Seanad Éireann - Volume 176 - 26 May, 2004

Health (Amendment) Bill 2004: Second Stage.

Question proposed: “That the Bill be now read a Second Time.”

  Mr. B. Lenihan: The Health (Amendment) Bill 2004 represents a further step in the implementation of the Government’s health service reform programme, which it announced last June. It is very much interim in nature and is being enacted pending the introduction by the Minister for Health and Children of legislation later in the year to give legislative effect to the other proposals in the reform programme.

As Senators will be aware, the reform programme is one of the most ambitious change management programmes undertaken in the health service. It has its origins in the national health strategy, Quality and Fairness — A Health System for You. The strategy forms a blueprint for the further development of our health system to meet the needs of patients and deliver high quality care in the years ahead. While the current structures have served us well over the past 30 years, the strategy recognised the need to review them to ensure they were appropriate and responsive to the needs and challenges of delivering health services in the changing environment of the 21st century.

The four principles of equity and fairness, the need for a people-centred service, quality of care and clear accountability underpinned the development of the strategy. On the basis of these principles, four goals were identified to guide and shape the strategic direction of the development of health services. These were better health for all, fair access, responsive and appropriate care delivery and high performance. The strategy recognises that the health service of the future must be co-ordinated and integrated with a consistent, national approach to delivery based on clear and agreed national objectives.

Arising from the strategy commitment, three reviews of the health system were undertaken. These included the Prospectus review, an audit of structures and functions in the health system, and [1271]a review commissioned by the Minister for Finance and carried out by the commission on financial management and control systems in the health system. The reform of the acute hospital sector was being advanced at the same time by the national task force on medical staffing which issued the Hanly report. This report set out recommendations on how to plan the reduction of average working hours of non-consultant hospital doctors by 1 August 2004 to meet the requirements of the European working time directive. Its recommendations also covered planning for the implementation of a consultant-driven service and the medical education and training needs associated with the working time directive.

A main finding of the review of the health system was that the number of agencies involved in the provision of health services caused the delivery to be very fragmented. This fragmentation resulted in an overlap in the delivery of certain services and, in some instances, a lack of clarity as to who was responsible for the delivery of the service. The Government announced the health service reform programme based on the recommendations of the Brennan and Prospectus reports in June 2003. The programme’s priorities are improved patient care, better value for taxpayers’ money and improved health care management. The reform programme centres on an organisation of approximately 100,000 staff and a budget in excess of €10 billion. I am sure Senators can recall me pointing these figures out before.

Key elements of the programme include a major rationalisation of existing health service agencies, including the abolition of the existing health board and authority structures and the establishment of a health service executive, which will be the first ever body charged with managing the health service as a single national entity. Furthermore, a health information and quality authority will be established to ensure that safety and quality of care are promoted throughout the system while the reorganisation of the Department of Health and Children will take place to ensure improved policy development and oversight. It is also necessary to modernise the health system’s supporting processes of service planning, management reporting, etc, to bring them into line with recognised international best practice and to strengthen governance and accountability across the system. The establishment of a health service executive as the first ever body charged with managing the health service as a single national entity is the cornerstone of the reform programme. On its establishment and following the abolition of the health boards and the Eastern Regional Health Authority, the executive will be responsible for the delivery of health services on a national basis.

The responsibilities of the proposed health information and quality authority will include [1272]assisting the health service executive in the development of high-quality health information systems to enable it to plan and arrange the delivery of health services based on evidence-supported best practice.

The HIQA will also provide an independent review of quality and performance and it will be involved in promoting and implementing quality assurance programmes nationally. Its analysis will support and inform the Department in its policy development role.

The HIQA will be established as an independent statutory agency, directly accountable to the Minister for Health and Children. The reorganisation of the Department of Health and Children to allow it to support the Minister in focusing more on strategic and policy matters is also proposed in the reform programme. Following its restructuring, one of the Department’s fundamental roles will be responsibility for holding the service delivery system to account for its performance. The reform programme also involves a programme of consolidation and rationalisation of 27 existing agencies, which will be subsumed by the HSE, HIQA or the restructured Department. This consolidation of service providers will help reduce the fragmentation of services in the health system and make services more integrated and easier to access for the public.

The implementation of the reform programme is now well under way. Phase 1 included a communication and consultation process; the establishment of the national project office within the Department of Health and Children; the establishment, work and output of 13 action projects; the establishment of the interim health service executive and appointment of the chairman and board of the interim executive; and the development of a high-level programme plan identifying key milestones for 2004.

A national steering committee, whose role is to oversee, monitor and steer the reform programme, has been appointed. It reports to the Minister and to the Cabinet committee on health and children on progress achieved on implementation. Its task is to drive the overall reform programme in a co-ordinated manner, involving the interim health service executive, the Department and the Hanly group, and to ensure that direction and progress are in line with the Government’s decisions.

The interim health service executive, which has been established as a corporate body, has begun its work of drawing up a plan, for the approval of the Minister, for the establishment of a unified management structure for the proposed new health service executive. It will also need to plan for the smooth transition from the current structures to the new HSE structure. The interim executive is also required to put procedures in place for the development of a national service plan for the delivery of health services on a national basis and for the establishment of appropriate structures and procedures to ensure [1273]proper governance and accountability arrangements for the proposed health service executive.

As I mentioned earlier, the Minister will be bringing forward legislation later in the year which will provide for the establishment of the health service executive to replace the Eastern Regional Health Authority and the health boards. That legislation will also provide for the establishment of the health information and quality authority. It will make provision for improved governance and accountability as well as planning, monitoring and evaluation. It will provide for the establishment of a statutory complaints framework for handling of complaints in the health services, as recommended in the health strategy. The framework will provide for greater clarity and uniformity of approach in dealing with complaints and will also provide for structured local resolution processes with an opportunity for independent review.

The Minister is conscious of the concerns expressed regarding the lack of public participation in the restructured health system. This Government takes the issue of democratic accountability seriously. The Minister has, therefore, given much consideration to the appropriate mechanisms to be put in place to facilitate opportunities for input at both regional and local level between locally elected representatives and the health service executive.

The provisions in the legislation are likely to include the establishment of a series of regional forums to facilitate local representatives in raising issues of concern to do with health services within their regions with the executive. Membership of the forums would be based on the participation of a number of nominees from each local authority. Putting such arrangements in place would ensure that the voice of local public representatives would continue to be heard in the matter of the development of health services. These arrangements will be designed to complement and reinforce the role of the Oireachtas Joint Committee on Health and Children in reflecting the views of public representatives in the ongoing oversight of the health system.

The health strategy identified the need for a more structured approach to community participation in decisions about the delivery of health services. In furthering this objective, the health boards executive, in association with the Department, issued guidelines to the health boards on community participation. These guidelines set out the principles and framework for structures for such participation. Most health boards have established consumer panels that deal with a wide range of issues such as the development and delivery of services. Two boards have also established regional advisory panels for older consumers and their carers. The Minister intends to establish these structures on a legislative basis in the next Bill. It is the Minister’s intention that these structures will be in place from January 2005.

[1274]As I said at the outset, this is interim legislation pending the introduction of legislation establishing the new structures which the Minister will be bringing forward later in the year.

The Bill provides for the abolition of the membership of the Eastern Regional Health Authority, area health boards and health boards, while retaining the authority and boards as legal entities; the termination of office of all members of the health boards and the authority from the date on which an order is made bringing the Act into operation; the assignment of the authority or boards’ reserved functions to the chief executive officers or the Minister for Health and Children, as appropriate; and the amendment of existing legislative provisions regarding the acquisition and disposal of property by the health boards and the Eastern Regional Health Authority by re-introducing the need for ministerial consent prior to the acquisition and disposal of property.

The Bill amends the Health Act 1970, which established the health boards, the Health (Amendment) (No. 3) Act 1996, which deals with accountability issues and defines “reserved” and “executive” functions, and the Health (Eastern Regional Health Authority) Act 1999, which established the Eastern Regional Health Authority and the area health boards. It also amends the provision of the Local Government Act 2001 which provides for the nomination by local authorities of members to the health boards and the Eastern Regional Health Authority. I will now deal with the main provisions of the Bill.

Section 1 deals with the Title of the Bill, its collective citation and its construction. It is a normal type of section. It provides for the commencement of the provisions of the Bill by order of the Minister and it provides that different provisions may come into force on different dates. Section 2 deals with the definitions used in the Bill. Section 3 provides for the repeal of sections of previous Acts detailed in the Schedule.

Section 4 of the Bill amends section 4(1) of the 1970 Act by deleting the reference in that Act which enabled the Minister to specify the membership of health boards. The provisions specifying the membership of the boards, the application of certain rules in the nomination of members by county or city councils and the obligation to consult such councils before making regulations defining functional boundaries of the boards are being repealed.

Section 5 of the 1970 Act deals with the rules that apply in regard to membership and meetings of health boards and authentication of the board’s seal. These provisions, subsections 1(d) and (e), 2 and 3 and the Second Schedule, are being repealed. Currently, the signature of the chairman or that of another member of the board is required to authenticate the seal. As a result of the removal of the membership of the board, section 5 of the Bill provides that the board’s seal shall be authenticated by the signature of the [1275]chief executive officer and another officer authorised to do so.

Sections 6 to 8, inclusive, delete the requirements of the chief executive officer to consult or agree with the chairman or vice-chairman of a health board on any matter. These are necessary to take account of the fact that there will no longer be a chairman or vice-chairman of health boards in this interim period.

Sections 9 to 14, inclusive, make amendments to the Health (Amendment) (No. 3) Act 1996. Currently, under the 1996 Act, reserved functions of a health board are functions exercised directly by the board and the authority, while executive functions are those exercised by the chief executive officer. Section 9 of this Bill assigns all functions of health boards to the chief executive officer. Section 10 provides that the CEO must provide the Minister with any information in regard to the performance of his or her functions which he or she may request from him or her.

Sections 11, 12 and 14 make amendments to the provisions relating to the adoption of service plans by health boards and the authority and to the provisions relating to the submission of accounts to the Comptroller and Auditor General and the publication of the annual report. Section 13 assigns the board’s function in regard to the appointment and removal of the CEO to the Minister.

Section 15 amends the Health Act 1947. It provides that the board and the authority must obtain the consent of the Minister prior to the acquisition or disposal of property. This reverts the legal position to the state of affairs which obtained before the enactment of the 1996 Act, which introduced an amendment permitting the boards and the authority to acquire and dispose of land subject only to general directions by the Minister. In the absence of appointed boards, there is a need for control in this area in the interim period.

Sections 16 to 24, inclusive, make the necessary amendments to the Health (Eastern Regional Health Authority) Act 1999 to abolish the membership of the ERHA and the area health boards. Sections 18 and 21 deal with the authentication of the seals of the authority and the area health boards. Section 20 assigns the functions relating to the appointment of the regional chief executive to the Minister. The functions relating to the appointment and removal of an area chief executive are assigned to the Minister in section 23. Section 25(a) assigns the functions of the authority to the regional chief executive and section 25(b) assigns the functions of an area health board to an area chief executive.

Under section 220 of the Local Government Act 2001, local authority members are empowered to nominate members to specified linked bodies. Section 220 is amended by section 26 of this Bill by deleting the inclusion of a health board, the Eastern Regional Health Authority or an area health board from the definition of [1276]“linked body”. The effect of this amendment is that local authority members will no longer have nominating rights to health boards, the authority or to area health boards.

Section 27 of the Bill terminates the membership of all members of the boards, the authority and the area health boards from the date on which an order bringing the section into operation is made. As the terms of office of the members vary for the different categories, the purpose of this section is to ensure that the terms of office of all members is terminated at the same time.

Section 28 makes provision for work commenced by the members of the boards, the authority or an area health board to be carried on by the CEO without having to begin the process again.

Section 29 of the Bill was inserted at Report Stage in Dáil Éireann. A similar amendment was tabled on Committee Stage by Fine Gael and the Minister provided his own amendment which is now in the form of this section. This was voted on last night by the Dáil. It provides that the Oireachtas Committee on Health and Children may require the chief executive officer of a health board, the regional chief executive of the authority, or an area chief executive of an area health board to appear before it to give account for the general administration of the board or the authority. Similar provisions are included in other legislation establishing State bodies, such as the Courts Service.

As I said at the outset, this interim Bill marks a further step in the process of the implementation of the health service reform programme. Its enactment is a further indication of the Government’s commitment to the delivery of a reformed health service which has as its objective the maximisation of the level and quality of care provided to patients and clients in the years ahead. It is obvious the Minister has undertaken an ambitious programme of fundamental reform on health structures in the State.

This Bill is necessitated by the fact the local elections are now due. In the absence of this legislation, the new authorities would begin the process of appointing new members to health boards. It would be pointless to do so when the Government is committed to introduce legislation to abolish these boards within the year. That is why the Bill is before the House. I commend the Bill to the House and I look forward to hearing the views of Senators.

  Mr. Feighan: I welcome the Minister. He stated that the enactment of this Bill is a further indication of the Government’s commitment to the delivery of a reformed health service, which has as its objective the maximisation of the level and quality of care provided to patients and clients in the years ahead. He went on to state that he looked forward to hearing the views of Senators.

[1277]  Mr. B. Lenihan: I did not use the word “client”. I did not deliver that speech.

  Mr. Feighan: It is in the leaflet handed out to us.

  Mr. B. Lenihan: I did not use those words. I used the word “patient”. I did not use the word “client”.

  Mr. Feighan: “Patient” is much more appropriate, but “client” is here in the leaflet.

  Mr. B. Lenihan: That speech was delivered by the Minister for Health and Children.

  Mr. Feighan: The Minister of State claimed he was looking forward to hearing the views of Senators. I do not think the Minister will be too keen to hear my views. Fine Gael is opposed to this legislation and I have problems with the manner in which Government legislation and reform is carried out, especially the Hanly report. In the past year there has been much confusion, bitterness and division. The Minister decided to close Ennis hospital and Nenagh hospital, but has granted them a reprieve as the local and European elections approach. What kind of Opposition does he think exists? He stated he was going full-steam ahead with all the reforms, but wavered for political expediency. People have a right to change their minds, but the Government is wrong, and it is completely wrong regarding the Hanly report. One Senator on the Government benches has already called for the report to be binned. That call should go to the Minister as the report is dead in the water.

As someone who was not involved in politics until relatively recently, I was part of that public mood that wanted to get rid of all politicians from health boards, VECs and so on. I felt politicians did not have the expertise or professionalism, or might have had an agenda, when making very serious decisions. However, when I was elected to Roscommon County Council, I sat on VECs and the county enterprise board. I took my job with great pride, enthusiasm and even impartiality. I later found out on an interview board that there were people within the system who made the decisions because they had worked with or knew a candidate, or were repaying a political candidate.

Once again with these reforms, we are leaving decisions to people within the health boards to repay favours to those who wish to climb the ladder. I do not think that is acceptable. The Minister, in trying to capture the public mood, is getting rid of politicians and I think he is wrong. We are replacing politicians with bureaucrats. Why should anyone bother to go for election any more? Should seats on a health board be given to some doctor’s secretary to speak on his behalf? Since I have seen the system from the inside, my mind has changed on this issue and I feel very strongly about it. Politics is part of everything, but [1278]the Minister ignores the fact that there is politics in VECs and in the areas of health and education. Without an elected representative on a health board standing up for the rights of patients, we are on a downward spiral to a less efficient health system with less accountability.

There is much debate on decentralisation, while CIE and Aer Rianta are to be broken up. Many years ago, county health boards existed and were an effective model, but it was decided to abandon these and develop regional health boards such as those in the west. Now there will only be four regional health boards. I do not think that bigger is better, I prefer small, accountable health boards. We have an ombudsman for the insurance sector. We should have the same for the health sector, particularly in a system where everyone is represented. Every trade and profession has an association, union, consultants and public relations. Yet the patients and the health boards do not have anyone on their side. Unless accountability is put back into the system, these reforms will fail.

Every day I deal with constituents who are some of the 27,000 people on waiting lists for an operation or the 46,000 who have lost their medical cards. Who will speak for the people on the hospital trolleys? Who do I talk to as an elected representative? Should I tell these people not to come to see me but to go to some bureaucrat the Minister has appointed who has worked his or her way up through the health system to that position? The Minister is getting rid of democracy, and that is a dangerous route to travel.

There are 100,000 people working in the health system, which has a budget of €10 billion. The Minister is playing with people’s lives and careers and, most importantly, he is putting the patient in danger. I ask him to ensure that public representatives have a say in the health system. We are going down a very dangerous road. Fine Gael will oppose this legislation. Accountability is being lost in this legislation and in view of this it, like the Hanly report, should be abandoned.

  Labhrás Ó Murchú: Cuirim fáilte roimh an Aire Stáit agus gabhaim buíochas leis mar gheall ar an soiléiriú a thug sé dúinn maidir leis an mBille seo. I welcome the Minister and thank him for the clarifications he has given us. He mentioned that what we are dealing with is interim legislation, the first of two Bills which will be coming before the House. The purpose of these Bills is to give legislative effect to the proposals of the reform package the Government is bringing forward on the health services.

It is right also to make the point that the health service has served us well over the past 30 years and we should salute all those who made a contribution to that service. The health boards in particular should be given credit for the work they did. They were the conduit between the service and the community, and we all realise the importance of that in this age of transparency and [1279]accountability. The local authority members who served on those boards were in touch with the needs of the community. They were often able to undertake fire brigade action where that was required. The people on those boards were very committed, and they had a good knowledge of the way the service worked. Anybody who studied any of the boards over the years will realise that without them we may not have had the same observance in regard to the delivery, quality and accessibility of service, which is particularly important.

When the Minister is considering the new fora which are intended to allow input by public representatives I ask that he ensures they have teeth and that they are not merely advisory bodies which exist to question the executive. They should be given a status, which in many ways they deserve, and their expertise and experience should be availed of. In view of what the Minister of State said in his speech it is clear an opportunity exists to closely examine this proposal before we deal with the further development of the new structures being brought forward.

It is not an exaggeration to say that good health and a good health service are fundamental requirements to any society, particularly a progressive society. The health service is always a priority in public debate, as it is with the Government. However, we sometimes make the mistake of equating money with service. Over the years we have seen that irrespective of the amount of money that has been invested, there is not a commensurate return for that expenditure on the ground. It behoves a Government to ensure we get value for money, particularly when such a large amount of the total budget is expended on health. That has been a consistent demand of media commentators and public representatives over the years.

There has been much confusion in trying to analyse value for money. There are many demarcation lines within the service where people take a particular stance and where consultants, hospital management or whatever have their own agendas. I do not say that in a critical way. It is understandable but it is important that there is cohesion among all the interests because the patient, like the pupil in school, is the most important person in this debate.

We should also give credit to the religious orders which played a central role in the delivery of the health service in this country. There is not a person in this House who, over the years, has not remarked on the excellent management, including the overseeing of a medical input structure, provided by the nuns. Many would bemoan the fact that they are no longer available to us but society moves on. In any hospital I have had the opportunity of visiting, particularly in the early part of the 30 years under review, we got value for money and a professional approach. [1280]Compassion was also always provided, an important element which should not be overlooked.

To return to the issue of quality, what we are dealing with today is totally different from what we dealt with 30 years ago. Those of us who are old enough to look back on the history of Dr. Christian Barnard will remember his work in the area of heart surgery. Many people felt at the time that he was indulging in a form of black magic yet what is happening in that area today is almost like cosmetic surgery. We all see the wonderful results which have been achieved as a result of progress in medical science but it also puts pressure on the health service because what is being offered today is many times greater than what was being offered years ago. We have to bear that in mind when we try to assess progress and what still needs to be done. It is like saying that An Post provided a much better service 20 or 25 years ago in that one could send a letter to some area of the country and it would arrive the following morning. Even in that case one has to acknowledge there is a much greater volume of mail than there was in those years. The first action we must take, therefore, is to examine the services now being provided.

Second, we have to be particularly careful in our criticism. While there must be criticism it should be balanced. Often a controversial approach is taken to many issues, particularly health. One would imagine that no hospital was delivering a good health service and yet when one talks to patients — this has been my experience throughout this debate — they invariably say that when they went to a hospital they were well looked after. They praise the medical staff and the structure. When we make reforms we must not throw the baby out with the bath water. We must look at what has delivered the service and at the commitment of those who work in it.

People have different expectations within the health service today. Nurses now take a different approach and it is not for us to say they are wrong in considering their job to be a career rather than a vocation. Everyone else has moved also. A good service is being provided but if we want to have transparency, quality and accessibility, which are the aims of Government and of the public, we must put the necessary structure in place. No service can be delivered without a proper structure and that is the position at present.

Senator Feighan was correct when he referred to confusion with regard to the Hanly report. That confusion arose when people rushed to comment on the report before they had a full understanding of what it set out to do. I am not sure that we fully understand it yet. However, as the debate proceeded people got a greater understanding of the report, alarmist headlines disappeared and the attitude of political point scoring became less prevalent. I do not blame a particular political party for that. Politicians are right to look after their own functional areas with [1281]regard to any service, particularly the health service. Those who are proactive in a debate make a positive contribution to it. As the debate proceeded people gained a clearer understanding of what was being proposed and of the need to provide acute and specialist services where and when they are needed for all people and not just those who have insurance cover. If the Hanly report had received that type of attention early on we could have sought information, analysed the report in greater detail and indicated where corrections, if necessary, might have been made. Senator Feighan was right to say we started from a base of confusion which clouded all opportunity of extending the debate in the future.

The strengthening of governance and accountability is vital. If we continue to allocate State resources to health but cannot see a net result of that, we will have this debate all over again. The Government is right to be courageous and strong in its approach to this issue and the Opposition is right to tease the matter out and to question where we are going. However, the health system must not become bureaucratic to the point where common sense, local knowledge and individual concerns can not find accessibility.

That is why I return to the question of the proposed fora. It has been suggested to me that they might be like the advisory committees which existed in the past. Nothing which existed in the past should be revived simply for the sake of saying we have local democracy in the new system. The Minister must examine this issue very closely. There remains an opportunity for flexibility. I recently attended a seminar on this issue in Tipperary where the issue of local authority representation in the health service was discussed. It was clear that local authority members were not interested in jobs for the boys or in holding on to what they had. They were principally concerned with having the necessary expertise and with delivering on their responsibilities exceptionally well. They were determined that local representation would be an ingredient in any future reform.

I wish the Minister well in what he is trying to achieve and reiterate the four points which have been mentioned: better health for everyone; fair access; responsive and appropriate delivery; and high performance. If we keep within those four guidelines it will be possible, with the constructive and positive help of everyone, to get this right once and for all.

  Dr. Mansergh: I welcome the Minister of State. We all have an interest in the successful implementation of the national health strategy. I agree with my colleague, Senator Ó Murchú. Despite what I read about problems in the health service, the experience of those close to me has been, on the whole, good. They have not experienced the health service as the lurid disaster area depicted in the media. Nonetheless, I accept there are serious problems and pressures, which are particularly heavily concentrated in the [1282]greater Dublin area. We need to remember that the population of the country has increased from little over 3 million in 1971 to almost 4 million today.

I have mixed feelings about the abolition of the health boards. Their establishment was one of the pieces of genuine decentralisation, in the sense of devolution, we have had. We are now saying that has not worked efficiently and we must have a centralised delivery system. I have concerns about that. Some of the controversies which have arisen are due, in part, to a resistance to centralisation. This is so in the case of Cavan/Monaghan/Dundalk and of radiotherapy services in Waterford, for example.

When we talk about the health services we talk in terms of delivery but we must also think about the people who are in receipt and need of services. We must not simply consider efficient management from the point of view of the providers of the services. We must also look at the service from the point of view of the patients who need care. I recently attended a meeting in Carrick-on-Suir which discussed the pressing need for a radiotherapy centre in Waterford to serve the south east region. Today’s newspapers contain a report of the very different outcomes for cancer patients in different parts of the country. This must have something to do with proximity and access to services. The journey from Waterford to Dublin takes a minimum of three or four hours by car. A patient must spend an entire day coming to Dublin for a radiotherapy treatment which takes between a few minutes and an hour. Cancer patients are not, in the main, particularly well and this journey puts considerable strain on them.

From the point of view of efficiency of delivery and throughput, I can see why this service should be centralised in two or three places. However, we must look at the service from the point of view of the patient. The south-east regional authority has suggested that a new look needs to be taken at the Waterford radiotherapy issue and I am totally in support of that suggestion. When I was still working in Government Buildings but heading in the electoral direction, I had an argument with a former adviser to the Minister for Health and Children. When I told him I supported the Waterford radiotherapy centre he replied that I was sounding like a county councillor. I respect county councillors and so did not take that as the insult that was, perhaps, intended.

There is a disadvantage in downgrading democratically elected representatives. I agree with Senator Feighan that local representatives have not treated decision-making on a highly partisan or biased basis. My experience has been — I can only speak for the South Eastern Health Board area — that public representatives want to do the best job for people in their area. Obviously, there are sometimes arguments about what should be prioritised and where best to locate facilities. I am not happy about moving [1283]elected representatives from a co-decision making function to a purely advisory one. I agree with Senator Ó Murchú and others that the issue needs further consideration.

A particular problem for health boards has been the issue of resources. A lively debate is currently ongoing in Tipperary regarding the allocation of resources for the completion of Clonmel hospital and the knock-on effects of that for Cashel. It is easy to believe, when one has a problem in any area of Government, that if one changes the structures or the name of the Department, one is somehow solving the problem. Sometimes that works. However, if something is not working one may have to try another way of dealing with the problem including trying new structures. Very often changing structures is a cosmetic panacea which does not get at the real problem.

I am a little sceptical about what is being proposed. We have to try it because the current system is not working. I implore Ministers not to accept uncritically the mania for centralisation. Patients want facilities that are reasonably close and accessible to them. Cancer patients, in particular, are entitled to such services. We must rethink the issue of providing only a few centralised facilities which deal too much from the point of view of the medical professionals and not enough from the point of view of the patients who need the services.

12 o’clock

  Mr. P. Burke: I, too, welcome the Minister of State. The Government is losing the run of itself in terms of this legislation. The Government has, over the past number of years, completely changed how local authorities perform and should take a closer look at what happened in that regard. The new systems introduced were to make local authorities transparent and more accountable. I do not believe they are any more transparent. The new systems created more tiers of bureaucracy which make it harder for the public to find out where to go, what is being done and how it is being done. The legislation before us is, in my view, more of the same.

I cannot understand the logic of a Minister giving the go ahead to legislation to be implemented in 2005 to radically overhaul the health services. In that regard, what the Government is actually saying is that the Department of Health and Children, which has overall responsibility for the health boards, has not performed its duties over the past number of years and that health boards have not been accountable for the past 30 years. Health boards have performed well and have carried out their duties. However, some tightening up is required and better structures could be put in place for health boards by way of resources. Many health board problems arise due to a lack of resources.

The health system in Ireland is one of the least resourced in the European Union. The [1284]Government will say it is investing billions of euro every year in the health service, that it is a black hole, is eating up all the money and that something has to be done. We know something has to be done. Waiting lists have increased and now stand at 27,000 and rising. What the Minister intends to do will not alleviate the waiting lists.

This legislation is window dressing. The Bill proposes the establishment of local area advisory committees. Who will they advise? Who will listen to them? Members of the previously established SPCs were frustrated because advice or decisions made by them were not taken on board. The same will be true of the proposed local area committees which will not be able to make decisions but will only give advice, 90% to 100% of which will not be taken on board because the system, when commenced, will be run by bureaucrats. The Bill proposes the putting in place of a bureaucratic system.

I cannot understand why the Minister wishes to remove public representatives from health boards. In all the years in which I have served in public life, I have not come across a case of a public representative putting his or her interests first. The Minister is, in that regard, handing over the making of decisions to vested interests. He proposes to appoint people involved in health care areas, many of whom may have vested interests. Currently, many doctors who are members of health boards put forward their interests. I have never witnessed local authority members putting their own interests before those of the public. They have always put the public first. The Minister should take another look at this issue. Nobody will listen to the proposed advisory committees. The previous system included public representatives who were at the heart of the decision-making process. Unless those appointed by the Minister are involved in that process, they will lose interest and will not put any enthusiasm or drive into the work they are supposed to do. I ask the Minister to take another look at this issue.

The vast majority of appointees to health boards by various Governments over the past 30 years were public representatives. One has to ask why that is the case. Obviously, the Minister of the day correctly believed such people had a contribution to make to health boards. Such people did have contributions to make. I am sure if one looks back on health board records one will find that in many cases public representatives made huge contributions to their particular health board.

This is window dressing by the Government to buy time. I ask the Minister to examine this legislation. We all appreciate that something must be done to alleviate the crisis in the health service. The Department has not carried out its duties. Proper resources should be put in place as the management exists within the health board system. The strengthening and resourcing of the current system along with a little rationalisation would go a long way to help solve the problems.

[1285]  Mr. J. Walsh: Ba mhaith liom fáilte a chur roimh an Aire Stáit don díospóireacht tábhachtach seo. There is no topic that has been given such attention over the last decade as health and much ink has been used on the subject of health issues. This is not just an Irish phenomenon. It occurs in our neighbouring island and countries in mainland Europe. It is obvious for many reasons that where there is an ageing population, such as in Europe, people have a greater interest in ensuring health sector services are of the highest standard.

There has been a significant investment in the Irish health services since 1997. Expenditure has increased from €3.5 billion in 1997 to €10.2 billion this year. Not everybody would agree that the improvements in the service have been commensurate with the very significant increase in expenditure. Some of the criticisms are unduly focused on hard cases. The comments made by a number of Senators reflect the general opinions of those who use the health services. In general there is an overwhelming satisfaction with the service provided, particularly in the hospitals. That is not to say there is not the occasional criticism. Last year over 1 million in-patients were treated in our hospitals and the number of those treated since 1997 has increased by 200,000.

The numbers employed in the health services have increased significantly, from 68,000 in 1997 to 95,800 last year, a 40% increase. Much of the problem stems from the many vested interests in the health services and in the administration of the health services. This was a structural fault in the regional health boards.

The national treatment purchase fund is a very worthwhile initiative by the Minister for Health and Children. Approximately 11,000 patients who were on the waiting list since 2002 have been treated under the scheme.

  Mr. U. Burke: How many more were added?

  Mr. J. Walsh: It must be noted that not all consultants have embraced the scheme because they believed it would impinge on their level of income. This has emphasised that the issue of vested interests must be tackled as a priority. However, the vast majority of professionals working in the system provide excellent care and service to their patients.

If we value our republican ethos, we cannot allow a situation to continue where consultants who are contracted to provide care to the ratio of at least 80% public patients and 20% private have moved to a skewed position of 60% to 65% public and 35% to 40% private. Considerable incomes can be earned because of the skewing of the system. It demonstrates a structural failure which needs to be addressed. Priority for hospital treatment must be based on medical need and not on the ability to pay. I wish the Minister well in his deliberations with the consultants to establish new contracts and to employ consultants who will be dedicated to public service.

[1286]The Bill deals with the change in the structure of the health boards. I acknowledge the points made by other Senators that a significant contribution has been made by both local and national public representatives who were part of the health board system. In the early days of the State, county councils administered many of the health services, including the management of the hospitals, and were then replaced by the regional structure of management.

The Brennan report recommended that the health board structure should be retained, although their number and functional areas should be reviewed to safeguard the need for local democratic representation. One of the major reports on which the future of the health service is based recognised the benefit of that local input and the necessity to ensure it continued in the future. Much emphasis has been placed on the Hanly report, commissioned to deal with the working-time directive. In view of the implications of the directive, Hanly’s remit went much further than the narrow remit given at the outset.

I agree with Senator Mansergh that the Hanly report may not have been properly digested by everybody and therefore much of the criticism is misguided. A balance must be achieved. This is the era of specialisation. Most sensible people will accept that it is neither possible nor affordable to have the full range of every specialist service available in every hospital. However, some recognition must be given to the practicalities of certain situations.

Both Senator Mansergh and I are from the south-east. He spoke about people from the area travelling to Dublin for radiotherapy treatment of five or ten minutes a week which adds to the stress of the illness. That facility will be available in certain strategic locations and there is a compelling argument, because of our situation in the south-east, for a facility to be located in Waterford hospital.

The organisation chart of the new health board structure shows the Minister and his Department at the head. The Health Services Executive Board and its chief executive is on the next level followed by the national hospitals’ office which will manage the acute hospitals sector, which I regard as a good initiative, and the regional health offices are on the next level. From a corporate governance point of view, a board at national level in control of an expenditure of €10.2 billion is unlikely to be able to exercise the influence required of a board of directors. A company of that magnitude would have subsidiaries and subsidiary boards. If the health areas are to be reduced to four, there is a strong argument to be made for revisiting the proposals. Instead of executives reporting to executives, each area should have a board with some local input of a specialist nature, but not including those with a vested interest, and some public representatives.

[1287]I welcome the regional health forum which is a good initiative. It would be preferable to reintroduce local health committees at county level because public representatives will, in the main, be interested in what happens in their own functional area. I am sure other Senators will echo my comments as regards their counties. My interests are Wexford General Hospital, St. John’s Hospital and other hospitals in the county as well as the regional hospital in Ardkeen. This should be recognised in the new structures.

I will make two points regarding the success of the health reforms. First, it will be incumbent on all stakeholders to adopt the role of interested participant, rather than pursuing vested interests, if we are to achieve the best possible service for the patients they serve. Second, people, through taxation, fund the health service and are, accordingly, entitled to representation at all levels to ensure an effective input into the provision of such services. The Minister will discharge this role at national level but councillors, given their representational role, wealth of relevant experience and historic contribution since the foundation of the State, must be given a meaningful input into all areas of the health services at regional and county level. This is an imperative for the successful implementation of the health reform programme.

  Mr. U. Burke: Will the Senator vote against the Bill?

  Mr. McDowell: I am fascinated by the comments of Fianna Fáil Party Senators. Briefly looking over the report of the Dáil debate, the capacity of colleagues to speak one way and vote in the opposite direction immediately afterwards, within less than an hour in this case, is remarkable.

  Mr. J. Walsh: That is parliamentary democracy.

  Mr. McDowell: It is not parliamentary democracy. One either represents taxpayers or one does not.

  Mr. J. Walsh: That is the type of parliamentary democracy we have.

  Mr. McDowell: The Senator will tell local councillors throughout the country that he did the business by them when in fact in 45 minutes he will vote to abolish their role on health boards. I cannot see how that can be called democratic.

  Mr. J. Walsh: I did not use the word “democratic”. I referred to “parliamentary democracy”.

  Mr. McDowell: It is parliamentary democracy à la Fianna Fáil.

  Mr. U. Burke: It is deception.

[1288]  An Leas-Chathaoirleach: Allow Senator McDowell to continue without interruption, please.

  Mr. J. Walsh: The Labour Party would know that better than any other party.

  Mr. McDowell: I suspect I have more sympathy with the purpose of the Bill than most of colleagues who have spoken. There are genuine difficulties with local health boards and the way in which they have discharged their duties over the years. I do not lay the blame specifically or exclusively at the health boards’ door because they have an impossible job. They have been asked to administer a system and be responsible for the local delivery of services when all the decisions that matter are taken by the Department of Health and Children.

There has been a growing tendency in recent years, partly for understandable reasons, for the Department to micro-manage, to the extent of deciding budgets on a local basis, not just specifically for health board hospitals but also for non-health board hospitals. It has become impossible, in the absence of an independent funding mechanism, for local health boards to make genuinely independent decisions which do anything other than reflect what the Department wants them to do. While they have not become redundant by an stretch of the imagination, they have been less than fully efficient in doing what they were set up to do.

The Bill does not abolish the health boards, it removes them without removing the sub-structure underpinning them. The decisions previously taken by elected members and members representing professionals will in effect be taken by the chief executive. The Minister will argue that this will only be the case for six or nine months or the time it takes to establish a national structure. This may well be the case but it strikes me that the decision to take this action now and follow it with further legislation at a later, unspecified date is typical of the way we do things here. It is like abolishing local authorities by effectively removing local councillors and leaving all power in the hands of managers, while leaving the whole local authority sub-structure in place. We are taking the easy option by removing the elected members and professional representatives and leaving everything else in place. By virtue of the action the Minister will succeed in taking today, an unsatisfactory system will become even more unsatisfactory.

While reading through a file on health in my office this morning, I noted the remarkable number of reports published on the health service, even in the past three or four years. The trio of recent reports was preceded by the value for money report by Deloitte & Touche, the bed capacity report and the medical personnel report.

The plethora of recent reports on the health service, many of which have much to recommend them, were drawn together before the previous [1289]election in the national health strategy published by the Minister for Health and Children, Deputy Martin. My party is on record as supporting a great deal of the national health strategy, including the planned reorganisation of structures. Since its publication, however, we have only had the easy bits. It is not too difficult to change the organisational structure, particularly when it involves abolishing rather than establishing bodies. It is difficult to deliver additional capacity or funding and specific strategies intended to deal with particular types of illness. The Department and Government have been peculiarly deficient in that regard.

In some ways the national health strategy document was a departure from what most civil servants would regard as common sense in so far as it has seven pages of specific dated targets, something civil servants prefer to avoid. Unfortunately, the document makes very sad reading. I was struck by Senator Jim Walsh’s reference to the public private mix, which is specifically addressed in recommendations 89, 90 and 91 of the national health strategy. They refer, for example, to seeking greater equity for public patients in a revised contract for hospital consultants. We still await a revised contract. They also state that the rules governing access to public beds will be clarified. While this may have happened, I am not aware of it. They then refer to taking action to ensure that admission to public patients for elective treatments is managed in a particular manner. If anything, the problem identified in the strategy of private patients using designated public beds is getting worse, as we know from a report produced just a few months ago, yet nothing has been done to address it.

My point is simple. We have a great number of reports, many of them good, including one recommending that bed capacity be increased by 3,000 in the next seven years, but nothing is being done. The reality is that where political will was required and recommendations needed to be cleared with the Department of Finance, the Minister or Department have failed to do so, not because of any lack of political will on their part but because of a lack of will on the part of the Minister for Finance and Government as a whole. I see nothing to persuade me that this position has changed. As a result, we will end up in a typically Irish position in which we simply rejig the structures, while failing to do address all that underpins them, including in particular the need for greater capacity and investment.

I acknowledge there is a difficulty with local health boards, that health professionals see themselves as representing what are sometimes called vested interests and that at least some of our colleagues in the county councils have not taken their positions as seriously as they should. Having said that, there is an unquestionable need for a forum to be established to allow the views of patients to be represented at board level or addressed to the people who make the decisions [1290]about funding in the health service and the administration of the health boards.

I am not convinced that the regional fora to which the Minister refers will have this affect. We all know that health professionals, the people who deliver the service, and those involved in the executive side in deciding how a service will be delivered, will only listen to representatives of patients and local elected representatives if they must. This will require a structure to be established that would still allow a measure of decision making to be taken by elected representatives. As others have noted, if there is a better way to do this than having local councillors on such a body, I do not know what it is.

It is incumbent on the Minister when he refers to accountability, as he continues to do, to spell out in realistic terms how it can be delivered in a manner that makes sense. There is no sense in setting up a regional forum to meet quarterly, if people collect their expenses and express views which are discounted within minutes or hours of the meeting. We must have a forum with teeth to underpin the structure the Minister envisages. Nothing of that nature is in place.

I support the general thrust in the health strategy to reduce the number of agencies, approximately 57, involved in the health service as a whole. All of us accept there are too many and there is a need for not only a central policy making body, but also greater streamlining down the road. The Minister has suggested a reduction in the number to the low 30s or high 20s and that would be sensible. However, it must be ensured the baby is not thrown out with the bath water. The Minister should not rationalise for the sake of saving money. Given the way the Department of Finance has captured the health strategy and is dictating in financial terms the way in which it should be implemented, I am pessimistic because it will be implemented in a way that will ensure certain financial rather than health outcomes and that will be a tragedy.

The Minister has little time left in which to salvage the credibility of the health strategy. Significant promises made during the last general election campaign relating to the abolition of waiting lists by May 2004 and increasing the number of medical cards by 200,000 have been broken, but most of us knew that would happen. However, many other commitments which are to be met further down the line were made. A number of these, for example, setting up primary care teams, are even more important but they are running into the sand primarily because money is not being provided but also because the political will is faltering and a number of vested interests are busy obstructing the strategy. It is important that initiatives such as the setting up of primary care teams are driven not only by the Minister for Health and Children and his Department, but also by the entire Government and the Minister for Finance, in particular, who ultimately has a [1291]veto on such strategies, regardless of whether we like it.

Much of the strategy is good but there are plenty of reasons to be concerned regarding the process and pace of its delivery. It is in all our interests that the strategy should be delivered. Many of us will have canvassed over the past while. There is an increasing sense of desperation among people who depend on the health services. They do not believe the delivery of services can be improved and, unfortunately, that, in turn, has led to a belief that money spent on them is wasted. That is a profoundly wrong view. It is possible to examine the past seven years and beyond and point to successes in addressing issues concerning older people and people with disabilities and, for example, reducing the cardiac waiting lists. It is important that we in Opposition as well as members of the Government highlight where investment has paid off in terms of better services. However, unfortunately, the successes are being seriously compromised by a failure to deliver on so much more and by an insistence for political, cynical and opportunistic reasons on talking up promises, a number of which are not deliverable.

During the 2002 election campaign, following the publication of the Fianna Fáil manifesto which promised the abolition of waiting lists, I was asked whether the Labour Party would match it. We were in Opposition and we felt it would not be honest or serious to give people hope and set a target that was not achievable. The Government has played cynically and opportunistically on people’s hopes and, by dashing them, it may have done serious damage in terms of the ability of future Governments to invest for the future and to achieve the political will and agreement of the electorate to do so. Health boards have problems and the legislation will not resolve them. However, a mechanism for local decision making is needed for the delivery of services.

  Ms White: The Health Act 1970 relates to the scope and level of activities mandated to health boards. These have increased and that is why the legislation is necessary. During the interim period, individual health boards have evolved at various paces, resulting in considerable variation in their organisation structure, practices and efficiencies. Legislation had to be brought in because of the variation in population growth in different parts of the State.

However, I refer to the future role of elected representatives in regard to health boards. The Prospectus report is among the reports on which the Minister has based the legislation. It states: “In our opinion, democratic input in best represented at regional level through twice yearly meetings between Oireachtas Members in their respective regions and the director of the regional health organisation.” When county council members read this statement, they got their act [1292]together and were ably led by Councillor Jack Burke. They visited the Oireachtas last October.

  Mr. U. Burke: Will the Senator let them down?

  Ms White: A delegation of councillors met Fianna Fáil and Fine Gael Senators and we were asked for help in maintaining a role for elected representatives in the new health service structures. This is a cross-party issue.

  Mr. U. Burke: The Senator is spreading the blame.

  Ms White: All councillors and parties are in agreement on this point.

  Mr. B. Lenihan: And all the panels in this House, no doubt.

  Ms White: Yes. I got to know Councillor Jack Burke over the past six months and he is an impressive man. He knows how to instigate action. He was ably assisted by Mr. O’Connor, the chief executive of the Association of Health Boards, and they lobbied the Minister intensively.

I am happy, following the Minister of State’s contribution, that a role will be provided for democratically elected representatives. He stated: “The provisions in the legislation are likely to include the establishment of a series of regional fora to facilitate local representatives in raising issues of local concern in relation to health services within their region with the executive. Membership of the fora would be based on the participation of a number of nominees from each local authority.” However, the Prospectus report states that Oireachtas Members will be the democratic representatives on behalf of the national treasury to make the health service efficient.

Councillor Crowe, a Fine Gael member, Senator Ó Murchú and myself participated in a conference on the proposed changes to the health service, which was organised by Councillor Niall Dennehy in Clonmel earlier this year. Together with Councillor Seán MacCarthy, we spoke passionately about the need for representation at the micro level. Such representation may not be as extensive as in the past but Councillor Jack Burke and his fellow local authority members agreed there must be change. Everything must change on a constant basis. However, I am optimistic the Minister of State’s statement will address their needs, although not completely, as they would prefer the continuation of the status quo. I am happy the recommendation by the consultants that Oireachtas Members only will provide the democratic input will not be accepted by the Minister and the regional fora will comprise local authority members.

  Mr. U. Burke: The Senator reneged on her councillor friend.

[1293]  Ms White: The regional fora will comprise county council members.

I congratulate Councillors Jack Burke and Niall Dennehy for going to the trouble of having a conference, chaired by Senator Ó Murchú and in which I participated. Councillor Seán MacCarthy made the point that, at this level, 95% of the issues concern people. It is down to the micro level. The councillors are available 24 hours per day, seven days per week, to meet the people and interpret their needs. I am happy the Minister will compromise. I hope Councillor Crowe will also be happy because he made a fabulous speech in Clonmel.

  Mr. U. Burke: He must have been number one the last time.

  Ms White: The bottom line is that lobbying by the Association of Health Boards was not let slip through because those concerned were on the ball. Our job as Senators was to help county councillors in what they were trying to achieve because they came to us and asked for help. I raised a matter on the Adjournment advocating that they be given a meaningful role. I am optimistic that it will work out successfully.

  Mr. U. Burke: I welcome the Minister. I certainly do not envy him his task of delivering this legislation, which is effectively abolishing the health boards. For most people, this means further centralisation of the health services. If we are to have one central executive delivering the health services for the whole country, it will be a retrograde step. If there is a service more in need of decentralisation, it is the health service.

I have been a member of the Western Health Board for many years.

  Mr. Leyden: And a good one.

  Mr. U. Burke: The most important matter is that we recognise that the very many personnel within the health boards were top class in delivering the services. The Minister of State referred in his contribution to the strengthening of governance and accountability across the system. Surely this raises a question regarding the governance of the health services at local level and accountability. The Minister stated we must make changes in this area, but one must ask what is wrong with the current system.

Many speakers have said money is being invested but that they do not know where it is going. It is the responsibility of the Government to know where it is going and what it is being spent on. Therefore, the Minister has failed to recognise that he has a responsibility in regard to the failure of the system. The only thing he has done in response to some people or some sections of the media is to remove public representatives from the health boards and claim this will ultimately lead to a proper health service.

[1294]What has happened in recent years under the Minister’s governance? Despite the fact that we were promised the elimination of waiting lists for health services in every area, whether it be in the public or private sector, they have become longer. One might argue that we have a system in place whereby we can send patients abroad where we can buy treatment for them. However, many people at the coalface contend this is wrong because we would have the necessary facilities if only they were organised. The Government has failed to organise them at a low level. If one went into an accident and emergency unit in any hospital, one would note the level of organisation. There is nobody in control to manage the needs of people in this area and consequently the nursing staff have to take all the abuse.

Are we now contending that we will have the desired response if we establish a senior executive that will operate at a distance? Consider all the reports, one of which was mentioned by Senator White and which is supposed to be the absolute gospel dictating how things are to be done. The strategy entitled Quality and Fairness — A Health System for You, published a few years ago, was launched in a blaze of glory. It was to contain all the answers and it was touted that every ill in the health system was to be eliminated within a short time. Within 12 months, however, there was a total withdrawal from that policy document in favour of the Hanly report, which proposes the very opposite to what the former document proposed for the delivery of health services.

There is no doubt that under the Minister for Health and Children, we are leaderless and rudderless, and there is a total absence of any coherent policy to deliver the service needed on the ground. I do not believe any measures in this Bill will change that.

  Mr. Leyden: What are the Senator’s policies?

  Mr. U. Burke: Senator Leyden’s policies while chairman of the health board, and while Minister of State for that matter, were such that he squandered time, effort and resources.

  Ms White: Senator Ulick Burke is jealous.

  Mr. Feighan: Outrageous.

  Mr. U. Burke: When he was chairperson, he was pushed aside because of what was regarded as his parochialism. That is neither here nor there.

  Ms White: All politics is local.

  Mr. U. Burke: Consider the health service area I know best, the Western Health Board area. The purchase of Portiuncula Hospital in Ballinasloe was a good measure.

  Mr. Leyden: I signed the contract.

[1295]  Mr. U. Burke: It was welcomed by all, both at local and national levels. However, what has happened in the interim? The Hanly proposals now encroach and we are to have downgrading. We have been told by local politicians in the heat of the election campaign that the hospital will not be closed. Nobody, including Mr. Hanly, ever said it would be closed but we are to have downgrading and the Minister of State seems to believe this is necessary because he is nodding in agreement with me.

  Mr. Leyden: We bought the hospital. I signed the contract.

  Mr. U. Burke: Furthermore, consider the closure of the Bon Secours Grove Hospital in Tuam. We were told by none less than the Taoiseach at a public meeting in Tuam that this hospital would be up and running by 2005 and would be a fully upgraded community hospital. However, there are now chains on the gate. One cannot even have a carpark in the grounds.

What are we to do with the health board properties throughout the country? Each health board has many land resources, associated mainly with the psychiatric hospitals and other properties.

  An Leas-Chathaoirleach: The Senator has one minute remaining.

  Mr. U. Burke: That is a pity, a Leas-Chathaoirligh.

  Mr. Feighan: The Senator is only getting going.

  Ms White: The Senator should make his point now.

  Mr. U. Burke: What do the Minister and Department intend to do with the vast amount of property of the health boards? Are we going to force the health boards to sell it, grab the money and invest it in other areas? If the moneys from the sale of these properties are not invested in the health services locally, it will again be robbery by another Minister.

The double-speak of the Minister of State and the Government Senators is loud and clear in all instances.

  Mr. Feighan: Whatever you are having yourself.

  Mr. U. Burke: Senator White has asserted that all the local councillors are glad to be off the health boards. She has told them it is sure that there will be one or two jobs for the boys or whatever it might be. They are quite content but the Senator should wait until the next election when she will have to state how she reneged on them. Today she is going through the lobbies to deny them access to the health services.

[1296]None of them is so vociferous. They stayed away from the topic. The Senator will have to answer directly to them in the very near future.

  Ms White: I am afraid of nothing.

  Mr. U. Burke: Along with my party I am totally opposed to this legislation, which represents a retrograde step. We have no notion as to what are the Minister’s intentions. We will abolish a structure without replacing it. We will have absolute chaos in the health services. This is further chaos for those in greatest need and the patient will be forgotten.

  Mr. Moylan: I wish to share my time with Senator Leyden.

  An Leas-Chathaoirleach: Is that agreed? Agreed.

  Mr. Moylan: I welcome the Minister of State. Public representatives who have served on health boards have expressed serious concern about the Health (Amendment) Bill. I served on the Midland Health Board for 20 years, including a spell as chairman. I enjoyed my time and felt we had a good board even though I know there are health boards responsible for much greater populations than that which is served by our board. Great credit is due to the local authority members elected to health boards who have served the country well. They worked on many visiting committees, land purchase committees and farm review committees. In my time the visiting committees played a major role in ensuring everything worked well on the front line, where staff worked and patients were cared for.

Huge improvements have taken place in mental institutions, which I welcome. People were always happy that their public representatives were in a position to visit such institutions and ensure that their relatives were being cared for in the best possible manner. I am concerned that this may now change. The voice of the people must be heard on the new health executive through their local public representatives. Action needs to be taken on this matter. I have fought this issue vigorously through my party and I will continue to fight it when the new legislation is passed.

Health boards had annual service plans and got their allocation from the Department. They ensured they lived within the service plan and everything was 100% above board. At local level there was very good hands-on involvement by public representatives who did an excellent job for so long. I am disturbed when we create good facilities for patients that are not fully utilised. In my home town, we built an age care unit for 90 patients with 40 due to move in immediately. This is being delayed because staff, who are working in very bad conditions and who fought for so long to get a new unit, as a result of some union [1297]problem want €4,000 to move 300 m up the road. That is very wrong in the context of care for patients in the health board area that I represented for so long.

The Health (Amendment) Bill represents an interim measure that must be taken. We look forward to the Bill that will define the future role of local public representatives.

  Mr. Leyden: I welcome the Minister to the House, but I do not particularly welcome the Bill. While there is no doubt that change was needed, the proposed rationalisation represents throwing out the baby with the bath water. I was a member of the Western Health Board from 1992 to 2002 and was chairman when we bought Portiuncula Hospital and the Bon Secours Hospital in Tuam. We built a new accident and emergency unit in Roscommon and upgraded all the wards. Everything was going extremely well and the situation was never better.

  Mr. Feighan: Then they got rid of the Senator.

  Mr. Leyden: The removal of public representatives from health boards is a retrograde step. They have been blamed by the media for the ills of the health service when in reality they were not responsible. They supported the operation of the health boards in a most effective way. For example, Councillor Tim Quinn in Belmullet fought for his local hospital and got it upgraded to incorporate a better screening system. No more voices will come from Belmullet, Achill or Roscommon under the new structures, which will be a big disadvantage.

I welcome that the Minister of State said local authority members would have a consultative role. I was very impressed with Quality and Fairness — A Health System for You, which represented very good structural change. However, there has now been a very radical change in this regard. The national treatment purchase fund scheme has made a huge difference to waiting lists. It has represented a radical and helpful change.

I take this opportunity to express the admiration of the people for the public representatives and other professionals who served on health boards since the 1970s. They were unselfish in their approach and made a major contribution and we record their passing today with this Bill.

I wish to say to Fine Gael, the small Opposition party, that it——

  Mr. B. Hayes: The biggest Opposition party.

  Mr. Leyden: ——has no policies. How cynical it was of Fine Gael to call a public meeting under the guise of an independent public meeting attended by its party leader.

  Mr. Feighan: It was an independent public meeting addressed by the leader of Fine Gael.

[1298]  Mr. Leyden: It has no alternative policies.

  Mr. Feighan: If the Senator was interested, he should have come to the meeting.

  Mr. Leyden: I am opposed to the Hanly report, which I believe will not be implemented in respect of accident and emergency units.

  Mr. B. Hayes: Captain Pugwash.

  Mr. Leyden: Jimmy White, the snooker player, recently collapsed and was brought to hospital to have his appendix removed, which shows the effectiveness of the hospital. I will only take lectures from Fine Gael when it produces an alternative. It has no policies or ideas and is defunct. Farewell to the health boards and good luck to them.

  Mr. B. Hayes: Voltaire is back from the grave.

  Mr. Leyden: I regret their departure and I hope that public representatives will be given a voice on any new structure put in place. That is our call on behalf of all those standing in the local elections on 11 June.

  Mr. B. Hayes: That was fascinating.

  Mr. B. Lenihan: I thank Senators for the great interest——

  Mr. Feighan: And passion.

  Mr. B. Lenihan: ——they have shown in this measure. Not for the first time we have had a very vigorous and interesting debate on the health system. Senator Feighan opened for the Opposition by referring to the Hanly report. The Bill has nothing to do with that report, but arises from the Prospectus report, which recommended the changes we are now beginning to implement through this legislation.

  Ms O’Rourke: With the approval of the Leas-Chathaoirleach, I wish to propose a variation to the Order of Business agreed this morning, which stated this debate would conclude at 1 p.m. I propose that the debate conclude at 1.10 p.m.

  An Leas-Chathaoirleach: Is that agreed? Agreed.

1 o’clock

  Mr. B. Lenihan: The Prospectus report recommended very far-reaching changes in our health structures. In a House in great part elected by local representatives it is understandable that concerns have been expressed on all sides at the prospect of eliminating the local councillor as a key feature in securing accountability in the health system. Senator Mansergh highlighted this concern and I reply to him by asking him to [1299]consider the historical position regarding the organisation of our health services.

We started with the poor law unions in the 1830s and the original health services were organised on a poor law union basis — a sub-county unit — and certain elementary services were introduced through that structure. We then moved to a county-based system at the foundation of the State with the services centralised on a county basis. In 1970, the then Minister for Health, Mr. Erskine Childers, introduced the current health board system we all know and love so well as it was found that the county was inadequate as a unit. While I am not making judgments about the Hanly report or any other issues, the county as a unit was not sufficient. Prior to the 1970 Act, many local authorities had already formed joint county boards to administer particular hospitals and health services. As the county was seen simply as being too small a unit, we adopted a regional approach in 1970.

There have been significant social changes in the 34 years since. Communications, medical technology and the nature and character of our social services have changed a great deal. It is understandable to adopt a unified approach to the administration of the health system in a state with a population of only 3.7 million. There are many single health authorities in other parts of the world which cater to populations well in excess of 3.7 million and there is a solid intellectual case to be made against fragmenting the organisation and delivery of services across eight health boards. People in public life will be well aware of obvious examples of problems in this regard. Whether medical card guidelines can be waived and a special or exceptional case made rests ultimately with the discretion of the chief executive officer of a health board. Is it right from the point of view of the citizen that his or her entitlement to a medical card should be dependent in exceptional cases on the discretion of an executive officer who may follow a different set of criteria to those followed by his or her seven peers? Clearly, it is not and the public does not understand why this practice obtains.

It is clear that there has been a revolution in hospital management and practices with significant increases in the costs borne by the Exchequer to provide services. That is as it should be. If one considers hospital services in their totality, it is clear that there is a significant degree of interdependence. To maintain that a health board area has a self-sufficient hospital service is to state the unreal given modern medicine as it obtains in Ireland today.

I do not make judgments on the Hanly report as that is a debate for another day. Senator Leyden expressed his views on the report very clearly and I do not want to go down that road [1300]now. This Bill is not about the Hanly report, it is about how we organise the health service.

Almost every Senator said there must be a real and proper role for local authority members in the context of the delivery of health services. I agree with them. It must be remembered that health service funding is borne by the Exchequer and he who pays the piper must be allowed to call the tune. There must be some form of central direction in a system where the funding is being provided from the Oireachtas. However, the size and complexity of the system, the vast numbers of staff deployed and the significant range of health and social services provided make it essential to ensure that local authority members continue to have a real contribution to make to the assessment of delivery. The Minister subscribes to this point of view. Senator White outlined how he was brought around to it in the course of her contribution. Continuing input from local authority members is one way of ensuring accountability in the system in a very important way.

I hope Senators will forgive me for not responding to every contribution in turn. I have replied in a general sense to the points which have been made. It is important to note the issues raised about complaints and an ombudsman. The statutory framework for complaints will provide for an appeals system. If a complainant is not satisfied, he or she will have a right to appeal to an ombudsman. This system is part of the provisions the Minister envisages. I join Senator Ó Murchú in paying tribute to those who served on health boards and did a great deal of public service down the years. The issue is to refashion the system through the measures we are considering today.

Senator Paddy Burke expressed concern about the increased powers of health board management. Under this temporary legislation, health boards will be accountable to the Minister. There is real accountability. Senator Ulick Burke expressed the view that the Bill represented a retrograde step and ran contrary to the need for greater decentralisation. We have decentralisation. The Hanly report will not be used as a threat to local hospitals. Local hospitals and community care facilities are decentralised organisations as they stand. However, given the large amount of public money being spent, we must ensure overall accountability and transparency in the health area. That is what the public is telling us and what we are learning from examining the sector. It is the basis of the Minister’s reform proposals.

I take the strong message of today’s debate that Senators are anxious that local authority members should continue to have a real input in the analysis and questioning of the delivery of health and social services at local level.

Question put.

[1301]The Seanad divided: Tá, 24; Níl, 13.

    Bohan, Eddie.

    Brady, Cyprian.

    Brennan, Michael.

    Callanan, Peter.

    Dardis, John.

    Dooley, Timmy.

    Fitzgerald, Liam.

    Hayes, Maurice.

    Kett, Tony.

    Kitt, Michael P.

    Leyden, Terry.

    Lydon, Donal J.

    MacSharry, Marc.

    Mansergh, Martin.

    Minihan, John.

    Moylan, Pat.

    O’Brien, Francis.

    Ó Murchú, Labhrás.

    O’Rourke, Mary.

    Ormonde, Ann.

    Phelan, Kieran.

    Scanlon, Eamon.

    White, Mary M.

    Wilson, Diarmuid.

Níl

    Bradford, Paul.

    Browne, Fergal.

    Burke, Paddy.

    Burke, Ulick.

    Cummins, Maurice.

    Feighan, Frank.

    Finucane, Michael.

    Hayes, Brian.

    McDowell, Derek.

    O’Toole, Joe.

    Phelan, John.

    Ross, Shane.

    Terry, Sheila.

Tellers: Tá, Senators Minihan and Moylan; Níl, Senators U. Burke and Feighan.

Question declared carried.

[1302]  An Cathaoirleach: When is it proposed to take Committee Stage?

  Ms O’Rourke: Tomorrow.

Committee Stage ordered for Thursday, 27 May 2004.

Sitting suspended at 1.20 p.m. and resumed at 2.30 p.m.