I move: "That the Bill be now read a Second Time."
This is important and far-reaching legislation which puts in place an organisational structure to deliver a more integrated, efficient and patient-focused health service for the people of Dublin, Kildare and Wicklow. The need for radical structural reform in the health services in the eastern region has been recognised for some time. The existing organisational structure is no longer suitable for the size of the region it serves and the scale and complexity of the issues with which it deals.
In the 30 year period between 1966 and 1996 the population in the Eastern Health Board area increased by 41 per cent. Some 11 per cent of that increase has occurred since 1981 and the population is expected to increase still further in the next few decades. At present, it stands at 1.3 million people compared with the populations of the other health boards which range between 200,000 and 0.5 million people. The size of the board's population, coupled with the fact that most of the acute hospital care in the region is outside its remit, has made it difficult for the Eastern Health Board to achieve a strong sense of identity among the community it serves.
The years since the board's establishment have also seen a marked increase in the range and extent of social problems, such as drug abuse, child abuse and homelessness, which have become part of its remit. The acute hospital services in the region have also come under pressure over the years with ever-increasing demands for services. High levels of deprivation occur in many parts of the region. It has been predicted that the inner city and the rapidly enlarging and gradually ageing suburban population will make substantially heavier demands on the local health services as we move into the next century. Anyone with a knowledge of the complexity of the health services will recognise that although funding will always be an important issue, throwing money at all these problems is not the full answer. We need to organise the services in a more efficient and effective way.
Several expert reports over the years have highlighted the need for radical organisational reform of the structures in the eastern region so that the services can respond effectively to the challenges they face. The core problems identified by successive reports are the absence of a single authority with responsibility for planning the delivery and co-ordination of all services for the region; over-centralised decision-making within the health board; the lack of an appropriate management structure at district level, given the increase in population over the past 30 years; and the need for better communication and co-operation between the voluntary sector and the health board.
This Bill is designed to tackle all these problems. Its primary and overriding objective is to achieve real improvements in the health and personal social services delivered to patients, clients and service users in the eastern region. The new authority and the three area health boards established by this Bill will enable the delivery of health and personal social services to be brought closer to the people. Decisions regarding the provision of local services will be made closer to the point of delivery and, through the involvement of local councillors on each area health board, more involvement by local communities in the planning and organisation of their health services will be made possible.
The second objective of the Bill is to ensure in a more accurate and accountable way than is possible at present that the £1.2 billion now spent annually on the health services in the eastern region provides the best possible value for money for the taxpayer. Under the terms of this Bill, all service provision within the eastern region, whether the service provider is a statutory body or a voluntary agency, will be on the basis of a written, legally binding service agreement between the authority and the service provider.
Service agreements will facilitate better planning, better budgeting and more accountability at all levels of the services. They will ensure a degree of continuity and financial security for providers, on the one hand, and will ensure that the use of public funds can be fully accounted for, on the other. The Bill requires the authority and each area health board to put in place systems, procedures and practices to monitor and evaluate all the services provided on their behalf.
This Bill follows closely the recommendations of the task force on the eastern regional health authority, which submitted its report to me at the end of June 1997. The task force consulted widely with all the various interests involved in the course of preparing its report. Meetings and discussions were held with many of the principal parties, including the members of the board and the management of the Eastern Health Board, the owners and management of the voluntary hospitals, the voluntary agencies and organisations providing services to persons with a mental handicap and some staff associations. The task force is continuing with its work, preparing the ground for a smooth transition to the new structures.
The new authority proposed by this Bill will replace the Eastern Health Board as the statutory body with responsibility for the health services, but its focus will be significantly different from that of the current Eastern Health Board. It will be required to focus on the strategic planning of services for the region in response to identified and measured need; the commissioning of services from the statutory and voluntary sectors; and overseeing and evaluating the services provided.
This will be a body charged with examining the health needs of its population as a whole, ranging over all the health services: health promotion and disease prevention; primary care, acute hospital care and community care, including personal social services, in both the voluntary and statutory sectors. It will carry out its functions in the context of the objectives of the health strategy maximising health and social gain; addressing inequalities in health status; tackling the main causes of premature death; promoting good health; preventing disease; treating the sick and helping families and individuals to deal with personal social problems. In its allocation of resources, it will be charged with responsibility for deciding priorities on the basis of those parameters and with ensuring efficiency, effectiveness and value for money.
The Eastern Regional Health Authority will present us with an unprecedented opportunity to develop a comprehensive, cohesive and integrated health system in the eastern region. It will have the potential to deliver real benefits to the people in the long-term, by bringing about a re-orientation of the services, so that all services are integrated around the patient and are seamless in the perception of the user.
Let me give an example of the sort of improvement I hope this reorganisation will help to bring about. Take an elderly patient who is under the care of her general practitioner, who needs urgent geriatric care in a voluntary acute hospital. On discharge from hospital she might require convalescent care provided by the statutory services, followed by some time in a private nursing home. Finally she may be allowed home, with domiciliary support provided by the statutory services and attendance at a voluntary day hospital.
Each one of the components of health care received by this not untypical patient is managed, staffed and organised by different sets of people, with different training, protocols and procedures. However, if our imaginary patient can move through the sequence easily, without delay, and if her perception is that she is receiving a unified, comprehensive and seamless service, then the system is working. The positive experience of that elderly patient is the one I want to have available in future to all the people who use the health services in the eastern region. That will be one of the key criteria by which the authority will be judged.
The delivery of statutory services in the new structure will be the responsibility of the three area health boards established by the Bill. The Northern Area Health Board, the South-Western Area Health Board and the East Coast Area Health Boards will each have responsibility for the delivery within their own areas of the services currently being provided by the Eastern Health Board. They will also plan and co-ordinate all services within their areas, in co-operation with the local voluntary service providers.
I would envisage these area health boards operating to all intents and purposes as health boards in their own right, but within an overall policy and financial framework laid down by the central Authority. Each area health board will elect its own chairman and vice chairman and will hold its meetings in accordance with the rules which apply to all health boards. Each area health board will have its own chief executive, who will manage the statutory services within the board's functional area. This will allow the area health boards to focus more closely than is possible in the present structure on issues which affect their own local communities.
A unique characteristic of the health services in the eastern region is that, to a greater extent than elsewhere in the country, a very significant proportion of the services are provided by voluntary hospitals and agencies, at present funded directly by my Department and with no formal links with the health board. It is accepted that this direct funding of voluntary providers by my Department has impeded the proper co-ordination and development of services at local level. In particular, it has hampered the development of linkages between community and hospital services and between voluntary and statutory services – linkages which are essential to the development of coherent, integrated responses to important health care issues such as care of the elderly. This Bill addresses that situation by bringing about a major change in the funding arrangements for the voluntary hospitals and agencies in the eastern region. The introduction, under this Bill, of service agreements between the authority and the major voluntary providers means that the voluntary sector will be formally tied into the overall services in the region for the first time. The proposals will allow the voluntary hospitals and agencies to retain their operational autonomy, while making them fully accountable for the public funds that they receive.
I emphasise at this point, as I did on the publication of this Bill, that there is no intention on the part of the Department or the Government to "take over" the voluntary hospitals, by way of this Bill or by any other means. The health strategy, published in 1994, made it clear that the independent identity of the voluntary providers would be fully respected in the new structures and this Bill delivers on that promise. As I have said before, the challenge for the authority and its management will be to develop an ethos of partnership between statutory and voluntary providers, with the shared objective of delivering a fully integrated service to patients and clients, and to develop the requisite level of co-operation between professionals and between agencies to achieve this.
The challenge for the voluntary sector will be to demonstrate, particularly through good governance and management, that it can continue to deliver the required level of services in a sensitive, caring and cost effective manner. I believe the best guarantee of continuing autonomy into the long-term future is the excellence of governance and management in the provider agencies and their ability to participate fully in the planning and review of services.
I now wish to turn to the main provisions of the Bill. This Bill is divided into six parts: Part I deals with preliminary matters; Part II deals with the establishment of the Eastern Regional Health Authority; Part III with the establishment of the three area health boards, Part IV with the dissolution of the Eastern Health Board; Part V with the establishment of the health boards executive and Part VI with the amendment of other Acts.
In Part I, section 3 provides that the Minister shall by order appoint a day to be the establishment day for the purposes of the Act, that is, the day on which the authority and the area health boards will come into being.
Section 5 allows the Minister to amend the First and Second Schedules to the Bill. The First Schedule sets out the boundaries of the three area health boards. The Minister may amend the boundaries after consultation with the Minister for the Environment and Local Government and the local authority concerned. The Second Schedule is a list of the voluntary hospitals and agencies which are currently funded directly by my Department. The Minister is empowered to amend this Schedule, but he must consult with a voluntary body before deleting its name from the list. I will return to the significance of this provision later.
Part II of the Bill deals with the Eastern Regional Health Authority. Section 7 establishes the authority as a body corporate and defines its functional area, which will correspond to that of the existing Eastern Health Board. It provides that any reference in any enactment to a health board shall be interpreted as including a reference to the authority. This is a simple legal device which allows the authority to take on all the legal powers and duties of a health board. Elsewhere in the Bill some of these powers are delegated to the area health boards.
Section 8 sets out the functions of the authority. These will consist of the existing functions of a health board and the new statutory functions of planning, arranging for and overseeing the provision of all health and personal social services in the region.
One of the key recommendations of the task force's report was that a clear division should be established in the new structures between the funding of the services and their delivery. Accordingly, the authority will not be involved itself in the direct provision of services. Instead, it is required to make arrangements for the pro vision of services with the three area health boards and the voluntary service providers. This section also requires the authority to co-ordinate the provision of services in its region; to put in place systems to monitor and evaluate the services provided and to have regard to the advice tendered by each of the three area health boards.
The authority is required, in section 8(2)(d), to have regard to the right of voluntary bodies providing services to manage their own affairs in accordance with their independent ethos and traditions. This provision has been included in the Bill in response to the concerns of the voluntary hospitals and agencies providing services for the mentally handicapped that the new structures might in some way cut across their long cherished status as independent institutions.
There will be no change under the new arrangements in the status or operation of any voluntary provider, whether an acute hospital, a mental handicap agency or other service provider. Their ownership will not change; their governing bodies, whether boards of management or trustees, will remain and retain all their functions, and there will be no change in the existing personnel and recruitment arrangements. Neither will the new arrangements interfere with the close co-operation between the universities and their associated hospitals. What will change is that the voluntary providers will be funded by the new authority instead of the Department of Health and Children.
Section 9 requires the authority to delegate its reserved functions in relation to service delivery to the three area health boards. Reserved functions are those functions performed directly by the members of the board. With a similar provision in section 17 dealing with executive functions, this provision will ensure responsibility for service delivery rests at area level. Where the authority decides that a certain function would be more efficiently performed in respect of the whole of the region by one area health board, this section allows it to delegate that function to one area health board.
This section is an important provision. Its effect will be that the authority must adhere to its strategic functions. It cannot and ought not become a court of appeal or a forum in which operational decisions taken at area health board level are reopened for discussion. The authority's standing orders, which will be agreed by its members on its establishment, will have to reflect this important feature of its operation.
Section 10 requires the Eastern Regional Health Authority to make arrangements, or service agreements as they are more commonly known, with service providers for the provision of services in its region. These arrangements will apply to the three area health boards as well as to the major voluntary service providers – that is, hospitals and mental handicap agencies – which are funded directly by my Department.
The authority is required to make an arrangement with each area health board for the provision, within that board's area, of the services formerly provided by the Eastern Health Board. If it considers it appropriate to do so, the authority may terminate any part of a service agreement which it holds with an area health board and make an alternative arrangement with a voluntary body for the provision of the service concerned. The reverse can also happen, as the section allows the authority to make arrangements with area health boards for services other than those formerly provided by the Eastern Health Board, for example, new services or services formerly provided by a voluntary service provider.
Every arrangement made under this section – whether with an area health board or a voluntary body – must consist of two parts: first, a long-term agreement of three to five years setting out the general principles by which both parties agree to abide and such other standards in relation to efficiency, effectiveness and quality as may be agreed between the parties and, second, an annual agreement specifying the services to be provided in respect of that year and the level of funding to be made available therefor. Voluntary bodies providing services in accordance with arrangements made under this section will be required to keep accounts in such form as may be approved by the authority.
Under section 10(5), the authority may delegate the making of arrangements to the area health boards, except in cases where the arrangement is with another area health board or with one of the voluntary bodies listed in the Second Schedule. Deputies will recall that, under section 5, the Minister cannot remove a name from the Second Schedule without consulting the voluntary body concerned. This provision acts as a guarantee for the voluntary hospitals and agencies funded by my Department that they will be funded by the authority at central level, until and unless they decide that it is in their best interests to be funded by their local area health board.
This provision does not mean the voluntary agencies can ignore or bypass the important work of local planning and co-ordination which will be done at area level. On the contrary, the service agreements negotiated by the authority with these voluntary bodies will specifically require them to co-operate with the management of the area health boards and to participate in whatever mechanisms are put in place for that purpose by the area chief executives.
Section 11 provides for membership of the authority. In this section, I have followed the recommendations of the task force on the Eastern Regional Health Authority which offered a well thought-out and logical solution to a potentially contentious issue. In this context, the task force was constrained in its work by a number of parameters which had been laid down for it by the previous Government, and accepted by this Government, including the requirement that public representatives hold a majority on the authority.
This is a principle I fully endorse, because I do not want a democratic deficit to develop in the governance of the health service, a problem which has arisen in health services elsewhere. We must all accept that, once this rule of a majority of public representatives is applied, the scope for substantial numbers of other representatives on the authority is limited, unless we want a body of 100 members or more. This is an important point which has not been given due consideration by commentators.
The Eastern Health Board has 38 members. Given that the inclusion of the voluntary hospitals will provide the new authority with a budget twice the size of that of the Eastern Health Board, the increase in membership from 38 to 55 is reasonable.
Of the authority's 55 members, 30 will be public representatives, nominated by the six local authorities in the functional area of the authority. The remainder will be made up as follows: 13 members of registered professions – doctors, nurses, dentists, pharmacists – elected by their peers in the same numbers and in the same manner as currently applies to the Eastern Health Board; nine representatives of the voluntary service providers, appointed by the Minister and three ministerial nominees. Of the nine representatives of the voluntary service providers, the section provides that three will be nominated for appointment by persons or bodies the Minister considers representative of the voluntary hospitals, three by bodies representative of the voluntary mental handicap agencies and three by other voluntary bodies.
I acknowledge that, for a governing body, the size of the authority as proposed in the Bill is large. The challenge for the members of the authority will be to adopt, from the outset, working practices and processes which will take account of its size and which will ensure the overall task is broken down into sensible and manageable parts, enabling full use to be made of all the talents available among the membership. The mechanisms by which this might be achieved are being developed by the task force, so that concrete proposals can be put to the authority on its establishment.
Section 12 provides for the appointment by the authority of a regional chief executive, pursuant to a recommendation from the Local Appointments Commission. It gives the regional chief executive all the powers of a health board chief executive officer, by providing that any reference in any enactment to the chief executive officer of a health board shall be interpreted as including a reference to the regional chief executive.
The section provides that the Minister may appoint the first regional chief executive in advance of the establishment of the authority, for a period not exceeding three years. I am taking this power to ensure the planning and prep aration for the new authority can get under way as soon as possible after the Bill has been enacted. The first regional chief executive will be an important influence in achieving a smooth transition to the new authority. A person of the highest calibre with the requisite leadership qualities and experience is required to be put in place as quickly as possible if the transition to the new structures is to be successfully carried out. I intend to make this appointment shortly after the Bill has been enacted.
Section 13 provides that the regional chief executive can be required to attend before the Committee of Public Accounts to account for the expenditure of the authority and the three area health boards.
Part III of the Bill establishes the three area health boards and defines their functions. Section 14 establishes the boards and provides that they will be known respectively as the Northern, the South-Western and the East Coast Area Health Boards. Each area health board will be a body corporate with the power to sue and be sued and to acquire, hold and dispose of land and other property. The population of the northern area, according to 1996 census figures, is 454,088; that of the south-westen area is 515,568 and the population of the east coast area stands at 324,308.
The functional areas of the three boards will be as set out in the First Schedule to the Bill. The boundaries follow the recommendations of the task force on the Eastern Regional Health Authority, which spent considerable time examining what might be the optimum division of the region and consulting with the various interests involved. The detailed rationale for the boundaries can be found in the task force's interim report. They follow the local authority boundaries as far as possible. Where the boundaries diverge from the local authority boundaries, they do so for sound service delivery reasons and follow instead local electoral area boundaries.
Section 15 sets out the functions of the area health boards. They are required to perform the functions delegated to them by the authority; to provide services within their functional areas in accordance with the arrangements made with the authority under section 10 and to plan and co-ordinate the provision of all services in their areas, in co-operation with voluntary service providers.
This last function, the planning and co-ordination of services at area level, is perhaps the most vital of all the functions of the area health board. The need for substantial improvements in planning, co-ordination and integration of services in the eastern region is widely recognised and was one of the key factors in bringing forward the proposals for new structures in the Bill. The role of the voluntary sector will be crucial.
Each area chief executive, once appointed, will set about putting in place mechanisms, which will be inclusive of voluntary sector providers, for ensuring good planning and co-ordination of services in their areas. One option for such mechan isms would be the concept of the providers forum, as outlined in the task force report, but other routes could be followed. The legislation is not prescriptive on this point, so as to allow each area to develop its own dynamic and build up the relationships between providers as it sees fit. Voluntary providers in each area will be fully involved in the discussions on the approach to be adopted in their area. My Department is already in discussions with the major voluntary hospitals on this and other issues and I expect that process of consultation will continue and be extended to include other voluntary providers after this Bill's enactment.
This section also requires an area health board to carry out its functions subject to the general directions of the authority and to co-operate with the authority and the other area health boards in matters of overall co-ordination of services across the region. Where area health boards make arrangements with third parties for the provision of services, they must put systems in place to evaluate and monitor those services.
Section 16 provides for membership of the area health boards. It provides that the membership will be specified by the Minister in regulations, subject to certain parameters as set out in this section. Members of area health boards will be appointed by the authority from within the authority's own membership for terms of office of not more than five years.
At least one member from each of the categories on the authority – that is to say, public representatives, health professionals, voluntary sector and ministerial nominees – will be represented on each area health board. Public representatives will hold the majority on all area health boards and the public representatives appointed to each area health board will be from local electoral areas within that board's functional area. Area health boards may make payments to members for travelling and subsistence expenses and may pay allowances to their chairmen and vice-chairmen.
Section 17 provides for the appointment by the authority, pursuant to a recommendation from the Local Appointments Commissioners, of three area chief executives and their assignment by the authority to the three area health boards. The Minister may appoint the first incumbents prior to establishment day, pursuant to a recommendation from the Local Appointments Commissioners. I hope these three posts could be filled very shortly after the enactment of this Bill, so that the new area chief executives can begin the preparatory work in their areas in advance of the establishment day.
Area chief executives will hold office on terms and conditions similar to chief executive officers of health boards and shall act as chief executive officers of their area health boards. They will be delegated certain executive powers by the regional chief executive to enable them to manage the services provided within their respective areas and they will be required to exercise their functions subject to the general direction of the regional chief executive.
Section 18 provides for keeping accounts by the three area health boards. The accounts of the authority itself will be governed by existing legislation on health boards. This section is an important expression of the stringent accountability which will characterise the work of the new authority.
