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Dáil Éireann debate -
Wednesday, 12 May 2004

Vol. 585 No. 3

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

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

I forgot to say on the previous occasion that I propose to share my time with my colleague, Deputy O'Dowd.

I oppose the proposal to abolish the health boards on the basis that it is ill-thought out and an elimination of one of the few remaining elements of democracy in the health service whereby locally elected public representatives can have an input on behalf of the people. It is a continuation of the Government's policy of centralisation rather than decentralisation, which is not what the health service needs.

This Bill does away with democracy. The county council health committees on which members of local authorities and the health interests were represented used to meet, but they were abolished in favour of regional health boards. These boards have not worked successfully in every case but, in every board, there is a voice for democracy, elected representatives and all the other special interests, including doctors, psychiatric nurses and other health professionals. This Bill does away with all that and hands over power, lock, stock, and barrel, to officialdom and faceless chief executives and their staff. Although they are excellent people in every way, from the day this Bill is enacted, they will not be responsible to a transparent and democratic process in terms of decision-making which can be challenged.

In Dundalk, a consultant surgeon is on duty and on call in the hospital 24 hours a day, but this service is being transferred to the Our Lady of Lourdes Hospital in Drogheda. That decision is being challenged and discussed by the board. When this Bill is enacted, such discussion will not be possible. The Minister for Communications, Marine and Natural Resources, Deputy Dermot Ahern, who is from the constituency, has called for a mediator to mediate in the dispute between the population of Dundalk and the North Eastern Health Board. The Minister is powerless if he cannot discuss this proposal with the Minister for Health and Children at the Cabinet table and insist that it does not proceed. Dundalk hospital must be kept on call and there must be a full consultant surgeon service in it at all times.

When this Bill is enacted, intervention will not be possible. There will be a wasteland of officialdom. There will be no way the decisions of health boards can be held accountable to locally elected representatives or even to this House. The Minister for Health and Children is destroying the part of the health service which can be held responsible and where elected members and the health professionals, including doctors and nurses, can challenge and discuss issues. I cannot believe the Minister, Deputy Martin, who allegedly does so much for the public — the man with the nice smile and the progressive views — is putting the boot into representative democracy, handing over the running of the health services to officialdom and removing the possibility of public debate.

This Bill is also missing another opportunity. I refer to the Neary affair and the setting up of a judicial process in which all the issues surrounding what happened in the Our Lady of Lourdes Hospital will be transparently and fully examined. Everyone is happy with what the Minister has done, with the judge and her team who have been appointed and with the professionalism and integrity of everybody concerned. The women concerned suffered appallingly and grievously at the hands of Dr. Neary. However, the compellability of witnesses is a serious matter. Patient Focus and many others believe this Bill must be amended to allow for the compellability of witnesses if there are any who are reluctant. Let us hope there are none but, if there are, at present they cannot be compelled to attend and give evidence. There is no power to find out what happened and what was the truth behind the decision-making processes in the Our Lady of Lourdes Hospital at that time. There is no mechanism to compel everybody to attend and to be respond to the issues raised.

Patient Focus announced last week that it would not participate in this important inquiry. It is not that it does not want to but it believes that if all witnesses cannot be compelled to attend, the inquiry, despite the professionalism and integrity of everyone concerned, is pointless. I urge the Minister to examine this issue before the Bill proceeds to the next Stage and to table an amendment to allow for the compellability of witnesses in this case. I know there are constitutional issues in this regard which have been discussed. However, the truth about what happened must be the prime objective. The women concerned believe everybody must attend. The Minister of State, Deputy Brian Lenihan, said last week that if a witness does not turn up or is not helpful to the inquiry, the judge can report it to the Minister who will report it to the Government. Implicit in that statement, I presume, is an expectation that the Government would act decisively should such a situation arise. This inquiry cannot proceed if Patient Focus and the women concerned do not participate. That is the kernel of the issue which is in the Minister's hands. I urge him to change his mind.

The Hanly report is being debated throughout the country, especially in towns such as Ennis, Nenagh and Dundalk. Thousands of people will protest on the streets about the Hanly report and what it will do. The core of democracy is the ability of elected representatives to debate and challenge officials and officialdom on issues, regionally and locally, but this Minister is taking the power of representation away from them. When the power is wiped out by the Government, there will be chaos and political anarchy because there will be no mechanism through which people will be able to vent their frustrations or make their arguments.

That is why this Bill is a sham. It is a disaster which is handing over representative democracy lock, stock, and barrel. There will be no place for the public. There should be no place for the Minister in this House if this Bill is enacted. Will Government Deputies remain forever mute on and absent from this debate? There will be no debate if this Bill is enacted.

I welcome the Bill. Anybody who examines the composition of the Department of Health and Children and the health boards and at the way services have been delivered will see a lack of integration between the Department and the health boards which leaves much to be desired. Over the years, many of us have examined what was happening to the delivery of health care, but how many of us have wondered whether we were obtaining value for money in this respect? How many people are satisfied that adequate funding is going to the coalface where patient services are delivered? The Minister has access to all three reports, which indicate that change is needed since so much has moved on in terms of health care.

I recall that last year health board representatives appeared before the Committee of Public Accounts, of which I am a member. On one occasion, a health board representative predicted that in June the board would have a deficit of €13 million. In December, however, we discovered that the same health board had a surplus of €6 million. More recently, representatives of three health boards appeared before the Committee of Public Accounts. The Mid-Western Health Board and the Western Health Board each had a surplus of €15 million, while the South Eastern Health Board had a surplus of €6 million. If these boards were functioning well and were properly managed, why did they need to have such surpluses at the end of the year? Could some of that money have been used to deliver extra services in each of those three health board areas? The only conclusion one can come to is that the money should have been used to that end.

How many people were aghast to find not only that information technology systems were incompatible between the various health boards, but were also incompatible with the Department of Health and Children? There would be real difficulties in planning for the future if statistics were not up to date and there was no integrated IT system.

The Bill examines health board structures, in addition to going to the heart of the Department of Health and Children. A proper restructuring of that Department is both timely and necessary. I was a member of the Southern Health Board for several years and its chairman for two years. While it is easy to criticise, it should be emphasised that there are outstanding people working in the health services. Outstanding contributions have been made on health boards by members of the medical profession and political appointees, including local authority members.

The democratic deficit has been mentioned and that issue should be examined seriously. In the past, when there was a move to close certain railway lines, there was a similar move to close some hospitals. However, the fact that local representatives were sitting on health boards meant that many hospitals were kept open, and they are thriving to this day. I would not like to see the removal of elected politicians from health service management structures. I am glad the Minister for Health and Children has indicated that there will be a democratic input into the four regional boards he is to establish, including the involvement of local politicians. That is an important matter upon which the Minister should lay great emphasis when finally deciding what form those structures will take.

There has been a media frenzy over the question of removing politicians from health boards and their cost, which of course was minuscule. It is strange that there was no media frenzy about the role of medical personnel on health boards and how well they were able to look after the interests of their own people, sometimes to the detriment of delivering services. As regards new structures that are to be established, I would like to think that the medical profession will not be in as strong a position as before when they could influence — adversely, at times — decisions that should have been progressive and in the interest of patient care.

The Brennan report is an outstanding publication because it got to the facts and highlighted financial control inadequacies within the health boards. The report reflected badly on the control mechanisms that operated within health board structures. It showed that some health boards did not even know the number of people who were employed. It showed that during the Celtic tiger era, large numbers of people were taken on, many of them in central services, but was the same percentage of personnel taken on to deliver patient care?

The proposed new structures are well worth introducing. They should be given a new focus, direction and dedication towards delivering patient care. The opposition has talked about the dangers of centralisation but let us look at the facts. Under the old system, health boards had individual departments for payroll services, human resources and information technology. Such services were, thus, being unnecessarily duplicated across the country. The new centralised structures, including the hospital agency, community care and mental health services, will have a dedicated focus so that health services will be run far more efficiently. All the expertise required for one particular area of health care will be centralised. That is a good thing which everyone will welcome.

An integrated IT system is certainly to be welcomed. If the ESB can have a national payroll, why can the various health agencies not have one? Is there any reason we cannot have a central purchasing agency for the health service, including all our hospitals? Is there any reason why health boards and health agencies had to advertise separately rather than centrally? The centralisation of certain areas of the health service will bring about major improvements.

No doubt, however, there will be a big question over staffing. I estimate that approximately 5,000 people are involved in the centralised services. The Minister for Finance has indicated that there will not be redundancies, as such, within the system but that is a problem Mr. Kelly will have to face. There will be people who are surplus to requirements when the new management structure comes into place. He has adopted a sensible approach by embarking on a process of consultation with staff and unions. Many of these people can be retrained to operate at the coalface of health service delivery.

I also wish to deal with the issues of the hospital agency, community care and mental health services. We should welcome the placing of all acute hospitals and the delivery of acute services under one umbrella. The co-ordination and integration of those services and the re-direction of patients from Dublin to other centres of excellence is something we support and espouse.

Difficulties can arise, however, if proper integration is not maintained. If a consultant in an acute hospital indicates that a patient can move on to a step-down facility and separate agencies with separate funds are responsible for each facility, what guarantee is there that the patient will be transferred? We must achieve proper integration. Last year, 1,200 acute beds in University Hospital, Cork, were tied up by patients whose families refused to move them from those beds, resulting in 1,200 fewer operations for those on waiting lists. For the new structure to work, there must be integration to ensure ease of access to step-down facilities for patients who are fit to move from acute beds.

An issue raising its ugly head is the funding of mental health services. In the three reports that have been produced there was little emphasis of funding for this area. In some of the presentations we have received in the Oireachtas Committee on Health and Children, it was stressed that there must be a focus under the new arrangements for the funding of mental health services. We are all aware that hospitals gobble up funds. We told Mr. Kelly, therefore, that under the new funding arrangements in 2005 for the various agencies, money for mental health should be ring-fenced. That cannot be forgotten.

There will be problems establishing the new structures. Some health boards chief executive officers will not be appointed to the new regional boards and staff wonder how they will be assimilated into the new system. Mr. Kelly is a wily operator. He is embarking on a process of consultation with staff and has appointed 30 people to examine the options open to him. He is ensuring the path to change is made easier by consulting those affected.

In terms of location, the Minister of State should remind the Minister for Health and Children, a fellow Cork man, when he is planning the decentralisation of health services that there is a great town in Cork South-Central called Ballincollig.

The Minister is from a different constituency.

The rehabilitation hospital should be located there.

A developer has recently taken over the Army barracks and there is plenty of space for the offices that the new health authority will need. The Minister of State should outline to the Minister the advantages of such a relocation to the Cork hinterland.

I am very fond of Cork.

He will look after Cork North-Central first.

I will look after Dublin North-Central first.

We should not underestimate the enhanced role envisaged for the Oireachtas Committee on Health and Children under the new structures. Its members will take over many of the roles played by the representatives on the health boards. The new boards will spend a great deal of time appearing before the committee and the Committee of Public Accounts.

The Hanly report raised practical issues but anything related to the health services will always cause an emotional reaction, particularly local hospitals, often because of misinformation and people playing politics. The report recommended the upgrading of the ambulance service to ensure that rural areas have a service second to none. That should be prioritised by the Minister.

I had difficulties with the recommendation in the Hanly report that all hospitals should continue to provide accident and emergency cover, with the same numbers envisaged using it. In many accident and emergency units, 29% of those attending should not be there but should be treated at their general practitioner's surgery. We must examine the number of people who are being sent to accident and emergency who could be treated in surgeries. Instead of tying up accident and emergency for those who require treatment, we should consider a role for the GP service within the accident and emergency area and under the supervision of a consultant to deal with minor accidents as they arrive.

We must examine appointments. If a new hospital agency for community care is established, do we also need Comhairle na nOspidéal? It takes nearly two years to appoint a consultant. The local health board makes a recommendation to the Department of Health and Children for funding for a post and that is acknowledged by the Department. A message is then sent to the health board to state that the funding is in place. The health board then must go to Comhairle na nOspidéal and this takes a long time. In Cork, where there are voluntary, private and public hospitals, the head of Comhairle na nOspidéal will ask if services can be shared. I recommend that we examine the future existence of Comhairle na nOspidéal. It is surplus to requirements.

I wish to share time with Deputy Deenihan.

Is that agreed? Agreed.

I welcome the opportunity to speak on the Bill before us. The Health (Amendment) Bill 2004 is critically important to the future of health services around the country. The fact that the Government is pushing through this legislation means it will be the first step in the implementation of the Hanly report. Let us consider the downgrading of hospitals such as the county hospital in Roscommon in my own constituency and Portiuncula Hospital in Ballinasloe which adjoins it. The legislation before us will give the Minister a free hand after the local elections to implement the closure and downgrading of accident and emergency units around the country. The Minister will have the power to implement those measures without recourse or referral to any public representative anywhere. That is what this legislation intends.

The law does not abolish the health board structures, as some on the Government benches seem to believe; it merely removes the health board members, the only people who might question the planned downgrading of facilities and the fact that many communities will be left without any service. The Minister is removing the current arrangements before any alternative can be put in place. That is the clearest indication yet that the Government is prepared to implement the Hanly recommendations throughout the country, closing accident and emergency units.

On the Government benches there seems to be the misapprehension that this legislation will establish the health services executive. I heard my colleague, Deputy Finneran, on local radio yesterday saying that the Health (Amendment) Bill 2004 would set it up. If one looks at what is in the Bill, one sees it abolishes the membership of the ERHA, the area health boards and the health board itself, while retaining the boards as legal entities. The legislation provides for the termination of the office of all members of the board and for their reserve functions to be transferred to the CEO and the Minister for Health and Children. The other issue concerns the acquisition and disposal of property, which was a reserve function of the board members. That is now being transferred to the CEOs and the boards must get the consent of the Minister for Health and Children before they dispose of property. There is no mention of the establishment of any health services executive in the legislation. That has been trotted out to the backbenchers on the Government side in the hope they will support the legislation when it is voted on later this afternoon.

We must have a reality check. The Hanly report is being implemented, and while Members on the Government benches will say there is no mention of such and such a hospital in the first Hanly report, there was also no mention of Our Lady of Lourdes Hospital in Drogheda. The Hanly report is being implemented as we speak. The Drogheda hospital is being downgraded and the Hanly report will be implemented over the coming weeks.

In the House yesterday and again today, the Tánaiste stated the Hanly report was central to the Government's health reform policy and that the Health (Amendment) Bill 2004 was the first phase in the report's implementation. That is the reality and anything else said by Members in this House is a misrepresentation of the truth. This Bill will solve nothing in the health service. It will not solve the health crisis and will remove the current arrangements without putting any alternatives in place. No one will be accountable or answerable regarding value for money or greater efficiency, both of which are needed in the health service. I know the Minister is hoping he will avoid any opposition to the implementation of his measures by introducing this legislation. That will not happen since there will still be very strong local opposition to the proposals to downgrade many of the smaller accident and emergency units around the country.

Another misconception trotted out is that hospitals such as University College Hospital in Galway, Sligo General Hospital and those in Limerick and Dundalk will all be upgraded. Government Deputies have failed to say there will also be an increase of one third in admissions to accident and emergency units because smaller hospitals will be downgraded. Patients will end up lying on trolleys, not only in the accident and emergency units and corridors leading to them but, as is happening in Dublin at the moment, in the backs of ambulances, since there will be no room in the accident and emergency units. What is happening in Dublin will be replicated across the country by the proposals because the Government has not set aside one extra cent for the implementation and expansion of the services and facilities in the regional centres of excellence about which it speaks.

Facilities such as those at Roscommon and Portiuncula will be downgraded by the implementation of this legislation. The Minister has gone around the country and given commitments to Nenagh and Ennis, making U-turns as he did so, but he has not given similar commitments to any of the other smaller hospitals around the country. There is no doubt people in such counties as Roscommon will be left as second-class citizens once this legislation is enacted because locally-available services will be downgraded and transferred up to 70 or 80 miles away, requiring a journey of two and a half hours, while we do not even have a decent ambulance service. There are currently no plans to upgrade any of those facilities.

Let us take one example of this farcical situation, the county hospital in Roscommon. Before the last general election, the Government allocated €7 million to upgrade the accident and emergency unit, to make it a state-of-the-art facility. We need €2.6 million to be sanctioned by the Department of Health and Children to provide the additional 36 staff required at the county hospital but the Government will not provide that. It has provided the building and the capital investment, and that is welcome, but it is not prepared to provide the current expenditure that will maintain the service. The plan is to close it in the short term. There is no radiologist on call after 6 p.m. or at weekends as the Department will not provide the resources to ensure that service is provided.

It is critically important for the future of the county hospital in Roscommon that a third consultant physician be appointed. We all know the Royal College of Surgeons recommendations coming on 1 July will mean that, if there is not a third consultant in each accident and emergency unit around the country, with the required ratio of junior hospital doctors, Roscommon will not be able to provide a 24-hour service. Taken in the context of what is being proposed under the European working time directive, that will compound the problem in Roscommon and impact on hospitals such as Portiuncula.

To date, the Department of Health and Children has not once recognised the catchment of Portiuncula Hospital in Ballinasloe. Not only does it cover much of east Galway and the southern part of County Roscommon, it also covers southern Westmeath, west Offaly, north Tipperary and many parts of Longford. However, no recognition has been accorded regarding the funding provided. Portiuncula Hospital is the only one on the N6 national primary route. The Government, in its spatial strategy, is talking about developing Athlone as a city. Nothing has happened in that regard because one cannot have a city unless one has a hospital. With the proposal to downgrade the maternity and accident and emergency services at Portiuncula Hospital, it will be farcical to talk about a city in Athlone without having such facilities close by.

That is the reality. The whole system is breaking down and nothing is happening to change that. Once this legislation is passed, no one will be accountable for these services. I will give another example of the farcical situation with which we must deal over the coming weeks. The Plunkett Home in Boyle, which is under the Minister's competency, provides services for the elderly. The Western Health Board has had discussions with staff, including a gardener and an ambulance driver, about transferring them from their current jobs of mowing the lawn and ferrying people in and out of the home to providing patient services. The ratio of staff to patients in the home is inadequate. The solution is to contract out the service previously provided and let the gardener look after patients along with the cooking and cleaning staff. That is what is currently being proposed.

At least public representatives are accountable to the electorate as regards this. As and from the enactment of this legislation and the local government elections on 11 June, no one will be accountable. Health care should be brought close to home and it should not be contingent on wealth or geographic location. The Hanly report does not allow for that. In fact the opposite is the case and the communities around the country, including the people of County Roscommon, will be short-changed by this.

As the Minister of State said, this Bill is very much an interim measure. He promises to bring forward more expansive legislation later in the year. The legislation and the changes to be implemented on the way health services are organised are based closely on the three reports with which we are all familiar: the Prospectus report, which was an audit of structures and functions in the health system; the report of the commission on financial management and control systems in the health system, from the Department of Finance; and the national task force on medical staffing, now referred to as the Hanly report.

We all agree and have been calling over the years for better systems, a more patient friendly health system, better value for money and so on. However, as Deputy Mitchell said in her contribution on Second Stage, this legislation removes all accountability from the system based on elected representatives and fails to replace it with an alternative. The whole area is totally grey as regards what is to be put in place and what the structures will be. I inquired this morning from people involved in major functions in the health board as to what the new hospital agencies group will do about the health service executive, the new hospital services agencies and what the implications will be for hospital clusters. They certainly did not know. Obviously, there is a lack of clarity and no certainty on this issue. The only certainty with this legislation is that it takes local representatives out of the equation.

Listening to Deputy Naughten, I probably had not read this into the Bill, but it appears that the function is to take local councillors — in particular local Fianna Fáil representatives — off the health boards, so that it will make it much easier, both for the health authorities and the Government to close hospitals and reduce services around the country if the Hanly report is to be put in place. Deputy Naughten made a convincing argument in that regard.

Like all other Deputies I will take the opportunity to refer to my area and to Tralee General Hospital in particular, which has been in the news recently. It is rather unprecedented for a hospital consultant to write a personal letter to the local Government Deputy and accuse him of not being aware of what was happening in the services in the hospital. The letter also implied that the Government had no particular interest in Tralee General Hospital and was not concerned about it. Tralee General Hospital is overwhelmed with patients. There are not enough consultants to deal with the number of patients being admitted; and there are not enough beds. This is impacting enormously on the health of the people of Kerry. For example, for the past two years because of closures there has been a reduction in elective procedures. Patients who should have been dealt with under elective procedures are now being admitted as emergencies, which is putting more pressure on the consultants, on beds and other resources. Recently I met someone who had to wait six hours in the accident and emergency department in Tralee. That is not the fault of staff. It is due to lack of resources and staffing.

There were plans for a new accident and emergency unit, but I understand these have been scrapped. With the health board gone, there will be no representatives from Kerry as such, not that the incumbents did a great job. We have six elected representatives, five of them from Fianna Fáil — including the two Healy-Raes, who I presume are Fianna Fáil. They did not constitute a sufficiently strong voice for Kerry, but at least they were there. The people could identify with and refer to them.

A ward will be closed in Tralee for three months over the summer period. No non-urgent patient will be seen in the out-patient section during that period. At present up to 2,000 patients in this category are waiting to be seen, many of whom would have undiagnosed cancers. The Minister of State may be aware that in one instance a legal case is pending because of cancer remaining undiagnosed owing to a patient not being seen. In addition, the population of Kerry swells over the summer months, in July, August and September, in particular. When one considers a hospital facility in Kerry it does not cover just 126,000 people, but the large tourist population that visits the country on a continuous basis. The level of service provision in Kerry must be considered totally different from other counties that would not have the same influx of tourists.

Hospital authorities and administrators are worried that under any new arrangement the current budget for the hospitals of €57 million will be left in place. This is just not adequate. There are now threats of mass protests and marches on the Dáil from other politicians in the constituency. I do not want that to happen. I am just saying to the Minister of State and his officials that Tralee General Hospital should be looked at again. A top official from the Department of Health and Children should be sent to Tralee to look at the provision of service there and the hardship that the closure of the ward during the summer would cause. The proposed closure is bad for patient care and disappointing for the staff. With proper funding for the hospital the closure would not be necessary. Last year the hospital was under funded by about €2.5 million, and this year it is under funded by about €1.5 million. A day surgery ward was provided and equipped, but it lies empty and unused because there is no money to staff it.

As I mentioned, elderly patients with broken hips and those who may require major surgery for cancer have had their operations delayed because of the lack of intensive care beds. A high dependency unit has been equipped and would solve the intensive care problem, but there is no budget to staff it. I saw recently in the Sunday Tribune that something like 1,500 people are to be appointed across the country to the health service, for hospitals and various matters. Approximately €400 million will be provided. Perhaps these figures are exaggerated. They came from Government memos. This is happening throughout the country at a time when the services in Tralee are being cut back and the hospital there is not receiving its fair share.

Kerry has the highest rate of cardiac illness in the country and, until now, Ireland had the highest rate in the European Union, although this may change with the accession of new member states. There is no cardiologist in Tralee. An appointment was promised but this has not happened. Last week on Radio Kerry I promised the people of Kerry that I would ask the Minister to send an official from his Department to Tralee general hospital to discuss what is happening there with the consultants and the manager.

As the last remaining health board and Oireachtas Member I welcome the opportunity to speak on this Bill which regrettably I cannot support. This morning I received a call from a distressed mother in Monaghan whose 17 year old son is in hospital there. The consultant physician describes the boy's condition as urgent and advises transfer to Beaumont hospital but that cannot happen unless he has private health insurance. If I thought that abolishing health boards would eliminate such problems, I would endorse the Bill, but these problems will recur. There is a need to change health board structures. When the boards were established more than 30 years ago, they comprised four representatives from each county council in an effort to soften the blow of removing the responsibility from the councils. Many would argue that there was a better health service under the county councils and when there were fewer executives.

Health board members are blamed for the failure of the health service. They are being presented as the rogues in the set-up. That is wrong and false. We will have health service problems in future. Getting rid of health boards will not get rid of the problems. Up to 97% of health spending is predetermined before it gets close to the health board. Even if all health board decisions for the remaining 3% were wrong, that would not explain the pathetic state of the health service. Instead of abolishing the boards we should reconfigure the service. The health boards have given us good service. Board members were watchdogs seeing where services were delivered and, more importantly, where they were removed and objecting to that. Executives no longer seem to manage the health services. Whenever a decision is required, they set up a committee, look for a report and this becomes a policy. Too many health board members are prepared to endorse rather than question these committee reports and recommendations.

There are 11 chief executives running the health boards and they have 55 deputies. If one were to transfer that structure to Birmingham, which has a similar population, people would say the system was failing because it had too many executives and not enough hands-on employees. Health board cutbacks usually start from the bottom with the carers or home helps, never at the executive level. Those positions are always full. If we want to ensure value for money, we should cut back at that level. Rather than abolish health boards we should ask whether these executives are necessary. For example, who runs the services in Ennis and Nenagh? Is it the chief executive of the local board?

The same might be asked of the north-east because the Ministers seem to take a large slice of the action whenever it moves into their back yard. They do not want these things happening and that is why the Hanly report has been conveniently sidelined for a short time in Ennis and Nenagh. This is a type of band-aid solution to carry the Government over the forthcoming elections, but the agenda will not go away.

The Minister for Communications, Marine and Natural Resources, Deputy Dermot Ahern, who comes from County Louth, this morning demanded inquiries and action by the chief executive of the health board into problems there. No one is listening. The abolition of health boards will not change this.

I thank all the Deputies for their contributions to this debate and I and my officials have noted the views expressed. It is unfortunate that the Opposition opposes this Bill because I and most people in the House believe it is necessary to have the required radical reforms of the health services. That is why I do not understand the opposition to the Bill.

When we see them we will support them.

The provision and delivery of our health services is a core priority of the Government. Many positive developments are happening in the service and the Government has made a good beginning, but we acknowledge the need for and wish to achieve a great deal more to improve and enhance the delivery and provision of all services to meet a first-class world standard.

I am equally frustrated that the Opposition complains about the services because, while we all agree that the present situation cannot persist, no real alternative has been proposed.

We apologise for not running the country on behalf of the Government.

The existing structures have been in place for approximately 30 years, except perhaps in the east where the former Eastern Health Board, now Eastern Regional Health Authority and the three area boards, was established. In that time there have been significant changes in society, medicine and its delivery, technology, diagnostic equipment and the way we do our business. That is all the more reason for us to have the appropriate reform of the health structures that have served us well for the past 30 years.

The primary purpose of the reform programme is to improve patient care by providing a responsive and high-quality service while also providing an improved working environment for all those employed in it. While it is acknowledged that the current structures have served us well for the past 30 years, it must now be recognised that change is needed to ensure that the health services are responsive to the needs and challenges of delivering high quality services in the changing environment of the 21st century.

This is the first of two Bills which the Minister for Health and Children intends to bring to the House this year to provide the legislative basis for the reform programme. The Bill before the House today is only an interim measure which is being put in place to ensure the smooth transition from the existing structures to the new structures which will be established by the second Bill. That legislation 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 provide for improved governance and accountability as well as planning, monitoring and evaluation.

In this context I wish to deal with some of the points made by Deputies during the course of the debate and to assure the House that the Government takes seriously the issue of democratic accountability throughout the system. This is why the Minister outlined his plans to the House last week to include accountability at all levels of the system as a central part of the reforms. He specifically mentioned his plans to put in place appropriate mechanisms to support the development of structures 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.

When the damage is done.

I support the view, as I said previously, that locally elected representatives should have a meaningful role in the new structures being proposed.

Not just a superficial one.

The Minister has pointed out that the provisions are likely to include the establishment of a series of regional fora to facilitate local representatives in raising issues of concern with the new executive about health services within the region concerned. These fora would allow local representatives to comment on and raise issues regarding the development and delivery of local health services. Members would also have the facility to raise particular issues with the executive.

The overall objective of putting in place such arrangements is to ensure the voice of local public representatives will continue to be heard on the development of health services. These mechanisms will complement and reinforce the role of this House and the Joint Oireachtas Committee on Health and Children in holding the system to account at national level. There is no question, therefore, of relying on the Dáil to replace the democratic input of public representatives at regional level.

The health strategy set out as one of its objectives greater community participation in decisions about the delivery of services. The health boards executive, in association with the Department of Health and Children, issued guidelines to the health boards on community participation which set out the principles and framework for structures for such participation. To date, most of them have set up consumer panels which deal with a wide range of issues such as the development and delivery of services. Two boards have also established regional advisory panels for older consumers and their carers. The Minister clearly stated his intention to establish these structures on a statutory basis in the Bill which he intends to bring before the House later this year. In addition, he indicated that as part of the Bill he would establish a statutory framework for complaints procedures in line with the commitments given in the health strategy. This will further underpin the level of accountability throughout the system. However, as well as ensuring greater accountability, it must also be recognised that there is a need to address the management of the system.

A number of colleagues raised the issue of management. The previous speaker referred to the number of executives in the health service. He appeared to suggest that the proposal should be abolished and that everything else should be left in place. I am not sure if that is the way we should go about our business; cherry-picking some from the system and leaving others.

I said the numbers of executives should be reduced.

Deputy Naughten referred to a commitment to introduce legislation on the Health Service Executive. The Minister could not have been clearer; he made a definite commitment to introduce legislation to establish the executive later this year.

He also made a commitment to provide 200,000 medical cards.

The Minister of State should show me where that reference is included in the Bill.

The Deputy should have listened to what was said. It is not included in this Bill. We said it would be included in the next Bill.

I agree, that is the point I made.

We do not trust the Minister of State.

Why is Deputy Naughten raising the matter?

Evidently, the Minister of State was not listening to me.

Please allow the Minister of State to continue without interruption.

Can we rely on that promise?

The issue is clear. The Bill only provides for the interim period between the date this Bill comes into operation and the establishment of the executive.

I have my doubts.

Deputy Deenihan referred to the removal of public representatives with no indication of what structures would replace the current system. That is not true.

He also indicated that it was a means and mechanism to close hospitals. Any level-headed individual listening to the debate would consider a person indicating the Government will close hospitals——

They would be right.

——in need of hospital attention.

We will give the Minister of State all the attention he requires.

The reality is that hospitals will be downgraded.

They will be turned into nursing homes.

Some may need a long-stay institution, rather than a nursing home.

Will gardeners be taking care of people?

The Minister of State should be allowed to reply without interruption.

When the Minister of State begins to hallucinate, we will know what the problem is.

Please allow the Minister of State to continue without interruption.

It is necessary to terminate the office of members of health boards to prepare for the replacement of health boards with the Health Service Executive next year. As Members of the House are aware, it is stated in the Health (Amendment) (No. 3) Act 1996 that it is the function of health board members to approve a service plan for the board for the following year. Without in any way questioning the integrity of health board members, it has to be acknowledged that it is against all principles of good governance to have a body making decisions regarding budgets and services for which it would have no responsibility for implementing. I would like to hear the argument if that was planned. It is for this reason that the arrangements set out in the Bill are being put in place for the short period of time prior to the establishment of the executive. I hope this clarifies the position.

I had the privilege of serving on a health board and a health authority with a number of Members of the House, including my good friend, Deputy Olivia Mitchell. We did much good work in the Eastern Health Board and the Eastern Regional Health Authority. Other Members of the House such as Deputy Durkan have also given great commitment to serving on local health boards. I pay tribute to every health board member over the past 30 years or so who contributed to the excellent work carried out to meet the needs of the area in which they served.

I totally dissociate myself from the remarks of Deputy Fiona O'Malley, particularly those regarding the role of health board members. She referred to the 263 members of health boards and also the accounting procedures of particular health boards. As someone who has considerable experience of serving on health boards since 1985 and working with executives and board members, I have nothing but the height of admiration and respect for the vast majority who served on them. I am amused by her comments and question the reason the Progressive Democrats continued to nominate health board members up to recent times if that was the party's policy in this regard.

Why does the Minister of State not ask them? He is serving in government with them.

We had and have a tremendous Eastern Health Board, Eastern Regional Health Authority and three area health boards.

Why abolish them then?

We have had a great input from board members and great commitment from executives and chief executives who have done a tremendous job working together in partnership. There was concern in different circles when the Eastern Health Board was restructured to form the Eastern Regional Health Authority. We should learn from our experiences and ensure we get it right. This will facilitate the modernisation of the management of the service and enable it to deliver services in a more efficient and effective manner as well as helping to strengthen governance and accountability across the system. I am running out of time.

So are health services.

Please allow the Minister of State to reply without interruption.

The issue of funding was raised. The spending figure for capital and revenue this year will be more than €6.5 billion higher than the level of funding provided in 1997.

We now have a worse service than we had then.

We will spend €10.4 billion which is close to——

How could the Government achieve that? The service has been reduced and we have to pay more for it. Houdini would not have managed to do that.

The way the Government has squandered money is a disgrace.

——a 200% increase in funding.

The Minister of State must conclude.

I have been interrupted. The Deputies opposite do not like hearing the truth.

We pay more money but we get less service.

Will the Minister of State apologise to the House? I am surprised at him. Some €6 billion is being spent, but people are getting a reduced service

That figure is just shy of a 200% increase in funding. This extra investment has brought about record levels of activity in acute hospitals——

There has been an appalling squandering of money by the Government parties since they took office in 1997.

The Minister of State's time has concluded and I am obliged to put the question.

——-and provided a range of additional services across all care programmes.

We do not have any service, but more money is being paid for it.

I ask the Minister to conclude.

This level of funding and activity confirms the Government's commitment——

It does — just about.

——to strengthening and further developing the health services which will be enhanced by the reform programme.

The new structures——

What new structures?

There are no new structures.

——are essential to ensure that health services are responsive to the needs and challenges of delivering services in the changing environment in the years and decades tocome.

The Minister of State will not conclude.

This interim Bill is only a small but important part of the reform programme——

There is a downgrading of services throughout the country.

——and marks a further step in the process of the implementation of the programme.

It is a process of elimination.

It is a further sign of the Government's commitment to the delivery of a reformed health service——

As outlined by the Hanly report.

——which is designed to maximise the level, quantity and quality of care provided to patients and clients.

Question put and declared carried.
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