mr Worthington for consultation did not include any of the options that he adopted. Have we had consultation then? The jury may be de facto. But that took place without regard for the people concerned.

I commend the Minister for his endeavours and do not intend to diminish them in any way - for instance, he has reviewed the case, he has visited the hospital and he has listened to delegations.

When the then Minister, Mr Worthington, made his decision he was challenged and reports were submitted and references were drawn to changing requirements in at least three different fields. In May to July last the joint working party of the Royal College of Surgeons, jointly with the British Medical Association, the Carter Review for the provision of hospital services in rural and urban areas of Scotland, and even the members of the Royal College of Obstetricians - which denied in a sense the basis upon which the previous decision was made - were put into the melting pot again, and no change took place.

I draw this parallel in detail because this is the sort of scenario that may be visited on other local hospitals. The previous Minister's decision has been confirmed, and a special press release was issued four days ago in which the Minister asked the board to review hospital provision in the area in the light of 'Putting it Right' and to report their findings by March.

However, we do not know the parameters of the new business case. Is it the one which previously went to public consultation and to a private finance initiative inquiry and which was endorsed by all concerned, or is it a new one promoted by the then Minister, Mr Worthington, or is it yet another new thing promoted by the Department and launched as this document? Those are the questions which we must address, as must the rural areas outside the conurbations of Belfast, Derry and Craigavon. That is why I make no apology for raising it.

Mr Worthington made two positive points when making his decision. First, he said "We will build a new hospital in Down". Secondly, he said "No major changes to services provided in the Downe are planned until the new hospital opens." Yet the rundown of this hospital, through undermining and the creation of a crisis, is well under way. The community in rural Down and in other rural areas need to know exactly what "business case" is going to be applied.

I ask the Minister to listen to the people and to the practitioners. They are the deliverers, they are the receivers, and they are the people who should be satisfied primarily. There should be accessibility tempered with technical effectiveness.

Mr Shannon:

I welcome the Minister to the Assembly, and I thank him for his prompt responses to my letters.

My first question is about the Ambulance Service, specifically in the Ards Peninsula. The 'Putting it Right' document talks about making it happen. It says

"The development of a highly effective Ambulance Service must be integral to the new arrangements."

I want to illustrate the specific problems which the Ambulance Service has in my area. The roads of the Ards Peninsula are twisty, narrow, difficult to negotiate and the dangers are obvious.

The Ambulance Service response time, as stated in the citizen's charter, is 18 minutes. On a number of occasions in the last few months, the response time from Portaferry has been 28 minutes, and in one instance in Kircubbin, it was 24 minutes. This was an ambulance coming from Newtownards to Kircubbin - a distance of 11 miles. I am sure the Minister would agree that no matter how bad the roads are, 24 minutes is not a satisfactory response time in which to deal with an emergency - in this case a child who had been taken ill.

The problem does not lie with the Ambulance Service or the crews; they are very efficient and have the necessary ability and experience. The problem is the fact that the Ambulance Service cannot cope with the poor-quality roads on the Ards Peninsula.

For many years, elected representatives have lobbied for an outstation in the Ards Peninsula. Can the Minister give an assurance that an outstation will be built at either Ballywalter or Kircubbin, thus providing constituents in the Ards Peninsula with an effective Ambulance Service which meets the standard laid down in the citizen's charter?

My second point is in relation to the accident and emergency services, specifically those in the Ulster Hospital at Dundonald. The Minister is aware of the many stories about its accident and emergency services, and Members have been trying to address these issues directly with the Department and with the hospital service.

We have heard stories about people who have had to spend up to 18 hours lying on a trolley and about people who have had a lengthy wait in a cubicle - indeed, one lady from Portavogie was forgotten about. How could anybody in a cubicle in the Ulster Hospital be forgotten about? It is hard to believe, but it happened. All these things have happened because of the shortage of beds and lack of money.

Can the Minister tell Members how he intends to address the very serious problems that exist in relation to accident and emergency services in the Ulster Hospital? These problems have nothing to do with the staff who are pushed and under a great deal of pressure. The service needs more staff, more beds and more money.

Would the Minister also like to comment on information that was given to me yesterday, namely that the accident and emergency service in the Ulster Hospital may be relocated, in the short term, to the Ards Hospital, because the Ulster Hospital cannot cope with the demands?

Does the Minister agree that services should always follow demographic trends? The population of Strangford has increased by 16% in the last 10 years. This demonstrates that people are moving away from the Greater Belfast area and into country areas. Consequently, greater demands are being placed on services there. I suggest to the Minister and his Department that services should be moved to where the people are.

Mr M McGuinness:

I too would like to welcome John McFall for this very important debate. It is obvious from contributions made by the representatives of all the political parties that they were articulating in a very heartfelt way their constituents' concerns about the current state of the health service and what it might be in the future.

In relation to the document 'Putting it Right' and its vision of the future - and this is an important point for me - in recent times the Health Service in the North has been driven by bodies like the British Government, the Royal College of Surgeons, and the four health boards which have been established in the North.

There has been a totally lopsided approach to the issue of health, as is clear from the reaction of people in County Tyrone regarding the south Tyrone Hospital; in south Derry regarding the Mid-Ulster Hospital; in south Down and in other parts of the North. The people who depend on hospital services have been absent from the debate.

The Government must take notice, just as we have had to take notice when we saw 20,000 to 30,000 people on the streets in south Down, in Dungannon and in other parts of the North. There is something seriously wrong when there is such a turnout of people objecting to the way hospital services are directed. People feel that this is an issue over which they have very little control.

It was clear to me, in the course of the Assembly elections, that, for the first time, people in the North of Ireland, certainly in the constituency that I canvassed, felt a sense of empowerment that at last hospital services were going to be in the hands of the local community.

I have listened to this debate and to the smart alecs in the media who say that it remains to be seen whether, on the transfer of power, we will be prepared to take the tough decisions. My party is not afraid of tough decisions, and there are representatives here from other parties who are also not afraid. We want to take those decisions against the background of a complete review of hospital services in the North, including the views of the Royal College of Surgeons and the health boards - or what remains of the boards after the Assembly Executive takes control. The views of the people who are directly affected by the hospital services - patients and potential patients - should also be sought.

People who voted in the Assembly elections voted for the fullest implementation of the Good Friday Agreement as a matter of urgency. We have come here today to raise matters with the Minister, and while we may have criticisms of the Government's approach - and we certainly do - it is also fair to criticise the failure of the Assembly to provide, for example, a shadow Health Minister, and a shadow Committee on Health for the people who voted in the referendum and in the Assembly elections.

The Assembly has failed those people dismally. If we had in place a shadow Assembly Committee on Health and a shadow Minister of Health, we would be much more powerful in our debate with the British Government about the future of health services in the North. We would be much more relevant, instead of coming here today and listening to people with quite legitimate concerns about Whiteabbey Hospital, Lagan Valley Hospital, South Tyrone Hospital, the Mid-Ulster Hospital and hospital services in south Down. We have to get our act together, and we have to provide leadership.

There is much concern among people that, through the downgrading of hospitals such as Whiteabbey, South Tyrone, Mid-Ulster and others, they are being softened up. We are being conditioned to accept, in the future, a hospital service which will revolve around the golden circle of six hospitals, the rest being reduced to the status of glorified health centres.

3.45 pm

The document mentions no hospital closures, but I do not think it is being honest. Members are experienced politicians, and it appears to me that we are talking about hospital closures -ultimately, the closure of the South Tyrone Hospital and the Mid-Ulster Hospitals. This will not be within the next 12 months, maybe not even within the next two or three years, but ultimately, the way things are going, this is what we are talking about.

The situation west of the Bann is a massive issue. Many people feel that discrimination is taking place, particularly when one considers that of the "golden circle" of six hospitals, four or five are within a 30-mile radius of Belfast, the other being Altnagelvin in Derry City. If one were to draw a line across the map from Derry, through South Derry, into county Tyrone to the Ballygawley roundabout, one would see that there is not one "golden circle" hospital to deal with the needs of this rural area. There is something badly wrong with that.

I listened with sympathy to what Mr McGimpsey said about maternity services being lost at the Jubilee Hospital, but people in that area can use another hospital 100 yards away. However, in the last month maternity services have been withdrawn from the South Tyrone Hospital meaning that people have to travel up to 40 miles to Craigavon Hospital.

There is something seriously wrong, and it affects my constituency of Mid Ulster. For example, if there were to be a tragedy in the Pomeroy area, particularly given the state of the roads around Toomebridge - and there will be no bypass there for four or five years - people would have to lie in an ambulance for an hour to an hour and a half. That is absolutely mad, and the sooner Members get to grips with these issues, the sooner the great fears and concerns of our constituents can be dealt with.

I agree with Mr McGimpsey that health boards and the British Government should not be taking decisions on the rundown of services at any of these hospitals until a Health Minister, or Shadow Health Minister, is appointed by the Assembly.

Ultimately, I would like to see all the political parties in the Assembly deal soberly with our many difficulties in a Health Committee. That is a job for us; we will not shirk our responsibilities; and we are not afraid to make unpopular decisions. Weight needs to be given to the views of the tens of thousands of members of the public who are frightened by the way in which they are being treated - their voices are absent from this debate.

The Royal College of Surgeons, the four health boards and the Government need to take on board the views of the elected representatives and the marching feet that we are going to see more of in the coming weeks. People in the South Tyrone area are disgusted at the removal of maternity services in the South Tyrone Hospital, and in the course of the coming months they will see a further debilitating situation developing at their hospitals. We are critical of the rundown in health services and of the way in which the review has taken place.

The Initial Presiding Officer:

May I ask you to bring your remarks to a close.

Mr M McGuinness:

We should also be critical of ourselves, be honest and recognise that we have failed the people - we have not produced a Shadow Minister for Health; and we have not produced a Shadow Committee to deal with health in the Assembly.

Mr Hussey:

Mr McGrady talked about being parochial. I intend to be parochial on a specific issue, the major issues having been dealt with well by other Members. I trust that the Minister is aware of the many valid concerns that constituents in West Tyrone and Fermanagh/South Tyrone have about their future health-care -

"a service which guarantees equally high quality care to everyone in Northern Ireland, no matter where they live."

Mr Gibson referred to the closure of hospitals in Castlederg and Strabane, an area which I know well. In that area, there are also many concerns about whether the co-operatives, which local GPs have organised, are operating effectively. People in the area may face journeys of up to 30 miles for after-hours services and weekend services. People are also concerned about the Ambulance Service. The crews are doing a great job, but we need to be sure that they are based in the right places to cover the relevant area. Recently, in my area, an ambulance had to travel from Enniskillen to Castlederg in response to a call-out.

The Minister's report has not "put it right" for those who rely on the services that are provided by the Erne and Tyrone County Hospitals. A lack of vision on the future of these two hospitals has caused great concern among local people. They have been left in limbo, and the report gives a choice of either the Erne Hospital or Tyrone County Hospital.

The report says that decisions of this kind could be made by the Assembly. However, the Assembly could have made a different decision, rather than simply choosing one or other of those hospitals. The Erne and Tyrone County Hospitals are currently run by the Sperrin Lakeland Trust as a combined unit, and together represent the seventh largest hospital unit in Northern Ireland, covering over 20% of the land area of Northern Ireland and providing a service for more than 15% of the population.

I said that I would be parochial on this matter, and that is quite a parish! Demography is more than simply a number of people, and a proper study of the demography of the area should lead to the clear conclusion that to retain only one or other of those hospitals would be inadequate. Mention has been made of the golden six hospitals. Could this not have been the lucky seven?

On page 14 the document states

"While acknowledging the advantages of larger hospitals, these are significantly outweighed by the disadvantages for patients in terms of accessibility."

Why does the report not consider the retention of those two hospitals as a single unit - that is, both hospitals operating together with complementary specialist services available in each, and with accident and emergency services available in the two county towns, Omagh and Enniskillen.

Mr Haughey:

I should like also to refer to the situation west of the Bann, and, in particular, to the situation in south and east Tyrone and south Derry. Two of the hospitals which will clearly be affected by these decisions lie in that area, namely in my constituency of Mid Ulster. They are the South Tyrone in Dungannon and the Mid-Ulster in Magherafelt.

We all know that not all of the 17 existing acute hospitals will escape change. There has to be change, and change is vital to maintain or improve standards of medical care, and the improvement in the standards of medical care is the most important consideration in this debate. Our citizens are entitled to the very highest quality of service.

However, even though the improvement in medical standards is by far the most important factor in this debate, it is not the only factor. The availability and accessibility of services are also matters of serious concern, as is the best use of existing resources. The integration of Health Service provision into our comprehensive development strategy for the entire region is another concern.

That brings me to my first charge. The Department of Health and Social Services Ministers - not so much Mr McFall, but his predecessors over a period - must stand indicted for their failure to produce a comprehensive strategy for the development of acute service provision in a way that is geographically fair and maximises accessibility and availability.

Only their monumental failure to do so explains how it is that five of the six hospitals that have been chosen to provide the extensive ranges of acute in-patient services form a cluster within a 30-mile radius of Belfast. The sixth one is in Derry city, the farthest point north-west.

I understand and accept the need for a degree of concentration. But concentration on the periphery is not the centralisation of services, which is what the Royal Colleges have called it. The concentration of services in a fair and evenly distributed way across the whole community is what is needed. The Department of Health and Social Services has not devised a strategy for such provision, and it must stand indicted for that.

That brings me to my second, more specific, charge. Over the years, many of us have been critical of the various health and social services boards whose members are unelected. There is a widely-held view that they have shown a good deal of insensitivity to public opinion and to the representations of local politicians. I want to single out the Southern Health and Social Services Board for its recent decision to close the maternity unit in the South Tyrone Hospital in Dungannon, and for the way in which that decision was reached.

For many years, the surgeons in Dungannon have been pleading for the appointment of paediatric consultants to provide cover for its maternity unit. Other hospitals with similar birth rates each year have two or three paediatricians to provide such cover. Board representatives have argued that they made every effort but could not succeed in providing the cover.

Many of those who are close to the hospital and have fought its cause dispute that. The inactivity of the Southern Board over time led inexorably to the situation which arose a couple of weeks ago. Surgeons at the hospital, at long last and quite properly, pointed out that they simply could not carry on without paediatric cover. The reaction of the board was not to provide the cover but to close the unit. I charge the Southern board with contriving to bring about that situation. I believe that it was always its strategy to downgrade or close the South Tyrone Hospital.

4.00 pm

The decisions made by the Southern Board over the years which led inexorably to that situation must be intensively scrutinised. Consequently, along with the MP for Fermanagh and South Tyrone, I have initiated a cross-community complaint to the Ombudsman. We invite other MPs and Assembly Members to join us in sponsoring this complaint, and we will make it available in a number of centres in the area served by the South Tyrone Hospital so that the general public may sign.

Unelected quangos should not be immune from being scrutinised by those empowered and equipped to do so. The Department of Health and Social Services should also be made to answer for its failure to produce a fair and equitable strategy for the provision of acute in-patient services in a way that gives reasonable and fair access to the whole of Northern Ireland. They should answer to the charge of conniving at, if not devising the strategy to aggrandise the lucky hospitals which were eventually chosen.

I hope that it will not be long before this Assembly takes on the reins of power; however, it may be February, March or even April before that happens, and a lot of damage can be done in that time. Wrong decisions made by unelected quangos now could cost a lot to put right when it becomes our responsibility to do so, and, therefore, I urge the Minister to freeze any further decision making until this Assembly, through its Minister and its Departmental Committee, has an opportunity to devise a fair and equitable strategy for the delivery of acute in-patient services across the region.

Rev William McCrea:

I welcome the Minister but, unlike others, I do not necessarily welcome this document. It has neither the right tenor nor the right agenda for the future of hospital services throughout the Province. Many Members clearly supported the document or rejected it. Some welcomed it; some are sitting smugly because their hospital has been saved or upgraded, and, therefore, this does not bother them. They welcome the approach that has been taken.

Others who represent areas where hospital provision is under serious threat - and this document does nothing to allay those fears - far from being smug, are concerned about the health and welfare of our constituents as we approach the end of this century and go into the next. We approach that next century not with hope, not looking forward to the health provisions that are being made, but with deep concern. I understand those views.

Most people expressed their views very clearly, but I am confused by the representations made by two Sinn Féin Members, both from the Mid Ulster constituency. When we read Hansard, I think we will find that one person was saying one thing while the other was saying something else. One was welcoming the document, while the other seemed to have a different opinion. I can assure you that there will be no lack of clarity on my position with regard to Mid Ulster.

This document is not ill-prepared, as some Members have suggested. Its agenda for the future of hospital services is very clear, and I do not accept it. I had the privilege of representing the district of Omagh and the Tyrone County Hospital when it was in the former Mid Ulster constituency. I saw maternity services withdrawn from the Tyrone County Hospital, and I genuinely believe that that was an injustice to the people of Omagh - an injustice that needs to be put right. Those services were not necessarily removed on medical grounds.

If it could have been justified, I was certainly open to persuasion, but on top of everything else there was a concerted effort of political manoeuvring, and the people of Omagh have paid the price for that manoeuvring: the loss of their maternity services. I wish the Tyrone County well in its efforts to ensure a solid future for that area, because it has a vital role to play in the future of Health Service provision for that rural community.

In the document 'Putting it Right' the Minister, and those who prepared it, have made sweeping and idealistic statements about the provision of modern and effective hospital services. We are informed that the Minister wants

"a service which guarantees equally high quality care to everyone in Northern Ireland, no matter where they live."

That sounds good - a sweeping statement: "no matter where they live." Members who read the document carefully will notice that that phrase occurs over and over again, as if that was what this document was going to bring about. I suggest that it is doing the very opposite. It is not giving equally high quality care to people throughout Northern Ireland. How can such a statement be justified when, in reality, the changes that are being suggested will remove or change in one fell swoop 60% of the acute hospital services currently provided.

Equality of service also involves equality of accessibility. The time taken to get to high quality care can be a matter of life and death. Why should we accept, west of the Bann, the destruction of the excellent acute services that we already have at the Mid-Ulster and South Tyrone Hospitals, and thereby risk the lives of our constituents? The Minister is proposing to give us far less than we have enjoyed until now, and far less than is enjoyed by the rest of the Province. That is totally unacceptable to my constituents.

There is no pressure whatsoever from the community to downgrade the acute services at the Mid-Ulster or the South Tyrone. The very opposite is the truth - 30,000 people came onto the streets to oppose such action. Surely that is the community saying "No" loudly and clearly to downgrading and to the withdrawal of maternity services from the South Tyrone.

And yet this document suggests that the community will not allow the present situation to go on. The truth of the matter is that the community is demanding that local acute services be provided close to the community, bearing in mind the vastness of the rural area that we are talking about. This document is saying that if you get sick, race as quickly as you can to the east of the Province before it gets dangerous. Best of all, do not get sick west of the Bann, for you are sure to die. That is ridiculous. What way is that for a health service to look after the people of an area? The Minister may think that that is funny, but let us take a look at the map and talk about geographical accessibility.

Let me give an example. At the weekend no beds were available in Belfast hospitals. One patient was sent from the verge of the city to the Mid-Ulster Hospital in Magherafelt. His wife paid a £42 taxi fare to visit him. Today, the consultant decided that the man was able to go home, but the trust concerned was unwilling to provide an ambulance. He was told that he could don his pyjamas and an overcoat and get on a bus. He would have had to travel in to the centre of Belfast and then get a connection to his home in Newtownabbey.

So his wife had to pay another £42 to collect her husband from that hospital today and take him home. She had to pay a total of £84 inside three days. Do Members realise that this is an example of the caring service that we are going to have in the future? They are taking the service from the local community. People are having to travel to the service. Is the answer to make it as comfortable as possible for the Royal College and consultant to guard their time at the expense of the ordinary members of the community? This is an example of what is in store for people in the rural areas of this Province, if the six golden hospitals receive the approval of the Assembly.

I ask the Minister and his Department to ensure that the Assembly is free to take this decision without any predetermined plan being put into operation, such as happens with non-elected quangos which make certain outcomes inevitable. Any independent assessment of the position of the new six golden acute hospitals shows that the rural area west of the Bann is not only disadvantaged,

The Initial Presiding Officer:

Could you please bring your remarks to a close.

Rev William McCrea:

but discriminated against. We have to look carefully at the provision of health services, not because of the pressure from the British Medical Association or the Royal Colleges, but because this document says that the number should decrease from six to three. We are on a roller-coaster towards contracting the service even further, and those who are sitting smugly today had better realise that if they yield to the pressure of these professionals their hospital will be under threat as well.

I ask the Minister to stop travelling along the road that he and his Department are on and to allow the Assembly, unshackled by the decisions of unelected boards, to make the decisions about future health provision.

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