John Gormley

Deputy Gormley: The presentation by Dr. Cunnane was clear and concise. With regard to arthritis, can a price be placed on the lack of early detection in this country and the fact that we do not have proper infrastructure in place? Does the lay person need to be educated on recognising the symptoms because there are people who display them early on? What causes arthritis? Is it genetic or can it be brought on by certain activities? How does Ireland compare internationally? Are our rates higher because of our climate? What would the proper infrastructure cost?

Chairman: I welcome the Minister of State at the Department of Health and Children, Deputy Brian Lenihan, and his officials to discuss the Ferns Report and the report of the Ombudsman for Children on complaints received about child protection in Ireland…. I invite the Minister of State to begin.

Following the report:

Deputy Gormley: Will the Minister of State explain what he means by “executive privilege”? He spoke of consultations with the Attorney General on new legislation. When will it be introduced?

On accusations of abuse, to be abused is damaging; to be accused of abuse is also damaging. It is an extremely complex area. If an individual is accused of this heinous activity, there is no way back for him or her, even if he or she is proved innocent. Has holding such court cases in camera been considered or is that impossible?

On mandatory reporting, is there not a case to be made for whistleblower legislation? People are often afraid to report and need some protection to do so. This does not only affect sexual abuse offences but others also. The events at Our Lady of Lourdes Hospital, Drogheda, highlighted how people could be afraid to come forward to report certain actions. Will the Minister of State agree that the Opposition is correct on the urgent need for whistleblower legislation?

Deputy B. Lenihan:  Deputy Gormley raised questions about the meaning of executive privilege. It means that certain information which comes to the attention of the working group does not have to be automatically disclosed in court proceedings and the inter-agency group can work without the threat of immediate and automatic disclosure of all the information which comes before its members in the course of the performance of their duties.

The Deputy referred to the problem of false accusations. This is part of the difficult balance the general law must observe. Clearly, the law of libel protects the reputation of individuals, while provisions to protect an accused person against wrongful conviction are built into the criminal legal system. There are procedures are in place, therefore, and the Deputy must consider this issue in the context of these general protections.

A matter referred to by the Deputy and several other members which caused me considerable concern was that of protection for persons reporting child abuse and whistleblowers.

Legislation is in place. The Protection for Persons Reporting Child Abuse Act 1998 came into operation on 23 January 1999. It provides immunity from civil liability for any person who reports child abuse, reasonably and in good faith, to designated officers of a health board, now the Health Service Executive, HSE, and any member of the Garda Síochána. It provides significant protection against discrimination for employees who report child abuse. It creates an offence of false reporting of child abuse. It was our preliminary response to the issue of mandatory reporting, with the promulgation of Children First - National Guidelines for the Protection and Welfare of Children. Although I appreciate there was a recent debate on whistleblowing, such a debate is not needed in this area as legislation is in operation.

Deputy Gormley: I thank the delegation for coming before the committee. They referred to the hospital at night data collection exercise and stated that it now takes diary form. Could they expand on what was said earlier? Is it as Deputy Devins indicated, namely, that people write in diaries? Who will comprise the national implementation group? It was stated earlier that the full co-operation and active participation of the IHCA is required. Is there an indication that full co-operation has not been forthcoming from consultants? As far as our guests are concerned, what is the status of the Hanly report?

Mr. Carey:   I am anxious to respond also to previous questions from Deputies O’Malley and Gormley. To deal with the question about the consultants, unfortunately they are not co-operating with us at present because of the extension of the clinical indemnity scheme to include claims against hospital consultants with effect from 1 February 2004. The position is that formally they are not engaging with national groups. This was one of the reasons the second phase of the medical task force staffing implementation could not take place, in other words, developing the networks outside the two pilot areas. There is industrial action threatened which if it goes ahead will commence on 14 March 2005. That is the position as regards the consultants.

On the issue of the recruitment of hospital consultants and the fact that hospitals are being told they cannot recruit consultants because of the uncertainty about the situation, I wish to draw the committee’s attention to a statistic. Since 1 January 2000, an additional 505 consultants have been recruited for the public health system. I will make this tabular information available to the committee. The number of consultants employed on 1 January 2000 was 1,440 and on 1 January 2005, the number was 1,945. Of those, 121 were recruited during 2004, a 40% increase over five years. I do not think the claim, made in certain quarters, that everything is frozen is correct.

Deputy Gormley: The problem is that once the big hit arrives, many people will descend on accident and emergency units. Mr. Tom Clonan, who carried out an analysis recently on the coping abilities of our accident and emergency units, estimated that real problems would arise within 20 minutes. How well can the units cope and will people be refused admission to them?

Dr. Kelleher: Our aim is to conduct a major communications campaign in order that people understand that their first point of contact should be a telephone helpline, which they can ring to learn where they should go. They will then be diverted for treatment either to a general practitioner or to a flu clinic. We will be advising people against presenting at accident and emergency departments and that the only people who should go to hospitals will be referred there by doctors and admitted directly. We recognise the issues raised by the Deputy and are trying to avoid them by putting a system in place whereby people are diverted away from accident and emergency departments. We are currently looking into the details of the content and method of transmission of the communication campaign because the front end elements are important in terms of keeping as many people as possible away from the hospital system.

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Deputy Gormley:  …This is a huge imponderable because, while I understand the surveillance unit is speculating in the dark, I would hate to think that we will only get our act together when a flu pandemic hits. At present, I do not see the vigilance at ports and airports, which obtained for foot and mouth disease. Will the matter become serious only when a pandemic breaks out? In other words, is the unit making a distinction between a flu pandemic and avian flu? We need to understand whether a significant difference exists in terms of the approach because I believe the message is that it may not become a pandemic. On the other hand, the literature I studied suggests that is inevitable. Will the delegates agree that a flu pandemic is inevitable at some stage?

Dr. Kiely: Deputy Gormley talked about the inevitability of this. All the evidence and intelligence on this issue indicates it is a question of “when” rather than “if” a pandemic will occur. The question is when and what will cause it. It is not inevitable that the bird flu will cause it. Although it is the most likely candidate because of its prevalence in the areas where it occurs and the fact that it can be transmitted to humans, there is no certainty that if and when a pandemic comes it will be the H5N1 virus. The only certainty is that there will be a pandemic some time.

The only intelligence we have on the validity, accuracy and sustainability of figure from other countries, for example, Vietnam, is that the WHO and the international public health organisations, including the veterinary public health people, have been involved closely over recent years in such countries. They have helped these countries implement improved and enhanced surveillance systems and continue to help. We do not know if these figures are reliable and valid but we must depend on the figures as validated to the greatest extent possible by the WHO. These are the only figures we have on which to base our assumptions and it would be invidious of me to suggest that countries were not being upfront. I would not want to do that.

The Department has entered into agreements to stockpile many hundreds of thousands of doses of antivirals, enough to treat 25% to 26% of the population in the event of an emergency. This figure is generally recognised around Europe as being sustainable and credible. Our colleagues from the Department of Agriculture and Food might have an answer to the question about poultry imports.

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Deputy Gormley:  Many reports have stated it [Tamiflu] is not as effective as assumed. How true are those?

Dr. O’Flanagan:  There have not been many but there has been a number of isolated reports of resistance, especially among people treated with it prophylactically who then became ill. The treatment dosage is double that for prophylaxis. If a person develops symptoms it is important they go on the larger treatment dose. Given the isolated incidents, we are seeking additional supplies of an alternative drug [Relenza or Zanamivir].

Deputy Gormley: Is Relenza [an alternative] more reliable?

Dr. O’Flanagan:  As it must be inhaled, it is not suitable for young children or for the very elderly. Widespread resistance to Tamiflu is not inevitable. Although recent viral isolates from Turkey have shown no resistance, it is possible that there will be pressure. The more people receive Tamiflu, the more likely it is that resistance will emerge.

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Deputy Gormley: People who are relatively healthy will survive, as if it were ordinary flu. Only the most vulnerable will be badly affected.

Dr. O’Flanagan:  That is not necessarily true. Most of the deaths from avian flu so far have been of young and healthy people. In this country most deaths occur in the elderly who had some predisposing illness such as chronic heart disease but avian flu has heretofore occurred in either healthy children or young adults.

Dr. Kelleher: That was the same in 1919.

Deputy Gormley:  Do we know why that is?

Dr. O’Flanagan:  No. It is one of the questions on which the European Centre for Disease Control has set up scientific panels. They will look at why there has been predilection so far for young and healthy adults and children.

Deputy Gormley: I welcome the delegation and I thank the committee for dealing with this important item. I believe the witnesses are the conveniently forgotten victims of this case, because the mobile phone business is very lucrative. Anything that will queer the pitch for those companies is put to one side.

Can Mr. Colbert explain to the committee the difference between the various types of radiation? At the moment, 3G masts are being erected throughout Dublin city, including in my constituency on Ardee Road. The Office of Public Works, under the Minister of State at the Department of Finance, Deputy Parlon, is allowing this to happen. Why is it that the guidelines for the Department state clearly that these masts should not be erected on schools, yet this mast is being erected right beside a school? Can Mr. Colbert confirm that radiation travels laterally? In other words, it is probably worse if it is erected right beside the school. What are the effects on children? It seems to me that investigations such as the Stewart report state that the effects of radiation are more profound on children. These are technical questions, but the committee needs to get the facts on the effects.

Mr. Enda Dalton:  Deputy Gormley asked about the different forms of radiation and what they consist of. I am not sure if the committee members understand radiation in any way but, generally, it is divided into two sets within a spectrum of electromagnetic waves, which are generated by literally shaking electrons in space. They are divided at the line where we see visible light. The lower side is called non-ionising radiation and the upper side is called ionising radiation. Ionising radiation is the radiation we refer to when we are talking about nuclear physics, X-rays and the like. Non-ionising radiation is more or less in the field of radio, television and telephones.

The spectrum is divided into frequencies. Each frequency has its own characteristics and is used for specific purposes. The frequency used by the mobile phone industry is approximately 900 MHz, which means 900 million oscillations per second. It is that frequency, which is highly penetrative and can penetrate 30 feet of concrete, to which we draw attention. The mobile phone industry uses this frequency because of its penetrative quality so that one can receive telephone calls inside buildings and so on. Unfortunately, it appears that this range of frequency is the most inimical to people as it appears to interfere with the cellular structure of the body.

Embedded in that frequency are lower frequencies used for control purposes at eight to ten Hz. These low frequency pulses refer not just to ordinary GSM but also to 3G and the ordinary analogue signal. They are used in all three as control signals and they are more or less in line with brain waves. Therefore, there is a conceivable possibility that everybody, not just those of us sitting at this table, could be in some way affected by this radiation. It is not a simple matter of saying that we are sensitive. Everybody could be affected.

The effect of radiation is often dismissed as unimportant. A transistor radio is not connected to a mains as it is powered by battery, yet it will pick up signals and convert them to music, speech or otherwise. If one examines that radio, one would find that every component in it is perfect but if one turned on a vacuum cleaner next to it, there would be a hum or a buzz from the vacuum cleaner although it is not connected to the radio by cable or wire. This is because of electromagnetic interference inside the transistor radio, despite the radio being in perfect working condition.

A similar process applies to people. If a person is sensitive, he or she will react to the energy in the atmosphere, which is literally like a blanket fog of heat waves all over that person. However, if one goes to a hospital or doctor — this highlights the difficulty of proving the connection with illness — one will be examined in a biological sense and told that the heart, liver, lungs and so on are perfect and that, therefore, one must be healthy. However, while it cannot be demonstrated that there is any biological problem, people are being affected just as a transistor radio is affected by an outside source. This points to the difficulty medical professionals have connecting one issue with the other but if one is a victim, as we are, one would have no difficulty. People feel this damn thing so badly, and it affects them so badly, that they ask: “What in the name of God is bothering me but not bothering other people?”

We notice what is happening to others. As Mr. Colbert stated, people are suffering from asthma, bronchitis, brain tumours, cancers and leukaemia. The medical profession cannot connect this to a mast down the road but we can because we see it from the point of view of sufferers and believe it is likely. Lately, the medical profession has begun to examine this issue. The Irish Doctors Environmental Association, of which we are members, is concerned about the fact that radiation of this nature can interfere with biological operations in the body.

We ask the committee to consider the possibility that there is an invisible cloak of energy that affects us and perhaps everybody on the planet, for all we know. The possibility must be examined. Somebody with the required knowledge must become involved and interested in the subject.

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Deputy Gormley:  Does it help if the power is reduced? Mr. Cummins referred to other countries and stated that our levels are much higher. Should the joint committee examine the possibility of reducing them?

Mr. Cummins:  Yes, because it would reduce the intensity of the signal. The signals are very strong here and it attacks one’s entire immune system.

Deputy Gormley:  Very well.

Mr. Gormley:  Those of us who are members of the Joint Committee on Health and Children need the opportunity to express not only our disappointment but also our dismay at what has occurred [money went astray in the health budget in respect of the transfer from capital to current funding]. It is incredible that this practice can occur. We were told the reason for setting up the Health Service Executive was to ensure the health service would be run efficiently. We have now discovered not only do we have an extra layer of bureaucracy but that the executive is incompetent. It is sheer incompetence - nothing more, nothing less. Are members of the committee, particularly those of us in Opposition, expected to let it pass? It is our duty to hold the Government to account. One can pass the buck to the HSE but, ultimately, it stops with the Government, particularly the Tánaiste and Minister for Health and Children, Deputy Harney. That is why she ought to be present to answer questions. To slip it in last night and for the Minister for Finance, Deputy Cowen, to sheepishly announce it to the Dáil was not good enough. We need answers as quickly as possible.

Vice Chairman: Amendments Nos. 5 to 8, inclusive, are related and will be discussed together.

Mr. Gormley: I support Deputy McManus, as she has probably met representatives of the Pharmaceutical Society of Ireland, as I have recently. It was shocking to hear what they had to say. I am sure representatives of the society have also met the Minister for Health and Children and perhaps the Minister of State who knows that the case is shocking.

 I support Deputy McManus, as she has probably met representatives of the Pharmaceutical Society of Ireland, as I have recently. It was shocking to hear what they had to say. I am sure representatives of the society have also met the Minister for Health and Children and perhaps the Minister of State who knows that the case is shocking.A pharmacy Bill has been promised since the time Brendan Corish was in office but nothing has appeared. Meanwhile, there is potential for serious malpractice, as the Pharmaceutical Society of Ireland has told us. Who will take the rap? Deputy McManus cited a number of examples. A further example furnished by the society is that of someone operating as a pharmacist who clearly is an alcoholic and addicted to various drugs. Some of the drugs this person handles must be dispensed very carefully. If the dosage is wrong, it can affect a person’s life, yet there is no protection against such malpractice. Recently nine pharmacies dealing with animal medicines were taken to task. If pharmacists are prosecuted in respect of animal medication, why have there been no prosecutions in respect of human medication? While I believe in proper animal husbandry, I regard human health as far more important, yet it is not protected.

The Minister of State needs to get his skates on and introduce a pharmacy Bill as soon as possible. In the meantime he should provide the protection offered by the amendment. He is in a better position than most to know that there is a serious problem.

Mr. T. O’Malley: I appreciate the point made by Deputies McManus and Gormley. They are correct in saying I am well aware of the issues raised. The Minister for Health and Children has given an undertaking on the fitness to practice Bill which she hopes to bring to the Government soon. It will be dealt with. I thank the Deputies for their contributions and do not dispute what they say.

Deputy Gormley: I want to ask the Tánaiste and Minister for Health and Children two questions, the first of which concerns the alcohol products Bill. This Bill mysteriously disappeared off the list of promised legislation. Does she agree that alcohol is the most damaging, albeit legal, drug in Irish society? Knowing from much experience that self-regulation does not work, why has she allowed the industry to regulate itself? She has stated that if it does not work, she will introduce the Bill. What period of time is involved? For how long will the Minister provide for self-regulation? On the one hand, the Department is running advertisements on television telling people to drink sensibly but, on the other, they are outweighed by the number glamourising alcohol and encouraging people to drink.

I refer to water fluoridation. Ireland is the only country in the world that experiences mass fluoridation of water. The last time the Minister appeared before the committee, she stated the jury was still out on the issue. Has it come in to give its verdict? Has the Minister changed her mind, given that the latest evidence from a study conducted by a US university links water fluoridation with cancer?

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Deputy Harney: Deputy Gormley asked me about the alcohol products legislation. It has been decided to make progress in that regard by means of a code of practice as a single Bill will not alter the fact that alcohol abuse is a major problem in Irish society. The cultural patterns endemic in our society need to be changed by means of increased educational awareness, for example, although that will take quite some time. One of the frightening aspects of the drinking patterns of the young people of today, as opposed to my generation, is that they seem to engage in binge drinking in order that they can be out of their minds within a short period of time. I am not certain about the role of advertising in that regard. As somebody said to me recently about a different issue, it is difficult to target campaigns at young people because they do not read the newspapers we read and do not listen to the radio programmes to which we listen. We need to be innovative in our use of forms of technology such as texting, for example.

Deputy Gormley: Young people watch television.

Deputy Harney: The Government has decided to initiate a voluntary code of practice in the first instance. I was asked about a timeframe. I expect it will take a code of practice of this nature at least two years to have any impact.

Deputy Gormley: Two years.

Deputy Harney: At least two years, to be fair. I am a fan of the philosophy of “if it ain’t broke, don’t fix it”.

Deputy Gormley: It is broken.

Deputy Harney:  If we want this to work, we need to give it a chance. I agree we have a great deal to do if we are to combat alcohol abuse as the lifestyles of every generation have been associated with alcohol. We have a long way to go — it will take much longer than many of us anticipate to develop a healthy attitude to alcohol in this country. Such an attitude does not necessitate encouraging people not to drink alcoholic products, as it can involve drinking in moderation and responsible drinking, which I favour.

The medical experts who have advised me at departmental, EU and WHO level take a contrary view to that of the Green Party on water fluoridation. That is a fact, although I accept there is an alternative view. I would like to think I am open-minded. If something needs to be changed because it makes good medical sense, I will agree to change it. If it does not, I have to maintain the status quo. That is the position on the fluoridation of water.

Deputy Gormley:  I welcome the delegation. As I see it, Professor Drumm’s approach is to go back to the root causes of poor health. I agree that is what primary care ought to be about. Would he agree that one of the main problems in society is alcohol? We only have to look at the number of intoxicated people attending accident and emergency units to see this. The professor spoke about a disconnection. Does he agree that a blind eye is turned to the problem? Task forces have advised the Government on the best way to approach the problem and consultants were hired and paid well for their advice. They all advised that we should proceed with the alcohol products Bill but the Government has dropped it. The executive is not directly involved in policy making but is it possible for Professor Drumm to have a word in the ear of the Tánaiste and talk a bit of sense to her on the issue? We must return to the root causes.

Senator Henry hit the nail on the head with regard to the introduction of more private hospitals. Dr. Risteard Mulcahy spoke about his concerns to my party and possibly other parties. He said that if we look at the American model, we see that the private patient is sometimes over-treated because of the money involved. Last week I raised a question about general practitioners and antibiotic prescription. I was told that if general practitioners do not prescribe antibiotics, people will vote with their feet and go elsewhere. Therefore, general practitioners look at retaining their customers. This is a serious problem. The professor referred to measuring performance. How are general practitioners regulated in this regard? It is an issue we must consider seriously.

Will Professor Drumm gaze into the crystal ball and tell us about the future? We have a problem in all health services because we have an aging population. We have better technology and medication and, as a result, people are living longer and using up more resources. We will, therefore, be obliged to pay more for our health services and health insurance premia will rise. How does Professor Drumm see this panning out? Will there be a huge drain on the resources of the State? If, for example, we improve primary care and people remain healthier for longer, they will eventually become ill. We know more money is spent on people in the last years of their lives than at any other stage. Many people will live longer but this issue has not been debated. It is one of the most crucial challenges we face.

Professor Drumm:  I will respond to Deputy Gormley’s questions. Alcohol abuse, a societal issue, exerts great pressure on parts of the health system such as accident and emergency departments. It is a challenge in the widest sense. If the HSE is to deal with it, it needs to decide whether accident and emergency doctors should be responsible for dealing with inebriation as a social problem. Should their dealings with people who are inebriated be strictly medical in nature until they are no longer inebriated? Fortunately, a medico-legal approach has been taken, that doctors are responsible for inebriated persons who arrive in accident and emergency units until it is shown that they are sober and capable of operating independently. This medico-legal and societal issue creates tremendous problems in the health service, not only because it leads to a direct increase in the workload of accident and emergency departments but also because the arrival of inebriated persons in such departments can have catastrophic effects on their ability to provide services for other patients. An improvement in the syndrome of acute alcohol intoxication would take a great deal of pressure from the health service. The problems caused by chronic alcoholism do not have such immediate effects on the service. I am not sure what the HSE can do to alleviate the problem of late-night and weekend inebriation.

The representatives of the HSE have given their views on the issue of publicly owned sites being used for private hospitals. The question of antibiotic control is central. Everyone is aware of MRSA which is by no means a uniquely Irish problem. It is having a huge impact in the United Kingdom and central and southern Europe. Most countries in northern Europe had managed to keep MRSA levels quite low but it looks like such levels are starting to increase significantly from a small base. I agree education is central to this issue. Those involved in the health provision system cannot legislate for how doctors prescribe. It is helpful for everyone — general practitioners, consultants and everyone who prescribes — that the MRSA issue has become part of the public agenda. It is the first time in my professional career that I have felt a certain level of awareness of the effect of prescriptions of antibiotics on MRSA. I was not aware of the problem to the extent I should have been. We all knew there was a problem but none of us was accepting responsibility for it. It is almost as if we are lobbying on behalf of the public in order that the message is transmitted. As medical practitioners, we feel we should be responsible for dealing with the matter. The concerns in this regard have to be taken on board, in conjunction with a major education programme. The HSE is heavily involved in trying to increase the level of education on the use of antibiotics.

I was asked whether future demographics would lead to increased costs in the health sector. Perhaps what was being described is not clear to everyone. This country has enjoyed the most advantageous demographics in the developed world in recent years. Our youthful population has enjoyed tremendously high standards of education. We have done many things well, for example, by keeping down taxes. We will have to face some challenges such as providing for more long-term stay facilities as the system has to deal with increased costs. We will have to take what this means on board. I accept that health costs will rise. I am challenging many of our present calculations on the basis of our advantageous demographics. We will face a tremendous shock if we do not face the challenge. If we are unable to meet the current challenges in an efficient manner, how will we cope when we face a real challenge in 20 or 30 years when there will have been an increase in the percentage of the population that is older?

Deputy Gormley: Dr. Cunny says that two thirds of hospital infections are inevitable, which brings the figure for those developing infections in hospital down to roughly 6%. How does that compare to countries that are very good at managing infections, such as the Netherlands and Sweden, where best practice prevails?

Dr. Cunny: I do not have the exact figures to hand but we are roughly comparable. The overall average is approximately 10% but the rate varies from 5% to 15 % across different countries, types of hospitals and types of infections. Countries such as the Netherlands are closer to the lower end of the scale.

Deputy Gormley: Does Dr. Cunny know what the figures for Ireland are at present?

Dr. Cunny: Unfortunately, we do not know and that is one of the purposes of the major international study mentioned by Dr. Kelleher, in which we are participating next year. That study will help us to establish the baseline level of hospital acquired infections here. The beauty of the study is that when we are collecting data in Irish hospitals, similar data will be collected in hospitals in Northern Ireland, Scotland, England and Wales, thus enabling us to compare our figures with other regions and groups of hospitals within the United Kingdom.

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Deputy Gormley: Has Dr. Hynes any costings on measures to make it easier for hospitals to comply? What level of increased investment would be required?

Did she say that there is no direct correlation between overcrowding and MRSA rates or did I misunderstand her? I always believed that to be a significant factor.

I raised the issue of antibiotics last week. Some GPs seem more responsible than others in terms of prescribing antibiotics. There are doctors in my constituency who freely supply antibiotics and patients who complain when they are not prescribed for minor ailments. Should we not be more rigorous in our scrutiny of this matter because the real source of the problem is antibiotic resistance?

Dr. Hynes: We have conducted a gap analysis on the personnel required to make it easier and this has clearly indicated the levels of funding involved. While the pit is almost bottomless in terms of the fabric of hospitals and what can be done, we have agreed to invest an initial €20 million in 2006. The latter will be focussed on measures that can be put in place quickly. Not only should compliance be made easier for hospitals but we should also facilitate individual members of staff, including porters and allied health professionals as well as doctors and nurses. If we want them to clean their hands, we must make it easy for them to do so.

My remarks on the direct correlation with overcrowding referred to cleanliness rather than infection rates. For example, St. James’ Hospital, which has one of the busiest accident and emergency units and highest occupancy rates in the country, managed to achieve good results. On the Deputy’s question on overcrowding, logic dictates that patients who are close together are more likely to infect each other. Hospitals that have high occupancy rates but insufficient isolation units will face greater difficulties in keeping infected patients separated. That is a problem with regard to infections.

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Deputy Gormley: Is Dr. Cunny saying hand washing is vital but environmental cleanliness is not?

Dr. Cunny: One must know what is required to control hospital acquired infections. Factors include hand hygiene, environmental hygiene, control of antibiotic use, staffing levels, laboratory resources, infection control infrastructure and surveillance programmes. No single component will control MRSA.

The United States focussed on hand hygiene for many decades but it did not work. MRSA rates in the US increased and their problem is bigger than ours because they did not address all the factors. The countries that have succeeded took a multidisciplinary approach and tackled all the problems at once, and we must do the same. The SARI progress report has identified this in its priorities for next year and onwards.

On trying to correlate the results of the hygiene audit with MRSA rates in individual hospitals, the problem is that we have no national system for measuring MRSA in individual hospitals. We have a system that allows one to calculate the overall national figure for the number of MRSA bloodstream infections. That does not detail the rate in individual hospitals or tertiary referral centres. One does not know how many infected patients were transferred from other hospitals, came in from the community or acquired it in the hospital. A hospital that is aggressively testing for MRSA will detect more cases while a hospital with inferior surveillance will detect fewer cases and will look better. It comes back to information for action. We need better data, but first we need the resources to gather it.

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Deputy Gormley: There seems to be inconsistency among general practitioners in the prescription of antibiotics. What is the current position? Are there data on it?

Dr. Kelleher: We provided data to the committee in advance of this meeting. Rates are higher than the EU average and must be addressed seriously. It is an issue of behaviour affecting all of us. People take a child to a GP with earache or a sore throat and expect to come away with an antibiotic prescription. It takes 15 minutes for a GP to persuade them not to go on a course of antibiotics but it only takes a minute to write the prescription. We in the profession have a responsibility to get that message across and develop guidelines for our staff on such matters as prescriptions and washing hands.

I will answer a couple of important questions. Professor Drumm has clearly stated we must address the resources in our system and how we deal with the community side of primary care. Having read the transcript from last week we must address how we support people coming out of hospital with MRSA and other infections. We also learnt from last week’s transcript that we must get the message to everybody in the health services that they must spend more time passing on information about infections so patients understand them and can take appropriate action. People must tell patients what is happening.

The patients’ association told the HSE they wanted to help us and we are grateful for that. It was suggested they should be represented on our groups and we must explore that in our meeting with them in January. Dr. Hynes and I will meet them again on Friday to discuss actively progressing that idea. They are keen to have a voice in the process and we are keen to hear that voice. That meeting will be very important in directing us on the way forward.

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Deputy Gormley: Dr. Kelleher said he has data on the prescribing of antibiotics. Does that compare prescription rates from GP to GP or what sort of data is available?

Dr. Cunny: There are two types of data available. The first is national level data that we report as part of a Europe-wide surveillance system where we can compare our overall level of antibiotic use, and patterns of antibiotic use across the Continent. That is how we know that our overall level is not the highest in Europe. Ireland is among a group of countries in which levels are a little above average but are not as high as those in some countries, such as Spain or France. There is also individual prescription level data available through the GMS scheme that is fed back to individual GPs generally through GP units within the old health board structure or GP tutor groups. It is the tutor groups model that is being used in the pilot work going on in the southern region, which is being rolled out to other regions as well, of giving GPs feedback on their own prescribing patterns. The work done in the southern region has been very successful in that the GPs can examine their own prescribing patterns and identify where they are overusing particular types of antibiotics or problems with particular types of patients. The focus has been on addressing many of the cultural issues and the way patient demand, or perceived patient demand, for antibiotics should be addressed. That model appears to be successful but the next stage is tying it in with patient and public education. That will be a major focus of the joint meeting we will have with our colleagues at the end of this month in Armagh in terms of drawing on the success they have had in this area in Northern Ireland.

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Deputy Gormley: When the Lorenzo system is in place, will Dr. Cunny be able to get that prescription data back quickly? Is part of the process that he will be able to know that very quickly?

Dr. Cunny: The difficulty with the prescription level data is that it is only available for the GMS scheme. There is no data at prescription level for non-GMS antibiotic use but work is being carried out at the national centre for pharmacoeconomics in St. James’s Hospital, which is examining overall GMS prescribing n a quarterly basis. At local level, that data is also fed back to individual GPs and that is where it makes the difference. Feeding back the data to individual GPs means they can then use it to modify their own prescribing if necessery.

Deputy Gormley: I welcome the delegation and thank them for their presentations. The witnesses spoke about 1995 and the 55 reported cases of MRSA infection. At that time I was working with FÁS and the father of one of my colleagues died. That colleague overheard a conversation among nurses to the effect that her father was “the MRSA patient”. His death was not reported as being MRSA-related and I believe there was an enormous level of under-reporting. I simply do not believe there were only 55 cases of MRSA in 1995——

Dr. Graham:  Or 550 last year. We do not believe that either.

Deputy Gormley: We must get the reporting right. That is the first requirement.

The most fundamental hygiene standards are still not being followed. I was shocked to hear from an intern who has just started working in a Dublin hospital that he saw no hand-washing and no use of sterile gloves by staff there. We are dealing with abysmal hygiene standards in the midst of a crisis that has been so eloquently outlined to us today.

Bugs do not become superbugs unless there is real antibiotic resistance. I have raised the issue of antibiotics a number of times in the House and it is directly related to this discussion. I am concerned about doctors handing out antibiotics to patients. Antibiotics are being handed out far too freely. Can Dr. Fawsitt comment on that point? There seem to be no standards in this area. We have talked about standards in other areas but they also seem to be lacking when it comes to antibiotics. Some GPs do not hand out antibiotics willy-nilly but others hand them out like Smarties. That is part of the problem.

Dr. Fawsitt:  There have been moves by GPs over the past 20 years, nationally and internationally, and very successfully in the United Kingdom, to reduce antibiotic prescribing. Since the mid-1980s we have recognised that there is an emerging problem of antibiotic resistance. The Irish College of General Practitioners has taken the lead in trying to reduce prescription rates. However, GPs are not the only prescribers of antibiotics. For example, God only knows what is in a MacDonalds burger. At least, we are regulated and audit our members. Improvements have been made in the United Kingdom, where antibiotic prescriptions have decreased by 20% to 30% in recent years. That trend is beginning to be followed here. While we accept we have contributed to the problem, the issue should be seen as a societal one. Antibiotics have brought so many benefits during the years that problems such as MRSA were bound to arise. Unfortunately, we have known about the issue for a long time but not taken steps to address it. People are not being isolated in hospitals and we are neither washing hands nor observing EU demands to ensure beds are 2 m rather than 2 ft. apart.

MRSA is probably present in my surgery and, if not, will be before long. I have to exercise vigilance by performing risk assessments and informing my practice nurse and staff on the issue. The problem is no longer confined to hospitals but affects the entire community. How many wash their hands after using the toilet? Hygiene is a societal issue. We could complain about CEOs and standards but we are all responsible for changing our culture when it comes to hygiene. While I accept GPs have had a role in this problem, but we are not the only culprits and are doing our best to resolve it.