Health (Amendment) Bill 2004: Second Stage.

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

I am pleased to have the opportunity to address the House today on Second Stage of the Health (Amendment) Bill 2004. This is the first of two Bills I intend to bring before the House this year to give legislative effect to the proposals contained in the Government's health service reform programme which was announced last June. The Bill represents a further phase of the implementation of the reform programme which has been under way since that time.

It is important to remember that the reform programme has its origins in the national health strategy, Quality and Fairness: A Health System for You. This strategy sets out the vision and goals to guide planning and activity in the health system up to 2010. While the strategy acknowledged that the current structures have served us well for more than 30 years, it recognised the need to review these structures to ensure that they were appropriate and responsive to the needs and challenges of delivering health services in the changing environment of the 21st century.

Using the underlying principles of equity and fairness, a people-centred service, quality of care and clear accountability, the strategy identified four goals — better health for everyone, fair access, responsive and appropriate care delivery and high performance — which should guide and shape the strategic direction for the future development of health services. It also identified the need to have a consistent national approach to the delivery of health services based on clear and agreed national objectives.

Arising from the commitment to reform the health system, three reviews were undertaken, including one by Prospectus entitled An Audit of Structures and Functions in the Health System, and another commissioned by my colleague, the Minister for Finance, entitled Commission on Financial Management and Control Systems in the Health System. In tandem with these reviews the reform of the acute hospital sector was being advanced by the national task force on medical staffing, which issued the Hanly report. This report set out recommendations on how to plan for the reduction of average working hours of NCHDs by 1 August 2004 to meet the requirements of the European working time directive. Its recommendations also covered planning for the implementation of a consultant-provided service and the medical education and training needs associated with the working time directive and the move to the consultant-provided service.

One of the central findings of the review of the system was that there were too many agencies and as a result the delivery of services was too fragmented. In June 2003 the Government announced the health service reform programme, which was based on the recommendations of the Brennan and Prospectus reports. The programme's priority focus is improved patient care, better value for taxpayers' money and improved health care management. It is the most ambitious change programme for the health service in more than 30 years, involving an organisation with close to 100,000 staff and a budget of more than €10 billion.

The key elements of the reform programme include a major rationalisation of existing health service agencies, including the abolition of the existing health board or authority structures; the establishment of a health service executive which will be the first ever body charged with managing the health service as a single national entity; the establishment of a health information and quality authority to ensure that safety and quality of care is promoted throughout the system; the reorganisation of the Department of Health and Children to ensure improved policy development and oversight; the modernisation of the system's supporting processes so that they will be in line with recognised international best practice; and the strengthening of governance and accountability across the system.

The cornerstone of the reform programme is the establishment of a health service executive which will be the first ever body charged with managing the health service as a single national entity. The establishment of a health information and quality authority, HIQA, is also proposed in the reform programme. The HIQA will be established as an independent statutory agency, directly accountable to the Minister for Health and Children. It will provide an independent review of quality and performance and its analysis will inform policy development within the Department of Health and Children. It will also support the health service executive in the development of high quality health information systems to enable it to plan and arrange delivery of health services based on evidence-supported best practice. Other functions will include responsibility for promoting and implementing quality assurance programmes nationally and for overseeing health technology assessments.

The Department of Health and Children will also be reorganised to remove its current involvement in day-to-day matters. This will support the Minister in focusing more on strategic and policy matters. One of its fundamental roles will be responsibility for holding the service delivery system to account for its performance. The reform programme also proposes the consolidation and rationalisation of 27 existing agencies, which are to be subsumed by the HSE, HIQA or the restructured Department. Implementation of this recommendation will help reduce the fragmentation of services in the health system and streamline services to make them more accessible to the public.

The implementation of the reform programme is being undertaken on a project management basis. Phase 1, which has now been completed, included a communication and consultation process; the establishment of the national project office within the Department of Health and Children; the establishment, work and output of 13 action projects; the establishment of the interim health service executive and appointment of the chairman and board of the interim executive; and the development of a high level programme plan identifying key milestones for 2004.

Phase 1 also includes the appointment of a national steering committee, the role of which is to oversee the different strands of the reform programme. The committee has begun its work. Its task is to drive, in a co-ordinated manner, the overall reform programme, involving the interim Health Service Executive, the Department and the Hanly group. It will also provide guidance on programme planning and ensures that direction and progress are in line with the Government's decisions. The steering group reports to me and to the Cabinet committee on health and children on progress achieved. It is a useful conduit for drawing attention to issues that may require a response at Government level.

The interim health service executive has been established as a corporate body and its work is well under way. Its functions include drawing up a plan, for my approval, for the establishment of a unified management structure for the proposed health service executive. Other functions of the interim executive include putting in place procedures for the development of a national service plan for the delivery of health services on a national basis and the establishment of appropriate structures and procedures to ensure the proper governance and accountability arrangements for the proposed health service executive. The interim executive is also tasked with making the necessary preparations to implement the plan, on its approval, so as to ensure as smooth a transition as possible from the existing structures to the new health service executive structure.

The successful implementation of the reform programme leading to the subsequent successful operation of the reformed health service is dependent on all these participants working together in partnership and having a willingness to welcome change. The primary purpose of this major reform programme is to have a health service that will improve patient care by providing a responsive and high quality service while also providing an improved working environment for all those employed in it.

This is the first of two Bills I intend to bring to the House this year to provide the legislative basis to the recommendations of the reform programme. The second Bill will provide for the establishment of the health service executive to replace the Eastern Regional Health Authority and the health boards. It will also provide for the establishment of the health information and quality authority. The legislation will make provision for improved governance and accountability as well as planning, monitoring and evaluation.

I also intend that the second Bill will set out a statutory framework for the handling of complaints in the health services. The need for such a framework was identified in the health strategy. The strategy recommended that the framework should provide for greater clarity and uniformity of approach in dealing with complaints and should also provide for structured local resolution processes with an opportunity for independent review. It is my intention these structures will be in place from January 2005.

This Bill is very much interim legislation pending the legislation I will bring forward later in the year. It provides for the abolition of the membership of the ERHA, area health boards and health boards, while retaining the authority and boards as legal entities; the termination of office of all members of the health board from the date on which an order is made bringing the Act into operation; the assignment of the authority-boards' reserved functions to the CEOs or the Minister for Health and Children, as appropriate; and the amendment of existing legislative provisions regarding the acquisition and disposal of property by the health boards and the ERHA by re-introducing the need for ministerial consent prior to the acquisition and disposal of property. There is a need to modernise the current health care system to achieve the objectives set out in the health strategy to allow the health system to meet the numerous challenges facing it in the years ahead.

Concerns have been expressed regarding the issue of public participation within the restructured health system. I have indicated his intentions to bring forward proposals to provide opportunities for democratic input in the context of the new structures. I have given consideration to the most appropriate mechanisms to support the development of appropriate interfaces at regional and local level between locally-elected representatives and the health service executive, with a view to including provisions for these mechanisms in the legislation being drafted.

The provisions are likely to include establishment of a series of regional fora to facilitate local representatives in raising issues of concern about health services within the region with the new executive. These fora would allow local representatives to comment on and raise issues related to the development and delivery of health services locally. Membership of the fora will be based on participation of a small number of nominees in respect of each local authority in each regional forum. Members will also have the facility to raise particular issues with the executive.

The overall objective in putting in place such arrangements is to ensure the voice of local public representatives will continue to be heard in regard to the development of health services. These mechanisms would be designed to complement and reinforce the role of the Oireachtas Joint Committee on Health and Children in reflecting the views of public representatives in the ongoing oversight of the health system. In addition to providing fora for local representatives, arrangements will be put in place to allow professionals involved in the delivery of services to express their points of view.

The health strategy set as one of its objectives the greater community participation in decisions about the delivery of services. The Health Boards Executive in association with my Department issued guidelines to the health boards on community participation, which set out the principles and framework for structures for such participation. Most health boards have set up consumer panels that deal with a wide range of issues such as development and delivery of services. Two boards have also established regional advisory panels for older consumers and their carers. It is intended that these structures will be established on a statutory basis in the Bill, which will be brought before the House later this year.

This legislation amends the Health Act 1970, which established the health boards; the Health (Amendment)(No. 3) Act 1996, which deals with accountability issues and defines "reserved" and "executive" functions; and the Health (Eastern Regional Health Authority) Act 1999, which established the Eastern Regional Health Authority and the area health boards.

I refer to the main provisions of the Bill. The definitions used in the Bill are dealt with in section 2 and the sections of the Acts proposed for repeal by this Bill are provided for in section 3 and the Schedule.

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

Section 5 of the 1970 Act deals with the rules that shall apply in regard to membership and meetings of health boards and authentication of the board's seal. These provisions provided under sections 5(1)(d) and (e), sections 5(2) and (3) and the Second Schedule are being repealed. Currently, the chairman’s signature or that of another member of the board is required to authenticate the seal. However, because of the removal of the membership of the board, section 5 of this legislation provides that the board’s seal shall be authenticated by the signature of the CEO and another officer authorised to do so.

Sections 6 to 8 delete the requirements on the part of CEOs to consult or agree with the chairman or vice-chairman of a health board on any matter. Sections 9 to 14, inclusive, make amendments to the Health (Amendment)(No. 3) Act 1996. Currently, under the Act, reserved functions of a health board are functions exercised directly by the board and the authority, while executive functions are those exercised by the CEO. Section 9 assigns all functions of health boards to the CEO.

Section 10 provides that the CEO must provide the Minister with any information regarding the performance of his or her functions which he or she might request from him or her. Sections 11, 12 and 14 make amendments to the provisions relating to the adoption of services plans by health boards and the authority and to the provisions relating to the submission of accounts to the Comptroller and Auditor General and the publication of the annual report. Section 13 assigns the board's function in regard to the appointment and removal of the CEO to the Minister.

Section 15 amends the Health Act 1947 and provides that the board and the authority must obtain the consent of the Minister prior to the acquisition or disposal of property. This reverts to the position prior the enactment of the 1996 Act, which had introduced an amendment permitting the boards and authority to acquire and dispose land subject only to general directions by the Minister.

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

Section 25(a) assigns the functions of the authority to the regional chief executive and section 25(b) assigns the functions of an area health board to an area chief executive.

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

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

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

This interim Bill marks a further step in the process of the implementation of the reform programme and is a further sign of the Government's commitment to the delivery of a reformed health service to maximise the level and quality of care provided to patients and clients. I commend the Bill to the House.

Lest there be any confusion, Fine Gael will oppose this legislation. It abolishes a framework of accountability within the system without giving us any idea of what will replace it or if it will be replaced. That is a leap of faith which Fine Gael is not willing to make.

I have many problems with what is proposed in terms of the reforms I know are planned. I have many outstanding questions. I have problems with the way the Government is dealing with some aspects of the reform, especially the Hanly report reforms where it seems the intention is simply to confuse us and ensure lack of clarity until the local elections are over.

My main reason for opposing this legislation is that it removes all accountability from the system and fails to replace it with an alternative or even give us any idea if it will be replaced. This statement will not surprise the Minister. I signalled my reservations about this aspect of the reform on the day that the Brennan and Prospectus reports were published, and I have reiterated my objections on several occasions. Although the Minister replied to one of the questions I recently asked and said that the Brennan and Prospectus reports recommended this reform, they did not. The Brennan report did not refer to the abolition of the health boards. Ms Brennan's recommendations assumed that the health boards would remain in place.

The Minister may not regard accountability as an important issue. He may think that I do not, or that Fine Gael does not, and that we are merely paying lip-service to the concerns of our councillors who are health board members. I assure the Minister that I have never been more serious about anything. I regard democratic accountability as being of the utmost importance, nowhere more so than in the health service. The Minister may assure us that there will be accountability because he is accountable to the Dáil. Even if that were to happen, and it is not clear that it will, there can only ever be limited accountability. There are too many issues in the health service to do anything more than skim the surface of a fraction of the problems that emerge. An ongoing concern is that the kind of accountability that will be available to us will be similar to that of the National Roads Authority, the Environmental Protection Agency, CIE, VHI and all those bodies about which no Minister will answer direct questions.

I accept that the health service has outgrown the current structures and that they were designed for a different time and population. Over the years, by an accretion of functions and services, the structure has become unwieldy and fragmented. On the one hand there is duplication of services and functions, yet patients and the public have difficulty accessing the services they want. This is the result of the multiplicity of layers within the system and, where the increased burden of extra functions is coupled with increased specialisation of staff, a paralysis of administration ensues with a need for endless meetings within the system whereby one group with certain responsibilities must spend a great deal of time informing other groups about its actions. The integrated and seamless service to the patient, to which we would all aspire, is lost in the morass. That is inevitable when one tries to push individual patients with different problems through an inflexible and programme-based system.

The patient is now largely lost in the current system. Will the patient ever be found in the new one? Perhaps, but I am not convinced that streamlining and centralising the services as proposed is necessarily consistent with better patient care or greater efficiency. My concern is that if it is not consistent, there is no-one to speak for patients, call a halt and ask hard questions or any questions. That is not allowable, it will not do and we cannot vote for it. Patients by definition are vulnerable people, often too sick, passive, bewildered and intimidated to speak for themselves, and any system must include a voice for them, preferably a local voice accountable to the patient and taxpayer for the services provided.

I have never been one of those people who saw the health boards as the sole root of our health service problems, even though it has become politically correct to thoroughly deride and ridicule local councillors and health boards. I have heard it suggested that only for them and their alleged petty local interests, we would have had reform long ago and that they stood between the public and a much better service. That is rubbish. As I said before, if there are any people on the health boards who stand between change and what we have now, in my experience they are the professional representatives on the board who are much more likely to be obsessed with local empires and professional self-interest.

The real barrier to reform has always been the lack of direction from the top and the lack of leadership. Boards, including managers and administrators, were merely pawns in the process, torn between indecisive Ministers who could not wait to get out of the Department of Health and Children, dysfunctional departments which always seemed to wish they had some role in the health service other than the one they had, and Comhairle na nOspidéal which, while it may well have been working to a clear objective and agenda, unfortunately no-one ever knew what they were. This was the cause of huge frustration and suspicion at local level and within the health boards.

Merely abolishing the health board structure will not necessarily give us a better or more efficient service. What concerns me is that we may end up with new structures, but with all the old problems of indecision, tensions and self-interest, and the same posts, administrators and layers of bureaucracy, but all with new titles. All that we know for certain will have changed if this Bill is passed is that no one will be democratically accountable for anything. The health executive will be set up and, from this highly centralised office, wherever it is to be located, the entire hospital policy for the country will be decided, funded, managed and administered. This model has all the worst features of the highly centralised but utterly failed Soviet system. The Minister will provide the hospitals, employ the staff, decide the level of services and dictate the price, and all this is being done in the name of efficiency.

Where was it ever thought that a centralised, State-owned, controlled and provided system of anything, never mind the health service, could bring about greater efficiency? It is a policy which runs against the trend in other sectors to devolve and decentralise. We are breaking up almost every other service provided by the State, including CIE, Aer Rianta and others.

Whatever about the centralisation of the hospital services and the lack of accountability, the essence of a community care system is that it is local, within the community, flexible and responsive to local conditions, and certainly accountable to locally elected representatives of the people served by the system.

The Minister may think that the public is in the mood to get rid of politicians from all areas and that this will be a popular move. He is wrong. Most thinking people, however much they may rubbish politicians publicly, would quickly regret the absence of accountability and the substitution of politicians for rule by bureaucrats. With local elections imminent, they might well be asking why one should bother to elect anyone if bureaucrats can do the job so well. People might also ask themselves why, since bureaucrats can supposedly do the job so well and politicians are supposedly so superfluous to people's needs, they are so quick to contact their local councillors and Deputies when things go wrong.

We might not always consciously articulate how much we value democracy, but we know we would miss it if it were gone. The Minister made several references in his speech to accountability because he realises that this is a huge weakness in the proposed reforms. He spoke about consumer panels and advisory groups. In effect these are focus groups and, while they are worthy, they are not democratically accountable. The meetings which some of the Minister's own councillors seem to accept as a substitute for accountability are a nonsense. They do not meet even as frequently as the old health committees which were toothless talking shops rightly abolished by the Government. The proposed panels and groups are a nonsense and an insult to the public, and this arrangement does not represent at any level a substitute for local democratic accountability.

A mechanism must be found within whatever new structures we have to ensure the service can be held accountable in terms of standards and policy implementation at local level. There must be full answerability to the Dáil through the parliamentary question mechanism. There must be compellability of managers to report to the committee of the Dáil as requested. We must also have an ombudsman to defend and fight on behalf of patients and those who are aggrieved by the system.

The Minister talked about a complaints mechanism but there is no point in having such a mechanism if nothing ever happens or it happens so far into the future that it becomes irrelevant. We have an ombudsman system for the insurance area. Why not have an ombudsman for health, particularly in a system where everybody else is well represented? I made a point earlier at the committee's Estimates meeting about the resources available to the Minister and his Department. We have a strong Department. Every trade and profession has a trade association, trade unions, consultants and public relations people but the patients in the health system do not have anybody. They should have somebody on their side and unless we put accountability back into the system, the reforms will fail for that very reason.

I do not know if there are specific plans to administer the health service. I am aware we will have a health executive with overall responsibility for implementation and a hospitals office but I do not know what will happen to everyone currently working in the health boards. Perhaps all the current structures will stay in place; personnel will certainly remain in place but I do not know the areas that will be covered by the four community care offices that are proposed. They are sometimes referred to as offices but I notice others refer to them as if they were boards. There is no clarity in terms of what is being proposed. I do not know any of the detail of what is planned and if this legislation is passed the Minister will be removing the only mechanism through which we can find out what is going on.

It may be — this is a concern — that the only real change that will result is that the local and professional representation will be gone. The next six months will be critical in terms of decision making, change and reform in the health service and the Minister, the Department or whoever can do what they want behind closed doors protected from all questions, difficult or otherwise. It is enclosing the system, so to speak, at a point where all of the critical decisions are to be made. The reserve powers of councillors are to go to the chief executive officers of the former boards, and they will not be asking any difficult questions. The Minister will find very little opposition there as they help him re-write their futures and the future of the health service. Neither Fine Gael nor I will collude with what we regard as the outrageous destruction of our local democracy.

During his term of office the Minister has talked a good deal about health reform. We now have legislation before us but it is not about reform. The fundamental flaw in this Bill is that it removes democratic involvement in local health services without proposing any equivalent new system of accountability. As such, it is a disturbing and unwelcome change that augurs badly for the future. Members across the House are agreed that there is a need for reform of health boards but reform is not being proposed in the Bill. It is about dismantling a system without any thought of its replacement. This Bill is the greatest grab for executive power in the history of local administration. It is an even more sweeping victory for the officials than the handover of power to county and city managers in local government.

The Government proposals for reform of local health administration, following the Brennan and Prospectus reports announced on 18 June 2003, provided considerable scope for democratic involvement in the new structures if the Government wished to take that course. The Government made clear that the new health executive will have a national board and will also have regional offices, thereby giving scope for involvement of democratically-elected representatives. In a speech in the Dáil on 27 June 2003, the Minister informed the House he had agreed to present further detailed proposals on democratic involvement in the new structures in the coming months but the explanatory memorandum to this Bill is silent on that issue. The Minister has rushed ahead with the Bill to create a political and accountability vacuum, pending the establishment of new structures some time in the future. The Minister's statement in the House today has no standing in law.

The Labour Party has argued for health board reform. We have argued strongly for accountability and that any new structures being established should have that link to the people. The current system whereby county councillors carve up appointments among themselves is unacceptable to us. The only appropriate system to deliver on accountability is to have direct elections to current management structures or any new ones being proposed in order that there is a direct link between the person elected to represent the people and the people. Public representatives sitting on these or any new structures would have the mandate and the power of popular support.

Instead, regrettably, the Government is removing power further away from local communities and current members of health boards, who are predominantly members of Fianna Fáil, are quietly acquiescing to such a removal and loss of local accountability. Generally, they are expressing satisfaction with some notional set of regional meetings of county councillors, who probably meet four or five times a year, which are nothing more than talking shops. Fianna Fáil members appear to be happy to trade real power at local level for expenses to attend regional chit-chat meetings.

The Minister talked about fora but again there is no direct mandate, willpower or determining role for these fora. The Labour Party argued for a national forum on health, and we would still put forward a model for discussion, where the key players and participants in the health service would be able to meet. That is quite a different idea from the fora the Minister has proposed. We would not see a national forum on health being a decision-making body but it would be able to provide the type of platform and meeting place for all the different players in the health service. One of the key problems we envisage is the fact that the system is so fragmented people are isolated from one another, do not understand each other's requirements and often end up blaming each other for the deficiencies in the health service rather than trying to come to some understanding.

I met the idea of consumer panels with a certain amount of cynicism and doubt. Who determines who will go on consumer panels? How would we get a person who truly represents patients, or indeed older patients, without having self-appointed people who may have particular personal reasons for being on these panels?

I would like to refer to Professor Niamh Brennan, who was very critical of the current health service, but one point she insisted upon when she was asked about her deliberations on her report was that the group she worked with and chaired had thoroughly examined how to make the system accountable. The conclusion of their deliberations was that the public representatives had to be included in a decision-making capacity and that there was nobody else who could describe himself or herself as representing the people or even sectors within the population unless they are democratically elected. Like them or loathe them, public representatives have the characteristic that nobody else has, namely, a popular mandate. Professor Niamh Brennan recognised that and it is a great pity that the Government, which itself is democratically elected, is choosing to deny the people that kind of link and that power in terms of who represents them.

The Government embarked on other changes at local level in local government areas. When it decided to end the dual mandate, and it had the support of the Labour Party in doing that, there was a provision under the Local Government (No. 2) Act that allowed the Minister require local authorities to give information about their activities to Members of the Oireachtas. It is clear there is a major need for a similar information provision to be inserted in this Bill to require health boards, at least in the gap between now and whatever will happen in the future, and it could be a long time, to give information about their activities to members of local authorities and Members of the Oireachtas. In my experience as someone who has come off a local authority, that has worked well in terms of getting information from local authorities. At the very least, health boards should have that requirement.

How many minutes have I left?

The Deputy has 22 minutes left.

I thought that I had only 20 minutes in total.

The Deputy has half an hour.

I thought that I had 20 minutes in total. Perhaps I am a special case.

The opening spokespersons have half an hour.

No one else knew that either. Members need not be concerned that I will go on for all that time. This is generosity.

The Minister did not use his full half hour either.

It is a pity that there was not such generosity when it came to debating a change to the Constitution that needed time and attention, instead of a Bill such as this, which is quite straightforward.

It can all be attributed to Deputy Costello being in the Chair.

Then I thank him.

We will have more time for the Independents too.

I will return the favour some time.

Regarding the role of health boards, sometimes people do not get services directly from them and are curious as to what they do. They have a wide remit, both in being important providers of services and in ensuring the delivery of services, the management of hospitals, and the development of primary care and other services not directly considered health services. There is a question about whether health boards should be involved in the area of housing and rent supplements. Specifically, there is an issue concerning the relationship with voluntary organisations. Services and connections with health boards are the subject of a considerable degree of angst and complaint about them. Many organisations find it quite frustrating trying to get funding commitments from the health board, especially — this is not the health board's fault — to get any kind of long-term planning in place because of the one-year budgeting system in place. That creates a great deal of grief, especially in the greater Dublin area.

I have certainly received complaints about the Eastern Regional Health Authority, which was established to sort out structural problems in the greater Dublin region, where there are now three local area health boards and the Eastern Regional Health Authority. In that debate, everyone complained about the old Eastern Health Board. However, with this reform, we will presumably go back to the Eastern Health Board, since we will have only four regional offices. There will be one authority for the Dublin area. We must consider what will happen with those regional offices and how they will work at a practical level in relating to communities dependent on the services provided by health boards.

It was interesting this morning when we had our first meeting with the interim Health Service Executive, and I was grateful that it agreed to come before us. The executive, in these early days, has already embarked on appointing senior officials and managers for the structures to be prepared for the new system coming in, presumably by the end of the year and certainly by 1 January. In effect, we are essentially seeing two parallel structures beginning to emerge. I am still mystified and the question has not been answered as to how that parallel system will be developed in future. We are talking about quite a complex organisational structure and system being established through the interim Health Service Executive and the national steering committee. However, we have also been publicly told by the Minister for Finance that he does not envisage any job losses or redundancies in the existing health board structures. There is, therefore, an incompatibility.

I know that the Minister, some time ago, said that there would be a reduction in staff in the health boards. I would be interested to know how successful he has been in that policy. He is now stating that the number of staff employed across the health service is almost 100,000. Will we see more administrators as these appointments are made, some of them very senior? One hopes that highly qualified administrators will be put in place. How will that impact on the elaborate administrative structures of the health boards? When the old Eastern Health Board was abolished, we ended up with several empires being built. In my own area, the East Coast Area Health Board has one chief executive officers and five assistant CEOs. That is an elaborate structure when multiplied across Dublin, and the figures do not match up regarding how this is to be delivered. I get the impression that the Minister has set a fairly tight timeframe.

The first action of health boards was to set up several project groups, which presumably have an interest in ensuring that the health board staff in general, and the administrative staff in particular, have a future. That is the nature of people today and always has been; it is an issue. The chairman of the interim Health Service Executive agreed to my request this morning that he provide members of the committee with the report, which he described as the "roadmap", produced by the different committee projects outlining how the changes would be delivered.

It is important, if the Minister's credibility is to be sustained into the future, that the document be provided to the Oireachtas Joint Committee on Health and Children. Regrettably, we will now have a greater role to play in ensuring that the public interest is protected, since there will not be anyone at local level to carry out that work. It is regrettable and inappropriate, but I am certainly willing to take up that task. The first step should be that we know the "roadmap", in the words of the chairman of the interim Health Service Executive, and that it is working too. Otherwise we will simply be mystified by what is going on in an elaborate service such as the health service. We need to have that information.

I must come back to a point that I raised recently with the Taoiseach. There is now a concentration on elaborate, grandiose and overly ambitious plans and proposals, partly because the Minister got all those working groups together, probably as a stalling mechanism as much as anything else, and must now deliver on them. We have a really ambitious plan for health service reform, but the ordinary nuts-and-bolts legislation with which the Department of Health and Children and the Minister should be dealing is falling back down the timetable.

I can think of no Bill more important to the good management of the health service than the medical practitioners Bill. People must have trust in their medical practitioners and know that, when they fail, there is a system of checks, balances and accountability that will protect patients. They especially need to know that now that we have seen the horrific experience of the predominantly young women who suffered such barbarism at the hands of Dr. Neary. That was a salutary lesson for us all. When the Irish Medical Council came to its conclusions on him, we received undertakings that the medical practitioners Bill would be passed without undue delay. The Irish Medical Council wanted to see that as much as anyone else, and it came out of the process reasonably well, although it was very slow to deliver a verdict. Now the medical practitioners Bill is being put back to the point when the Government cannot even say when it is to be published. We had a date which I believe was 2005. People understood it would take some time to be finalised. However, we do not even have that commitment any longer. It could be 2007, 2008 or even longer because the energies of the Department of Health and Children are now concentrated on health service reform. The nurses Bill has been put in the same category. We cannot say when it will be published.

There is a problem when it comes to nurses and it has not been solved by the Minister. Reports in recent years have shown 1,000 vacancies. We still have serious problems in terms of vacancies. Were it not for these wonderful Filipinos who come here and leave their families behind, our hospital services simply would not function. Nobody has given them enough credit for the work they do in our hospitals, not just Filipinos, but other non-nationals. We are now taking in Indian nurses. The argument the Minister puts is that he is satisfied the Philippines is oversupplying, in terms of the number of nurses. However, I do not believe that to be the case in India. I have grave reservations about the idea that, somehow, we can afford to skim off nurses from India, without worrying whether this is having an impact on local needs. Agencies will say there is not a problem, but I would like to know the situation on the ground, because certainly, that is not my understanding. I understand that in India there are needs that are not being met and nurses should be made available to meet them. Again, the nurses Bill has been relegated to the future, unspecified, shoved aside because health reform is where it is all at.

One point I must make, to be consistent and because it is central to the whole health reform idea — as it relates to the way the health boards operate — is the issue of equality. Generally community services reach out to people and do not discriminate on the basis of income, unlike hospital services, where private patients have a completely different experience to public patients, once they get past the accident and emergency department. Equality is a central issue. It has not been included even among the priorities set out by the health service executive. It talked about the "patient experience", "staff experience", good working environment and value for money. It is interesting that when the document relating to a national steering committee meeting became public by accident from the Department of Health and Children, this point was actually raised by the Department's officials. When officials raise matters of this kind it is time we all paid attention. One point in this report, dated 10 February 2004 is as follows:

This Department has major concerns abut the lack of clarity in relation to roles and responsibilities in the structures and about the confusion evident in the work of the Action Groups regarding the policy-executive split. One example of this is that the NHO report recommends that the NHO should oversee the public/private mix and develop a strategic relationship with the private sector. This is clearly a high level policy issue affecting all aspects of the Health system and not a matter for one pillar of the executive.

The point was made that a committee was to be established to look at the issue of the public-private mix. Inherent in that is the whole issue of equality. The committee had not been established even by 10 February, when the national steering committee met. If the Minister ignores the issue of equality and does not put it central to any health reform programme, no administrative change will deal with the fundamental inequality and unfairness that defines our health service and makes it different from any other in Europe. The Minister has bypassed this issue. It is like missing the elephant in the garden. He does not see it. It is not an issue.

We are talking about value for money, working environment, efficiencies. Let us talk about inequality, who will deal with it and how it is to be dealt with. What will change for the thousands of public patients who are on hospital waiting lists and cannot access care? They know that if they had private health insurance they would be able to access that care within weeks. According to the last available figures, approximately 27,000 are waiting, many of them for more than 12 months, despite the strict commitments in the health strategy. What is the message the Minister has today for these people? Will this change in terms of the health boards affect their lives in any positive way? Hardly. It is probably unfair for me to expect legislation such as this would. However, the Minister in his speech has concentrated a good deal on health reform. This is a relatively small part of a much larger project. The biggest project has to have a purpose, however. It is not about administrative change. It is about what happens to the patient.

What happens to the patient in Ireland is largely determined by whether he or she has sufficient income for private health insurance. Approximately half the current population has private health insurance, even though all of us are entitled to hospital care. Many of these hospitals are run by health boards and that issue has not been addressed. There has been some tinkering here and there but really nothing that makes a fundamental difference. The proof is evident.

At the last election the Taoiseach clearly read the message from the electorate that people did not like this and wanted something done about it. He made a clear, uncompromising promise at the time that hospital waiting lists would be eliminated within the next few days. They have not been eliminated. They have gone into some kind of secret mode because we do not even know where the hospital waiting lists are now. However, we know every waiting patient is for real and that he or she was conned by the Taoiseach and the Minister for Health and Children at the last general election. They knew they were conning the people. That was a deliberate, cynical, opportunistic promise that was given.

Even worse was the commitment made to the people that 200,000 medical cards would be provided. That would make a real difference to the lives of thousands of people including those who cannot afford to see a family doctor and get medication. That promise was made again. People voted on the basis that this was what they would get if they supported Fianna Fáil. What did Fianna Fáil give them? Fianna Fáil took away 100,000 medical cards. That is the record. Rather than giving out more medical cards, the number has actually been reduced. Fianna Fáil says in justification that more people are working.

Fianna Fáil has strayed a long way from its roots. It does not seem to see low pay or exploitation of workers any more or that the cost of houses is denying access to the housing market to people in overcrowded conditions and stuck on waiting lists. These are things Fianna Fáil does not see any more. It is blinded by being too long in office. Cruellest of all is the broken commitment that denies people medical cards. At a time when this country was much worse off than it is now almost 40% of the people had medical cards. They had the protection in a State that could not afford many things, but understood that health care was an essential right. It is to the great shame of Fianna Fáil that it has reneged so far from a progressive philosophy which developed the whole concept of medical cards — a legislative change that gave security to people and dignity from the old dispensary system. This was introduced by a Fianna Fáil Minister, Erskine Childers. Fianna Fáil has moved far from that kind of progressive thinking. Now it is concerned with equestrian centres, Abbottstown, looking after the very wealthy and the Minister for Finance, Deputy McCreevy, says let us party, deepening the gulf between rich and poor, increasing inequality. Fianna Fáil should be ashamed of that legacy but shame does not figure in its lexicon.

It is an equality issue that health boards are able to deliver services and where they are most needed. Everyone who public representatives meet when looking for votes is of equal standing. It does not matter whether a person is rich or poor, a public or private patient, each has a vote. It is reassuring to know that a public representative can at least speak up when one needs an advocate. Similarly, if a community needs a particular type of health or community care it is good to know that there is someone to argue the case. There is deep suspicion that this Bill is being introduced to ensure that when the second Hanly report is published and uproar ensues there will be no public representatives in a position to do anything about it.

The first Hanly report has been changed, although the Minister is wriggling and squirming to pretend it has not. One has only to visit the hospitals in Nenagh and Ennis to know that everyone there realises their accident and emergency departments are doomed, unless the Government policy changes. The second Hanly report will go the same route and undermine local emergency services throughout the country. Fianna Fáil should not be under the misapprehension that getting rid of public representatives will eliminate local opposition. The voice of the public will be heard, despite this attempt at removing the role of public representatives from the structures.

I wish to share time with Deputies Finian McGrath, Gormley and Ó Caoláin.

I am very glad to speak on this Bill. The major problem with the health service has always been a lack of proper investment and we bear the scars of that failure, with a 3,000 bed deficit and people waiting five years for a basic appointment. That is the acid test of the service. There are 120 reports on the health service, yet there is still health apartheid because the necessary money was never put into the service. The primary care strategy does not have a penny of designated funding this year. Thousands of people are waiting to get onto an official waiting list which should have been abolished by now. It is obvious that reform is necessary. While we were anxious for reform because of the lack of co-ordination and co-operation between health boards which compete with one another, have different schemes, such as the mother and child scheme, different software or none, different interpretations of vaccination policy and so on, this may be a case of throwing the baby out with the bathwater. We have moved from over-representation to under-representation and have created a major democratic deficit. Instead, the Prospectus report gives elected representatives the right to meet regionally, which is totally unacceptable. The system has gone full circle.

Having a complaints system will not help. The real democratic deficit needs to be addressed because we have another quango, such as the NRA or the system in Northern Ireland which is run by a quango, established by ministerial appointment. Just as it is difficult to get information from or in any way influence the NRA, the Minister will tell us that he has no function, and the Department of Health and Children, which is also sidelined, will say the same. Who will have the input to enable people to express their points of view so that the situation can change for the better? We need a health ombudsman or surgeon general who would be independent of the proposed health service executive, the Department and the Minister, to represent people with serious problems, who are often those on the lower end of the socio-economic scale. When policies are made in Dublin it is difficult for those people to find advocates. Proper representation should be available and now is the time to consider this.

There is a cynicism in this Bill, which seems to be all about money just as the Hanly report is about money and cutbacks. It is interesting to see that in the new health service executive the Minister for Finance, the real Minister for Health and Children, must decide who is to be hired and fired. Where will it end? We still have health apartheid and confusion about what will happen over the next six months when all the power formerly residing in elected representatives will go to the CEOs and we do not know what will happen after December. That is not good enough.

I am grateful for the opportunity of speaking to the Health (Amendment)Bill 2004. We can have all the legislation and reports we want but unless we change the system urgently we will go nowhere. The people are sick and tired of all the reports and talk about our health service. They want real action on frontline services. Waiting lists continue and there are people on trolleys. Last Monday night I received a call at 9.15 p.m. telling me that a 79 year old pensioner brought in by ambulance at 4 p.m. was forced to sit on a chair for five hours as the beds and trolleys were all occupied. Eventually the patient was placed on a trolley and saw a doctor at 4 a.m., having spent 12 hours on a chair. This is the reality of the health service in a wealthy country in 2004. Unless we provide beds, doctors and nurses on Monday nights in accident and emergency departments this debate is futile. The Minister for Health and Children is not doing his job and has not delivered to the citizens. All the positive media spin will not change the fact that people are on trolleys and chairs, there are long waiting lists and 2,286 people with intellectual disabilities are in need of day care, respite and residential places.

In recent days there has been much talk of citizenship and rights — by the way I urge everyone to vote "No" in the forthcoming referendum. The people have a right to a decent health service. They need it, demand it and are not afraid to pay for it. Most people in the State would be prepared to pay a little extra in tax if they were guaranteed a quality health service but that is not happening. The Government is not taking responsibility. The Minister is turning his back on the real issues, taking on board populist issues and ignoring people in need. It is time for some tough decisions to reform our health service radically. This legislation lacks teeth, takes the easy option and blames the elected councillors for the bad management, inefficiencies and disastrous leadership of the Minister for Health and Children.

The Bill is another example of cop-out politics. It puts the blame elsewhere. The Bill provides for the amendment of Health Acts from 1970, 1996 and 1999. It also amends provisions in the Local Government Act 2001 governing the nomination of members from city and county councils to health boards and provides for the amendment of the Health Act 1947, as amended by the Health (Amendment) (No. 3) Act 1996 concerning the acquisition and disposal of property.

The Bill provides for the abolition of the membership of seven health boards, the Eastern Regional Health Authority and the three area health boards. It is wrong to blame the democratically elected councillors who serve on health boards, many of whom have made an excellent contribution. People such as Christy Burke on Dublin City Council have given years of dedicated service to health boards. There should be cross-party acknowledgement for the great work he has done on behalf of the most disadvantaged people in the city.

The Minister has a brass neck. With a budget of €10 billion he takes on the people who cost less than €1 million per year. He is also pandering to sections of the media that want to hammer local councillors.

Sections 4 to 8 make the technical amendments to the Health Act 1970 necessary to enable the abolition of the membership of the health boards and delete any requirements on the part of the chief executive officers to consult or agree with the chairman or vice chairman of a health board on any matter.

Section 15 provides that the boards or the authority have to obtain the consent of the Minister for Health and Children before they can acquire or dispose of land. We must be careful in this regard, especially given the extreme views of some Cabinet members who would sell their grannies to get a few extra euro.

I urge Members to vote against the Bill which does nothing for the most disadvantaged and for patients on hospital trolleys.

No compelling argument has been made for the major change to the health service which the Bill represents, nor has it been demonstrated how the change will improve the health service. It is important to cast our minds back to when this was first mooted. It was done in a professional way by the Government which is great at leaking information and building up a head of steam to get the public behind an initiative. It was presented in such a way as to suggest that it would go after local politicians on health boards — people who were milking the system. I detected overwhelming support for this going by the vox pops and radio interviews that took place at the time.

Local politicians are easy targets. If one is seen to be taking action against politicians, there is no question that the public will support that initiative. The health boards have become the fall guys; they are an easy scapegoat. It has not been shown in any measurable way how the reform will improve the health service.

How are health boards to blame for the miserable state of the health service? In terms of expenditure, this has not been shown in any reports. Two reports have been commissioned — the Deloitte & Touche report and the Brennan report. Professor Niamh Brennan did not recommend the abolition of health boards. Nor did she show how health boards were misspending money. A number of health boards came before the Oireachtas Joint Committee on Health and Children. Four of them underspent their budgets because they were under so much pressure from the Department of Health and Children, which it was claimed was under the cosh of the Department of Finance. That is what it comes down to; they are under pressure. In terms of financial management, they have, if anything, been over-cautious. I have not heard any argument for the abolition of health boards in what the Minister has said thus far.

We are facing major problems in our health service. A number of my colleagues referred to serious problems in accident and emergency units. I can also recount horror stories from Beaumont Hospital where, not alone is it impossible to get a bed, one cannot even get a trolley. One is lucky to get a chair. My colleague recounted a story of a person who was on a chair for a day. I know of a polio victim who died in Beaumont Hospital who was on a chair for three days. The doctor was so tired; he fell asleep while pumping air from a bottle into her lungs. This is typical of the kind of story we hear as public representatives. While they are horrific, they are true.

We have not been told how the abolition of health boards will improve maternity services, yet the Minister for Justice, Equality and Law Reform, Deputy McDowell and others, have said this is one of the reasons for the forthcoming referendum. We have been told there is chaos in maternity hospitals because of citizenship tourism. We know that these are bogus arguments. In 1973 we had 108 maternity units in the country, we now have 22 units with plans to cut a further ten. This represents a centralisation of the health service. That is why we have had such a huge disimprovement in maternity services. The system is now similar to a conveyor belt where the aim is to get women in and out as quickly as possible. The quality of services has disimproved.

The proposed change will result in less accountability, both at local level and in this House. Once one sets up organisations such as the National Roads Authority or the Environmental Protection Agency, the focus shifts to them. They take on responsibility for specific areas. This allows the Minister to pass the buck.

I agree with Deputy McManus that it will be impossible for Members of the House to be responsible for the running of local hospitals. That is a huge burden to place on us. In fact, it is an impossible task; we will not be able to do it. We will be lucky if we get to interview the health executive now and then. We will have time to put a few questions and it will leave, having done its duty. The Minister will tell us he is unable to answer our question, that it is a matter for the health executive. That will become the mantra of the Minister for Health and Children. We will not get answers and we will have little input. The answer to the lack of accountability is decentralisation.

Many political representatives on health boards have done a fine job. I accept there is a need for co-ordination and harmonisation, but scrapping these decentralised boards is a mistake we will come to regret. Where are the beds that were promised? Why have waiting lists not come to an end, as was promised? Where are the promised nurses and medical cards? We were promised 200,000 medical cards, yet there are now 100,000 fewer people with medical cards. Where is the money for primary care? Investment in primary care can deal with 90% to 95% of health problems. Unfortunately, the investment in our health system is being directed towards further centralisation and further technology. That type of centralisation is referred to in the Hanly report.

We need a good ambulance service to ferry people back and forth. The quality of our health services has deteriorated over the years. It is astounding to think we had better maternity services and a better health system years ago when we had less money. That shows the priorities of the Government. Its main priority is to put more money into rich people's pockets. As a person said recently, what we have here is socialism for the rich and capitalism for the poor. That inequality will only get worse with this sort of measure.

If the Government is thinking of a root reform of our health services, its members should discuss the financing of it. The Minister has said the health budget has been increased over the years, but I ask him to examine how the funding of our health services compares to the funding of health services in other countries. We are still close to the bottom in terms of the European Union and the OECD. We have got our priorities completely wrong.

As far as the Government is concerned, the provision of health is about providing for the private individual. That is very much a Thatcherite philosophy. We hear people consistently repeat that if a service it private, it is good, and if it is public, it is bad. That is the simple refrain we hear constantly from the PDs, in particular, and from those in the Fianna Fáil Party who have become more PD than the PDs themselves. It does not include the Minister, Deputy Martin, because he——

What about the Minister of State, Deputy Browne?

I do not know about the Minister of State, Deputy Browne, but the Minister, Deputy Martin, when interviewed on the "Late Late Show" and asked a direct question on whether we need to raise taxes to have a better health service, replied, "Yes, we do." Therefore, perhaps he does not belong to that PD wing, but he certainly has not got his way because that sort of Thatcherite politician is the dominate force within the Government. I hope other members of the Government will see sense and realise this type of policy will not reform our health services. The terrible problems we see and about which our constituents tell us will continue unless we invest more in our health services.

This Bill is yet another example of the Government treating the Oireachtas as a rubber stamp. The Government is seeking to circumvent any real debate and to take from elected representatives in the Oireachtas and at local authority level the power to determine policy on the major issues affecting our society.

There is no greater issue than the state of the health services, their delivery, deployment, management and resourcing. Yet with what are we presented by the Government? We are not presented with a measure to address inequality in the health services nor are we presented with one of the promised Bills to enhance standards and increase accountability in the health services, namely, the medical practitioners Bill, the nurses and midwives Bill, the pharmacy Bill or the Irish Medicines Board Bill. All these Bills were promised for 2004. Now we are told some of them will not be published until 2005 and in respect of some of them the Government does not know when they will appear. In place of those Bills we have this Bill, the purpose of which is to abolish the health boards and end even the modest degree of democratic accountability we have in the area of health service management.

This legislation is a blow to local democracy and to accountability within the health services. It should not have been presented in advance of the promised substantive Health Bill which is due to establish, among other new structures, the Health Services Executive. This is an enabling Bill for a legislative and political stroke to vest all the powers of the health boards in their CEOs and in the hands of the Minister for Health and Children for an indefinite period. The Minister of State and other Members of this House should carefully note that. To accomplish this, the Government must ensure that the new local authorities elected on 11 June are not allowed to nominate members to the boards.

The Department's note to the Chief Whip refers to the proposed abolition of the health boards and the establishment of the Health Services Executive, which it states is scheduled for January 2005. Where did we hear words such as "scheduled for" previously and how many times did we hear them used? However, there is no reference to a cut-off point of 31 December 2004 in the Bill or in the explanatory memorandum. The question that immediately arises is, how long will this period of rule by the CEOs and the Minister last? We are being asked, in effect, to sign a blank cheque. We are being asked to abolish existing structures while being kept in ignorance of the exact nature of the new structures. This is no way to proceed.

I would be the first to acknowledge that the health boards, as currently constituted, are flawed. I was a member of the North Eastern Health Board from 1999 until the end of last year and often it was a most frustrating experience. The restrictions placed on the elected members of the board were often intolerable. The power wielded by the Minister, the CEO and Comhairle na nOspidéal often ran counter to the real health service needs of the people we represented. That said, as a board member I was able to provide representation to and for the people within the north eastern region. There was a direct link with the executive and with the staff in all areas of health board activity. I use this opportunity to record my appreciation for those members of staff in the North Eastern Health Board who assisted me during my time as a board member and who have assisted my colleague councillor Brian McKenna since I vacated my seat on the board.

I also acknowledge the consistent and persistent stance of colleagues on the board who put up a stoic and courageous challenge to those who were orchestrating the demise of important critical services at Monaghan General Hospital. Bad and all as things are, where would Monaghan General Hospital be today but for that effort? I say "well done" to those Fine Gael and Independent voices who with this Deputy faced the worst of days together in the interest of our communities. I am proud of the role I played throughout in support of our hospital and its future and I pledge to continue to do all in my power to help restore the capability of and the services lost at Monaghan General Hospital which should be restored.

The health board system was flawed and the Prospectus report on structures and functions in the health system identified some of the problems. Its central finding was that the system was too fragmented. There was a lack of cohesion and too many agencies and structures. That reflects the piecemeal approach and lack of cohesion in the health policy of successive Governments. I see the problem as not being structures and bureaucracy but the policy basis, or lack of policy, on which they operate. Most fundamental of all is the refusal of successive Governments to end the two-tier system in our health services.

However, the piecemeal approach continues. For example, the Minister has made an order to establish the National Treatment Purchase Fund Board. That statutory instrument was laid before the Dáil this week and will come into effect on 1 May, this Saturday. The treatment purchase fund was conceived by the Progressive Democrats as a stop-gap measure to address hospital waiting lists, the same hospital waiting lists, need I remind the Minister of State, that the Fianna Fail party, two years and four days ago, promised to permanently end within two years. Yet the treatment purchase fund is being institutionalised and yet another board is being established. The Government will point to the thousands of people who have benefited from the fund, which I acknowledge. However, institutionalising this fund is an admission of failure. It is an admission that the waiting lists will continue and the two-tier system will persist.

As I said to the Taoiseach yesterday, an adult public patient must serve a minimum sentence of a year on the waiting list before being considered for the treatment purchase fund, and if one is a child, the minimum sentence is six months. Once again the Dáil has been mistreated by the Government. The national treatment purchase fund board, if it is to be set up at all, should be established by legislation so we can debate the matter properly in this Chamber.

The Government's approach to this Bill is equally flawed. I re-emphasise that we should have the substantive health Bill before us. We should know exactly and in detail what is going to replace the health boards. I know, for example, there is concern in the disability sector about the implications for the delivery of services at health board level. What effect will these changes have on the way services are delivered? How will the CEOs and the Minister be held accountable for the delivery of those services?

What of health board properties formerly owned by local authorities which now have question marks over their future in the overall delivery of health care needs? Will unaccountable and faceless bureaucrats move to dispose of key health care sites to fund their pet projects in communities far from the people who sustained real care in our hospitals and psychiatric institutions by their hard-earned contributions over many years? I challenge the Minister, Deputy Martin, to guarantee that the proceeds of the sale of any and all land and building assets be invested in existing or new health care sites within those communities which host and sustain them.

In my view there will be no real accountability in our health service after 11 June. For that reason, I am opposed to this Bill and the Sinn Féin Members will be voting accordingly.

It is a challenge to speak on the Bill for a number of reasons. In particular, however, it will be a challenge to follow the eloquent contributions of previous speakers. I watched the earlier proceedings on the monitor in the privacy of my office. If some of the contributions already made were broadcast, members of the public would be frightened out of their lives at the prospect of what is being presented as what might loosely be described as an alternative Government. I had the opportunity of listening to speakers who might hope to serve in that Government and I admit I am frightened. Perhaps we should call for as many of those contributions as possible to be broadcast so people will be informed of what the parties in opposition are doing.

Deputy Neville is looking at me in a quizzical manner but I would say he was also frightened by some of the comments made by Members seated behind him. He appears to be stirring other colleagues up against me but there is no need for him to do so. If I need the protection of the Acting Chairman I will call upon him to provide it.

I am honest enough to make an admission about the background from which I came. I often say at meetings in Tallaght that I was not born a politician and that I used to be quite normal. I moved to Tallaght with my then employer in 1969 and I believe I have a good background in the community. I have always worked hard in my community. I got the opportunity to become a public representative by accident in 1991 when I was elected to the council. I was elected to the Dáil in the most recent general election. In 1994 I was delighted to have the opportunity to replace my good friend, Chris Flood, as a member of the then Eastern Health Board. I remained with that body until shortly after the general election. Just as I was reluctant to leave South Dublin County Council, I was particularly reluctant to give up my membership of what had become the Eastern Regional Health Authority. I had the privilege of being the founding chairman of the South Western Area Health Board. Placing matters in context, however, I accept that times change. I would be just as happy if I was still a humble health authority member or county councillor.

I accept that colleagues will be obliged to take advantage of the situation in respect of the legislation and try to score as many points as possible on the Minister. In the debate so far, no points have been scored. In the business of politics, trying to score points is fine.

I was not happy when the legislation first came to my attention. I have strong views about political accountability and over the years the local health boards and bigger authorities in the Dublin region — the Eastern Health Board and its successor the Eastern Regional Health Authority — played a part in that regard. Colleagues who have worked within the health board system will attest to the fact that times have changed.

Reference was made to deficiencies in the health system and I am of the view that people deserve a first-class health service, particularly in light of the amount of public funding that is being invested. I am not going to rehash the Minister's speech but the health spend is now the biggest in the history of the State. There are still challenges as far as the system is concerned. One can visit Tallaght hospital, the Mater and other hospitals throughout the country and see that difficulties and challenges still exist. The challenge for the Minister, with our support, is to create an environment in which we exert as much pressure as possible to bring about change. It is a question of management of resources. If the significant amount of moneys to which I refer are available, there should be progress as far as the management of resources is concerned.

I am not afraid to say I take a simplistic view of this matter. If a sick person enters a hospital anywhere in the State and genuinely needs a bed, he or she should be given one. I am an ordinary person who has had the same experiences as everyone else. I am not saying it in a virtuous way but I have had the experience of lying on a hospital trolley. I was happy to remain on it in the knowledge that I was being well cared for. However, it is not a good system and we must continue to say so.

I do not know if Members read theDaily Star but many people in Tallaght do so. A woman recently wrote to the newspaper to discover if any Member of the Oireachtas had ever spent time on a hospital trolley. I do not know how many Members volunteered information in this regard but it was revealed in the newspaper that I had spent time on such a trolley. I did not make a fuss about that fact or make a virtue of it. However, I had the experience and I saw the great care given to people but I also witnessed the difficulties that arise as a result of the type of system we have in place. The legislation is about trying to address those difficulties.

I do not disagree with the previous speaker and I believe that, for a long period, the health board system served the State well. However, like other systems it has been affected by the passage of time. If the system is not working, one must discover why that is the case.

I am a strong supporter of and proud of my association over a long period with the National Association of Health Boards. That organisation has a particular point of view about the legislation and Members are aware of the concerns it has expressed. I am sympathetic to those concerns. I hope my good friend, the Minister of State, Deputy Kitt, with whom I share a constituency boundary, will convey to the Minister the fact that a body such as the National Association of Health Boards, which has served the country well, retains its voice and still has an opinion to express. The Minister clarified the position as to what will happen when the legislation is passed and indicated the kind of body that will be put in place as far as public representatives are concerned. I hope he understands there are still views which can be represented by the National Association of Health Boards.

I have always taken the view that public representatives played an important role in that process. I do not wish to be too critical — I know there are no doctors in the House at present — but it often happened, not only in the Eastern Regional Health Authority area or the South Western Area Health Board, which embraces the Dublin region and Kildare and Wicklow, that there were challenges at budget time. Politicians had to take the hard decisions and people representing other interests, for one reason or another, abstained, sat back and did not take decisions.

If I was the Minister for Health when this legislation was being formulated in the Department, those issues would have had an impact on me. I will not say that the health board system did not have merits; however, it also had downsides and there were often difficulties and challenges in that regard.

A number of colleagues have reminded us that the local and European elections will take place in 42 days' time. That will be a busy and demanding time for all. I am sorry I am not contesting the local elections because I would welcome the opportunity of going around the estates in Tallaght knocking on doors and hearing people's opinions. I would also welcome the opportunity of visiting the rest of my constituency. As Members know, I represent Dublin South-West which embraces Tallaght, Firhouse, Templeogue and Greenhills. I know when I mention Firhouse that the Minister of State, Deputy Kitt, is upset that some of his loyal voters are now being given the opportunity to see other candidates. I am happy about that.

The Minister of State knows that people in the area take an enormous interest in local politics and the issues of the day. Over the next six weeks they will give us the opportunity to discuss the issues and will share with us their various views. I suspect that they will want to discuss health matters and that is good for democracy. I hope — it is relevant to say this in the context of this debate — that the local election campaign in all 42 Dáil constituencies will remain focused on local issues. It is fair that the electorate and the media get the opportunity to focus on the issues of the day. I have no problem with that and as a democrat I am part of that system.

We must also remember that local authorities are about local community issues and the empowerment of local communities. People do not want to be distracted by national issues. However, they will be because we are to have a referendum and people are running all over the place on that. People should be allowed to focus. When candidates from the different political parties knock on their doors, people should get the opportunity to discuss the issues to see how the candidates will serve their communities over the next five years. I will try to do this when I am voting for my local authority and will examine the candidates, beginning with those of my party because they are the best, especially in Tallaght.

Whatever about taking the opportunity to deal with all sorts of issues, as I am sure we will, such as the management of the Irish soccer team and Roy Keane — I was at doors the other night and people spoke to me about Roy Keane, which is fine — the local elections are important. They are an important part of the democratic process and public representatives have an important role to play. People, therefore, must be given the opportunity to select those candidates who will be brave enough to join the local authority and take the decisions necessary for the betterment and empowerment of local communities.

The abolition of health boards will leave a void. I hope the use of the word "abolition" is not too emotive but that is the reality. The Minister will continue to examine how views can be represented in a forum and I think he will get support for that. Members of the Dáil still have a role to play in that regard. We should take an interest in what is happening with the health services.

When I come into the Dáil every day I try not to talk just about Tallaght. Tallaght is the place where I live and I am proud of it and of Tallaght hospital which was founded six years ago this June. The hospital was an amalgamation of the Adelaide Hospital, the Meath Hospital and the National Children's Hospital, all of which had served the people of Dublin for hundreds of years. The move to Tallaght was a historic event and many people were involved in the move which some people thought would never happen. The hospital provides a tremendous first-class health care service to a wide community. Not only does it serve Tallaght, but its remit also covers parts of Kildare and Wicklow.

If one was to stand in the reception area of Tallaght hospital, which I sometimes do, one would find people arriving from all over the country. A general hospital in a major population centre such as Tallaght is a major boost. It provides a tremendous service. However, like those of all other hospitals, its accident and emergency department will always be under pressure. That is the nature of the business. We are proud of the number of positive developments which have taken place in Tallaght in recent times. Across party lines, all the local politicians would say that Tallaght is making a tremendous contribution and I hope people will continue to contribute over the coming weeks.

It appears to be all right for politicians to criticise systems, hospital, staff etc. for what may be delicately termed electoral advantage. I do not suggest that any of the parties represented in the House at the moment would do that, but it does happen. It is all right to make constructive criticisms. However, I have often visited Tallaght hospital and found staff upset at the criticisms of outsiders which, as in the case of many hospitals, is often unfounded. These staff members carry on with their job of caring for the sick.

I hope there is more interest in this legislation than appears evident but perhaps the lack of interest is because this is a quiet Thursday afternoon. I would be just as happy to be in Tallaght too. This legislation will have a more significant impact than is obvious at present.

I take this opportunity to congratulate the Minister for Health and Children, Deputy Martin, and his Ministers of State. I admire the Minister enormously and do not say that for party reasons. I have often been amused to hear the Opposition criticise Ministers for keeping us informed, for sending out material legitimately and for ensuring facts are available to public representatives. It is amusing that the Minister for Health and Children is criticised in that regard. It proves the Minister and his team are doing their job. The Department, under the Minister's stewardship, should remain focused and understand that any improvements it can make and any benefits that accrue to the hospital care system will be strongly supported in communities in both the Dublin region and throughout the country.

I look forward to development of this debate and to hearing colleagues from different county constituencies speak and tell us about their experiences in light of the Hanly report and the various other reports which have been debated. There is no question but that the health board system has served the country well. I have no difficulty in saying that and I ask the Minister of State to convey that message to the Minister.

Like many other institutions, the health service has evolved and it is now time to move on and examine other ways of structuring it. However, in implementing this legislation the Minister must not take his eye off the ball. It is necessary to ensure that the new system remains accountable, open to change and to constructive suggestions and that it continues to serve the communities it is intended to serve, whether in Tallaght hospital or in other Dublin hospitals. I am sorry to keep mentioning Tallaght, but I pass it every day and it tends to impact on my mind, although I had major surgery five years ago in the Mater hospital — it often amused colleagues that I had to be taken from Tallaght to the Mater to be saved. However, I was glad the Mater hospital was there.

I hope I have managed to convey my support for this legislation. I am never afraid to mention misgivings I have and I have documented that. However, throughout the time I have been privileged to be a public representative, politicians of all parties and none have served the health board system well. My experience has been in the Dublin region, on the Eastern Health Board, now the Eastern Regional Health Authority, and the fledgling South Western Area Health Board. I will be sorry to see them go and I will be sorry to leave the local authority. I will not say I am sorry I have come to the Dáil because I am not.

I hope the Minister takes the opportunity of congratulating all who have served on our health boards over the past 30 odd years and have given tremendous service. I was saddened the other day by the death of a prominent former member of the Eastern Regional Health Authority, Mr. Martin Miley, from Athy, County Kildare, but also reminded of the dedication of many people over many years.

The Minister should remain focused on what he is doing and should understand that he will get public support as long as good service continues to be provided. That will be the test of this legislation.

I welcome the opportunity to speak on this Bill. I am also disappointed because I believe it is a regressive Bill. Having spent 18 years as a local representative, seven of which were on a health board, I am very much aware and convinced of the strong role local government should have in our democratic system. This Bill is an affront to local democracy. When local democracy is attacked, democracy at all levels in the State is attacked because all representation begins at local level. The effect of this Bill will be to eliminate the health boards and provide that the people elected to serve on them should no longer do so. Consequently, the people who use the health board services will no longer have representation or influence on what happens in the health service.

We have heard much talk about the role of politicians on the health boards. Inevitably it is sometimes negative. However, in my experience the role played by local representatives on health boards and by representatives of the various professions has been enormously positive. Members of county councils represent service users and bring to the health boards the views and the difficulties experienced by their electorate. Representatives of professions bring the views of their members. There was a synergy in that both the service providers at the coalface and the service users through their public representatives were represented and a response, sometimes not adequate, was obtained. That will now be eliminated and it is a regressive step.

The Bill has been hailed nationally as a great move. There have been editorials in its favour. However, I disagree with this because if we believe in democracy we should believe it starts at the lowest level. When we joined the EU there was much talk of subsidiarity and other buzzwords of the time. The concept of subsidiarity is a good one. It means that people should be represented at the lowest level. Under the present system the views of the public on the treatment and services provided by the health boards are expressed by local representatives. This is a very important aspect of informing the health authority, the managers and, through them, the service providers. I saw that in action during my time on the health board. It made managers very uncomfortable to be questioned on many aspects of their work by those representing the service users. However, it provided a forum where representatives could put forward people's views of the provision of health services.

When people contact local representatives regarding waiting lists or because they are in pain and are trying to get an appointment with a consultant, about being on a trolley for days or about an elderly patient being discharged from hospital who is not fit to go home and needs alternative services for a period of time, it influences their contribution to the health board and brings a view to the board that it will not now have.

On the other side, it has not been all criticism. In my time we have been very complimentary regarding the services provided and the actions of certain programme managers who did very positive and progressive work. Much progressive work is going on. It is important that those who are influenced by the public and the people who are serviced by health boards are able to bring that view to the health board. That will not now be possible. Managers will decide on the basis of financial considerations rather than on the basis of need, the services that will be provided in accident and emergency departments, the number of beds that will be provided, the level of consultancy and the level of nursing care.

I have here an article from one of the papers which refers to the representation of public representatives on health boards as a codocracy. I was upset when I read it because of the implication that in certain circumstances public representatives want their views published for political advantage. If a public representative makes a genuine statement, what does it matter if it is published? If it is not genuine, the public or the editor of the paper can be the judge of that. In the article it is stated that health boards will soon be abolished and replaced by four executives and that this will not be widely mourned partly because local councillors use them for personal publicity and electoral advantage. What is wrong with publicity? If, at a meeting of the Mid-Western Health Board or Limerick County Council, of which I used to be a member, I raise an issue that is of serious concern to those who elect me, is it not appropriate that the media should pick up on it? Should people not be made aware of my contribution so that they can judge me on what I bring to meetings at local level? The media's role is to inform people of what is happening so they can judge whether I am engaging in "codocracy" or representing the people.

The newspaper article referred to politicians using their membership of health boards "for electoral advantage". What kind of democracy would we have if politicians stopped being concerned about being re-elected? Is there an expectation that politicians should not be concerned about their re-election? If politicians are concerned about re-election, they will represent those who will judge them at the next election and respond to their needs. If politicians do not consider electoral advantage, they are not responding to the needs of the people.

In any democracy, one must distinguish between political satire, which we all enjoy, and political reality. We can laugh at what happens in places like Ballymagash — we all enjoyed such satirical sketches — but we should not believe that they represent any more than satire. When public representatives attempt to address the needs of people on trolleys, on waiting lists for six or 12 months or looking for nursing home subventions, they are engaging in democracy by representing those who elected them. It is a shame that such an opportunity is being withdrawn from us.

Those of us involved in local democracy should encourage, support and stand up for it. While there was bad and good in what was done, the vast majority of those involved were concerned about issues that were brought to their attention, such as service delivery in the health boards, the performance of hospitals and community care centres or the need for home help. We discuss such issues in the House sometimes. People can respond to programme managers at that level. I agree with other speakers who criticised the programme manager system, which has become a bureaucracy. It has been revealed in recent months that health service officials do not know how many people are working in the programme manager system. They do not know how many people are working in the health boards.

I would like to mention something about which I am quite disappointed. Before this debate took place, the Revised Estimates for the Department of Health and Children were being discussed by the Select Committee on Health and Children. The Minister had made his statement and the Opposition spokespersons had responded. I was anxious to query the Minister on issues of concern to me, especially those relating to the budget for mental health services. The meeting adjourned at 1 p.m. to allow Members to vote on the Twenty-seventh Amendment of the Constitution Bill 2004 and to allow the Minister to introduce this Bill. The discussion of the Estimates has resumed, however, while this debate is continuing. As Fine Gael's deputy spokesman on health, I am obliged to be here and to contribute to this Bill. I want to do so and I welcome the opportunity to do so. I have been denied the opportunity to question the Minister on the fact that he is prepared to allocate just 6.6% of the health budget to mental health services. He is now taking questions and I hope he will still be doing so at 3.30 p.m., but I doubt it.

When I try to raise the matter next week, the Ceann Comhairle will quote Standing Orders and tell me that there are other ways of doing so. I like to question the Minister when I get the chance. I could do so at a select committee meeting that is taking place this afternoon, but I am obliged by my party, quite rightly, to be here to speak about this Bill. I am denied the opportunity to query the Minister and to hear his comments on the disgraceful allocation he has made to mental health services.

When representatives of the Irish College of Psychiatrists spoke about the health budget at a meeting of the Joint Committee on Health and Children last week, they raised serious issues of concern about the health budget. They reminded us that:

Funding for the mental health service dropped from 11% of the total health budget in 1997 to 6.6% in 2003. The level of increase in funding of psychiatry is the lowest of all the medical specialties . . . Although mental ill health affects one in four of us during our lifetime and causes more disability than lung problems, the development of services is neglected year after year.

The Minister of State, Deputy Kitt, is not in a position to respond to me, but the Minister, Deputy Martin, is taking questions about health at a committee meeting at the moment. I am not in a position to ask him questions, however.

In light of the imminent abolition of the health boards, it is clear that politicians will no longer have the same opportunity to represent the people at board meetings. We will be treated in a different fashion when we make representations. It may be the case that those who write letters in response to public representatives feel that we should not make representations in any event. I am sure Deputies O'Connor and Killeen would defend our right, as public representatives and as Members of this House, to make representations when constituents are concerned about issues. People are often unaware of how to deal with bureaucrats and to raise issues, especially in respect of the health service.

I made representations on behalf of a constituent who contacted me late one night — I will not give the exact time. The woman in question, who was an elderly pensioner, was in extreme pain. She asked me to find out when her CAT scan would take place. I spoke to her and said that I would make inquiries on her behalf, but when I did so I received a letter from a health board official telling me that if he were to keep me informed of the woman's condition after she had been seen by the hospital consultant, he would be "in breach of Hospital Confidentiality Policy". He went on to say:

This practice, as I say, would be in breach of patient/clinical confidentiality as well as being very time-consuming . . . Again as your recent representations to me are bordering on this practice I must ask you to cease this immediately. If a patient's medical condition deteriorates, since that patient went on a waiting list for a specialist service in our Hospital, a Consultant must receive a letter from the Patient's General Practitioner [I have no problem with that] before the patient's condition will be re-assessed and re-graded by a Consultant. I trust this clarifies the matter.

I showed the letter to a number of my colleagues at the time. I was appalled to be told that I should "immediately" cease trying to find out when a pensioner's CAT scan was to take place. When I decided to submit a parliamentary question, the Minister directed the health board to reply to me. I received a detailed reply telling me that a consultant physician had requested a thorax CAT scan on 6 June 2003 for the woman in question. I was informed that when her case was later discussed at a case conference with a radiologist, it was decided that it was not appropriate to her to have a thorax CAT scan. The letter stated that the woman in question had a chest X-ray on 24 September 2003, the result of which has been made known to the consultant and the woman's GP. When I asked a simple question, the answer to which could have been given to me in two days, I was told that my query was "bordering on this practice" and I was asked to cease "immediately". When I tabled a parliamentary question, I was referred to this reply. This will be the new attitude to public representatives when our representatives can no longer raise these issues on the health boards.

I raised this matter with Mr. Stiofán de Búrca, the board's chief executive officer, who informed me he would consult the freedom of information officer. However, he had no problem when the Minister directed him to do so. Once the health boards are replaced with bureaucracy and managers, public representatives will be ignored. We will be told it is none of our business when inquiring about people in crisis, waiting lists and on behalf of elderly people looking for nursing home subvention.

I am disappointed that the Bill is not being discussed along with the Estimates. Members raised issues on the service itself but I wanted to concentrate on the involvement of public representatives who assist those who may not have the education or wherewithal to access information from the health boards.

Debate adjourned.