Health Bill 2004: Second Stage (Resumed).

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

Fine Gael supports the reform of the health service. However, it is not interested in the perception of reform because this issue is too important to both patients and potential patients. Earlier I pointed out that we need to know the qualifications of the new board of the HSE to have an informed opinion on their ability, we want clarity on the issue of accountability and that we want lines of command and delegation of roles that are clear for everybody to see when the HSE comes into operation.

The risk of all these changes not working is extremely high. The opportunities for patients to express their concerns through the consultative and regional fora are unclear and are not binding on Government. The opportunity to dismiss, elude and even hide patients' complaints is a significant possibility. The patient is not fully protected by this legislation. On those grounds alone Fine Gael must oppose this legislation.

The view of workers must be respected. Although the Minister said there will be no forced redundancies, many of the employees of the health service are extremely concerned about what their roles will be. We must be crystal clear as to the role of advisers, consultants and committees established by the HSE if it is not to contribute to the difficulties we have seen in the health boards up to now, with no rationalisation of the administration of the health service and another tier of administration simply added in place of one we have removed.

There are two major points I did not reach before Private Members' business that I want clarified. The former Minister for Health and Children, Deputy Martin, and the current Minister, Deputy Harney, have stated that the HSE will be accountable to the Minister for Health and Children. I do not see undisputed evidence that this is the case. My reading of this legislation is that the Minister will be able to avoid difficult questions on the health service after 1 January 2005. This is not the way to deal with a crisis in the health service. If we have failed the public over the past five years, covering up is no solution.

Earlier the Minister stated: "The CEO will, under section 21, be required to appear before Oireachtas committees when requested by those committees to account for the performance of the executive." She continued: "Political responsibility for the activities of the health service will rest with the Minister for Health and Children who, supported by the Department, will hold the executive to account." The legislation does not refer to that. The only reference to a Minister is in section 9 where it is stated that in carrying out the duties under this section the CEO shall not question or express an opinion on the merits of any policy of the Government, or a Minister of the Government or on the merits or objectives of such a policy. There is nothing to indicate that the HSE will be accountable to Dáil Éireann. This is, therefore, another agency similar to the National Roads Authority, which is an unaccountable statutory body from which we will get very poor answers when we request them after 1 January.

Section 20 provides that the new CEO, and not the Secretary General of the Department of Health and Children, will be the accounting officer of the executive. The Minister believes this is a very strong form of accountability for public funds and will give much greater clarity than before, but I disagree. Accountability could be worse than before given that the only information we might get will be what the CEO and the HSE decide to give and we will have no way of finding out for ourselves the details we now get from the health boards. When we have questions regarding what is happening to our patients, what is happening in the health boards, how money is being spent, we can get relatively detailed answers at present. I am afraid that soon this will no longer be the case.

I have read the reports that have been published. I have read the health strategy, and I have read the Prospectus and Brennan reports. They are fairly nebulous. They do not set out clearly what will happen regarding the administration of the health service after 1 January. Nothing in this legislation makes me comfortable about voting for it. There is still much that needs to be changed in the primary legislation. There is a huge amount of information that could still be put out into the public domain by the Department of Health and Children. The role of the Department after 1 January is not clear. The people who work there are a great source of advice for Members of this House, but we are not sure what they will be doing after 1 January.

There are so many ifs, buts and possibilities. As both a politician and a medical doctor, this is creating the fear that we will not know what is happening in the health service after 1 January and that in some respects this legislation is letting the Government off the hook on significant issues that are continually raised in this House. These issues must be clarified even if the amendments Fine Gael will be tabling on Committee Stage are passed.

I move amendment No. 1:

To delete all words after "That" and substitute the following:

"Dáil Éireann declines to give a second reading to the Bill in view of:

(a) the inadequate time given to members of the Dáil to consider the terms of the Bill;

(b) the fact that the position of Chief Executive of the Health Service Executive has yet to be filled;

(c) the threatened industrial action by 15,000 members of the trade union IMPACT, arising from concerns about jobs and working conditions;

(d) the confusion and uncertainty that remains about Government plans for reform of the health services.".

This Bill is a major legal instrument that will result in a new configuration of administration of our health service. It is an important Bill worthy of full public scrutiny. It is clear the Minister for Health and Children believes otherwise. By forcing through a rushed debate without any period for reflection or consultation, she is trampling on every safeguard that a reasonable person, regardless of their political outlook, expects of a Parliament worthy of the name. By her actions the Minister for Health and Children is treating this House with disdain and the people we represent with contempt.

This Government has had 18 months since it announced its plan to abolish health boards and establish a Health Service Executive. During that time we have seen no detailed proposals of the legislation envisaged. No heads of the Bill have been published and no briefings on the Bill have been held for Members of this House. The arbitrary date of 1 January was set as the start-up date for the new HSE and due democratic process has been sacrificed at the altar of expediency as a result.

There is, at the very least, a convention in this House, which I understood the Minister supported, that a Bill, particularly a major Bill of this type, should be published two weeks — at a minimum — before it is debated on Second Stage so that time and attention can be given to the changes contained in it. That procedure has been flouted by the Minister. Debate on the Bill was due to begin tomorrow, although it was published only last Friday evening. However, even that ludicrously tight timeframe was not tight enough for the Minister and the debate is now shoved back into today's Order of Business. I am not interested in any statement of regret from her about this decision. What is needed is a full and comprehensive explanation as to why the Government is so intent and determined to stampede this important Bill through the House just 96 hours after publication and 36 hours after Members received their copy of it. It may be a record but, if it is, it is a despicable record. A new low has been reached by a Government that has lost the run of itself. The Minister should tell us the reasons for her hurry and tell us what is so important or pressing that democratic accountability must suffer at her hand. The Minister built her reputation on telling it as it is so let us hear it from her now.

Maybe we should not be surprised — this high-speed hijack of democracy is only the latest twist in a comedy of errors that has characterised the Government's approach to health care reform since it was announced in June 2003 — but we should begin to worry. The comedy of errors has every likelihood of becoming a catalogue of disasters. Back in the heady days of the health strategy launch in 2002 we were promised health care reform. However, by June 2003 we discovered what was on offer was administrative reform only.

The big challenges facing a true health care reformer were ignored then and continue to this day to be ignored. The Government has no policy to tackle the inherent inequality in our health service. The system of apartheid between the treatment of private and public patients is intact. There is no policy to shift care towards the most appropriate level, to move, that is, towards primary and community care so that fewer patients end up in hospital. The Cabinet decision on generic drug description has disappeared off the map, the 3,000 beds did not materialise, the hospital waiting lists did not disappear and the 200,000 medical cards were taken away. Yet, those who suffered are expected to be grateful for a cheap, yellow pack substitute.

We have a new Minister but we still have the same old spin. On RTE's "This Week" programme last Sunday the Minister for Health and Children spoke to the Irish people and told them a cock and bull story. She told them that the level of medical card coverage is now at its highest level since 1995 as a consequence of the provision in this year's Estimates, which is simply untrue. The claims made by the Minister are unfounded and she knows well that a medical card provides for a whole range of benefits other than the visit to the doctor, and to claim that a free general practitioner card is a medical card is gross dishonesty.

The Minister talks, as her predecessor did, about a patient-centred health service, and she again referred to it in this debate. To have the patient at the centre of the service is a wonderful idea but it does not match reality despite the best efforts of professionals caring for patients. It is worth noting that in this major Bill, which covers 68 pages, there is only one mention of the word "patient". We may have been promised a patient-centred health service, but instead all we got was an announcement from the Government of its intention to abolish health boards and to establish the Health Service Executive. This is hardly a health care reform programme. Nor it is correct to maintain, as the Minister repeated in her contribution, that the changes announced followed recommendations made in the Brennan and Prospectus reports. This was the spin but the truth is different. The truth is that Professor Brennan's report specifically recommended the retention of health boards, in the Minister's words, "to safeguard the need for local democratic representation". Her only caveat concerned the size and number of health boards, which should be reviewed, a point on which I support her. All that is left in the Bill of her recommendation is sham local representation.

Even within the narrow confines of administrative reform there is a shortfall between what was promised and what we received. The Government's health care programme states:

A key policy aim of the health strategy is to deliver high quality services that are based on evidence-supported best practice. In order for the reformed health service to base planning and policy-making on world-class standards, it is essential to ensure that high quality information is available to the system. The Health Information and Quality Authority will be established to achieve this aim.

The Government is merrily pursuing its course of establishing the HSE on 1 January next without this essential reform being published. There is no sign of the Health Information and Quality Authority or the Bill to establish it. Information and quality should be central to the new structures which are to come into being. Without this piece of the jigsaw in place, the proposal to set up the HSE is seriously defective and even risky.

It is 18 months since the Government set in train an interim HSE to deal with transition issues and to enable a smooth transfer to the new structures. Instead, there has been a lack of consultation and certainty at all levels over that period as new structures and systems affecting around 120,000 people are being mooted and developed. The Minister for Finance stated publicly that there would be no forced redundancies and the Government stated there would be no voluntary redundancies. Meanwhile, however, health boards have been abolished and will no longer function as an entity in the new structures. It is difficult to envisage how this circle can be squared, particularly as a whole new layer of administration is being created by the interim HSE.

Today I received the most extraordinary answer to a parliamentary question in regard to senior management posts which might have been filled by health boards. I discovered that a circular went out from the Department of Health and Children last March advising health boards that they were not to appoint to new posts without permission because of the changes in the structures, which sounds reasonable on the part of the Minister and the Department. However, it turns out that since March last 22 senior management posts have been filled. That does not make sense. These senior management posts have been filled at a time when the employers making the appointments are in effect out of a job in the sense that the health boards are defunct. These 22 posts mean that a remarkable number of senior managers have come into the system at a time when we should expect, if anything, movement in the opposite direction.

The Minister should tell us how many staff will be left in the Department of Health and Children when these structures go through, which might provide a picture of what is happening within the service. It would be useful also if the Minister would tell the House how many staff currently employed in particular positions will no longer be employed in those positions given this change across the health board structure. I presume she knows the answer.

IMPACT is a trade union with an honourable record of embracing change and is not one of the trade unions which has tried to block development. However, even that trade union has been driven through frustration to the point of holding a strike ballot and directing its members not to attend briefing meetings. The vote was endorsed by a massive margin of 7:1, whereupon Mr. Kevin Kelly, chairman of the HSE, went on radio and stated it was all due to a misunderstanding. A misunderstanding, if that is the problem, should not arise if the people driving change are doing their jobs properly. However, the IMPACT spokesperson, who was also interviewed on radio, made it clear that this is about more. He spoke about a breakdown in trust, delays, breaches of agreements and an AIB culture intruding into the health service. This is serious from a trade union that has welcomed health care reform and helped to deliver it in the past. We will have to wait and see if this is to be another first for the Minister. Will she be responsible for the birth of a new statutory body that on opening its eyes for the first time will confront the possibility of a strike by the workers for whom it is responsible?

We move on to the matter of the new chief executive officer or, to be more accurate, his failure to show.

Professor Aidan Halligan was to be the Bonnie Prince Charlie of our day, coming over the waves to liberate us. He was such a catch that he was offered the highest salary rate ever for an Irish public servant, who could afford to get home in time for his tea every day by helicopter if he needed to, and whose coming was announced officially by the Minister, again with a virtual fanfare of trumpets. First he was to come next April. Then he was convinced to come by the end of next January. Deliverance, we were to understand, was at hand for the Irish health service.

Alack and alas, like the Young Pretender the professor never did come over the sea. It turned out he had not signed any contract nor signed off on his existing job. He is perfectly entitled not to do so, but I would love to hear what he has to say about all this. The failure to appoint a CEO further undermines confidence in the Minister responsible. Professor Halligan's withdrawal leaves a disturbing lacuna. There is little reassurance to be drawn from the temporary appointment of Mr. Kevin Kelly in that position.

We have no proper debate or scrutiny of legislation, no information and quality authority, no partnership, no streamlined system of change, no CEO and no need for the headlong rush to meet the 1 January deadline. That is why we in the Labour Party are tabling this amendment.

With regard to the appointments to the HSE board itself, appointments which as Deputy Twomey pointed out are still unknown, the Bill quite rightly specifies that no member of the Oireachtas or European Parliament should be appointed. However, there is no statutory bar on other inappropriate appointments other than the obvious ones related to criminal records and the like. This board will have sole responsibility for the management of our health service. It will meet in secret. It will be very different from the current management system which is essentially the responsibility of the Minister and is managed by the Civil Service. Whatever about the shortcomings in the current system, there was little if any possibility of a conflict of interest. In the new environment, where private individuals rather than civil servants will be managing the health service, that will no longer be the case.

We hear a lot about vested interests in the health service. In this new structure there is even greater likelihood of influence from vested interests such as the pharmaceutical industry, for example. A person from that industry is currently on the interim board, and I note that solely as an obvious example.

A code of conduct is provided for in this Bill for those appointed to the board but it is for guidance only and looks like a very poor protection against powerful interests that have much to gain by having a foothold in a body managing the entire Irish health service. The reference to gender balance is so weak as to be meaningless. We do not know who these members will be but we know they will meet in secret. The media will not have the access it has hitherto had to health board meetings and the public will not have access either.

In section 20 of the Bill, the CEO is defined as the accounting officer. That is a significant change. I find it unacceptable that the Minister for Health is going to bring in amendments as yet unseen to her own Bill on this particular section. If they are simply technical amendments as she claims, what is the delay in publishing them?

Section 32 of the Bill requires the executive to prepare and adopt a service plan specifying the services to be provided within the financial limits for the year. The Minister has extensive powers and can amend the plan and issue directions as to its form and manner of preparation. However, there is no requirement on the Minister to publish the draft service plan or give any ministerial directions, nor is there any requirement in this Bill to publish the service plan even in its final form.

I have grave concerns with the proposal that the Oireachtas Committee on Health and Children will have the oversight role. That is unrealistic and my experience so far has not been encouraging. The only time that Mr. Kelly addressed the committee was in his early days, when he clearly did not have much experience, but he referred repeatedly to the road-map being the composite plan towards which everyone was working. As a member of the committee I looked for a copy of that composite plan. I did not get it for weeks and I had to badger everyone, including the then Minister, the Taoiseach and others before I got it. That is not a very encouraging experience if we are talking of an Oireachtas committee which is very busy and which has to concentrate on many aspects of the health service, playing such a central role.

Part 8 outlines a series of bodies that have the potential to be expensive and time-wasting talk shops. A national consultative forum "may be convened" from time to time — big deal. The county councillors are to be pacified by regional health forums with no power, but of course with expenses, and if that is not enough we will have local panels which will be circumscribed even in the matters they can discuss.

The biggest failing of the health board structure was the lack of direct accountability. Members of health authorities should have been and could still be directly elected by the people, not channelled through county councils. Had that decision to have direct elections been taken and had Professor Brennan's advice been heeded, we would have a dynamic and responsive structure, unlike this plethora of bodies that will be all mouth and no teeth. I am dissatisfied because the nature of this Bill is to offer much promise but then let us down. It is very disappointing in what it does.

Do the proposals for a complaints procedure satisfy the need for a clear and independent assessment of complaints? The appointment of complaints officers will be made internally both at executive level and at service provider level. Inevitably that will not protect the independence of any response to a complaint. I would have thought that the experience of the Garda Complaints Board and its utter failure to deal with complaints from the public should be a warning to the framers of this legislation. I would prefer to see the proposal for a health ombudsman who would play an effective and focused watchdog role which would benefit the service as well as the user and would be a much healthier, cleaner way to deal with complaints. A complaints procedure was promised for a long time even before this Bill was mooted but what has been produced in the Bill is a deep disappointment.

The voluntary hospitals are not mentioned in the Bill. I wonder what discussions have been held with them, or with the Department or the HSE with regard to their future relationship within the health service.

Will the Minister define personal social services? The Minister may need to seek legal advice on that issue. Part 2 of the Disability Bill defines "health service" as meaning a service, including a personal social service, provided by or on behalf of a health board. "Personal social service" is undefined in that Bill and in any other statute. If one looks up Oasis, Comhairle's information on the public services website, one is cross-referred to "community care services", a term that has no statutory definition either. According to the website, public health services provided in the community in Ireland are sometimes referred to as community care services. They are generally provided by the health boards or by voluntary organisations in conjunction with or on behalf of the health boards. Entitlement to community care services is not as clear-cut as entitlement to hospital services. There is also wide variation in the level of services available in different parts of the country. In general, medical cardholders are entitled to community care services free of charge, though not of course the "yellow pack" unfortunates. Others may also be entitled but it is not always possible actually to get the services.

Community care services can include the public health nursing service, home help service, physiotherapy, occupational therapy, chiropody service, day care, respite care service and so on. The rules about which community care services must be provided differ in accordance with the different services. In some cases, health boards are obliged to provide services, while in others the health board has discretion about whether to make the service available.

The website goes on to deal, in turn, with public health nurses, care assistants, home helps, physiotherapy, occupational therapy, chiropody, technical aids, respite care, day centres, meal services, transport, social workers, speech therapists and dieticians. I can find a statutory basis for the provision by health boards of some of these services — for example, for home nursing, home help, employment training and technical aids for disabled adults. However, other services do not seem to fit within the statutory framework but, admittedly, the framework is piecemeal and I may have overlooked something.

In regard to social workers, the position seems to be that on the abolition of public assistance provided by local authorities and the introduction of supplementary welfare in the 1970s, the remaining public assistance officers were transferred to health boards but the health boards, in general, and these transferred officers, in particular, apart from dispensing supplementary welfare, were not given any specific social welfare brief. It would be odd if there were no statutory basis for the employment of social workers or the provision of services by them outside the context of child care and the Child Care Act, but perhaps the Minister might find out and advise us in her reply.

Are physiotherapy, occupational therapy and chiropody sought to be justified as being outpatient services under the 1970 Health Act which includes institutional services other than inpatient services provided at, or by persons, attached to a hospital or home and institutional services provided at a laboratory, clinic, health centre or similar premises? Where does respite care fit in? Is it deemed to be a form of home help for which there is statutory authority? Is a health board justified in providing or funding a day centre which provides activities such as recreation, sport or leisure facilities outside a strict employment training context? Where do technical aids for disabled children fit in? Neither seems to fall under section 68 of the Health Act 1970. It may be that the Disability Bill not only deals with the provision of an indeterminate range of undefined services, variously described as community care or personal social services, but that in regard to some of them at least, there is no statutory basis for their provision in the first place.

The matter is confused rather than clarified by the Health Bill 2004. This Bill proposes to define health and personal social services for the first time. It is clear that it is simply to be a compendious term which encompasses everything existing health boards already do. The term is defined in section 2 as meaning services provided in accordance with the scheduled Acts. The Schedule lists every Act that contains a reference to a service provided by a health board. For example, health board functions under the Marriages Act 1844 and the State Lands (Workhouses) Act 1930 and 1962 are health and personal social personal services. A person with a disability will be entitled to an assessment as to whether health board services under the Rats and Mice Destruction Act 1919 are required to meet the needs occasioned by his or her disability but not, apparently, whether he or she needs a speech therapist. That may seem like a technical point but it is an apposite one since we have been dealing with systems and structures with which we have become familiar and which have provided services at community level. However, I raise the question whether they all have a statutory basis. Does that issue need to be addressed in this Bill?

The concentration has been on changes in administration to the point of obsession. Essentially, the problem lies in the hospital sector and I would prefer if a new national hospitals authority had been established and if the health boards had been directly elected and streamlined, that is, fewer in number, larger in geographic area, and maintained not to deal with hospitals but with community services such as primary care and so on for which they have built up a responsibility. That separation would have made a lot of difference but with a lot less disturbance and cost.

Obviously, there are always concerns about bureaucracy and streamlining to make sure there is not unnecessary bureaucracy but I do not see this Bill resolving that issue. I remember discussing proposals to create four health boards in the Dublin region and making the point that everyone acknowledged that the old Eastern Health Board was a monster but that there was a real risk that we are going to create four monsters instead of one. There is a real risk here in that this Bill is being rushed through to the point where nobody has stopped to reflect and to ensure things which could be done better will be done better. There is a real risk we will end up with a board that is unaccountable and untouchable, other than by way of its connection with the Minister, that there will not be proper oversight and that it will not be open in the way modern society and the protection of patients demand.

I wish to share my time with Deputies Gormley and Ó Caoláin.

I welcome the opportunity to speak on this Bill. It signals the biggest shake up in the health services in 43 years. The establishment of the Health Service Executive will transform the administrative function of the health boards with the effect of centralising services. Effectively, we will move from 11 health boards to four nationally. Health board members, the democratic voice of the people, were the people's watchdog in regard to services at local level. There was a myth that health board members cost the health boards a fortune. If one looks at what they cost, it was in the region of .003% of the total budget. Before it reached health boards, 97% of health board funding was predetermined so the influence health board members had was negligible. The benefit was that the people felt they had a voice. There was also the voice of the professionals representing professions in the health services.

As Deputy McManus said, rather than abolishing health boards, we should have looked at ways of tweaking the system and of re-examining what we had. I have no doubt it needed to be changed and that there was a need for accountability in the way services were delivered. However, I am not particularly happy with the way we are moving in terms of ministerial nominees and so on. These people do not have to go back to the electorate. Effectively, there will be a bunch of head nodders on this board and there will be a lack of accessibility for the press and so on. It is an issue of major concern.

The abolition of these health boards and the establishment of the HSE is clearing the way for implementation of the recommendations in the Hanly report. There will be no democratic objections and no voice for the people. Given the changes to the health services which were signalled, health board members were a thorn in the side of the Department, the Executive and the professional bodies. The easy option was to get rid of health boards so there would be no objectors.

There has been a number of reports on the health services recently. I believe the cost of those reports totals approximately €40 million. I wish to refer to the health strategy and the Hanly report. The health strategy refers to services being accessible to all. Under the Hanly report, I do not see how that can happen because the Hanly report, irrespective of what people say, is about removing services from the smaller hospitals. There will be a withdrawal of services from hospitals such as Monaghan General Hospital and Ennis, Nenagh and Loughlinstown hospitals. In particular, services are being withdrawn from accident and emergency units. That is the big threat hanging over each of these hospitals. Looking at the situation in Monaghan General Hospital, lives have been lost. The North Eastern Health Board is a prototype of what the Hanly report is about. If one reads that report and supplants the North Eastern Health Board, that is what it is and what it has given us. The mid-west region has been described as the pilot project but we are a step ahead of it. The north east is never out of the news and always for the wrong reasons. Much of this is accounted for by the fact that the region has the most underfunded health board in the country.

The rush to implement the Hanly report relates to the requirement to satisfy the EU working time directive which was to be implemented on 1 July this year. The report considered many options but only certain of those options are being taken. These are the cheap options. Smaller hospitals have been robbed of their staff to accommodate a reduction in staff hours in the larger hospitals in line with the EU directive. The Hanly report also referred to the need for beds. More than 2,000 beds are required in the system. The report also referred to regional centres of excellence. I would be very happy to be shown these centres.

The changes are more hospital-focused than patient-focused. We are familiar with environmental impact studies. A patient-impact study of the changes proposed in the Hanly report should have been undertaken. The major question is how to marry the requirements in terms of local services with the changes proposed with regard to the establishment of regional centres of excellence. This will be the acid test. There is a perception that my Independent colleagues and I are opposed to such regional centres. This is grossly unfair. We are pro-people, pro-services and pro-local hospitals.

However, I do not know how these centres will cope with the additional volume of patients that will be transferred from smaller hospitals. If regional centres of excellence include such facilities as Beaumont and Tallaght Hospitals, the reality is that they cannot cope with the current volume of patients. Cavan General Hospital cannot cope with the overflow of patients from Monaghan General Hospital. This problem will be magnified in larger hospitals. The notion of regional centres of excellence with spare capacity is an excellent prospect. However, where are we to accommodates patients? They are being put on trolleys in corridors and in dental rooms. There was a case last year where patients were put in a hospital carpark.

Are the regional centres going to adopt a system similar to that initiated by Holles Street Hospital whereby notice will be given that only a certain number of patients will be treated at a particular time? The precedent has been set in this regard. The situation will arise whereby we simply cannot handle the volume of patients presenting for treatment. Hospitals may effectively put themselves off call in such cases.

My colleagues and I have been accused of wanting all-singing, all-dancing hospitals at every crossroads or in every county. We know this will not happen. We do not expect that heart or brain surgery, renal operations and orthopaedic units can be provided in small hospitals. That is not what people want. The key issue is the provision of well functioning accident and emergency units at all these small hospitals. Other services must be provided also if the accident and emergency services are to be sustainable, to have the volume and mix of staff necessary in smaller hospitals. This issue must be considered. There is no point in people being told at Monaghan General Hospital, for instance, that they should hold on for another hour and they will brought to a regional centre of excellence. People have died on the way to other hospitals and this will continue to happen.

The priority must be to save lives. People's concerns regarding their local hospitals is to have faith that their lives will be saved rather than endangered. They are willing to undertake journeys for elective treatment. Patients have travelled to Cork, Waterford, England and elsewhere to receive elective treatment under the national treatment purchase fund. There is no objection to such travel because it is not a matter of emergency and their lives are not under threat at that time.

A significant issue is consultant numbers and I wish to offer some comparative figures in this regard. The average EU figure is 139 surgeons per 100,000 population while the corresponding figure here is 31. The EU average for gynaecologists and obstetricians is 131 as compared to Ireland's figure of 23. The EU figure for paediatricians is 146 while in Ireland it is 22. There are on average 98 radiotherapists per 100,000 population in the EU but only 39 in this country. We must begin to employ more consultants, professionals and hands-on people in the service.

Last week, the Tánaiste and Minister for Health and Children sent her adviser to the Cavan-Monaghan area. When she receives the report of this visit, I hope she will listen to the concerns expressed by the Monaghan Hospital alliance, the Monaghan Hospital development group and the staff in both hospitals in the area. This will allow the Tánaiste to gain a better enlightenment as to the services required.

There has been talk of providing clinical nurse practitioners in hospital units. This sounds like a good idea. However, the training period for clinical nurse practitioners is some seven years and there are five such qualified people currently employed in the health service. Moreover, clinical nurse practitioners must have a consultant in the room with them. Allocating such a practitioner to a hospital, therefore, necessitates the co-operation of a consultant surgeon. They are not stand-alone staff and the Tánaiste should take this into consideration.

I welcome the opportunity to speak on this important legislation and appreciate the Tánaiste's attendance at the debate. The Tánaiste did not sell herself short in her introduction of the Bill. Words such as "historic" and "once in a generation event" tripped off her tongue. I am only surprised she did not use the words "ground breaking" to describe the legislation. She also claimed to be putting the patient first, a claim we have heard before. We heard it at the launch of the health strategy in 2001 when so many other promises were made. We were promised 200,000 more medical cards but all we got was an extra 30,000 courtesy of the Estimates. This is what the Government describes as "putting the patient first". We were promised 3,000 new beds but little has happened in this regard three years later. This is another element of the Government's policy to put the patient first. The Tánaiste should communicate this policy to those patients on trolleys and chairs in accident and emergency units as we speak.

The Tánaiste will tell us this is just the start of a brand new era in health care which will usher in a state-of-the-art, world-class health service, as she has described it. In order for it to happen, we must give it time. I do not buy that. This Bill represents yet another rebranding of the health service. More importantly, it represents a rebranding of the Government parties as caring, even socialist, and an attempt to buy time.

The Government is not socialist.

It represents an admission by the Government that, after more than seven years in power, the health service is a mess but that we should trust in its strategy of applying new, slick, corporate principles to the service. In a short time, perhaps after the next general election, waiting lists and the crisis in accident and emergency provision will be in the past.

As I said when this legislation was first mooted, the Bill sets up another layer of bureaucracy, centralises control of the health service and will result in less accountability. Under section 21, the chief executive officer can appear before an Oireachtas committee but woe betide him or her if a word of criticism of the Government should cross his or her lips. Section 21 (9) prohibits any such critical statements and means that the CEO might as well be gagged before coming in front of an Oireachtas committee. What rights do members have with regard to Question Time?

What questions will the Ceann Comhairle rule out of order because a matter is deemed to be one for the Health Service Executive? It would be helpful if the Tánaiste could spell out in detail matters about which we will not be allowed to ask questions. Will we be able to ask about bed shortages, the accident and emergency crisis, orthodontic or cancer services? What will be off limits? If a subject is off limits, does that not mean there will be less accountability? What precise input will the House have in making health policy? We are told that under section 29 the executive will have to produce a corporate plan. Under section 30, such a plan will have to be placed before the House after the Minister has approved it. Surely if the Minister is serious about accountability, the House should have the opportunity to debate such a corporate plan and to make amendments. Likewise, we should have the opportunity to debate the progress reports. We will have progress reports and they will simply come before the House, but we will not have the opportunity to debate them. That is a missed opportunity in the legislation.

Perhaps that can be revisited on Committee Stage. However, I believe this will not happen because, essentially, this legislation is about removing power from Deputies, councillors and health boards. Were the health boards costing the State a fortune, as was claimed when the idea to disband them was first put forward? No, the Brennan report did not call for the disbandment of the health boards. A few advisory panels will replace them. They will give advice but will anyone pay a blind bit of notice to what they advise?

How much will this new executive cost? It will not come cheap. We will pay an inordinate amount of money to its chief executive so that he or she will take the poisoned chalice from the Minister. His or her primary function will be to protect the Minister, essentially, to be her mudguard, for which he or she will be handsomely remunerated.

The legislation does not address the root causes of our health crisis. Like conventional medicine, it deals with the symptoms of the problem. We may be — I say "may be" because this is disputed — living longer, but we are becoming sicker. As pointed out in the latest Feasta review entitled Growth: The Celtic Cancer, which I advocate as recommended reading for the Tánaiste——

It is a joke.

It is not a joke.

It recommends poverty is good for one's health.

It is an excellent document.

I read a bit of it.

That is good because I will remind the Tánaiste about a few key statistics in it.

It proposes we go into recession because it would be good for our health if we were unemployed and poor.

The review is no joke because it is founded on the fact that——

The review is mad.

It is not mad.

It is crazy stuff.

It is an excellent piece of work. I commend the authors of it, in particular my Green Party colleague, Dr. Liz Cullen, for her fascinating and insightful contribution. What it states is the key to solving the problems we are currently experiencing in our health service. I am glad the Tánaiste has at least dipped into it.

I was so amazed by what I heard about it that I had to read it to see if it could possibly be true.

It is all true.

It states that economic success is bad for our health.

The Tánaiste wants to believe what the Taoiseach calls the right wing economists who write forThe Economist who would have us believe that we are living in some sort of nirvana in that they claim we have the best quality of life in the world. That is bunkum. This publication puts paid to that myth.

It suggests a recession would be good for our health.

We do not have the best quality of life in the world. A question I have put over and over again to the Minister's predecessors, and which I will put to her, is the role played by stress in causing illness. We have to examine stress levels——

The Deputy is causing me stress.

I will try not to.

He should think about my health.

I might be bad for the Tánaiste's health if I do, but I will try not to cause her so much stress.

I will give a few statistics. A survey of 1,000 people carried out in 2001 on behalf of the Mental Health Association of Ireland found that 73% reported finding life more stressful than five years previously, 19% of the respondents said they were smoking more and 17% said they were drinking more in order to cope with stress. The national health and lifestyle survey of 6,539 people in 1999 to ascertain what people believe would best improve their health found that the majority reported that less stress would improve their health regardless of their age, sex and social background. A follow-up report in 2001 also reported that stress was the most common answer from males and females in reply to that question. These are the facts.

In an on-line survey in 2001 a sample of 2,000 students were asked if they thought that the level of stress experienced by the general Irish population had increased, in response to which more than two thirds said that it had increased a great deal, 30% said it had increased a little and only 3% said it had not increased at all. All the indications show that stress is increasing.

One of the surveys I find fascinating was one on depressive disorders. In 2003, research involving a representative sample of 12,702 women in four European countries found that women in Dublin were more susceptible to depressive disorders than in similar cities in other countries. It was found that one in three suffered from depression. One of the authors, Professor Patricia Casey, commented that this study was conducted at a time of economic boom when one would expect depressive disorders to reduce.

They have not reduced. This is the problem. The Tánaiste created the Celtic tiger, so she claims. She has created this mess, this level of illness and now she claims she will fix it, but I do not believe she will.

One third of women here do not suffer from depression.

This Bill will not provide one extra bed in our hospital wards. It will not reduce by one hour the waiting time of a single patient in any of our chaotic accident and emergency units. It will not lead to the employment of a single extra nurse, doctor or paramedic. It will not extend radiotherapy services to the regions. It will not restore a single service that has been lost to local hospitals. Above all, it will not address the scandal whereby money can buy superior health care in this State and where public money subsidises the private health business while public patients suffer. The Bill diverts vital energy from the real delivery of services. I support the amendment tabled by Deputy McManus.

Before this Bill was even published the changeover process had descended into chaos. The duly appointed chief executive officer of the Health Service Executive, for which the Bill legislates, stepped down less than two months before he was due to officially take up his position. On the day this Bill was published, IMPACT which represents 25,000 workers in the health services, announced that its members had voted to stop co-operating with preparations for health service reforms until it gets safeguards about the continuity of health services, jobs and working conditions when the new health structures come into force on 1 January 2005. Its members have endorsed industrial action by a margin of 88% to 12% in a national ballot of staff directly employed by existing health boards, including nurses and other health professionals as well as clerical, administration and managerial staff. I do not believe these workers took that decision lightly. They feel they have been left in the dark and that they face an uncertain future.

I have also listened carefully to what has been said by organisations representing people with disabilities. They too are very concerned at the lack of clarity and information about how services on which they depend will be delivered under the new structures. This is surely yet another example of the disastrous mismanagement of the health services by the Government, which published its health strategy in 2001, the Prospectus report in 2003 and which is now presiding over a situation where those who deliver the services and those who avail of them are left in a state of uncertainty and agitation.

This Bill is based on the recommendations of the Prospectus report. When it was published I stated that it proposed not real reform of the health services but bureaucratic change. Everything that has happened since then, supports that contention. We see all around us the glaring need for real reform and real improvement in the delivery of services in our crisis ridden health system. Instead what do we have? We have this Bill that is the wrong remedy for the wrong illness. We have a Bill to establish an all-powerful quango appointed by the Minister for Health and Children and subject to no direct democratic accountability.

When the Prospectus report was published I stated that few would shed tears for the old health boards. They were too cumbersome and it was widely agreed that they would have to be replaced. The Minister's comments in her introductory speech were accurate in that respect. However, they had a degree of democratic accountability. There was representation of elected councillors and of bodies representing health service workers. That degree of accountability is now gone. The Government tries to cover up the democratic deficit by providing in the Bill for fora and powerful talking shops. They will be powerless talking shops. Decisions will be made even more remotely from the communities and individuals they will affect.

The people of my constituency know the consequences of that only too well. The day before he left office the Minister's predecessor, Deputy Martin, issued a public statement which appeared to provide for significant improvements at Monaghan General Hospital and to reverse some of the loss of services we suffered during his term of office. The promises have turned out to be a carefully woven fabric designed for public relations. That fabric has been unravelling ever since. Last week, it was confirmed that all surgical doctors are to be removed from Monaghan General Hospital, finally reducing our hospital to the status of a day clinic.

As a former member of the North Eastern Health Board, I know that colleagues of most political shades fought hard to retain services at Monaghan hospital. We were met time and again with deliberate efforts to deceive, confuse and conceal information. The executive of the health board, the Department of Health and Children in Dublin and the professional bodies, such as Comhairle na nOspidéal and the Royal College of Surgeons in Ireland, dictated from on high.

The Bill will make a bad situation even worse. Decision making will be even more remote from the citizen and the community. For at least all of next year, energy will be concentrated on this massive bureaucratic change instead of on real delivery for patients and real reform of the health services. It cannot be stressed enough that any so-called reform that does not challenge the grossly unfair two-tier public/private system will only maintain inequity and inefficiency. We should have a much fuller discussion on that issue. Such a debate would address the Government's policy of subsidising the private health industry.

The guillotining of this Bill will not allow such a debate, but I will make some points briefly. I ask the Minister to clarify the following issue in her concluding remarks. Spin doctors in the Department of Health and Children, or perhaps in the Progressive Democrats, recently told the media that the Minister wishes to increase private sector involvement in the health services. Lo and behold, a 43% increase in funding for the treatment purchase fund was signalled in last week's Book of Estimates. I have asked the Taoiseach how this tallies with his claim to hold socialist and republican principles but he has declined to answer. The increased privatisation of services can only lead to a reinforcement of the public private apartheid in our services, which is driven not by the need of patients but by the profit motive of the private health business. Money must be invested in our public health system.

We have yet to be given an explanation of why the Minister went on a visit to New York recently to look for ideas for our health services. I hope she has carefully examined the grossly unequal health system in the United States where an estimated 43 million people have no health cover whatsoever. Perhaps the Minister will also explain that trip to us in her closing remarks.

For years, the Government has been promising a separate health complaints Bill to provide a statutory framework for the handling of complaints within the health services. Then we were told statutory provision for health complaints would be included in this Bill. What have we got? We have little or nothing. It is left to the Health Service Executive to establish these procedures. There will be no independent complaints system. Section 52 sets out all kinds of limitations and restrictions on the type of complaints which can be made.

The Bill provides for the most far reaching change in the administration of the health services since the establishment of the health boards. It is a significant Bill for our health services, the foremost issue of public concern and a foremost responsibility of the Oireachtas. Yet, this long promised and long delayed legislation was only published late last Friday and we are being asked to debate and pass Second Stage of a major Bill of 82 sections in the space of three days. It is to be rammed through the Oireachtas by Christmas in a desperate effort to hide the shambles that is the so-called health policy of the Government. At the core of this issue is the ongoing erosion of our health services by the Government and its failure to grasp that fact.

Accordingly, I will be supporting the amendment tabled by Deputy McManus because the Bill is a mess and should be withdrawn and redrafted.

I welcome the opportunity to contribute to the debate and I acknowledge the presence of the Tánaiste and Minister for Health and Children and the Minister of State, Deputy Tim O'Malley.

Unlike my colleague, Deputy Gormley, I do not have a book written by a party member to promote. I must pass on that opportunity. This is important legislation and it is important that we debate it in the time allowed. There is pressure to pass the Bill because many people are awaiting its enactment.

I too lament the passing of health boards. I was elected to Dublin County Council in 1991 and was nominated to be a member of the Eastern Health Board in 1994. I was delighted to be given that opportunity and to gain that experience. Working on the health board, I learned about the working of the health service at first hand. I have also had the opportunity to serve on hospital boards, including the board of St. James's Hospital and the board of Tallaght hospital, which I first joined in 1987. I enjoyed my time on the Eastern Health Board. Subsequently, I was nominated by the council to the South Western Area Health Board. I became the founding chairman of that body and was a member of the Eastern Regional Health Authority. I value the experience I gained of the workings of the health board. For most of that period, my good friend, Deputy Callely, was chairman of the Eastern Health Board and of the Eastern Regional Health Authority and was a great help to many of us. I valued that period of my political life and I enjoyed it hugely. While I lament the passing of the health boards, I accept that times change and things move on. We are now trying to achieve a different model. Like all models, it will not be perfect in the first instance but we must work on these things.

As a Fianna Fáil backbencher, I am not afraid to say that when huge amounts of public money are being put into the health services — more than €11 billion this year — it is right that we demand proper services and facilities. We demand that sick people who turn up at accident and emergency units, whether walking wounded or in ambulances, be facilitated properly and given a hospital bed as quickly as possible. I am not talking about people with cracked finger nails. I have little sympathy for such people or for those who turn up at accident and emergency units the worse for drink. I am talking about people who are genuinely sick. We must continue to exert pressure to ensure that such people are facilitated. This pressure must be maintained throughout the country and not only in my constituency. Public representatives are often called upon to intervene on behalf of families and to calm people when their relatives are in accident and emergency units. Every opportunity should be taken in this Chamber to support that view. I have heard comparisons being made with other jurisdictions but until we reach that situation we must keep the pressure on.

I have always supported the accountability of health boards. In fairness, the political system served the health boards well, even though I often saw criticism being levelled from fairly eminent people around the country, including Dublin, who did not quite see the contribution of politicians in that positive way. Unfortunately, that criticism created a different sort of view, although many politicians, including councillors, served the health authority and its predecessors well.

I want to put on the record the great work that was done over the years by the association of health boards under the chairmanship of Mr. Jack Burke who did a tremendous job. I hope the Minister will examine ways in which people of such expertise will have an input under the new legislation.

I have strong views about representation on hospital boards. I was first appointed to the planning board of Tallaght Hospital in 1987 by the then Minister for Health, Deputy Rory O'Hanlon. He asked me to serve at that level and bring a local perspective to the work of the board. I remember attending my first meeting of the board in Harcourt Street and asking the chairman and members when we would meet in Tallaght. I almost caused consternation because that was not done at the time. I and others brought that Tallaght feel to the board. Even when I was on the board of St. James's Hospital I tried to do that, as did other colleagues.

Where the Eastern Regional Health Authority's nominees have lapsed it should be understood that there is still a need for local representation. I recently made representations to the Tánaiste, asking her to look at that gap. As far as Tallaght is concerned, other than the nominees of the National Children's Hospital, the Adelaide Hospital, the Meath Hospital and the archbishop, the charter does not provide for other representation. I hope that matter will be examined. I also appeal to those in a position to nominate members through that process — and I am talking specifically about Tallaght — to look at nominating more local people. It is important to have a local perspective on all hospital boards, along with the required professional expertise. I have already made that point to the Tánaiste and I hope the Minister of State, Deputy Tim O'Malley, will take it on board. Hopefully, it will come to fruition.

We must support the health services in our respective regions. Normally, I would not make a Tallaght speech but it is important for me to talk about my constituency for a while.

I was there today.

The Deputy should stay under the Whip.

Alan Dukes No. 2 — the Tallaght strategy.

I represent Dublin South-West which has approximately 35,000 houses and a population of about 70,000. It goes from Brittas to Tallaght, Firhouse, Templeogue and Greenhills.

He has a vote in every area.

During my period in public life, I have continued to campaign strongly with colleagues from all parties for proper facilities throughout that region and not only in our hospital. We all campaigned in Tallaght to ensure that the Adelaide, Meath and National Children's Hospitals came to Tallaght, which they did in June 1998. There are other facilities there also, however. I sometimes invite people to come to Tallaght and I would be happy to show colleagues around. Now that the Luas is there it is easy to access.

The Deputy should not forget Beaumont.

Other facilities in the area include the brand new health centre in Jobstown, the new GP centre in Killinarden and similar facilities in Brookfield. The need for a refurbished and developed health centre in Millbrook Lawns remains an issue, although the Government has grant-aided that to the extent of €1 million so far. I wish to tell the Minister of State that we are knocking on the Tánaiste's door for further increased funding in that regard at a time when there is buoyancy in the economy through sound management of the economy by the Fianna Fáil-led Government with our good friends from the PDs.

I apologise to the Minister of State because I should have linked those words better. It is important that Tallaght gets its share, as should Limerick or other parts of Dublin.

Or Beaumont or Clontarf.

Beaumont, indeed. The Deputy will understand that I do not go to Beaumont all that often, although I am happy to acknowledge the tremendous contribution that hospital has made to our health care services.

I want to make the case for Millbrook Lawns because it is currently going through the planning process and the site needs to be properly redeveloped. I hope to have the continued support of the Department and the Minister in seeking those facilities. There is a need to keep pace with requirements throughout my constituency and the region generally. Sick, vulnerable people who wish to access health services should be entitled to do so in proper facilities.

Where I came from in Crumlin, I remember looking at health centres that had not been upgraded for some years. The case for upgrading such facilities must be made when there is money in the economy to do so. I applaud the work of health board staff throughout the country and specifically in my own area in the Eastern Regional Health Authority which succeeded the Eastern Health Board. People make the point that there are too many staff but we should appreciate the great work they have done.

Like my colleagues in the House, I have had many dealings not only with hospital staff but also with those looking after medical card applications and the delivery of health services generally. I acknowledge the work they are doing and support them in their efforts.

But they cannot cope.

In the context of the developments taking place under the remit of the Bill, health staff should be properly briefed about what is going on. They should also have an opportunity to discuss their future. When I worked in an ordinary job, I went through phases when we did not know what was going on in companies but it is important to understand what is happening. Those of us who are privileged to represent constituencies here have a responsibility to continue to make that point. When I meet health workers in Tallaght, Millbrook Lawns, Brookfield, Killinarden and Jobstown I get the sense they would like to know what is going on and what the future of the structures will be. That is a fair point for them to make.

Not only am I a strong supporter of Tallaght Hospital, having been associated with the board from 1987 to 2002, but I have been a patient there also. I have queued for my blood test like everybody else. When I had a heart attack in 1999, the hospital was there to care for me. I recall driving back to Tallaght that night to make sure I got sick there, rather than anywhere else. That is where I wanted to be. I am happy to acknowledge the great job that Tallaght Hospital does. The hospital's cardiac rehab team is responsible for looking after so many people. I am not being flippant about this matter. I am speaking seriously about my own illness and the manner in which I was assisted to recover. I would not be here but for the work of that cardiac team.

The Deputy is lucky to be here.

Like many people who become sick, sometimes one wonders if one wants to bother any more. Lots of Deputy Neville's colleagues told me to take up golf but I wanted to be a politician and here I am.

A safe seat.

I do not have a safe seat. The Deputy need not worry. He probably has the safest seat in the House. I am working on what I am doing and I am always happy to acknowledge what my friends in Tallaght Hospital did for me and many others. While I do not want to single out one department ahead of another, I am always in awe of the work of the cardiac rehabilitation team, which does a tremendous job.

Tallaght Hospital is deserving of the support of all of us. Deputy Finian McGrath spoke about Beaumont Hospital. Like every other hospital, Tallaght Hospital gets picked on. A massive Sinn Féin protest took place outside the hospital last Saturday, involving, I understand, four protesters. Last week Deputy Twomey visited the hospital without me and addressed a meeting about health care. While in a democracy that may be fair enough, I am always more positive about such matters.

I take every opportunity to support my local hospital and if I lived close to Beaumont Hospital I would do the same as Deputy Finian McGrath. My local hospital has a catchment, which not only includes the third largest population centre in the country but also stretches as far as Carnew, almost 70 miles away. Many good people come to Tallaght Hospital for its services.

I am always happy to stress that Tallaght Hospital should not just be about cut fingers and illnesses, it also has a clear role to play in the development of our health services and can do a considerable amount in the area of health promotion. While I do not want to again talk about the cardiac area, those familiar with the building will know of the "heart walk" pathway right through the building. Many people especially on cold winter days have the opportunity to walk there. I am always happy to promote that as it is important that health promotion should get a considerable amount of our attention.

That is not to say that I do not share concerns about accident and emergency because I do. We need to continue to apply pressure in that regard and to support the staff in every way. I have often had the opportunity to talk to front line staff in the accident and emergency department in Tallaght Hospital who have told me about their problems and difficulties. As I am known to some patients, when I go there I am sometimes asked if I have come to check. I do not go to check. When I go it is usually to visit neighbours and to support what the hospital does. I hope we will continue to do that in all our hospitals.

During the remainder of this debate, we will hear much discussion of the Bill, the services and what we are trying to achieve. I hope that we will not engage in silly political point making, although I have no problem in dealing with that and having such debates. I am particularly proud of what we have achieved in Tallaght Hospital and throughout the region with the development of health services. I will continue to be as strong as anybody and stronger than most in stressing to the Minister the need for resources, which is what the public is telling us.

As I go about my business people talk to me about health services with other issues. While this is certainly an issue, I will not wait the remaining 900 or so days until the next general election to go around Tallaght and the rest of my area listening to what people are saying. I do so on a daily basis and am always happy to do so. It is important that we continue to do that. We need to take those opportunities to listen to what people say, both negative and positive, and represent those comments in these debates.

The programme for last Sunday's Gilbert O'Sullivan concert contained a note suggesting, "Think negative, but always act positive". In terms of what we are trying to achieve in this debate, I hope we will always do that. I have no problem with colleagues listing the difficulties, as I have done. I am not afraid to make representations about the difficulties. Where there have been cases in Tallaght of people unable to get through the system and get a bed quickly enough or get the services they require, I have not been afraid to take on the bureaucracy.

We need to continue to strongly support the initiatives to reduce waiting lists. Not only in Tallaght but also throughout the country, people are concerned about waiting lists and the manner in which appointments are delayed. We must continue to voice those concerns while also making the point the hospital authorities often stress to me that people fail to show up for appointments for all sorts of reasons, which leaves others without appointments.

I thank the Minister of State for his attention and I wish him well.

He was listening very carefully.

I listened to every word.

All Ministers listen to us humble Fianna Fáil backbenchers and we get a good response from them. The Minister of State has come to Tallaght on a number of occasions and has done very positive work. I am happy to wish him well and congratulate him. I look forward to supporting the Bill and to listening to other contributions.

I welcome the opportunity to contribute to the debate. I am pleased the Minister of State, Deputy Tim O'Malley, is present. I concur with the previous speaker's comments on health boards. The abolition of the health boards is unfortunate. I strongly support the notion of local representation and public representatives representing their constituents on key issues of concern to them. The Minister of State and I served on a health board and our experiences were positive. We made a contribution and held the Executive to account. I compliment the Minister of State on the work he did while a member of the Mid-Western Health Board during the many years he served there.

Deputy Noonan with others from all parties was on that board. We made our contribution in representing our people and in ensuring the executive and administrators were accountable and questioned them on issues of concern. While sometimes they were put under pressure, on all occasions they appreciated that they needed to account to the people of the mid-west region through their representatives in that forum. That forum has been removed and we now have a health executive whose accountability is very vague.

It is obvious that this is becoming the National Roads Authority of the health service. While we can get information on our national roads, all Members know how difficult it is to influence the decisions of such an authority in the interests of the people we represent. Even more significant and delicate is trying to influence an executive that makes decisions on one of the most basic issues that concerns everybody, the health of our people. While I am very dissatisfied with the response to representations at local level rather than at ministerial level, at least we had the opportunity to make those representations and to talk to people in the health boards. This area needs to be clarified.

Some people believe we should not make representations about issues of concern, such as people on waiting lists, people concerned at how they are dealt with in accident and emergency departments and similar issues. However, people with such concerns should have available to them the avenue of their public representatives to represent them. In a utopia that should not be necessary. Such complaints and difficulties should not exist and people should not need to contact us. People have concerns, however, and are sometimes upset about their dealings with the health services and we are the conduit to bring those concerns to the health board. Some people know how to go about these matters but there is a large number who do not know how to make contact or achieve access and who do not have the confidence to do so. Even when we advise them to take a certain route independently, they are often reluctant to do so. This might be nothing more than contacting the consultant dealing with the family member. I am surprised by the number of people who approach me in difficulty about a family member, often a parent or child, who are reluctant to talk to a consultant.

We act as advisers and mediators for those people. Will these functions of ours disappear? Currently we can carry out these functions and if we are dissatisfied, we can go to the deputy chief executive officers or the chief executive officer or table a parliamentary question and get a reply. Will all that assistance, representation and mediation still be available when the new executive is established on 1 January? For those of us who see assisting such people as part of our role, this is important work and I would appreciate it if the Minister for Health and Children would clarify the position.

In general, I can only compliment the people in the various Departments who respond to our requests and assist in every way they can by informing us of issues of concern to our constituents. I find it difficult, however, to get the same level of response from the Mid-Western Health Board. Perhaps the Minister of State has experienced this or maybe it is a personal thing against me. I do not know and I have not discussed it with my colleagues. I have, however, discussed it with the chief executive officer of the health board.

A year ago, a person came to me in pain late at night. She asked me if I could obtain information about the results of a CAT scan for which she had been waiting for some time to assist in obtaining relief from the pain and advice on what was happening. She felt the delay in getting the results inhibited the treatment of her condition. I contacted the Mid-Western Health Board and was told it would be a breach of hospital confidentiality policy if it kept me informed at every stage of a patient's condition once she has been seen by the hospital consultant. I simply asked when the patient would be seen. The reply to my inquiry stated that this practice would be in breach of patient clinical confidentiality as well as being time-consuming, and the health board would not respond. It continued that recent representations bordered on malpractice and I was asked to cease immediately.

I tabled a parliamentary question on this which was responded to by the assistant chief executive officer who informed me that the consultant physician requested a CAT scan on 6 June, which was later discussed at a case conference with the radiologist where it was decided that it was not appropriate to have a CAT scan for this patient. However, a chest X-ray was carried out on 24 September 2003 and the results were made known to her, the consultant and her GP. That is the information I wanted on the first day but instead I was told that I was to stop making inquiries.

I have other examples of such behaviour. On 3 August I spoke with extreme concern about a distressed patient and said that there was a danger to the person's life. I was told by an officer of the Mid-Western Health Board that I was very rude to say that and I should not do so. I have a letter about another person on a waiting list that states that the patient will be informed of the prognosis and treatment and there is no need to continue to make representations because the person was in the system and the correct course of action would be decided by the medical team. This person had been on a waiting list for a long time and he just wanted to know when he would be called.

I expressed my concerns on this issue to the chief executive officer of the Mid-Western Health Board on 5 April. He said he would look into it but I am still awaiting a reply from him so I have given up. The Minister of State is from my area and I appreciate his professionalism but I am concerned about this because I have never experienced anything like it in any Department.

People take politicians into their confidence and in all my experience of public representatives, those confidences have always been respected. I cannot remember a person coming to me to express concern about a political colleague using information given in confidence. Every interview in a clinic is confidential and will only be dealt with by relevant people who can give the information to assist the person in their query. We do this work even though the perfectionists would say that we should not, that we should only legislate. I totally disagree. We have a role in legislation but we also have a role in representation and that role exists for politicians in all countries. In Britain, MPs who live in London spend more than 50% of their time dealing with queries from their constituents. I make no excuses for doing the same. We would like the Minister of State to respond to our concerns on representation.

Complaints may be made under the Bill if a patient feels he or she has not been treated in accordance with fair and sound administrative practice. We often, however, have queries about other areas, sometimes of a clinical nature. Will such complaints be excluded? Why should someone not complain about clinical aspects of his or her treatment?

In the area of mental health, especially, which the Minister of State deals with extensively, as I do because of my responsibilities as party spokesman, I am conscious that we may differ on certain aspects, because of our different roles. Deputy Tim O'Malley is a Minister of State and I am an Opposition spokesman. I am not being personal, but I deal with this area on an ongoing basis and I get many complaints. Last week there were two suicidal patients, one of whom would not go back to 5B in the regional hospital because of his clinical treatment there. I understand this complaint would not be allowed under the proposed legislation on the grounds that it is only an administrative issue. It is not an administrative issue, but a clinical problem. Are clinicians eliminated from the Bill? As the Minister of State is well aware, the report on the death and suicide of Ms Anne O'Rahilly from Adare in 2002, certainly raised many clinical problems and queries about clinical issues and decisions which were vital to the quality and credibility of that excellent report. It queried the clinicians on several occasions. In this legislation, can such a report be compiled under the complaints procedure? If it is just a question of administration and the limitation of clinical queries, then it is extremely limited. It now seems that certain clinicians and clinical decisions are above questioning. Most people who query clinicians just want information or assurance and sometimes have definite complaints to make. Many of these can be satisfied locally through a complaints procedure, but if it is being asserted that any of these issues cannot be queried, the likelihood is that the Minister will end up in the courts. People in such circumstances do not want to go to court, they just need to have their complaints responded to under the system. The Minister of State is aware of the many issues that I raise in that area, and I will not repeat them on this occasion. However, this is an area that should be covered and to which the Minister for Health and Children, Deputy Harney, might respond when she comes to debate the Bill.

Under section 21, the CEO will be required to appear before the Oireachtas committees when requested by them to account for the performance of the executive. The Minister for Health and Children of the day is responsible to this House directly and we can hold him or her responsible. We cannot hold the CEO responsible. However, last March the Joint Committee on Health and Children wrote to the then Minister for Health and Children, Deputy Martin, and invited him to attend a meeting on three issues about which members were extremely concerned. He was due to meet us before the end of May, but could not make that meeting. He was due to meet us before the House rose for the summer recess and that did not happen. We were anticipating a Cabinet reshuffle and he did not want to come anyway. There was a change of Minister and we invited the new incumbent, who now tells us that she must read into her brief. That is perhaps fair enough, but I reckon that if a Minister attends the committee to respond to those queries, the process will have taken approximately 12 months. This is the Joint Oireachtas Committee on Health and Children, where the Minister is directly responsible to this House. What chance is there of getting a CEO to a meeting of the committee, who is not responsible to it, apart from section 21 specifying that he or she may appear before the Oireachtas? The Minister for Health and Children is directly responsible to the Oireachtas and it takes 12 months to get him or her to meet the committee to discuss issues of concern.

Finally, I would like to deal with one of the Minister of State's own areas of responsibility, since he is in the House. We were extremely concerned that yesterday's Estimates showed that the contribution to the mental health services as a percentage of the overall budget has dropped again, to 6.15% from 6.69%. The relative contribution has dropped for every year since 1997 when the Fianna Fáil-Progressive Democrats Administration began. The Minister of State has spoken about €15 million being contributed. However, one of the key recommendations in the report is for a dedicated isolation service or a special care unit for people who are suicidal in 5B. The cost of that is €10 million and it is being promised as "imminent" in that report. However, there is only €15 million extra for the whole country, so where is the rest of the expenditure that is needed to come from? I was hoping and expecting a response for the needs of our own area, and we then see a total of just €15 million for all the areas of need, which are our responsibility as well. This puts the entire issue into context and the Minister of State will understand our concern. I believe he deserves a better response from the people who decide how the budget is allocated within the Department as regards mental health services.

I welcome the Bill. Before dealing with some of its aspects, like many other Members and indeed those in public life in general, I have been critical of the bureaucracy surrounding the health services and the manner in which replies are delivered to us, whether in the context of a parliamentary question or by way of correspondence to the CEOs of health boards. The previous speaker has outlined his experience in a way that ties in with the matter I want to address. A serious inadequacy exists in terms of the health boards and the information they give. Likewise, there is inadequacy in terms of the accountability of the health service to this House. In the course of this Bill, while public representation is mentioned as well as the public being represented in other fora, there is a strong need to ensure there is clear responsibility to the Members of this House in the context of the questions we ask of the service, or in individual cases, while recognising the confidentiality that must exist between the health service and its client. There is no excuse for the virtual non-accountability that exists at present.

I welcomed the abolition of the health boards as a step towards reducing the bureaucracy in the system. I also welcomed the appointment of Deputy Harney as Minister for Health and Children. I wish her well, because like many others, I believe she is the right person in the right place at this time to do the business in the context of delivering an efficient health service by removing vested interests from it and the top heavy bureaucracy we have seen. All one has to do is look at the increase in the number of employees in the health service, when it is obvious that it is primarily accounted for by bureaucracy rather than people in the front line, with the administrative square footage substantially greater than the area reserved for centres of care.

I have tabled umpteen parliamentary questions and have got unsatisfactory answers. I have been critical of our local health board. We are at a point where the Bill is being introduced and the system is being radically modernised. There is a need for a common sense approach across parties, as mentioned by the Minister. There should almost be a Tallaght strategy because it is the health of the country we are talking about which involves a budget of €11 billion per year. To continue to haggle over the health policy would not be helpful. There is no sense to the Labour Party position on medical cards and its comments generally on the medical services. Some of the comments do not facilitate constructive debate. The terminology "yellow pack" used in regard to medical cards is a disgrace and the Labour Party should refrain from that type of language in the context of this debate. I appeal to all parties to work towards a political consensus, to urge constructive debate and to take the emotions and political positions out of the debate in order that we can come to some resolution on an overall package for the heath service.

During the course of the debate leading up to the launch of the Bill, I saw St. Luke's Hospital in Kilkenny being transformed. I will use it as a model given that a number of backbenchers from all parties have visited the hospital. The Fine Gael spokesperson has visited it and I commend him for doing so as it is not part of his constituency. He is showing an overall national interest. I commend the Minister of State, Deputy Tim O'Malley, who also visited St. Luke's Hospital. During a visit to Kilkenny, the Minister, Deputy Harney, visited the hospital. I extend a personal invitation to her, without any political bells ringing, to come and walk through the hospital with the consultants and those who run and manage that hospital because it is a model for the rest of the country.

Thirty years ago Carlow hospital closed. There were beds in the corridors in every part of St. Luke's Hospital in Kilkenny. The consultants and the managers at the hospital, separate from the health boards, saw there was a crisis and that something had to be done, and worked together. Today there are no beds in the corridors. Some 17,000 in-patients and 40,000 out-patients are seen. For that service there are only five rooms and three cubicles, plasterboard separating them. It is not a modern facility.

There is no surgical waiting list. All of this has been achieved with 317 beds. It is possible to radically overhaul the service and deliver care directly to the patient where it is required. They have pioneered these initiatives. They have dealt with paediatrics and geriatrics. The hospital also has a stroke unit. The plan was supported by the investment of millions of euro in that hospital by the former Minister for Health and Children, Deputy Martin. The hospital can act as a model for the rest of the country against the backdrop of the Mater and St. Vincent's hospitals, each of which has 14,000 in-patients beds. The figures are generally the same.

The Hanly report is condemned throughout the country and politically one should not speak about it. There is a sentence in it that refers to the general hospitals. I suggest the activities of St. Luke's, as of today, fit into its description of a general hospital. That service should proceed under the Hanly description of a general hospital and be funded and expanded accordingly. It does not take that much money. St. Luke's Hospital is considering an out-patients facility which would cost €3 million, which is in addition to the work it has done. The staff are excellent and one gets the best of care. If it succeeds in getting the out-patients facility it can use the building to improve the accident and emergency unit. It has moved from the provision of services, the whittling away of the waiting list, dealing with thousands of people across the services to endeavouring to improve the quality of service being delivered. The cost of that improved quality is €3 million. It is seeking a Dexascanning system to define how brittle or otherwise are the bones of the elderly and get them the appropriate treatment. It is seeking accommodation for step-down facilities. It has the initial facility for analysing patients on the way in. There are those who will vacate the acute beds and end up in the care facility before going home. That has all been achieved on a shoestring budget. It is the finest campus in the country staffed by the best people. I urge the Minister to look at not only what has been achieved but at its short shopping list to put the hospital at the cutting edge of the development of the health service without waiting lists or people being delayed for a considerable period in the accident and emergency unit. If the system in that hospital is replicated we will have a system based on that model which will relieve hospitals throughout the country. There is a need for sensible debate and accountability.

As one who promoted the notion of abolishing the health boards and reducing bureaucracy, I say there is a need to speed up that process. I hope the Bill has a speedy passage through the House. I hope too that the debate is constructive, and if sensible amendments are proposed on Committee Stage they will be accepted.

I have no doubt, given the long political career of the Minister, Deputy Harney, we will have that type of approach in trying to reach agreement across parties to resolve the many problems in the health service. We can strive towards the working model where we do not have waiting lists and services are available immediately. I consider the health portfolio to be a work in progress. There will always be new problems, new services coming on stream and demands of one kind or another but we can deal with those.

An issue that annoys me greatly in St. Luke's Hospital is that the scanning system is not available out of hours, it is available from 9 a.m. to 5 p.m. Monday to Friday. When patients have to be scanned outside of those hours they have to be sent either to Waterford or Beaumont hospitals. There was a case some time ago where the proper care and attention was not given to a patient and the journey to Dublin was simply too much and the patient died. That was one death too many. We have to resolve the staffing issues in regard to that problem, ensure the mechanism for a resolution is found immediately and that the service is delivered not only to Kilkenny but to the region it serves.

Last but not least, care of the elderly must come first. A unit is being completed at St. Canice's Hospital in Kilkenny, which will make available a separate unit that the Minister of State has seen. I urge the Minister of State to ensure that unit is delivered on time and within budget and that the next phase is funded immediately in order that care can be extended to the elderly and pressure can be taken from the beds in Castlecomer and Thomastown.

Debate adjourned.