Dáil Éireann debate -
Wednesday, 8 May 1996

Vol. 465 No. 1

Health (Amendment) Bill, 1996: Second Stage.

Minister of State at the Department of Health (Mr. O'Shea)

I move: "That the Bill be now read a Second Time."

This is an important Bill which aims to modernise planning and management systems in health boards. It sets down in legislation new planning, management and accountability provisions which will change the way health boards conduct their business. It presents a challenge to everyone involved in the health sector to work within a planning framework which is linked to specific resources and clear objectives. It brings accountability much more to the fore both in planning and reporting terms. In short, the Health (Amendment) Bill is at the centre of the process to require health boards to carry out their tasks in a context which emphasises planning, strategic management and accountability.

Before dealing with the individual elements of the Bill, it might be useful for the House to consider the background to the Bill both from a strategic and financial viewpoint.

Our December 1994 policy agreement, A Government of Renewal, endorsed the health strategy as the basis for the Government's programme in the health area. The health strategy reorients our health care system and sets out a four-year action plan with targets for reductions in risk factors associated with premature mortality together with improvements in other indicators of health status. The strategy outlined a number of principles which would guide the development of our health services. These are that the Minister and the Department of Health should be responsible for the development of health policy and overall control of expenditure but should not be involved in the detailed management of the health services; greater responsibility should be devolved to the health boards and other executive agencies; the roles of all key parties, including the members of boards and their managements, must be clearly defined and greater autonomy must be balanced by increased accountability at all levels. I am pleased that all of these principles find expression in the legislative proposals now before the House.

The Health Estimate this year is approximately £2.4 billion, including £110 million to be spent on capital items. Taking account of the transfer of responsibility for funding the disabled person's maintenance allowance to the Minister for Social Welfare and allowing for certain other once-off items of expenditure in 1995, this represents an increase in the Health Estimate of approximately 4 per cent over 1995.

Within this total figure, a sum of £1.34 billion has been allocated to the health boards. Taking account of the disabled person's maintenance allowance transfer and other non-recurring expenditure, this allowed for an average increase in health board funding of just over 3 per cent on last year. This is designed to cover the full year cost of developments initiated in 1995 and includes the 0.7 per cent savings on non-capital expenditure required of each Minister in the context of the 1996 Estimates. We were fortunate to have been able to negotiate the use of these savings as a contribution towards the cost in 1996 of the further development of services in line with the Government Programme A Government of Renewal and the action plan in the Health Strategy. These developments include improvements in child care services, services for the mentally handicapped, the physically disabled and the elderly, psychiatric services, dental services, acute hospitals, and services for those with AIDS-HIV and drug problems. The funding allocated for the health services this year should enable health boards to maintain services at approved 1995 levels and provide for the critical service developments in the areas I have just outlined.

Despite this level of investment, we continue to face enormous pressures in terms of the demand for services. The increasing complexity of the technology available, the new drugs continuously becoming available and the ageing of our population, all put an increasing strain on the resources available to the services. It is worth noting that during the last five years — at a time of unprecedented growth levels in our economy, the levels of non-capital expenditure on health has increased by 7 per cent in real terms.

While the economy will continue to grow, the forecast is that the rate of growth will slow down. This will have implications for the level of resources which will be available for public services generally and, in turn, for the level of public investment in health care. At a macro level, we need to start planning for the implications likely to flow from our obligations under the Maastricht criteria. We will need to develop a strategy to cope with this new discipline on the public finances and the implications can be expected to extend into all areas of public policy.

One serious message arises from all of this. It is that we can anticipate two sets of pressures in the years immediately ahead, one being the inexorable pressure for additional and higher quality services and the other will derive from the stronger discipline on public spending to which I have already referred.

Current spending on health and social services is comparable with other EU and OECD countries. If more resource is required for our health services each year, taxpayers, consumers and opinion formers will require a greater depth of information and clarity on service planning and performance. The Bill does not represent a critical or negative judgment on current management within the health boards, but rather about the establishment of a process whereby clear parameters are laid down for the future management and the conduct of performance review, among other things.

In bringing forward this legislation the House must be keenly aware of the difficulties confronting those involved in the delivery of health and social services. There is no denying that, on a day-to-day basis, workers must deal with ever increasing demand for services from a more knowledgable and informed public. They are required to deal with competing demand and priorities within the confines of the funding available. Their achievements in doing so are a testament to the co-operation, professionalism and dedication of health service workers and management. The Government recognises the contribution of all those working in the health service.

Health boards will be aware of the many conflicting demands and pressures when developing their service plans. Developing service plans will present health boards with challenges but will also help them to reflect local priorities in a manner seen to be reasoned and justified.

It is vitally important to the successful implementation of this Bill that health boards, their members and managements, accept that they are now required to deliver services in line with the determination in any year.

It is against this background this Bill has been developed. The Health (Amendment) Bill, 1996 has three main objectives: to improve financial accountability and expenditure control procedures in health boards; to clarify the respective roles of the members of health boards and their chief executive officers, and to begin the process of removing the Department of Health from detailed involvement in operational matters.

The first of these objectives is to strengthen the financial accountability arrangements in health boards. The Government is determined that the health boards will in future operate in the environment of service planning aligned to strict financial control and accountability. In A Government of Renewal, we committed ourselves to introducing legislation to improve the accountability of health boards. This Bill gives effect to that commitment. It reflects the Government's strategic management initiative with its emphasis on making the public service more responsive, more accountable and more open.

The public expect a more open and accountable system of health administration. Health boards will be required to prepare and adopt an annual report on the performance of their functions during the preceding year. This will help taxpayers to judge whether they are getting the best value possible for the money they contribute to the public finances. Services will have to be even more responsive to people's needs and more information will have to be made available about the actions and decisions taken on behalf of the people.

The second objective is to clarify the respective roles and responsibilities of members of health boards and their chief executive officers. One of the key problems identified by the Commission on Health Funding in the present structure is that it confuses political and executive functions to the detriment of both.

The Health Strategy, Shaping a Healthier Future, proposed that this be tackled by making board members responsible for policy functions e.g. determining overall levels of service and expenditure while delegating to chief executive officers responsibility for operational matters. Clear lines of responsibility must be drawn between boards and their chief executive officers. All modern organisations, whether public or private, must have clear lines so that each level understands its role. A board which interferes in operational matters cannot perform its functions in an adequate way as it will lose sight of the broader issues and strategy with which it must be concerned. A chief executive officer who moves into an arena which is proper to the board may neglect his or her main objective which is to implement the policy decisions taken by the board. The Bill gives effect to this by specifying the functions to be performed by board members and chief executive officers respectively.

The third objective of the Bill is to begin the process, signalled in the Health Strategy, of removing the Minister and the Department of Health from detailed involvement in the management of individual services by devolving greater authority and responsibility to the health boards. The development of greater expertise in the health boards in service planning and evaluation allied to the improvements envisaged in the governance role of health board members will create an environment in which greater authority and responsibility can be devolved to health boards.

While the Minister will continue to have ultimate responsibility to the Oireachtas for all health services, his Department will no longer be involved in the detailed management of individual services.

I will turn now to the main provisions of the Bill.

Section 1 contains definitions of key terms used in the Bill.

Section 2 requires health boards in carrying out their functions to secure the most beneficial, effective and efficient use of resources; to co-operate and co-ordinate their activities with other health boards, local authorities and public bodies and to give due consideration to the policies and objectives of Ministers and of the Government.

Section 3 and 4 clarify the respective roles of the members of health boards and their chief executive officers. Provision is made for certain specified functions, to be known as "reserved functions", to be carried out directly by the members of health boards. These include the adoption, supervision and amendment of service plans, the appointment and removal of the chief executive officer, the purchase and disposal of land, the borrowing of money and decisions to continue the provision and maintenance of any premises. The chief executive officer will assist the board, as appropriate, in these matters but the board will have the final say in the performance of these functions. Any function that is not reserved to the members will, subject to some minor exceptions, be a function of the chief executive officer and the staff of the board.

The chief executive officer will be obliged to provide the board with any information they might require in relation to such functions but will otherwise be autonomous in performing them. The effect of these changes will be to bring the management system in the health boards into line with the arrangements that have worked well in the local government system over many years.

Section 5 requires the Minister to specify the maximum amount of net expenditure that may be incurred by each health board in any year. The term "net expenditure" means the gross expenditure of a health board less the income of the board, other than grants made by the Minister. This amount which is referred to as a "determination" must be notified to the board within 21 days of the publication of the Estimates. There is provision to enable the Minister to make a determination in respect of a period other than a financial year.

The Minister is empowered to vary the determination at any time during the year for example, to make additional funds available to meet agreed pay increases or to develop particular services or facilities.

Section 6 requires a health board, within a period of 21 to 42 days of the receipt of a determination as the Minister may direct, to adopt a plan specifying the services to be provided by the board within the financial limits determined by the Minister. The board is required to submit a copy of its plan to the Minister.

If a health board does not submit a service plan within the relevant timescale, the Minister may allow a further period, not exceeding ten days, to enable the board to do so. If a health board fails to submit a service plan, the Minister may direct the chief executive officer to prepare and submit a plan within ten days. The Minister may, not later than 21 days after the receipt of a service plan, direct a health board to modify its plan and the board is required to comply with such a direction.

Service plans are already in operation throughout the health boards on an administrative basis and the plans of boards for 1966 have already been discussed with the Department of Health. The plans cover all the main service programmes such as general hospitals, handicapped, elderly, etc., and describe how boards will manage those programmes during the year. It is vital that plans present a coherent, integrated approach to the services and reflect the expenditure resources committed by the Minister to the agencies. The development of service plans will continue with the Department of Health to ensure that they represent a satisfactory basis to the planning and management of services.

Section 7 provides that where the Minister amends a health board's determination, he or she may direct that the service plan of the board shall stand amended accordingly or, alternatively, require the health board to submit an amended service plan. The power to direct that a plan stand amended is intended to deal with situations such as where the Minister makes additional funds available to meet agreed pay increases or to develop particular services or facilities.

The members of the board will be required to monitor expenditure to ensure that it does not exceed the amount set by the Minister. In addition, a health board may vary its plan at any time during the year provided it does not breach the financial parameters laid down by the Minister.

Section 8 provides that whenever the Minister makes a determination, he or she shall specify the amount of indebtedness that a health board may incur and a health board shall not exceed the amount determined by the Minister.

Section 9 requires the chief executive officer to implement the service plan and to ensure that net expenditure and indebtedness do not exceed the amounts determined by the Minister. Where the chief executive officer forms an opinion that a decision or a proposed decision of the board will result in net expenditure or indebtedness exceeding the amounts so determined, he or she is required to inform the Minister and the board of that opinion.

Section 10 provides that if, at the end of the year, the expenditure incurred by a health board is less than the amount set by the Minister, the savings can be carried forward into the next year. However, if expenditure is greater than that authorised, the excess expenditure will become a first charge in the income and expenditure account for the following year.

Section 11 requires health boards to keep all proper and usual accounts and to prepare and adopt annual financial statements on or before 1 April in the year following the year to which they relate. This is also the date by which health boards are required to submit their accounts to the Comptroller and Auditor General.

Section 12 provides that if the Minister is satisfied that a health board is not performing any of its functions in an effective manner or has failed to comply with any direction given by the Minister, he or she may, by order, transfer specified functions of the board for a period of not more than two years to either the chief executive officer or such other person as the Minister may specify. This provision is intended as a measure of last resort to deal with situations where a board is not being governed in a satisfactory manner, for example, where a board has seriously and without good cause breached the expenditure limits set down by the Minister.

I hope that this power will never have to be invoked and that any difficulties or disputes that might arise can be resolved without resorting to this provision. I would also point out that before exercising this power, the Minister is required to have a report prepared in relation to the performance by the board of its functions, must give the board at least 14 days' notice of the intention to exercise the power and must have regard to any representations made by the board in this regard. I believe that this process provides some breathing space to allow problems to be resolved by agreement between the Minister and the board.

Section 13 empowers the Minister to give directions in writing to health boards and requires boards to comply with such directions.

Section 14 provides that future appointees as chief executive officers of health boards shall hold office on a fixed-term contract basis, as is already the case with senior civil servants and city and county managers. The new provision will not, of course, affect the tenure of existing office holders.

Section 15 requires each health board to prepare and publish an annual report in relation to the performance of its functions during the preceding year. I see this as an important step in bringing the principles of accountability, transparency and freedom of information to bear on the activities of health boards.

Section 16 provides for the dissolution of the Dublin, Cork and Galway regional hospital boards, the local health committees and the national health council. As Deputies will be aware, all these bodies have long since ceased to function and this provision is merely giving formal effect to their abolition.

Section 17 contains miscellaneous amendments to the Health Act, 1970. Most of these are required to bring the relevant provisions of the Act into line with this Bill. Of particular interest is paragraph (g) which imposes a new statutory obligation on health boards to develop and implement health promotion programmes. The need for an explicit statutory duty in this regard was identified in the health promotion strategy, launched last year. I believe that this provision will assist in the successful implementation of that strategy.

Sections 18 and 19 dispense with the need for health boards to obtain ministerial consent to the acquisition or disposal of land and to the payment of grants to voluntary bodies; however, the Minister may give general directions which must be complied with by the boards.

Section 20 makes it an offence to carry on a nursing home that is not registered under the Health (Nursing Homes) Act, 1990. This is required to plug a loophole in the 1990 Act.

Section 21 allows the Minister to extend by order the term of office of An Bord Altranais which is due to expire on 3 October 1996. Work on the revision of the Nurses Act which will involve the establishment of new board structures is under way in the Department and it is hoped to publish the nurses Bill before the end of the year. The purpose of this provision is to enable the present board to continue in office until the new Act comes into force, I hope in the summer of 1997. This avoids Boad Altranais going to the trouble and expense of holding elections to a board which will fall to be reconstituted under the new legislation.

Section 22 amends the definition of "health service" in the Health (Corporate Bodies) Act, 1961. This is the Act that provides the statutory basis for a number of health agencies, including Beaumont Hospital and St. James's Hospital and the National Rehabilitation Board. The current definition of "health service" in the Act has a traditional medical orientation and this has prevented the establishment of bodies under the Act to perform functions in relation to personal social services. The revised definition is designed to overcome this problem.

Sections 23, 24 and 25 contain standard provisions regarding repeals, the laying of orders before the House of the Oireachtas, short title, construction and commencement.

This is an important Bill which will affect all aspects of the management, planning and accountability of health boards. It is fully in keeping with the aims and objectives of the health strategy and indeed its enactment is central to the achievement of those objectives. The Bill also reflects the Government's desire to introduce a more strategic approach to management in the public service. I commend the Bill to the House and look forward to hearing the contributions of Deputies.

Mrs. Geoghegan-Quinn

I read the Official Report of the debate on the Health Bill in 1969 when the then Minister for Health, the late Deputy Seán Flanagan, introduced the concept of the establishment of health boards, legislation governing which was implemented by the then Minister, Mr. Childers. I will not bore the House with quotations from it except to say that we were saved from a certain fate. At column 1647 of the Official Report of 16 April 1969, the Minister said: I should mention that I have received representations from the medical profession that each chief executive officer should be a doctor". With due deference to my colleague on my right, I believe we have been saved in that the Minister did not accept that recommendation. From a financial point of view, I am sure the Minister would agree that neither the health board nor Department of Health could afford to employ a doctor as a chief executive officer.

I welcome the Bill. Health is an important issue for all members of the public and treatment of a patient is a constant source of discussion and analysis. Often in such scenarios debate arises about the delivery of health services. Families will discuss how they were treated at the local hospital or health centre and the manner in which an application for a medical card or a refund of medicine costs was handled by a health board. These examples highlight the interaction of people with their health boards. Apart from them, few State organisations have such a daily impact on people's lives.

A vast array of health and social services are delivered by each health board through the hospitals, health board offices and health centres in the regions. As a consequence, everyone identifies with the local hospital or health clinic and regional health board.

There is also considerable local democracy in the structure of health boards, as public representatives, health professionals and interest groups are represented on them. The absence of direct representatives of consumers on health boards must be seen as an inadequacy of the current structures and I hope that will be rectified by the Minister on Committee Stage. Consumers should be part of the democracy as health boards received vast sums of taxpayers' money through the Department of Health. Of the £2.4 billion under this year's Health budget, £1.34 billion will be allocated to the eight health boards. That money is spent in diverse ways on general and psychiatric hospitals, general medicine, especially for holders of medical cards, a wide range of community health care including child protection, drug treatment and women's health, home help and supports for the elderly.

Health boards are also major employers in each region. In that way they have a major impact on people's lives in that everyone knows someone employed in a hospital, health centre or health board office. Given this vital role, the health service should be subject to constant review and change but this is the first major Bill to review the operation of health boards since 1970 when the current health board structure was established.

This legislation has been introduced following a review of the health services by the former Fianna Fáil-Labour Government. The outline for it was drawn in the health strategy document, Shaping a Healthier Future. That document noted there were key problems in the current health board structure, political and executive functions were confused and often undermined the structure and there was a lack of balance between national and local decision-making which did not provide for sufficient information and evaluation. Accountability within the structure was deemed to be inadequate and there was insufficient integration of related services and inadequate effective representation of the interest of individual patients and clients within the structure.

The health strategy document also identified a weakness in the Eastern Health Board area, in that significant services were provided by voluntary agencies in the region, but no single authority had overall responsibility to co-ordinate all services and to ensure appropriate links between them. In Shaping a Healthier Future it was proposed to introduce legislation to provide for a new authority in the eastern region and to remedy the deficiencies identified in all the health boards. The Minister appears to have taken a minimalist approach to the outline proposed in that document. Will the Minister of State outline how stands the proposal concerning the eastern regional authority? Will that be covered under another Bill? Originally we were told it would be, but it did not appear on the Government's programme supplied to the Opposition at the beginning of this Dáil session. If that is the road the Minister intends to travel, will the Minister of State outline why it is necessary to introduce two separate Bills to deal with what is essentially the same topic.

The role of health boards needs to be clarified. I hope this legislation will ensure they will be more accountable. It sets the framework within which health boards and the Department of Health will act. The more detailed day to day arrangements for putting it into effect will have to be worked out later and as is often the case with legislation of this kind, that element may prove to be the most controversial. Will the Minister of State outline how that will be achieved? Will a standard code of operation or individual codes apply to each health board? What will be the health service consumer's input? Will the Minister establish a working group with representatives of the various interests to negotiate the arrangements and will he report such progress to the Houses of the Oireachtas?

Health board accountability is required in many areas. Many controversies have arisen recently involving health boards' handling of child abuse cases. Almost all health boards have had to deal with a major case, ranging from the Kelly Fitzgerald case, to that of the west of Ireland farmer to the Kilkenny incest case and so on. In each episode there has been considerable public concern about how the health board concerned and other States services dealt with the matter. I am sure the Minister of State would agree that the public consider the responses to those cases inadequate and ineffective. They have highlighted the necessity for the implementation of strict codes of practice for operational matters and for procedures to be put in place to deal with concerns expressed by other jurisdictions.

I argued on many occasions on the need to introduce mandatory reporting of child abuse. That is the only way to clear up the grey areas that exist. Once a decision is taken to introduce mandatory reporting, experts in health boards can discuss the procedures, processes and the guidelines that must apply. It is only in that way difficulties, which are often more perceived than actual, will be ironed out.

I do not believe the health document,

Putting Children First, introduced by the Minister of State, Deputy Currie, has greatly assisted health boards in dealing with these issues. While presenting the issues the document appears to make the case for not introducing mandatory reporting. This is hardly the purpose of a discussion document.

The Minister of State, Deputy Currie, has not aided the work of health boards in terms of the new structures put in place for a child care inspectorate within his Department. Like me, the Minister, Deputy Noonan, strongly believed that a child care inspectorate should be put in place. However, health boards should not be seen as inspecting themselves which in effect is what will happen. I would much prefer to have an inspectorate which is not only independent but is seen to be independent. This is very important and I hope the Minister will reconsider the matter.

Even though the inspectorate will inquire into the social, child care and other services administered by health boards, at the same time it is located within the arm of Government which controls health boards. I believe the public would much prefer to see it established as a separate organisation. In recent years we witnessed the controversies and difficulties which have arisen between the Department and health boards. This was obviously the case in regard to the Kelly Fitzgerald report. I believe the Minister, his two Ministers of State and the officials in the Department wanted to publish the report but that the health board believed it was its property and decided not to publish it. This is an area where disagreement will continue to arise between the Department and the health boards. If the inspectorate was established outside the Department it could make an independent decision as the health boards would not have the same lien on it as it now has on the Department.

Consideration must be given to combining the work carried out by the children's divisions in the Departments of Justice, Health and Education under the one Minister. A start has been made in this regard and as a former Minister for Justice I know the difficulty in doing this. I am not particularly concerned about the home of this independent unit but the present structure, whereby the children's division in each Department does its own thing, is not the best way of ensuring value for money from the point of view of the Government. The Minister should examine the matter to see if this work can be carried out in a more coherent way. I am not one of the people who believes that there should be a Minister for children at the Cabinet table as this is a bit like saying that one cannot secure the delivery of services for the west without a Minister for the west. There are only 14 places at the Cabinet table — the Taoiseach has 15 — and one cannot have a Minister for every area of policy. However, there is room for manoeuvre and it should be possible to co-ordinate the delivery of services to children by the Departments of Education, Justice and Health.

As the many cases which have become public in recent years show, health is becoming an increasingly complex and controversial area. Drug treatment is also another hot topic at health board level and it must be tackled in a co-ordinated way. Fianna Fáil will shortly produce a position paper outlining how the matter can be addressed by health boards and the health authorities generally. The document will not look at the problem from a health perspective only but will also examine the issues arising in the Justice and Education areas and the employment perspectives. In this way we hope to achieve an integrated approach to the topic which will assist health boards and, I hope, lead to a unified system of drug treatment at local level.

Dublin receives most publicity but in almost every area difficulty arises when a health board decides to set up a methadone treatment centre or an addicition treatment centre. This happens when the health board attempts to locate these centres in communities. This is a laudable idea but local communities worry that the units may not be administered in a proper way and that children may obtain access to used needles, etc. Health boards could reduce that level of concern and secure local agreement if they confined such units to campuses owned by them, for example, health board administrative blocks, hospital campus or health centres which are already on site. There are hospitals in almost every area of Dublin city and it would be relatively easy and much less painful to establish such facilities on health board property or hospital campuses.

There has been much coverage of the nurses' dispute in recent days. The threatened industrial action has major implications for the services delivered by health boards. For the first time in 16 years we are facing a wholesale dispute by nurses. Fianna Fáil has said it wants to see justice for nurses because of the key role they play in the health services. It has also stated that the level of frustration among nurses should not be underestimated. That frustration was apparent in the ballot when the deal was put to a vote. It must be noted that if the package was not put in the deal document immediate industrial action would have taken place as strike action had been suspended pending negotiations. The aspirations of nurses in regard to pay and conditions can be met over a reasonable timeframe. They would yield tangible and measurable improvements in health service delivery. It was not wise of the Government, following the announcement of the ballot result, to make it appear that it was going over the nurses' heads to the Congress of Trade Unions. This sent a wrong message to nurses and may have hardened attitudes. The correct course would have been to speak first to the nursing unions. However, this seems to have been added only as an afterthought.

In addition to the immediate disruption of services, a strike by nurses will have major implications for the hospital waiting list initiative. In the Government's policy document A Government of Renewal there is a commitment to continue the progress made over the past two years in reducing hospital waiting lists for a range of surgical procedures. However, this has not been achieved to date and the Minister has attempted to disguise this failure to make progress. In reply to a parliamentary question from me on 23 April the Minister for Health said that in December 1994 there were 28,004 patients on the waiting list. He went on to make a comparison with 1993 when there were 40,130 patients on the waiting list. A commitment was given in December 1994 in A Government of Renewal to make progress on this issue. At that time there were 23,835 patients on the waiting list, and that progress had been made by the then Fianna FáilCoalition Government. Since then the number of patients on the waiting list has increased from fewer than 24,000 in December 1994 to 28,004 at the end of December 1995, the latest date for which figures are available.

In the context of this debate about resources for health boards and how they are managed I would like the Minister to explain why the number on the list has increased so greatly over a short period, why the list increased in 1995 when more money was spent on the initiative and how he intends to fulfil the commitment made in the Government programme of renewal. Will he also say why the latest figures are so out of date, how often the Department of Health receives updates from the health boards and hospitals and whether this information is transferred by computer or in writing?

I wish to refer to another issue which arises in the context of the use of resources by health boards and hospitals and responsibility for departments. Every year without fail there is a crisis in the accident and emergency departments of the major hospitals. There are also numerous complaints about overcrowding, dangerous conditions, patients left on trolleys for hours, medical conditions made worse by long delays, lack of dignity for patients left on corridors and upset relatives. This crisis has been going on for several years and a resolution appears to have eluded the Department, the hospitals and the health boards. Last year a series of summits was convened in which the Department of Health decided not to participate. It passed the buck to the hospitals and the health board. This abdication of responsibility appears to have resulted in the crisis continuing and this autumn we will probably face another series of disruptions. Will the Minister indicate whether he has any plans to alleviate the crisis? Will he arrange for the ambulance services in Dublin to be co-ordinated? Has he plans to get involved now rather than when that crisis hits?

The co-ordination of ambulance services in Dublin is important. There have been complaints about the ambulance services and difficulties that have arisen in particular situations. A bizarre situation exists whereby, in cardiac cases, two ambulances arrive on call, one from the fire brigade service and one from the Eastern Health Board. I heard a radio programme yesterday on which a couple from the US who had spent a holiday in Ireland were very complimentary to Beaumont Hospital and its staff. The husband had had a cardiac arrest and his wife was impressed when two ambulances arrived at the scene. It was pointed out in the programme that two ambulances arrived because it was a cardiac case. It is a little ridiculous that two ambulances are sent to one emergency when one might be better used elsewhere.

The Bill includes a welcome provision that health boards will be required to publish an annual report by a set date. Taxpayers will thus be able to see where their money is being spent. The issue of reporting by health boards arises in the context of the hepatitis C controversy. The Health (Amendment) Bill, 1995 makes welcome provision for health care for hepatitis C victims. However, there have been many difficulties with the health cover to date. There have been inadequate counselling services and other facilities in health board areas. I proposed an amendment to the Bill requiring health boards to report annually on the resources they are making available for hepatitis C health care. The amendment requires them to give a breakdown under all health care headings.

The controversy has raised a fundamental question about the accountability of agencies such as health boards and about who represents the public interest. In the hepatitis C controversy serious doubts have been raised about the effectiveness of the board of the blood bank and, rather than concern about the board's handling of matters reducing with time, it has increased. There has also been a problem with the representation of the public interest. Apart from the Opposition parties and the lobby groups who represent the victims, everyone in the hepatitis C controversy has claimed to be party to a court case and refuses to take the public interest into account. A similar scenario could arise in relation to the health boards. The Minister might explain how this will be addressed under the new structures. Who will take the public interest into account when the Department and the health board are embroiled in a controversy or are before the courts?

If the then Minister for Health, the late Seán Flanagan, could have foreseen in 1969 the large, unwieldy and excessively bureaucratic structure which the health boards would become, he might have made a different decision in relation to their establishment. The proposal to set up the regional education boards is a good example to follow. We need to simplify structures, not to create overbureaucratic organisations.

The public can be infuriated by cut-backs in services. When the cut-backs hit the Department of Health and are transferred to the health boards, people are concerned that they always seem to affect the services in hospitals or health centres, yet never the administrative structures. Is the Minister concerned about that? If cut-backs are to be made, why do the health boards not look first to their own administrative services before hitting the weaker sections of the community?

Why is it necessary to put patients through the hell of form filling in hospitals? When patients arrive in admissions they have to answer ten to 20 questions about themselves and their families; when they go to their ward they are asked the same series of questions; and when a consultant finally sees them they are asked the same questions again. With the use of modern technology, is is not possible to have the responses recorded in a certain form and made available to those who need them?

I approve of section 14 which empowers the Minister to allow for the appointment of a chief executive officer of a health board for a set period. We believe the Minister should include the set period in the Bill and we will suggest a period on Committee Stage. There is provision for a set period of seven years for Department secretaries. Why not stipulate the same period for the chief executive officers of health boards? I am concerned about the provision which allows for a period to be set when an individual reaches a certain age.

People are being appointed to high level posts in the public service at a much younger age than in the past. If chief executives of health boards were appointed who were in their thirties they would have almost 30 years service if they did not have to retire until their sixties. A person in such a responsible position loses the appetite for change and reorganising health board services and administration. If a person's appointment is for a specific period of time it can sharpen their approach. A provision might be made whereby if after seven years it was felt a person should be reappointed that could be considered. However, I would prefer a tighter provision in section 14 with the period of time specified.

Despite the accountability now being required of health boards, it is important that the Minister for Health should still come before the House to answer questions on the activities of health boards and related issues of concern to Members. Deputies can no longer ask questions on semi-State bodies and when crises develop we have to have major debates in the House. Crises might often be averted if Opposition members could ask relevant questions which might alert a Minister to events in semi-State organisations. Despite the changes being made in this Bill, it is important that the Minister for Health remains able and willing to answer questions on the health boards in the House.

The chief executive officers should always be willing to appear before committees of the House to answer for the performance of their health boards. The powers of the committees must be changed to give them the power to compel witnesses to attend.

There should be an onus on the chief executive officers to appear before the committees when requested to do so. Such a request has been made to one chief executive officer already and will probably be made to others in the future. It is a good idea to have the chief executive officers appear before the Committee on Public Accounts because it allows them to answer for the expenditure of moneys in their health board area.

I welcome the Bill. I will be proposing a number of amendments on Committee Stage. A former Fine Gael representative, Deputy Richie Ryan, was very critical of the original Bill 27 years ago and expressed his anger to the then Minister, Seán Flanagan. However, Deputy Kyne — a representative of the Minister of State's party — was very kind to the Minister and supported the changes being put in place. I wish the Minister of State well with the Bill and look forward to hearing his responses to the queries I raised.

Mr. O'Malley

The explanatory memorandum accompanying the Bill sets out two basic objectives for the legislation — to improve the accountability of the health boards and improve the organisational and management arrangements in health boards. On behalf of my party, I enthusiastically support both objectives.

Public service organisations have a long way to go in terms of accountability. This is particularly true of health boards and other bodies associated with health and health administration. Major publicly quoted companies give us some idea of what we as taxpayers should be entitled to expect from large public bodies such as the eight health boards. Allied Irish Banks, for example, has total assets of £25 billion, 15,000 employees and a network of offices and subsidiaries spanning several countries. It is a huge organisation by any reckoning. However, the AIB is able to deliver a comprehensive set of financial results within two months of the end of its financial year. Senior executives of the bank can be and are quizzed by institutional shareholders, investment analysts and financial journalists about the company's performance within a number of months of its year end. That performance can be compared with the outturn for previous years, using appropriate indicators such as profitability and return on capital. Trends can be analysed, management capability evaluated and corporate performance measured with some accuracy. Compare this with the situation in the health boards.

The basic financial reporting instrument prepared by the health boards is the statement of non-capital income and expenditure. It can take a year or more for this document to be published. In the case of at least two of the boards, the report for 1994 has still not appeared and will not be published until at least the middle of this year. The Comptroller and Auditor General, who has responsibility for auditing health board accounts from 1994 onward, has not yet been able to certify the accounts of the Eastern Health Board, which is by far the largest organisation of its kind in Ireland.

Timeliness is one of the key requirements in any reporting arrangement. In the first half of 1996, we as public representatives should be scrutinising the financial reports for 1995 of the different State organisations, agencies, boards, companies and Departments. We could point out shortcomings, highlight difficulties and ensure that they were redressed as quickly as possible. In other words, we would be analysing and evaluating the 1995 performance to ensure that the 1996 performance was better. This should be one of our key functions as public representatives and would be of far greater value to our constituents than some of the work currently undertaken on their behalf. What is the point of analysing figures for 1994 in the middle of 1996? If figures are not published promptly after the period to which they refer, they lose most of their value.

The problem of late publication of accounts is not confined to the health boards but is widespread throughout the public service. In the case of the prison service, for example, we are still awaiting publication of the 1993 annual report. Assuming it appears at some stage during the current year, of what value will this report be? Delays of this length mean that documents are of little more than curiosity value when eventually published.

The eight health boards account for total expenditure of approximately £1.5 billion per year, roughly £30 million per week. This represents a huge amount of public expenditure in Irish terms and the highest level of accountability should be demanded for it. Section 11 of the Bill proposes that the annual financial statement of each health board shall be adopted on or before 1 April in the year following the financial year to which it relates. The Bill does not specifically refer to publication. It is imperative that annual financial statements should not be merely adopted within a three-month period but should also be published that period. Public representatives and other analysts and commentators will otherwise continue to be kept waiting.

The format of financial statements is also important. When the present financial statements eventually appear they contain a detailed analysis of health board expenditure under about 40 different headings. The financial statements under the new reporting requirements should be similarly structured in order to facilitate analysis and comparison across the different boards.

The Bill states that it aims to begin the process of removing the Department of Health from detailed involvement in operational matters in the health boards. I agree with this but I would go further. The Department should see itself not as the manager but as the evaluator of the health services. Within six months of the year end the Department should publish a comprehensive performance review for the eight health boards. This would provide a detailed comparative analysis of expenditure per person under the various headings in different board areas. High quality management information must be placed in the public arena on a timely basis to facilitate an informed discussion on the way in which the health service operates and a proper analysis of the efficiency and effectiveness with which it discharges its tasks. This kind of analysis is essential to ensure that we achieve value for money for the major expenditure devoted to the health services each year.

It is worth noting that spending on the health services has increased by almost 65 per cent during the past five years. As far as I am aware, that was the highest increase in public expenditure in any Department or area of activity in the public sector at the time. In other words, it now costs £17 million per week more to run the health service then it did five years ago. Has a study been conducted to ascertain whether that service is 65 per cent better than five years ago?

Although such a study has not been carried out, I can say without fear of contradiction, that the services is not 65 per cent better than it was five years ago. On what was the money spent and for what purpose? In a political culture where the solution to every problem appears to be the application of additional resources or, in plain language more money, should we not pay more attention to the concept of value for money and think in terms of quality rather than quantity?

The Bill contains a number of welcome initiatives on the management of health boards. It dispenses with the need for health boards to get ministerial consent for land transactions or the payment of grants to voluntary bodies. It also introduces a requirement that future appointees as chief executive officers of health boards should hold office on fixed term contracts. That is a positive development.

Because minor changes are made in the Bill the impression is given that the Minister and the Department are withdrawing from the day-to-day management of many of the services, particularly from a financial point of view, but that is not so. If one looks at the Bill, one will see that virtually every section from sections 5 to 14 includes new provisions under which the Minister may specify this, that or the other in relation to health boards. In removing the requirement to get consent in respect of one or two relatively minor matters it is wrong to give the impression that the Department will be less involved, it will be involved to a much greater extent.

The health service should be managed as efficiently and cost effectively as possible. I would welcome anything which contributes to the development of such a management culture within the service. Even though the Bill is relatively long it makes no reference to the concept of quality as opposed to quantity.

The concept of quality management standards is now widely accepted in the private sector, but has been slow to take root in the public sector. Over 1,000 business hold the internationally recognised ISO 900 quality standard. They cover the whole spectrum of industry and commerce ranging from food processers to pharmaceutical manufacturers, hotels and insurance companies. It is imperative that we bring the same quality management ethos to bear in the public service.

The document on Civil Service reform published last week highlights the desirability of improving quality and suggests the introduction of a quality service initiative. The ISO system is already in place and provides a readymade target at which to aim in terms of quality management. It is operated and administered by a State agency and should be a benchmark for health boards and all aspects of the health service. It might not be appropriate to enshrine such a requirement in legislation, but the Minister could demand that all health boards meet the standard within a specified timeframe.

There can be little doubt that the quality management ethos would improve our health services and help to avoid some of the catastrophes which have occurred in recent times. Would the hepatitis C disaster have happened, for example, if there were clear procedures in operation at the Blood Transfusion Service Board and they were properly adhered to? Would the terrible mistakes which characterised the sad story of Kelly Fitzgerald have been made if there were a quality management ethos in the Western Health Board?

I do not know the definitive answers to these questions, but I strongly suspect that the answer to both is that they would not have happened if the quality management ethos taken for granted elsewhere was followed in either organisation. If private sector businesses are capable of reaching an internationally recognised quality management standard, our health services should also be capable of doing so. It is, perhaps, even more vital that they should because of the nature of the work in which they are engaged and the inordinate cost of their activities to the public purse.

With regard to the organisation of health boards, does the Government have any plans to review the existing regional structure which is distinctly lopsided and has remained largely intact since the boards were first established in 1970? My recollection of the Bill is different from that of Deputy Geoghegan-Quinn because when it was finally enacted the Minister, Erskine Childers, was enthusiastic about the idea of eight boards at a time when it was the subject of some criticism in this House.

In the 26 years which have elapsed since then, the size of health board population catchments has changed substantially but this has not been taken into account in the Bill. Some of the smaller health boards have population catchments as low as 200,000. The Eastern Health Board on the other hand caters for a population more than six times larger than that served by the smallest board. Its total catchment, in excess of 1.25 million, accounts for more than 35 per cent of the national population.

There is, therefore, a case to be made for reappraisal of the existing structure to ensure it offers the best means of delivering a quality service to the community at large and value for money to the taxpayer. In particular, the question must be considered as to whether some of the smaller health boards should be amalgamated for the purpose of delivering a better service.

The Mid-Western Health Board has a population catchment of about 350,000, the average size served by the health boards. It does not deliver a proper cardiology service. It has inadequate equipment to enable what are now regarded as routine cardiac procedures to be undertaken. Most of them are carried out in Dublin. It is unfair and wrong that, because somebody happens to live in a particular health board area, he or she cannot undergo what are regarded as normal, run of the mill medical procedures within that area. Clearly, it does more than inconvenience people; it puts them at a serious disadvantage.

When talking about the need for cardiac procedures we are talking about facilities, the non-availability of which may well mean the difference between life and death. Non-availability of such procedures in a local area may mean that, unfortunately, somebody in that area will die whereas if he or she lived in another area where those procedures are available they would not. People should not be discriminated against in respect of procedures that are relatively routine. I fully accept that, for example, advanced cardiac surgery or advanced neurosurgery cannot be available in every part of the country; that is commonsense. However, the fact that some areas lack ordinary cardiac facilities is unacceptable and should not continue. The provision of facilities would be improved if health board areas outside the Eastern Health Board were sufficiently large to enable them to provide relatively routine procedures.

Because some effort is made in this Bill on the question of financial accountability I should conclude by referring back to the two episodes I mentioned earlier: the hepatitis C disaster and the Kelly Fitzgerald saga. It is appalling that each of these incidents occurred, but by far the worst aspect is that in the hepatitis C affair there is still no accountability for a degree of neglect so serious that in most countries it would be a criminal matter. There is no accountability and no penalty of any kind for those whose wilful failure brought about the hepatitis C disaster for hundreds, if not thousands, of people. On the contrary, as I pointed out previously, not alone are no sanctions brought against the people who wilfully allowed this to happen but, in accordance with the worst traditions of the public service they were given golden handshakes on the agreed termination of their services. The Minister for Health can hardly be blamed if the average person in the street thinks that the Minister of the day and the Department approved of the shortcomings and neglect. This is a very serious matter and if there was a repetition, would we expect similar approval from official sources? It is quite remarkable that there is such a poor level of accountability.

I again contrast what happened in regard to the use of infected blood here with what happened in France where at present several people are in jail, including a former Minister as well as several senior administrators, when it was discovered that HIV infected blood was used. In this country, people knew they were using blood infected by hepatitis and they continued to do so, inflicting serious injury, suffering and disease on innocent people who availed of that blood or blood plasma in good faith. Thousands of people are now being compensated with large sums by the taxpayer and they include not only those who were injured but those who caused the injury. It is the ultimate laugh that the taxpayer pays both sides, the injured and the injurers.

Mr. Ring

I agree with Deputy O'Malley. When I raised this matter in the House recently I said that people who are responsible for the suffering of others as a result of using infected blood are walking free and being paid by the State. People did not like to hear me say that those responsible should be behind bars, but anybody who puts the lives of others at risk should pay the cost.

My views on this Bill are probably different from those of other Deputies. I would like to see our eight health boards abolished. People should be responsible at county level to those whom they represent. For far too long health boards, particularly the Western Health Board, have not been accountable to anybody. I hope the Government is not handing over responsibility of health boards to the chief executives. Health boards should be accountable to the Minister for Health who, in turn, is accountable to the Dáil. The people elected to the Dáil should be able to get information from the Minister on all matters relating to health boards.

Deputy O'Malley talked about necessary services and I agree it is not possible to have every service in each county, but it is sad that most of the services required by the people of Mayo are located in Dublin. People have to travel to Dublin from Belmullet, Erris, Ballina and Westport for the most basic health services. I welcome the Minister's recent announcement about the allocation of £25 million for Castlebar county hospital, which will provide many new services. We fought for many years for a proper health service in Mayo and I am glad that at last it is being provided. I am aware that not all the services required will be available, but at least it is a step in the right direction.

I welcome the measure in the Bill which provides that chief executives will no longer be appointed for life — it has not been decided yet whether their term will be two, three or five years. As is the case with all State boards, chief executives of health boards should be appointed for a short time, perhaps two to three years, and if their performance is satisfactory their contract could be renewed.

Some health boards live within their budgets whereas others, regardless of how much money they receive, seek extra funding. Health boards are answerable to this House and to the people who elect us. Chief executives of health boards should be required to appear before a committee of the Dáil to answer questions put any Members.

I am concerned about a problem which affects many of my constituents, namely, the number of questions they are asked when they go into hospital. It can be like a question and answer session and patients may be required to answer questions three or four times while in hospital. This is the computer age and, while I accept questions must be asked of patients, much of the information required is on computer. Health service workers including doctors and administrators should talk to patients and explain their problems to them in layman's language rather than simply doing ward rounds accompanied by ten or 12 students. Patients are frequently left wondering what is wrong with them and that is not right. Hospitals should have a PR person who can speak to patients about their problems. Members of the public should not have to beg consultants to let them know what is wrong with their relatives. I ask the Minister to give some consideration to this matter.

I am amazed at the number of hospitals who arrange 30 or 40 appointments for the same time. What is the reason for having 30 or 40 people in a waiting room? It is degrading for people who are sick, particularly women who are often accompanied by young children. They find it difficult enough to get to a hospital without having to wait with 30 or 40 other people. This is a serious problem. Appointments should be staggered to avoid people having to wait for long periods.

I believe strongly that health boards should be operated at county level. We should have a county committee of health. I believe in the past such a committee existed in every county and they should be re-established. We have a proven county council system which has endured since the foundation of the State, but unfortunately local authorities are not given sufficient powers. Likewise health boards should be structured at a local level because local people can identify problems in their own areas. There should be representation from the general public, the doctors and the health boards which would result in a far better system. The health boards are too large. They are not responsible to anybody but if they were operated on a county level there would be a great deal more accountability.

People are at their weakest when they are sick and they are entitled to receive a proper service from the health boards. I acknowledge that over the years Western Health Board hospitals have provided a good service but I want to refer to a group of workers in that service who do not get the recognition they deserve. Consultants, doctors and chief executives get recognition and when there are staff shortages in these professions their numbers are maintained, but that is not the case with nurses. I am tired of hearing people say that nursing is a profession. Of course it is, but nurses must be paid; they need pounds, shillings and pence to survive.

I am happy the Minister is in negotiation with the nurses because they do a wonderful job. They are very kind to people who are sick and at their weakest. If one is in hospital it is wonderful to see the smiling faces of the nurses who do a difficult job under difficult circumstances. They give a wonderful service to this State and I want to thank them for that service. Nurses are easy to talk to; they are on the front line and they should be supported in every way.

We have too many pen pushers in the public service and if we continue the way we are going there will not be a sufficient number of buildings in the country to hold all the paperwork produced. I am referring to every part of the public service. We must look after the people working on the ground, in particular the nurses who must be complimented for their work. I hope the current dispute can be resolved to their satisfaction.

Deputy O'Malley referred to certain incidents that took place in my health board area. We need more social workers because we have many more social problems now than we had 20 years ago. In the past, psychiatric hospitals discharged patients into the community who were not capable of living in such an environment. That is not a popular view but if we continue to discharge these patients into the community, they will need proper supervision. I know of people in my county who, having been hospitalised for 25 or 30 years, were discharged into the community despite the fact that they were not well enough to cope with such an adjustment. Those people need help and they certainly must be supervised. Health boards must employ more social workers and nurses if the policy of discharging patients from psychiatric hospitals is to continue. Psychiatric patients need supervision on a day to day basis; they should not simply be discharged into the community to fend for themselves.

The chief executives of health boards have too much power while the members of health boards have insufficient power. I hope in this Bill the Minister is not removing any power because in the final analysis this House is responsible to the people. The Minister is not responsible for the day to day operation of health boards but the chief executives of the boards must be answerable to the Minister, who should have the final say in relation to certain issues. Taxpayers are paying for the health service and the chief executives of the health boards should be answerable to the Minister for Health.

I regret that the Bill does not provide for the operation of health boards at county level because it is impossible for people in the city of Galway, for example, to have an understanding of the problems in Belmullet and vice versa. If health boards were operated on a county level they would be more responsible to the people. They could meet on a regular basis and the people in the county would become aware of any problems.

The problem of staffing will have to be addressed. If we are to continue the policy of discharging patients who have been hospitalised for many years, we must have additional social workers and nurses to deal with them. People cannot be expected to walk out of a hospital and live their lives in a normal society when they have lived in a hospital environment for ten, 15 or 20 years.

The £25 million funding for the hospital in Castlebar was a major boost for the county. The local people believe that a Government has finally listened to them. We fought for that hospital over many years. Many new services will be provided but additional services are required. Women should not have to leave County Mayo at 7 o'clock in the morning to travel to a hospital in Dublin by train or by car, a journey which can take from four to six hours. Health services should be provided as near to one's county as possible.

We appreciate the Castlebar services. I thank the Minister and the Minister of State for the wounderful work being done in the Department. We in Castlebar have waited a long time for this good news for County Mayo. The people can now look to the future with confidence. We will have a good service in the next three to four years and a new hospital with plenty of staff and facilities.

Mr. D. Wallace

I wish to share time with Deputy Batt O'Keeffe.

An Ceann Comhairle

I am sure that is satisfactory and agreed.

Mr. D. Wallace

Ensuring the efficiency and effectiveness of our health services is a matter of concern to each and every family. Sooner or later almost every individual has to receive medical care whether from the family doctor or from hospital-based services. In general, we have much to be proud of in our medical services. The standard of primary care provided by our family practitioners is a match for that provided in the most economically developed countries.

It might be reasonably argued that our GMS system provides a more comprehensive level of access to excellent medical care than is available in many wealthier western countries. On the other hand it might be argued that our acute services are not as well developed as might ideally be the case. From time to time we see and hear of cases of undue delay in providing elective services such as hip replacements and various other surgical procedures. There is no doubt that such backlogs are the cause of much distress and pain for people dependent on the State for medical treatment. It is vital that renewed efforts are made to eliminate such unfortunate problems in our health services. We also have substantial resource difficulties in the area of fully equipping our acute hospitals. As medical technology becomes increasingly sophisticated, there is a tendency for smaller regional hospitals to be left behind in the race to provide comprehensive state-of-the-art services. This trend is totally unacceptable and must be addressed as a matter of urgency by the Minister and his Department. On the positive side it is accepted that our acute hospital health care personnel are excellently trained and their tremendous dedication continues to make a major contribution to society.

In the overall context one can have a certain degree of satisfaction regarding the quality of our health services. At the same time there is a number of warning signs that there is no room for complacency in terms of the service. There is clear evidence that a number of factors have combined to place an unprecedented level of demand for resources on the health sector. The increasing sophistication of modern medicine is exerting a major inflationary pressure. Costly procedures such as coronary by-pass surgery and organ transplant are becoming increasingly routine rather than exceptional in the daily practice of acute medicine. Similarly many newly-developed drugs are extremely expensive in the treatment of conditions such as cancer, chronic illnesses and infectious disease.

Population projections indicate that the number of elderly people in Irish society is likely to increase substantially in the next 20 years or so. This welcome trend towards increased average life expectancy will place a further major strain on our health care service, particularly in the acute hospital sector.

If there was ever a time to closely examine the efficiency of our healthcare system it is now. In a sense the Bill before the House is timely, since it addresses a number of key issues regarding the performance of our healthboards. Since the health boards act as the main arm of implementation of health policy, it is vital that they operate at the highest possible levels of efficiency and accountability.

Before considering the various sections of the Bill I will make a few points. Ideally, in parallel with the introduction of the proposed legislation, it would have been appropriate for the Minister and his Department to carry out a comprehensive review of both the structural and operational strengths and weaknesses of the current model of health care management. It is agreed by many that the health board structure helps to devolve power from the centre to the regions in terms of determining both the organisation and delivery of health care.

However, there are also a number of potential weaknesses in the structure. For example, it might be claimed that having eight health boards introduces an unnecessary level of duplication, especially in administration. It has been suggested that there should be a greater degree of centralisation in the treatment of patients with relatively rare conditions. Otherwise one runs the risk of developing a relatively large number of under-resourced centres rather than a smaller number of fully equipped and fully staffed units which are almost certain to be more effective.

It is time to review the overall organisation of the delivery of health care here and the preparation of the Bill provided an opportunity to carry out this much needed work. We seem to lack even the most basic information to compare the relative performance of the healthboards. Without such feedback how can either the Minister or the individual health boards decide on the best strategies to be adopted across a range of healthcare services?

I agree with the intent of section 2 which directs the boards to have regard to various standards and goals in their operations. However, I remain to be convinced that we have developed adequate quality assessment techniques to monitor the satisfactory implementation of the section. A cynic might suggest that the crude target of meeting an annual budget target combined with minimising negative media coverage is likely to be nearer the mark in terms of monitoring the performances of the different health boards. While this comment is probably too harsh, it must be agreed that sufficient resources have not been allocated to the vital task of audit and quality control within our health care services.

Sections 3 to 5 deal with the relative roles of board members and the chief executive. It is obviously important to allocate the overall responsibility for policy and performance to the board members while placing operational control in the hands of the chief executive officer. While it is important that the Minister maintains overall control of the health boards, I have some doubts regarding the necessity of the comprehensive nature of input by the Minister which is facilitated by section 13. In practice I presume it will only be used to deal with very specific problems.

I welcome the provision in section 15 which requires each health board to prepare an annual report on its performance during the previous year. For comparison purposes, it would seem sensible that each such report would have two parts. While the contents of one part might be totally at the discretion of the individual health board concerned, a standard format might be used in each health board area for the second part to provide precise comparative information. Without a fixed format of that type, one could end up with different reports from the regions without any facility to compare and contrast individual performances.

In summary, I welcome the general trend towards increased accountability which is the basic purpose of the Bill. In an area of such critical importance to the people, we must take urgent steps to improve the scope and detail of information and research which is available on the performance of our health services, for example, the Hospital In-patient Enquiry system, HIPE. This data collecting facility has tremendous potential to provide detailed information on the performance of our acute hospital sector. To-date this source of information does not seem to be fully exploited. I expect a similar position exists in many other areas of our health care system.

At a time when a wide range of factors have combined to create ever increasing demands for resources in our health care sector, we must take every possible step to ensure that audit and quality control becomes an accepted part of the delivery of health care services. We do not have an option in this regard if we sincerely wish to maintain and develop the quality of our health care system.

Mr. B. O'Keeffe

I welcome this long overdue Bill as the health boards were set up in the 1970s. As a member of a health board I am glad a clear distinction has been drawn between the functions of health board members and management as uncertainty in that regard caused great difficulties in the past.

When introducing the Bill the Minister should have taken cognisance of the recent announcement to reward efficiency and effectiveness in the Civil Service. It would be remiss to introduce policies for the Civil Service and not to take cognisance of them when introducing a new management structure for health boards. Major changes have already taken place in our health boards. Management performance has improved dramatically and there is a greater level of consciousness about spending. We want to provide the best possible service at a minimum cost and ensure that scarce resources are not wasted.

In placing demands on boards and management, the Minister also places a demand on himself. If he allocates a sum of money to a health board within which it cannot possibly operate, the dilemma will rest with him. How could he hold a chief executive officer responsible for the additional demands that might be placed on a board's resources? For example, two years ago there was a great demand for beds at Cork University Hospital because a large number of people became ill at the same time. This placed an additional cost of approximately £200,000 on the health board which could not have been anticipated and similar difficulties could arise in the future. If the Minister operates a tightly controlled budget, chief executive officers and health boards will have no option but to limit services and, consequently, the sick will be affected. The Minister will face major difficulties if health boards do not have sufficient funding to meet the demands placed on them.

A sum of £1.5 million was allocated to the Southern Health Board for nursing home subventions. This will cover only those at present in nursing homes and those approved for places. The Minister is asking the chief executive officer in the Southern Health Board to continue to approve nursing home subventions even though he knows that within six months the £1.5 million will be exhausted. At the same time he is introducing an amendment to the Health Act which specifically states that the chief executive officer must not exceed the funding allocated to the health board. Does the Minister realise the dilemma this will pose? The chief executive officer will have to cease providing certain services and it will have a serious impact on nursing home subventions.

As the number of elderly is spiralling, the number seeking places in nursing homes will increase dramatically in the next ten years. To overcome this difficulty the Minister should provide nursing home subventions under a demand led scheme, similar to the supplementary welfare allowance operated by the Department of Social Welfare. If a family member suddenly becomes ill and cannot be cared for in the home, the family may have no option but to seek nursing home subvention. Under the provisions of the Bill the chief executive officer would have to cut the cord in such circumstances and I do not believe that is what the Minister wants. As the Southern Health Board will face major difficulties in the next six months, I urge the Minister to consider providing such a demand led service. Otherwise, elderly people will have to be told they cannot be catered for in the system.

People care about the elderly and many would like to care for them in their homes. Will the Minister consider removing the basic eligibility requirements for the carer's allowance? Would it not be better to give a person £50 per week to mind an elderly person at home? How many people would opt to care for the elderly at home if they could receive a pension and a non-means tested carer's allowance? As many elderly people would prefer to be cared for in their homes, we must ensure people have the resources to provide that care. If that were the case, the demand for nursing home subventions would be much less. The average subvention is approximately £70 per week. If the present trend continues there will not be enough places in nursing homes to cater for the elderly. The number of people seeking places has mushroomed in recent years, the cost to the Minister's Department will mushroom accordingly and health boards will have great difficulty managing their finances.

The Minister may be responsible for the indebtedness referred to in section 13. I hope the Minister will ascertain how many of our public hospitals have vacant units, and, perhaps, make provision in the Bill for health boards to lease some of those premises to individuals who would be able and willing to provide a service for our geriatric patients at no extra cost to the health boards. It might generate finances for the health boards if vacant premises were leased to people who were willing to provide care for the elderly. The suggestion is worth considering. I will have more to say on that issue on Committee Stage.

While welcoming the Bill, I feel there are major cost implications that will cause problems for the Minister and grievous pain to health board managers and members in planning their budget for the year.

Mr. McCormack

I welcome the introduction of this Bill, the purpose of which is to improve the financial accountability and expenditure control procedures in health boards, to clarify the respective roles of members of health boards and chief executive officers, and begin the process of removing the Department of Health from detailed involvement in operational matters.

The overall Health Estimate for this year is about £2.4 billion and a total of £1.34 billion has been allocated to health boards. If the purpose of this Bill is to introduce measures for better planning and control of expenditure levels, that is to be welcomed, because we are dealing with very large sums of money.

This Bill attempts to establish a process where clear guidelines can be put in place for the management and the performance of health boards. Only two years ago the Exchequer had to bail out a number of health boards which had allowed their accumulated deficits to get out of control. This Bill is an attempt to put in place legal controls to ensure that this cannot happen again. The Western Health Board offended least in this regard. The overrun figures paid to health boards in 1994 were not part of their allocation but an extra allocation to cover deficits. The Eastern Health Board received £14.1 million, the Southern Health Board £10.2 million, the Midland Health Board £6.7 million, the North-Western Health Board £6 million, the North-Eastern Health Board £5 million, the Mid-Western Health Board £4.7 million, the South-Eastern Health Board £3.6 million and the Western Health Board £2.6 million. In future boards that manage their affairs prudently should be rewarded with increased allocations in the following year. This might be an incentive for boards to stay within their budgets and a penalty for boards which do not.

The general public do not seem to realise the size of the budgets allocated to health boards. For example, the expenditure for 1995 in the Western Health Board region was £216.4 million compared with a budget of a mere £9.47 million in 1972, the year the health boards were established. In the two major hospitals in Galway, University College Hospital and Merlin Park, we had considerably more bed spaces in 1972 than we now have, and this at a time when our population in the Western Health Board region is getting older — there are now more than 50,000 people over the age of 65 in the Western Health Board area.

People are living longer and there is a greater demand for hospital and institutional care. In the meantime the administrative costs of running our health boards has increased significantly every year. In 1992 the administrative and management costs in the Western Health Board region were £7.66 million. In 1994, two years later, they were £9.786 million, an increase of more than £2 million in two years. The general public would say that this increase in the cost of administration of the health service in our area did not result in a corresponding improvement in patient health care. That is what is important. How the money our health boards receive is turned into patient care is what the general public is concerned about. They see the hardship caused when people have to wait for operations or have their hospital bookings cancelled the night before an operation because there are no beds available. They are aware of the hardship suffered by patients who must wait on trolley beds in casualty to be admitted to hospital. That is a recurring problem in University College Hospital, Galway, and it is getting worse due to neglect and lack of capital expenditure on our hospital over the past 25 years. There has been little capital expenditure since the hospital was first opened.

I pay tribute to the dedication of the hospital staff, the doctors and nurses who must cater for this overflow in the casualty unit and work in extremely difficult circumstances. I speak about the hospital of which I have most knowledge and to which I am a regular visitor because it is in the area I represent. I cannot praise too highly the dedication of the doctors and nursing staff who do an excellent job under very difficult circumstances. The intolerable situation in the casualty section of the hospital cannot be allowed to continue. It is an indictment of Ministers for Health over the past ten years. Let us put the record straight — it is an indictment of Ministers who represented Galway for the past ten or more years. They stood back from the problem and neglected Galway's justifiable case while their ministerial colleagues ensured that major funding was provided for other hospitals in the region.

Castlebar Hospital received an allocation of £25 million only recently for the second phase of development there and I do not begrudge that to Castlebar. Sligo Regional Hospital received a major allocation also in the recent years. I blame our representatives who have neglected the case of the capital of Connacht, Galway City, and neglected to provide capital for University College Hospital over the past ten to 15 years. This neglect has resulted in the chaos we are now witnessing at the hospital.

I compliment the Minister for Health, Deputy Noonan, who in April last year, shortly after his appointment, visited University College Hospital at my request. He immediately sanctioned the drawing up of plans by the Western Health Board for an interim development at the hospital. Yesterday at a health board meeting which I attended, I was glad to hear the chief executive officer say that we are now at tender stage of this interim development which will provide four separate units with accommodation for 13 or 14 beds each, two additional X-ray rooms and ancillary accommodation, two additional operating theatres with ancillary accommodation, and refurbishment of the existing theatres. The work will also include an extension to and alterations in the accident and emergency department, including observation beds. That is a move in the right direction.

Although only an interim measure, I thank the Minister for Health for his quick response to the call from University College Hospital Galway, in respect of which the Western Health Board passed a motion yesterday seeking an updating of its 1982 plans submitted to his Department which have been so shamefully neglected ever since. We seek the go ahead for the major development required at that hospital, the most important within the Western Health Board region. I call on my colleagues in Government to participate in this campaign and have this essential development undertaken for residents of the Western Health Board area, particularly those in Galway city whose population has trebled since the establishment of that health board and quadrupled since that hospital was first built.

Daily one hears comments on radio programmes, including some by Opposition Deputies and Senators, about the scandal at University College Hospital Galway but there is never any acknowledgment of responsibility. I have been a Member of this House for eight years and this is the first time my party has been in Government. I am glad the Minister has responded positively, allowing the Western Health Board to proceed with the interim development at that hospital. Nonetheless, that will amount to repairing a leaking bucket and will not totally rectify the problem.

Another aspect of health boards' involvement I question is their administration of the rent subsidy scheme for the Department of Social Welfare, expenditure on which has escalated at an alarming rate over the past five to six years. The national cost of that subsidy was £8.6 million in 1990, £14.4 million in 1991, £23 million in 1992, £38.7 million in 1993, £44.8 million in 1994 and £52.9 million in 1995. In the Western Health Board area 8,262 applicants received £4.2 million in 1994 and in 1995 some 8,230 applicants received £5.1 million.

This type of accommodation being a major problem in Dublin city, in the Eastern Health Board area 33,445 applicants in 1994 received some £25.98 million and in 1995 some 34,253 applicants received £35.9 million.

The system must be examined thoroughly. Its administration is causing grave concern to those in built-up urban areas where those in receipt of rent subsidy must compete with young married, working couples who would not be eligible, further exacerbating the cost of rented accommodation. Rent subsidy is assessed by health boards on the prevailing rates for rented accommodation which was why in 1995 fewer applicants within the Western Health Board region received £1 million more than in the preceding year. This has become a vicious circle. The demand for rented accommodation is driving up costs and health boards are obliged to pay a subsidy based on the prevailing rate.

Another consequence of that scheme is that, whenever young people living at home apply for the £62 unemployment assistance, which is means-tested on the income of their parents, they are deemed ineligible, whereas if they move to a flat or other rented accommodation they immediately become eligible. Usually they will apply to the health board the following week for a rent subsidy, for which they will qualify, in addition to a medical card, further exacerbating the position of others who must compete for rented accommodation.

I submit that this is an anti-family scheme. Suppose my unemployed son or daughter lives in the family home and applies for unemployment assistance, based on my income as a public representative, he or she will be deemed to be ineligible whereas, if they live in a flat or other rented accommodation they will be eligible for unemployment assistance in addition to a rent subsidy from the health board. If my daughter, a fully trained nurse, finds she is unemployed and comes to live in the family home and applies for unemployment assistance, she will discover she is ineligible. Probably she will do what thousands more are doing, that is, move into rented accommodation. The following week her boyfriend might ask what is the point of both of them living in separate flats. He might then decide to move in with her and my wife and I might suddenly discover we are to be grandparents.

I am talking realistically in the present climate. If young people live at home with their parents, at the very minimum they will be encouraged to seek employment. I submit that for two years after the completion of young people's education they should qualify for unemployment assistance only if living at home, thus maintaining the family unit intact while costing society generally much less than the present system. I make that case based on the startling figures being paid out by health boards in supplementing the cost of rented accommodation.

I request the interdepartmental committee at present investigating that matter to seriously examine taking that responsibility from health boards. Why should they have to administer such a scheme? Would not its administration be more appropriate to the Department of the Environment?

I understand that health boards are also responsible for some aspects of the administration of grants for mentally handicapped persons, the Department of Education being responsible for others. Whenever a public representative inquires, he or she is told its administration is a matter for the Department of Education rather than the Department of Health. In turn, when one inquires of the Department of Health, one is referred to the Department of Education. Rather than have interdepartmental responsibilities, each Department must have its responsibilities clearly specified. The Department of Health should be responsible only for the administration of the health services and not for rent subsidies and matters that might more appropriately be handled by the Department of the Environment. There are several matters I would like clarified and I am sure the Minister will be glad to do so on Committee Stage. I welcome this Bill.

Mr. Browne

(Wexford): The Minister in his very detailed speech outlined the many changes he would like to see in the health boards in the coming years. Many politicians who have never served on the health board are inclined to be critical of how it operates. It is quite some time since the eight health boards were established and we have to ask whether they are capable of moving with the changing demands on health services today and into the next century.

I have been a strong critic of health boards, particularly the South-Eastern Health Board, because it does not provide the services needed on a country by county basis. Some counties seem to do far better than others. Even though the health board structure was put in place by my party I have always believed it was a major mistake to change from a county to regional structure because when the health service was administered by the local authority there was greater accountability for the operation of the service. I have been critical of the elected representatives who are members of the health board. A short time ago a Deputy said that the role of the members of the health board needs to be defined and I agree. Health board members have far greater powers than they exercise. They have allowed a chief executive officer and his administrative staff to assume overall power rather than exercise it themselves. Many of the public representatives on the health board have never initiated or implemented the policies that the people want.

I have argued — and will continue to argue — that health services should be administered on a county basis. Some people might think that would be a retrograde step but some counties have benefited far more than others. For example, in the South Eastern Health Board, counties Waterford and Kilkenny have benefited far more than Wexford and Carlow because the headquarters and the principal hospital of the region are located there. In the past year or two County Wexford has done reasonably well because the former Minister for Health, Deputy Howlin, is from Wexford and during his term of office many new initiatives were implemented in Wexford, including the upgrading of the hospital, which was initiated by Fianna Fáil and continued by the Fianna Fáil-Labour Coalition Government. New services such as day care centres were provided in the smaller villages. Prior to that time and for the best part of 20 years County Wexford had lost out badly because of the health board structure. The Minister of State, Deputy O'Shea, is from Waterford and while he is in office I am sure he will ensure there is a fair and even spread of resources throughout the region and not just concentrated in one or two counties. Chief executive officers of the health boards have too much power and I agree with our party spokesperson, Deputy Geoghegan-Quinn and Members on the other side of the House who have said that the chief executive officer should have to come before the Dáil on an annual basis to account for expenditure and the services provided in the region he administers. The health boards are not accountable enough to the general public, to Members and to the Minister. In the course of his address the Minister said greater responsibility should be devolved to the health boards and other executive agencies. The role of all key parties including the board members and managers must be clearly defined. I would like to see health board members accepting their responsibility and not continuously hiding behind the chief executive officer and his senior administrative staff. The powers have been devolved to the health board members and they could provide a far better service. The members are the policy makers and the role of the chief executive and his staff is to implement it. I am not satisfied that this is happening. Perhaps it is happening in reverse and I am glad the Minister will clearly define and spell out the role of both to ensure that we get a better service from the health boards.

The Minister must take a deep interest in patients' rights. Members are aware that patients are asked a great many questions and a detailed form has to be filled in. In this era of modern technology and computerisation surely this should happen only once and the data should be in the system on the patient's return visits.

I am very critical also of the way hospital appointments are handled. Everyone gets word to come to the hospital at 9.30 a.m. and perhaps 100 or 200 people arrive and are still there at 2.30 p.m. Surely it is not impossible for hospital staff to arrange appointments at different times so that one patient is called at 9 a.m. and appointments are made every ten to 15 minutes? People have to go to hospital from all parts of the county and sit around all day waiting to be seen. In many cases a neighbour or taximan, who had to be paid, brings the patient to hospital. It is totally unfair that the patient cannot even get a cup of tea, coffee or a sandwich. However, there are no problems with appointment times in the Dublin hospitals and one is seen at the appointed time. Will the Minister discuss ways of improving this unacceptable system with the chief executive officer, health board members and hospital administrators? Patients who are ill may have to wait up to two hours for their turn.

I have seen cases, especially in respect of older very ill patients, where people were allowed jump the queue to attend the doctor. Changes could be made in this area with little difficulty or inconvenience to the hospitals involved.

The chief executives and administrative staff of the health services appear to have no problem getting salary increases. However, those working at the coalface dealing with the public — nurses, ambulance drivers, community welfare officers and so on — always have to beg, threaten strike action and create all kinds of rows to get increases. This causes great anxiety and annoyance. It also causes concern to the public seeking a better health service. While there are substantial administrative salary increases every year, services on the ground do not appear to be any better.

This area must be looked at. Nurses, ambulance people, doctors and others dealing on a daily basis with patients should be given the salary increases which they deserve. At present, nurses are very dissatisfied. They are annoyed that this and previous Governments have not recognised the major role they plan in society caring for patients. Their role has never been adequately recognised by the powers that be. However, it is recognised by patients. Anyone who has been in hospital has seen the tremendous work done and service provided by nurses. However, teachers, whether primary or secondary, the gardaí, farming groups and others with clout get benefits and wage increases while nurses have to take a back seat. In view of the nature of the service they provide, nurses have never felt happy about threatening or going on strike or abandoning their patients. However, their patience has finally snapped and they are now serious about taking action to get a better deal for the work they do. Regardless of the time of year, nurses are always on call to look after people. This must be recognised by politicians on all sides of the House. The salary structure they seek should be negotiated with them and they should not have to beg for an increase they so richly deserve. The Minister of State is a caring man. I know that he, the Minister and the Department will continue to negotiate with the nurses because they recognise the major role they play.

We live in a changing society. The area of child abuse has come to the fore. Health boards are not geared to deal with this escalating problem. There is need for more staff training and greater expertise. The Minister should tour the country to discuss this with them. Board members and officials do not recognise their major responsibility to put an action plan in place and hold discussions with the children involved, their parents and other relevant people and groups. This most serious area requires a co-ordinated approach between the boards and the Department of Health. People are concerned that the boards have not recognised the importance of the problem and have not geared themselves to deal with it. The Minister spoke of devolving greater powers to the boards, which is welcome. However, in this area he must have a hands on approach to ensure that structures are in place to deal with it.

Many people do not have adequate access to transport to hospitals. The health boards provide a transport service to the major hospitals, for example, there are adequate mini bus services from Wexford to Ardkeen and Wexford to Dublin. However, if one wishes to travel from Enniscorthy or Gorey to the general hospital in Wexford, one must hire a taxi or get a lift if one does not have a car. Some mornings, especially on Fridays when, in my work as a politician I travel out of Enniscorthy to the county hall or some other destination, I would see nine or ten people on the road thumbing lifts to the hospital.

The Minister advised that £2.4 billion was being spent by the health boards and it baffles me that they are unable to provide adequate transport services for such people. It is not right to expect a mother who is not in good health to thumb a lift to the local hospital in the middle of winter. I hope the health boards will consider this issue again. Transport services were withdrawn some years ago. I never understood why they had to be withdrawn completely. Not much thought or consideration was given by the boards to this area. I have written to the chief executive and the members of the South-Eastern Health Board on a number of occasions and will continue to do. A transport system could be introduced on a small scale. Most people have cars, but there are some on or below the breadline for example, lone parents, separated mothers, etc, who do not and must thumb lifts to hospitals.

There is much talk about the fact that by the turn of the century the number of old people will have increased. What plans are the health boards putting in place to deal with this problem in ten years' time? I believe, from making telephone calls to the health boards and local health clinics, there are few plans, if any, being put in place. The Government introduced a bed subvention for nursing homes, which was welcomed, although many people do not qualify because of the rigid implementation policy adopted by the health boards. The Department of Health — I know it has set up a planning committee — and the health boards must look at a long-term plan to deal with this problem.

Nursing homes charge exorbitant fees. It costs approximately £250 a week to keep someone in a nursing home in Enniscorthy and it could be twice that figure in some parts of Dublin. A person on a pension would not be able to secure a bed in such nursing homes. Some Deputies suggested that grants should be paid to people to look after their aged mother or father at home. This should be seriously considered. A father or mother would prefer to stay in the family home rather than move to a local nursing home or geriatric hospital.

I ask the Minister to take on board some of my suggestions. I will also make representations to the health board. Our health services are on a par, if not better, than some of our EU counterparts. However, we should question what value we get for the increasing amount of money allocated by the Minister to the health boards each year. Health boards should be accountable and changes should be made to ensure that people get an improved service. I welcome the Bill which gives us an opportunity to put on record our views on how health boards should operate and the type of services they should provide for the people.

Mr. Boylan

I welcome the opportunity to make a short contribution to this debate. We have little if we do not have our health. Foremost in our duties as public representatives must be to provide a good health service for the people. I am happy with our health services, which are probably the best in the world and it must be acknowledged that successive Ministers gave their all to building the health services.

Some £2.4 billion is spent on the health services and £1.34 billion by the health boards. There must be accountability when spending such a large sum of money. A Deputy made the comparison between the health boards and financial institutions with a turnover which is treble or quadruple the health boards' total bill. They return their end of year accounts within two months after 31 December. However, that is their business and they must do it properly because they are dealing with our money. They are making money and they must know what to do. Health boards are different because they are not dealing with financial matters, but with the administration of health care which is costly. If people want the services, they must be paid for.

We have some of the finest surgeons in the world. I heard an interview today with Mr. Nelligan, our famous heart specialist. He said he was not stating his own case, but laying out the facts. He is only one of a large number of people dedicated to health matters. He works from 7 a.m. to 8 p.m. five days a week and is on call at weekends. How many people work those hours and give that type of service? He does three major heart operations a day, five days a week. People come here from all over the world for heart treatment. We should be proud of that.

Despite the fact that Mr. Nelligan and his team and many other surgeons who have trained both under him and abroad are providing this service, there is still a backlog. I cannot understand why this is the case given the improvements in health care. Mr. Nelligan said there is an 18 months' delay for a heart operation, but he reiterated that an emergency would be dealt with immediately. If someone is diagnosed as needing a bypass, it could be 18 months before they have their operation, although they are continuously monitored. It is a worrying time for the patient and his or her family. Mr. Nelligan indicated that we would need to do at least another 400 operations per annum to clear the backlog.

People whose eyesight is failing because of cataracts need an operation to remove them. I have brought people to Dublin on numerous occasions to have their eyes examined, but they were told they must wait for an operation because of the waiting lists. That has a traumatic effect on people. It is important that someone whose eyesight is failing has an operation. Orthodontic treatment is another area which must be addressed. We do not seem to be coming to grips with the growing waiting lists.

I am happy with the manner in which health care is administered through the North Eastern Health Board. I have been a public representative since 1974, although I have never been a member of the North-Eastern Health Board. However, I know the chief executive officer and the staff who are efficient and forthcoming as regards representations.

Cavan General Hospital is one of the finest in the country. When its development was sanctioned, the people of Cavan did not wait for someone else to do something for them. They set up a fund raising programme to provide major equipment and over £100,000 was collected for a CAT scan machine. Other equipment was also bought. The people will help if services are being provided and the Cavan people are no different from people in other parts of the country.

The health services in Cavan General Hospital are outstanding and we are fortunate to have a great team of surgeons, doctors and nurses who give great service.

There must be flexibility with regard to budgeting because if a person needs immediate health care in an emergency, he must get it and the people who provide it must be paid.

With regard to care of the elderly, there is a move towards providing small nursing home units close to communities rather than large isolated nursing homes. In County Cavan St. Felim's is being divided into nursing home units in Virginia, Ballyconnell and Cootehill and this is a step in the right direction. However, we should not focus our attention exclusively on nursing home accommodation. Medical advances mean that people live longer. They do not aspire to live in a nursing home but to remain in their own homes. More effort should be made with the help of the health boards and the Department of Social Welfare, to co-ordinate a proper service by which people can be looked after in their own communities.

In the past one of the younger children in a family stayed at home to look after the aged parents and that person's life might be spoiled because by the time the parents passed on, the carer was too old to set up his own home. Young people are more inclined nowadays to get on with their own lives. The elderly people are not being abandoned but young people have their lives to live.

If young people want to care for an elderly parent or relative they should be given help to do so. For financial reasons a young couple who want to care for an elderly relative may have to work but are reluctant to leave an elderly person at home alone all day while they are out at work. The idea of "granny flats" and extensions to houses is good, but a home help or carer's allowance is also needed. District nurses also do marvellous work in this regard and are greatly underrated. A system which helped young couples to care for an elderly relative at home would free up beds for those who cannot be cared for at home. Many people now in institutions could be cared for in their own homes or communities. In Cavan town, Cavan County Council has a policy of building old person's dwellings in groups. Old people fear burglaries and robberies so we have developed a system of small units in groups of three or four where people can live individually but have the company of neighbours. That model should be further developed because it gives a person the freedom of his own home in his community. It can readily be provided but it requires back up services and the carer's allowance, for example.

The Department of Social Welfare is too strict in laying down the rules and assessing incomes. With this system an elderly person can have the satisfaction of living in his community in his home, and there is a saving for the health boards in that beds in hospitals and nursing homes are left free for those who need them. If the Minister addressed this problem he would do a great service to those involved. It is important not to forget the elderly.

I have no complaints about the health services. We are fortunate to have them. The previous speaker referred to waiting times at clinics. People are often given morning appointments but may not be seen until the afternoon. This is due to carelessness on the part of the person arranging the appointments and a little time and attention given to the process would improve the problem. People who are sick should not have to wait for long periods, especially when they have young children. The problem is exacerbated if those involved have to travel a long distance to Dublin, for example. The system should be more streamlined to avoid people having to sit around for three or four hours. I compliment the Minister of State and the Minister for the work they are doing.

Dr. Moffatt

It has been some time since there was an examination of our health structures. We have been working from regulations devised in the late 1960s and early 1970s by the then Minister, the late Seán Flanagan. The health boards are delivering a good health service. I agree that the chief executive officer of each health board should be a doctor. I am aware that other Members would not agree with this but when the health boards were initiated doctors were appointed as chief executive officers because they had the greatest knowledge of health matters. However, things have changed since that time.

A major portion of organisational structures dates back to the 1970s. The Commission on Health Funding made a number of observations with regard to structural organisation, particularly in respect of confusion as to the way health services are delivered at local and national level. No proper evaluation has been completed in many instances and accountability has not been the hallmark of the health service. There has also been poor integration of services within the State. The interests of the primary user, the patient, have not been sufficiently taken into account.

In light of this background and the developments that have taken place since the 1970s, it is advisable that the current managerial system be considered. Many new aspects have been developed in the areas of management and high-tech medicine and we must also deal with the areas of litigation and the media. It is very important that health boards learn to deal with the media and problems of litigation that arise on a daily basis.

In 1991 the then Government decided to proceed with an organisational effort within the health boards because of the plethora of voluntary and statutory agencies and sub-agencies which have developed in recent years. There did not appear to be an overall management structure or linkage in place between these agencies. Greater information was needed with regard to the exact position of health boards vis-à-vis the chief executive officers, voluntary agencies, the Minister and his Department. It was decided that the time had come for a significant consideration of the problems of the health boards, particularly the Eastern Health Board.

Any changes to the health services should be directed for the benefit of patients, not civil servants, doctors or managers. The new structure should be patient-oriented and not oriented toward chief executive officers, executives or the personnel responsible for administering the health boards. We should consider the needs of patients and the type of service being delivered to them. Everyone has experienced poor service and management in many areas of the health service. There have been some successes in various health boards but decision-making must be devolved to grass roots level. We must work in conjunction with the voluntary sector and encourage practical development.

The health sector is one of the largest employers in the country. Ireland has many unemployed people and it should be within the power of the Department of Health, working in conjunction with other Departments, to see if some of these people could be employed in the health service. The health boards could consider various aspects including carer's allowance, minders, etc. There are areas which have the potential to help reduce the rate of unemployment.

Many problems have arisen in recent years which were not a feature of life in 1969 or 1970. New problems such as AIDS, hepatitis, drug abuse, the reemergence of TB in some areas, the issue of litigation and allergies seem to be becoming increasingly prevalent. Problems also exist with regard to funding and VHI cover. These issues have recently evolved and must be effectively dealt with by any new structure in the health boards.

We must not forget the bread and butter issues which have not been sufficiently resolved. For example, people still encounter problems when trying to speedily procure medical cards in cases of hardship. There is also the problem of assessment in cases where people have small amounts of money on deposit with the local bank. The interest is reckoned at 10 per cent for assessment purposes, when depositors might only be receiving 1 or 2 per cent. These questions must be considered.

We must also consider people's views regarding provision of services. Things have changed dramatically in relation to accident and emergency services in recent years. Road traffic accidents are more serious than 20 years ago, cars travel at much greater speeds and major accidents are a daily event. Is it sufficient to have a junior house doctor or senior house officer dealing with people involved in serious road accidents? Should a consultant physician or registrar be on duty at all times to obviate the problems that exist in terms of litigation? Health boards must carefully consider these issues.

Satisfactory progress has not been made with regard to waiting lists. Despite recent effort and financial investment, there has been an increase in the number of people on waiting lists. This matter must be reconsidered to discover the reason we have not succeeded in reducing numbers.

Many people have experienced problems in the area of orthopaedic medicine. People must wait a long time and endure much pain before being admitted for such necessary procedures as hip and knee operations. This is not acceptable. We must consider the position in the private sector vis-à-vis the public sector. People can have a hip operation in the private health sector within one or two months. In the public health sector they might have to wait years for such an operation. The health boards must look critically at the delivery of service.

The same problems pertain in the developing area of cardiac medicine where heart by-passes are the order of the day. Such operations will become more frequent and we must endeavour to deal with the problems that exist.