Private Members´ Motion – Speech by Mr Micheál Martin TD
I welcome this opportunity to address the House on the issue of Severe Acute Respiratory Syndrome (SARS) which has been the subject of much commentary and analysis in both the general and specialist health media in recent times. Firstly, I would like to present to you a brief overview of SARS and why it has become such a topic of worldwide public concern.
Severe Acute Respiratory Syndrome (SARS) is an acute respiratory illness of unknown origin, which was first recognised in South-East Asia in February 2003. Owing to the serious nature of the infection, its high mortality, and its spread to a number of different countries, it was declared a threat to international health by the Director General of the World Health Organisation in March 2003. As part of its worldwide surveillance of the syndrome, the World Health Organisation has requested Member States to provide information on their experience. As of 5th May 2003, a cumulative total of 6,583 “probable” SARS cases with 461 deaths have been reported from 29 countries to the WHO. To date, Ireland, in accordance with WHO guidelines, has confirmed to that Organisation that it has one “probable” case, reported a number of weeks ago. The 15 EU countries between them have 32 “probable” cases with no deaths. Our nearest neighbour, the UK, has 6 “probable” cases. Areas of Asia account for the vast majority of cases and deaths. Outside this area, Canada has been most affected.
The symptoms of SARS include high temperature (>38°C) and dry cough and/or shortness of breath and/or difficulty breathing. This is relevant only to people who have been in the affected areas and/or have had, during the 10 days prior to onset of symptoms, close contact with a person who is a suspect or probable case of SARS.
As the WHO itself recognises, the case definitions which it has provided to Member States to assist in global surveillance are subject to limitations due to the evolving nature of the illness. They are based on current understanding of the clinical features of the disease and the available epidemiological data and may be revised. It also makes allowance for the fact that countries may need to adapt the definitions to their own disease situation.
In order to understand this issue, a Ceann Comhairle I think it is worthwhile for me to set out clearly on record the case definitions for SARS.
A Suspect case is a person presenting after 1 November 2002 with history of high fever (>38°C) and cough or breathing difficulty and one or more of the following exposures during the 10 days prior to onset of symptoms:
- close contact with a person who is a suspect or probable case of SARS
- history of travel to an affected area
- residing in an affected area
a person with an unexplained acute respiratory illness resulting in death after 1 November 2002 but on whom no autopsy has been performed and one or more of the following exposures during the 10 days prior to the onset of symptoms:
- close contact with a person who is a suspect or probable case of SARS
- history of travel to an affected area
- residing in an affected area.
A Probable case is a suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) on chest X-ray or a suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause.
While threre was considerable media coverage in relation to the change in status between a ‘suspect’ and‘probable’ case, I would like to point out that the WHO’s own guidelines indicate that because there is no diagnostic test for the virus, SARS is currently a diagnosis of exclusion and that the status of a reported case may change over time. In their documentation, they describe a number of scenarios in which this process could occur.
Examples given include:
- a suspect case who, after investigation, fulfils the probable case definition, should be reclassified as “probable”
- a case initially classified as suspect or probable for whom an alternative diagnosis can fully explain the illness should be discarded.
The existence of SARS was first brought to the attention of the Irish authorities during the week ending 16 March 2003. The early advice from the WHO was merely to provide information about the new condition to the relevant authorities. When the existence and possible implications of this condition were first identified internationally in March 2003 the National Disease Surveillance Centre (NDSC), following consultation with my Department, issued an alert to all Directors of Public Health on 14th March 2003.
Contrary to reports, my Department moved immediately to respond to the threat of SARS to Ireland. Medical staff from my Department in collaboration with the NDSC spent the St Patrick’s weekend making the appropriate international contacts and literature searches to fully assess these factors and, having done so, to put in place the initial comprehensive public information and professional guidance which has been the basis for our approach to this issue since.
On receipt of the initial report of the situation following St Patrick’s Day – over seven weeks ago – I established an Expert Group under the chairmanship of Dr Darina O’Flanagan to advise me on the issue and to make recommendations as to what actions would be appropriate to prevent the establishment and spread of SARS in Ireland. The Group monitors the situation as it develops and provides advice in relation to the measures required to deal with the syndrome. The Group includes representatives of my Department, the Health Boards and the various clinical disciplines appropriate to the task. This Group, which is currently chaired by Dr Jim Kiely, Chief Medical Officer of my Department, has met 14 times to date and continues to meet twice weekly.
The deliberations and recommendations of the Group are based on a number of sound, well tried infectious disease surveillance, control and prevention principles which are internationally accepted and are exemplified in the guidance on this issue published by the WHO, the Centres for Disease Control and Prevention (CDC) in USA, and a number of other reputable international public health institutes including the NDSC.
- accurate, well informed and easily readable public information
- sound practical preventative measures including such basic measures as good hand washing
- early identification of cases
- effective clinical care including good hospital infection control
- effective follow up and management of contacts
- rational travel advice for people traveling to and from areas which are affected by SARS
- legal effect to recommended measures including the designation of SARS as a notifiable disease.
I would like to point out, a Ceann Comhairle, that experts from the WHO have fully endorsed the measures which we have put in place to prevent the establishment and spread of SARS in Ireland
On the basis of advice from the Expert Group, the following information and guidance, which is then disseminated through the system for use by health professionals and management staff, has been developed
- protocols and guidance for hospitals and health professionals which describe the syndrome and provide advice on how cases should be clinically diagnosed and managed have been developed and widely disseminated
- guidance for laboratory and infection control staff is now in use as is information and guidance for aircraft cabin and aircraft cleaning staff.
- travel advisories have been given in relation to travel to and from affected areas. Essentially this advice is not to travel to an affected area and persons travelling from an affected area are advised to monitor their health for ten days following their return; if they develop any of the symptoms they should seek medical advice urgently and advise the relevant medical practitioner that they have recently been in an affected area. Advertisements to this have been prominently displayed in the national newspapers on a number of occasions since the end of March last.
- specific travel advice has also been developed for health care workers and
Since the incubation period of SARS can be up to ten days, general registration or health controls, i.e. screening, at ports of arrival in Ireland are of little value. On the contrary, they may give the public a false sense of security. This in line with expert advice received from the World Health Organisation and the European Union Communicable Diseases Committee. Instead the WHO recommends that persons departing an affected area should be interviewed by a health worker to assess whether they have any of the symptoms of SARS or have had any contact with a probable or suspect case.
Recommendations have been made as to the nature of the public information which should be made available. Arrangements have been put in place to give effect to this and early in the process, information was made available by way of notices in airports to alert travellers to the issue. This effort was expanded recently and, with effect from Monday 28 April 2003, arrangements were made to hand out information leaflets on all incoming flights to Ireland and at other points of entry (ports & Enterprise trainline). It is estimated that circa 100,000 leaflets per day will be distributed through these channels.
- Public announcements are also being made on incoming flights and ferries
- SARS Information Desks have been set up at arrival terminals in all airports and ferry ports
- A national freephone line (1800 45 45 00) has been set up with effect from 28 April
- Full information is available on my Department’s website which is updated daily
- Consideration is also being given by the Expert Group to the issue of the public health implications of participation by a number of countries in the Special Olympics. It is anticipated that a decision will be taken by mid-May
- Finally, my Department has produced a detailed Frequently Asked Questions document which has been circulated to other health agencies and organisations, including trade unions, educational institutions, professional bodies, etc for circulation and display on their websites.
In addition, I have ensured that an organisational framework with clear lines of responsibility and whose function is to ensure that the recommendations of the Expert Group are implemented in their entirety has now been developed within my Department and includes the following:
- An Inter-Departmental Planning Group which is responsible for:
- co-ordinating the measures needed in other areas of public policy or public services to support the protection of public health
- feeding back on the on-going effectiveness of measures taken
- considering, in the light of SARS development nationally and internationally, any further measures required
In addition, there is now a Health Service Implementation Group which consists of senior management of my Department and the Chief Executive Officers of the health boards which is responsible for ensuring a full response by all aspects of the health system to the SARS threat including:
- arrangements for treatment of SARS cases, both in hospital and the community including appropriate surveillance
- adequate public information and advisory service locally
- adequate protection of health service staff
- staffing of information points at airports and relevant ports
- system for notification of potential cases and prompt follow up of contacts
- arrangements for isolation and quarantine where necessary
- prompt information flow to the Incident Room in my Department.
Furthermore a Communications Group, which is led by the Press Office of my Department in liaison with the Government Information Service (GIS) and Communication Officers of each health board, is responsible for coordinating all communications relating to SARS, including:
- information to the public
- statements to media
- daily press briefings.
We must recognise that SARS is a new and unpredictable condition. While the spread of the disease has been facilitated by rapid international travel, the actions of the WHO have allowed a remarkably rapid identification of the features of the syndrome, its causative organism, rapid progress towards the elaboration of a reliable diagnostic test and the implementation of a series of public health measures which have allowed for the control of the outbreak in a number of countries in which it was established and prevention of its wider spread. However, the continuation of the outbreak in the most populous country on earth gives serious cause for concern. It emphasises the need for continuous vigilance and for the effective implementation of the public health measures which have so far allowed countries in the European Union, including Ireland, to control the outbreak. We are determined to continue to draw upon the most up to date international and national information and expertise to inform our approach to this disease, to collaborate with our EU and WHO partner Member States in the fight against SARS and to maintain a state of readiness to deal with the illness as it evolves.
Of course the Public Health Doctors dispute has hampered our response to the SARS threat. In response to this, the Department together with the ERHA and each health board has put contingency plans in place to enable them to provide an emergency response to infectious disease outbreaks, including SARS, during the course of the strike These plans include –
- the establishment of a national network of Senior Co-ordinators at health board level. The coordinators monitor the contingency plans and report on suspect cases throughout the country.
- the establishment of an Incident Room with a dedicated national call number in the Department of Health & Children; staff are available at all time to deal with issues that may arise in health boards. Reports on queries that may arise are issued twice daily from health boards to the Incident Room.
- ensuring that the county’s experts in Virology, Respiratory Infections and Infectious diseases are available to advise and assist in the diagnosis and treatment of suspected SARS cases.
Although less than optimal, I am satisfied that the contingency plans have enabled an adequate response to the diagnosis and treatment of suspect SARS cases.
I now wish to turn to the strike by public health doctors, who are members of the Irish Medical Organisation. A national strike by any group of health care workers will always have implications for our health service.
Ceann Comhairle I, therefore, wish to state again on both my own behalf and on behalf of my Government colleagues our serious concern at the national strike action by public health doctors in pursuit of a 30% pay claim.
I would like to make it absolutely clear again here today that groups of staff at every level right across the health system enter claims about a variety of issues related to their terms and conditions of employment. If my job as Minister, or my Department’s role, was to simply say yes to each one of these claims and demands, not only the health system but the entire country would be bankrupt in no time. There are general frameworks- for example, the various pay agreements – within which any such claims have to be examined and considered. There is also the formal industrial relations machinery through which valid claims must be processed. It is simply not within my power or that of my Department or the HSEA or any other agent of management to simply concede major pay claims just because they have been demanded. Such a scenario does not apply to any group in the health system or the wider public services.
I also wish to put on record that this claim has been lodged in relation to the current duties and responsibilities of these doctors and is separate to any pay increase that the Irish Medical Organisation has indicated that they will demand for the implementation of changed working practices that may be required in the future.
I think it is important to clarify again the background to the current dispute, especially in view of the ongoing variety of selective historical accounts that are being circulated. In addition, I wish to remind the House of the offer that has been made to, and rejected by, the public health doctors. This substantial pay increase would be on top of the increases which fall to be paid under the Report of the Public Service Benchmarking Body and before the payment of monies which will arise from the new National Wage Agreement, “Sustaining Progress”.
The Regional Public Health Function was established in 1994, comprising the grades of Director of Public Health, Specialist in Public Health, Senior Area Medical Officers and Area Medical Officers.
Again, Ceann Comhairle, much coverage has been given to the suggestion that nine years or more have elapsed without the issues at the heart of this dispute being addressed. This suggestion is factually incorrect. Under the original 1994 agreement in relation to the establishment of new Departments of Public Health, it was agreed that a review would be undertaken within two years of the Departments getting up and running. This process took longer than expected which in turn delayed the establishment of the Primary Health Review Group until 1999. The Report of the Public Health Review Group (Brennan), which through no fault of the parties involved took longer to complete than anticipated, was published in April 2002. Discussions, both formal and informal, have taken place with the IMO in the interim, though as yet without agreement.
As I have indicated, a full review of the public health function commenced in 1999 with the report of the Public Health Review Group (Brennan Group) issuing in April 2002. The IMO were equal partners and co-owners of this review process. The HSEA/Department of Health and Children/Health Boards accepts the recommendations contained in the Brennan Report. The Report does, however, reflect the diverging views between the parties on the issue of consultant status for Public Health Doctors. The Chairman’s comments in relation to the status of Directors and Specialists were no more than a personal view and as such had not the status of a recommendation. The only recommendations contained in the Report were on those issues on which the parties were in agreement. It is important to note that the Brennan Report acknowledged that there might be a need to revisit its recommendations following the implementation of proposed changes recommended by the Health Strategy (“Quality and Fairness”) and the Primary Care Strategy. Both of these Strategies, and the forthcoming report on the Audit of Structures in the Health Service (Prospectus) and the Report of the Commission on Financial Management and Control in the Health Services, will have significant implications for the future role of Public Health Doctors and, as such, must be taken fully into account in any negotiations process.
I have already mentioned the payments which fall due to public health doctors arising from the Benchmarking Body; I now wish to refer to this matter in more detail. In 2002, following extensive consideration of a detailed submission by the IMO the Public Service Benchmarking Body recommended increases for Public Health Doctors ranging from 2.5% (Specialist in Public Health Medicine) to 14.2% (Director of Public Health Medicine). In making these recommendations, the Benchmarking Body was determining the rate of pay which should apply to the various Public Health posts based on their duties and responsibilities as of 30 June 2002. It is also important to note that these duties and responsibilities have not changed in the interim. The Benchmarking Body did acknowledge that it was not in a position to take account of the issues raised by the Public Health Review Group (Brennan Group) in relation to the restructuring of public health service provision.
In this regard, the Health Strategy envisages a Population Health Division being established in each health board, incorporating such areas as public health and health promotion units. These developments will obviously be influenced by the outcome of the restructuring proposals which are currently being finalised and must be central to any consideration of the future role and responsibilities of public health doctors. Once again Ceann Comhairle, I feel it is necessary to clarify and reiterate the pay increases that have been offered to public health doctors, based on their current role and responsibilities, in order to resolve the key issues at the heart of this industrial relations dispute.
On 14 March at informal talks in the Labour Relations Commission, management made an offer of 10.5%, excluding benchmarking, through the Independent Chair. This offer was confirmed in writing by the HSEA on 18 March.
Taking into account the increases awarded to Public Health Doctors under Benchmarking and the Sustaining Progress national agreement, the application of this increase would result in the following increases for Public Health Doctors between now and 2005, when the Sustaining Progress agreement ends;
- Directors of Public Health would receive an increase of€29,000 or 35.39%, bringing them to €111,000 per annum.
- Public Health Specialists would receive an increase of€17,000 or 21.52%, bringing them to €95,000 p.a.
- Senior Area Medical Officers (SAMOs) would receive an increase of between €17,000 and €19,000 or 30.41%, bringing them to between €71,000 and €81,000 p.a.
- Area Medical Officers (AMOs) would receive an increase between€11,000 and €13,000 or 22.11%, bringing them to between€59,000 and €69,000 p.a.
The HSEA also requested the IMO to agree to have all outstanding issues referred to the Labour Court. Unfortunately, the IMO did not agree to this request and the strike started on 14 April. On 17 April, I wrote to the IMO requesting that they return to the negotiating table.
On 22 April, I again wrote to the IMO confirming the availability of the HSEA and my Department to re-enter discussions with the IMO on the four specific issues identified as being in dispute. On 23 April I invited a delegation from the IMO to meet with me. Although it was not possible for the IMO to accept this invitation, I did have a telephone discussion with the IMO President on that day. On 24 April, the National Implementation Body urged the IMO to suspend its strike and to avail of the industrial relations mechanisms, in accordance with the conditions of the Sustaining Progress national programme. On 25th April, I had an informal discussion with the President and Chief Executive of the IMO at their annual conference in Killarney.
The IMO agreed, on 30 April, to enter into exploratory talks in the Labour Relations Commission with the HSEA and this Department. These took place on 1 May. At these talks, management indicated its willingness to discuss the implementation of the recommendations of the Report of the Public Health Review Group, including the development of a structured out-of-hours system. In addition, the above-mentioned increase of 10.5% was again offered. During these talks, management stressed that the issue of the granting of consultant status to Directors and Specialists was not the subject of a recommendation by the group, but merely the expression of the Chairman’s viewpoint.
I have already acknowledged on a number of occasions that the professional input made by Public Health Doctors to the management of infectious diseases and other public health threats is significant. I have also made clear my belief that the response of the health system is significantly hampered by the absence of that input. I, and my Department, have done and are doing all in our power to facilitate the resumption of negotiations on outstanding issues. I would again today take the opportunity to appeal to the IMO to call off their industrial action and, in accordance with the terms of ‘Sustaining Progress’, to participate meaningfully in negotiations under the recognised industrial relations machinery, with a view to having outstanding issues resolved as speedily as possible.
Turning now to the reform of the health system, the Health Strategy identified the issues which needed to be addressed in reforming the health system, namely –
- the complex structure of decision-making, roles and responsibilities within the health system
- the many layers and intersecting roles, and
- the lack of consistency in the development of systems and the application of schemes.
It concluded that while the system has served us well in many respects, there remained a need for stronger co-ordination and integration of functions and services, greater consistency in access to services and delivery of services throughout the country and greater clarity around levels of decision-making in the full range of organisations (particularly, vis-à-vis the role of the Department) and the requirement for “whole system” effectiveness.
There are three reports currently pending which will inform me in relation to the formulation of a comprehensive reform programme for the health system. These are:
- “The Audit of Structures and Functions in the Health System”
- “The Report of the National Task Force on Medical Staffing”, and
- “The Report of the Commission on Financial Management and Control Systems in the Health System” (being undertaken on behalf of my colleague the Minister for Finance).
These reports are at different stages of finalisation. My colleague the Minister for Finance has recently received the report of the Commission on Financial Management and Controls in the Health Service and is now considering its contents. The work of the National Taskforce on Medical Staffing is at an advanced stage but has not yet been finalised. A final draft of the Audit of Structures and Functions in the Health System has been received by the Steering Group overseeing the project. I anticipate that this Report will be submitted to me very shortly. In consultation with my colleague Minister McCreevy, it is my intention to propose an integrated reform programme to the Government, based on the findings and recommendations of these reports, in due course.