Deputy Pat Carey was in possession. There are ten minutes remaining in the slot. I understand Deputy Carey intended to share with Deputy Dennehy.
Health (Eastern Regional Health Authority) Bill, 1998: Second Stage (Resumed).
Question again proposed: "That the Bill be now read a Second Time."
I welcome the opportunity to participate in the debate even though I come from the southern part of the country. I welcome the Minister's initiative in setting up this new body. For many years it appeared to outside observers that the health care area in Dublin and the surrounding area was chaotic. There seemed to be a total lack of co-ordination and, in many cases, co-operation between the voluntary sector and the health boards. This initiative, therefore, is long overdue and I welcome it. Action was needed to provide the best possible service to the public in the most efficient and value for money fashion.
Matters extraneous to the Bill were referred to today. In complimenting the Minister, I welcome some changes which the Minister has facilitated through the Finance Bill. An issue that has troubled me for a long time is that of medical cards for the elderly. I welcome the change which will double the income levels allowed to facilitate people over the age of 70. In the Southern Health Board that will mean that most of the additional 10,000 people in Cork and Kerry over the age of 70 will automatically be entitled to medical cards. That is welcome.
In the context of the Bill we are talking about a very large area with more than 1.3 million people but the principles are the same in regard to efficiency, co-operation and co-ordination. I have been chairman of the Southern Health Board on numerous occasions over the past 12 years. That health board caters for half a million people and we try to maximise the benefits of the funding and the personnel available, not for the health board, Ministers or Deputies but for the patients. That has not always been the case in the Eastern Health Board region.
Much disquiet has been expressed about the Eastern Health Board by people in other health board areas and this was never more apparent than when we examined the question of the appointment of consultants. It appeared to those of us outside the Eastern Health Board region – the Southern Health Board found itself short of 46 posts four or five years ago – that cosy relationships existed in and around the Dublin area which resulted in a greater number of appointments being made there than in other health board areas. I welcome the co-operation that will be introduced under the Bill.
Deputy Shatter broadly welcomed the Bill but referred to some areas of concern to him. The allocations to the voluntary hospitals was one such area. My experience in the Southern Health Board is that the single funding agency has been in vogue for the past year and a half and has worked successfully. This is an area from which lessons can be learned.
In regard to the numbers on the board, I would be concerned that this might make it unwieldy. The board I chaired had 33 members which was a sufficient number to enable it to work in an effective manner, particularly at public meetings. I emphasise that one or two disruptive members can cause chaos on any board, regardless of its size, but the question of the number of people on boards should be examined.
I listened carefully to the Labour Party spokesperson, Deputy McManus, and was amazed at her opening attack on one of the initiatives of the Minister of State, namely, the setting up of the health board chief executive officers' executive. I do not know if Deputy McManus has been working in the health area in the recent past but she should be aware that this grouping has existed for many years on a voluntary basis. The eight chief executive officers meet on a regular basis and bring forward recommendations which are worked on by the Department and the Minister. One of the initiatives they produced was the health gain unit and they also set the guidelines for medical card qualification. This grouping is in place and Deputy McManus and others should be aware it has been working efficiently.
Deputy McManus seemed to be trying to create a scare in regard to buying and leasing property and other issues dealt with in the Bill. This is a standard requirement when a body is being set up. I presume it is office space, etc., that is being referred to and I am sure the Minister will deal with that question. That aspect concerned me because I had worked for a number of years to get greater co-operation among the chief executive officers throughout the country.
I hope Deputy McManus is not suggesting a return to the bad old days when chief executive officers did solo runs and tried to gain the edge for their own regions. We cannot return to that. We want a standard of health care which will apply equally in Donegal, Cork or Dublin and qualifying standards on other issues should be dealt with on that basis. That is the reason the co-operation of the eight chief executive officers is necessary.
In that context it should be pointed out that the new legislation introduced by the Minister for Health and Children has placed enormous responsibility on the chief executive officers both in terms of financial accountability and in other areas. They need support and a proper working relationship to deliver on the demands for accountability.
I welcome the transparency which the Bill offers. These people can be brought before the Public Accounts Committee and are responsible to other bodies. That is a change. We should continue on that route, not go back to the days of eight boards doing their own thing.
I worried the Minister might back off from establishing this executive. There was a reference to non-elected personnel. We deal with these people every day. They are highly efficient, competent and professional and now they are accountable as well.
The health boards have stepped back from policy decisions. The new format requires them to present a programme of services for the year before the budget is allocated, but the boards do not prioritise their services within that budget. Most of the public meetings are held up by trivial matters rather than discussing policy and priorities. That is the function of the boards and they have shied away from it. The Minister should be mindful of that when looking at the composition of the new board and ensure that it spends its time deciding on the best policy approach and the priorities.
The elderly and the handicapped have been left behind. They found that they and their consultants were competing with modern costly technology and specialties. They lost that battle in the general scramble for funding at all levels and did not get the opportunity to state their case like some of the more high profile specialties. The Minister is targeting funding for these groups and the new board should continue in that fashion. We know that the elderly and those suffering from Alzheimer's disease will need greater support in the future. If we do what we have done in the past and give the funding to the existing specialties, there will be nothing extra done for the elderly. The Tallaght solution is the easy way out. Those of us who stayed within our annual budget want to ensure that the favourite son does not get the lion's share.
Deputy Dennehy will not be surprised to hear me say that there were some of us who felt that the Southern Health Board had not done too badly and that sometimes it was at the root of some problems.
This Bill is the result of the work done by the Task Force on the Eastern Regional Health Authority which was set up by my colleague, Deputy Noonan. The report of that task force became available shortly after the 1997 general election. Today we are looking at what the Minister, Deputy Cowen, has done with the report. My colleague, Deputy Shatter, has given it a qualified welcome and he is justified in doing so.
Something is lacking in the approach. I am aware that a particular need was identified in the eastern region but I wonder if everything is perfect in the other health board regions. Is there a need to look at their structures with a view to achieving the same objectives as the Minister has set out for the eastern region?
The Minster spoke of the need for radical structural reform in the health services in the eastern region and mentioned the core problems which had been identified in discussions of that need. He spoke of the absence of a single authority with responsibility for planning, delivery and co-ordination of services, over-centralised decision making and the need for better communication and co-operation. Those are all things with which we can identify but are none of those problems to be found in the other health board areas?
The Minister contends there is a recognised need for radical reform of the structure of the health authorities as set out in this Bill. I can see the advantages if they work in the way they are supposed to work. There is also the new executive. This is not just a question of co-operation between the chief executive officers. They have a more crucial role in the operation of the system than simple co-operation. There is a question mark over that. Do we need to institutionalise that executive in the manner set out in this Bill in order to achieve the objectives?
There is another question which has not been addressed. There is the structure of health boards, a new structure being proposed for the eastern region and the Department of Health and Children. In many ways we have two parallel administrations in the health system. Without wanting to criticise anyone, that parallel administration system has not served us well. The hepatitis C problem was not detected or prevented in spite of the two parallel administrations.
So that people do not feel I am picking on the health sector, the same problem can be seen in defence. Again there are parallel administrations – the General Staff in Army Headquarters and the Department of Defence, one of which is more equal than the other, and one of which tries to second guess the other. This causes difficult things to happen. The parallel administration did not prevent the emergence of the major problem of hearing impairment claims, which will cost us dear.
This is an area where one thinks that having a belt and braces approach would be safer but both defence and health have had problems with parallel administrations and each has proved a very difficult nut to crack. It is time that issue was addressed, particularly as the Minister has articulated his objective of providing local services closer to the point of delivery. The Minister's objective for the new structure of more involvement from local communities in the planning and organisation of the health services is laudable. I am not sure that can be done efficiently and effectively with two parallel administrations still in place. That is not addressed here, but it should be. I hope it will be debated before too long.
The relationship between the Eastern Regional Health Authority, area authorities and bodies delivering services must also be addressed. Provision is made in the Bill for a direct relationship between the authority and a list of bodies in the Schedule. Many of those bodies will be familiar to Members, but there are other bodies which provide very important services that are not included. The bodies included in the Schedule have a relationship with the Department, while other bodies have different relationships with the health boards. The Minister should think again about the number of bodies in the Schedule. The Bill allows the Minister to change his mind about the bodies included in the Schedule, but he has an opportunity now to amend the Bill to achieve a certain result.
That result relates to four bodies which work in the general area of handicap that provide sterling service. I will be forgiven for mentioning the Kildare Association of parents and friends of handicapped people, KARE, first. Cheeverstown House, Sunbeam House and Peamount Hospital are the other organisations involved. I know KARE particularly well and the others perhaps less well, but they all provide a very valuable service. They are increasingly involved in meeting what appears to be a growing demand.
There are three reasons for the growth in that demand. As the population expands, almost inevitably the number of people who need these kinds of services tend to increase. The second reason is independent of population increase. As more and more people become aware of the services available, people who had not previously looked for a service begin to seek it. The third factor is that improvements in the general health of our population mean a great number of people who suffer from various handicaps and disabilities now have an increased life expectancy. We all welcome this, but it means the extent of the problem with which we have to deal in a given population is increasing.
All these factors have produced extra demand for services and the provision of those services by Governments and public service agencies has not kept up with the demand. That criticism applies to Governments generally over a long period, I am not making a particular point of it so far. These other organisations have stepped in to fill the breach and find themselves under increasing pressure. They often have to provide levels of service in excess of what they have agreed with public authorities and fund those services from their own resources. I am not arguing that they should receive 100 per cent funding for everything they do. There is a case for saying that, although there is a limit to the extent of the public purse. However, in some cases they provide services that come within the remit of public policy but which are not funded publicly. They are funded from private resources and other fundraising activities carried out by these organisations. These bodies need assurance that they will be able to continue to provide this service. Some currently have a relationship with the Department of Health and Children; I understand they are the organisations listed in the Second Schedule. Others have relationships with the health boards and are not included in the Schedule. I understand these are the bodies the Minister may add to the Schedule. I urge him to include the bodies I have mentioned in the Schedule.
The four organisations I mentioned provide a service in the same way as those mentioned in the Schedule. They have undertaken serious obligations and should be treated in the same way as those included in the Schedule. I mention those four bodies deliberately because of the nature and extent of their activities. KARE, for example, has a budget of £3 million per annum and is a very substantial organisation. Do not discount anything I say because that organisation is near where I live; I speak in genuine admiration of it. We get extremely good value for money for that £3 million. I know the same can be said of organisations in other health board areas, but KARE gives us very good value for money. These organisations are very effective and a large part of their work is voluntary.
I make the case, therefore, that they should be treated in the same way as the organisations listed in the Schedule. Some of the organisations listed in the Schedule provide services from their own resources that match the services for which they are publicly funded. They meet a demand the public purse does not stretch to cover and all of them have this in common.
There are provisions in the Bill for dealing with these organisations. Unless I misread it, similar considerations apply to organisations included in the Schedule and those that are not. They must have a two part service agreement with either the Eastern Regional Health Authority or the area health authority. The first part consists of a long-term agreement of three to five years which sets out the general principles relating to standards of efficiency, effectiveness and quality by which the parties must agree to abide and the second is an annual agreement that specifies the service to be provided in respect of that year and the level of funding to be made available therefor. Why does the agreement have two parts; one relating to principles and standards of efficiency over five years and another relating to funding on an annual basis? The Minister said these agreements would ensure a degree of continuity and financial security for providers.
I take that with more than a grain of salt. The part of the agreement that provides for standards of quality and efficiency over five years will certainly provide an element of continuity, but annual budgeting does not provide the kind of continuity that these organisations need. I propose we align the two and provide budgeting for these organisations, both on and off the schedule, over a period of three to five years, similar to the quality and standards provisions of these agreements. I suggest this because these organisations also must be able to plan how to provide their services, including the continuity of a service which comes within the remit of the first part. It is often the case that if they undertake to do something new or additional in the first year, the requirement for it will grow in subsequent years. Limiting them to annual funding means that once a year every year they must have a long and difficult discussion with the other party to the agreement, which also may have difficulty in forecasting its funding over a period. Particularly in regard to services for disability and handicap, we need to be able to look to the future in the provision of services to ensure we do the kind of job we all want done in this sector. I urge the Minister to align the two parts of the agreements and put the funding on the same multi-year basis as the agreement on standards, quality, etc.
Another matter related to the transition between the present circumstances to the new position which the Bill sets out to provide is the accumulated deficits of these organisations. I have not been privy to the discussions between these bodies but I understand they feel that part of what is proposed in the implementation of the Bill is that these accumulated deficits would be written off when the transition is made. Perhaps the Minister could confirm whether that is the case. For the four organisations I mentioned, and no doubt for others, that would be a major boost to their morale and would seriously ease the burden on them in considering what activities they will carry out over the next few years. It is difficult for any organisation in this field to start the year with a substantial deficit to which it may add over the coming year, not through extravagance or carelessness but because once it is involved in the provision of these services, there is a vacuum effect which sucks it along, and it is impossible to deny a service to people who so patently need it.
The Minister should be aware – although it may not be relevant to him – that there is one problem for people with disabilities which he could easily solve. There is provision in our current practice for a domiciliary care allowance for children with disabilities but it is not paid for the first two years of a child's life. A small number of families have a major difficulty with profoundly handicapped children and get no assistance for the first two years of their child's life – and, unfortunately, these children often have a short life expectancy. Several times in the past year the Minister told me he was reviewing the position; I ask him to decide now to make the domiciliary care allowance for the first two years of those children's lives, thereby to provide some psychological and small economic help to parents who find themselves in a tragic position.
Lest it be thought I agree with her, I have serious reservations about Deputy McManus's proposal that local representative members of these structures should be directly elected. We should look at that in the wider context of reform of local government. If, as I hope we do, we restore real powers to the people we elect on 11 June next, they should be involved in the provision of health services, and for that reason the idea of separate elections to these authorities does not commend itself.
I wish to share my time with Deputy Joe Higgins.
Is that agreed? Agreed.
The Minister outlined his reasons for the changes in the Bill, among which was changing demographics – the population on the east coast has increased significantly. He said these changes would return decision making to the lowest effective level and powers would be devolved. When I hear about devolution and decentralisation I am reminded of the experiment – that is what I call it – of splitting up Dublin local authorities, so that we now have Fingal, South County Dublin, Dún Laoghaire/Rathdown, and Dublin Corporation. We must ask ourselves, in reference to Deputy Dukes' remarks, whether we did decentralise, whether power was returned to local authorities or whether we merely created an extra layer of bureaucracy. I hold the latter opinion, and unfortunately I see the same thing in this Bill.
The motto of the Department of Health and Children has never been "small is beautiful", rather "big is beautiful", as we have seen most recently in Tallaght Hospital, which has eaten money. We will see this more often. The Minister said he wanted value for money and mentioned we were spending £1.2 billion in this region. If that is the case, and the Minister is serious in stating that service provision will be on the basis of a service agreement, we must examine how the Department of Health and Children tenders out projects, because we could get value for money in that area. I have not been happy with that process. In hospital waste management, for instance, we do not have value for money, nor have we examined the most environmentally friendly options.
Likewise, when the Minister talks about changing demographics and bringing services closer to the point of delivery, there is a prime example in my constituency of this not being done, and we have seen a total lack of forward planning and strategy. Two hospitals in the area were closed, the Meath Hospital and the National Children's Hospital in Harcourt Street, but they are now required because of changing demographics; many new families with children are moving into the area but they have been left without services because everything has been moved to Tallaght. I do not suggest that Tallaght does not deserve a hospital but we do not need a super hospital consuming huge amounts of money while the population of the inner city is increasing but is without acute hospital services, which we need in Dublin South-East and the inner city. That oversight has resulted in waste.
This is ultimately a question of vision and attitude. We can change the structures, but it is difficult to change the mindset. The mindset of the Department is based on too much bureaucracy. We need to move away from the concept of a Department for illness. It is not so much a Department for health as a Department for illness.
In a reply to a parliamentary question I was told that one of the reasons there are fewer nurses in Dublin is that it is a less attractive place to live. Given the traffic gridlock and the price of houses, many nurses are more inclined to live in the country, but this is symptomatic of a wider problem. I tried to address this problem this morning when Mr. Jerry O'Dwyer attended the Joint Committee on Health and Children. I asked him about the Department having a wider remit and not focusing only on the symptoms but the need to examine the root causes of many of our health problems.
There has been an increase of degenerative cancer and cardio-vascular diseases in Dublin and other parts of the country. How do we tackle them? We seem to home in on the health dangers associated with smoking. I agree it is a serious problem, but there are also other problems. It is ironic that the problem of traffic gridlock is being put forward as one of the reasons there are fewer nurses in Dublin, but that problem is also associated with the incidence of cancers. The WHO stated that 80 per cent of cancers are environmentally linked. While we are concentrating on curbing smoking, advertising of tobacco products and where people can smoke, in many polluted cities of the world children are smoking the equivalent of two packets of cigarettes per day by breathing in air pollution. There is a serious problem in Dublin where the level of air pollution breaches the limit set by the WHO, but there are no curbs on car advertising.
The Deputy is wandering from the content of the Bill.
I thought we were allowed some latitude on Second Stage.
The Deputy should leave the smokers alone.
It is all very well to talk about change, but there is a problem concerning the Department's attitude. Some systems could be easily changed; if not, their impact will cost a good deal of money in the long-term. Cancer care costs a great deal of money. We need to examine the root causes of the problem. There has been talk about antibiotic resistance and the increasing problem of MRSA in our hospitals. We could cut down on health care expenditure if we promoted more home births. These issues need to be addressed.
I was told at the committee this morning there is an inter-agency approach and that the Department of Health and Children is communicating with the Department of the Environment and Local Government, but I do not see that. The Department of the Environment and Local Government is spending a mere £20,000 on tackling the problem of air pollution in this city while that problem is giving rise to many more cancers. It is also affecting the elderly and there has been an increase in the rate of morbidity. While all of these issues count, such issues are put to one side because of the way in which we compartmentalise the health issue. Therefore, our approach to these issues needs to be examined. I agree I may have digressed slightly.
People on the front line identified that a problem with the Bill is that voluntary hospitals in the Dublin region, Tallaght, Beaumont, the Mater, St. James's, previously negotiated directly with the Department for their funding. With the introduction of the regional health authority, such negotiations will be with the new health authorities, but this will create another layer of bureaucracy and more barriers. The provision of regional cancer centres was promised, but I doubt if that promise will be delivered on. These buzz words, "decentralisation" and "devolution of power" have been used in connection with this Bill, but that will have to be tested because I do not believe that is ensured in this Bill. I hear the rhetoric, but it will be interesting to see what transpires in practice. It will also be interesting to see how much money we will save. I suspect we will end up spending much more.
(Dublin West): This Bill seeks to reorganise the structure of the health service authorities in the greater Dublin area, Kildare and Wicklow. A reorganisation is necessary, but I am not convinced by the proposals in this Bill. The Minister has lost an opportunity to bring innovative thinking to bear on how the health services should be structured and run in the eastern region. This Bill provides for a carving up of the Eastern Health Board area into smaller areas using the old style structure and the establishment of an umbrella body. It is regrettable much more radical thinking was not brought to bear on the organisation of the health services in the eastern region with a view to providing a health service that would be much closer to people who use it, allowing them to have an input in its organisation structure. On a related issue, I regret the Bill does not refer, in a radical sense, to the funding of the new structures.
The eastern authority will consist of members of registered professions, doctors, dentists, nurses and pharmacists, representatives of the voluntary service providers and ministerial nominees of whom 30 out of 55 will be public representatives. I question the time honoured arrangement by which local authorities nominate members to health boards. I witnessed the election of these representatives over many years, but the manner in which this arrangement operates is a rather cynical exercise. Eastern Health Board nominations are viewed as a sinecure or something allocated in the divvying up of various positions to which local councils elect people. They are not based on any consideration of the qualifications required by those who serve on a health board.
Specific elections to health boards directly by communities in the catchment area should be seriously considered as well as a method by which the local resident organisations, various caring organisations and those who use the health services could be democratically elected to the co-ordinating boards. It is regrettable that the Minister has not made provision for the representation of patients or potential patients on the overall board or the three local area boards. Surely that would be in line with current thinking in respect of those for whom the service is provided and it should have been included in the Bill.
Another matter which is open to question is the fact that, if this structure is put into place, we do not know how it will operate without having foreknowledge of the funding proposals that will be put in place by the Minister and his Department in regard to these three areas and the overall regional authority. People who use the health services in these catchment areas will be apprehensive about this.
There are approximately 34,000 people awaiting elective surgery at present. Some of them have been on waiting lists for a number of years and there are many cases of people, particularly the elderly – whose later years could have been made more comfortable through elective surgery – dying before their turn arrived. That created terrible trauma and bitterness on the part of the families, relatives and loved ones they left behind. Difficulties with waiting lists should have been related to the restructuring process because the question of resources and funding is indivisible from that of restructuring.
In recent years we have witnessed the scandal of people, the old and the sick, lying on trolleys in Dublin hospitals because wards have been closed down. All public representatives could quote many tragic and difficult examples of this from personal experience. I recently made a strong plea to a consultant surgeon at a prominent Dublin hospital on behalf of a constituent who needed urgent neurosurgery. I will not mention the names of those involved but I will quote from the letter the surgeon sent to me in reply to my request. He stated:
Unfortunately, there are fewer neurosurgeons in public practice now than there were in the 1980s and this has led to the accumulation of very long waiting lists. An additional difficulty is that there have been ward closures during the summer and we have now entered a period where there are insufficient theatre staff. This has led to a 25 per cent reduction in the theatre facilities available to me for November, December and January and I suspect it may well prove that the difficulties will continue after that. Seventy three per cent of the admissions to the National Neurological Centre last year were emergencies and the 25 per cent theatre cutback effectively means I am only treating emergencies at present.
That is the stark position which obtains. The reason for it is that the percentage of GDP spent on health in this country, relative to other EU countries, has been steadily declining and falling behind. On the frequent occasions when he refers to the large amounts of money being invested in the health services, the Minister tends to forget that.
Dr. Miriam Wylie, head of the health policy research centre at the ESRI, in a recently published book pointed out that while Sweden and Germany ranked as the biggest spenders on health throughout the 1980s, the Irish Estimates show that the rank occupied by Ireland was progressively declining. She further stated that the proportion of GDP devoted to health in Ireland ranked joint fifth relative to the other member states in 1985 and 11th in 1990. The question of funding is inseparable from that of structuring and that should have been addressed in the Bill.
Debate adjourned.