Amendments Nos. 1, 2 and 6 are related and may be discussed together.
Health (Amendment) Bill 2004: Report and Final Stages.
Would it be possible to have circulated the list showing the grouping of amendments? I have not yet been supplied with a copy.
The list will be circulated.
I move amendment No. 1:
In page 3, between lines 31 and 32, to insert the following:
"(3) Notwithstanding subsection (4), insofar as this Act provides for the removal of elected representatives from membership of health boards, area health boards, or the Eastern Regional Health Authority, this Act shall not come into force until meaningful new arrangements to ensure democratic accountability are in place.”.
I agree it would be helpful if, in terms of the grouping of amendments, we knew the position. However, this is all part of a grand stratagem. If we are issuing compliments, I commend the Government on teaching us how to railroad legislation through. I presume that the next move will be to railroad through legislation to get rid of local authority members. What do we need them for, if county managers can make all the decisions? The latter is the tenor of much of what the Government has been doing. Matters would be much neater if we removed any local accountability.
I wish to make the case in respect of this amendment for some understanding about what is important in terms of the operation of the health service. If there is no input from local communities, we will not end up with a better health service. Instead, we will create a service that will not appreciate or understand the needs of those communities. It is disturbing that, at a time when the Government has adopted a solely top-down approach, we are seeing the dismantling of a framework that was designed to serve local communities, particularly in terms of the provision of community and local hospital services. This is not being done for want of a reason.
The Government's intention is clear and is set out in the Hanly report. Regardless of the mumbo jumbo uttered by the Taoiseach on Leaders' Questions, it is clearly stated in the Hanly report that local hospitals will be downgraded and that accident and emergency services will be located in 12 centres. That agenda will be driven by CEOs in health boards who will be accountable to no one. These people will have significant powers and will be similar to despots. They will not be obliged to answer to anybody apart from the Minister for Health and Children regarding the disposal of property or the changing of services within their remits.
Everyone is aware that the existing system is not perfect. It is far from it. However, even Professor Brennan argued for the retention of democratically-elected public representatives on reformed health boards. However, the Government is not interested in that. Fianna Fáil and the Progressive Democrats are not concerned with democratic accountability because it gets in the way of their plan to ensure that the health service will operate on a centralised model that will be about value for money — a matter about which nobody argues — and because the agenda is being driven by the Minister for Finance, particularly regarding reducing funding. Never has the Department of Finance had an input into the management of the health service such as that envisaged under the health reform programme. There will be a great deal of accounting but no accountability.
The Labour Party is proposing, in the form of the amendment, to ensure the change will not come about until an alternative democratic framework is put in place. Such a framework has been outlined, in theory, by the Minister but he has never actually explained what is involved. A later amendment tabled in the Minister's name refers to CEOs presenting themselves in front of Oireachtas committees as if this somehow represents accountability. It is simply not tenable. Local democracy is about local communities, intensive scrutiny and the delivery of information and services at local level. No Oireachtas committee can deal with that kind of detail about local services in the same way that health boards can do so.
Everyone on the Opposition benches would agree that reform of the health boards is required. The Bill, however, does not represent reform. It will lead to the wiping out of an entire tier of democracy and local government which has sustained the health service, despite the various restrictions and limitations put in place by a Government which told many stories during the general election campaign but which, following the election, began to systematically cut back on services, to set embargoes on staffing and, by means of the ridiculous ELS requirement implemented by the Minister for Finance, to ensure that even where health boards were providing new services and facilities, they could not commission them.
We are losing something of value here. Something is being taken from the people by a Fianna Fáil Minister and the matter is not being dealt with in any satisfactory manner by an eleventh hour proposal by the Minister for Health and Children on Report Stage with regard to CEOs. As far as I can see, the Minister's proposal is all about let-out clauses for a CEO.
A CEO will be able to buy and sell property. On a daily basis a CEO will make decisions and determine the shape of the services the health board provides, but there will be no health board. It is like the Cheshire cat. The cat disappears and all that is left is the smile. The board disappears and all that is left is the name and the seal. This is nonsense, yet what is being proposed here is that somehow there will be an idea of a health board even though there will be no substance to the idea.
Local accountability and democracy are not easy and should not be treated with disrespect. They are about ensuring that where people do not have power at central level or influence in the higher echelons of Government, they can go to their local representative and tell him or her that their mother is dying because she cannot access care when she needs it, or that their grandfather needs services close to home but cannot access them because he lives in a rural area, or that children in a local school need dental services.
Whatever the issue, the rich, open access people had to representatives is being wiped out in a crude way by a Government which is bereft of ideas as to how to manage the health service, apart from presuming that, somehow, if financial accountants operate the system, everything else will fall into place. It will not. We may end up with good accounts but there is no guarantee that we will end up with a good health service. The likelihood is otherwise. The evidence is clear elsewhere, particularly in the example of New Zealand, which ended up returning to more health boards than ever with politicians and public representatives on them.
I urge the Minister, even at this hour, to take into account the concerns people have in communities about their health service and board and how they can ensure they are responsive to their needs.
I am upset about the situation with regard to this Bill. On Committee Stage, I discovered a worthwhile amendment was ruled out of order without any apparent reason as to why this should happen, which was a waste of time.
Amendments Nos. 1 and 2 seek to ensure that the democracy being removed from the health services through the abolition of the health boards is returned and that whatever part of the democratic system the Bill has removed is restored. It is like throwing out the baby with the bath water as there is no point in having a service that does not represent what the people want. People want to have a service they can access. However, we have seen our current service totally destroyed.
It seems we are now taking this road and the Bill seems to be the tool to allow a total dictatorship in our health services, where the Minister will decide what he wants and all opposition will be finished with. We will have to accept the Hanly report, the radiotherapy report and all Department of Health and Children-speak.
I am concerned about this Minister. He is a "Yes" Minister who has no mind of his own. He is taken over by his officials who make all decisions as to what he does or does not do. The zeal with which he took on the smoking ban was welcome. However, to me it smacks of being the good boy and doing what was needed, although I agree it was needed.
We also need a proper funding service but the Minister is not providing that. Instead, he is introducing a new audit system to ensure he can cut back even more. The problem we have had with our health system is its lack of finance and proper capacity. While we all agree reform is necessary, the proposed change is from over representation to gross under representation. This cannot be tolerated. The health strategy talks about equality and fairness. Where is the equality in this? It does not exist. The proposed structure is a complete audit structure to ensure that more money is saved and that we have less money for health services. It can only end in disaster.
The health strategy talks about, as the Minister mentioned on Second Stage, better health for everyone, fair access, responsible and appropriate care delivery and high performance. These amendments are necessary because we do not have fair access, as can be seen from the trolley situation. My locum received a letter yesterday from Mayo General Hospital asking him not to send any more patients to the hospital because there were already 13 patients on trolleys and there was unlikely to be a resolution of the situation. Where are equality, equity and fairness in this? This is health apartheid, which will be further reinforced by the new system.
We all agreed that there were too many agencies and gross duplication in the system. However, what is happening now is a total about change. It is a change to a dictatorship or quango. Yesterday when I asked when the orthopaedic unit would open in Mayo General Hospital, which was supposed to begin on 1 July, I was told it was a matter for the Western Health Board. At least I will get an answer from the board, however, where will such questions be passed from now on? Where will accountability rest?
The Bill proposes a complaints system but that will be of no use. A complaints system for people unhappy with their treatment in the health service has been mooted as an alternative. Previously people could make their complaints to elected representatives. However, the proposed complaints service seems to just provide a session where people will be able to state their gripes on four or six occasions a year. People with a grievance will not get a proper return on any complaint they make. The Minister will end up with people from all sides pressing him.
The proposed system will be another quango which will be as undemocratic as the NRA or any other such body. It is time we ended health apartheid. The confusion over the next six months when all the power of elected representatives goes to CEOs is not good enough. My fear is that in that context we will see full implementation of every wish list held by Department officials. We will see the Hanly report being pushed through and the end of any local service which would give a semblance of a proper health service to which people would have access.
The Minister could have put some money into the primary care strategy this year but he has not done so. Where is the fairness in that or does it show any attempt to improve the situation? The Bill's proposals smack of a Department agenda of centralisation. I cannot understand how the Minister can stand over it. It is regrettable that the Minister of State does not support and will not accept this amendment.
I also support the amendment. Deputy Cowley was not the only one who had an amendment ruled out of order on Committee Stage. We all had similar experiences. Minor changes were accepted as being legitimate but when proposed as amendments they were not accepted. There has been no real debate of the issues. If one was opposed to the principle of the Bill, which is what the Opposition should be doing, one was ruled out of order.
No Member would say that the health service is without problem or that it does not need to be reformed. Of course, it does. The question is why is this being done now by way of this legislation? From where did this proposal come? There was no indication this legislation would be necessary at the early stages when the three reports were issued and the Government's reform programme was published. It is not necessary.
I understand the local elections are coming up and the Minister did not want to reappoint people to health boards, but there is no reason he should not do so. Surely some continuity and certainty in this regard in the health system is essential until we know what will be put in its place. As I said on Second Stage, we are being asked to take a leap of faith but we have no reason to do so, knowing that in the next number of months critical decisions on the health service, which will dictate how it will develop over the next 20 years, will be taken. We want to be able to monitor those decisions. They may be wonderful decisions or they may not be, but nobody will know. That is the objection we have to what is proposed.
We must proceed carefully and slowly and with certainty that every step taken will be monitored and observed closely before we wipe away a health service system that is costing €11 billion a year and sacrifice the scrutinising function councillors performed on behalf of us all over the years. I do not know on what altar that function is being wiped away. Is it the altar of securing value of money? I doubt it. Nobody doubts that there is a need to secure value for money and perhaps we were not getting it. It was not being secured in every aspect of the health service. However, the reality is that there is no guarantee we will get it from faceless bureaucrats.
The basis of good governance is accountability which must be embedded, otherwise we will get inefficiencies, no matter how good the people are who deliver the service. I know a number of the CEOs of the health boards and their officials and I have the highest regard for them. They are wonderful people whose work goes unsung. However, the reality is that in any system where there is no accountability, particularly in one as vast, all-embracive and as critical to people as the health service, we will get inefficiencies, scandals, a lesser quality of health service and a disaffected workforce. Systems such as this, which do not have embedded in them democratic accountability, will eventually end up being self-serving systems. No matter how good these people are or how hard they try, they will end up being part of a self-serving system with the result that they cannot serve the patient, the taxpayer and the public interest. In view of this, I support the amendment.
I add my voice to the voices of those supporting this amendment. The intention behind this legislation is to centralise "quangoise" and ultimately privatise the health service. This is something to which Maurice Nelligan referred recently and I agree with his analysis.
Did the Deputy say "incentivise"?
No, I did not.
That was a nice try.
I said "centralise" and "quangoise", a word that probably is not in the Oxford Dictionary , but that is applicable in this case.
We are seeing a velvet purge of the democratically elected representatives on the health boards, people who have served us well, whose work in that regard did not cost the State a great deal of money despite the propaganda that they were going on junkets here, there and everywhere and being paid huge salaries. Niamh Brennan showed this was not the case. She put forward the idea of retaining those who are democratically elected because they know their communities best and can make representations on their behalf. It is precisely because they can become troublesome to the Government that they are being eliminated. That is the intention behind this legislation, to enable the Government to proceed with the reforms.
We have heard of the Government railroading legislation through these Houses, but in this instance it is railroading through radical and retrograde reforms of our health service. There is considerable evidence to show that those countries which follow a decentralised model are the ones with the most successful health service. I am thinking in particular of the Scandinavian countries. This is the model we ought to be emulating. Instead, I find what is proposed reprehensible in many ways. What we are getting is a health service that currently cannot cope with the demands placed on it. Those of us who have been canvassing at the doorsteps can testify that the issue that is raised most often is the terrible state of the health service.
People from the Fianna Fáil Party who served on health boards going back many years and who served that party well have made representations to me because they are disgusted with the way the party is treating the health service. What the Government is proposing in this legislation will remove the accountability we want in place.
The Minister of State said there will be more accountability in the system and that we will be able to put questions in this regard across the floor of this House. I do not believe that. It will be stated in the House that this is not a matter for the Minister but one for the health executive. Therefore, more accountability will pass from this House. We have been told that the members of the health executive will be answerable to the Oireachtas Joint Committee on Health and Children. How often will they appear before that committee, how long will those meetings last and how many questions will we be able to ask them? That will be a particularly frustrating and futile exercise.
When the history of our health service will be written and updated, this legislation will be considered as being particularly retrograde. It will lead to further reforms of a kind I find incomprehensible. I am out of the loop in terms of Progressive Democrats and Fianna Fáil thinking because I believe in a public health service but, clearly, many elements in Fianna Fáil and the Progressive Democrats do not.
The national treatment purchase fund is being used to pay people to go into private hospitals, which is ludicrous. Why do we not invest in our public hospitals? I do not understand the logic behind what the Government is doing. What was previously perhaps an election ploy is now a pillar of the Government's health strategy. Instead of getting the basics right and delivering on the promises the Government made to the electorate to provide more beds, deal with the capacity problem, tackle the waiting lists — we know how the Government has dealt with the figures in that respect in that they are completely wrong — it is going down a route which will make the gap between public and private health care even larger. Those who have a medical card are lucky to have one, but public patients will continue to be treated as second class citizens under the health service.
The Health (Amendment) Bill is not the work of a reforming Government. It is retrograde because it seeks to abolish democratic accountability for the delivery of health services in this jurisdiction. It is incredible that such a proposition has been made separately from the health Bill. As I said, the proposition and the Bill should, at the very least, have been presented in tandem. Such an approach would have ensured the House and wider opinion would have been informed of exactly what was being proposed. We know there will be a health services executive and that four regional bodies will be established to deal with community care. However, there is no democratic accountability.
Such a lack of democratic accountability is best underscored by the Ceann Comhairle's decision to refuse to allow me to move amendment No. 3. I support amendments Nos. 1, 2 and 6 which address the issue of democratic scrutiny and accountability. The Ceann Comhairle has ruled that my amendment is out of order because it is outside the scope of the Bill. It sought to insert in page 3, between lines 36 and 37, the words, "With respect to each function conferred on the Minister by this Act he or she shall be answerable and accountable to the Dáil by means of Parliamentary Questions".
Surely such an amendment does not threaten in any way the equilibrium between the Minister and the Opposition spokespersons. Surely the suggestion is representative of best practice. I am concerned that, like Macbeth, the Minister will wash his hands of responsibility for many of the actions that will be taken by CEOs in the months ahead. It is incredible that the Ceann Comhairle's decision ostensibly means that any attempt to make the Minister accountable to the House for the functions conferred on him by this Bill, for example, by means of parliamentary questions, will be deemed to be outside the scope of the Bill.
We have a serious situation in the North Eastern Health Board which has a significant portfolio of property. The portfolio was built up by the generous contributions of ordinary citizens during the local authority's period of responsibility and jurisdiction over health care delivery in their areas. Before the health boards were established, we had an excellent general hospital while excellent psychiatric services were provided at St. Davnet's Hospital, significant parts of which are under-utilised or no longer utilised.
There are real concerns because there is no democratic accountability. Will CEOs decide to sell properties and redirect the moneys realised to investment in other areas? It may be the case that areas which have not worked hard, suffered and invested over years of penury will benefit. Great contributions were made in most cases at a time when domestic rates were charged and rates imposed on agricultural holdings. We had a better and more comprehensive health care service in such times.
We have been left with a depleted and deficient health care service because draconian steps have been taken by health boards at the behest of the Minister and the representative bodies of the various consultancy groups. A diminution of services at any hospital site diminishes us all, regardless of where one lives. One cannot say it is not happening in one's back garden. The Taoiseach was happy to say he was lucky to live in a community that had easy access to all of Dublin's excellent services. He may like to boast but I do not doubt that many in this city consider the range of services to be beyond their reach in many instances. I mentioned that the availability of health services can be divided into two tiers on a geographical basis but problems arise for most on the basis of their ability to pay. As wealth can buy health in this jurisdiction, suffering is the reality of their day's condition for the many who have to go without.
The Health (Amendment) Bill 2004 offers no solace to those who have struggled to ensure adequate health care provision is within easy reach. We are not talking about all-singing, all-dancing centres of excellence at every hospital but about basic services. All maternity and paediatric services have been removed from Monaghan General Hospital, a notice at the entrance to which advises visitors that they should note that no maternity and paediatric services are provided by the hospital. The reality is that a sign has been erected to turn people away at the gate.
The Deputy will never bring it back.
I will always try to do so. As someone who was born in the hospital, I am not ashamed to say the umbilical cord has never been cut. I am as attached to the hospital as everyone else in my community. We will always struggle to reinstate a level of service that will lift the dark cloud from over the lives of our communities. The reality in our community is that infants have been lost during childbirth and women have been lost in the middle of cardiac arrest. It is sad that such a reality will be replicated because the Government intends to implement the Hanly report, using the Monaghan formula as a template, in hospital sites throughout the jurisdiction. As a Deputy said, when the history of this affair is written, it will prove to have been the saddest and darkest time in the history of the State's health care provision.
In my experience, the CEOs have sought to ride roughshod over the 30 member composition of their respective health boards. They will now be left to work on various projects, they are in place either to perform or progress without any accountability and pursue whatever agenda they wish. Nothing in the Bill or its explanatory memorandum states all of this will end on 31 December 2004.
Hear, hear.
Another amendment in my name which has been ruled out of order sought to insert a sunset clause. It proposed to bring to an end and at a specific date the objectionable and intolerable situation to which the Bill will give rise. I do not want such circumstances to start and certainly want them to end at the earliest possible date. The Minister has said that it is "scheduled" for January 2005. I am aware that various elements of promised legislation have been scheduled. We see it when the Government publishes its schedule of legislative intent for every parliamentary session and lauds it in the House. The reality is that there is no link between the two. One cannot say "snap" as one would do when playing a children's card game. They do not match and will not match in this instance. I wonder at what point in time the Minister will feel the CEOs have exhausted their usefulness. In the first instance, we have seen the devastation of hospital care over a whole range of services from primary care onwards. What devastation is promised now?
I support the amendments tabled by Deputies McManus and Cowley. We are looking at the last vestiges of health boards that have been abused by virtue of the Government's representative monopoly which was put in place to dictate policy. Rather than putting the interests of the respective communities first and having failed to recognise that diminution anywhere diminished us all, the Government played a parochial game; by putting the Minister first, it blocked real opposition and concerted campaigning to save critical services.
I have mixed feelings about the health boards, of which I have some knowledge. We all recognise that significant reform is necessary but this is not reform. Outright abolition is not the answer, it is only indicative of failure. I reject the Bill completely. For whatever modicum of rescue these amendments represent, I will support them.
I welcome the opportunity to speak on these amendments. I support those tabled by Deputies McManus and Cowley. I echo what my colleague, Deputy Olivia Mitchell, said — there is no mention in the legislation of democratic accountability and, in fact, the opposite is the case. It is somewhat hypocritical to be debating the Health (Amendment) Bill 2004 because it should be called the Hanly implementation Bill. That is what is before the House today and once the legislation is passed, the Government and the chief executive officers will have a blank cheque to implement whatever changes they want within the health service. The Minister of State has said that this is the first step in the reform process for the health service but there will be no debate about the reform process and no element of opposition to any of the reform proposals. When the amazing legislation, which we are supposed to see sometime next year, is published all this alleged reform will already have taken place and the Hanly report will have been implemented. That is the reality of what is before us today.
Everyone accepts there is a need for reform within the health service. The penny has only just dropped for the Government, which now realises that, after increasing the health budget from €3 billion to €11 billion, it was only throwing money into a bottomless pit. Everyone accepts the need for health reform and that regionalisation of the non-emergency acute services is the way to go. The issue, however, concerns the emergency acute services which will be regionalised, thus causing deaths. This legislation will facilitate that process.
It is disappointing that on Committee Stage the Minister was not prepared to consider genuine amendments that were being put forward to provide for democratic accountability, which is all we were seeking. The fair and reasonable amendments before the House refer to accountability and democratic scrutiny of executive agencies. Those who provided leadership for the health service in the past, and who had to take difficult decisions at times, were the public representatives on health boards.
Hear, hear.
They took difficult decisions and it galls me to hear references to the vested interests of councillors. I served on the Western Health Board for six years and the only vested interests I ever saw were those of the professional representatives who were only interested in their own angles and what suited them and their own members, rather than the public. If we want reform, we should look at where are the weaknesses within the health service.
The legislation before us will allow health board CEOs to do whatever they want, without being questioned. There will be no scrutiny or accountability concerning any decisions they may take. When I was a member of the Western Health Board, a specific decision was taken concerning St. Brigid's Hospital in Ballinasloe that the lands to be disposed of were to be ring-fenced for psychiatric services in east Galway. Of course, that decision has now gone by the wayside due to the legislation before us. Under the terms of the Bill, the chief executive officer can do whatever she wants to, with the Minister's rubber stamp. I am sure the Minister is not going to upset any CEOs around the country.
The legislation will not provide the type of accountability that is required. Even when democratic decisions have been taken by health boards, CEOs can overturn them, with the approval of the Minister, if they do not like them. The Minister will be given advice and will sign the relevant order without examining the details of specific proposals. The Minister will not be privy to specific details that may already have been agreed. It is disappointing that the legislation does not address that matter.
The issue that kept arising at the Western Health Board was that of value for money. The VFM principle, as it was known, was repeated ad nauseam. The only way one can have such value for money, however, is to provide for some element of accountability for chief executives and the executive health agencies that are to be established, yet that is not the case under the Bill.
The Department of Health and Children has spent €7 million constructing a new accident and emergency unit at the county hospital in Roscommon, yet we cannot get staff to run it. To all intents and purposes, the accident and emergency unit will be closed from July because the Government did not think it was worth its while to open it, even though Ministers are eager to open facilities around the country before the elections on 11 June.
Under the terms of the legislation, there will be no way of providing answers to questions about why that money was spent on the Roscommon accident and emergency unit and why staff were not provided for the facility. As we have seen in the past, many decisions to curtail services are taken during the months of July, August and September. As it happens, the House will not be sitting during the summer so no parliamentary questions — whatever use they might be — can be raised about the curtailment of health services at that time. When the House resumes in October, many of those decisions will have been taken. Parliamentary questions are critically important, even though Opposition Members often receive replies saying that a Minister has no official responsibility to the House for a certain matter. We will receive plenty of those responses concerning the health services because the Minister will have no official responsibility to the House and can wash his hands of the issue. There will be no accountability, although the amendment could provide for it.
We are being asked to take a leap of faith and trust the Government parties. With all due respect, however, how could the Minister of State ask anyone to trust a Government that misled the people two years ago with its manifesto and the programme for Government? Once it got into office it immediately overturned those decisions so that, in the intervening period, the opposite has happened. The Minister of State knows as well as anybody that the decisions that count as regards how the health service will proceed in future will be taken in the next seven months before that new legislation is in place.
The national treatment purchase fund, to which Deputy Gormley referred, is in a crazy situation. For example, University College Hospital in Galway, where there is bed capacity, can carry out procedures on patients from counties Offaly, Westmeath and Longford but cannot do so for patients from counties Galway, Roscommon or Mayo, patients for whom the hospital is supposed to cater. This is because the fund prioritises people on the length of time they are on the waiting list rather than the location, even though there is spare capacity. The difficulty is that resources are not being made available to take in patients. Nurses and beds are available but the hospitals cannot afford to fill the beds except through the use of the fund, whereby patients are taken in from outside the catchment area. It will not be possible to address this situation because of the lack of accountability provided for in the Bill. It is a disgrace that there will be no accountability in regard to the most fundamental service the State provides to the country, namely, the health service.
This is the one issue about which every member of the public is concerned and yet we will get no answers about it because the public has no voice. Instead complaints procedures will be put in place. However, the reality is that appeals and complaints, whether in the sphere of social welfare or to the Ombudsman, in some cases take years to be processed. What should people do in the meantime? Should they remain on the waiting list in the hope that some day they may be called due to an error on a list thereby causing them to be accidentally called for a procedure? The difficult reality is that people slip through the loops in the health services. For example, last week I came across the case of a child who has been waiting for seven years for orthodontic treatment. The child has fallen though the loop, but once this legislation is enacted, accountability and answers to issues arising in similar cases will not be provided.
The crazy thing about this legislation is that it will contradict Government policy and there will be no mechanism to question it. The Hanly implementation Bill provides for the regionalisation of emergency acute services. The national spatial strategy prioritises Athlone as a hub and a new growth centre but it will have no hospital in its catchment area. Portiuncula Hospital in Ballinasloe will be gone, as will the county hospital in Roscommon and Mullingar General Hospital. Can the Minister of State tell me of any employer from outside this jurisdiction who will invest money in a town which has no accident and emergency or maternity services nearby? It is crazy — vast areas of the country will be without medical services and there will be no chance of new investment in those communities because basic services, such as health services, are not being made available. That is the reality of what is proposed in the legislation.
The amendment provides for accountability and it will be voted down by the Government for that very reason — it is against the principle of the Bill. That is the real scandal. I am not approaching this from a political point of view. Supporters of the Government or other parties in this House believe there must be accountability and a mechanism through which people are answerable. There must be some kind of scrutiny. Proposals will be shoved through by CEOs in the coming months. For example, issues like the non-appointment of a third consultant physician at the county hospital in Roscommon, which will see the end of the 24 hour service there from 1 July, or the fact that there are not even pillows for patients in the hospital, will not be raised and there will be no forum or mechanism to do so once this legislation is enacted.
Furthermore, we have no guarantees as to how long this legislation will be in place. We are told it will be in place until 1 January next but many other Bills which have come before the House have been promised on numerous occasions and then continually long-fingered. In many cases, it has taken years for Bills to come before the House. In the meantime, the CEOs can do what they like and the Minister will rubber-stamp their decisions. The Bill proposes this crazy situation which we are being asked to accept.
I ask the Minister of State to accept the amendment to ensure that the people have a say, can get answers and that the new so-called reform proposals will not be forced on the public. People should not be forced to accept the closure of their accident and emergency units, the downgrading of their local services and the regionalisation of those services without some explanation or element of accountability. None of that is provided for because the Hanly implementation Bill will allow for the closure of smaller accident and emergency departments. All this is contrary to what is happening in the United Kingdom at present. We are following its example of ten years ago, when it closed smaller accident and emergency facilities. However, the UK authorities have now found that the efficiencies and quality of service they had in the health service have been lost. They are now trying to row back to where we are now but we are going in the opposite direction and no one will be answerable or accountable once this legislation is enacted.
When the Government Deputies vote this Bill through, they will be voting through the Hanly report and endorsing it as Government policy.
I welcome the opportunity to speak on the Bill and I support the amendments tabled by Deputies McManus and Cowley. I should declare an interest in that I believe I am the last remaining Oireachtas Member who is still a member of a health board — whatever benefit that may bring.
Reform of the health boards is needed after 33 years but to abolish them entirely is going several steps too far. The Government should have taken a sensible look and if the health boards needed reconfiguring — a popular word in the health service — it should have taken that on board. The make-up of health boards is far from perfect, being comprised as they are of a mix of county councillors and professional representatives. There are 11 professionals and 19 county council representatives as well as a number of ministerial representatives on the North Eastern Health Board. There were some excellent county council representatives but I have to ask whether some councillors were on a gravy train because they were not there to contribute but rather to welcome news from the CEO and be party loyalists. They were seen to have pulled a plum job when, having been elected to the county council, they were appointed to the health board. That is regrettable.
There were professional representatives on the board. Deputy Naughten referred to them as an interest group but while there was an element of that, 11 different professions were represented at health board level whose representatives brought a wealth of experience from each of their individual fields. They may have been self-serving to some extent but many made valuable contributions to health board meetings. I am concerned these county councillors and professionals will be replaced by hand-picked party hacks, appointed to boards of governors to act as "yes" men. The democratic input has been reduced.
When county councillors were on the hustings, the health service was one of the main issues they were asked to address. It was hoped the councillors the people elected would keep their eye on the ball when it came to local health services for which there was a great need in the North Eastern Health Board. I wonder what would have happened if the prototype for the Hanly report had been introduced in that area. The Department appears to have become concerned by the level of objections from all quarters at health board level, particularly the Opposition, and seems to want to do away with that type of democratically elected system, with people voicing objections to proposed changes.
There is now talk of a six month period before further legislation or changes are introduced. This is like letting a fox loose in a chicken house. In that six month period health board executives will be given instructions and the Minister and the Department will demand action. Those executives will not be accountable to anyone but the Minister and we know the changes he wants to drive through. He simply wants to drive the Hanly report through all health board areas. Different Ministers have said the report has been changed but I have not seen a changed version. I am only aware of one version about which I am as concerned as ever.
It is worth remembering that there are many consultants and rural GPs objecting strenuously to the proposed changes which are supposed to modernise services. First, we need an infrastructure to be put in place. The Hanly report states 3,000 extra beds are required but this is never mentioned. We only hear about the negative aspects of the report which affect rural Ireland. People are told accident and emergency services are to be closed down and that they will have to use a centre of excellence which is not available. Where such centres are provided, they simply cannot cope, as extra beds are needed.
I am concerned about property still in health board ownership. In Monaghan the health board owns 100 acres of land and valuable buildings near Monaghan town. Giving power to a chief executive to make decisions about property like this is nothing short of dangerous. We had excellent property committees in the health board in which county councillors came into their own as they could spot both value and someone trying to pull a fast one. For example, when Corbeg Farm in the North Eastern Health Board area was sold, there were certain provisos. Jobs had to be provided and it could not fall into the hands of speculators. It was taken back and resold. That is the kind of valuable work people can do if they are allowed to work through health board committees.
My health board was broken into two sub-committees, a hospitals and a community services committee. At least, members of the hospitals committee went out and visited hospitals, taking on board the concerns of patients and staff. The committees formed excellent parts of the health board and should have been retained. There was also a naming of buildings committee but I question the value of such a committee. Other elements were of equally questionable value to the health board system.
My major concern is that the proposed changes mean there will be nobody to voice concerns about lack of services in hospitals like Monaghan. When Cavan or Our Lady of Lourdes Hospital, Drogheda, go through a rough phase, there will be nobody there to voice an opinion. We cannot go to health board meetings and clap ourselves on the back from start to finish. We are not there to point out the good parts of the service, although we can and do acknowledge them. We are there to be critical and point out the deficiencies but across the country this facility will be lost. This is particularly true of those in rural Ireland. Unless one is fortunate — or unfortunate — enough to live in a city, one will not be able to access services fairly, as outlined in the various health strategies. I am also concerned that there is no longer a democratic input into the health service.
References are always made to how expensive health boards are and people find it hard to distinguish between executive and board members. Board members cost the health service an absolute pittance given the service they deliver. In the North Eastern Health Board they are the guardians of a budget of €500 million. In percentage terms, they account for 0.03% of the total health budget, which represents excellent value for money.
The removal of democratic involvement in the health boards is a major step backwards. In recent weeks I have tabled a number of parliamentary questions on health and been told in no uncertain terms that the Minister has no responsibility in the areas in question. Funnily enough, with no consultation with the health board, the Minister issued a statement this week to prop up his possible council nominees in Monaghan. That is a fact. I have nothing against the Minister of State present as a person but the fact that we are discussing a major Bill without the Minister raises major questions. He seems to be washing his hands completely of the problems——
He has washed his hands totally.
——in Monaghan, Louth and now Cavan. The limited benefits associated with the health board at least allowed democratically elected representatives to voice opinions but that is no longer the case and we face six months in an abyss. Where are we going? The CEOs did not show a responsive attitude to problems and management issues in the health service. The Minister had problems in employing consultants in Cavan and Monaghan and the CEO is the only person who is answerable to him. When it comes to discussing what needs to be done in Monaghan, however, the Minister does not even consult him. That is what the CEO told health board members this week.
There was no consultation about the possibility of an accident and emergency facility remaining open in Monaghan General Hospital. According to correspondence with the hospital, the Minister said people could go there with a medical problem 24 hours a day, seven days a week, and they would be seen by a doctor. However, there is no further commitment beyond this.
I was one of those who encouraged the Minister to bring in an independent consultant to see what could be done in Monaghan. While the Bonner report did not solve all of our problems, it stated clearly that a sum of €4 million needed to be spent on a treatment room and €14 million on the hospital altogether as a matter of urgency. The Minister proposed a figure of €2.75 million for the hospital, provided certain measures were agreed first to the satisfaction of the executive before the money could be spent.
Where is the health service going? Can the Minister of State give a commitment that somebody will be answerable? Will the Minister have any control over what the executives will do in the next six months, or will the existing limited health service disappear completely? I ask this question in the context of the comment made by the Taoiseach earlier today when he accepted the fact that people living in rural areas did not really matter and would not expect the same level of access to services. The present level of access to some of the Dublin specialist hospitals leaves much to be desired, as we discovered to our expense in County Monaghan during the past week or so.
The system is grinding to a halt. If the Minister of State thinks the removal of democratic involvement in the health boards will solve the problem, he has another thing coming. As my colleague, Deputy Mitchell, said, €11billion is being spent on the health service. As a party, we are not shouting that we want to spend oceans of money but we do want accountability and structures in place to ensure what money is available is spent.
Deputy Naughten said seven years had slipped by in seeking orthodontic treatment. I have dealt with several such cases and all I get is excuses; nobody is answerable. I was told here only a couple of weeks ago that in the North Eastern Health Board the position had improved dramatically. While the position has improved in the Meath-Louth division, it has certainly not improved in the case of orthodontic treatment so far as access is concerned.
We have recently heard the great news that the position on waiting lists is improving. I met a woman in my office this morning whose husband had been trying to get on a waiting list for the past three years. As such, he is not a statistic and, therefore, not a problem but for him and his good wife, who are well advanced in years, his need of treatment presents a real problem. This is not an issue of which the Minister of State can wash his hands or do a Pontius Pilate.
We are speaking to amendments tabled by Deputies Cowley and McManus. Essentially, they seek to delay commencement of the legislation. They are to section 1 which is a technical provision. As they are designed to delay commencement of the Bill, they essentially seek to frustrate the entire intention of the legislation.
Deputies have availed of the opportunity provided by the debate on the amendments to reopen the debate on the general question of the principle, namely, that the health boards be abolished. That issue has already been decided by the House.
The Minister has dealt in great detail with his proposals to implement the health service reform programme. On Second Stage he pointed to the provisions he will make in respect of participation by public representatives in the new structures. He outlined to the House his plans to include, as an essential part of the reforms, accountability at all levels of the system. He also specifically mentioned his plans to put mechanisms in place to support the development of structures at regional and local level and to provide for liaison between local representatives and the Health Service Executive. He will include these provisions in the legislation under preparation.
The provisions are likely to include the establishment of a series of regional forums to facilitate local representatives in raising issues of concern in respect of health services within each region with the new executive. These will allow local representatives to comment on and raise issues relating to the delivery of health services at local level. Members of the forum will also have the facility to raise particular issues with the executive. The overall objective in putting in place such arrangements is to ensure the voice of local public representatives will continue to be heard on the development of the health service.
These mechanisms will complement and reinforce the role of the House and the Joint Committee on Health and Children in holding the system to account at national level. The view of the Minister, therefore, is that the amendments are unnecessary. If accepted, they would serve to further delay the health service reform programme and, as such, the Minister is not disposed to accepting them.
On the numerous comments made, this Bill has nothing to do with the Hanly report. It implements the recommendations of the Prospectus report relating to the health boards and health structures. The inspiration for this——
If those structures were left in place, the Minister would never have——
The inspiration for this——
Ms Brennan had a different view. Why ignore her as she was consistent?
Political consultants differ and Governments must make decisions.
They are consistent. That is the trouble.
Members will have an opportunity to contribute.
The inspiration for this Bill lies in the Prospectus report. It is important to highlight this because it was suggested otherwise throughout the debate that it has something to do with the Hanly report.
Who is going to implement that report?
I realise there are only a few days to go before the local government elections.
Deputy Naughten raised the issue of the closure of hospitals and accident and emergency units. That matter does not arise.
It is happening, as we have seen at first hand.
The Members who have already spoken will have two minutes in which to reply.
Will the Minister of State deal with the reality with which we are trying to cope?
Of the eight contributors to this debate, three were from County Monaghan.
Is that an accident?
It is indicative of the reality.
It is indicative of the quality of political representation in the area.
It is indicative of the Government having washed its hands of responsibility for health service delivery in the county and a large section of the region. Shame on the Minister of State——
Deputies have national as well as local responsibilities. They will have to debate the issues in the health service which they have not done so far in this debate.
I take extreme exception to——
The Minister of State should not lecture us.
He has responsibility for services in Monaghan as he has for services in other areas.
He has given no response whatsoever.
The mover of the amendment will have a right of reply, if time permits.
We are very short on time. I will not refer to the position in Monaghan because there are others who can do so.
The Minister of State is perpetuating double-think. On the one hand, he has said the Bill is about bringing the health boards to an end — on which we are all agreed — and that the amendments go against the principle of the Bill. On the other, he continues to restate the publicly stated view of the Minister that he will introduce systems of accountability. He cannot have it both ways. The Bill is about bringing the health boards to an end.
We are concerned about the lack of accountability. We are concerned that Fianna Fáil does not trust the people and their representatives and wants rid of them. All the flimflam about accountability is designed to cover up the fact that the people cannot be trusted. They certainly cannot be trusted where the Government intends to downgrade local hospitals, close accident and emergency departments, as spelled out in the Hanly report——
To tell lies.
The Minister of State conveniently tries to separate the Prospectus report from the Brennan report, which argued for health board representation for local public representatives, and the Hanly report, even though the Government has always argued that the three are linked and part of an integrated set of health reform proposals. He cannot have it both ways. However, I compliment him — he represents his party so well — when it comes to speaking out of both sides of his mouth.
This is the classic Fianna Fáil reply. It will give something and take it away simultaneously. One has to allow for the fact that promises have been made about the Hanly report in the lead up to the local elections on 11 June. We all know the pattern which has been set down in the past. In the previous example of the general election what was given with one hand before it was taken away with the other once it was out of the way.
I was intrigued in listening to the Minister of State. I do not know what world he is living in but it does not appear to be the real world because what he is talking about does not make sense to me or anybody else in the House. It is obvious the Government wants to progress its agenda. By handing it over to the chief executive officers for the next six months, it believes it can achieve this. How else will it implement the changes recommended in the Hanly report? The impediment to cutting services even more is that the annual budgets would have to be accepted and passed by the members of the health boards. The Minister had trouble from members in accepting major cutbacks and does not want any more of this. He wants to fast-track all decisions. One will see parallels in the Department of the Environment, Heritage and Local Government where the Government wishes to bypass the democratic right of the people to have a say in matters. I agree that it appears that the Fianna Fáil Party is not interested in what the people have to say, which is regrettable.
Let us consider all of the services the local hospitals in Bantry, Mallow, Tralee, Ballinasloe, Letterkenny, Cavan, Wexford, Naas, Blanchardstown and so on will lose. What will be put in place to redress the democratic deficit? The Government refers to a complaints procedure but I guarantee it will take rooms to house the complaints that will not be answered. As regards the forum, suggested in the Prospectus report, the regional health authority of elected representatives will just be a nodding session where members will be tolerated for a certain period on a limited number of occasions in the year and that will be it. Politicians will have no meaningful input.
Matters will be no different at Oireachtas committees. The Minister was due to appear before the Joint Committee on Health and Children to discuss the report on radiotherapy services but he did not attend. He has been hounded to appear before the committee during the past year but has used every single dodge in the book. He is avoiding the people. If he did not appear before a joint committee to hear members express their concerns on the report on radiotherapy services, is he interested in listening to them? We know from the report issued today that the people must accept an inferior service. It appears that the Minister is being advised by his officials not to engage and listen to Members. I advise him that he will pay a very heavy price because one cannot deny democracy.
I object to the Minister of State resorting to insulting the Members who expressed their genuine concerns about the purpose of this Bill. The Fianna Fáil mantra for this election is to criticise the Opposition for not engaging in debate. We are looking for a debate. Last week it was the Minister of State at the Department of the Taoiseach, Deputy Hanafin, making the same comment; the week before it was somebody else. The Government is losing touch with reality. It is very reasonable not to support the circling of the wagons to ensure there is no opposition, no questioning and no scrutiny of the setting up of a new health service executive.
We accept the need for new structures and agree with the reform of the health service but what we are being given is auld guff and false promises. We are told we will have a complaints procedure but what good is that in an accident and emergency department when a patient is left with his or her leg hanging off? The proposed establishment of consumer panels to scrutinise the health service is like saying that having had the BCG, one is qualified to run a health service. It is a nonsense and an insult to the intelligence of the public.
It is proposed that elected representatives will have the opportunity to debate matters at regional fora. The reality is that approximately ten years ago the Government abolished local health committees as they were a pointless exercise. Who will question chief executive officers when they make decisions in the next six months? Will they continue to make the decisions? We have an interim health executive which, as far as I can see, is absolutely lost and in a complete tizzy as every day there is a new hybrid Hanly report being offered, which it is charged with implementing. The reality is that we need to debate the health service. I support the motion.
I echo the remark that it is a disgrace the Minister for Health and Children is not here to take this Stage of a Bill that has serious consequences for the delivery of health care in this jurisdiction. With all respect, I think the Minister of State, Deputy Brian Lenihan, made a disgraceful reference to the Monaghan Deputies who have moulded together all opinion, including that of Fianna Fáil Members, though they jumped ship. We have never made a party political issue of this and have endeavoured to be a community of all views, which is to the credit of all Opposition voices in this Chamber.
In this instance we are being asked to provide a blank cheque for the chief executive officers currently at the head of the respective health boards. I would not give a blank cheque, with no conditions as to accountability, to the chief executive officer of the North Eastern Health Board, nor would I offer the Government a blank cheque for the health service or any other matter of public concern, with no scrutiny or accountability. It is an absolute disgrace. What we face is the diktat of the chief executive officers and we know the agenda they are pursuing. We know this better than most in the North Eastern Health Board where we have been exposed to it time and again since the appointment of the chief executive officer.
The Minister of State failed to pick up on the very important point I made. I am passionate about the loss of critical services at any hospital site in this jurisdiction, as are Deputies Crawford and Connolly and everybody who has spoken in the debate bar the Minister of State. It is not a parochial position we take. We pointed out that the loss of services in Monaghan and Dundalk would be used as a template in the future, which has proved to be the case. We have no doubt that is exactly as it will happen. The diminution of services at any hospital site, from Kerry to Donegal, diminishes each and every one of us as we do not know when we will be dependent upon them. Even now, this Bill should be withdrawn.
The Bill allows for the implementation of the Hanly report. For the Minister of State to suggest that the Bill has nothing to do with the report is disingenuous. The Royal College of Physicians has a regulation that was due to be implemented on 1 July 2003 but allowed a stay of execution for 12 months. It will be introduced on 1 July 2004. It will mean that the 24 hour accident and emergency service in Mallow, Bantry and Roscommon hospitals will cease from that date.
The European working time directive will come into force on 1 August 2004 and the reality is that the recommendations of the Hanly report in the Mid-Western Health Board and Dublin will be replicated in the country by the end of the summer and start in the smaller hospitals, for example, the county hospital in Roscommon.
The chief executive officers will be given blank cheques which the Taoiseach had a habit of issuing but a blank cheque is being issued without democratic accountability and allowing them to implement the Hanly report on the basis that if they offend the Minister, they will not have a position under the new structures to be established in the new year. The report will be implemented before these new structures are put in place next year and it is disingenuous of the Minister of State to say the opposite.
I am absolutely shocked that the Minister of State should fall to this level. I am here solely to speak on behalf of the people of Monaghan. I try to work with the Minister for Health and Children, Deputy Martin, and do not engage in political cheap shots. I still wish to work with him if there is any hope of saving the hospital and, in so doing, saving lives. The Minister of State is obviously not interested.
I wish to reply to the charges made by the Deputy. The Bill incorporates a transitional stage in a fundamental reform of health structures — a root and branch reform. This has implications for every hospital and may have very positive implications for Monaghan Hospital.
That is a misleading statement. There is no root and branch reform.
I am now required to put the following question in accordance with an order of the Dáil of this day: "That the amendments set down by the Minister for Health and Children and not disposed of are hereby made to the Bill, that Fourth Stage is hereby completed and that the Bill is hereby passed."
Question put.
The Dáil divided: Tá, 50; Níl, 29.
Tá
- Ahern, Dermot.
- Ahern, Michael.
- Ahern, Noel.
- Andrews, Barry.
- Brady, Johnny.
- Brady, Martin.
- Brennan, Seamus.
- Callanan, Joe.
- Carey, Pat.
- Carty, John.
- Cassidy, Donie.
- Coughlan, Mary.
- Cregan, John.
- Curran, John.
- Davern, Noel.
- de Valera, Síle.
- Dempsey, Tony.
- Dennehy, John.
- Devins, Jimmy.
- Ellis, John.
- Finneran, Michael.
- Glennon, Jim.
- Grealish, Noel.
- Hanafin, Mary.
- Haughey, Seán.
- Hoctor, Máire.
- Jacob, Joe.
- Keaveney, Cecilia.
- Kelleher, Billy.
- Kelly, Peter.
- Killeen, Tony.
- Lenihan, Brian.
- Lenihan, Conor.
- McEllistrim, Thomas.
- McGuinness, John.
- Moynihan, Michael.
- Ó Fearghaíl, Seán.
- O’Connor, Charlie.
- O’Dea, Willie.
- O’Donnell, Liz.
- O’Malley, Fiona.
- Parlon, Tom.
- Power, Seán.
- Smith, Brendan.
- Smith, Michael.
- Treacy, Noel.
- Wallace, Dan.
- Walsh, Joe.
- Wilkinson, Ollie.
- Wright, G.V.
Níl
- Boyle, Dan.
- Broughan, Thomas P.
- Bruton, Richard.
- Burton, Joan.
- Connaughton, Paul.
- Connolly, Paudge.
- Cowley, Jerry.
- Crawford, Seymour.
- Crowe, Seán.
- Deenihan, Jimmy.
- Durkan, Bernard J.
- Ferris, Martin.
- Gormley, John.
- Hogan, Phil.
- Kenny, Enda.
- Lynch, Kathleen.
- McGrath, Finian.
- McGrath, Paul.
- McHugh, Paddy.
- McManus, Liz.
- Mitchell, Olivia.
- Naughten, Denis.
- Ó Caoláin, Caoimhghín.
- O’Shea, Brian.
- O’Sullivan, Jan.
- Pattison, Seamus.
- Stagg, Emmet.
- Stanton, David.
- Upton, Mary.
Tellers: Tá, Deputies Hanafin and Kelleher; Níl, Deputies Durkan and Stagg.
Question declared carried.