Health Service Reform: Statements.

Minister for Health and Children (Mr. Martin)

The sole objective of our health policy is to provide every person with access to high quality services. Services have expanded significantly and there are more people receiving care and support services than ever before. I have addressed this House before in relation to the investments and gains made in the health system over the past five to six years. Notwithstanding these gains, I have often referred to the need to couple investment with reform. The purpose of today's debate is to outline the Government's planned reform programme for the health service. The programme will be an essential tool in achieving the improvements in health care which we want and which the public deserve.

It is important to recognise that the reform agenda is a central theme in the health strategy and does not exist outside or separate to our strategic vision for the health system. At the time we published the strategy, we said that structural reform would have to follow. There were complaints that the system was disjointed. Very often patients and clients had to respond to the way services were organised, rather than services being organised to respond to their needs. It was acknowledged that we needed to be certain the structures in place were fit to meet our new goals and objectives. Under action 114 of the national health strategy, I commissioned Prospectus Strategy Consultants to complete an audit of structures and functions in the health system. The central objective of the project was to examine whether the structures in place were the most appropriate and responsive to meet current and future needs in the context of the principles, goals and objectives of the health strategy. Also included in the terms of reference was the need to assess the adequacy of governance, integration and responsiveness to identified consumer need.

The Minister for Finance established a commission on financial management and controls in the health service. The commission, chaired by Professor Niamh Brennan, focused on financial accountability and management issues, but also identified the need for structural reform to support improvements. It is interesting to note that the reports have, independently of each other, reached similar conclusions about the system and have made comparable recommendations. These reports provided the background against which the Government made its decisions in relation to the health service reform programme.

Health board structures are over 30 years old and the wider health system has seen the addition of a large range of specialist agencies during that period, often to give focus to and protect particular policy developments. The result is that there are now 58 agencies operating in the public health system which is, obviously, unsustainable. This multiplicity has resulted in a complex and fragmented system which has itself become an obstacle to achieving improvements. Both reports have emphasised the need to introduce rationalisation, standardisation and a much improved co-ordination to overcome this fragmentation and to give me, as Minister, a realistic span of control over the agencies for which I am responsible. Both reports also reiterated the need to clarify roles between the Department and the delivery system. They also draw attention to the tensions between local representation and decision making vis-à-vis national policy objectives. In a system as complex and as broad in scope as ours, there must be clarity about roles and accountability. The Brennan report focused in depth in this area and made specific recommendations which have also been endorsed in the reform programme.

Issues were raised in relation to the way in which things get done in the system. The need to enhance needs assessment and service planning was recognised. If we are serious about putting people at the centre of care, we must begin with an assessment of needs which informs us about how to plan our services. In turn, once we have declared and agreed service plans, we must link them with funding and measure activity and outcomes. The Government has taken these reports on board and agrees with their analysis of current problems. There have been improvements in all these areas in the past, but these have represented part solutions which are, by their nature, limited. The Government has recognised that it is time to devise a comprehensive and integrated solution.

The principles underlying the reforms are a new national focus on service delivery and executive management of the health services, a reduction in fragmentation within the system, clearer accountability, improved budgetary and service planning and, most importantly, improved patient care. There will be a major rationalisation of existing health service agencies to reduce fragmentation which will entail the amalgamation or abolition of over 30 agencies. This process will include the abolition of the existing health board and health authority structures. A health services executive will be established as the first body ever to be charged with managing the health service as a single national entity. The executive is to be organised on the basis of three core divisions which will include a national hospitals office, a primary, community and continuing care directorate and a national shared services centre. The executive will have its own board and chief executive officer and the board will report directly to the Minister for Health and Children.

The primary, community and continuing care directorate will be made up of four regional health offices of the health services executive at regional level. At local level, existing community care structures will be strengthened to support the maximum local delivery of services and to provide an integrated framework for the development of the primary care model. The Department of Health and Children will be restructured to ensure improved policy development and oversight. There will be a clear separation between the executive and non-executive functions of the Department. Key to its role will be holding the health services executive to account for its performance.

The health information and quality authority as set out in the health strategy will be established as a key independent agency in the new structure. A new governance framework will be developed. The purpose of this governance framework is to ensure that there are common professional parameters across the system designed to deliver accountability, standardisation and value for money. All remaining boards and any new boards established, for example, the board of the health services executive, will be subject to audit against the new governance standard. Supporting processes such as service planning, management reporting, etc. will also be modernised to bring them in line with recognised international best practice.

These reforms are essential to the advancement of the national health strategy. Without them, the health services will not be able to respond adequately to their strategic objectives. The new structures will provide a clear national focus on service delivery and executive management. It will achieve this through reduced fragmentation and the creation of clear and unambiguous accountability throughout the system. In the area of primary, community and continuing care, services will continue to be delivered through community care structures but they will be strengthened and will operate within a fundamentally realigned national management structure. This will be a proper framework within which all primary, community and continuing care services can be integrated.

On acute hospital services, the reforms clear the way for a reorientation of the hospital sector around national priorities, high quality, best outcomes and better value for money underpinning the commitments made in the health strategy. It will provide a unitary approach to the delivery of hospital services and support the even and consistent introduction of consultant delivered services in Ireland. The health information and quality authority will ensure that quality of care is promoted throughout the system by developing a framework of quality standards and promoting the strategic development of information, communications and health technologies within the system. This strengthening of information systems and quality standards will support the evaluation of policy efficacy and system performance.

In the area of accountability, the programme will ensure maximum clarity between roles, clearer lines of accountability and best practice governance. In regard to efficiency and value for money, it also provides for the development of shared services, where economies of scale can lead to resources being freed up for front-line services, improved standardisation and a pooling of expertise and best practice. The delivery of some actions in the strategy will be linked to investment and this will continue to be true. However, the reform programme will ensure that the system can absorb additional investment effectively and will help to demonstrate to the taxpayer and my colleagues in Government that any additional money invested will be well spent in delivering an improved service to patients and clients. The new structures must have a positive impact on the delivery of the Government's health strategy. That is its central premise.

The issue of democratic accountability in the new structure has been raised. As a first step, the most important voice to be heard in planning the delivery of services is that of the patients, clients and their families. Arising from the health strategy, progress has already been made on developing and enhancing the opportunities for such input. Regional co-ordinating committees, consumer panels and advocacy services are all being developed as feedback mechanisms. There has been some misunderstanding of the term "consumer panels".

The objective of consumer panels is to ensure that people who have used services or are current users of services have a genuine influence in the shaping of services locally, in community care areas or at regional level. We have made a good start on that in recent years. It is essential that the people at the coal face in terms of bearing the brunt of particular disease conditions or other issues, have a say in shaping services at local level and that they are involved with the professionals, administrators and decision makers in the health offices of the 32 community care areas and in the new regional health offices. The system will benefit from that type of advocacy. That was the origin of the concept in the health strategy and there are good examples of it happening in the mental health area, in terms of the development of the network and peer advocacy which we launched early last year, in the regional co-ordinating committees in the disability sector and on a number of other specific disease fronts.

With regard to political representation, it was the view of Prospectus, which was endorsed by the Government, that as we have an Exchequer funded health service with centrally determined resourcing decisions, Oireachtas Members should have a responsibility to ensure there is a match between funding of services and national priorities. It is important that public representatives have an opportunity to articulate their views on issues at regional and local level. I intend to place an obligation on the HSE and its regional offices to appraise and inform local representatives and the public generally on service plans and developments regionally and locally. However, it should be noted that the emphasis must be on ensuring that democratic input at regional level is focused on the delivery of national priorities. In addition, the roles of the Oireachtas Joint Committee on Health and Children and the Cabinet subcommittee on the health strategy will be increasingly important in ensuring adequate reflection of the views of public representatives in the ongoing oversight of the health system. I have agreed to bring more detailed proposals to Government on the representation arrangements over the coming months.

I have already mentioned the implications for acute hospital service delivery. I draw Members' attention to this issue because it is another strand of reform which will be put to Government shortly, the report of the task force on medical staffing. The principles emerging are centred on high quality and optimal outcome. International evidence consistently demonstrates that clinical outcomes for patients are improved when they are treated by multi-disciplinary specialist teams operating in units where there are high volumes of activity and access to diagnostic and treatment facilities. However, it is neither practicable nor realistic to suggest that we can provide this within immediate reach of everyone's home. We need to face up to these issues. As a society, we need to achieve consensus about the reality of achieving high quality safe care in a country of this size and population.

I would prefer to achieve Oireachtas consensus on this issue going forward, on a cross-party basis. These issues have dogged successive Governments. For the ultimate benefit of the patient and in the interest of developing the right solution for all concerned, we should—

Mr. F. McGrath

If the Minister funds it.

Mr. Martin

I understand and accept that different political parties have different policies and ideas on the health system. However, on key issues such as patient outcomes, better survival rates and how we construct services around that, there is an opportunity for the Oireachtas, leaving party political considerations aside, to do the right thing. I have in mind a genuine interaction on a cross-party basis.

Managing the change programme will be challenging. I will not understate the enormity of the task ahead. Change will depend on the people working in the system. In that context, the reports do not criticise the people in the system but the system itself. In fact, they emphasise our human resources as a key strength. The first step in implementing the new structures is an extensive programme of communication and dialogue with key stakeholders. I have already started on that process. I have met five health boards so far and am due to meet the sixth today. We are endeavouring to bring the message to the staff and to answer their questions as quickly as possible following the announcement of the Government decision. The preparations for the consultation phase of the communications process within the health service are well advanced and the first sessions will commence on 9 July. The office of health management is organising that.

As an immediate priority, I will set about establishing structures to drive the implementation as soon as possible. This will include a national steering committee which will oversee and audit progress and a project office to plan and advance the programme. One of their first tasks will be to prepare a detailed project plan setting out a timetable for the various elements of the reform programme, including identification of those actions that can be tackled early. The Government has also agreed to the establishment of an interim board of the health services executive as well as an interim national hospitals office. I intend to put these structures in place in the autumn to take early action on the advancement of the reorganisation of the hospital sector on the basis of the type of principles that it is understood will emerge from the Hanly report to be published shortly. In addition, I hope to make an early start on the internal restructuring of the Department itself. This debate today is the commencement of the debate in the House.

I am determined to move forward as quickly as possible with implementation. The decisions made will reinforce and build on the efforts to date in creating a more innovative and participative working culture in the health services, focused on continual improvement in service quality. This programme is about providing a framework for developing services and maximising the impact of these services on the patient and clients who rely on them. I look forward to the debate that has just started. It will, no doubt, continue into the autumn both inside and outside the House.

Ms O. Mitchell

I thank the Minister for his presentation and the opportunity to begin the debate on these health proposals. My greatest criticism is not just of the Minister but of the Government for waiting until its seventh year in government to even consider talking about reform of the health service. Major investment is required for the reforms already announced, the structural changes which are proposed to achieve efficiencies. It will also be needed if the Hanly proposals, which are to come, for regional centres of excellence are to be pursued in any meaningful way, yet we are talking about these reforms when the existing service is falling apart. Unlike factory production, a health service cannot be turned off when processes are being changed. Costly parallel systems will have to be kept in place, possibly over many years.

Reforms of this kind could have been introduced quite painlessly during the boom years and it is now difficult to see how they can be introduced at all. It is unforgiveable that it never occurred to any member of this Government, and it has been an extraordinarily well and expensively advised Government, that one simply could not increase spending in any organisation by over 125% and ask it to accept 25,000 additional employees without reform. That was impossible for any organisation and it is unbelievable that it did not occur to this Government until its seventh year in office. That is why people are understandably cynical about the motivation behind talk of reform.

Nevertheless, I welcome the reforms, as does Fine Gael, and we accept the need for a more centralised administration and for a clear chain of command through the health service, which was lacking. We contend, however, that these proposals do not go far enough. They are changes to the administrative structure of an existing system of health care delivery when an entire systems change is needed. This kind of so-called reform mirrors what many of us have seen over the years in the so-called reform of local authority structures. In that instance, instead of looking at the functions or funding of local government the structures were repeatedly reformed and the result was a deterioration in the governance of local government and an increased irrelevance of its structure.

It is likely that this will happen in the health service unless it is accompanied by a complete systems change. Changing administrative structures may produce temporary savings but eventually all the inefficiencies inherent in an entirely State provided service, particularly one that is now proposed to be highly centralised, will re-emerge, no matter how hardworking, conscientious or professional the administrative staff may be.

Fine Gael believes that we must move to a system of managed competition where private sector providers compete with one another on price and quality and so produce the best deal for the patient. There is no reason for the Government or the State to be involved in running hospitals or in the direct provision of the myriad health services. It is not necessary for services which are publicly funded to be also publicly provided and while this is accepted across all State services extraordinarily we do not apply the same principle to health, which is the most expensive service. The State's role should be to articulate values; to set, monitor and enforce standards both in delivery of care and in the standards of the professionals involved in giving that care; to plan the health service and to purchase health care insurance cover for the population from a variety of competing health insurance companies.

The insurance companies would in turn purchase these services on our behalf from competing hospitals and other health care providers. If I have caused some ripples in the insurance world by my anxiety about the introduction of risk equalisation it is because I believe that the future of the health service depends absolutely on a thriving insurance market for health care. The level of entitlement could be similar to that which we already enjoy except that people might be able to access it. The difference is that money will come only if the patient is treated so there is an incentive for hospitals, doctors and consultants to treat patients. Under the current system the incentive is to treat the minimum number of patients because every additional patient is regarded as a drain on the resources of hospitals.

In an insurance-procured, competitively provided health service the patient has choice, of doctor and hospital. The patient is no longer forced to wait for rationed services and while those who can afford it can top up their insurance cover if they wish there is equality of access for treatment and that is the key improvement that is required in our health service now. There is a total absence of incentive and all the criticisms that we have heard of hospitals and consultants boil down to the absence of incentive to treat patients. It is far more efficient for hospitals to close their wards. What kind of business would do a similar thing when faced with difficulties? Would a hotel close its rooms when it was faced with financial difficulties?

The challenge for the future is to provide the best possible quality of health care at the lowest possible cost, even though, and particularly perhaps because we know, health care will become increasingly expensive regardless of who is paying for it or who is providing the service. Fine Gael wants to capture the benefits of the market for consumers and the one major benefit that the market has is its inbuilt and inherent incentives for efficiency and innovation, and the use of technology which can operate automatically to control costs and to ensure quality is maintained.

The latest Government proposal, announced last week, will have no immediate effect on the crisis in the health service and in many ways it has the potential to make things worse. I have already alluded to the fact that when the Secretary General talked about these reforms he said that they would be the priority agenda of the Department for the next 18 months. This means in effect that all the Department and the health boards, the senior personnel, the human and financial resources and all expertise will focus on the abolition of health boards while the health service is falling apart.

That does not have to be the sole concern when there are 500 beds closed in hospitals and people are queueing for every service, not just for hospitals, and there is not a single extra cent to meet any of these additional demands. It is like calling the fire brigade when one's house is on fire only to be told that the fire cannot be put out until one has improved one's safety arrangements. That is what we are saying to patients now. Capacity is the real, immediate and widely acknowledged problem in the health service: too few beds, too few consultants, nurses, therapists, medical cards and not a single proposal at this stage to meet any of those needs.

It is difficult not to be cynical, to avoid the conclusion that this announcement and the hype that led up to it is little more than a device to distract attention from the real problem. The Government may hope that publication will somehow have the same distraction value as the health strategy had, but people are understandably cynical. They welcomed the health strategy two years ago but nothing was delivered and they are now watching every movement as a result of these announcements and will be extremely judgmental so the Minister better deliver on every one of these promises.

It will add insult to injury if they are being dressed up as a considered response but with no real intention to deliver on them. My cynicism grows when it seems that it will take at least until after the next general election to abolish the health boards and centralise the organisation of hospital and other services. This may well provide a better service eventually and at a lower cost than is currently the case, but this is still far from certain. Why is it that less than four years ago it was considered that the best thing that could be done for the health service was to abolish the Eastern Health Board and produce three additional health boards? Small was going to be beautiful. We were going to have a flexible, responsive service locally. Now, fewer than four years later, the exact opposite is true. Big is beautiful again, and we are not abolishing that, having spent over €100 million in those few years to change the service. If these new proposals are the correct way for us to proceed, it was a complete waste of money.

I have three major reservations about the report, the first being that it is difficult to see the efficiencies being achieved through the central management and control of all hospitals from a Dublin office. The Deloitte & Touche report on value for money in the health service identified two major problems. The first was lack of capacity, and I have spoken about that. There are no proposals to address those problems. The second is the complete absence of accessible and usable information in the health service on the basis of which sound decisions can be made regarding health, finance, management or investment. There are no proposals and no money to address that problem. Unless we have basic information about numbers of patients and employees, and numbers on waiting lists, we cannot organise the system from the centre. Whatever chance one has of doing it at health board level, there is no possibility of achieving efficiencies from a remote office in Dublin and trying to manage a hospital in Donegal or Kerry.

My other worry about the proposals is that, if one has a centrally administered hospital agency and locally delivered community service, the structure might be anathema to a seamless health service locally. Every aspect of the health strategy referred to the integration of services where local budgets would be considered as one and there would be no competition between community services and the hospital, with the latter trying to push patients back into the former and vice versa. It was to operate as one, coherent, holistic service. I cannot see how that is to happen with central administration, and that will have to be examined very carefully. If the Minister is serious about the strategy and all the promises for primary care, how is that going to fit into the new administration? It seems that primary and community care and preventative medicine are the aspects, if he is really looking for value for money, on which he should be concentrating. He should keep people healthy and out of hospital rather than trying to deal with the problem after it has deteriorated.

One of the reports talked about at great length is the Brennan report on how GPs might be budget holders. That is fine in a system where one has groups of GPs who are well resourced. If there are single GPs operating on their own, I do not know how that will work or how they can be budget holders. How does one enforce it? Who pays if a GP does not control his or her budget? As far as I can see, under that sort of system, in the absence of service, the only person who pays is the patient. All those aspects of the service seem to have been glossed over as if they were not relevant. I would also like to mention the issue of democratically-elected councillors being on health boards. We heard on every news bulletin for about ten days before the final announcement how those wonderful reports regarding reforms were going to be fought tooth and nail by local councillors. There was not a whimper from any of them.

Mr. Durkan

We have heard that before.

Ms O. Mitchell

Then we moved onto the consultants and whomever the next target was. It was a case of giving out about anyone apart from the Government.

Mr. Durkan

Where did we hear that before?

Ms O. Mitchell

Many of those councillors gave years of service and knew the health service and its local problems better than anyone. There is not even a pretence of accountability in the new proposals. The Minister's talk about consumer panels is all very laudable, and I am sure that they have a great advocacy role. However, it is not democratic accountability, and there is no point in dressing it up and pretending so, for that is simply not the case. Consumers represent themselves and no one else. They are certainly not accountable to the rest of the community.

Whatever structures the Minister sets up, some mechanism must be found to ensure that there is accountability and that patients are protected. By definition, they are vulnerable people. The commonly touted accusation that local politicians stymied progress on reforms locally because of parochial interests is nonsense. The health service does not need local politicians to stymie reform, for it is awash with all sorts of professionals with territorial and sectoral self-interests. They are all well represented by unions and highly articulate. They are far more likely to oppose reforms which threaten their interests, and they always assume that those are synonymous with the interests of the patient. However, their interests are narrow, and quite often the local politician is the only person looking out for the common good. The protection which they gave to the health service should not be underestimated or discarded lightly.

I have left myself short of time, but if I were to say one last thing it would be that the question mark hanging over the reforms is their cost. I have spoken about the absence of an IT service, and unless the Minister invests in IT, I can see no possibility of achieving any efficiencies from centralised control. When the Hanly report comes out, we will really see the extent of the problem in achieving the kinds of reforms now needed. It was reprehensible of this Government not to introduce these fundamental changes when money was available. It is estimated that if we get rid of some of our acute hospitals, taking the number down to about 12 regional hospitals – which I understand is roughly what is recommended – we will lose 2,000 acute beds. They will have to be replaced in the regional hospitals as well as making up for the 3,000 beds which were due. Where will the money for that come from, and how long will it take for the reforms to be introduced?

I have a horrible feeling that my successors and those of the Minister will still be discussing this in 20 years.

Ms McManus

At his recent press conference to launch the two reports, the Minister for Health and Children stated his intention to introduce a new health Act. Much of the defence of his approach is based on the premise that, as it is 30 years old, the Health Act is out of date. The Labour Party believes that there is a great need for health care reform and new legislation to underpin it. We have argued – and will continue to argue – for reforms that deliver excellence, fairness and value for money through an integrated system of care which universal insurance can create, and a major shift towards primary care and health promotion. However, that is not what is on offer from the Government.

Flawed as it is, the Health Act 1970 was about changing the health service, at least in part to meet the needs of patients. On the evidence so far, the new Bill being proposed will not deliver even limited or incremental reform. Essentially, it will be about swapping one bureaucracy for another, possibly more streamlined but definitely less accountable. The central issues in the health service of capacity and access are completely and shamefully ignored. That said, I am not even convinced, on its record so far, that this Government has the stomach to deliver all the administrative changes that it proposes. The public has a right to ask why it is being short-changed. At a time when so much is wrong with the health service and so much promised by the Government, why are the big questions being left unanswered?

There are three pillars to health care reform: capacity and funding; access and fairness; and administrative value for money. However, in these reports, and particularly in the Government's published plan, no solution is offered to the capacity and funding issue and there is no reconciliation of the gross inequities in the health service that are crying out for redress. Worse, the Government is shifting the focus from the reality of people's experience of the health service towards systemic and structural concerns which are primarily of internal interest to those who run the health service. The complicated changes proposed will absorb massive amounts of energy and attention on the part of the Department of Health and Children, the health boards and all the agencies affected. The process will take years to complete and will demand as yet unspecified amounts of money.

Already the Minister for Finance is on record as saying that no additional money has been provided for this year, although the setting up of an interim health service executive and hospitals office is promised for early autumn. The details of these bodies should be debated in the House prior to their establishment. Can the Minister promise today that they will be debated? When replying, the Minister should outline the cost of his implementation plans and the timeframe for implementation. Interestingly, the Government is silent on whether this exercise will save money. At the launch, the Minister for Health and Children promised that his plan threatens no one. If this is true, how can the Government describe it as a major rationalisation programme?

The Labour Party has argued for some time now that a health services authority should be established. We look forward to its role being developed and the important issue of information technology being handled and resourced. We welcome also the establishment of a new hospitals agency. Separating the acute hospitals sector from community and primary services makes sense. We are gravely concerned at the democratic deficit in the Government's model of reform and today's fudge by the Minister is unconvincing. We have argued for an extension of public involvement in a national health forum to create a sense of ownership of the health services and build badly needed consensus about priorities and change among all stakeholders, including patients, but the Government's approach is diametrically opposed to this view. The Government has even rejected the advice of the Brennan report it commissioned, which was to preserve local democracy in any new regional configuration.

Mr. Connolly

True.

Ms McManus

Niamh Brennan has made the point that this issue was the subject of deliberation by the commission and that it concluded that nobody, other than public representatives, had the necessary understanding of local needs, but the Government plan is to kill off local democracy. Abolishing health boards will not stifle dissent, but is likely to make communities feel even less empowered about decisions being made on their behalf. Such alienation is fertile ground for the growth of the hospital candidates of which Fianna Fáil is so afraid.

It is salutary to consider the New Zealand experience which uncannily mirrors our own. In a country of similar population there were, at the beginning of the 1990s, 14 health boards. In 1993, four regional health authorities with no elected input were introduced. In 1996, a single transitional health authority with no elected members replaced the regional authorities. In 2000, a new structure was introduced based on district health boards, of which there are 21, which have directly elected members. Are we looking to a future where the 32 community care areas retained by the Minister in his plans will have to be given a democratic mandate as has happened in New Zealand?

A principle, which we support and which should be applied in these proposals, is that of direct elections to give local communities a mandate in the delivery of local community services in any new structures, whatever their number. At national level we want to see democratic accountability built into the new structures. We will judge our support or otherwise for change accordingly.

On the reconfiguration of hospital services, our view is that the patient should be at the heart of any changes, not the needs of consultants or administrators. A statutorily based health care guarantee which allows for access in reasonable time and within reasonable distance is an important measure that will provide access regardless of whether one lives in Dingle or Dublin. Such a basis for the reconfiguration of hospitals will reassure patients and would also require that issues of transport and the accessibility of regional centres of excellence would be addressed. There is no indication that the Government is even considering such a provision. We understand the requirement in many specialities for a critical mass of patients. It is unacceptable, for example, that general consultants with only a handful of cancer patients each year carry out major breast cancer operations which should be done at specialist centres. There is no requirement for all tertiary centres to be located in Dublin or Cork. In America, the Mayo Clinic is located in a small town with a population of only 50,000. We should be able to locate at least some of our major tertiary medical centres outside the metropolitan base. We should be conscious also in striving for centralisation that there is evidence that over-large hospitals carry their own inefficiencies and that smaller hospitals can play an essential role in health care delivery.

It is worth remembering that the Government's plan will not open, or reopen, a single hospital. It will not provide one extra medical card. It will not provide a single residential place for someone with intellectual disability. The serious catch-up in capacity building is not addressed in these proposals and we need to hear the Minister for Finance, Deputy McCreevy, state publicly a commitment to resourcing the health service to eliminate the suspicion that the real agenda of these reforms is to cut health spending.

Public confidence is already at rock bottom as a result of the Government's appalling track record on mismanagement of the health service. There is despair at all the promises made and broken, the targets set and over-shot, the stealth charges and the plethora of cutbacks. I will give just one example. More than 1,000 children are still waiting more than six months for treatment today even though the health strategy promised that no child would be waiting that length of time by the end of 2002.

In her excellent book, Unhealthy State, Maev-Ann Wren makes the point better than I can:

The state of healthcare is a metaphor for the condition of this society. . . Directionless during the boom, Irish society is at risk of rediscovering its former fatalism, of accepting passively that the boat will remain beached until the tide turns; that children must remain awaiting tonsillectomies, old people awaiting the drug therapy that could alleviate their arthritis, the intellectually disabled awaiting the community care. . . Since an election fought on the promise of massive investment in health, there has been a concerted effort to throw dust in the eyes of the public and imply that wasteful spending is the central problem in the health service. This has been part of a political agenda to distract from the service's investment needs and defend the low-tax regime achieved during the boom. . . To every speaker who talks about value for money, the response should be "what about access?".

What about access? The Health Act 1970 established the general medical services scheme to replace the old and grossly inequitable dispensary system. For the first time, it offered the poor equity of access and treatment at general practitioner level. The GP contract specified there could be no differentiation between public and private patients. It was a good, progressive reform that brought about practical improvement for patients. It is the kind of reform, if applied to our hospital service, that would make a tangible, transforming difference to public patients today. Such a change should be central in the new Health Act and should be central to the Government's position on the re-negotiation of the consultants' common contract. There should be no discrimination. Yet, as the Brennan report shows in the hard-hitting analysis of the over 70s scheme, the Government's handling in that instance was totally inept, extremely costly and grossly inequitable.

While Brennan proposes one solution in relation to the common contract, we still have no idea what the Government proposes. Does it intend to tinker around with the present system and just get some flexibility in hours from the consultants or will it go the Brennan route and risk the danger of institutionalising the two-tier system and deepening the difference of care between public and private patients? At present at hospital level, there is no legal definition between private and public patients. All patients are entitled to hospital care. Insured patients choose private care but can just as easily choose when it suits to become public patients. It is an inherently unstable system and the Government must be aware that ill-thought out shifts in policy could end up overloading the public system to an unbearable degree.

The task should be cast differently. How can we provide a fully integrated system of hospital care which treats people solely on the basis of need? Providing the same incentive to hospital and consultant for all patients, regardless of their income, rewards productivity rather than penalising it. It also eliminates the incentive to favour the treatment of private over public patients. Extending insurance on a universal basis is the obvious mechanism to reach that objective. There are other mechanisms also. However, any such discussion is academic when the Government is so far off the mark it has no policy at all regarding the delivery of fairness of access.

I have only touched on a few of the many significant issues in these reports and in this plan. I wish there was more time. This is no way to debate health care reform. The time and format of the debate – three hours on a Friday with no dialogue by way of questions to the Minister – confirm yet again just how defensively this Government operates and how much it depends on public relations instead of parliamentary engagement. Even this minimalist debate was endangered by the possible delay in the publication of the Brennan, Prospectus and Hanly reports until after the Dáil had safely risen for its summer break.

Fortunately the Government was shamed into publishing two of these reports but we are still waiting for the Hanly report even though the genesis of the medical manpower proposals extend back to the long ago days of Deputy Cowen and his time in Angola. Will the proposals increase capacity within the health service? Will they provide additional funding? Will they improve quality of care and eliminate hospital waiting lists by 2004, as was promised by the Taoiseach and the Minister? Will they re-open the hundreds of hospital beds closed as a result of cutbacks? Will they provide more medical cards for poor people? Prior to the election, 200,000 more medical cards were promised but not one of these has been provided. The answer to all these questions is "no".

As we speak, 25 beds are closed in Our Lady's Hospital for Sick Children in Crumlin, directly affecting the health of seriously-ill children. The Mater Hospital is setting out to ensure it can care for people in its car park. The proposals do not deal with the essential issues of our health service. The crisis was not faced by Government and its response now is inadequate. While it is dealing with the specific issue of administrative reform which is set out in this plan, it does not deal with the issues of capacity and access.

Mr. Gormley

I will share my time with Sinn Féin and Independent Deputies.

The Government's latest health strategy represents yet another triumph of spin over substance. It seeks to blame the wrong people for the problem in the health service. It will result in no cost saving measures and less accountability. It fails to tackle the real problem in our hospitals – capacity.

This is a superficial Government only concerned with appearances. The latest health strategy is just another cheap makeover. The promises of the last health strategy have now faded away like a fake tan. Prior to the launch of this strategy the masters of spin were busy again. The build up was perfect. We had a judicious leak – the Government was going to scrap the health boards and face down the local politicians. This was perfect. People do not really like politicians so it worked. The implication was as clear as it was ridiculous – local politicians on health boards were somehow responsible for the health crisis.

On "Morning Ireland" some poor unfortunate from a health board was asked, "What do politicians know about health? Why not leave it to the experts?" I could ask what does the Minister for Health and Children know about health and how is he qualified to talk about it. How is any Minister qualified to talk about his or her particular subject? The argument is false. To blame the health boards for the health crisis is wide of the mark and yet the Government's version succeeded until we read the reports. The Brennan report does not recommend the scrapping of the health boards and neither Prospectus nor Brennan show how the move would result in significant savings.

A parliamentary reply to one of my questions this week revealed that the proposed reforms could cost money. The reports show that there is no black hole. The Minister for Finance, Deputy McCreevy, has admitted that there will be no redundancies as a consequence. How will this save money? It will not. However, it does mean that the Minister for Health and Children can now go back to the Minister for Finance, like a spendthrift son to his rich daddy, and say, "Dad, I am a changed character. I have reformed. Now please give me the money because I need it." I have to break it to the Minister that he is not going to get the money because there is an ideological split in Cabinet.

This Minister has stated publicly that he believes taxes should be raised in order to provide money for the health service. I agree. However, when this suggestion was put to Deputy Harney at the press conference she was not for it at all. The Minister knows that the Minister for Finance manages to be more of a progressive democrat than the Progressive Democrats themselves on economic matters. He will have none of this suggestion either.

Let us be clear. The real problem in our health service is capacity. We are still trying to deal with the loss of 6,000 beds since the 1980s while the 3,000 beds promised in the health strategy are slow to materialise.

This reform package may not address the real problems but it means the Minister does not have to take the rap. He can wash his hands and evade his responsibilities. If I ask about bed shortages he can say, "Sorry Deputy, that is a matter for the Health Service Executive." We can imagine the letters we will get back from the Ceann Comhairle's office saying our question is out of order and has been disallowed.

The new strategy means less accountability at local and national level. It does not properly confront one of the main problems, namely, the power base of the consultants. We may have to wait another day for that. To her credit, Professor Brennan has performed a valuable service in revealing to the public how privileged the position of the consultants is and how lucrative their contracts can be.

Our health service will be reformed but will it be to the benefit of patients? It is unlikely. We need reform which is genuinely patient focused and for that we need greater investment. This package will ensure the continuation of a two-tiered health system for a two-tiered society created by Fianna Fáil and the Progressive Democrats.

Albert Schweitzer once said, "Happiness is good health and a bad memory." If that is so, I can only conclude that the Irish electorate is unhappy. We have a terrible health service but the people's memory is improving. Next time they will not forget. They will remember who created the mess and will realise that the only way to improve the health service is to get rid of this discredited Government.

Caoimhghín Ó Caoláin

I am thinking of one family in my constituency and how the health services impact on it. The father of the family has recently received devastating news about his health. He has prostate cancer. This news was followed shortly by a notice from the health board saying that the family's medical card cover was being cut off as, following a review, it was determined it had exceeded the income limit. There are three young children in the family, two infants and a primary school pupil. For this family the unfairness and inequality of access to our health service is a cruel reality. This is the human face of the issues we are addressing in this debate. The success or failure of health service delivery is measured by how it assists this family and hundreds of thousands of people like it. The sad reality is that the system is failing them.

It is a tragedy and a scandal that health care in this State is delivered by means of a fundamentally flawed two-tier public private system. The Government's health strategy opted to retain this system. The two reports we are addressing do not challenge it either, although they do expose some of the unfairness and inefficiency of the two-tier system. There is now a vicious cycle in the system. Waiting lists and bed closures in the public system have meant that more and more people who can afford it – and some who cannot – have opted for private health insurance and care. The public system suffers as a result. Health apartheid divides our society on income lines. The contribution to the common good which those on higher incomes could make is lost to the public system. As the Brennan report again exposes, many hospital consultants profitably straddle the two systems and it is public patients who lose out. The two-tier system is inherently inefficient and no amount of better financial management or administrative restructuring can change that reality.

The vision and political will to reform that fundamentally unequal and inefficient system is absent from the Government. The two reports we are discussing, Brennan and Prospectus, were commissioned by two Departments, Finance and Health and Children, respectively, under two Ministers who have differed publicly on the question of health. One report focuses on financial management, the other on administrative structures. The Government's so-called reform programme published with them is an attempt to marry their conclusions and tie them in with the health strategy.

However, when one returns to the health strategy, one finds that one of its key policy objectives and targets was for all additional beds to be designated solely for public patients. Instead of additional beds we are seeing bed closures – over 500 this year. At the same time, public money is going to buy treatment in beds in the private system under the Progressive Democrats' cherished treatment purchase fund. This is a classic example of the piecemeal and contradictory approach of this and previous Governments. Another example of the piecemeal approach was the extension of the medical card to all people over 70 years old, regardless of income. Why was the principle of universal access applied to these citizens and not to others who are equally deserving? Was it because a greater proportion of them vote? This was supposed to cost €19 million but ended up costing €55 million.

Administrative inefficiency meant that the numbers involved and the costs were significantly underestimated. More fundamental, however, was the political decision to introduce this measure. It had nothing to do with equity or real health delivery. If it is right that a wealthy retired professional with a hefty pension and a portfolio of shares and property can benefit from the medical card, regardless of income, then it is right that the hard-pressed young family I cited at the start of my contribution should also benefit.

The Government is embarking on administrative change rather than real reform. The most important recommendation of the Brennan report is that all new public consultant appointments be on the basis of a commitment to work exclusively in the public sector. However, the Government has chosen not to include that essential reform in its package of measures. We are urged to wait on the Hanly report, but I suspect that the powerful consultants lobby has been at work and unless the Government champions this proposal, it will be shredded in negotiations with Mr. Finbarr Fitzpatrick and his colleagues.

The administrative changes will mean less democratic accountability. Few will lament the passing of the existing health boards, but where will the democratic input be? There is a reference in the Prospectus report to Oireachtas representation at the level of the four regional health offices but there is no detail and the Minister would not indicate, in his response to my question on Tuesday, what the composition of the Health Services Executive will be.

These reports come at a time of escalating Government cuts. As beds are closed, as queues lengthen, as services for people with disabilities diminish and as people just above the income limit struggle to pay for GP visits, the Government will wave these reports at us and make more promises of a world-class health service – but not yet. It is not good enough and we will not stand for it. Sinn Féin will continue to campaign for a truly reformed health service which cherishes all of our people equally. If the Minister embarks on that course, he will have our whole-hearted support and co-operation in that endeavour.

Mr. Connolly

I agree that we need health service reform because most people acknowledge that the health service is in a shambles. We are treating people in car parks, storage areas for dead bodies and on trolleys for days. In drawing up the report, there should have been a greater reliance on people in the health service. If one was drawing up a report on the taxation system, we would not employ medical consultants. It should be likewise with accountants. That is why they have missed the point in this report.

There are now three reports with three different sets of recommendations. This is a recipe for confusion. The large number of reports should have been collated. We should have gone forward with a definitive plan for the health service. Coming on the back of 120 other reports in the past few years, the public should be forgiven for their cynicism in not believing there will be a bright new future for the health service.

The reports identify two sets of villains who are responsible for all the ills in the health service, namely, the health board representatives and consultants. It is wrong to tar all consultants with the one brush because a substantial number of them do a good job. However, there is a small group which has a major power base, of which it will not let go, and it will have to be addressed. They are largely based in regional centres of excellence, in which we propose to carry out a great deal of treatment.

Some 97% of health board budgets are predetermined, therefore, the influence in financial terms of health board representatives is negligible. Local representatives represent local views and ensure that people receive a degree of openness, transparency and accountability. Certain basic services should be provided at local hospitals on a seven day a week, 24 hours a day basis. If someone arrives at the hospital with an asthma attack or a heart attack, if a woman arrives in labour or if someone is haemorrhaging badly, hospitals should be able to cope with these situations. They should be able to stabilise such cases, treat them and send them to regional centres of excellence. It is worth noting that the earlier the medical intervention, the better the outcome. People have no difficulty with travelling for major operations and accept that we cannot have all sorts of specialist units in every hospital.

Our regional centres of excellence are operating at emergency levels at present. They have 100% bed occupancy and cannot cope with the number of patients they have. If we persist with the plan to close 22 accident and emergency departments, it will have a disastrous effect on the elective work in these major hospitals. We will have regular cancellations of operating lists.

The accident and emergency unit in Monaghan General Hospital was closed which in turn overloaded the accident and emergency department at Cavan General Hospital, with the result that those people were put in beds which had been reserved for elective surgery. This situation will develop nationally if this practice continues. Another result of the closure of Monaghan's accident and emergency department is that there are ongoing industrial relations problems in Our Lady of Lourdes Hospital in Drogheda, simply because nurses cannot get to attend patients with head injuries for a period of two hours.

It is wrong that every minor injury, from a broken finger to a broken toe, is channelled through a regional centre of excellence. It is uncalled for and will lead to a clogging up of the system. The regional centres of excellence should be allowed to get on with their specialty work. Giving them work which can be adequately handled at local hospital level is the wrong step.

While these reports recommend a hub and spoke system within the health service, the national spatial strategy recommends hub and gateway towns. However, we now have a situation where one Department states that a hub town should have a hospital and another department is taking the hospital away. There is a breakdown in communications in this respect.

Minister of State at the Department of Health and Children (Mr. T. O'Malley)

I am pleased to contribute to this debate because this marks the beginning of the largest ever reform of the health services in Ireland, which aims to put patients first. The reforms before us put patients before politicians, boards, structures and bureaucracy. They will assert the public interest before the many vested interests involved and will bring a rational and affordable basis for quality health services to the whole population. Summer 2003 will be seen as an historic time in Irish health policy. It is the time when the scale of our reforms matches the scale of our investment in health services, when the focus moves to action and implementation and away from argument and analysis. This is the beginning of a reform process that will continue for some years. It will require energy and commitment from Government. I assure the House that this will be sustained over the coming years. I congratulate my colleague, the Minister for Health and Children, Deputy Martin, for his courage, vision, determination and energy in driving this process forward. It will require a willingness to embrace change from everybody involved in the health services. People should not be looking over their shoulders at past positions or what other groups are doing, but should look forward to real improvement for patients and the public. The process will require reasoned and informed debate in the House and elsewhere, not the point-scoring and rhetoric that leaves the public weary and dispirited about our capacity as elected representatives to drive real reform for the benefit of patients.

I take the opportunity to record our appreciation for a job well done by the 12 members of the Brennan Commission, who made their expertise available in the public interest, and the authors of the Prospectus report. These reports form a solid basis for major aspects of the Government's reform programme. The forthcoming Hanly report on medical staffing and hospital services will complement these two reports. It will form a third pillar for reform of the health services nationally.

I do not propose to review the actions the Government has decided to take on foot of these reports, as the Minister, Deputy Martin, has ably done so already. I wish to address an aspect of the analysis of the Government's reform policy that has been offered to the public since we published our reports. The public has been offered an analysis that the Government's health reform plans are all very well but the so-called funding issue has not been solved. This analysis would have us believe that health is substantially under-funded in Ireland and that there is need to raise taxes to provide funds for health spending. It argues that we must increase the proportion of national income spent on health to keep up with European Union standards. This view ignores the facts, all of which lead to the conclusion that the issue of health funding has been addressed.

The Irish economy and our tax policies have allowed us to provide an additional €5 billion in funding since in 1997. In this challenging year, the state of the economy and our tax policies have enabled us to provide an additional €800 million for health services, an increase of 10%. If we had asked in June 1997 whether increasing health spending by €5 billion would solve the health funding issue, the answer would have been an incredulous and resounding "yes" from all the analysts. If we had asked how we would find an extra €5 billion, the answer from some would have been the same as that offered today – raise taxes, increase the health levy and PRSI contributions. The last thing the advocates of higher taxes would have talked about would have been strong economic growth, low taxes and full employment. However, this is where the new resources have come from to increase spending on our health policy. The health funding issue is about the health of our economy. It is about reaching our economic potential by removing the barriers to growth and maintaining full employment with low taxes.

To put it in an international perspective, this week the OECD released its annual health figures that showed that between 1990 and 2001, Irish spending on health per person grew at an annual rate of 6.7% per annum. That is the second highest rate among all OECD countries and double the OECD average. It is 13 times the level of growth and spending on health in Finland. It is more than three times the growth rate of Sweden and twice that of Germany and the US. We are catching up internationally in health spending even though many OECD countries have older populations and more expensive health care systems. Our health spending as a proportion of national income is now at an OECD average of 8.4% and is higher than Finland, Spain and Britain. We now spend €2,300 on health care for every person in the State, more than is spent in France and greater than the EU average. Indeed, the French Government recently described increases in health spending in 2001 and 2002 as particularly steep. It was talking about 4% compared to our spend of 8.4% per annum.

Nowhere in the world can policy on health spending be divorced form the state of the economy. All our increases have been possible due to our successful economy. Going forward, that success will depend on maintaining low taxes on work and enterprise and opening up more areas to competition. This brings to mind that famous Clinton slogan, "It is the economy, stupid." The funding issue is now the economy. We can and will maintain continued increases in health spending if we generate the resources from real economic activity. The Government is committed to prioritising resources for health. If we reach our growth potential of 5% in real terms – higher than most countries – we can expect to maintain the ability to fund some of the highest increases in health spending in the world. However, if we give up on economic growth, take it for granted or stifle it with new taxes, we will simply shoot ourselves in the foot and cause a real health funding crisis, as happened during the 1980s.

The focus of health policy now is reform rather than funding. Some of the Opposition parties and spokespersons now recognise this. We know how to raise resources and prioritise resources. It is now about how we utilise them. We must better manage the resources we generate and measure the results in every area. As in other areas of public services, we must focus on outcomes, not ownerships. We must align incentives that influence people with the outcome we and the public want. We have to be more flexible and creative in applying new resources or savings to new services.

The Government is determined to press on with the reforms which commenced last week. They are aimed at achieving well-managed, sustainable quality health services on a national basis. We are determined that the reforms will make a visible difference to patients and users of our health services. We are also determined to ensure that scarce, valuable public resources are used efficiently to deliver the health services people want and need.

There is one other aspect of the OECD analysis on health I wish to raise. It states:

The increase in public and private spending on pharmaceuticals has been one of the main drivers of rising health expenditure in many OECD countries in recent years, reflecting the introduction of new and more expensive drugs. Pharmaceutical spending rose by more than 70%, in real terms, between 1990 and 2001 in Australia, Canada, Finland, Ireland, Sweden and the US. Pharmaceuticals now account for more than 10% of total health spending in nearly all OECD countries, and over 20% of health spending in France and Italy.

In Ireland, for example, the cost of the drugs payment scheme has doubled since it started from €140 million in 2000 to a budgeted €280 million in 2003. In the GMS, the cost of drugs, medicines, appliances and pharmacists' fees is budgeted to be €660 million this year.

There is a vital public interest in controlling costs in the use of drugs. That is why I favour the payment for generic drugs where they are available. The Government has accepted this recommendation from the Brennan Commission. Pharmacists are an integral element of the health care delivery system. They see it is in the public interest to control drugs and pharmacy costs. The forthcoming report from Deloitte & Touche on the GMS will also inform the Government's approach on controlling costs, alongside the analysis and recommendations from the Brennan Commission.

Health reform is at the heart of public service reform. It touches everyone in the State, as it involves 40% of our public servants. Many of these excellent public servants are de-motivated by the comments from some politicians who should be better informed. It is of great importance for our future well-being as a society. It is a central task of Government to lead and implement reforms. The Government is committed to achieving fundamental reform in its lifetime and it is prepared to be judged by the House and the public on this task.

Mr. Connaughton

It is only when Fianna Fáil and the Progressive Democrats get the answer to that one that they will be sure of being back in government again. They do not have it at present.

I have no doubt the Minister, Deputy Martin, does the best he can and I have said so on many occasions, but that is not to say it is good enough. I have a grave suspicion that the new health strategy has more to do with a Government that is bloated, inefficient, out of favour with the people and in dire need of a public relations success, because that means everything to it. If the PR is right, then everything is right.

Mr. Eoin Ryan

Fine Gael could do with some itself.

Mr. Connaughton

People are turning against the Government in droves and that is seen from the opinion polls. Health is the pivotal issue, and rightly so.

Mr. Roche

It deserves a higher level of contribution than the Deputy is making.

Mr. Connaughton

The health issue affects every family in the land and the perception, even on the part of those who are not sick, is that if the Government has a chance of doing what it did prior to the previous general election, they will have a huge problem if they become sick. This is what the opinion polls show. As far as the Government is concerned, the perception is wrong.

Regarding the health strategy, I am as long a Member of the House as many on the Government side, and I was taken in by it. When I heard waiting lists would be abolished in two years, I could not see at the time how it could be done, but I thought the resources would be made available to do it. Little did I think that two years later and a year after the general election, 29,000 people would still be on the waiting list and that it would be longer than ever. The Government knew what was happening 18 months ago. It knew the general election was coming up and that hospital waiting lists would be a huge problem at the polls. As a response, it produced this waiting lists target. I do not know if the Minister believed at the time it would work, but it was a failure. Now we have this health reform plan.

There have been leaks in the media in recent months that there would be a revolution in the health service and that the villains of the piece and the cause of all the trouble, local politicians on health boards, would be dispensed with.

Mr. Durkan

Cut out dissent.

Mr. Connaughton

The Minister must show that the reform will work this time and will do so at local level. When he canvasses in the local elections in a year's time and the general election in three or four years time, this health reform will be a huge issue, and rightly so. If the changes were made for the right reasons, there may be some hope the reform might work, but the foundation is wrong.

There are three reports, two of which have been published. Is it not ironic that as we come to the end of this session, we have not seen the Hanly report? It was possible to abolish health boards before that report was laid before the Houses. The reason given that it has not been published yet is that some of the stakeholders have not signed off on it. Is it not remarkable that it was possible to bring forward the other two reports? The Minister's timing has been impeccable. I do not think I will be too far wrong when I say that the Hanly report is likely to be published during the August bank holiday weekend.

Mr. Martin

The Deputy should take that weekend off.

Mr. Connaughton

It will be released when the Dáil is not in session. Health boards have no clout and it makes little difference what they say in the Hanly report about what is happening in the health service because they know they will be disbanded. This has been cleverly done, publishing these two reports first. I compliment those involved who put a great deal of effort into them and much expertise is evident. However, we should have had the Hanly report today to let us see the precise delivery of the health service and if there is a need for centres of excellence, something with which most agree and with which there would be no great trouble.

However, we have seen in the national spatial strategy how huge areas of the country will be left without railways, decentralisation and so on. This was underpinned by the outcome yesterday of the agriculture negotiations in Brussels. If the Hanly report shows and the Government accepts that there will be huge areas of the country where people will not be able to avail of the health services to which they are entitled for reasons of time and distance, there will be uproar. Large centres of population will be seen to have won out again and people in areas of lower density of population will either have to travel too far or wait too long to obtain health care which means they will be second class citizens.

I will say the following now because I will not have the opportunity to do so in the House when the Hanly report is published. I am sure the Minister remembers when he gave an undertaking to me and a deputation from the health board in Ballinasloe prior to the previous general election that the community hospital in Tuam would be built. That was one of his general election promises.

Mr. Martin

We bailed it out. We bought a private hospital.

Mr. Connaughton

The Minister said that and the Taoiseach came to Tuam two days later and gave the same guarantee. There is no getting away from that. I want to hold both of them to that guarantee to the people prior to the previous general election that Tuam and the surrounding areas would have their hospital. In so far as the Hanly report is concerned, in the case of a hospital such as Portiuncula in Ballinasloe—

Mr. Martin

We bought that as well.

Mr. Connaughton

The Minister did invest in Portiuncula hospital but he was not the first to do that. The Government of which I was a member years before put money into it. I want the Minister to state that as far as the Hanley report is concerned, because of its position neither the hospital's maternity or accident and emergency unit will be closed or services downgraded. That is the bottom line.

Will the people I mentioned to the Minister of State, Deputy Tim O'Malley, get a better service as a result of these reforms and what will the Hanley report do for those parts of the country that are not as populous as Dublin? Those are the crucial tests.

Minister of State at the Department of the Taoiseach (Mr. Roche)

By any standard this is a timely debate and one that deserves to be taken seriously – frankly, it deserves better than the tripe we have just heard from—

Mr. Durkan

Easy now.

Mr. Roche

—a politician seemingly more interested in mileage payments than in the health services. Localism and gombeenism will not serve the people of the State or deliver the health services they deserve and are paying for.

The health services have received huge injections of current and capital funding in the past six years and, to be fair to the previous Government, there were significant increases while it was in office. By 1997, however, we were delivering just €3.4 billion into the health services and by 2003 this figure had risen to in excess of €8.6 billion, an increase of 150% in current funding.

The figures are the same on the capital side. In 1997 we pumped €138 million into capital services and this has increased to €514 million. We all know the statistics, we have heard them often enough. The health services' current and capital expenditure has increased over the past six years by well in excess of 160%. As a percentage of GNP it has grown dramatically and as the Minister of State pointed out earlier, it has increased far in excess of the equivalent figures elsewhere in the OECD countries.

The rate of increase has been dramatic and we all know, if we are being truthful with ourselves, that it has not been matched by a similar level of improvement in health services. By no objective standard has the increase in funding been paralleled by improvements in the delivery of services. That is what we should be debating, not scoring political points.

We should look at the other end of the medical spectrum – consultant provision. The reality is that consultants consume a vast amount of resources and do not deliver, although I accept Fine Gael has a difficulty taking them on.

Ms O. Mitchell

Everyone is to blame except the Government.

Mr. Roche

The most fundamental change of all will have to take place in the management of services. Again if we were honest, we would accept that the management of the services is wrong.

I compliment Professor Brennan and her group, they have done a phenomenal job. I also compliment the Minister for Health and Children, Deputy Martin, who has shown the courage to bring this forward. It is better than the sneering, classic Fine Gael response that we get together to try to solve the problem. Having listened to the tripe from the Opposition and the characteristic responses from Deputy Durkan, we have no reason to expect anything positive from Members on the other side of the House.

Mr. Durkan

The Deputy has been in Brussels for too long.

Mr. Eoin Ryan

I welcome the health service reform programme outlined last week by the Government. It provides the framework to deal with the very real but too often overlooked health service needs of the Dublin area.

There has been a great deal of debate about the protection of services in rural areas. We often see demonstrations from local hospital action committees outside the gates of Leinster House and there are Members who were elected on the basis of very specific local health needs. Deputies will remember signs such as "No Cavan trolleys for Monaghan patients", and some TDs lost their seats because of local health demands – one Fine Gael member in particular comes to mind. This has not been the case in Dublin, where there is no tradition of electing representatives on the basis of local health demands.

This is not because people have fewer health needs or no attachment to the traditional hospitals, it is because people accept that to improve a service, the manner in which it is delivered often has to be changed.

In my constituency in the past 20 years, a number of hospitals have been amalgamated, moved or closed completely. The services once provided by Sir Patrick Dun's Hospital, the Meath Hospital, the Adelaide Hospital and Harcourt Street Children's Hospital are now not to be found in the same areas. I am glad to see that the Sir Patrick Dun's premises is now used for long-stay patients and the Meath Hospital is rolling out new health services to the local community.

We do, however, have an attachment in Dublin to the hospitals. I have a great attachment to Harcourt Street Children's Hospital, where one of my children was very ill and was treated very well. My wife and I were very sad to see it closed but, hopefully, as a result of those closures and amalgamations we will get a better service.

If I was in charge of planning the services, I would probably have sought a different configuration and some of the now abandoned sights could still make a contribution to local health services. The change, however, has been made and I fully accept the professionalism of those who say that the new configuration of services is improving standards and achieving positive outcomes for patients.

Having said that, there is a major problem whereby Dublin hospitals are asked to take an unreasonably large burden of cases from the regions. The waiting list figures show that Dublin people must wait longer for elective hospital treatments than people elsewhere. This is not because the treatments are only available in Dublin, it is because patients are being referred to Dublin for treatment even when their local hospitals have the capacity to treat them. Unfortunately, an absurd situation exists where people are joining waiting lists in Dublin when these lists are either shorter or non-existent in their local hospital. I do not regard the planning of hospital services as a threat to regional services; it should have the opposite effect. There are too many services which are only available in Dublin. If the principle of having regional centres of excellence is developed, that will automatically mean the availability of a greater range and quality of service outside Dublin. The national planning of hospital services should also mean that we could have proper enforcement of the principle that where a treatment is available locally, it should be used locally. Without requiring any major developments or expansion in bed or doctor numbers, this will both increase the number of treatments and begin to address the serious capacity issues in Dublin.

It is not just in the area of hospital waiting lists that Dublin has needs which have to be addressed. In nearly every other area of care service, needs arise because of the nature of a densely-developed and socially-mixed city. The accident and emergency departments of the major Dublin hospitals are consistently under pressure and see an incredible range of cases every day. When one sees the Dublin accident and emergency departments in action, especially at weekends, one can understand why measures to relieve that pressure should be a national priority. We cannot just talk about the number of people who present at accident and emergency units because of drink or drugs.

An Ceann Comhairle

The Deputy's time has concluded.

Mr. Eoin Ryan

Part of that is the need for a comprehensive, out-of-hours general practitioner service. When I was Minister of State with responsibility for the RAPID programme, each area in the programme drew up its own plan and all of them discussed primary health care centres. I cannot emphasise—

An Ceann Comhairle

The Deputy's five minutes has concluded.

Mr. Eoin Ryan

—the importance of primary health care centres in areas throughout the city. That is vital. There is an urgent need in my own constituency and I am glad to see that some centres are being planned for the next number of years.

I hear a lot of debate—

An Ceann Comhairle

I ask you to conclude, Deputy, because, as you know, the debate is due to conclude at 1.30 p.m.—

Mr. Eoin Ryan

I am concluding.

An Ceann Comhairle

—and you are taking up the time of colleagues who are in the House and will not have an opportunity to speak.

Mr. Eoin Ryan

We all get complaints but we cannot forget the number of people who get a great service in our hospitals. We do not hear anything about that.

Mr. Durkan

The Deputy mentioned the RAPID programme. Where is the RAPID programme now?

Mr. Eoin Ryan

It is still there.

Mr. Durkan

I am delighted to have an opportunity to contribute to the debate. Unfortunately, unlike many other speakers, I will not be complimentary because the series of reports before us are nothing more than a well-concocted plan to deflect public attention from the total mess that has been made of the health services by the current Administration and its predecessors. Over the past six years, every time something appeared to go wrong there was a quick application of a financial bandage to the system. We have now arrived at a situation where the Minister, the Minister of State and their predecessors are attempting to placate the consultants, the GPs and the administrators but they have forgotten about the consumers. Massive amounts of money are being pumped into a system in order to produce something, but nothing has appeared. We have had less value for money on an annual basis.

Before the last general election, and this is what it is all about, everything was calculated to tide the Government over the threshold of the general election. That was the golden goose that had to be cooked in the public arena and when the Government got over the general election, everything would be rosy. It had a health strategy – a ten-year plan. That was only a year and a half ago. Where is that now, and all the money that went with it?

Mr. Martin

It is still there.

Mr. Durkan

The Minister's great-grandchildren will never see it. In the meantime, the election took place. What do we have now? We have two reports today, and there is another report. Various administrators have been brought to the media training services to assist them in codding the rest of us on what is contained in the plan. The ten-year plan means nothing and it will never see the light of day. Announcements as to what will happen are now leaked beforehand but when the Ministers are toasting their toes in Roaring Water Bay during the holiday period, that is when something will happen. The House will not be sitting then but that is when the real action will be taken. That is when we will know what is contained in the plans before us and the plan we have not yet seen. Has anybody asked whether the plan we have not yet seen conflicts with some of the other information available to us? That will be really embarrassing for the Minister. What will we do then?

Like a number of other Members of the House, I spent a long time as a member of a health board. We saw the changes taking place where an attempt was being made to give a perception of delivery. Nothing was happening, yet it was costing more and more money. The greatest laugh of all, however, was about two and a half or three years ago when there were enormous changes in administration and a significant influx of personnel, but where were the personnel going? They were all going into administration.

In the Eastern Health Board, as it was then called, there was a chief executive, a community care programme manager, a special hospital services programme manager and a general hospital services programme manager. That was a small number of people but there was direct access to the top of the service by way of a telephone call at any time. There were no answering machines then or people telling customers their calls were being logged and somebody would call them back in ten days' time. There was none of that then. There was a direct, hands-on approach to the services.

The Minister and his Department then got together and decided this was an area to invest in heavily in the run up to the general election. They thought it would look good and that the consumers, the consultants and the GPs would be very impressed with it but nobody cares about the patients. What rights have they under the patients charter, which was often talked about?

It is symbolic of the edifice created by the Minister that when wards have been closed across the country and throughout Dublin and the possibility of treating patients in the car park of a hospital is being contemplated, we are sending patients abroad under the treatment purchase scheme to countries and jurisdictions which are providing the services we are failing to provide here.

Mr. Callanan

Having been a member of a health board for the past 15 years, I acknowledge the great work health boards have done for 30 years in providing health services. Significant advances have taken place and the number of patients treated has doubled over this period. I accept that modernisation of the health service is necessary and I welcome the reforms proposed by the Minister. I particularly welcome the reduction in the number of health agencies by almost half. While the proposal to appoint a single national agency to control all our hospitals is welcome, we must make sure small hospitals in remote areas are looked after.

I accept that centres of excellence cannot be provided in every corner of the country and should be regionally based. We want to modernise the structure of the health service to bring about better quality patient care for everyone. Interest groups have been mentioned frequently and it has been suggested that true reform is not possible. This is wrong. Surely we can agree on one overall point, namely, that only one interest, that of patients, should be considered when planning and delivering health services.

The objective of reform has been to deliver the maximum benefit to the maximum number of people. The health strategy sets out detailed service objectives for every area of the system. These are based on international best practice and on the idea that every person, irrespective of where he or she lives, should have fair access to high quality care. The reform programme sets out the structures required to deliver these service objectives, and we must press ahead and implement them.

Our system has to be more flexible and capable of delivering high quality service which is open to all where it is needed. Services must be planned on the basis of evidence which shows how to maximise successful outcomes for patients. Where work practices hinder the achievement of these objectives, they should change. These points should be agreed by everybody before negotiations begin.

The health system is now our largest employer. It is a dynamic sector which has expanded significantly in terms of funding and the quality of care provided. The fact that 180,000 more cases are being dealt with than six years ago is testament to this. We must push forward to develop services and all groups must acknowledge their part in the process of change.

The Government has committed itself to a health service which continues to reward its professionals well. In many areas, Irish health professionals are the best paid in Europe. There is also a commitment to continued investment in improving services, For example, investment in new buildings and refurbishment of facilities is at a historical high.

The public has strongly supported the prioritisation of investment in health. We have reached the stage where the equivalent of every euro raised in income tax is invested in health services. In return, it is proper that the public demands that we work to ensure maximum returns from this investment. I strongly support the policy that where funds are involved, the interest of the public patient must come first. I look forward to a better health service in the future and wish the Minister well in his proposals.

Mr. Moloney

I welcome the attempt to reform the health services and congratulate the Minister and Minister of State on their efforts in this regard, not as a member of the same party, but as a health board member of 20 years standing who has observed the difficulties of delivering services in the regions. While many things are being blamed for the ills of services, as a long-standing member of a health board, I have experienced major difficulties in trying to achieve agreement on the ground on supporting and locating new services. I welcome, therefore, the proposal in the reform to establish a national hospitals office. I do so from experience in observing a health board struggle to secure services for a region and obtain agreement on their location.

I recognise the difficulties in Dublin hospitals, particularly with regard to waiting lists. Over the years, large numbers of people have left my region, the Midland Health Board area, to obtain services in Dublin because agreement could not be reached on the provision of such services in the region. I refer specifically to the national cancer strategy, which I watched unfold following its introduction by the then Minister for Health, Deputy Noonan. I wished it well and supported it at health board level. For five years the service on offer could not be taken up because we could not achieve agreement among the three acute hospitals in the region. Such difficulties have led to the problems we are experiencing in the health service. On the one hand, funding is made available for services, while on the other years are allowed to elapse before it is drawn down and patients, unfortunately, suffer as a result.

When the Midland Health Board finally reached agreement on the location of services under the national cancer strategy, a High Court case was taken challenging its decision. Subsequently, I proposed at health board level that rather than await further offers from the Department to provide services, members of the board should go away for a brainstorming day and, with the help of politicians and consultants, establish the role of the health board, define the needs of the local area and seek agreement on action to be taken in the event of such proposal being made by the Department. We did not succeed in doing this.

I have cited one health board region, but I have seen this happen throughout the country. The Minister's reform plans in this regard are correct. We should not continue down the road we have been taking for years, whereby, for example, a fully funded service is offered, no agreement is reached on its location and no action is taken for five years, as happened in my health board region. Central Government is not to blame. The reality is that counties will naturally fly their county flag and unfortunately local politicians will have to support it. I supported my sister county, Offaly, when the national cancer strategy was introduced, a decision which was not well received in my home county. For years I found myself finding fighting a battle to ensure the service was secured, yet the public could not accept it by way of delivering a service. In that regard, I welcome this.

I welcome most of what is contained in the national hospitals office proposal and see it as the way forward. I also recognise that the aims can be summed up as providing better patient care and better value. The idea of making the management of the health service more structured so that it can provide a better service for the patient and the community is a simple one and well overdue. I say this as a health board member of 20 years standing.

These reforms come on the back of the national health strategy, the most comprehensive and ambitious health strategy ever produced in this State. The follow-on from this must be the health service reforms. In order to implement the health strategy, a number of changes have to be made to the overall structure of the health services and this is where the health services reform programme comes in. The current structures have been in place for 30 years. I have been a member of a health board for 20 years and while I have seen great changes in the commercial and banking worlds, I have seen no change whatsoever in the delivery of health services. The time has come for change. This is not a cop-out as has been suggested; it is a recognition of the significant demand from the public and, more importantly, the need for the Department to deliver the service throughout the regions rather than having them centrally based.

The core of the health service reform programme is the modernisation of health structures so that it can deal with demands placed on the system now and in the future. We need to put in place a system that will be able to cope with any changes or challenges future decades may throw up. I welcome the main element of the reform programme, namely, the major rationalisation of existing health agencies, including the abolition of the health boards, to reduce fragmentation. While local politicians, as members of boards, may now feel that the heat is on them, it is fair to recognise that the boards are being dismantled in their entirety and not as a cop-out to blame them. It is a recognition that the boards have gone past their sell-by date.

In my region and others, I have seen that boards can never agree. While I asked that the consultants come together to map out a strategy for my board, they could not agree on this. Politicians on the board provided local involvement, yet when it came to medical strategies we involved consultants but we could never get agreement from them.

I welcome the national hospitals office. I want to get away from the day where services are decided upon by the level of political support in a particular county.

Dr. Upton

There is no other issue that has engaged the minds of the public in recent times as much as that of the shambles in the health service. It is the common currency of every local meeting I attend, of public discussions and many individuals that attend my advice clinics. The immediate problem is that of waiting lists and it is now a matter of waiting to get on the waiting list. They do not see any light at the end of the tunnel; it seems that someone might only deal with their problem somewhere in the dim and distant future.

My constituency of Dublin South-Central is the location for Our Lady's Hospital for Sick Children. The local people are, or rather were, proud of this facility even though the hospital serves the country as well as the locality. The pride in this hospital has changed, not because of the staff or those providing the facility, rather it is because of the lack of supports and services that are available to the hospital to deliver an adequate service. It is extraordinary that 25 beds have recently been closed. The Minister is well aware of this as it has been raised on a number occasions. A local public meeting was held on this issue this week. The immediate concern is that the procedures that might otherwise have been engaged in are now being postponed again. It is reckoned that 2,000 procedures will not be carried out there this year on account of the closure of these beds.

There are other concerns apart from the closure of beds and this is highlighted by the establishment of a parent's group of children attending the hospital, or who have attended it in the past. While the group is loud in its praise for the staff and the services provided in the hospital, there are major concerns about the lack of equipment and the failure to update facilities in the hospital. The report the group commissioned is damning of the circumstances that exist.

There is something grossly inequitable in having a system whereby patients may be eligible to go outside the State for treatment while hospital beds are being closed. The procedures are not particularly sophisticated or elaborate, the system is simply not able to provide them here. It is extraordinary that funding is available to allow individuals to avail of the patient treatment fund while the facility is not available locally. Many of those that come to my advice clinics do not want to avail of the service. They want to be treated at home and the elderly especially are nervous of going abroad. While some people accept and avail of this facility, it is far from the optimum for them and they are not comfortable with it.

The Brennan report makes a number of recommendations, including the rationalisation of the existing health agencies. I have one simple question for the Minister, should the changes implemented. When I table a parliamentary question to the Minister, will I actually get a reply within a reasonable period? I appreciate the way the current system operates in that the Minister replies to my question, the reply invariably lets me know that it is not his direct responsibility and the query has been passed to the health board. I regret to say that weeks usually pass before I get a reply. There may be questions of bureaucracy and a lack of facilities. It is unacceptable that one should have to wait two or three weeks for a reply. The replies I receive are often evasive and inconclusive and leave me in a position where I cannot provide any reasonable information to the person that came to me in the first place. I should add that I am not, and never have been, a member of any health board. I recognise the need for reform in this area and would like to see it happening sooner rather than later.

In the House earlier this week I raised the issue of two young autistic adults awaiting places with the Irish Society for Autism to be funded by the health board. This has dragged on for months and there has been no response from the board. This is unacceptable. I hope the Minister will engage in this issue and seek a substantial reply on behalf of those parents. The streamlining of the health board system has to kick in sooner rather than later. It is unacceptable that bureaucracy or anything else should hold up the system to this extent.

When it was announced that the medical card scheme would be extended to everyone over 70 it seemed like an attractive idea. I thought it was a good idea and, having looked at the figures, it seemed as though it would work. The glitches have now shown up in the system. At the time, the estimate was 39,000 eligible patients, but this grew to 77,000 with an associated increased cost of €36 million. The principle of making medical cards available to elderly people has to be lauded. However, it is inequitable that people over 70 that can comfortably afford to pay for a medical service are given medical cards while young families that are a little above the income limit are refused them. Some of them are now afraid to go to a doctor as they cannot afford to pay. Invariably, parents of young children find they suffer as they feel it is more important that the children be treated. If one has to make two visits to a doctor in a month the cost can range from €80 to €90 depending on one's area of residence.

I have listened to the explanation as to why it is not a question of funding but reform. It did not take two or three reports to establish that. Anybody on the street would have been able to observe that that reform was the fundamental issue. Reform entails grasping the nettle and dealing with the issues highlighted in the reports. It must be asked why it has taken so long to discover that the problem is not only one of funding – the availability or lack of which has been much debated – but the need for fundamental reform, which must be addressed sooner rather than later.

The question of dealing with consultants has been referred to by a number of speakers. The issue was well analysed in the Brennan report and I subscribe to its findings in this regard. It is for the Minister to grasp the nettle. It is no longer sufficient to pass the buck and prescribe what other Members must do. He has been provided with the detail of what needs to be done. It is a matter of having the will to implement recommendations and decisions.

Reference was made to accident and emergency units. It is a salutary lesson to visit St. James's Hospital in my constituency late on a Friday or Saturday evening and observe the stress to which members of staff are exposed. They work very well under severe pressure. There must be a radical reform of accident and emergency units, including the way emergencies are dealt with.

I was interested in Deputy Eoin Ryan's remarks on the possible application of the RAPID programme to addressing some of the problems with the health care systems. The programme was meant to be available in my constituency, but there has been an unfortunate lack of implementation of funding for all areas, not only in health.

Mr. Carey

I wish to share my time with Deputy O'Malley.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Carey

In the past, employment and economic failure dominated political discussion, but over the past five years health has become the No. 1 public issue. That is as it should be because no public service is more important. Developing a modern health system is the goal we should all share. That is why I welcome this debate and the health service reform programme. It is an intelligent and comprehensive blueprint for the development of the health system. The two reports which are being used as the basis for the programme make an unanswerable case for change. If we want to have the kind of service set out in the health strategy, we must implement the recommended reforms. No vested interest should be allowed to stand in the way.

We all know where problems are to be found in the health system. While the need for improvement is obvious, the way of achieving it is never simple. Many people in this House and outside believe a magic wand can be applied by the Minister and the Minister for Finance to cure all the nation's ills. Unfortunately, this approach undermines the implementation of real solutions.

More than in any other area of public activity, the answers to problems in the health service are always complex and require action across a wide range of fronts and over a sustained period. Those who sit on the sidelines and call for instant solutions help nobody. The need for rational debate is huge, but, too often, this is the last thing that happens. A sense of perspective regarding achievements and challenges is missing. Every international study on our system says it provides good care for large numbers of people and is on a par with other developed nations in terms of overall quality. While the health service has problems, nobody outside the country considers it to be a Third World service.

As with everything else, there is no point in looking to the Opposition for a real contribution to the formulation of health policy. Day after day we hear the empty rhetoric and crocodile tears of those whose only interest is to try to exploit often tragic situations.

Mr. F. McGrath

That is out of order.

Mr. Carey

It is well over three years since the Labour Party indicated it would produce detailed costing and legislation for its promised health care revolution, but nothing has been done. Realising that they might have to defend their policies, party members have backed off and contented themselves with praising their vision and commitment.

Fine Gael's policy is, as usual, whatever it thinks the public wants to hear on a given day. Many Deputies enjoyed the tenure of Deputy Olivia Mitchell's front bench predecessors, where the policy on universal health insurance seemed to change every week. The party ended up fighting the last general election on a platform of radical change accompanied with a commitment to retain everything.

That kind of thing is to be expected from opportunistic parties, but, unfortunately, much of the media coverage has been little better. It is increasingly clear that various elements of the media see health as providing a rich supply of human interest stories rather than an area on which they should provide balanced coverage.

Ms O. Mitchell

Another example of everybody being wrong but the Government.

Mr. Carey

According to them, the only group to be held accountable is the Government, and their working principle is that a half empty bottle is a better story than a half full one. There are times when it seems we no longer have a health service, but an ailing, failing or crumbling one.

Ms McManus

The Deputy has said it.

Mr. Carey

According to this view, there is a constant crisis in every part of the system and we would be better off moving to a Third World country where at least the United Nations would look after us.

The reality is dramatically different. The fact, disputed by no objective sources, is that over the past six years, every element of the system has seen real increases in funding and care. The 180,000 extra cases being dealt with in the hospitals this year are real people receiving real treatment from real staff. It is amazing that no sense of this can be found in the coverage of hospital issues. It does not fit the storeyline, so it is ignored. A similar situation applies to disability care service, community, psychiatric and palliative care services, out of hours GP care and so on.

Mr. F. McGrath

The disability care service is in crisis.

An Ceann Comhairle

Deputy McGrath will shortly have the opportunity to contribute.

Mr. F. McGrath

I cannot accept Deputy Carey's comments.

Mr. Carey

Undoubtedly, many people do not receive the quality of care they require when they need it, but it appears that a new, unattainable standard has been established when covering health issues, which is that until everything is done, nothing is done.

We have an improving health system although it is not good enough. It has structural and, in many cases, funding problems. However, progress is being made in addressing these issues. Unless this perspective is allowed in the coverage of the system, we will never be able to hold a credible public debate on health policy. There are many aspects to this approach that must change. For example, last week, when the Minister was interviewed about the reform programme on "Five Seven Live", it was suggested that nothing had been done to reduce waiting lists.

I congratulate the Minister for refusing to be deflected from his commitment to development and reform. His approach will stand the test of time and I hope he is not deterred in his determination to sort out the service, which we all want to see being done.

Ms F. O'Malley

Even a cursory look at the first two volumes of the health reform trilogy bear witness to the obvious failures in the health service. In many instances it has been guilty of serving its own systems rather than patients. The Minister of State, Deputy O'Malley, has indicated that reform will put patients before politicians, boards, structures and bureaucracy. This provides us with the opportunity to look forward to reform in this area.

All the participants and providers of health care bear some responsibility and share in the blame for the failures of the health service. They must be prepared to make the changes outlined in the reports and which the Government is determined to implement. They are obviously necessary.

I wish the Department well in implementing change. It will be a challenge. The two published reports are an indication of the Government's determination to prioritise health care and implement change. It will not occur overnight – indeed, it will be a number of years before real differences are apparent. However, that is no reason not to have the courage to start making change and to have faith that the public will respond when services have improved. Nobody should be exempt from these changes. People are nervous of them and they are already the cause of conflict in the public arena.

The Hanly report, the third part of the trilogy of reports, has yet to be published. It will be the instrument by which change will be delivered. I have every faith in the Government and I offer my congratulations to the Minister for his courage in taking this on. It is an admirable quality in any politician, but it is necessary in a politician who is determined to bring about change and in a Government which is going to drive that change. The Government will see that the people get the health care they deserve.

Mr. Boyle

I wish to share time with Deputies Morgan and Finian McGrath.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Boyle

We have received the three reports which were anticipated. They are not the only reports this Department and this Minister have brought forward and I suspect they will not be the last. There seems to be a relentless logic in the production of reports and strategy documents from the Minister to the extent that I think we will eventually see a report entitled the "report of the commission on health report commissions". One can only evaluate the evaluators at this stage. Nothing really changes in terms of public concern at the condition of the health services and the use of resources. Even the Government's response to the two reports which have been released seems to indicate that it is not adopting a clinician's approach to the health services. It is still a case of dealing with symptoms rather than trying to treat the disease. No one has confidence that the measures which have been suggested will significantly improve the delivery of services for the public.

There are proposals to welcome in both reports and the Minister can be assured of some level of support on this side of the House in respect of some of them. There is a logic on economy of scale grounds to have a national authority to oversee some elements of the health service, but certainly not all. Capital grounds and the need to deliver specialised services on a national basis mean such an authority is necessary, but to move to total centralisation of the health service is to go in the wrong direction. There are areas of health service reform which require a greater degree of decentralisation. A single national authority cannot properly deliver a community care programme which is still largely based on resorting to voluntary organisations and local knowledge in the delivery of services. If the Minister can explain how that can be done, I would like to hear him do it.

I am glad the Minister for Finance has come to the House to join the debate. He has tended to play the role of the ghost of Hamlet's father today. Very often the problems which have arisen in the health service have been the result of an accountant's approach which does not recognise changing demographics or acknowledge that health conditions can vary at any particular time. The approach has been to measure by cheque book. That is not to say we should not seek a better result from the money which is being spent, but it must be noted that in European terms we spend less per capita than many other states. Spending is still lower in terms of social protection expenditure than in any other European country, but the Government chooses to boast about providing the lowest tax rate in the EU. It would be preferable to boast about having the best quality public services. As long as the Government indulges in that sort of double think, we will see report after report into the health service.

Mr. Morgan

This is a plan for bureaucratic change to be carried out at the expense of accountability. Where will be the democratic input and accountability? More importantly, these proposals fail to challenge our most fundamental problem which is the two-tier public private system. The proposals being made do not include the core Brennan recommendation that all consultants in the public sector should work exclusively in that sector.

The Department of Health and Children is notorious, as Deputy Boyle has said, for producing reports and strategies, but they are rarely implemented. Even if they are, provisions are quickly superseded by something else. In this instance we are presented with two reports at the same time, one from the Department of Finance and one from the Department of Health and Children. Will the next one be from the Bank of Ireland, the Central Bank or some other such institution? It is unfortunate that the Minister for Health and Children, Deputy Martin, is being used as a mudguard by right-wingers in Cabinet who wish to destroy the health service. They seem to be trying to "Americanise" it and Boston is winning out.

We are told the national hospitals office the Government proposes to establish will provide a strong single approach to the delivery of hospital services. Under the supposedly decentralised system we have in place at the moment, we see the closure of essential services in Louth and Monaghan. These proposals will undoubtedly give us more of the same. To help Deputies to appreciate the madness of what has occurred, I inform the House that Louth County Hospital had an excellent paediatric unit, a fine maternity unit and a first class gynaecology unit, all of which are now closed. The services involved are denied to the people of the region. The accident and emergency unit is now under threat and ludicrously, if a car accident occurred outside the hospital's gate, the victims would be brought 25 miles away to a hospital in Drogheda. We are supposed to be seeing centres of excellence at work, but I have seen no evidence of it. Perhaps this can be got right in future, but where there were fine hospitals, people are now enjoying services which are much worse than they were 30 or even 40 years ago. How does that constitute improving the health service and how does it constitute looking after one of the core facilities people need in the regions?

I ask the Minister for Health and Children to have another word with the Minister for Finance in an attempt to overcome the obstacles we face.

Mr. F. McGrath

I am grateful for the opportunity to contribute to statements on the audit of health structures report and the commission on health funding – Brennan – report. However, I object strongly to the short time given to this important debate, particularly as a member of the Independent health alliance which was elected on a health and disability platform. It is unacceptable and totally undemocratic.

In the short time I have I wish to make some very important points. We all know that our health service is in need of urgent reform and change. I welcome the recommendation in the Brennan report that the executive is to manage the health service as a unitary national service and I welcome the sections which call on consultants to work exclusively in the public sector. We must root out inequality in our health service and the patient must always come first. I accept those proposals as progressive ideas. While I do not agree with every aspect of the proposals, there are concrete ideas in the reports. We must be vigilant in the interests of patients and taxpayers. The establishment of a national hospitals office to run all publicly-funded hospitals represents a progressive step and I welcome the proposal. However, I sound a note of warning. The Government must listen to the people on the front lines of the health services.

These proposals will not be worth the paper they are printed on if we do not invest in our services. Successive Governments have failed to provide the necessary infrastructure to support the health system. We have an opportunity to prioritise public spending to eradicate all health waiting lists. Reforms without investment are useless. We must face up to the word "tax". If we want a quality health service, we will have to raise more taxes to fund it. We cannot have it both ways. The so-called black hole syndrome in Government circles must be challenged. We must have more efficiency and quality output, but we must also invest because if we do not, we are deceiving ourselves. It is a shame that this Government is running away from that reality. With investment, waiting lists could be eradicated within three years. Investment, efficiency and accountability would transform our health service. Those in government who seem to be obsessed with the low tax disease should take a look around them in the real world and recognise the waiting lists and the trauma. Most people would not mind paying a little extra if they were guaranteed the delivery of a top quality health service. Now is the opportunity to provide for that.

I listened to the Minister's comments this morning with regard to cross-party support on the health issue. I am open to many of the proposals he outlined, provided funding and investment are part of the package. I call for a little more respect from the Minister for Finance and other Deputies. His attitude and the attitudes of the other main parties, particularly on "Questions and Answers" on Monday night, have left much to be desired. The major parties have a great deal of baggage in terms of the Independent Deputies whom the people elected on the health platform. If the Minister is serious about consulting people and respecting those with direct experience of the downside of the Department, he has a duty to respect that mandate and democratic view. Then we can all move forward and do something practical about the health services. The key words in this debate were in the Minister's contribution, "investment with reform". That is the way forward.

Minister for Finance (Mr. McCreevy)

The demands on the health service are enormous and growing. Almost one million people were treated in our acute hospitals in 2002. That is equivalent to one quarter of the entire population of this country, in just one year. In addition, there were approximately two million consultations in out-patient departments and more than 15 million consultations in general practice.

Equally, the amount of public funds we invest in the health service is enormous and growing. In 2003, we allocated over €9.1 billion for health services. This is more than two and a half times greater than the €3.6 billion spent in 1997. Over that same six year period, spending on health has risen from 19% of total Government expenditure to 24%. Health expenditure as a proportion of GNP has risen from 6.2% in 1997 to 8.3% this year. To put this level of investment in perspective, almost every cent of the total income tax receipts for this year, €9.3 billion, will be spent on health services. In 1997, income tax receipts totalled €6.6 billion and just over half of this was spent on health.

These statistics clearly show that we have delivered, and are delivering, the funds necessary to develop quality health services. Now we need to ensure that the system is organised in a way which allows us to get the maximum value from this investment. The Brennan commission, which I set up, concluded that "there is scope. . . to provide better services to those who require health care and to provide better value for the substantial investment in health services." This is what the reform programme is about. Make no mistake, this is about services. The point of the reform is to ensure that the investment we are already making in the system delivers improved services for the public.

The key features of the reformed structure as decided by Government are now well known and I do not need to describe them in detail again. However, I wish to emphasise the outcome that we can expect from the reform programme – a simpler, clearer, more accountable and responsive health system. This will be achieved in the first instance by establishing a clear chain of command, developing service plans to set out in detail what will be done for the total, not just incremental, resources provided and reorganising acute hospital services as a matter of urgency. Further elements of the reform process will be put in place when the Government has considered the report of the national task force on medical staffing, otherwise known as the Hanly report, the Deloitte & Touche review of the general medical services and a national health information strategy.

The reformed organisational structure will put in place a more rational and clearly accountable system. This will be achieved by, first, reducing the number of agencies involved in delivering health care and integrating their functions within the new system, a reduction of 32 agencies in total. Second, we are putting in place a structure where the responsibilities and powers of the various players are more clearly identified. The Department of Health and Children will be responsible for formulating policies and advising the Minister on service priorities. This will be done in light of available resources following the usual Estimates process involving my Department. It will also be tasked with forming its own independent assessment of the health services executive's performance and advising the Minister in that regard.

The health services executive will be responsible for delivery of services within its assigned budget, based on a national service plan outlining the quantity and quality of services to be provided. This national service plan will be subject to formal approval by the Minister. The new health information and quality authority will support the Department of Health and Children by assessing whether health services are managed and delivered to ensure the best possible outcomes within the resources available.

This is a clear and sensible chain of command for the health services. Health policies and priorities are determined as part of the political and governmental process and professional managers are tasked with their efficient and cost effective delivery and must account to the Minister for Health and Children. Ultimately, the Minister and the Government are accountable to the Oireachtas and the electorate.

In line with the Brennan and Prospectus recommendations, we have decided to set up a national management structure. At regional level, rather than reduce the number and powers of health boards, the Government decided to make a clean break with existing structures. This is not about blaming health boards for the failings of the system, it is simply that the health board structure has been in place for over 30 years having evolved from local government's role in health services. It does not suit the requirements of a modern society. However, I wish to make it clear that democratic accountability will be maintained. The Oireachtas, the Government; and the Minister for Health and Children will have key roles in this regard. The board of the HSE will be directly accountable to the Minister for Health and Children. The chief executive officer of the HSE will, as Accounting Officer, be accountable to the Oireachtas.

It is understandable that some of those working within the system feel some uncertainty as to the future shape of the organisation within which they work. However, the Brennan report states that the people who work in our health service "deserve no less than the opportunity to work in a system which will support them in doing what they wish to do: offer the highest quality service to the public." This is the aim of the reform programme, a well managed and organised system supporting its staff in delivering the best possible care to patients. This is in the interests of everyone – staff, patients and taxpayers and will, I believe, be supported by everyone. In fact, this programme has already been anticipated in the new national partnership agreement, Sustaining Progress. All parties have accepted the need for reform of the health services in order to protect their long-term sustainability. All have agreed that the substantial resources being invested in the health service need to be used efficiently and effectively.

I have been asked about the impact on staff of this reform programme. I wish to make it clear that, with the reduction in the number of agencies and the general streamlining in management structures, I expect some jobs will no longer be needed in the new system. However, this does not have to mean redundancies. I expect that changes will largely be absorbed by natural wastage and redeployment. The bottom line is to free up the maximum level of resources in order that these can be put into the improved delivery of front-line services. In this, we have the support of the social partners. This will be one of the benchmarks for delivering better value for the money being invested in health and improved services for patients.

The role and work practices of hospital consultants have also been the subject of much discussion over the past week or so. This reflects the central role which consultants occupy within the hospital system. The reality is that, by and large, it is consultants and other senior clinicians who decide on and direct patient treatments and thus, directly or indirectly, determine how money is spent within the system. This gives rise to two inescapable conclusions. First, such clinicians must be closely involved with management when resources are being allocated and managed. Second, senior clinicians must be willing to accept responsibility for the resources they consume or cause to be consumed. The consultant's common contract must support these needs. We have already signalled that we intend to begin negotiations with consultants on their contract without delay. We will bring the various recommendations from the Brennan report as well as the emerging issues from the Hanly report to the table for those negotiations.

I wish to emphasise again that these reforms are about improved service, not only by ensuring that the system delivers better, more responsive, service and value for money, but also that it can be clearly seen to do so. There can be no doubt that this substantial reform programme can yield significant benefits for our people, both as patients and taxpayers, over the coming years.

Mr. Kehoe

I welcome this opportunity to comment on the most recent efforts by the Minister and the Government to tackle the most pressing issue in Ireland today. While all efforts to make the necessary improvements are welcome, the publication of the most recent reports should not be seen as providing the answers to the most critical issues in the health service. Members on this side of the House will welcome and support real reform. This Government has failed to introduce real reform. The latest in a series of 120 reports prepared by the Minister may provide the illusion of action for the public but there is no genuine action to tackle real and immediate problems. These issues include bed and staff shortages and the pressing need for radiotherapy services in the south-east. The Brennan report highlights the need for effective spending and only this week I pointed to an example of questionable expenditure by the South-Eastern Health Board in County Wexford. The board is spending a significant amount of money renting office space in Enniscorthy when nearby there is a hospital full of free offices. I cannot understand how a health board or anyone could justify paying thousands of euro every year while a mile or less down the road there is free office space. I call on the Minister to make sure this does not happen. It is happening all over the country as I know from speaking to some of my colleagues in Fine Gael. Health boards are paying significant amounts of money while in hospitals there are wards closed which they could be using and saving money.

Two years ago the public was treated to a similar glossy launch of the health strategy as we saw last week for the Brennan and Prospectus reports, but the Government has since quietly shelved the strategy and underlying problems remain today. The plan to remove public representatives from health boards to create new structures for four regional offices has an adverse effect on the provision of health care in small rural communities and especially in my own constituency where councillors make sure that the health boards are doing their job properly. The Minister is afraid to have councillors on health boards in case they criticise. Councillors should be left on health boards because they are there to see what is happening and to make sure everything is being carried out. The health needs and concerns of people in smaller rural communities such as Wexford must be articulated. All we have heard about so far is the closing of boards and the removal of democratically-elected members who give a voice to the concerns of these people.

I am concerned that the Hanly report may be published while this Dáil is in recess. We should debate the report in this House and I hope the Minister will not publish it when the Dáil is in recess. It should be debated here and all Members should have an opportunity to air concerns. The Hanly report may have serious repercussions for hospitals such as my own in Wexford and it is ironic that it will emerge while we cannot scrutinise it.

Since I won the nomination to stand for Fine Gael in July 2001, two of my constituents have died while waiting for heart bypass operations. How can any public representative go back to a family and say he or she could not get the person into hospital and that is the way it is, even if the person dies? That is very sad. One man had a five year old child. How do I go back to his widow and say that if her husband had had a bypass he could be with us today? In another case a lady of 75 years of age was waiting for a cataract operation. Her appointment was fixed for October 2002, it was cancelled and she was told to come back in December, in January and then in February. Finally she had the operation near the end of April. This is happening in every hospital, in every health board area. It is ludicrous.

I have to laugh at Deputy Carey who said that there are no problems in the health service. He must not hold any clinics or listen to any grievances from people because when I talk to my colleagues in Fine Gael and the Labour Party and every other party, it is the same. When I go to my clinics on a Saturday morning, Friday evening and on Monday, I can guarantee that I will have three or four people at each of those clinics making representations because they are waiting for something from the health system, whether an operation, help for someone with a disability or whatever. Some say the health service is a leaking bucket, and we are throwing more money into it. The Minister for Finance, Deputy McCreevy, said that over that six-year period spending on the health services has risen from 19% of total Government expenditure to 24% now. Can the Minister for Health and Children, or Deputy McCreevy, say that the health system has improved in the past five or six years? I have seen no improvement in the health system in that time.

Deputy Carey talked about the policies of all the other parties in this House. Fianna Fáil was going to end waiting lists, the Progressive Democrats were going to be the watchdog. I do not know what they are looking at because they are not watching the health system. Maybe it is best that Deputy Tim O'Malley has left the House because what this Government has done is ludicrous. It has not improved the health system one bit. What I see in my county, and it is probably the same in other counties, is that people are being let out of hospital within three or four days of admission. Some of the hospitals are like a conveyor belt, the patient goes in and out and fends for himself or herself after that. District nurses are under severe pressure in rural communities trying to see all their patients and maybe in a week or two the patients come back into hospital which holds up the system.

Our geriatric hospitals show that we are not looking after our elderly. The importance of this cannot be stressed enough. The Government does not realise how lucky it is because there are good people looking after their grandmothers or parents or whoever, while the carer's allowance is gone and the medical card system is a joke. I would not like to be in the Minister's position, which is a tough one. This Government has failed. It is a joke to issue reports when the Dáil is in recess and cannot scrutinise them.

I am disappointed with the handling of the health system over recent years. We will support real reforms that will matter to the people. The more money that is thrown into the system, the worse it gets. People will recognise this when they get a proper health care system.

Minister for Health and Children (Mr. Martin)

I thank all Deputies for their contributions to the debate so far. I do not see this as the end of the debate but rather as its commencement and although the House is going into recess it will come back into operation in the autumn. There will be further opportunities then for discussion in the plenary session on matters pertaining to the health reform programme, such as the establishment of the new health services executive of the new hospitals agency. I will not have a difficulty debating those issues in the House in the autumn.

Ms McManus

Will they be up before the debate?

Mr. Martin

I will come to that in a moment. I do not have a difficulty in dealing with aspects of this reform programme with the Oireachtas Joint Committee on Health and Children, if the committee wants to go into more detail on these issues. My staff and I are available to pursue that option as well because despite what is being said there is no agenda here to avoid debating this in the House. The timing is a function of when the reports are concluded and decisions are taken. The Hanly report was not ready to go with these three reports and even if it was, it is arguable that it needs space for a genuine informed debate by all concerned.

Mr. Kehoe

Why was it not ready?

Mr. Martin

All of the partners were involved in the process. There was a steering committee involving the different partners in health and for the Hanly report to come as an agreed report from all the partners, which is a significant thing to happen, people have to sign off which they did in the last few days. We have to prepare a memorandum and go to Government. They had not signed off prior to this and waiting for them would have delayed publication of the Government's decisions on Prospectus and Brennan. There was no point in doing that. Four weeks ago Opposition Members accused me of delaying this, saying I was afraid to come forward with the Prospectus and Brennan reports—

Ms O. Mitchell

The Minister was afraid of the councillors from the local authorities.

Mr. Martin

—which was a somewhat ridiculous assertion. When I produced it, I was accused of other things, and there was no logical consistency from the Opposition in its comments about the publication of the reports, the timing of the announcement and Hanly.

We must prioritise access and so forth. Equally, the consultants' contract negotiations have many more factors than simply one or two. It is a slow process, but the idea was to achieve a shared vision, moving forward to a consultant-delivered service as opposed to the consultant-led one that we have had for donkey's years, so that we have senior clinical decision-makers in the key specialities around the clock and that when someone comes in at 12 a.m., he or she will not be totally dependent on trainee doctors. That is as much about equity as anything else, but it has never featured in the equity debate surrounding health, which has been far too superficial.

I have met patients who could talk about an elaborate network of cardiac rehabilitation facilities across the country in almost all county hospitals. We are now treating—

(Interruptions).

Mr. Martin

I listened to everyone and did not interrupt.

An Leas-Cheann Comhairle

Order, please allow the Minister to conclude.

An Leas-Cheann Comhairle

We must conclude.

Mr. Martin

I welcome the contributions of Deputies today and look forward to an ongoing debate.

Dáil Éireann debate - Friday, 27 Jun 2003