Health (Amendment) Bill 2004: Second Stage (Resumed).

Question again proposed: "That the Bill be now ready a Second Time."

There is considerable agreement on the need for a health service reform programme. Unfortunately, there is little agreement between parties and, even in some instances within parties, on how best that might be achieved. The national health strategy, Quality and Fairness: A Health System for You, set out the vision and goals for the health service up to 2010. This Bill is the first of two planned for this year, as outlined by the Minister for Health and Children, and is intended to reform structures which have served us reasonably well for more than 30 years.

I recall the debates that took place in council chambers, where I was a member, and elsewhere, during which councillors castigated regional health boards more than they did successive Ministers for Health, even when they came from a different party. Most councillors who were members prior to 1974 claimed that the change from a county to a regional structure was disastrous for health care generally, but in particular for outlying areas and hospitals in outlying counties. It is somewhat amusing that so many now lament the proposal to abolish the health boards given that many councillors were calling for their abolition 25 years ago and often again in the interim.

Among the charges laid against health boards, which are now lauded as wonderful structures, was that they were remote, committed only to the regional centre, over-bureaucratic, and employed more management, administrative and clerical personnel than health care personnel such as doctors and nurses. I was never a member of a health board but councillors of all parties were solid and constructive members. Some of the very best of those protest least about the proposal in this Bill. I am not convinced that all the representatives of the professional bodies made as positive a contribution to the health boards as most councillors did. There were some exceptions. Some of the professionals were very constructive but there were others who, despite their expertise and commitment to the health service, were disappointing.

One difficulty besetting the health boards and which, unless we are careful, may beset future structures was the perceived tug o' war between the executive of the health board and the Department of Health and Children. Sometimes the Department of Finance would oversee that, which would be considered a negative influence too. It was clear to anyone who observed the health service and how it did or did not develop, particularly outside Dublin, that the Department of Health and Children operated to some kind of invisible blueprint.

Most of us rural dwellers believed that blueprint was the Fitzgerald report, which is 70 years old. There were guidelines that could not be found anywhere but which militated strongly against the development of hospitals other than regional ones. In the mid-west, they probably militated against development of the regional hospital as well. Had the report been implemented in County Clare and Ennis General Hospital the consequences would have been disastrous. Even the worst effects of the Hanly report would be a major improvement on the health clinic model proposed by the Fitzgerald report and adopted by a Government in the 1980s. While economic considerations at various times have retarded the development of our health services, the Department blueprint has also had a negative impact.

It is important that the Government had the foresight to provide for demographic and geographic considerations as an amendment to its adoption of the Hanly model. The Minster's announcement in County Clare that the 24 hour accident and emergency service will be maintained and be doctor-led is welcome. This does not undermine the general principle of the Hanly report, but merely varies the model for deployment of additional medical personnel, in this instance mainly consultants and senior doctors. It facilitates the much improved blueprint for health care which, together with this legislation, attempts to achieve a much better quality of health service. Whatever other considerations may come into play, and there are many issues which one must take into account, it is incumbent on all of us to do everything we can to ensure that the outcome is the best level of health care.

However much I fault elements of what is proposed in the Hanly report, I concede that it is by far the most coherent and constructive response to the litany of difficulties that have beset the health service in recent years. It is the only reasonable way forward in terms of addressing the difficulties arising from the working time directive.

The report contains a major defect in regard to accident and emergency services, particularly in the mid-west region. We must be clear about what we need in terms of accident and emergency services. A large percentage of this work revolves around care for relatively minor injuries, mostly referred by GPs. Another important element, to which those opposed to the Hanly report have drawn attention, is emergency provision for accident victims, cardiac patients and others. It is clear that this area can be improved.

Almost every Member of the House will have been in an accident and emergency unit, either as a patient or accompanying a family member. I have been in accident and emergency units on many occasions, usually taking in young people injured in matches who are generally in need of an x-ray or stitches. The quality of care, response time and treatment of people in smaller hospitals, especially in Ennis, has been far superior to what is available in other places. I will not embarrass those regional hospitals by naming them. We need to take account of this and value it.

The Hanly team would probably say that most of the cases I described are ones which present between 8 a.m. and 8 p.m. It must be acknowledged that the Hanly report provides for them. We also need to acknowledge that accident victims and cardiac patients will present outside of those hours. Even if the numbers are small, these are patients with medical needs who have family and friends and who would otherwise add to the congestion at regional centres. We must also acknowledge that some of these people would be at considerable risk if they had to make the longer journey implicit in what is proposed in the Hanly report. I welcome the amended model which provides for 24 hour accident and emergency cover. I especially welcome the fact that the people providing such cover will be considerably more qualified than has been the case heretofore.

We must also face the fact that implicit in the Hanly report, and virtually all reports on the health service, is the belief that major improvements need to be made to the quality of patient care. Many of those opposed to the Hanly report have used extreme language. They have said that if the report's recommendations are implemented, people will die. We need to look at the flip side of the coin and examine whether this is already happening because of existing deficiencies.

Hear, hear.

Some of the improvements proposed in the Hanly report might address the problems. At the very least, Mr. Hanly and his team must be credited with addressing the issue and coming up with a blueprint. It is also important to remember that those involved in preparing the report were not all based in Dublin. Expertise was drawn from all medical disciplines and from around the country.

There have been strong campaigns, especially in counties Clare and Tipperary, to address the perceived deficiencies in the Hanly report. Their aim is to achieve improvements in what was set out in that report. The difficulty relating to junior hospital doctors and the working time directive is adequately addressed in the report. Other proposals such as those in regard to the ambulance service, primary care and the provision of additional consultants would bring enormous improvement in the quality of health care. Twenthy-four hour accident and emergency cover is worthwhile in Ennis and Nenagh. I am delighted that it has been possible to achieve that.

I acknowledge the support of party colleagues in County Clare and County Tipperary in bringing about a successful conclusion in that regard. I am happy to work with them and other members of the action committees, some of which are called hospital development committees, to achieve the amendments which will give us the kind of health service to which we are entitled.

We need to ensure that the campaign is cohesive and constructive. Some of what has happened recently in the campaign against the recommendations of the Hanly report, have had a negative effect. Most people involved in the campaign, and I know best those involved in the campaign in County Clare, including some public representatives of Opposition parties, are genuine in their concern and extremely constructive in their approach. They usually resist the temptation to take cheap political shots. However, others who are on a party political crusade are damaging the campaign to make improvements on the Hanly proposals. These people have no regard for patient welfare or the professionals delivering the service in our hospitals. This is having a damaging effect on morale in some smaller hospitals. It also damages public trust in them.

In pursuing the campaign to improve the health service, we need to be clear as to whether we accept the Hanly report as a suitable blueprint for reform. I believe it is and I publicly supported the amendments which will improve the quality of service provision as outlined in the report. Many people are trying to dismiss the report in its entirety and, in doing so, they are damaging and diminishing the opportunity to bring additional services to the counties and regions. Ultimately this will contribute to a delay in providing good quality patient care, which is not in anybody's interest.

It is a great weakness in the national campaign that we do not have clarity on whether there are positive aspects to the Hanly report. The majority of the recommendations in the report are positive. It sets about addressing the difficulties that exist and the Minister has accepted the merit of the amendments for which people fought.

Regarding the health service reform programme, the Bill sets out a major rationalisation of the existing health service agencies. The most significant element is the abolition of the current health boards and authorities. The Health Service Executive will be the first body ever charged with managing the health service as a single national entity. Anyone who has had reason to examine the work of the health service would agree that something of this nature is required at national level. Many people would also admit that this kind of structure is required at individual hospital level. There seems to be a weakness in management or in the structures in place in a great number of hospitals. From what one would observe as a patient or visitor to an accident and emergency department, one would have to conclude that there are better ways of managing systems.

The establishment of a health information and quality authority to ensure safety and quality of care is promoted throughout the system is welcome. I would have thought that was a given, but there seems to be a need to proceed in this manner. The change of role of the Department of Health and Children in this area is fundamental and important. There have been weaknesses in policy development and oversights over the years. One of the reasons for that undoubtedly is that the health service has grown laterally to an extent that could not have been foreseen. A range of specialties at hospital level have arisen and a range of care models have been set up. A great many of them are operated semi-professionally or by the voluntary sector. They do important work, by and large, in a cost-effective manner, but ultimately as part of an agglomeration that does not deliver to the patient and to the user in the best possible way.

In the health service reform programme there is provision for the modernisation of the supporting processes of the system in terms of service, management, planning, reporting and so on and an aspiration towards international best practice, which I very much welcome. There is also provision for the strengthening of governance and accountability across the system. I believe that will also bear positive results as time goes on.

There is the work of the national steering committee, which I hope will be fruitful and progressive, but I also hope it will be open to scrutiny by the Oireachtas to suggested improvements and that, as it moves forward, it will have a positive impact on the quality of our health service.

Having regard to this area and specifically what is proposed in the Bill, the changes proposed in structures are quite radical and one would be concerned to ensure that the interim arrangements would not become semi-permanent or last too long. Any elected representative would have some concern about the assignment of the reserve functions of the authorities and the boards to the chief executive officers in the manner proposed.

In moving forward from the current position to what is planned for the future, there is probably no other way to do this. There must be an interim arrangement and I am not in a position to propose an alternate model other than transferring such authority to the CEOs or to the Minister, but that interim arrangement should not be allowed to last very long. I would not like radical changes to be made during the period of this interim arrangement. Some people have a suspicion that in the absence of the boards to perform the reserve functions, there might be some sleight of hand. It is important to ensure that does not happen because there must be democratic accountability. While one acknowledges that some interim arrangement is required, it is important to ensure it is not abused in the short to medium term.

I welcome the opportunity to speak on this important issue. The problem in our health system is the most serious one with which the Government and country must deal. We all know of cases where the system has let people down badly. I warn the people of Ennis and Nenagh that it is only two years since the people of Cavan-Monaghan were given strong promises regarding Monaghan General Hospital.

This Bill aims to abolish the health boards as we know them and to give power to the CEOs to deliver the service. As one who has experienced the activities of the administrators of the health board in the Cavan-Monaghan region in recent years, this proposed change frightens me. Admittedly, the administrators did not take account of the views of the elected representatives in the area because the board, as structured, comprised many other members plus Government hacks. Many measures were bulldozed through regardless. The needs of the people of the area concerned were not a priority.

This Bill seeks to abolish the structures put in place under 1970 Act, the 1996 Act and the 1999 Act. It will amend the provisions of the Local Government Act 2001, which govern the nomination of members from the city and county councils. The main points of the Bill are that it provides for the abolition of the membership of the health boards, etc. and leaves the way open for the CEOs to take control. To use the Minister's words, what is proposed is the termination of office of all members of the health board on the date on which the order is made.

We are taking a serious step in this. A previous speaker said that prior to the health boards being set up, the health service was administered by the county councils. The record of Monaghan General Hospital reveals that when it was run by the local county council and by its chief — a matron — the services available were much better than those available today.

Section 10 states that the CEO must provide the Minister with any information on the performance of his or her functions as the Minister may from time to time require. Section 13 assigns to the Minister the board functions in the appointment and removal of the CEO. The Minister should take this provision seriously because he has avoided making any decision such as that, even having regard to the powers he has had under the existing legislation in the recent past. As a result, the people of Monaghan have seriously suffered. Somebody said that the Hanly might not be perfect and might need tweaking here and there. Those who believe the Hanly report can serve the good of the country need to note what has happened in Monaghan General Hospital.

We are advised that these proposed changes must be made because of the provisions of the working time directive and that the boards will be replaced by a group which will discuss issues with the Minister, the CEOs, etc. That will be a talking shop with no power. I record that in the case of the North Eastern Health Board, even members who were elected to it did not adhere to the agreement made by the people who put them there. I am mindful of the nurses' representative who voted at all times against the interests of Monaghan General Hospital, but when she resigned she was encouraged to go back there not by the nurses but by the administration. That is the type of concern people have about who will run our health service in future.

I want to return to the point I made about Monaghan General Hospital and the comment I made about the people of Ennis and Nenagh.

Some of the comments I intend to make about Monaghan General Hospital may not be pleasant but they reflect reality. Two years and three months ago the Minister visited the hospital. As reported inThe Northern Standard at the time, he stated: “I have been left in no doubt about the depth of feeling in Monaghan about the hospital. My visit has been very positive and productive from that point of view.” He further stated there was no question of Monaghan hospital closing and that this was simply not on anybody’s agenda. He then said: “I understand and realise there are significant credibility issues here. People do not believe what they are being told from official sources. I accept that.” He proceeded to list everything that would be done and stated that in the previous three years alone, €4.5 million had been invested and that 15% more people were using the medical and surgical services than was the case in 1997. All Ministers like to refer to the latter year. The Minister further stated at the time that, in terms of the future, the health board had adopted a plan in 2001 and outlined all the promises it had made.

These were the commitments made by the Minister to the people of Monaghan in the run-up to a general election. He was adamant that the hospital was needed because the country required additional capacity in its acute hospital services. Referring to the bed shortage nationally, he stated there would be no percentage for any Minister in closing hospitals because all spare capacity was needed. On concerns about the planned surgical services review, the Minister said the health board had indicated that surgical services in Monaghan could not be closed down and that the additional workload could not be met by other hospitals. He added that extra junior doctors would be appointed in order to ensure the accrediting body would not recommend the surgical service be closed. He also said that the latter issue would be "looked at in the coming weeks".

That is what happened in Monaghan. When one realises what happened in Ennis and Nenagh a few weeks ago, one is left to wonder about the future. What we want, from the Department's point of view, is for surgical services in Monaghan to continue. In the run-up to the most recent general election, the Minister's party gave absolute guarantees that future developments would include a midwife-led maternity unit. It further promised that all medical emergencies would be treated in Monaghan, that surgical emergencies would be treated in Monaghan as determined by the consultant on call and that 80% of accident and emergency would be treated at Monaghan General Hospital. It also promised that substantial funding would be made available for building and refurbishment, that ten extra beds out of the 38 for the North Eastern Health Boards would go to the hospital, that there would be one new consultant geriatrician, one new consultant dermatologist and one new consultant with five junior hospital doctors, and that Monaghan hospital would be staying open. What happened? On 2 July, Monaghan hospital was taken off call.

The staff at Monaghan General Hospital are doing a great job for those who know how to get in through the backdoor, namely, those who arrive by car. People cannot avail of the ambulance service unless doctors, in individual cases, insist that an ambulance is required. In one recent instance, a doctor simply ordered the ambulance staff to take a patient the short distance to the hospital. The man in question literally died on his way through the doors of the hospital but the staff were able to resuscitate him. That man would not have lived had he been obliged to travel to hospital in Drogheda or some other location. We are talking about matters of life and death.

In his contribution, the Minister outlined the reasons he wants to do away with the health boards. I am not completely against replacing the health boards, as currently structured. There are difficulties in the current service and there are reasons for making it more organised. However, it is naive to suggest this will result in an end to all our problems. The Minister stated the health strategy will bring about, "better health for everyone, fair access, responsive and appropriate care delivery and high performance". He also stated there are too many agencies and the service is too fragmented. He did not mention a health ombudsman or anything else that might improve the situation. The Minister also referred to:

a major rationalisation of existing health service agencies, including the abolition of the existing health board-authority structures; the establishment of a health services 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 quality of care is promoted throughout the system.

I will read no more of the speech because what the Minister said was meaningless. I do not mean that in any derogatory sense because that is not the way I operate.

We must consider what is happening at present. Only last week the Minister provided an outline of how well he is doing in terms of reducing waiting lists. I was visited in my office this morning by an aged lady who was making representations on behalf of her 79 year old husband who has been seeking help with his hip problem for the past three years but who, as yet, has not been placed on a waiting list. It is easy to state that waiting lists are being reduced if people are not allowed to be included on them. It is as if they do not exist.

I was contacted by a young man in connection with his three year old daughter. The man in question also has a four year old son and a year ago he had to bring him to a Dublin hospital to have his tonsillitis treated. The child's throat was literally closed and the man asked when the child would be dealt with. He was informed it would take three years. When he asked what would happen if he went private, he was told it would only take two weeks. He was obliged to part with €1,300 in order to have the operation carried out. A year later, he is again desperate because his three year old daughter has a similar problem. He is hoping the operation can be done at Omagh. These are the types of matters with which Members must deal in their clinics on an ordinary day.

I cannot help but think about the family of a man who had a heart attack the other day. He was rushed to one of the major hospitals in Dublin at 5.30 p.m. He was 22nd on the list for treatment and was cared for by a junior doctor between 5.30 p.m. and 7.30 p.m. However, the doctor's shift ended at that time and it was approximately 9 p.m. or 9.30 p.m. before the man was dealt with and he passed away. How must his family feel today? We have all seen footage on television of ambulances with their sirens sounding arriving at hospitals and being awaited by emergency teams. Hospital staff used to be able to do that and they should still be in a position to do it. However, Monaghan hospital and other hospitals are now off call and services are being grouped at centres of excellence that are not yet prepared to deal with people.

As a member of the British-Irish Interparliamentary Body, I was recently privileged to be part of an inquiry into health services in particular areas. One of the places we visited was the Isle of Man. People may say that money from this country has been invested there illegally and that it has adequate funding as a result. However, I saw how the service there operates. A new 314 bed hospital was built within four years for a population of 75,000 to 85,000 people, depending on the number of holidaymakers in the area. The new hospital will have 24 new consultants and does not seem to have any trouble getting personnel. The charge on the taxpayer for the health service there is just a little higher than what we charge, about half as much again. They apologised because they have a waiting list of six months for a person needing a hip operation, but they hope to reduce that time to three months shortly with the six new theatres in the hospital.

On another occasion we visited a hospital outside Cardiff to see a new modern midwife-led childbirth service. A similar service was promised for Monaghan, but nothing has happened. We then went up to Wick, 108 miles north of Inverness and 15 miles short of John O'Groats. There the maternity service was under pressure with only about 200 patients using it in a year, I think it may have closed since.

That visit opened my eyes to what is wrong with our system. The Minister's personal adviser was with us on the trip and he pointed out that there was nobody in the emergency unit of the hospital we visited. It is true it was not under pressure, but it was at least able to provide a service to any patients who turned up and to ensure they were safe to travel the 108 miles to Inverness.

We also visited the health care service there where five or six doctors worked. They ran an ultra modern health service providing care at primary care level for people so that they do not have to end up at the accident and emergency unit. This service is provided free, which makes all the difference. The Minister should remember that a promise was made before the general election that 200,000 extra medical cards would be provided. However, a reply to a parliamentary question indicates that instead some 47,000 cards have been withdrawn.

I listened to a colleague from the Fianna Fáil party and Deputy Olivia Mitchell argue on radio about the issue. The Fianna Fáil Deputy said the reason the cards were removed was because all of the people involved were on such good incomes that they no longer needed the cards. This is one of the biggest issues in my office on a daily basis. People with genuine long-term illness have their medical cards removed and their families are in dire distress. If the Minister does nothing else, he should fulfil the commitment to deliver the extra 200,000 medical cards. He should also restore the 47,000 which have been withdrawn.

I cannot help reminding the House of an 87 year old woman who has to take care of her adult disabled children. She worries about what will happen when her life ends or when she is no longer able to look after them. The "Prime Time" programme on RTE last night dealt with the area of autism. When will this Government pass the disability Bill which will give some rights to people who desperately need help? I did not have the opportunity to see the programme last night. However, I heard snippets on the radio. It would make anybody cry that so many people are enduring so much distress at a time when this country was never as well off financially. Some €500 million more than expected has been added to the kitty from taxes and €150 million extra has come in from dormant accounts. Money is also available from other areas.

I beg the Minister to do what is necessary to get Monaghan General Hospital re-opened on call to provide a proper service to people. He appointed Kevin Bonnar to examine the issue and said that €14 million was necessary for the service. The Minister has decided he will provide €2.75 million. In order to provide some comfort to hospitals such as Ennis, Nenagh and other hospitals around the country, the least the Minister should do is to treat Monaghan General Hospital with some dignity and respect and bring it back on call.

I wish to share my time with Deputy Devins.

Is that agreed? Agreed.

I welcome this debate. I also welcome the changes proposed in the Health (Amendment) Bill 2004 as they are a key part of the Government's reform of the health service as announced last year.

I recognise, as anybody should, that there is always room for improvement in the health services and no matter how much was spent in recent years, further improvement must always be welcome. However, I cannot close my eyes to the huge improvements that have already taken place, particularly those in my constituency and health board area over the past seven years. Members may point out that years ago services were always readily available in their local hospitals. However, the reality is that most people from the rural health board areas headed to Dublin for treatment. Therefore, it was quite easy to provide the limited service required in those hospitals.

I welcome the changes I have seen over seven years which I am sure are consistent with changes in most health board areas throughout the country. Government policy has insisted that we have services in the regions, and this has happened. My area, which is covered by the Midland Health Board, is not much different from other areas and I have seen huge capital investment in my local hospital in Portlaoise. In the past month the Minister for Health visited to open the new paediatric and the new acute psychiatric units. There have been major improvements in the hospital's services.

If one examined the information from the headquarters in Tullamore, one would recognise the huge increase in the throughput of patients in every faculty of the hospital and recognise that services have improved, that the throughput of patients has grown and that the level of confidence in hospital services has improved. I see the changes as positive. Services are dealing with the issues on the ground and providing a service. In my time as a health board member I have seen better ENT, orthodontic and cancer services in my region.

Great play has been made of the fact that this Bill mentions the abolition of health boards. People are trying to tie a noose around the Government's neck by suggesting this is anti-democratic and they suggest that removing public representatives from health boards is a way of removing the local voice by stealth. I do not wish to go against colleagues who have been health board members; I was on the health board in County Laois for 20 years. However, my experience is that when a member from the Government side tried to improve services or secure services for our region, opposition members felt it had to be opposed straight away, purely because we had a Fianna Fáil administration and that created the impression it was a Government proposed motion.

For example, in 1994 we proposed the location of a regional cancer service in Tullamore. I learned then that the involvement of public representatives from the different counties of the health board area acted as a deterrent, unfortunately, towards attracting services. I welcome the changes because I saw the huge pressure brought to bear on public representatives to insist that whatever improvements would occur, they would occur in the county of the strongest public representative.

The Minister speaks in the Bill about the need to move forward and progress quickly. I welcome the change the Minister is initiating. Approximately 1,200 people in our region present each year with cancer-related illness, 1,000 of whom must travel to Dublin for treatment. Even though funding was allocated and services committed to by way of a regional cancer strategy, non-Government members of our health board went through the nonsense of a High Court action to create the impression that they had fought their damnedest to secure the service for the county. In the meantime there was a delay of four years in providing the service. Any change in that regard is, therefore, welcome. I sincerely welcome the removal of pressure to provide a service from local public representatives who acknowledge they will have a role in a regional structure and are glad to have that pressure removed.

I have often made the point at health board meetings that while public representatives have a role in deciding on the level of funding under different specialities at the annual Estimates meetings, medical issues should be left to consultant or medical representatives. Having learned from the sad experience of the row about cancer services in the midland region, the only region to wind up in the High Court, I proposed that from then on, whenever the Department signalled the possibility of new services for a region, it should be left to the medical representatives from each county, not the public representatives, to make recommendations to the health board on the location of services, particularly in health board areas with two or three acute hospitals delivering service. The experience in my region brought home to me the point under discussion in the debate on this Bill. The consultants on the board could not make a recommendation. If the consultants could not do so, how could a public representative? I, therefore, welcome any change to remove pressure from public representatives regarding the location of services.

I agree with the Minister that the current system has served us well for more than 30 years, and recognise the major role played by the health boards in those years. However, few public or private companies operate under the same structures and guidelines for more than 30 years. If we are to have a world class health service, we need structures that can move to provide such a service.

I recognise that, given the problems that could arise, making progress is important. That is why the Minister has brought forward this legislation. By his own admission it is of an interim nature. Nevertheless, it represents an important step. I do not see the decision to remove public representatives as a measure to undermine democracy or local involvement. There will be room for that as well.

Another part of the legislation deals with assigning the various powers of the authority to the CEOs and the Minister for Health and Children. Such measures are necessary if we are to make progress. If we want to achieve reform quickly, we need a streamlined executive structure so that the necessary measures can be put in place.

The reform of the health service will pose a number of challenges, including the need for the various bodies of the service to pull in the same direction and make decisions quickly. There would not be much point in increasing the level of spending each year if decisions are not quickly made and adhered to. The old structures were often accused of being unwieldy. This Bill will correct that.

The decision to transfer any decisions with regard to the purchase and disposal of property is another necessary step. For years the land purchase committee was often under extreme pressure from different areas within the health services. I am glad we are dealing with that issue as well. We must have a central decision-making process. We cannot have each area making decisions that might be of benefit locally but which fail to take account of the bigger picture. That is what the Government's health service strategy is about. It is about examining the overall scenario and ensuring that we provide a service for the country of which we can be proud.

It will be difficult to change old ways. Colleagues who served on health boards for years express the belief that they will be left out of the decision-making process. However, some health boards operating within the guidelines have suffered, particularly my own. I have often wondered why all of the health boards could not act in step with one another. For years the health board on which I served operated within budget and provided a service plan that remained within budget, while other boards exceeded their budget. Those health boards were not penalised and were able to provide more services and it was often pointed out that my health board had a marked lack of services compared to other health boards. If people check the records of the early 1970s, they will find one reason was that my health board could never agree on the location of services.

I thank the Chair for allowing me to contribute. I wish the Minister and the Ministers of State well in steering this Bill through the House and recognise that serious attempts have been made to resolve the difficulties within the health service.

I am delighted to have this opportunity to speak on the Health (Amendment) Bill 2004. Everyone in this House is aware that improvements are needed in the health service, despite the great work being done by people who work in the service both at a clinical and administrative level and despite the enormous amount of money that has been allocated in recent years. I have said repeatedly, and I will repeat it again tonight, that the most important person in the health service is the patient and yet some patients are unhappy with the service. That unhappiness appears to be centred on long waiting lists for certain specialties and overcrowding in the accident and emergency departments of some hospitals. Only today I came across a patient who had been waiting an incredibly long time for an orthodontic appointment. Deputy Olivia Mitchell on the opposite side of the House is well aware of the problems that exist in that specialty.

Recognising these problems, the Minister has undertaken a comprehensive review of the health service in its totality. These problems and their solutions have been clearly signalled in the three reports published recently, namely, Brennan, Prospectus and Hanly. One of the issues identified as needing reform has been the structure of health boards. I spent a considerable time working for a health board, the North Western Health Board. It is one of the better health boards, if not the best. I do not say this purely from a parochial point of view but from experience gained from listening and talking to members of the public and Members of the House from all sides. However, the present structure of health administration dates from the 1970s and it is not best suited to deal with the complexities of health administration in the 21st century.

The health strategy clearly identified the need to have a consistent national approach to the delivery of health services based on clear and agreed national objectives. The key element of the reform of the health service is the rationalisation of the existing health service agencies which will involve the abolition of the existing health boards. In the case of the North Western Health Board, I shall be saddened to see its abolition but in the light of the evidence presented by the reports I have just mentioned, the overall improvement of the health service requires new structures. I hope the end result will be a health service executive which will be responsible for managing the service as a national entity.

Last week the chairman of the interim Health Service Executive, Mr. Kevin Kelly and some members of this interim board appeared before the Dáil health committee. I was very impressed with the level of consultation they are undertaking with all interested bodies in the health service before the executive is established next January. I take this opportunity to wish them well in their very important task because the success of the very necessary reforms depend on the successful operation of this very important structure that is the Health Service Executive. The end result of this reform programme will be a health service which will improve patient care and that is something everyone wants. The Bill is the first stage in the legislative process to bring about that reform. It is somewhat ironic that some members of the Opposition oppose that process. Having listened carefully to what they have said, it appears that many of them have fears about the perceived lack of democratic accountability in the new structures.

I welcome the Minister's clear indication of his intention to bring forward opportunities for democratic input in the new health service structure. I particularly welcome the proposal to establish regional forums to allow local representatives to raise with the new executive their concerns about the health service within their regions. The membership of the forums will be based on nominations from local authorities. Therefore, the input of public representatives into the health service will be maintained. It is important that local councillors have an input into the running of the health service in their own areas so that their voices will continue to be heard as things happen in the health service.

I also welcome the proposal in the Bill to increase the role of the Joint Committee on Health and Children. I have mentioned that the chairman of the interim Health Service Executive has appeared before the committee. I foresee an expanded role for the committee under this legislation, as it will mean that issues raised by constituents can be put directly to members of the executive. This open and accountable process is already happening in other Dáil committees. I am sure the members of the joint committee, including all the main Opposition health spokespersons, will relish their increasingly important role as public watchdogs.

A considerable number of places on health boards are reserved for health professionals, such as doctors, pharmacists and nurses. I welcome the Minister's recent announcement that arrangements will be made to allow such professionals to express their views. The voices of patients, who are the users of the service, have been overlooked in the past, however. It is true that some health boards have established consumer panels, but it should be done on a more formal basis. I urge the Minister to proceed with such panels as soon as possible.

While the health boards have served the country well for the past 34 years, generally, the evidence of the exhaustive review of the Irish health service is that more appropriate structures need to be put in place for the modern age. The Bill is the first step in that process and I commend the Minister for bringing it to the House.

I intend to share time with Deputy Morgan.

Is that agreed? Agreed.

A myriad of reports has been issued during the term in office of the Minister for Health and Children and under the auspices of the Government since 1997. I do not believe the Government's intention in producing such reports has been to illuminate the needs of the health service and to address those needs into the future. The reports have been requested and provided on a political basis to allow the Government to engage in prevarication and to delay the reforms that are required. Many of us believe that reforms can be implemented to enable a fair and efficient health service to exist. One can wonder why such a service does not exist. I do not doubt that we continue to suffer through the efforts of various vested interests, who are unwilling to put in place the necessary changes to allow us to bring about such a fair and efficient service.

Who are they?

I will name some of them if the Minister of State allows me to continue. The changes being suggested in the Bill do not address the issues I have mentioned, just as many of the reports that have been issued do not answer the questions that need to be answered. The Bill is an exercise in moving the deck chairs on theTitanic. The fundamental question of the needs of the health service continues to be ignored.

There is an obsession with the administration of the health service, rather than an interest in making clear the philosophy that should underlie the service. We need to consider how best to achieve and maintain a philosophy of the "wellness" of citizens. The Minister, Deputy Martin, and his Government colleagues have never addressed how "wellness" can best be regained if it is not available to individual citizens. Such problems are further entrenched by the legislation before the House today, which underlines the Government's poverty of thinking in this area.

We have been obsessed with the administration of the health service throughout the history of the State. It has to be acknowledged that the Department of Health and Children has had various manifestations. It did not exist when the State came into being. It became an adjunct of the then Department of Local Government, before becoming a fully fledged Department in its own right. Many Governments have been uncertain about how best to deal with health as a political issue. I am afraid that such confusion continues to exist.

Given that there is such an obsession with the administration of the health service and the political packaging that surrounds it, many people are concerned about the extent to which elected public representatives can and should be represented in the process. How should resources be allocated within the health service? Who should make such decisions? We are avoiding the fundamental questions because of our obsession. We have Cinderella services in areas such as preventative health care, community care and mental health care. All such areas would benefit from a more open and imaginative political approach. The political structures we allowed to develop will be allowed to continue in the future, albeit in a more modified form. The Cinderella aspect of many important areas of health care will continue to be overlooked because they are not deemed to be political priorities.

Successive Governments have continued to make mistakes in respect of mental health care in the community. I am sorry the Minister of State, Deputy Tim O'Malley, has had to leave the Chamber because he is directly responsible for this area. There continues to be a Dickensian aspect to mental health services, even in the 21st century. The moves that have been made in recent decades to move people from institutional care to community settings have been badly thought-out. Measures have often been taken in the interests of financial savings to the health service, rather than the medical care of individuals. The Minister of State, Deputy Callely, may shake his head but this has been the experience of individuals who have encountered aspects of that service and whose relatives have endured aspects of the service. The Government is not addressing such issues, but prefers to concern itself with the administrative structure of the health service.

There is no cost saving in moving between three and six people from institutional care to a community setting.

We can argue that.

It is about quality of care.

Quality of care is lacking in many aspects of the health service.

It does not exist.

I will not embarrass the Chair by pointing out that gaps in provision are being bridged not by formal State structures or the Government's policies but by this country's well-committed, if under-resourced, voluntary sector. A more caring and prescient Government would be prepared to bridge such gaps.

I have given one reason this amending Bill is deficient, but two further matters need to be tackled as part of the reform of the health service. Nobody denies that proper organisation is needed, but I would like to concentrate on the need for proper resourcing. The myth has been allowed to develop that we do not need to worry about funding any more because enough money is being invested in the health service. If one examines international comparisons, however, one will see that we spend lessper capita and as a percentage of our gross national product than other European countries. We will be unable to provide the level of service that is found in other countries until we reach that level.

It is important for the organisation of the health service that it is dual-tracked. We have to recognise that the health service should have regional and a local components. There is also a need at a small level for a national body to achieve appropriate economies of scale to give us the best value for our money in the health service. The Minister's proposal to reduce the number of health authorities from 11 to four does not represent a step in the right direction. Regarding many aspects of public health care delivery, it could be argued that much of the health service should be decentralised into local and regional government structures. It is a weakness of Irish local government that we have our health system and aspects of our education systems separate from our local government decision-making bodies, albeit with some nomination rights at VEC and health board levels. In other countries, the delivery of health services and education is an intrinsic part of regional and local government. If the Government was truly concerned about proper reform of our health services, it would be willing to put such structures in place. Unfortunately, this is another missed opportunity.

There is also the issue of people's experience of the health service in terms of the current level of resourcing. My mother was an out-patient nurse in a busy city centre hospital in Cork for 20 years. A number of years ago, my daughter injured her hand in a car door and went to the accident and emergency unit in that hospital. What we saw there shocked my mother, who had worked there for decades previously. The staff were no less caring than they had been, but they were under much more pressure and decisions were being made in that unit which are being replicated in accident and emergency units throughout the country. The decisions are not always medical and often relate to other areas and resources. My daughter had the misfortune of being injured on a Saturday evening and had to compete for accident and emergency space with people in various stages of intoxication being brought by ambulance to the unit. That is where the priority was given on that night in that unit because the staff feared that if those intoxicated people were not dealt with, violence might occur. This happened some years ago, yet I recently received a similar complaint from a constituent. His young son suffered a head wound and was brought into another accident and emergency unit in Cork city. There he was asked to wait for several hours without being tended to, while the parent was asked to maintain pressure on the child's wound until trained medical staff could treat him.

Such situations are the weekly reality for many people using our accident and emergency services. The Government is prepared to stand over such situations and promise that somehow, without bringing in the necessary resources, this rearranging of the deckchairs will change the reality of life for people. The Government is compounding the deceit it has been so willing to spread during the last general election when it promised that waiting lists would by now be a thing of the past.

Sinn Fein's health spokesperson, Deputy Ó Caoláin, stated at the beginning of this debate that this is an enabling Bill for a legislative and political stroke to vest all the powers of the health boards in their CEOs and the Minister for Health and Children for an indefinite period.

Recent events at Louth County Hospital and the conduct of the CEO of the North Eastern Health Board regarding those events act as a timely reminder of the dangers inherent in vesting increased powers in CEOs. The people of Louth were horrified to discover in recent weeks that surgical services at Louth County Hospital are to be closed after 5 p.m. daily from 1 July next, effectively taking the hospital off call. This is the latest in a line of cutbacks and closures at the hospital. The children's ward, the maternity ward and the gynaecological ward have already been closed. The people of Louth are being told that this further closure is, as was said about previous closures, a wonderful boost for the hospital and the people of the area. How can anyone say that? The Minister of State, Deputy Brian Lenihan, repeated this assertion in the House last week when he stated: "Far from being a downgrading of the service in Dundalk, this is an enhancement of the service".

How did this latest cutback of services at Louth County Hospital come about? I will explain briefly. Amazingly, the North Eastern Health Board sent the proposal to Comhairle na nOspidéal saying that the medical board of Louth County Hospital had been consulted and had agreed to the proposal regarding the surgical services cutback. This was a blatant lie, making the North Eastern Health Board submission to Comhairle na nOspidéal a fraudulent document. The people of Louth have a right to know who signed this document. They need to know that someone in the North Eastern Health Board will be held accountable for the actions of the health board regarding Louth County Hospital.

Is anyone accountable any longer in the North Eastern Health Board management? How much longer will this level of gross incompetence be allowed continue? Does the Department of Health and Children give even a fleeting glance to what is going on in that area? It appears it does not.

As a result of being fed misinformation, the Minister of State, Deputy Brian Lenihan, misled this House last week by stating that surgical staff at the Louth hospital were in favour of these proposed closures. This is not the case. Why are paid public servants being allowed to tell lies and get away with it? This is scandalous.

The proposal to end surgical services after 5 p.m. daily is also very dubious from a best practice perspective. It has been described by the medical board of Louth County Hospital as an unsafe practice. The nursing staff at the hospital have been deeply angered by this decision and said it will place the lives of their patients in danger. They are so angry they have organised a protest march in Dundalk for 31 May from the hospital to the town square. The people of Dundalk will no doubt turn out in large numbers to say to the health board and the Minister that they will not sit back and watch while their hospital services are obliterated.

Who is going to intervene to examine what is going on? How can we introduce same modicum of control to senior management in the health board? The Department will not do so. Last week I called for the CEO of the North Eastern Health Board to be suspended pending an investigation into this botched affair. I repeat that call today in light of a litany of emergencies in the North Eastern Health Board area.

The North Eastern Health Board operates more on spin than on substance. We had a further example of its spin yesterday. Last night, on "Six-One News" a North Eastern Health Board spokesperson claimed it was necessary for the board to introduce the closure so as to comply with an EU directive that must be implemented by 1 July. When I checked with the health board today, it admitted it was referring to the European working time directive which related to working hours for junior doctors. This directive will have only very minor effects in terms of the proposed surgical services closure at the Louth hospital. The Minister of State, Deputy Brian Lenihan, attempted to explain this when I raised it with him in the House last week by saying: "The reorganisation of surgical services as announced by the health board is designed inter alia to facilitate a more appropriate training system in that junior doctors will rotate between the two hospitals during their employment, thus ensuring exposure to many different clinical experiences”.

Are the people of County Louth to accept the destruction of their health services based on this explanation? They will not do so. I commend my colleague, councillor Tomás Sharkey, for moving a emergency motion at Louth County Council to hold a special meeting to debate the issue. I understand that Dundalk Town Council is debating it as we speak.

Action is needed now. There is a serious crisis at senior management level in the North Eastern Health Board area. I implore the Department of Health and Children to send in an inspector and hold some sort of investigation. Until that happens, until people establish what is going on and understand the litany of catastrophes, the situation will worsen. Senior people in the Department of Health and Children must realise at this stage what is going on. I ask them to live up to their responsibilities by dealing with the crisis.

I am glad to have the opportunity to speak on this Bill because it is one of the important legislative reforms necessary to deliver health service reform and provide a refined and radically improved health service.

God knows we are paying for a first class health system but how many would claim it is being delivered. The Government is rising to that challenge in parts of its health reform programme and this Bill sets the ball rolling.

Everybody is familiar with the joke "How many people does it take to change a light bulb?" However, it is no joke to ask how many people does it take to make a policy for the health service. Certainly not 263. As the Tánaiste said at the launch of the health reform programme, we do not need 263 health board members in addition to the 166 Dáil Deputies and 60 Senators to make policy for the health services of a population of 3.9 million. This is the central point at the heart of the Bill and of the reform of the health services. We do not have 11 health services in the country, we have one and the system of governance should reflect that.

One of the great flaws of the present system, is that health boards have influence on making and implementing policy, without having to take responsibility to raise tax to back their proposals. Health board members do not have to face direct election to the board by the people whose lives they affect. It is inevitable that when a crisis hits, public concern is raised and responsibility is all too often passed like a hot potato to the Minister. When there is any trouble, it is as if patient, bed, ward and ambulance is the personal responsibility of the Minister of the Government in power. This is familiar to all Ministers who have held the health portfolio. It is part of the absurdity of the governance of health.

Health boards have statutory responsibilities, but all too often the boards escape political responsibility. Since political responsibility is always passed to central government, we may as well have a single executive and a unified system of governance of the health service. That is the logic of the Bill. It is not as if the health boards have provided a model of accountability and effectiveness in their functions. The Brennan report, Commission on Financial Management and Control Systems in the Health Service, gave some stark and simple instances of some very basic failures — unapproved capital spending, unauthorised staff appointments, late and inadequate accounts. To be fair, the Brennan report did not confine its critique to health boards, but that does not take from the relevance of what it said about them. It highlighted that between 1998 and 2000:

of the eight health boards then in existence, all but one received an unsatisfactory audit report [from the Comptroller and Auditor General] at least once in the three year period . . . .

in the case of one of the eight health boards, its audit report was unsatisfactory in all three years examined.

In a devastating comment, the Brennan report remarked on the new Eastern Regional Health Authority:

At the date of completing this report (January 2003) the year 2000 audit report for the Eastern Regional Health Authority is not yet to hand. By statute, the audit should have been completed by 30 September 2001.

If this happened in large companies, shareholders would sell out, regulators would require immediate corrections, suppliers would give no trade credit and banks would pull back on overdraft. The media and politicians would be raising a storm about corporate incompetence. What happened — nothing.

If one casts one's mind back to the period 1998 to 2000, does anyone remember any of the 263 health board members being under political, media or public pressure to take responsibility for these failures? Absolutely not.

I was one of the health board members.

I was the then chairman.

If the truth were told, has it not become the case that failures in the health boards have become accepted and people just shrug their shoulders. Thankfully, that will end.

Leaving aside political responsibility, our present system serves little purpose either in terms of health service planning or delivery. The Prospectus report demonstrated this conclusively.

There is a clear need for consistent health service strategy and consistent health service delivery across the country — not for the sake of the Minister or the Government but for the sake of the patients and clients of our health service.

The argument is also made that there is a need for a democratic input and accountability for health service planning and delivery. The Minister intends to allow structured input from elected representatives, but we can ill afford local political turf battles to interfere with the delivery of health services consistently around the country. People's concerns should focus on the quality and availability of services.

Members who believe that the new Health Service Executive will be unaccountable because its board reports to the Minister for Health and Children who in turn reports to the Oireachtas has a poor view of the oversight of the Oireachtas. Some of my colleagues made a point that the Committee on Health and Children, of which I am a member, had the health service executive before it, and a very impressive organisation it is.

No one has responded to anything the committee has done. For five years we have been trying to have something done about orthodontics. Deputy Cowley, who is in the Chair also tried to improve the delivery of the orthodontic service.

We have every faith it will deliver. At the end of last year when it was discovered that two health boards had not spent all their allocation, the health boards were called before the Health and Children Committee of the Oireachtas, the parliament of the people to account for it. I do not see how this will change.

Deputy Devins raised the issue, but it demonstrates a lack of faith and commitment and interest in the Oireachtas committee, if one thinks that accountability will stop because local councillors are not on a committee. The reporting lines proposed in the Health Service Executive are the same as those of many existing executive bodies. The chief executive of the Health Service Executive will be an Accounting Officer, and therefore subject to the highest degree of direct scrutiny by the committees of the Oireachtas and the Comptroller and Auditor General. The Minister has proposed structured consultation with local elected representatives in the management of health services locally, which is a worthwhile complement to the governance structure proposed for the Health Service Executive.

I commend the Bill to the House.

My greatest fear about the Health (Amendment) Bill is that it will be used primarily to cover up for future catastrophes rather than as a tool to start the reform of the health services.

I fully support the abolition of the health boards because they were of questionable benefit when their managerial or executive function was assessed, but they had one vital use as far as I was concerned, they were a great source of information as to how the Government was running the health services in different parts of the country. The regional health boards showed up the glaring inequalities that exist in the health service in different parts of the country. One of the dangers of having one body is that information that is so vital in a democracy will disappear. Information is the key to ministerial accountability and is also the lock that prevents further incompetence and corruption in how we deal with taxpayer's money. There is no guarantee that, as Members of the Oireachtas we will continue to have access to the type of information that can currently be obtained from the health boards. There is nothing in this Bill that will give us more information about how the health services will be run after 2004. We may only have parliamentary questions to obtain information and be given the same nonsensical answers that we often get currently. This is a very important issue as Deputies will be taking over the role of the county councillors after 2004. We will be the watchdogs of the health services and even though fine words has been said about the Committee on Health and Children, we know that downright lies have been told to the Committee on Health and Children and information is not exactly very forthcoming when we try to seek it out. A scandal similar to the hepatitis C scandal could occur and could certainly happen in an environment where information is covered up and there is no access to it. Not only that, but millions of taxpayers money can be thrown away and squandered on all sorts of building works, expenditure and wasted taking on staff without knowing what they are needed for. Again, getting this information can be difficult.

I wish to read a quote into the record. "To deliver transparent, reliable and accessible services that offer our customers choice, convenience and value for money." That sounds like the mission statement of a well-respected, competitive company but it is a statement made to the Oireachtas Joint Committee on Finance and the Public Service by a senior official responsible for retail banking in AIB last year. He was either being economical with the truth or he did not know what was going on under his watch. I will not accuse the official of lying but if he was unfortunate enough to find out what was happening in retail banking in regard to foreign exchange services next year, instead of putting his €24 million on deposit, he could have been fined €24 million by the Irish Financial Services Regulatory Authority. Unfortunately, the legislation needed to fine the bank will not be enacted until later this year.

We can easily be given rubbish as information if we do not have a method to clarify it or to institute penalties for bad information. Transparency and accountability are important. Unfortunately, we are leaving it up to the media to inform the electorate as to what is happening in regard to Government. We seem to be ignoring the words "transparency" and "accountability". They are thrown around every report by Government but they do not operate in practice. It is important members of the Government pay attention to them and not only see them as fine words to be thrown out at meetings because they are the essence of democracy.

Tonight's Private Members' business is a motion about instances where Ministers have leaped without looking, where they have become bogged down in pet projects and where it has taken millions of euro to get them out. These Ministers should remain accountable to the Dáil, whether these pet projects go pear shaped accidentally or deliberately. We need to know whether Ministers are abusing their ministerial power and are incompetent. We would not look for resignations every time but we need to know what is happening. It would help to ensure good use of taxpayers' money.

The Government has an annual budget exceeding €35 billion, yet so much of this money seems to be just thrown away, and tonight's motion will only touch on some of that. In some cases, people may have got a little ahead of themselves, such as in the case of the Abbotstown project where the national stadium was due to be built. The State Laboratory was moved and millions of euro were spent on certain ground works which no longer seem to be needed.

Most people who oppose the Hanly report do not do so outright — they oppose recommendations in it which are bad for patient care. To a degree, I agree with some that it may be used a little in the upcoming local and European Parliament elections. What is the definition of a "parish pump politician"? I would like that question to be answered when we are talking about issues such as the health services and accountability therein. Why is there a five-storey building in Mullingar in which four-storeys do not even have windows? What happened in Mullingar between 1985 and 2004 where somebody built a five-storey building but before construction finished, it was decided that the extra four storeys were not needed? What about the hospital in Blanchardstown which was practically rebuilt but which is not open because somebody says there is no funding or staff, or there are other problems? Does one not find it silly to talk about accountability and who is supposed to be accountable when these buildings are sitting on health board or Department of Health and Children land yet we have no idea what purpose they serve and nobody seems to want to offer a reason as to the purpose they serve?

The Minister for Health and Children, Deputy Martin, is spending €50 million on a new obstetrics hospital on the grounds of Cork University Hospital. This €50 million will pay for a new hospital with 25 new labour suites, 50 new neonatal beds and many other facilities for obstetrics for the Cork region. There is also an obstetrics unit in Tralee General Hospital in County Kerry. The South Eastern Health Board region has the same number of births per annum, 5,700, yet it must increase charges in the car park to take on extra paediatricians to look after the children born in that region.

The hospital in Tullamore is another case in point. It was without question the Cinderella of the three hospitals in the Midlands Health Board region until it had the luck that the prince became the Minister for Health and Children. Tullamore Hospital was suddenly brought up to the status of a regional hospital and had its future secured because the Minister for Health and Children at the time managed to get millions of euro invested in it. That is parish pump politics. That is investment in the health services which has more to do with political reasons than implementing Government health policies. Despite all this fine talk about the Hanly and Prospectus reports, nothing I have seen in the past two years indicates to me there is any genuine reform of the health services.

The alternative to the health boards is the Health Service Executive. It is great to see AIB again turn up in terms of the alternative to running the health services. Mr. Peter Kelly is overseeing it. To my knowledge, none of the members of this new board have any direct frontline experience or have any idea what it is like to work on the frontline, yet they will dictate policy. In some respects, one could say it is just as well they do not because whoever wrote the Hanly report does not seem to have had too much frontline experience as far as the health services outside Cork, Dublin and Galway are concerned. There is no doubt about that in my mind. Since all the public upset about the Hanly report has emerged, the only clear answers we are getting are from members of the medical service involved in writing up the report. I was at the Irish Medical Organisation conference in Killarney when Dr. Cillian Twomey, who was one of the authors of the report, made it quite clear that the Hanly report was not to be implemented until the primary care strategy was implemented and until issues such as the upgrading of the ambulance service were addressed. It may not be important to the Minister of State, Deputy Callely, because he comes from a Dublin constituency and he has little understanding of what happens in many rural constituencies——

That is not true.

Maybe the Minister of State should have read the Hanly report before it was published and he could have stopped it. As far as I am concerned, the Minister, Deputy Martin, does not have much interest because again he would have stopped it.

That is not true either.

If it is not true, one would wonder why it was allowed to go forward because it is not a serious piece of medical policy in regard to reform of the health services outside Dublin, Cork and Galway. Passing remarks were made on two issues, including the ambulance service. Fewer than half of the ambulance crews are emergency medical technicians. The other half are still at the stage of advanced first aid training. None of them are legally entitled to work as paramedics. One needs to be a paramedic if one is to carry a fairly sick patient from the site of an accident on the side of the road to a regional hospital. Not to remark on that shows a clear lack of knowledge.

What about first responders? Did the Deputy read that aspect?

Does the Minister of State mean first responders in regard to general practitioners?

In relation to the health reforms.

Deputy Twomey has the floor.

The Minister of State should not encourage us to go down that road.

How the ambulance service is to be changed is not mentioned, yet that is fundamental. The report mentions that the primary care strategy must be implemented but we know where that is going. Of the 400 primary care centres envisaged in the course of this plan, which began two years ago and is to cover ten years, less than ten have been started but I am not saying they have been finished. That is not going very far, yet they are two vital components.

The Hanly report did not touch on the issue of tertiary services and I was quite surprised by that omission, considering that we are reforming the health services. The existing tertiary services include neurosurgery, although some people think we do not have such surgery because they cannot gain access to it. The same goes for other significant tertiary services, such as the liver transplant unit at St. Vincent's Hospital and the heart transplant unit in the Mater Hospital. Nobody ever examined those services to see what should be done with them — whether for instance, they should be bunched together into one hospital. Perhaps we should ask the national treatment purchase fund to change its remit from doing toenails and hernias to seeking to provide tertiary services from abroad, because ours is only a small country of four million people.

The case of the young man in County Kerry who requires a lung transplant is unfortunate in so far as the Minister for Health and Children does not have much control over the situation. When we read about that case we also heard that the Mater Hospital is spending €4 million this year to do two lung transplant operations. Over the course of the next few years it will spend €60 million to set up a lung transplant unit.

That was a promise in the 1997 election campaign.

Hanly referred to closing down acute surgical services in many of the smaller hospitals around the country. Some of those hospitals had out-patient and accident and emergency units attended by 16,000 patients per annum. The Hanly report said such small hospitals should be closed down because they do not have critical mass or enough cases per annum to justify spending money on having them on call 24 hours a day. However, we do not seem to apply the same logic to lung or liver transplants. Are we to set up a lung transplant unit that will do two cases per annum? If that is the case, perhaps the Government is right to revert to having a hospital at every cross-roads because, on that basis, as long as one or two operations are done per year, one might be able to justify their existence. Much of what is being said is illogical and I am annoyed because every opportunity is taken by Government speakers to condemn me and other opposition speakers. The Acting Chairman and I are trained medical practitioners and, while we may not know everything, we have a good idea of what is going on in our respective areas. We know quite well that the Hanly report simply cannot work. It would be disastrous if anybody tried to implement the report, as I read it or, worse again, along the lines of what I heard about it before the local elections became an issue. That has been confirmed by many consultants who have taken the trouble to read it. This is why accountability and transparency in Government decision making is so important. The Government should be able to take criticism on the chin and, to some degree, the Minister, Deputy Martin, is able to do so. He is able to appreciate that sometimes one needs to listen to what is being said on this side of the House. There are fatal flaws in the Government's policy.

The Minister for the Environment, Heritage and Local Government, Deputy Cullen, was unfortunate in letting himself become embroiled in the current situation, where another €60 million is coming up for discussion. Before we have to round off our working lives with a tribunal into the current health services, we should examine seriously what we are doing. Some €10 billion is being spent but we should have a good idea of how it will be spent after the health boards are abolished. I would not be too keen on the South Eastern Health Board and the Southern Health Board regions being lumped together. As it stands, Cork University Hospital seems to be absorbing the vast bulk of the Southern Health Board's resources. If that pattern continues in the south east, we will definitely see some of our hospitals being downgraded and shut down to feed the monster that is Cork University Hospital.

No great consideration is being given to primary care services or general practitioners' services, even in the Minister of State, Deputy Callely's, constituency. He is probably well aware that there is one GP for 2,500 patients on the north side of Dublin, whereas the national average is 1,500 patients per GP. Therefore, there is already a deficit in the services on the north side of Dublin. It does not come as any great surprise that Beaumont and the Mater have the busiest accident and emergency departments. They are providing a very expensive type of health service but that money is being thrown away. It demonstrates a poor understanding of what general practice is all about. Perhaps because GP work is not very glamorous, not enough is being spent on looking after such patients, and so general practice is being run into the ground. I have not heard anything from the Department of Health and Children to show that it appreciates there is any impending crisis in general practice, even though some parts of the capital city are already facing such a crisis.

The Bill aims to get rid of health boards and transfer their functions to four new regional authorities and a health service executive, but that executive will be unaccountable to the people. Given the way in which the new system will be structured, the Minister also will not be accountable. That issue is growing in importance politically.

When I submit questions to the Minister I am sometimes told that he has no responsibility in regard to them, whereas I might obtain a response more quickly if I submitted them to the newspapers which would find them quite interesting. Some of these questions make perfect sense to me but the lack of response means that the disastrous situations we are discussing, and that are considered to be Government policy, could be implemented yet it would be difficult to discover what is going on. If we are to radically reform the health service and get county councillors off the new regional health authorities, at the very least Members of the Oireachtas should still be able to gain access to information so that they will know everything is being done in the name of the people.

I am glad to have an opportunity to speak about this legislation. I disagree profoundly with Deputy Fiona O'Malley's assessment. It may well be true that in some circumstances debates at health board meetings did not represent the epitome of the distilled knowledge of the wider community, but it was democracy. It gave an opportunity for elected representatives to give their tuppence worth, to say their piece and represent those who had elected them. If they did not do so, they would not be re-elected. It may well be that the level of debate was parochial from time to time and may have related to issues that were seen by some sophisticated administrators as being outside the remit of public representatives, but it was still democracy. It was a system whereby the public had a representative view and a voice on the board.

The proposed change has nothing to do with democracy, accountability or saving money. It has everything to do with centralised control, which is fast becoming the hallmark not only of the health services but of many other services. Two Departments are the greatest sinners: the Department of Health and Children, and the Department of the Environment, Heritage and Local Government. In recent times, a third Department has begun to show tendencies towards centralised control.

The main reason health boards are now being abolished is to coincide with what was seen as a necessity by the Hanly report. Let us look at what has been happening in recent times where centralised controllers and administrators have taken decisions — it is appalling. Let us look at some of those decisions for an instant. The decisions taken by clinicians or administrators in the hospitals in Monaghan and Cavan had serious consequences. If a health board or one of its members had made a proposal that had such consequences, there would have been a hue and cry.

In another example, the Eastern Regional Health Authority and the authorities at Peamount Hospital refused admission to a patient suffering from a highly infectious complaint requiring isolation and specialised treatment that was available in the hospital. Why was that? The administrators, the bureaucrats, those given the job of providing a service, and not merely providing a service in the way in which they thought it should be done, turned the patient away, thereby presenting a serious threat not only to the patient but to those other patients who were then expected to have this person alongside them in other hospitals. What was the response from the authorities? They said that such cases in future would be treated in other general hospitals.

I spent a number of years on a health board, entertained by the Minister of State, Deputy Callely, much as I entertained him.

We had a great working relationship and did much good work.

We did. If a similar decision had been taken at that time there would have been a hue and cry and a special meeting would have been arranged where the people responsible would have been called to account. What happens now? Nothing, and it is intended that nothing happens. If the Hanly report is implemented, although half of the Government says it should be while the other half says it would not be a good idea in the run-up to the local and European elections, there will be totally centralised control and no possibility of democracy prevailing in future.

We are all behind the Minister for Health and Children. There is total cohesion.

Until recently there were local area health advisory committees. Those bodies met in each community care area and vetted the performance of the health services on a month by month basis. The head of each discipline would give an account of his or her stewardship and all involved would comment. Representatives of the local authorities, nursing organisations and the medical profession were involved and when a proposal was made at a meeting that might have an impact on the delivery and quality of services, it would be discussed. There was no such thing as a person making a decision that would affect the quality of services or those working in them without a debate. Now, however, there is a new era in health politics where centralised control eliminates as much debate as possible and information is withheld for as long as possible from as many as possible, ensuring the Minister does not have to answer questions in this House. Local authority or health board members do not have the opportunity to ask questions, the entire operation is as secretive as possible and the services are run in a way not seen before.

I remember being on a health board in the early days and debating centralised control. The thinking then within the Department was that big institutions were the answer to everyone's prayers and the bigger the hospital, the better it would be. That was all rubbish because the degree to which specialised areas were able to operate and link with other hospitals made or broke the service.

It is amazing how they got away with it for so long.

It is amazing how they were able to think that for so long and then suddenly forget it. Since the Fitzgerald report was published in the early 1970s there has been no focus on where the health services are going at all. This proposal would result in even less focus in future and that is a sad thing because I thought Deputy Callely was a focused Minister of State. The reason there is no focus is that everything now revolves around the money available and the extent to which a service can be provided to meet a need.

It is about time we focused on the patient and geared everything towards him or her in terms of front line care. This is what these changes are all about.

I agree 100%. Deputy Batt O'Keeffe understands this but it is sad that there are not many on the Front Bench who also understand it. If I was the Minister of State I would be careful about Deputy Batt O'Keeffe because he could be on his way to the Front Bench.

I would not bet on that.

Deputy Durkan should have a word with the Taoiseach.

People with experience at the coal face should be involved in the administration of health services, be that experience in the medical or political professions. A combination of the two is urgently required.

The Hanly report is a classic example of recent trends. There were three reports in one year, one of which contradicted the other two. The purpose of the exercise was to deflect public attention from the reality that the health services were going down the tubes at an alarming rate and to give the impression that the Government was doing something about it when it was not doing anything. Not only would it not do anything, it would silence debate on the matter, as this legislation proposes.

It is a sad time, as the Acting Chairman, Deputy Cowley, knows because he has spoken on these issues many times himself.

He will be up in a few minutes.

The consequences if we continue to deliver health services in this way will be very serious.

I spoke to a senior staff member of this House some years ago. Waiting lists and hospital ward closures were in the news and he asked how we ever survived in the past when there was a multiplicity of hospitals throughout Dublin, the country had no money and the population was half what it is now. An extraordinarily good service was provided in those hospitals.

People were still complaining then.

We were not, that is the strange thing. It was possible to get rapid service and there were no waiting lists. What happened in the meantime?

Many of those hospitals were closed by the Government of 1982-87.

The Government of 1977-81 was the Government that put the nails in the coffins of many of those services and they have not revived since. The Minister of State's memory is not as good as I thought. I am sorry to see that the health services will be called upon again because Deputies Callely and Batt O'Keeffe are suffering from amnesia.

Debate adjourned.