Health Bill 2004: Second Stage (Resumed).

The following motion was moved by the Tánaiste and Minister for Health and Children, Deputy Harney, on Tuesday, 23 November 2004:
That the Bill be now read a Second Time.
Debate resumed on 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.".
—(Deputy McManus).

Deputy Haughey was in possession when the debate was adjourned. I understand Deputy Haughey had agreed to share time with Deputy Ardagh. I call Deputy Ardagh. There are 11 minutes remaining.

I am pleased to be able to speak on the Health Bill 2004. We must transform our health system through investment and reform and deliver lasting progress. We must put in place the best medical practice available. The Hanly report has set out the type of medical practice needed in Ireland.

Our first task is to consider the provision of a medical service which is provided by consultants rather than led by them. Too many of my constituents tell me they have spent time in hospital and have been very well looked after, but by non-consultant hospital doctors who are working extraordinary hours while trying to keep up to date with modern developments in medicine. Consultants are not sufficient in number to provide a service to all members of the public. The public not only demand but deserve consultant provided service.

In order to ensure the provision of such a service we need more consultants in the health service. If this is to be achieved consultants must be given a contract which will give them a reasonable return for the time they have spent in education, learning and developing their skills. The return should not be exorbitant, as is sometimes the case at present. Public service and the hippocratic oath are foremost in the minds of many hospital consultants, who think only about the care of their patients. Other consultants derive huge incomes, and increasing those incomes is a greater priority for them than looking after all their patients on an equal footing. That issue must be dealt with. I hope the Minister will do so in the not too distant future.

It is also important to achieve critical mass. There is no point in a consultant in a small rural hospital dealing with ten patients with a particular illness per year while the same consultant, in a larger location, might deal with 250 patients with the same illness and, thereby, gain greater knowledge of the best clinical and pharmacological programme for that disease. Such critical mass would allow consultants to gain vital experience from dealing with a large number of patients. It is vitally important that each region has an acute hospital in a single location so that sufficient patients will be treated there to allow consultants to gain experience and so that equipment, resources and knowledge are adequate to give the very best leading edge clinical treatment to patients.

To achieve the best possible medical service it is essential that the Bill be enacted. The plethora of independent health boards does not help to bring that service about. When the Bill is enacted the managerial responsibility for the health service will rest with a single executive which can establish the necessary structure to put in place the best leading edge medical practice. Political responsibility will, of course, remain with the Minister for Health and Children.

The board of the new Health Service Executive will be made up of 11 persons. These board members will carry an enormous responsibility, more onerous than that of a member of Government. A Cabinet Minister can accept a proposal made by another Cabinet member and pass it on the nod. The Government is not liable to judicial review for any actions it might take. On the other hand, every member of the Health Service Executive will need to familiarise himself or herself with today's report on the MRSA bug, for example, so that its decisions on how to deal with MRSA are beyond reproach. Any board member who is not completely up to speed on such an issue could find him or herself subject to judicial review and liable to be charged with dereliction of duty. All board members are obliged to be fully informed of all facts relating to any decision taken by the board. Most of these board members will act from a sense of duty to public service. They will feel it is incumbent upon them to do so because they have achieved so much in other fields. All these duties are becoming so onerous that it will be increasingly difficult to find competent people who are prepared to take on that type of responsibility in future. Mr. Kevin Kelly who was the chairman of the HSE and may still hold that post——

It looks like he is going to be chairman forever.

He will be the acting chief executive officer. Over the years, Mr. Kelly has always shown that he is prepared to give that type of public service which I hope will provide an example to others who have succeeded and done well out of this country. I applaud Mr. Kevin Kelly for that.

He had a peculiar effect on Halligan.

Improvements have occurred in the health system in recent years. St. James's Hospital, which is in my constituency, is a prime example of that. The Minister says she will put acute medical admission units into various hospitals around the country, but such a unit has been in St. James's Hospital for more than a year. It is the most successful initiative that has been taken to deal with the accident and emergency problem in that hospital. It has allowed seriously ill patients to be treated in a separate area away from those with only minor injuries. The system works very well and I commend the Minister for putting more acute medical admission units in place.

Phase 1H at St. James's Hospital is now opening as a result of the money being provided in the Estimates. That phase will provide 66 new beds, comprising 41 new long-term beds and 25 day surgery beds. There will be a further six beds in the oncology and haematology unit, in addition to the ten beds for day surgery. That represents a 60% increase for day patients receiving chemotherapy or other cancer treatment.

The day ward capacity in St. James's oncology and haematology department is increasing by 50% and is being transferred from old premises to a modern hi-tech building where the services and facilities for patients will be second to none. That will open in early December this year. A further 15 day-beds will become available in the first quarter of 2005. The 41 new long-term beds will be put into service then, also.

The first phase of the accident and emergency expansion at that hospital will be opened in early January 2005. By the end of next year, the accident and emergency section in St. James's Hospital will have doubled in size. This expansion reflects the Government's commitment to health services in Dublin south-central. I commend the Tánaiste and Minister for Health and Children, as well as her predecessors, Deputies Martin and Cowen. The latter started the ball rolling on all these matters.

I commend the Bill to the House and hope it will be passed quickly so that we can put in place the type of reforms necessary to provide people with a health service they deserve.

Tá mé ag roinnt mo chuid ama leis na Teachtaí Ferris agus Cowley.

Is that agreed? Agreed.

An Bille Sláinte 2004 is an important Bill in that it will have an impact on every citizen in the country. Unfortunately, however, it will not generally be for the better. That is because the Bill represents structural reform born out of a certain amount of panic in Government that health is deteriorating generally, and it needs to maintain some control on the revolution that situation may cause.

There is a lack of accountability in that while the chief executive officer of the new health service executive may appear before the Committee on Health and Children, the chief executive will not be subject to the sort of accountability the House should have from such people in powerful positions. They will have control of extensive public resources. The Green Party will push to have that matter dealt with on Committee Stage.

More telling than that, perhaps, is the way in which the Bill is being guillotined. It contrasts sharply with other legislation that is not being guillotined, such as the Finance Bill. While, in itself, the latter Bill is very important, nonetheless, if one compares the levels of emphasis placed on the Finance Bill and the Health Bill, one can see part of the underlying problem as to why health is ultimately becoming worse. This is evident from the current demand for hospitalisation and health services generally, including medication, not to mention the problems that give rise to such demand.

My colleague, Deputy Gormley, referred to reports that have appeared in a book entitledGrowth: the Celtic Cancer, Why the Global Economy Damages Our Health and Society, which was published by the Foundation for Sustainable Economics, Feasta. I found it extraordinary that the Minister for Health and Children dismissed the publication since the matter definitely warrants a more constructive debate than that. The book contains information gleaned from statistics that are in relatively short supply and are difficult enough to collate because they are not interchangeable. The statistics indicate that male suicide increases during economic growth, and point to worsening alcohol consumption, a big increase in alcohol-related offences, schoolchildren becoming heavy drinkers and illegal drug users and the poor getting sicker. Much of this comes down to a widening gap between those who have resources and those who do not. It goes beyond that, however, in that health does not get a look in when we deal with the country’s economic welfare. Along with GNP and GDP, health is not measured in that context. The Government needs to address that issue if it is seriously to tackle health problems in future. The Bill will do a certain amount to shift the deckchairs around but it will not ultimately provide for a healthy nation. We must focus on that objective because the Bill represents an end-of-pipe approach, rather than an holistic one.

Deputy James Breen referred to the MRSA bug in a radio interview this morning. His personal experience of the MRSA bug was both difficult and tragic, and indicates that antibiotics will not provide a solution to the problem. We need to be far more mindful of the need for a healthy environment, as much as adopting an end-of-pipe, hospital-based approach.

When it comes to this legislation, most people will be interested in the complaints procedure. I recently met representatives of Patient Focus, a group with much cause for complaint in that the misdemeanours in the health service, which form an ongoing subject of investigation, resulted in between 100 and 130 women having serious problems following questionable and in many cases unwarranted hysterectomies. The legislation should provide for a redress board. It is not sufficient to have a complaints process particularly if one has undergone a procedure that is so traumatic, irreversible and serious that it will have an impact for the rest of one's life. The Tánaiste should act swiftly to include such a redress board to deal with such serious cases alongside the ongoing investigation. The money should come from the medical defence unit as the patients have already had to pay many legal bills. This is a matter of basic justice as well as ensuring such mistakes do not happen again in the future.

I recently attended a lecture on children and health, which clearly showed that what was described as an obesogenic environment is developing in society. Increased numbers of hospital beds and consultants, and increased services and medication will not tackle or even keep up with the problems being created by what many in the health sector call an obesogenic environment. Some token moves have been made to address advertising to children. While the Minister of State was involved in launching the organisation, Sustain, it is clear that we need to consider what has been proposed in the UK, a children's food Bill, to seriously tackle the prevailing trends in marketing of unhealthy food.

The makers of the BBC television programme "Panorama" undertook to see if they could get away with producing unhealthy food. They found little legislation in the area and nothing to stop them producing high sugary food and marketing it as if it would improve one's health and fitness. I believe they called it "fit and fruity". While it was marketed as yoghurt, it was a sugary, sickening and sickness-inducing food, which was produced legally. If such activity continues to be legal we are fighting a losing battle in throwing more money at a health service, which, I agree, has been underfunded for many years. However, it will never be adequately funded as long as we continue to allow such clandestine sickness-inducing activity as producing food that will make people obese resulting in heart disease, strokes, type 2 diabetes, cancers and all the psychological problems of loss of self-esteem and the problems of bullying experienced by obese children. The Minister of State fully understands the problem as we both attended the same lecture.

The main flaw in the Bill is its proposal to increase the centralisation of overall administration and key services in the health sector. This will further the agenda laid down in the Hanly report whereby decisions will be made with no input from democratically elected representatives. While the Bill attempts to gloss over this matter by proposing to establish a national health consultative forum with fora at regional level, these will have no practical role and will merely provide a thin democratic veneer over the reality of centralised dictates.

Sinn Féin had criticisms of the old health boards, which we proposed ought to be reformed in a number of ways to increase their accountability and effectiveness. However, the Bill does not achieve that end. Instead it ensures that decisions with wide-ranging and possibly detrimental effects on local areas can be taken without any local input. The effect of the philosophy underlying the Hanly report and the Bill can already be seen in the withdrawal of services from regional hospitals. In my constituency severe hardship is being imposed on people who must travel to Cork for radiotherapy treatment. With the confining of this service to Cork, Dublin and Galway many other people will have to travel unacceptably long distances to receive treatment. The level of anger over this issue is huge in many areas with Waterford witnessing its largest public protest for decades in support of the demand for a radiotherapy clinic in the regional hospital there.

With the diminishing of local input into decisions made, many regional hospitals are being denied facilities and improvements that have already been promised. While Tralee General Hospital has been promised a new accident and emergency unit and a new maternity wing, neither of these has been delivered. It also needs a breast check unit with the current service being totally inadequate to cope with the demand. This week a neighbour of mine underwent a breast check in Tralee General Hospital. All that is available is one room for one hour on Monday and Friday mornings, which is totally inadequate and disgraceful.

Instead of throwing the old health board baby out with the bath water, the Government ought to establish methods to reform them in such a manner as would have retained and expanded their democratic accountability and eliminated the red tape and misuses which reduced their effectiveness. It might also have eradicated those elements within the boards, which were a result of certain political parties trying to run them as rewards for party loyalists and to ensure political control.

Further evidence of the concern over the health services has been signalled by IMPACT whose 25,000 members have voted to withdraw co-operation with proposed reforms within the service unless its members are given guarantees of no cutbacks in services, no redundancies and no diminishing of working conditions as part of the changes to come into effect from January. The concerns voiced by IMPACT have been echoed by other professionals within the health services. It is a poor sign when any Government service loses the confidence of those responsible for its day-to-day running and that lack of confidence will not be eased by the proposals in the Bill. The Department needs to listen more to those who work at the coal face within the health services and involve them directly in any proposed reforms rather than farming it out to consultants who appear to have a rather narrow definition of the verb "to consult".

The implications of the decision made by IMPACT may be serious as the union now has an overwhelming mandate to authorise industrial action. This must act as a red light to the Department to pause before going ahead with its proposals until it has fully explained the implications of the changes and inserted the necessary democratic mechanisms to ensure the concerns of those who work in the sector and of those who utilise these services are fully addressed.

The alienation of health service workers is another consequence of centralisation and the withdrawal of local accountability. At least the old health boards had some mechanism whereby workers representatives had an input into the decision-making process and many problems could be addressed at local level with the direct involvement of those concerned. Removing this increases the level of suspicion and potential conflict that can, as we have already seen, lead to issues quickly escalating into large-scale disputes, which might otherwise have been resolved. The consultative fora proposed in the Bill are a poor substitute for genuine involvement and consultation. For these reasons and others, I with the other Sinn Féin Deputies oppose the Bill.

On my first day in the Dáil, I outlined my support for the abolition of the health boards because of the lack of co-ordination and co-operation between them and the way in which they compete with each other. They applied health schemes and interpreted vaccination policy differently, used incompatible software and duplicated administrative functions. The situation, however, has gone full circle and there is now a major democratic deficit. Reform is a good idea but it is only one aspect of the equation. Funding is fundamental and the Tánaiste's statement that there is no black hole in the health services is a good starting point.

This Bill, however, must be amended to allow for democracy. People expect and demand value for money, but there should also be a proper health service. Health apartheid in the service is a severe problem.

This Bill sidelines the Department of Health and Children from the day-to-day running of the health services, which is not a bad thing. We already know about decisions made by the Department, the health boards and other bodies which create a two tier system, such as giving BreastCheck to only half the country in 2000 and leaving the other half to wait until 2007. A breast screening programme has been in place in Northern Ireland since 1993 and death rates have been reduced by 20%. There is no reason to delay a service until 2007 when 65 people in the south west are dying from breast cancer every year.

Today in Mayo a woman will appeal on the radio for someone to take her father's place because he is unable to go to Galway for dialysis treatment. He cannot get into a state-of-the-art dialysis unit in his own town as a result of bad planning. Only half those who need dialysis receive it. The national average for dialysis requirement is 600 to 800 people per million but only 256 people per million can get dialysis in Mayo, a situation that has an impact on every one of those people.

The health service has been starved of resources. The new legislation will make the Minister for Health and Children the kingpin. As the song says, "one is the loneliest number", and the Minister will be lonely, as will the chief executive officer of the new health executive. It is no wonder Professor Aidan Halligan thought twice about it. The Minister for Health and Children, however, is granted major powers in this Bill and, if amendments are accepted to it and she receives the necessary funding, mechanisms to address the problems in the health service will be put in place.

The power in the Bill is surprising. The Minister's bidding will be done through corporate plans that she can send back if she does not like them. Under section 21, neither she nor the chief executive officer of the Health Service Executive may be questioned by an Oireachtas committee. The CEO and the Minister should watch their heads or they will end up like those in the French Revolution who lost theirs. The Eastern Regional Health Authority crumbled because there was a need to put something between the people and the Minister but the people did not support it.

This agenda suits centralisation and the rail-roading through of new plans and policies. The Minister will select the 11 board members. Where are the medics? These people are all accountants and this is another quango, as I said on the Health (Amendment) Bill 2004. Just as it is difficult to get information from or influence in any way the NRA, the Minister will inform the House that she has no function and the Department will say the same. Who will have any input to ensure the people's bidding is done? Who will force the people's agenda?

This is a cynical Bill which is about money and implementing reports and cutbacks. In the new Bill, the Minister for Finance will decide who will be hired and who will be fired. Where will this end? I hope there will be an end to the current system of health apartheid and I wish the Minister for Health and Children well but she must listen to the people and address the democratic deficit in the Bill.

I wish the Tánaiste every success in her new portfolio. Health is clearly one of the most serious issues facing the Government and we all look forward to the successful tackling of the issues. I have every confidence that the Tánaiste will achieve that.

This Bill contains much that we could spend days analysing. Most of the issues that create difficulties for health board members are addressed in this Bill. Many speakers have referred to the boards competing with each other and anyone who has served on a health board knows the problems that causes. Boards compete with each other when the Estimates are published to reach the premier league by implementing policies that cause difficulties in adjoining health board areas.

County councillors feel they are being ignored in this legislation but I take heart from the fact that the HSE will manage and deliver health services on a national basis as a single unified system replacing the health board structure. That is where I part company from people who have criticised the Bill on the grounds that it has not taken local public representatives into account. This Bill will go a long way to help deliver localised and regionalised services. I remember the difficulties of many health board members over the years who were mandated by their own local county structures to support health facilities on a county basis rather than take into account the need for regional services that will provide a far better level of service, attract medical experts and deal with more patients.

The independent advice given to the National Cancer Forum by Professor Fennelly was often ignored as a result of political pressure from local interest groups to ensure the county flag was flown. My health board area had to park essential cancer services for four years when funding was provided by the Minister but members of the board felt they were letting down their county and challenged the independent medical advice, thereby delaying the process. In the meantime people were attending Dublin clinics, often travelling there in unsuitable transport and enduring long delays while we waited for a High Court judgment.

I welcome this legislation because it transfers decision making to the HSE and makes it responsible for service delivery. If we recognise the major contribution this could make in a short time with adequate funding and services put in place in the regions, we will see tremendous improvements in essential services. I appeal to former health board members to recognise that their contribution can be considered in the regional structures. It is time to put health ahead of politics and realise if the funding is in place, we should grasp the opportunities it presents.

The Tánaiste stated that there is no black hole in the health service, as Deputy Cowley mentioned.

I experience some concern, however, when asked where all the money has gone, as if this were a spending spree without a definite commitment or endgame in prospect. People are often bored by statistics, especially when a few points are clarified. As I reflect on the 1980s when health boards were trying to put budgets together to provide essential frontline services, nobody can challenge the fact that those days are gone. Health boards have not had difficulty in securing adequate day-to-day finance from the Department of Health and Children over recent years. However, when one examines where the money has gone, quite clearly it has paid for the hiring of 8,200 nurses since this Administration came into being in 1997, 438 new consultants, 661 occupational therapists, 456 physiotherapists and 200 speech and language therapists. That is the reality of where the money has gone. To appreciate specifically where the money has gone, it must be recognised as well that local, general or regional hospitals cannot cope without those services.

Money has also gone to the largest hospital modernisation programme in the history of the State as well as to the dramatic increase in care places for people with disabilities. I congratulate the former Minister for Health and Children, Deputy Cowen, who is from my constituency and who recognised early in his time in that Department the need to ring-fence specific funding for the disability sector. That is another prominent and welcome feature of the health budget.

We must recognise, however, where problems exist. We have seen significant investment in areas that have contributed to early death. I refer specifically to cancer treatment. As we embrace and recognise the potential in this Bill, we must concede that mistakes have been made over the years. The greatest mistake was relying on and expecting a 30 year old system created in 1973 or 1974 to deliver in present-day conditions when there has been an increase in demand for specific specialties within hospitals. I recall that the demands on my local general hospital in Portlaoise years ago were relatively limited in scale compared with the level of services now being delivered there. I see this Bill as an attempt to manage and deliver these services on a national basis, while containing the responsibility for this initiative within one structure.

Many people have asserted that public representatives will have no direct input, but I do not agree. If we are expected to deliver First World services that are second to none, we cannot be handcuffed into believing that one must deliver for one's own county first and, by failing to do so——

That is the flaw.

That is not the flaw. That is exactly——

It is the first sign of the erosion of democracy. It is an appalling decision.

The flaw is that we delayed so long before bringing this legislation before the House. I refer any Deputy who cares to go back over the record of health deliveries in recent years to the fact that the flaw emanated from public representatives in different counties blockading attempts by Government to put the necessary funding together to deliver services by way of regionalisation.

We have 35,000 more staff and 50% less delivery. Even Einstein could not come up with that.

Deputy Durkan will have an opportunity shortly to make whatever points he wishes to make.

Since I am prompted to respond to that, if not directly, I refer to 1995 when Deputy Durkan's party was in office. The then Minister for Health, Deputy Noonan, whom I complimented, brought forward the National Cancer Forum and signed off, as it were, by suggesting that the lead hospital should be Tullamore for the delivery of cancer services in the Laois-Offaly and Longford-Westmeath region. It is ironic to reflect that a member of that Minister's party challenged that decision and we wound up three years later fighting the case in the High Court. Deputy Durkan speaks of a flaw. The flaw was that when a Government had the courage to put together the funding——

When the Deputy has lived four or five years with the proposed new system, he will know. There will be no delivery of service, no consultation and to hell with the patient.

Deputy Durkan should allow Deputy Moloney to speak without interruption.

I apologise to the Ceann Comhairle. I am upset.

I make the point only because I have been goaded by Deputy Durkan. Where services were agreed and funding put in place, is it not ironic that a member of the then Government party challenged a decision purely because of pressure brought about by the home county? I regard this Bill as a means of escape from that type of pressure.

I reject criticism that there has not been consultation on the Bill; there has been. There is little point in having medical representatives on health boards if medical advice is ignored when it is called for. I am often amazed when a public representative's advice is taken over and above that of a specific medical adviser, as I instanced previously.

I welcome that so much has been provided, not just last year and the previous six years but specifically for this year. I congratulate the Tánaiste on securing a further increase in the level of funding. There is a 9% increase in the Estimates this year. All that will go towards the provision of specific levels of service. The total spend in 2004 will be €6.58 billion or 188% higher than in 1997. When a challenge is put as to where the money is going, people want to ignore the facts of extra nurses, frontline services and speech therapists across all the specific headings. The Government has provided €6.2 billion in increased revenue funding over several years. This is 185% of the 1997 figure of just under €3.4 billion.

This extra investment has brought about significant results, including record levels of activity in the acute hospital system, with a range of additional services provided across all care programmes. One way the success of a hospital service delivery programme may be gauged is in its throughput of patients. More than 1 million day care patients were discharged in 2003, an increase of 43,000 or almost 5% over the 2002 record. I do not deny that figures may be produced to put the best slant on a particular case. However, patients cannot merely be passed through the front door and out the back door of a hospital for cosmetic reasons. The reality is that these figures are genuine.

There has been a substantial increase in day cases of more than 190,000 or 76% since 1997, to give a total of almost 441,000 at the end of 2003. I see this Bill as vindicating the decision to support the level of investment in terms of revenue and capital as well as the throughput of patients and the newly recruited medical personnel. I welcome what the legislation contains and recognise its possibilities and benefits.

Perhaps the people who condemn this initiative most are fearful that the health issue might be removed from the national agenda leaving them with little to criticise. However, I prefer to look at the larger picture and accept that they are concerned, as are all Deputies on the Government side, to ensure the people of this country secure a health service of which we can be proud.

The final cornerstone has been put in place. The capital programmes exist and there are few main county towns which have not enjoyed substantial investment. We are about to see changes in the style of delivery, performance and responsibility. I welcome everything in the Bill and look forward to supporting every part of it as it proceeds through the House.

Tá seanfhocal sa Ghaeilge a deir, "Is fearr an tsláinte ná an táinte", agus níl aon rud i saol an Rialtais nó i saol an ghnáthdhuine níos tábhachtaí ná sláinte an phobail agus na ndaoine. The English equivalent is "Health is wealth". The Irish version goes further in saying health is better than wealth. Most politicians subscribe to the latter because since joining this band of politicians here I notice that one's health is continually challenged. Therefore, health is very important. It is a core ambition of all politicians to improve the health of the nation. It has to be a core ambition and responsibility. To do that requires two approaches, namely investment and reforming how we deliver the services.

During the next 12 months the Government will invest €11 billion. The income tax take is approximately €7 billion. For every euro from income tax that is put into health we put another €4 with it. Some 25% of the Estimates as announced by the Minister for Finance, Deputy Cowen, goes to health, yet many are unhappy. There is the problem of those in my county, for example, having to use trolleys at weekends. The infrastructure in Wexford is such that the tourist population almost doubles the natural population. Obviously keeping pace with the social infrastructure and the number of tourists would be difficult because they make a huge demand on Wexford General Hospital. Even somebody from Mars would agree the Government is investing significantly.

The next step is reform. The challenge of reform which the Minister, Deputy Harney, and her Ministers of State, face is that of getting a balance between health administrators and health practitioners. I congratulate the Minister, Deputy Harney, and her Ministers of State. She has a track record of confronting and winning challenges. I am certain she will win this significant challenge. I have no doubt the 19 beds we are waiting for in Wexford will be provided also.

The initiative of 200,000 medical cards which will enable people to visit doctors will relieve the accident and emergency units. I have do doubt, from my experience as a politician, that many people go directly to accident and emergency units, perhaps because they cannot afford the fees of general practitioners. The 30,000 traditional medical cards and the additional 200,000 is a wonderful initiative on which the Minister deserves to be congratulated. We must get a balance between administrators and health practitioners. We must also get a balance between the delivery of health services and the role of the public by way of politicians and the role of the professionals. That is what the Health Bill seeks to achieve.

The Minister said there is a need for clarity on roles and responsibilities. The Bill goes a long way towards identifying that clarity. For example, consultants will use 20% of hospital beds and 20% of hospital capacity to treat their private patients. We have to make certain that one is not disadvantaged by virtue of the fact that they do not have access to private medicine. That is one of the purposes of the Bill. It seeks an administration system that will deliver without the awful fragmentation that many different studies have identified.

The Health Service Executive will be a separate entity. From my experience as a new politician there were too many health boards. For example, in Great Britain, Birmingham has one board for approximately the same population. We had ten or even more health boards. One of the objectives of the Health Service Executive will be to reform how we deliver our services and to restructure. As a separate entity it will be able to call on the expertise of the various people who will be needed to help to achieve success. It can interact in a unitary way with the Department. It can demand that the Department sets out goals and policies that are clearly identifiable. There will not be one for the north west and one for the south east. It is time we got away from that so that we know what we are doing. I congratulate the Minister, Deputy Harney, the Minister of State, Deputy Tim O'Malley, who is present, the Minister of State, Deputy Seán Power, and all those others who are involved in trying to address what successive Governments have failed to address.

I hope the Health Service Executive will demand of the Department that goals are set out and that the Department will demand of it that we get value for money, as the Government has invested money.

I wish to share time with my colleague, Deputy Gay Mitchell.

Is that agreed? Agreed.

I disagree with the concept and structure of the Bill. I disagree strongly with the views expressed by those who believe, rightly as far as they are concerned, that this Bill is the panacea to the health problems. I do not agree with the notion that the abolition of the health boards was the answer to the maiden's prayer. It was the issue the Minister seized upon to extricate himself from a difficult position before the local elections. It was the Barabas handed to the multitudes before the elections and sacrificed and was a populist course of action but it served no useful purpose whatsoever. What I strongly disagree with is that there is absolutely no accountability so far as the House is concerned. Power is totally vested in Government. The Government or the Minister no longer have to account to anybody. They do not have to account to the House under any circumstances. Having listened to some of the speakers on the Government side, they appear to think it is a good thing, but I do not agree.

Let us look at what has happened in many areas in recent years. The partnership agreements have essentially moved Opposition and Parliament away completely from the whole area of collective bargaining. The result is that the Executive deals with the various agencies that report to it, but Ministers and the Government do not report to anybody. People can speak about these issues outside the House anytime they wish but they can never speak about them in the House or raise questions about them on the Order of Business. With each passing day less and less democracy is vested in the House and that is sad.

The issue speakers on the other side should have addressed is how did it happen that 35,000 extra staff were employed in the health services in the past four or five years and yet it delivered only 50% of the services delivered heretofore. The answer is in the way it was done. There was a theme called, delivering better Government and delivering better health services and delivering better local government and therein lies the flaw. The Government and the relevant Ministers failed to deliver and did not appear to understand it was the public, the consumer, the patient in this case, who deserved delivery in the first instance. It is the patient who has been left waiting, who has been left on a trolley and who is full of anxiety while awaiting the result of tests. In all areas it was the patient who was left waiting. The service was operated as if it was an employment agency. That is not what the health service is about.

I do not agree with Deputy Cowley who said big is beautiful and that the massive multi-storey hospitals are the answer. They are not and they have not been able to deliver all services. There was a time when the notion of two hospitals on the northside of the city and two hospitals on the southside would deliver all services was current, but it did not work that way. What has been forgotten is that approximately 5,000 beds are missing from the system compared to ten or 11 years ago. What in Heaven's name was the Minister thinking? Where was she going to provide the services previously provided by these 5,000 or 7,000 beds? What thinking was behind the notion that somebody supposed it would be possible to provide them elsewhere?

I was a member of a health board for a long time. A genuine notion arose of deploying patients in psychiatric institutions into the community. This requires money, attention and supervision. In many cases, people who were institutionalised found themselves out on the streets sleeping in the open air, barely subsisting simply because there was no follow-up and because that part of the plan was never put in place. It still has not been followed-up and there are still people sleeping on the streets. As I was driving along the quays in this city this morning, I looked up one particular side-street and saw two people sleeping in the open air, even though this is November and Christmas is approaching.

Let there be no doubt that the original plan was correct. It fell down because it was not followed through. This is also the case in respect of the general health services. The primary care system should be such that we can identify and deal with problems at an early stage and deliver services at a local level, thereby eliminating waiting lists.

The health services have been appraised more than space in the past five to ten years. We have had a series of rescue plans, a one year plan and a three year plan. When the former Minister for Health and Children, Deputy Martin, saw an election looming, he said it would be better to have a ten year plan. This plan was trotted out but did not really draw all the fire away and therefore a number of reports were commissioned, the most recent of which is the Hanly report. There have been more reports on the health service that there have been on the moon. I am not blaming the Minister of State, Deputy Tim O'Malley, but he should note that it is time that somebody called a meeting of all the relevant health specialists and the Minister. They should acknowledge that whatever they have been doing to date has been wrong and that the services have not been delivered. It is a farce.

The idea behind the controversial Hanly report is to shut down services in smaller hospitals and deliver them through a major, centralised delivery service, a conveyor belt system in which a group of highly specialised surgeons will be taking patients off trolleys. This does not work either. Can we not return to the old-fashioned system of dealing with patients' requirements before the other issues? We should consider what happens when a patient is referred from a GP to subsequent stages in the system and how long this takes. This will allow us to redress the problems that exist.

What in Heaven's name can anyone make of the recent resignation of the chief executive of Aer Lingus, Willie Walsh, and his colleagues? This is very serious from the Government's point of view. The company had been turned around from a loss-making to a profit-making position. Mr. Walsh and his colleagues made the unfortunate error of suggesting that there might be a management buyout. As far as I am aware, management buyouts have been encouraged in many other institutions around the country, but Mr. Walsh's suggestion must have been a bridge too far for the Government. It must not have merged properly with the socialism of the Taoiseach, a concept which he has embraced with both arms.

The Deputy is digressing far from the Health Bill 2004.

This is an example. It could affect everybody's health, including the health of the Government. The three senior managers of Aer Lingus resigned because——

The Deputy should return to the Health Bill.

I am coming to it. The Ceann Comhairle will see how healthy it is in a minute. The three senior managers of Aer Lingus resigned because they had no confidence in the Government.

Compare this matter to a recent incident that affects our health service. A senior, top-ranking international specialist in the health services, who was originally an Irish specialist, indicated that he would come on board to head the new Health Service Executive. He was interviewed by a couple of people and he interviewed a couple of people himself but all of a sudden he stated that, for family reasons or otherwise, he would no longer come on board. He did not come on board because he had no confidence in what was being proposed by the Government. It is quite clear that he did not want his reputation tarnished by what was happening.

The Ceann Comhairle stated the two aforementioned issues are not related to health. They are intrinsically related to it and will be proven to be part and parcel of the unhealthy attitude that exists towards the administration of services on the part of this House and the Executive in recent years. The lack of accountability and lack of recognition of patients' needs in the health service are serious. The production of reports to deflect public attention from the real issues is also a serious matter.

I, like many other Members of the House, was a member of a health board for a number of years, during which period there were three programme managers and a chief executive catering for one third of the population. One was able to ring the chief executive or any of the programme managers at any time one wished and they or their secretaries would deal with the issue speedily. Now, however, the numbers of these officials have been multiplied by at least 20 in each case, the result being that the system is almost like a hospital in which one is lucky to get a trolley, never mind a bed. One cannot get anybody to respond to one's queries for about three or four months. The problem lies in the administration of the health services, which is the responsibility of Government.

I thank Deputy Durkan for sharing time. When I was health spokesman, I used to draw attention regularly in the House to the excessive number of committees, review groups and study groups that existed in the Department. Whenever a crisis arose, the then Minister for Health and Children, Deputy Martin, appointed yet another review group or committee. It got to the stage where the Department could no longer tell how many committees existed. When I asked a parliamentary question to this effect, it took months for the relevant information to be compiled, after which I discovered that there were approximately 160 different committees. This was extraordinary. All of the vested interests were represented on those committees and the patients got what was left over. This practice must be brought to an end and if this Bill does so, I will welcome it. It is important that we put the patient first. We must not leave for the patient the leftovers that remain after the practitioners and others have carved up the budget.

It is not too strong to say that we have an apartheid-ridden health service. We know about private and public health care in the hospital system. If one considers more closely the primary health care system, one will note that it is also characterised by apartheid. People who have money can visit their doctor whenever they want and do not have any difficulty doing so, but those who do not have money cannot do so.

There is an agreement between the Irish Medical Organisation and the Government that up to 40% of the population can be covered by medical cards. The figure was approximately 39% when the rainbow Government left office, but it subsequently decreased to 28%. Some 28%, comprising the poorest citizens, were covered by medical cards, yet those who were marginally over the poverty line were not covered.

There are fewer poorer people since this Government took office.

It may be different in the Deputy's part of the country.

According to research done for the ESRI on Irish men aged 55 to 64, higher professionals have a death rate of 13 per 1,000. This rate rose to 22 per 1,000 for semi-skilled employees and to 32 per 1,000 for unskilled manual groups. The latter have a death rate per 1,000 almost three times higher than that for professionals aged 55 to 64, yet these are the people to whom we deny the medical card. They need it most and are dying in greater numbers because they cannot afford to go to the doctor. Neither can they afford to be joining health clubs or to holiday, and therefore they are more likely to have a drink too many or smoke cigarettes.

If we are serious about reforming the health services, we should ensure that they are opened to those who need them. It should not be the case that because one does not have the money, one's child cannot see a doctor. People should be able to see a doctor when they need to, irrespective of their bank balance. It was an absolute outrage to give doctors three times the going rate to treat medical card holders over the age of 70. That is the deal they sought and got. Prior to this deal, they said they would not agree to it because poor people were being left without a medical card, yet they forgot about the poor, accepted the deal and gave the medical card to the over-70s. I have no problem with that. However, I am concerned that poor people were omitted by the Government and doctors, and this must end.

I want to refer to the point made by Deputy Durkan. I would like the Minister to consider on Committee Stage that Members of this House cannot ask questions of agencies set up and funded by this House. It is time to create an office of surgeon general, and that person would not necessarily need to be a doctor. A qualified person, similar to the Comptroller and Auditor General, could report directly to Dáil Éireann. The report could then go to the health committee where the surgeon general would sit as a permanent witness, as does the Comptroller and Auditor General at the Committee of Public Accounts. He or she could be the powerful advocate of patients working with the Dáil to make the system accountable. There is a yawning gap in accountability between these agencies funded by Dáil Éireann and accountable to the House.

Much more could be done to keep people at home. For the equivalent of approximately IR£10 million or €15 million — I did the calculation before we entered the euro — we could allow elderly people to spend up to IR£3,000 to convert their homes by fitting stair rails, bath fittings and so on. These people could then remain at home and not end up in step-down facilities. In some health board areas there is a three year waiting list to get an occupational therapist to assess whether an 80 year old needs a rail to get up the stairs. If that elderly person falls down the stairs, he or she is hospitalised and put into a step-down facility. I advocate that GPs should make these decisions until the waiting list is cleared.

I have two further points to make, one of which relates to pharmacies. Pharmacists who are well qualified and available to the community should be given a better opportunity to advise people. However, one would not like to stand in a shop while somebody else is buying photographic equipment or make-up and ask the advice of a pharmacist behind a cash register. Pharmacists should be given an incentive to set aside part of their premises where people can consult them quietly, and that would take significant pressure off doctors.

It is clear there is a serious problem with paedophiles, which in the past was swept under the carpet. It is not just an Irish problem, it is an international problem. This appears to be a psycho-sexual condition, with which we are not coming to terms. When we come to terms with it, it is usually at the criminal justice end of the cycle. Vincent Browne wrote a controversial article on the issue some time ago. During his commentary later he said that he would do terrible violence to anyone who attacked one of his children in that way. I am sure many of us would share that emotion. However, some paedophiles do not give in to their tendencies. I am aware of one such person who visited a Deputy to find out where he could get treatment, and he received treatment.

There should be some strategy to encourage people who have these tendencies to receive treatment. Treatment should be made available to them before a crime occurs. This might entail psychological and psychiatric advice, and psycho-sexual advice if necessary, particularly on avoiding places where there may be children and so on. People who have this condition but have not committed a crime should be treated. There should be a specific plan to make treatment available to people who have committed a crime before they are readmitted to society. I ask that some strategy be put in place in this regard. I am raising the issue because it is never debated and the issue arises usually after someone is sentenced by the courts. There is need for a much more proactive approach in this area.

Any reforms to improve the health system must be welcome. However, there must be transparency and accountability. Even though we are low in the OECD expenditure league on health compared to other European countries, particularly before the Union was enlarged, our health expenditure has grown and is still growing. This expenditure must give value for money, result in productivity, serve patients' interests and put patients first. I ask the Minister to ensure that there is full accountability to this House for that expenditure.

I welcome the opportunity to discuss the Health Bill. It gives Deputies an opportunity to broaden the debate on the health service. At the outset, we must acknowledge a few simple facts. We have spent large sums of money in this area, more than €10 billion this year. The health budget has been doubled in seven years. The number of people working in the health service has been increased from 67,000 in 1997 to more than 100,000 in 2004, which is welcome. We must also acknowledge that while we have an excellent health system, it is not as satisfactory as we would like. We would like it to be better than it is. However, it is wrong to dismiss the wonderful work done on a daily basis by all those involved in the health service.

For too long we had a health industry as opposed to a health service — Deputy Mitchell referred to this. The important aspect was to ensure that salaries, wage increases and so on were factored into the equation and what was left was divided up to ensure patient care. We must examine the issue from the other side. First, what do patients require and when that is established, we should work backwards to ensure the staff are available to provide patients with a service.

I have advocated for a long time that the health boards in their present structure are not functioning and delivering the required service. The number of health boards in place for a population of less than four million did not allow for efficiencies and economies of scale within the health service. The fragmentation of tendering procedures, purchase of equipment and so on was expensive and inefficient. I hope the new Health Service Executive will achieve large-scale efficiency and economies of scale.

There are significant opportunities available to us. There has been massive capital investment in hospitals, including new accident and emergency units, operating theatres etc. In the area of surgical procedures, hospitals should operate 24 hours a day. I cannot understand why specialised equipment must wind down at 3.30 p.m. or 4 p.m. Hospital procedures, particularly surgical procedures, should be carried out on a 24-hour basis, five to seven days a week. It is not acceptable to have expensive specialised equipment lying idle at certain times. When it is established, the Health Service Executive should examine this matter.

On the centralisation of procedures and treatment, for too long services have been too fragmented. Some services were scattered throughout the country and more specialised services operated on a regional basis. I do not think people will object to travelling a certain distance for guaranteed specialised treatment. We cannot have specialised units in each hospital and community throughout the country. Politicians have a leading role to play in this regard. We must accept that on occasion difficult decisions must be made in the interests of the greater good. Because there were so many political agendas within the health boards, they were unable to make difficult decisions. Very often people said it undermined democracy. This is not about democracy, it is about providing health care for patients who need it.

I welcome the overall thrust of the Bill. I advocated the abolition of the health boards, because they were inefficient and unable to cater for and cope with changes in medical practices and the demands of new technologies and advances in treatments.

It is simplistic for people to pick figures out of the sky with regard to waiting lists. Many new procedures have come on stream in the last number of years. A new advance in medicine means a new waiting list. People who were previously unable to avail of treatment automatically go on a waiting list. It is disingenuous for people to use waiting lists as a barometer of the efficiencies of a hospital or health system. If one did that the logical conclusion would be not to provide a service in the first place. In that way, there would be no waiting lists.

The problem with accident and emergency services must be addressed with a positive and imaginative approach. Until recently, one went to a GP with various ailments or injuries. The GP examined the ailment, analysed whether it was serious and wrote a letter of referral to an accident and emergency unit for an x-ray or further check-ups. This system of referral has caused huge problems and delays. The new Health Service Executive should set up community health centres with specialised facilities where GPs work co-operatively. Why must everybody go to accident and emergency for an x-ray? Technology exists for x-ray units to be situated in health centres outside of hospitals. In this way, one would go to the local GP, perhaps with a broken arm after falling off a bike. The GP would make a judgment by x-raying the arm and deciding whether it was broken or sprained or whatever. Such a measure must be taken.

Doctors can make the call 99% of the time. However, they cannot be 100% definite. For that 1% they must make a referral. It is wholly unacceptable and inefficient to go to one's doctor and then sit in a car or on a bus on the way to accident and emergency. If one goes to an accident or emergency unit on any day of the week, as I have, there are people there who went to the doctor with a pain in their chest and were referred on. Doctors cannot make a 100% definite call. We should be imaginative in setting up health centres where GPs practise co-operatively. Specialised facilities would be available for them to make a definite call. Doctors have referred people to accident and emergency units for treatment of an ingrown toenail. GPs are capable of treating it themselves, and a mechanism should exist to allow them to do so.

The new Health Service Executive must be imaginative. It should be allowed tax incentives or financial inducement or assistance if necessary. Capital expenditure could be invested in specialised equipment, and tax reliefs could be used to set up these centres. We have a wonderful centre in Glanmire, headed by Dr. Tadhg Rafferty, who is also involved in setting up Southdoc which is a positive service. It would be of huge benefit to the community and would stop referrals if the centre in Glanmire was able to purchase specialised equipment.

We often speak of the health industry. However, the previous Minister was worried about the health of the population, and the new Minister has appointed a Minister of State with special responsibility for obesity. This issue must have a single focus. The Health Service Executive will do its own thing, the Department of Health and Children will promote health within communities and society, the Department of Arts, Sport and Tourism will promote sport as a healthy option, and the Department of Education and Science will encourage health within schools. There should be a single focus between all Departments in encouraging people to partake in healthy lifestyles.

There are anti-smoking, anti-obesity and anti-drinking campaigns. However, they have not been significantly effective. The smoking ban was effective in that it cut down consumption of tobacco, which is a positive development. The effect of that reduction will be seen in future years. However, there are statistics relating to obesity in young people and an increase in alcohol consumption. These problems will have a negative impact in terms of pressure on health services in future years. Whatever the Health Service Executive does with regard to the provision of services which tackle such issues, it must manage and bring forward any scheme in conjunction with Departments, and must be singularly focused on healthy, preventative measures as opposed to providing services thereafter.

With regard to the issue of an ageing population and care of the elderly, alarm bells ring when one looks at the demographics after 2025. Provisions have been made with regard to pensions. We must examine the matter seriously and start planning in the next few years. People are not able to cater for older relatives because of pressures such as double income families, the cost of child care, changing society and expectations etc. We must be imaginative in terms of how we cater for the elderly. Currently, the system is haphazard. There is respite care, whereby people go into a nursing home for a few months. They then go home, and then go back into respite care at the nursing home and so on. Proper facilities should be in place whereby an elderly person can be in a nursing home and also access proper medical care. We are not at the stage we would like to be. If we are not at that stage now, one can imagine what will happen as the population ages drastically in 20 years. We must plan well in advance for the provision of such services. It takes a long time to build facilities in terms of planning problems and providing capital costs. It is a bubble that could burst.

The carer's allowance exists for people who are able to give up work and care for elderly relatives at home. However, are these people properly supported? They are willing to make sacrifices to care for an elderly person. They are also saving the State a huge cost and doing it a service. Any person who does the State a service should be rewarded in some manner. We should look at how we support carers in the home. The disabled person's grant is one issue. It beggars belief that people wait months and months for an occupational therapist to inspect a house and the person applying for the disabled person's grant. Any person involved in the medical services in that person's area would be able to do this. An occupational therapist is not required to say a stair lift is needed because an elderly person is 83 years old and cannot climb the stairs. That is well beyond what is required to draw downfunding.

The disabled persons grant should be streamlined because its administration is quite confusing. However, the matter regarding occupational therapists should be considered immediately. I know of cases in which people waited six or eight months for an inspection to be carried out. When an inspection is over, a case can move quite rapidly, but to have the inspection carried out is often the hardest part. If we are serious about encouraging families to keep their loved ones at home, there must be a financial incentive. While the carer's allowance is in place, we must be imaginative and more must be done.

In a conversation in a pub or at a football match, consultants are often blamed for every ill, which is wrong. Consultants work, have contracts with health boards and the Department of Health and Children and provide the services. The buck stops at the top desk, which is normally that of a consultant. We must move to a situation where we appoint contract consultants to work in the public patient area only. For too long, consultants have had the trump card in negotiations because they are specialists in their area and can dictate the pace.

I do not understand why a consultant in one health board area can carry out four procedures per day while a consultant in another area can carry out seven. We must ask whether consultants are the cause of the difficulties or whether they are not given the support to work in the public patient area. However, they would fall over each other to treat private patients. This must be investigated. If we are imaginative in using facilities such as hospital theatre facilities and having consultants contracting for public patients only, we could make progress in removing from the system patients waiting for various treatments.

The accountability of the Health Service Executive to the Oireachtas was referred to. Accountability must stop with this Parliament. We live in a representative democracy and have an obligation to ensure that public representatives can highlight issues of concern to their constituents or to the taxpayers funding the services. Section 21 of the Bill refers to the attendance of the chief executive officer of the HSE before an Oireachtas committee. While I do not know how effective the section will be in guaranteeing accountability to Parliament, it provides a level of comfort. However, a Deputy should be able to come to the House, put a parliamentary question to the Minister and receive a response to address the concerns of a constituent or a group which had approached the Deputy with some concern.

The Government got rid of health boards.

It is an area we will have to consider. While the committee structure works reasonably well, it is often only the members of the committee who attend, although any Member of the Houses can attend to ask questions. However, Members have constituency pressures and sit on so many committees that they may not have time to state their case.

Some measure should be introduced so that a Deputy can table a parliamentary question and be guaranteed a reply. I realise there is a procedure whereby if a Deputy tables a question on a Tuesday, it will be answered the following Tuesday. I would not mind waiting a few days if I was to get a proper response. However, the standard response is that the issue is no longer the responsibility of the Minister and has been referred to the chief executive officers of the various health boards. That is not good enough.

The Deputy might get a reply in three months.

One might also get a prompt response but some mechanism should be in place to guarantee Members a reply and accountability. I urge the Minister to consider this concern, which was raised by the Opposition but is a concern of all Members. My question is whether I can get an answer if a problem arises in my constituency or on a broader matter.

The answer is "No".

The motto of the Health Services Executive should be fairness and equality. There is no doubt, as Deputy McManus stated, there is apartheid in our health system. It could be argued that there is apartheid in many systems, such as the education system and society in general, which is a matter we must address. For example, a family may have a great deal of money but their child gets free primary, second level and now third level education. It must be asked whether this is fair or equitable if we want a fair society.

The question is whether we have the bottle to change it.

Did the Deputy's party have the bottle to implement it? It was quick to implement it but the public saw through that stunt by a previous Government.

The Government has had seven years to deal with this.

Will Deputies Costello and Sean Ryan go again?

With regard to fairness and equality, I welcome the general practitioner-only medical card. No Member should criticise that positive, imaginative and proactive measure which ensures that those who are just outside eligibility for the full medical card will now get free GP care. I urge the Labour Party to reconsider its opposition to this imaginative approach.

I wish the Bill a speedy passage through the House.

It will get that in any case.

I hope we will have more accountability to this House at the end of the process. I hope all working in the health services can implement the Bill in a spirit of co-operation to ensure we provide better services to all who require them.

I wish to share time with Deputy Sean Ryan.

Is that agreed? Agreed.

Listening to the contributions, there is a sense ofdéja vu. We have been through all this before over the past seven years and little has changed. We are in a crisis. There is a crisis every time we discuss the health services in the House but we are repeatedly told that billions of euro have been invested in the services, more is being invested every year, there will be change, new structures and new plans and all will be hunky-dory in the future. We have been told this again in this debate.

It is inauspicious that the Bill is dated 17 November last but, after three short days of debate which have not been full days by any means, the Bill will be guillotined. Everything that is important——

The Deputy is still on this issue, as he was in the Seanad. He will never change.

It works for him.

It is old hat now.

Deputy Cassidy was the Leader of the Seanad.

I had to listen to the same old stuff then.

He spent his time keeping others in line.

Will the Deputy change and give us a new line?

However, he is now totally indisciplined. Perhaps he should go back to the other House and impose some new discipline on the current Leader of the Seanad.

The Deputy is reading from a page from 1999.

I am not reading. It is an inauspicious beginning that we should in a short period put through important legislation of this nature. It seems that every important issue we debate is dealt with as an emergency and must be rushed through without the real issues being dealt with. I have had it up to the teeth with the Minister for Justice, Equality and Law Reform in this regard when it comes to his brief. It is wrong that we should rush through this legislation when it is supposed to redress all the grievances of the past seven years.

I compliment the Patients Together group on coming out on the streets to highlight the crisis in accident and emergency departments. The Byrne family, when their mother was left lying on a trolley, had the courage to go public on the issue when many others would not have had the confidence to do so. However, the Byrne family had the courage to do so and to organise a campaign. I have no doubt this is part of the reason for the sudden alacrity now being displayed by the Minister for Health and Children and the Government in seeking to get the legislation through at this early stage.

The health service and the accident and emergency departments have been in crisis for the past seven years and steps of any kind were not taken to deal with the situation. In the Mater Hospital there are still 20 to 35 people lying on trolleys at any given time. The Minister could go to see them. It would be a very useful exercise for her to pass through the accident and emergency unit where there is no separation or distinction between someone arriving after an accident perhaps related to alcohol or drug overdose, and a little old lady who has had a stroke or a heart attack. Such people lie cheek by jowl there, side by side. That is not good enough in this day and age. Every accident and emergency unit should have separate admission sections so that people would not be mixed like that for long periods of time, especially when they must lie on trolleys for days.

The accident and emergency unit in the Mater Hospital is short of four nurses and needs more medical staff. The hospital currently has 60 vacancies for nurses. Patients who could be catered for in a recovery unit if there were such a unit, occupy more than 70 beds. According to the staff, 100 new beds are also urgently needed. There are 4,000 people waiting for serious operations and treatment. That is the level of the problem facing the Minister in one hospital. That is how far the situation has deteriorated there.

The hospital consultants said that 3,000 beds have been lost to the system. There is no point in denying that. In my constituency the Jervis Street and Richmond Street hospitals have closed. Looking immediately across the Liffey I can see the closure of Sir Patrick Dun's, Mercer's and the Meath Hospitals. These have all closed in the heart of the city and the beds have not been replaced. Some 3,000 beds were lost to the system by 1990 and with an increased population we expect a service to be provided. It cannot be provided. We urgently need more beds. We also have hospitals and units where beds or wards are closed down, or units which have not been opened due to lack of funding. We are promised funding for these in the Estimates but we must wait to see if it will arrive.

I have always wondered why the Minister could not do something with the old nurses' home in the Mater, which after about five years still lies idle. Could the Minister knock down a few walls and provide either a step-down or accident and emergency facility there? We do not know when it will be demolished, nor when the plans for the new Mater and Temple Street hospitals will be drawn up. There is an unused facility there which could provide much-needed space in terms of hospital beds either for accident and emergency purposes or for normal admission and treatment.

The Estimates allow approximately €11 billion for spending on the hospitals this year. The Minister goes to great lengths to explain what a fine job he is doing in that area, with an increased spend of €950 million on last year, an increase of 9%. Approximately 40% of the total of the extra money being spent in the Estimates this year is going on hospitals. That is a great deal of money. The Minister tells us that since 1997 there has been a spending increase of 205%. Yet here we are in the Dáil again discussing the crisis in the hospitals.

The Minister said it was wonderful that 80% of those on waiting lists do not now have to wait more than a year. Waiting a year for an urgent operation is not wonderful by any means. The waiting lists remain very long. The changes and improvements have not taken place. As far as I know, accident and emergency waiting times have not improved at all and there is no mechanism to ensure that someone who has been admitted to hospital, who has perhaps spent a couple of days on a trolley and perhaps has then had an operation, can be moved on.

I will give an example that might be useful to the Minister. I visit a friend of mine in the Mater Hospital every week. Following a stroke, he arrived in the hospital in August. He is in pretty good shape, though he needs physical therapy. Mentally he has suffered no detrimental effect. He is receiving physical therapy in the hospital but could just as easily receive it at home. However, he cannot go home. He has no medical card. That was a problem we had to sort out. He also needed a ramp at his home. The local authority installed the ramp but it was the wrong size and has not yet been adjusted. This man then needed downstairs facilities in his home because he could not go upstairs. Those facilities have to be installed but there will be no sign of them in the near future.

This man has been occupying a hospital bed since August. Being in fine mental shape, he would love to be out of the hospital but cannot leave. There is no step-down facility. If the old nurses' home in the Mater were available as a step-down facility he could spend recovery time out of the main hospital. If the link with the local authority and the community services were strong enough he could be dealt with there too.

I share the concern expressed by Deputy Kelleher and others in the House about accountability and transparency. If we cannot ask the Minister parliamentary questions in the House we are handing over the responsibility which should be conferred on this House to an agency to be established, which is not right or proper. We should not allow that to happen. Whatever mechanism is put in place, it must ensure that this House is paramount and that on behalf of our constituents we can get answers directly from the Minister.

I am pleased to have the opportunity to speak on the Health Bill. I am delighted the Tánaiste and the Minister for State are present.

I attended specially for the Deputy.

The main objective of the Bill is to provide for the establishment of the Health Service Executive. It is now almost 18 months since the Government set in train an interim HSE with the objective among others of facilitating a smooth transfer to new structures. As an outsider it seems to me that the Government has failed miserably. For example, the IMPACT trade union which has negotiated and facilitated change in the health service over the years deemed it necessary to seek a mandate from its members for industrial action, which it secured by a seven to one majority. This was because of what IMPACT alleged was a lack of consultation and the resulting utter frustration. While the Minister may well have taken her eye off the ball at a time when the chief executive officer designate, Professor Aidan Halligan, did a U-turn and refused to accept the post, generally speaking there is no excuse for the state of industrial relations in the health service. I seek a commitment from the Tánaiste that the deficiencies in this important area will be addressed as a good working relationship is vitally important if the new system is to work effectively.

During the debate on the new structures, Ministers, particularly Fianna Fáil ones, came under extreme pressure from Fianna Fáil councillors who were losing their positions on the various health boards. To deal with the issues and to try to address some of them, the Government recommended the establishment of regional health fora. Are these solely to be talking shops or will they be given any legislative power or responsibility? As one who is firmly in favour of local accountability, I need the Tánaiste to spell out the role of the regional health fora.

Deputies Kelleher and Costello referred to accountability. We do not want a situation similar to that which exists with the National Roads Authority where we cannot ask questions and relay queries for our constituents. We need a structure, or an effective mechanism, to be put in place so that we will get answers and there will be accountability.

This legislation will be irrelevant to the public unless there are real and substantial improvements to the health service. As Labour Party spokesperson on older people's issues, I am angry and frustrated at the way older people have been affected by cutbacks in the health service. The lack of services has reached crisis levels in many health board areas. Older people made considerable sacrifices over the years and in difficult times to care for their children and to provide them with the education which has, in many ways, been responsible for the Celtic tiger and made this country one of the richest in the world. What have they received in return? It is an utter scandal that many of these people must lie on trolleys in accident and emergency units in Beaumont Hospital and in the Mater Hospital, the two acute hospitals in my catchment area, for up to 30 hours in some cases waiting to get access to medical wards.

On a recent visit to one hospital, the scene resembled something from "ER". The department was full of nurses and doctors running from patient to patient. The centre aisles and cubicles were filled with trolleys and chairs. As I moved out of one of the units, I came across two people standing beside and consoling an older man on a trolley. One of them recognised me, called me over and said, "My father has worked hard all his life to educate his family on a modest income, he has paid all his taxes and his PRSI contributions and on the first occasion he has required the assistance of the State, he has been left for up to 24 hours on a trolley waiting for a bed." He asked "What sort of society is this?" He was right. The current position is a scandal. I have confidence the Tánaiste will endeavour to respond to this, but there is nothing in the Bill, as far as I can see, that will guarantee an improvement of the service to the people affected.

In the greater Dublin area, people in need of long-term care in a public nursing homes face a waiting list of up to twelve and a half years. That is the reality. The withdrawal of contract beds by health boards on 1 September has made things worse. I have also been advised that the withdrawal of the contract beds means that, on average, only one vacancy arises per month. This usually occurs when a patient dies. That is the reality for many people. During the past two and a half years I raised with the previous Minister the issue of older people trying to get care and the fact that there are vacant beds in private nursing homes, but I was told they could not be used. They are being used now about which I am pleased. It is an issue which must be addressed and this is one of the solutions.

I will not refer to the inappropriate use of acute beds due to the non-availability of non-acute hospital beds for older people but specifically to people living in the community. If we are to arrive at a situation where we can get older people out of the hospitals quickly and back into their homes or prevent them for going into hospital in the first place, they must have supports. Older people are forced to remain at home and to rely on family support at a time when community care and home help services are being cut back. There was a reduction in the provision of 300,000 home help hours throughout the State in 2003 as compared with 2002. Despite all the money available, a service required at local level was cut back viciously. It is imperative that we maintain and improve these services so that older people can return to and live in their own environment following a stay in hospital. Having read this Bill, there is still no guarantee that this range of community-based services will be provided.

In regard to long-term care beds, I am very pleased with the Lusk community unit. Most people try to get a bed in a public community facility because they want to be as close as possible to their families and communities. There is a limited number of beds in Lusk community unit. To cater for the demand in the wider north Dublin catchment area, it is imperative that we get two more community units. I ask the Tánaiste to take that on board.

Recently on the Adjournment I raised the position of 230 people with intellectual disabilities accommodated in St. Ita's Hospital. As I said on that occasion, I am sick and tired of the neglect of St. Ita's and the ongoing broken promises of Government regarding the needs of people who have minimal political influence. Planning permission has been secured, but over six years later a sod has yet to be turned. This scandal must be addressed. I demand that the Tánaiste and the Minister of State, Deputy Tim O'Malley, who has been very supportive in regard to this project, deliver on their promise. I look forward to turning the sod on this project with the Tánaiste in the near future. We cannot shove this group of people aside. This project is ready to commence but it needs the go ahead from the Tánaiste and the Minister for Finance. I look forward to their support.

The Tánaiste is in a difficult Department and I wish her every success in it because it will be in the interests of all of us if she succeeds in even some of her objectives.

I am pleased the Tánaiste is here while I make my contribution. Everyone knows the challenges ahead in regard to the health portfolio. All fair-minded people would say that the former Minister, Deputy Martin, did a good job, worked hard and was committed to the health portfolio, as was his predecessor, my colleague from the midlands, the Minister for Finance, Deputy Cowen.

Everyone would agree this is the biggest challenge the Tánaiste has faced since she became a Member of the Oireachtas in 1977. I congratulate her for seeking the portfolio. As Tánaiste and leader of her party, the Taoiseach was pleased to accede to her request. The Tánaiste has been a close family friend and I assure her of my full support in her term as Minister for Health and Children.

That is a very nice sentiment. Deputy Cassidy is going soft.

I became a member of the Midland Health Board in 1985, when Deputy English was still in school. The board faced a difficult situation in that year and the challenge increased in 1987. In 1988, when the Ceann Comhairle was Minister for Health, we put our estimates through on Holy Thursday. All of us in public life at that time, including Deputy James Breen from Clare who is here today, can well recall that protective notice was given to a significant number of health workers throughout the country. There were queues of cars outside my home that night, containing staff from the local hospital, St. Peter's Hospital in Castlepollard, upon whom protective notice had been served. It was evident that there was a significant problem in the health service.

The difficulties now experienced by the sector are nothing as compared to the situation in 1987, 1988 and 1989. There are young people in this House today who do not remember bad times. The difference today compared to those earlier years is that there were then no resources to address the problem. The resources are now available, if resources are the difficulty. The difficulties experienced in the 1980s and early 1990s by nursing staff, those who ran our health boards and by the unfortunate patients who bore the brunt of these difficulties were tremendous.

As a member of the Midland Health Board for 18 years, I acknowledge the public representatives of all political persuasions who served on that board and selflessly gave of their time to ensure we can enjoy the health service we have today. I also served as a member of Westmeath health board and health advisory committee, which used to run the health service before a former Deputy from my constituency and former President, Mr. Erskine Childers, established the health board system during his time as Minister for Health.

In view of the long track record of difficulties in this area, we now look forward with confidence because the resources are there to solve those difficulties. The transparency issue is the most significant challenge facing the Tánaiste. We all know there are difficulties in the health service. Since 1997, the allocation of funding to the Department of Health and Children, which has increased three-fold, has not solved the problem. All Members are anxious to know why this approach has not worked. The Tánaiste has only begun her Ministry at the Department and it will take a little time for her to get her bearings. Some Members of this House are health sector professionals. I call on them, from all sides of the House, to assist the Tánaiste in the dilemma in which the Government finds itself.

There are positive elements to be welcomed. In the midland area, the MidDoc facility which provides a 24-hour doctor service is working very well. Some weeks ago, my grandson succumbed suddenly to a virus and we availed of the MidDoc service in Mullingar. He was seen within ten minutes. This is the treatment every child deserves. It is a terrific service, replicated in other parts of the country through WestDoc and so on. I compliment the previous Minister who established it and everyone in the health services involved in its delivery. Mullingar General Hospital has acquired a new consultant and a new accident and emergency unit. I attended this unit recently on account of treatment required by my mother and there were 18 staff employed there. Positive advances such as these are seldom mentioned.

However, I observe that there is a hospital building in Mullingar which has stood idle for more than ten years. I invite the Tánaiste to visit Mullingar General Hospital and Longford-Westmeath General Hospital to see the great State asset there, ready to be fitted out for the increased demand that exists in the midland area. The national spatial strategy incorporates Athlone, Tullamore and Mullingar, while Longford and Portlaoise are designated hubs. We are told that the populations of these towns will grow from approximately 20,000 to some 60,000 over the next 15 years. The critical mass for the area as a whole will be 350,000, which represents a significant number of patients.

Longford-Westmeath General Hospital is the only acute hospital between Dublin and Sligo. That is a long distance. In 2002, there were 1,600 births in the maternity unit of Mullingar General Hospital. This increased to 1,800 in 2003 and the number will be in excess of 2,000 for 2004. The hospital provides a fantastic service, with excellent nursing staff and a great medical centre for the two counties. However, funding should be made available at the earliest opportunity for the additional wing that is standing idle. It defies logic that it should be built but not utilised. The two old wings for male and female medical patients in the hospital in Mullingar were built of mass concrete in the 1930s, during the tenure of my predecessor, the former Minister of State at the Department of Health, the late Mr. M.J. Kennedy, with whom I am honoured to have been closely associated.

I came to this House as Mr. Kennedy's assistant in 1962. In the more than 40 years since, I have seen many changes. There has been significant improvement, most of it under the jurisdiction of Fianna Fáil and our partners, the Progressive Democrats. I also acknowledge the work done by the Opposition parties in this area over that 40 years. We have come a long way, even in the last 15 years. Some 40 years ago, there were areas with no running water or sewerage systems. All fair-minded people will agree that we have transformed our country. The visit of the late United States President, Mr. John F. Kennedy, was a turning point in our history.

We are here as Oireachtas Members for a short time in order to serve the people of the counties which we represent, whether it is Tipperary, Clare, or the maroon or white of Galway or Westmeath. Having considered the various difficulties and challenges that Members have experienced in different portfolios, the health service represents the most significant challenge I have seen in my 40 years coming to this House, whether as assistant to Mr. M.J. Kennedy or as a Member representing the people of Westmeath. There has been much repetition in the commentary about this Bill. I officially invite the Tánaiste to visit the asset that exists in Mullingar. I also invite her to visit one of the country's worst senior citizens' long-stay units, St. Mary's care centre in Mullingar. Much of this facility is closed due to the difficulties experienced there. It has a fantastic nursing staff with a great commitment to caring for the elderly. My late father died as a patient there. The design team has been appointed for it and I am committed in my support for the facility.

The design team has also been appointed for work to be carried out to the Longford-Westmeath General Hospital. Under the programme of care for the elderly, there is the possibility that every senior citizen would live no further than 15 miles from a long-stay care unit or a general hospital. I look forward to a new 50-bed unit in Castlepollard being built, I hope during the term of this Dáil. Perhaps the building of that unit could be provided under a public private partnership process. I do not see why it could not be. While the proposed unit will be small, it will make a great difference to the lives people living in the rural areas in the vicinity of it.

Two major challenges face senior citizens living in rural areas, one of which is loneliness. As a former postman, I know about the experience of loneliness from having visited people living in the remote areas. The postman might be the only person these people meet in the day. The second challenge facing them is the issue of security, which is a serious problem for people living alone in rural areas. We all represent people from rural areas, although Deputy Woods might be a little more fortunate in his constituency in Dublin, but as a former Minister he is aware of the difficulties faced by people living alone and worrying about their security. There have been cluster developments such as those in Carnew and Mulranny, the latter in which Deputies representing Mayo have been involved. As public representatives, we can make an immeasurable contribution in this area.

I am associated with the North Westmeath Hospice Association, of which my wife is chairperson. It is appalling that the Department of Health and Children and the Government do not pay the nursing staff who visit people suffering from the plague of cancer and allow those suffering to die with dignity in their own homes. It is appalling that people must fund-raise morning, noon and night and friends of those being cared for must give back their wedding presents to ensure that these nurses are paid, even though it involves only two or three nurses in each county. I do not suggest we should interfere with the hospice regime of fund-raising, but perhaps the Tánaiste would examine the possibility of paying the wages of the nurses who call to these unfortunate patients who are suffering in their homes. Such care gives them the dignity of seeing the end of their days at home. This is an issue that should be addressed soon.

People ask me about the good old days, but everyone agrees that the good old days are now. It is a wonderful time to be in public life. Representatives can achieve a great deal for the people they represent because resources are available. Those of us who are Members of this House or the Seanad, as I was for 20 years, saw the dreadful drift of people from the land and the heartbreak of mothers and fathers who reared their sons who then left to benefit the economies of other countries. Through my other line of business, I visited hundreds, if not thousands, of sons and daughters of friends in Sydney, New York and London who faced the prospect of going home to a flat at night in which there was no one and the alternative was to go to the public house. That does not happen any more. One can be born in Ireland, be educated well, get married, live in a brand new house with one's spouse and rear one's family here. Such opportunities have not existed for our people for hundreds of years. They exist now at a time when we are all Members of the Oireachtas and Deputy Harney is the Tánaiste and Minister for Health and Children.

I do not want to be repetitive or long-winded, but I wish to make the point that the unsung heroes of our society are the carers of Ireland. The daughters and sons who give up their jobs to look after their mothers or fathers get a raw deal which is despicable. Will the Tánaiste use her influence to address this issue? If a son or daughter returns home having left his or her place of employment, he or she should be given the necessary incentives to address his or her needs. If one has a parent in a nursing home, and I have personal experience in this regard, a stay costs anything from €500 to €1,000 a week. That said, the care and attention people receive is magnificent. However, there is not a parent in a nursing home who would not want to be in the four walls of his or her home and have a son or daughter look after him or her. At present, the system does not allow that to happen. I appeal to the Tánaiste as a caring person, which I know she has been all her life as well as a good family person, to address this issue in some way, if not in the budget given that there may not be the time to make such provision, in the Finance Act early next year.

I wish the Minister well in her portfolio. I also wish the Bill well. I congratulate all those who have taken the health system to where it is today. I pay tribute to their hard work and dedication because to be a nurse or a doctor is to have a true vocation. Many people make that unbelievable contribution of looking after those who are sick and not able to look after themselves. The greatest gift the good Lord could give any of us is to have our health. We are privileged people to be able to make this contribution on behalf of our constituents.

I hope the Tánaiste will visit the people of Mullingar, Longford and Athlone in early January because these areas are in need of investment. There is massive road expansion in those areas and it will be followed by the provision of services and a growth in population. Anyone who saw the figures for the number of students attending third level education will have realised that Laois, Offaly and parts of Westmeath have the lowest figures in the country. The question must be asked why that is the case. The reason is simple; it is a matter of resources. The midlands is getting a chance for the first time to have proper roads, namely, a motorway from Kilcock to Kinnegad and a dual carriageway from Kinnegad to Mullingar. Work will commence next May on a dual carriageway from Kinnegad to Athlone. The sum of €1 billion is being spent in the midland counties which have never received such a level of investment. The sum of €218 million is being spent on sewerage schemes in Westmeath this year. It is a good time to be in public life. I wish the Bill well in its passage through the Houses and wholeheartedly support it.

I wish to share my time with Deputy Healy.

My comment on the Health Bill is that too much emphasis is put on expenditure and financial limits. Our health system should reflect the ending of poverty and disadvantage and the promotion of greater equality among our people to ensure that the new Health Service Executive establishes a more patient related care system which is integrated and improved. Public services are experiencing unprecedented pressures due to the lack of available resources. It is detrimental to think we can put a price on health.

We face the reality of a number of our prominent health boards being abolished and turned into a national service. I refer to the Eastern Region Health Authority, the Northern Area Health Board, the East Coast Area Health Board and the South-Western Area Health Board, all established under the Health Act 1970. Also, employees of the dissolved bodies are being pushed towards the Health Service Executive which is being established on a statutory basis. Whether this step will improve the health and quality of life of individuals and communities remains to be seen.

However, appropriately addressing the health care needs of the people requires a commitment to greater access to and provision of services throughout the urban, suburban and rural communities and increased access to services to ensure health care needs are addressed. Closing equality gaps will require new resources, which will be more than the redistribution of existing resources. It should not be an outcome of the planning process that some groups and locations are asked to give up necessary, important and well utilised services. However, better use of existing services should always be pursued. Cost-effectiveness and cost-efficiency are about ensuring services provide and support the highest quality of life for the lowest cost as opposed to simply being about cost reduction. Society has played an important role in increasing the health care provision for its people. Continued increases in longevity and maintenance and enhancement of quality of life require a commitment to maintaining access to and redesigning services that support meeting the health care needs of people.

I am deeply concerned about the impact the Hanly report, if implemented, would have on the people of Clare, particularly those living in remote areas such as the Loop Head peninsula, which is approximately 60 miles from Ennis hospital. I am also concerned that the report, if implemented, will downgrade Ennis hospital to the status of a local hospital. The hospital will not have 24 hour emergency services and that will ultimately cost people their lives. I call on the Minister to scrap the Hanly report and ensure that Ennis is upgraded to a regional hospital, fully staffed and fully equipped to deal with any emergency.

In 2005, there will be a 9% increase in the health budget. We have a new Minister and a new style, but no apparent change in policy other then the creation of a three-tier health service by the Minister and her Government.

Today, a new report on the MRSA super bug has been published. This may come as a surprise to the general public but it comes as no surprise to me, a man who has suffered from the bug for the last six months. I thank the Minister for starting an investigation into how I contracted MRSA. The Minister is sincere in her statements regarding the bug but this problem has to be dealt with as a matter of extreme urgency. Overcrowding in our hospitals has to stop and proper hygiene standards must be adhered to. Hospitals will have to make regular reports on the number of patients contracting the MRSA bug while in their care.

I also draw the attention of the Minister to a young boy suffering from autism in County Clare, who is currently a patient in a secure psychiatric hospital. Is the Minister prepared to ensure that there is proper care and assistance for people like this young boy? It is not right that people suffering from autism should be locked up in secure psychiatric hospitals.

I wish the Minister well in her post. She has a tough job before her. As Deputy Cassidy invited her to come to Mullingar, I invite her to come to County Clare and to take up the cudgels where Deputy Martin left them down. Four years ago, Deputy Martin came to my constituency and promised £15 million for the upgrading of Ennis General Hospital. To date, not a penny of that money has been drawn down. We need an upgraded hospital in Ennis. We need a cat scanner, two extra radiologists, a surgeon and two more consultant physicians.

I ask the Minister to use her good offices to look after the people of Clare. I have no doubt she will.

For many years, and particularly in recent years, politicians of almost all persuasions and commentators in the media have claimed that a huge problem in the health service derives from over-manning of management and administrative posts. Nothing could be further from the truth. It has been independently demonstrated that this is not a problem and that focusing the debate on this issue is a diversion from tackling the real problems in the health service.

Only 6% of health service staff are in administrative or management roles which do not directly affect and serve patients, doctors, nurses or other health professionals. Approximately one in 20 health service workers is directly administrative. The Brennan report has confirmed this situation. It states that ten out of every 11 additional employees in this category recruited since 1997 are engaged in duties of direct service to patients and to the public. The report went on to state:

There has been ongoing comment during the course of our deliberations that the majority of increased employment in the health sector has been taken up by administrators, that is, that administrative staff rather than those providing a direct patient service have consumed the additional resources allocated. We have not found evidence to support this perception.

The writers of the report did not find evidence to support that perception because it is not a fact.

A reduction in administrative and clerical staffing would mean doctors, nurses and health professionals spending their time typing, filing and preparing budgets, PAYE returns and payrolls. These roles are not appropriate to professionals of that kind. Any attempt significantly to reduce clerical and administrative staffing would be seriously detrimental to the delivery of health services.

The basis of the Health Bill and of the Hanly report is that centralisation is good in itself and will be beneficial for the health services. That argument cannot be sustained and is fundamentally flawed. There has been a serious lack of consultation relating to the Bill and to the new structures proposed in it. Those people who do admirable and trojan work in the health services have been consulted considerably less than they should have been.

Existing health boards are to be abolished before adequate new structures are put in place. If the Bill is enacted we will have a health service executive in five weeks' time, but many issues will not have been clarified. How will jobs be protected, what will the new staff structures be, how will roles of responsibility be allocated and where will staff be located? These and many other questions have not been answered. If this is how the Health Service Executive means to go on, we can look forward to a health service in even more difficulty and in even more of a shambles than at present.

The Bill leaves a huge democratic deficit in the health services. It removes elected public representatives who were doing an excellent job on health boards and who carried the views and concerns of patients and constituents to those bodies. I worry that we will have a body such as the National Roads Authority. Deputies will have no right to ask parliamentary questions regarding the executive. We will be told by the Ceann Comhairle's office that the issue raised is a matter for the Health Service Executive and that the Minister has no day-to-day responsibility in the matter. The Health Service Executive will not be accountable to the Dáil.

The Bill does nothing to address the serious problems in the health service. One of these is our two-tier health system. A wealthy person can have access to health services at the drop of a hat while those in lower or middle income groups without access to health insurance must wait for months and years. Recently, a constituent of mine, who had a medical card, was told he would be waiting eight months for an out-patient appointment and another 18 months before a necessary orthopaedic procedure would be carried out. The gentleman and his family got sufficient money together and he became a private patient. He had an appointment within the week and had the procedure carried out the following week. This example gives an indication of the inequality and unfairness of the health service. There is a geographical, two-tier health system depending on where one lives. For instance, in the south-east there is no BreastCheck or radiotherapy service. The situation is similar in Limerick, Sligo and other locations. It is a form of health apartheid.

The Hanly report is part and parcel of the new approach to health services, which includes the legislative proposals before us. When it comes to hospital services, we are told centralisation is everything. Unfortunately, however, the Hanly report is based on a number of serious fallacies, the first of which is that centralisation will improve quality and safety. That is not correct. The second fallacy is that smaller hospitals have lower standards, which is also incorrect. The third fallacy is that smaller hospitals are inefficient, which is not true either.

I worked as a hospital manager for 21 years in the South Eastern Health Board area and I know that some of our smaller hospitals are more effective, efficient and have higher standards than many regional and tertiary hospitals. Smaller hospitals are supposed to have poorer training for NCHDs and it is claimed that larger centralised hospitals would provide a better quality of access, but nothing could be further from the truth. If the Hanly report's recommendations are implemented, we will witness a downgrading of general hospitals such as my local one in south Tipperary and others in Nenagh, Ennis and elsewhere. In addition, only elective surgical and medical day procedures will be catered for, while there will be no on-site, overnight medical presence and no accident and emergency services. We will have nurse-led minor injury units, which I had the unfortunate experience of seeing in Clonmel in the 1970s and early 1980s. We had to close the unit down because it was ineffective; it was not staffed by medical personnel and could not provide a proper level of service despite excellent work by the nursing staff involved. Such units simply do not work. I am concerned for the future operation of obstetric maternity and paediatric units in general hospitals if the Hanly report is implemented as outlined.

Part 8 deals with public representation and user participation but there is no obligation on the new health service executive to take into account anything that comes from the various fora to be established under the provisions of the Bill. For example, according to the terms of the Bill, the national health consultative forum may "advise the Minister on matters relating to health". In addition, a regional health forum may "make such representations to the executive as it considers appropriate . . . ", but there is no obligation on the Health Service Executive to take into account the views of public representatives or users.

Part 9 deals with complaints but an independent complaints procedure is required, not one that is operated by any body established under this legislation. Those who have legitimate complaints about the health service should have access to an independent complaints procedure, rather than to someone who is part of the system. The perception would be that such a person would not have the same feeling for dealing with genuine individual complaints about the various health services provided.

A redress board should be established to deal with complaints deemed to be well-founded. People who have gone through the health service and have come out at the other end with serious disability or trauma should be able to seek redress.

The idea behind the Hanly report and other reports published is to centralise the health system, including hospital services. I am satisfied, however, that centralisation is not always a good thing. In fact, as many health services as possible should be provided at local level, thus ensuring wider public access to them.

Many of the Hanly report's recommendations are based on a seriously flawed understanding of the services currently available in local general hospitals compared to regional hospitals. It is not true to say that big is best. We should not go down that road. I will oppose the legislation when it comes to a vote.

This historic and hugely important Bill deserves our full attention. The health system embraces so many different aspects that affect everyone, whether it is dental treatment or care for old age pensioners, those suffering from disabilities or people who need help to lead healthier lifestyles. The health service is much broader now than it was in the past. Ten, 15 or even 30 years ago, the parameters of the health service were much narrower. Nowadays people complain about the numbers of staff working in the health service but that service has expanded and developed to meet people's needs in the modern age. As regards the increased numbers working in administration and other branches of the health service, people forget that a hospital porter brings a patient to theatre for an operation, not the consultant.

I have had recent experience of patient services because I could not get through to a particular consultant, even via his secretary, on behalf of a medical card patient. When I contacted patient services, however, they got in touch with the consultant who said he recognised the urgency of the situation and would look after the person very shortly. Communications within the health system, therefore, have improved tremendously. The case to which I referred was in Beaumont Hospital which deals with a huge volume of patients.

Major expansion and development have occurred in the health service, particularly in the eastern region. As the Tánaiste said, this development is urgent. She stressed the importance of getting clear results and value for money, and there is big pressure to do that. As public representatives, we are involved at the customer end and we want to see a caring health system. While we must pursue value for money, eliminate waste and be prepared to change, the health service must adopt a caring approach and have a human face. I would add those requirements to that of value for money. We are familiar with this from the point of view of nurses and others working in the hospital services generally.

The Tánaiste also said that we no longer need the 273 people who serve on separate health boards in addition to the 166 Members of the Dáil and 60 Senators. A new system is about to be introduced. Those people have given us tremendous service over the years. While the quality of service has varied because people vary, it would be a pity not to recognise the service they have given. We will have a single unified health service with the dissolution of the Eastern Regional Health Authority, the health boards and the agencies. I thank all those who have worked in these agencies and services for their work, commitment and vocational contribution, which in many cases have been exceptional.

I dealt with health board members during the three periods when I was Minister for Health. When those members worked together on practical problems they were prepared to find solutions. The important word is "together". As Minister, I brought representatives of each health board together once a month. I discussed the issues and the savings required. Afterwards we had a light lunch around the same table. I do not want people to believe we went off to a hotel or something.

The Deputy and his colleagues are good at that also.

The chief executive and chairman of each health board used to attend. One board would not move unless the other moved owing to the way the system worked, which was that any unspent money at the end of the year was lost. One board would not make savings unless the other boards made similar savings. By bringing them together they agreed what had to be done. We were able to bring our budgets back on target even during the MacSharry era, which was a fairly tough time in terms of money. It took considerable hard work to maintain the services and get them back on line.

All these bodies have now been dissolved and their members must feel as we do on the day the Dáil is dissolved. As Deputies, we must go to the people to look for our jobs back. The former board members must find where they will go. While they have been given guarantees that their jobs will still exist, this is a traumatic period for them. We should publicly acknowledge the work they have done and their achievements on our behalf. Huge improvements have been made in the services in the past ten years.

The Tánaiste mentioned a budget of approximately €10 billion with almost 100,000 employees, which reflects a massive increase in the past six years and has resulted in better services. In the Estimates the Minister for Finance mentioned a figure of €11 billion at a time when our population is increasing. The Tánaiste has said the CEO will be the Accounting Officer for the Vote, not the Secretary General of the Department of Health and Children. This issue should be teased out on Committee Stage, as I would like to understand how that will work in practice. The CEOs often need to call on the Department of Health and Children, which needs to call on the Minister for Finance for the money to keep services going or deal with urgencies and emergencies which arise. It will be interesting to see how that will progress. I note the Tánaiste adverted to some potential technical amendments in this section on Committee Stage.

Yesterday in his speech on the Estimates, the Minister for Finance pointed to significant improvements since 1997. He said:

The cumulative increase in gross expenditure on health over the period 1997 to 2005 will amount to 205%, representing an extra €7.4 billion. Staffing levels have increased by almost 50% from a base of 66,000 in 1997 to almost 98,000 this year.

The Tánaiste might be somewhat closer to the mark with her figure of 100,000. If home helps and others were included the figure would be in excess of 100,000. The Minister for Finance continued:

This has included a significant increase in front line service staff. There is an additional 6,500 nurses, representing 21% of the increase in staff numbers, with further additional staffing increases in the provisions of therapists, dentistry and orthodontic services, medical professionals and social care professionals.

I fully appreciate the difficulties with orthodontic services because it is very difficult to get people to serve the public sector in that area. The Minister for Finance also pointed out:

There has been a concomitant improvement in service delivery with an increase of 30% since 1997 in the number of patients treated in hospitals as inpatient and day care patients. There has also been a reduction in waiting lists with 80% of patients now waiting less than one year . . . and an increase in the elective surgery rate in public hospitals of 85% between 1995 and 2002.

These are all huge achievements in recent years.

I live in the Eastern Regional Health Authority area, which covers a vast area. That authority has been operational for just over three years. Its first chief executive officer was Donal O'Shea, who came from Donegal and I congratulate him on what he achieved in that time. I knew him in the early 1980s when I was Minister for Health. He made tremendous advances in the north-western region, particularly for older people. He put enormous time and work into what he did, as did Alderman Joe Doyle, the authority's chairman. People underestimate the contributions of people like Alderman Joe Doyle of Fine Gael, who is an excellent person, to the development of the health service we have today. Michael Lyons is the regional chief executive officer now.

While the Tánaiste talked about an historic development, the dramatic improvement in the Eastern Regional Health Authority area in three years has been an historic development for us. The voluntary hospitals and agencies have been co-ordinated into one administrative body. It would have been impossible to talk about such a development four or five years ago because the voluntary hospitals were all independent, voluntary and very conscious their entitlements and rights. Budgets and financial matters are all handled in the one body now. Further decisions can now be taken based on what has been achieved in the area and it has opened up huge possibilities.

Of the €11 billion almost €4 billion will be spent in the Eastern Regional Health Authority area, which gives an idea of the number of hospitals and amount of treatment in the area. Every section of its report, the Eastern Regional Health Authority shows dramatic increases in day care patients and inpatients. For the first time we will have an integrated service for the community, a huge increase in support staff and a far better service. While we will always be able to find problems and issues, I deal with a cross-section of people whose appreciation of what is achieved on behalf of individuals in, for example, Beaumont Hospital, the Mater and other hospitals is great. We only hear about cases, however, where something goes wrong and someone was not treated as well as he should have been.

Growth has been phenomenal and rapid in recent years. Just as we need roads and rail services, we need more hospital beds. In my constituency alone, 15,000 houses are being built between the race course in Baldoyle and Belcamp, all in the catchment area of Beaumont Hospital. It is estimated that 40,000 more people will move into the area, resulting in even more pressure on the hospital. Mr. Charles Haughey was involved in the vision for Beaumont Hospital. He used the Cork Wilton model so he would not be delayed and built it on that basis. The hospital was completed in 1982 and it now has to deal with the huge extra demands. It is bursting at the seams and needs capital investment or it will be unable to cope. Similar pressures exist in Tallaght, the Mater Hospital and St. James's Hospital. Someone mentioned to me yesterday that St. James's Hospital is like a shopping arcade there are so many people there. I was in Beaumont a week ago and the volume of people coming and going was incredible.

These hospitals are not big enough to cater for these numbers. It is important to look at and meet capital needs. People worry that if we build more hospitals, we will need more staff. That is an issue but staff numbers are not always a problem. Often we are just talking about extensions or rooms for recuperation. We need major investment in beds for older people to free other beds in the hospitals.

We are storing capital to pay for pensions in 20 or 30 years. I disagreed with the figures for pensions that indicated that demand would be far greater than it will be. A report has now been published indicating that it will not be as bad as we thought in the first instance. Why is that? Because the country is growing and the population is increasing. There is more activity and there are more people. Those estimates were made on the basis of a small, static population largely based on the birth rate. Now, however, people are coming from all over the world to live and work in Ireland. There is plenty of scope for work and development in Ireland. We are now waking up to the fact that we are important internationally and have a valuable contribution to make. We are making that contribution, not just in Ireland but throughout the world in every respect. The argument on overseas development aid has made people realise how much we are spending in that area.

We should invest the capital we have, not try to hide it. The Minister for Finance cannot let the economy overheat and must keep the international investors happy that things are under control but capital can be prudently invested in the provision of facilities. Our health facilities are seriously under-provided on the capital side and we should not let that continue. We should not say that we will do more when we have more money. The Minister will do more in the budget, but he should be brave about it. I got away with five secondary schools when I was Minister for Education and Science under public private partnership that cost €85 million in one year. The spend that year, 2002, was the highest ever without including that figure. It was my job to find ways to do things for the children who did not have proper school facilities and we must do the same type of thing in health.

I wish the Tánaiste every success with this legislation. The sole caveat is that this must be done with the people in mind. If the people are supportive, it does not matter how much money the Department has. Perhaps I should not say that or the Minister for Finance will jump on it, but it is amazing what can be done with the support of the people. We want the services and we want value for money but we must look after the people.

I wish to share time with my colleague Deputy Timmins. I wish the Minister for Health and Children well in the portfolio. She has taken a major political gamble because when the election comes, there is no better party than Fianna Fáil to put her in the limelight if this legislation does not work. The Fianna Fáil candidates will go around the country saying it has nothing to do with them, that it has all to do with the PDs. I compliment her because she could have taken any Department but had the courage to choose the Department of Health of Children. I wish her well, but I do not, however, want her to think that she can walk away from this. She was part of the Government that made a disaster of health in the past seven years and created the present problems. She now thinks the PDs can deal with this. I wish her well.

There is nothing worse for a Deputy than a constituent contacting him or her about a loved family member who needs a hospital bed urgently. Every week we are contacted by these people and the most important thing in their lives is that family member and getting the best for him or her. I hope what is proposed will work.

If I table a parliamentary question in future, will I get a response from the Minister for Health and Children or will I be told that it is now the responsibility of the chief executive of the new Health Service Executive? If the Minister will given an answer, I am happy, but if not, it is a serious blow to democracy. We are turning into a police state where all power is being taken from this House and the elected representatives and handed over to the State. That is wrong. I would not mind if we had a police state where the police dealt with the criminals and thugs but they do not, they deal with ordinary Joe Soap who breaks the law in a minor way. We are elected by the public to this House as Teachtaí Dála, messengers of the people. They want us to get replies from Ministers who are responsible for their respective Departments.

I read in my local newspaper last week about two schemes. One is the general medical service scheme which is a good initiative whereby doctors are paid for their services to medical card patients. I did not know about the second one, the drug initiative scheme. I regret I did not stay at school and become a doctor because it is a nice little earner. Will the Minister of State say what accountability is in place for this scheme?

In case Members do not know the scheme, it provides for every general practitioner in the GMS to be given a certain amount of money to run his or her surgery. If a patient has a heart complaint and three or four drugs are available, one costing €60, another €50, another €40 and another €30 and the doctor prescribes the €30 drug, €30 is saved, €15 of which goes to the Department and €15 to the drug initiative scheme which the GP may draw down for equipment, a new surgery etc.

I have no problem if this is good for the State and minimises the impact of the drug companies which promote and sell the drugs. However, it is Minister of State's responsibility, as it is mine, to ensure that the consumer or patient is protected. We do not want anyone playing God or people being short-changed in any way. I do not say that happens, but I want to see accountability for this scheme to ensure the patient is protected.

As for the health service, a constituent contacted me yesterday, who is in his eighties. He is in hospital in Galway and will go home tomorrow. He needs dialysis and to get it he will have to travel a 110 mile round trip from his home in County Mayo. The consultant has said he is not fit to travel to Galway every day. Despite this, in Mayo General Hospital in Castlebar, there is a dialysis unit that is not being used properly. I will qualify that. The hours it is in use and the staff are wonderful. Greater capacity could be brought into play at that hospital for a small amount of money and more staff, and the dialysis unit could be running 24 hours a day. Then my constituent would not have to be inconvenienced. He is not able to travel to Galway every day or every second day or whatever.

Everything need not be located in the cities. I listened to Deputy Woods and he is correct. I was in St. Luke's last night visiting a number of my constituents. I give full credit to that institution. One could only be impressed by the cleanliness of the hospital, the efficiency of the staff and the manner in which they carry out their duties. I compliment them. St. Luke's is not a nice place to have to go to, but if one has to, it is a wonderful institution. My constituents were quite happy to be there. I spoke to a number of them and I must be careful as I do not wish to identify them. They must go to Dublin on the train on a Monday and receive their treatment from Monday to Friday. In fairness to the hospital and its consultants, they do their best to have them treated in time to catch the midday or evening train home on the Friday. I compliment them on that also.

Nonetheless, it is difficult for individuals to set off from Donegal, Kerry or wherever. I would like to see the service available as close as possible to the west so that patients would not need to travel to Dublin. I accept that all these services cannot be available in every hospital. Everything need not be big, however.

If I were Minister for Health and Children, I would get rid of the combined private and public practice of medicine. A consultant should either be in private or public practice but not both. Consultants practising in both the public and private sectors have destroyed the health system. There is too much conflict of interest within the health service. Private medicine should be run by the private sector and public medicine should be run and paid for by the State without any recourse to private practice for consultants. They must deal on a day-to-day basis with the public sector.

I want to see Mayo General Hospital as well as hospitals in Galway and Dublin getting a certain number of specialties. These specialties should not all be located in the one hospital because this creates chaos and traffic congestion. Different Ministers say that there has never been so much money spent on health as in recent years. We are informed that there have never been as many staff. If so, why is there a crisis in the health service? Something must be wrong. I hope the new Health Service Executive works, but I am doubtful. I hope someone takes the initiative and outlines what must be done.

I do not want this to happen to the disadvantage of small rural areas and the county and regional hospitals, however. I do not want the Health Service Executive to insist that patients may be treated only in Dublin. These services must be spread throughout the State because there are sick people in rural Ireland as well as in Dublin. I have nothing against Dublin. People have given out to me on this and the Dáil ushers will say that I am against Dublin, but I am not. Dublin is a lovely city and I love to come to it, but I love to get out of it as well. One can never beat the west. One should not believe that Ireland is Dublin. I hope the Health Service Executive works so that the people can get a proper health service and be treated when they are sick without their relatives being embittered because their loved ones are unable to obtain treatment.

Everybody wants health reform. No one is happy with the present situation and people have different experiences of the health service. Many good people work in it, but we always hear the bad stories. Certainly, there has been a dramatic increase in funding but without a corresponding increase in services. I will quote from a Second Stage speech on the Health (Eastern Regional Health Authority) Act 1999:

This is important and far-reaching legislation, which puts in place an organisational structure to deliver a more integrated, efficient and patient-focused health service for the people of Dublin, Kildare and Wicklow. The need for radical structural reform in the health services in the eastern region has been recognised for some time . . . Several expert reports over the years have highlighted the need for radical organisational reform of the structures in the eastern region so that the services can respond effectively to the challenges they face.

At the conclusion it says:

The proposals in this Bill amount to the most significant reform of health service structures in this country since the establishment of the health boards under the Health Act, 1970.

That was the speech of the then Minister for Health and Children, Deputy Cowen, on 11 February 1999, on the establishment of the Eastern Regional Health Authority, which all of us in this House supported, if my memory is correct. Time has shown that this initiative has turned out to be an unmitigated disaster.

When I came into politics first in 1997 and was dealing with the health board, matters were difficult enough. By 2001 or 2002, I could not find my way around the various services because of the re-establishment of the Eastern Regional Health Authority. Only last Thursday, together with a number of politicians from all parties, I attended a meeting in a place called Crab Lane in south Wicklow. The only impact it had on this community was that people from the area who could have attended the old district hospital in Baltinglass, west Wicklow, could no longer do so. They must now go to Rathdrum in east Wicklow, 34 miles away, as opposed to the previous journey of 12 miles. That type of intransigence and negative impact ultimately came to focus people's minds in the locality. It was an indication that the system did not work. That is why we all want reform. There is little public confidence, however, that reform is possible. While I appreciate that the Minister, Deputy Harney, the Minister of State, Deputy Brian Lenihan and others are committed to reform, the confidence does not exist.

Deputy Richard Bruton produced a fine document in recent days. He said that health spending had led the field in public spending from 1998 to 2003, when it increased by €5 billion, or 94% in real terms. The numbers employed by the health sector grew by 28,000.

However, the question patients and taxpayers ask is what was achieved with this massive expansion in spending. The hospital programme dominated the health budget. Spending on hospitals more than doubled, increasing from just under €2 billion to €4.2 billion. Adjusting for inflation, this was an increase of 73% in the five-year period. However, the outcomes from this investment were much less impressive. Despite this massive expansion in spending the crisis in the accident and emergency departments of our hospitals worsened. This deterioration occurred not in the face of a massive increase in numbers attending the accident and emergency departments. In fact, numbers declined by 33,000 over the period.

The Government made the elimination of hospital waiting lists one of its key objectives for the hospitals sector. In this period of massive increases in expenditure, waiting lists has declined only by 6,000 and the Government's promise to end waiting lists in two years has proved to be one of the hollowest ever made. One can understand, therefore, the scepticism in respect of this legislation delivering a better health service.

There was a dramatic rise in the unit cost of treatment. The average cost per patient attending the hospital increased by 53% after adjusting for inflation. The average cost of an inpatient procedure in 2002 was €3,500, an increase of 42%. It was only in the case of day surgery that costs were contained where the average increase was just 6%.

Another statistic relates to the general medical services scheme. Most of the expanded budget has gone on medicines. The frequency of prescriptions to medical card holders has increased by 31% and the average prescription cost has increased by a staggering 151% after allowing for inflation. The average cost is €620 per card holder per year. While it is not Fine Gael Party policy, I have encountered enormous waste in medical supplies. For example, a person who receives a prescription under the GMS uses some it and puts the remainder in a closet. I have been in houses where people who passed away had inordinate amounts of drugs which cost a substantial amount of money. I do not know if the Department has ever carried out any research on this.

I do not want to see what I have to say next misquoted, as often happens with the Fianna Fáil press office. If there were a nominal fee on prescriptions, be it €1 or whatever, it might make people more aware of the cost and they might treat matters with a little more respect. When we, and I include myself in that, get something for nothing, we are inclined to abuse it. This system may have been tried out in other countries and it may or may not have worked.

I will not take a note of it.

I am sure somebody will. I recall the debate on the first-time buyer's grant during which I made a valuable point that only one third of first-time buyers received the grant because two thirds bought secondhand houses. Therefore, the grant was inequitable as well as not being index-linked and so on. That point was thrown back at me afterwards in isolation. I appeal for the point I have just made not to be taken in isolation, although it does not matter to me. I firmly believe what I have said to be the case. It is not Fine Gael Party policy but it should be examined. I do not make this suggestion for the purpose of trying to extract €1 from a person who cannot afford it, but it is the principle of making people aware of the cost.

The percentage of gross domestic product spent on health has increased dramatically. It is not inappropriate to devote a percentage of our GDP to health care as we become richer. The dilemma is judging what should be the appropriate level of spending. One of the risks associated with health care is excess spending. It would appear that some providers may have captured more than their fair share of the increase in health spending. As we can clearly see from those figures concerning drugs, some providers have received an inordinate share of the increase of the funding and it has not gone to the provision of care. Many countries have faced the same challenges as us over the decades. However, due to work practices and historical factors, the solutions may not necessarily be the same. When Ireland was a much poorer country there was less dissatisfaction with the health service than today.

There must be two pillars to the health service. A health service must provide quality care, access and value for money. We have quality care and access for some, but there is a disparity of access, which is one of the main difficulties. In addition, we do not have value for money, as evidenced by the percentage of funding that goes to providers as opposed to users. Countries that were more developed than us in the 1960s and 1970s spent an increasing amount of their GDP on health services. However, they realised they were not getting the benefits and, in the 1980s, they reformed and cut back on spending. We are going through that growing process in which we are trying to reform.

I am pleased the Minister alluded to the second pillar in one of the sections of the Bill. It must involve a recognition of behavioural and risk factors, such as cigarettes, alcohol, obesity, violence, a low social awareness of what is good for oneself, income distribution and the ability of people to purchase goods or services that help them in the first instance not to require health assistance. The clinical aspect plays a secondary role. I am pleased the Minister recognises that in the Bill because the health service is not only about provision but also prevention.

Time does not permit me to go through the sections of the Bill. In a nutshell, one of the difficulties we in Fine Gael have is that, although the reports have been published for a number of years, we do not have time to elaborate on the issues in a debate over one or two days. Other speakers referred to the role of the chief executive as the Accounting Officer. I agree as a public representative that we must have access to the information. I have attended too many public meetings in recent years, be they with the National Roads Authority or the Environmental Protection Agency where ultimately our hands were tied and we could find out nothing. The Minister said that our policy must be implemented, that a corporate plan and a national service plan must be produced by the chief executive and that they must be proofed on Government policy. We on this side want an assurance that there will be accountability to the House and that we will not be informed it is not within the remit of the Minister. There has been a failure in political society in recent years to take responsibility. We do not trust ourselves and we side-step issues instead of taking the blame. It is the same with An Bord Pleanála. If I were Minister for the Environment, Heritage and Local Government, I would abolish An Bord Pleanála and take the flack.

I will note that one.

We support reform. However, the time factor is a difficulty and there is also the difficulty about accountability.

I wish to share time with Deputy McCormack.

Is that agreed? Agreed.

I am pleased to have an opportunity to speak on the Bill on Second Stage and to make general comments on the health sector and health reform. There is a genuine desire on the part of the Government to make a change for the better in the health area. It is the key political challenge for the Government over the next two and a half years.

I wish to share some ideas from my experiences on the Southern Health Board and as a Deputy. The first area concerns mental health and the share of the overall health budget that goes to that discipline. There has been a steady decline in its share of the overall budget. In the recent Estimates its share is 6.15%, having been reduced from 6.69%. I am not trying to compare politics or Governments, but if one goes back to 1997-98, the share was 10% or 11%. This trend is of great concern, especially for those working in the area and for families. I understand from a capital programme point of view the specific need to build in respect of accident and emergency units and hospitals generally and the general trend towards moving away from institutional care to trying to support community care in the mental health sector in particular. However, it is unacceptable to allow the percentage share of current expenditure on mental health services, including staffing, to continue to reduce at a time when one in four Irish people suffers from a mental illness at some stage in his or her life. One in six or seven suffers seriously from a mental illness of some description, be it depression, schizophrenia or other conditions.

I was on the psychiatric services committee of the Southern Health Board for four years. It was an absolute eye-opener for me. We held our meetings in different institutions and community service locations for mental health services in Cork and Kerry. There was, and still is, a strong determination to move people from institutional care to independent living/supported independent living in community care. I support this but it can only work if one is replacing the support people are receiving in institutional care with sufficient support in the community. The tragic consequence of failing to do so is that those affected are left with the worst of both worlds. They no longer have institutional care because one is trying to reintegrate them into the community, yet the necessary support services are not being provided to allow the transition to occur successfully. This leads to desperate circumstances in which one has insufficient support in the community and no institutional care to which to return. A number of such cases have been documented in Cork, where people ended up living on the streets because of mistakes made during the transition. I refer to Cork only because I have experience of mental health services in that county. The making of mistakes in the transition is one reason I am so concerned about the reduced current expenditure, in percentage terms, on mental health services, even though it may be increasing in net terms.

We need to continue to promote community care, community support and independent living for those with mental health difficulties, just as we need to promote them for senior citizens. Will the Minister increase the priority accorded to expenditure on mental health services?

This leads to the subjects of senior citizens and psychogeriatric care, on which I have one or two ideas that the Minister might like to pursue. There are now some very good templates available that serve as examples of how we should be supporting senior citizens who do not want to enter institutional care or nursing homes but who are no longer able to live at home by themselves as they may have no families to support them. One such template is the Westgate Foundation in Ballincollig. I am not sure whether the Minister has ever had a chance to visit it. It was established because of the drive and determination of the Ballincollig Senior Citizens' Association. The centre is like a village in itself. There are approximately 36 one-bedroom houses surrounding a courtyard, in the centre of which there is a community centre with a social hall, in which a range of activities takes place and where medical assistance is offered. Both mental and physical well-being are supported in the complex. It is in the heart of Ballincollig, which has a population of approximately 17,000. The centre results in a win-win situation for all concerned. It is far cheaper to stay there than elsewhere. Many of the senior citizens contribute to renting their accommodation and at the same time receive support from the State and from a very professionally run system.

The State would not have established this complex if it had not been for the drive of the community itself. I encourage the Minister and the Department to consider such examples — they are also to be found in other parts of the country — so we can provide the kind of community help people deserve in their old age. This would allow them to retain their sense of independence, pride and self-respect at a very vulnerable time in their lives.

Another area of concern relates to adolescent and youth psychiatric care, particularly the emergence of conditions such as ADHD, AHD and a range of other autistic spectrum disorders. The State has not responded sufficiently to these conditions. Whenever I talk about ADHD, I recall a speech that John Lonnergan made in Cork some years ago at a conference for parents. It was attended by more than 1,000 people. Mr. Lonnergan made the case that at least 40% to 50% of the prisoners he supervised had the exact symptoms of ADHD in particular, indicating that a whole group of people is falling through the net. The State should be trying to offer those with ADHD and other conditions early intervention, early assessment and support. If these conditions are subject to early intervention, they can be dealt with in a very manageable manner by the individuals concerned and their families.

Youth suicide has been raised in the House time and again, particularly by my colleague Deputy Neville. A lack of time prevents me from stating all the relevant figures but I am sure the Minister of State, Deputy Brian Lenihan, could reel them off himself. Suffice it to say that if one compares the youth suicide figures of the United Kingdom with those of Ireland, one will note a steady reduction in the suicide incidence of young men in the United Kingdom and that the opposite is the case in Ireland. We need to start asking ourselves why. When one considers the time, effort, money and PR that the Government rightly devotes to the prevention of road carnage, particularly among the young, one will realise that we need, at an absolute minimum, to implement immediately the recommendations of the recently published report on youth suicide that was rightly commissioned by the Government.

On accident and emergency services, I welcome the controversial new medical card scheme. Let us be honest and admit that the cards are not full medical cards but GP cards. However, the Minister for Health and Children made a brave and correct call in this regard. We need to encourage people to go to their doctors more often for check-ups because early intervention and assessment prevent diseases and other conditions from becoming more serious. We want to keep people out of accident and emergency departments. The choice the Minister had to make was between issuing another 70,000 full medical cards or 200,000 GP cards. She made the correct choice in choosing the latter. It was a brave political decision to make and I encourage her to stick to it.

We need to keep investing in the type of care that keeps people out of hospital. GPs play a major part in this process. With this in mind, we must encourage people, men in particular, to visit their GPs as often as possible, and encourage parents to take their children to their GPs when necessary.

A hobby horse of mine is the percentage of people presenting at accident and emergency units who are heavily under the influence of alcohol. This is an issue on which the Government should take some brave decisions. If someone staggers into an accident and emergency unit because they are too drunk to get home, and have fallen and hit their head off the pavement and require stitches, they should be made to pay for the service. There should be some deterrent to people under the influence of alcohol going into accident and emergency units and often causing difficulties for the nursing staff on Friday and Saturday night. If a person is in an accident and emergency unit primarily because they are drunk, they should pay for the cost of their care so that they will think twice about ending up in hospital rather than in their own bed.

I welcome any reform of the health sector. I am concerned about what the Bill sets out to do and what it may be able to accomplish. It is proposed that the Health Service Executive will replace health boards and CEOs. Does this mean that all health board CEOs will now be redundant or will the new executive create another layer of administration in the health boards? Some 25 years ago when health boards were formed, the health service was run by the local authorities. They were all run from one office, with one executive in charge, and a very small staff. In the opinion of many, the way the health service is currently run is the crux of the problem.

People who contact me on a daily and weekly basis ask how long will their mother, father, aunt, uncle or child have to wait on a trolley in an accident and emergency unit. Does the Minister of State realise the trauma, anxiety and frustration this causes to patients and their families? This is currently the reality in the health service. Is it any wonder there are groups such as the recently formed Patients Together and Patient Focus, in which my wife was involved in Galway? These groups were set up because of the frustration suffered by families because of the manner in which their loves ones were treated, or rather not treated, in accident and emergency units. This is why there are street protests and such groups are set up. This frustration is as a result of many beds being closed, not with the quality of the nursing service provided in accident and emergency wards.

Another issue relates to medical cards for the most neglected and vulnerable sector of our society. These people cannot afford the necessary health care because they are denied medical cards. In An Agreed Programme for Government, the Government promised 200,000 extra medical cards. Currently 100,000 less people are eligible for medical cards. Following a reply to a recent Dáil question, I discovered that in 1997, 73,724 people in Galway city and county were eligible for medical cards while today only 66,400 people are eligible for them. This is a reduction of 10%, despite the Government's promise of 200,000 extra medical cards. The reason for this is simple. The threshold for a single person living alone is just €142.50 per week. If one lives with one's family, the threshold for a single person is €127 per week. If one's income exceeds that threshold they will not be eligible for a medical card. How could anyone live on €127 a week and pay to visit their doctor or for medication? It is time the income threshold was increased. The threshold for a married couple under the age of 65 with no children is €206.50, with two children €238.50 and with four children €270.50. It is impossible for such a family living on €270.50 to avail of any medical service. If one is over the age of 65 and living alone, the threshold is €156. I will not go into all the figures. There are some modest allowances for rents and mortgages but that is not much use to these people.

What does the Minister propose to do — this is the crux of the problem in accident and emergency wards — about the closed beds in hospitals throughout the country? Will she lift the embargo on the recruitment of staff? I was told in reply to a recent Dáil question that there was no embargo but health boards could not exceed the ceiling, which is the same thing. There are some 50 beds closed in University College Hospital Galway because it would take 40 full-time nursing posts to keep the beds open. If the beds remained open, the accident and emergency ward would not be overcrowded, because many of these patients could be let into these wards.

Deputy Cassidy made a good contribution on the building of a 50 bed unit in Castlepollard. Fair dues to him, he is a very down-to-earth politician. He said during the course of the debate that he was an assistant to former Deputy Kennedy in Longford-Westmeath, then he was a postman, he was 20 years in the Seanad and he is now in the Dáil. If one threw in the fire house five and every other occupation in which he was involved, he is a very experienced grass roots politician. He said he wanted a 50 bed unit in Castlepollard. A ten bed unit was built in Clifden two years ago which has not been opened. I raised the issue on the Adjournment three weeks ago. An elderly lady who campaigned for this facility in Clifden will go on hunger strike in December if the facility is not opened. I advised her not to do so. She is threatening to go on hunger strike because she is frustrated that the Western Health Board is not getting the go-ahead to appoint the necessary 14 staff to which I referred on the Adjournment debate. The Minister of State said that provision might be made for the facility in 2005. The people of Clifden and the surrounding area want a commitment in writing as soon as possible that this facility will be open in 2005 to avoid a dangerous situation which is developing. The unit should be open because it would cater for families in the area who can no longer look after their loved ones.

I am sorry I do not have more time to go into more detail on the issue. I appeal to the Minister of State to ensure the people of Clifden that their facility will open early in 2005.

I am pleased to have an opportunity to make a brief contribution on the Health Bill and on the issues surrounding the provision of the health service. The Minister, Deputy Harney, must be commended for taking on the portfolio of Minister for Health and Children. Since the Government took up office in mid-1997, when spectacular promises were made and equally spectacularly broken, the Government has taken a very cynical and brutal approach to the health service. In 2002, the Fianna Fáil Party promised 200,000 additional medical cards. Since then, not only did it refuse to countenance the provision of additional medical cards, it made a brutal and cynical decision to cut the number of medical cards by more than 100,000. This spectacular breach of faith has been the hallmark of the Government's approach to health spending.

There has been ongoing chaos in our accident and emergency departments. The Government has refused to tackle the vice grip of vested interest, in particular that represented by consultants. Throughout our lives we have endured nonsense, whereby accident and emergency departments did not have a consultant or senior medical directorin situ during late evening and early morning hours. We should have modern treatment centres rather than the chaotic, disgraceful and shameful situation which exists in hospitals, as is the case at those near my constituency on the northside of Dublin. It is astonishing that the leading clinical directors of health care in the State were not forced to deliver the type of on-demand services required by any civilised society. Fianna Fáil, the Progressive Democrats and Fine Gael have never been prepared to take on vested interests in the health service. As my great predecessors, Dr. Noel C. Browne and Mr. Barry Desmond, discovered——

Dr. Browne was a member of Fianna Fáil.

He realised his mistake and left the outfit. Historically, he was on the left and he ended his days in the Labour Party. The Government has never had the bottle or the resourcefulness to take on the key vested interests in medicine.The Economist ranks Ireland close to being number one in the world in terms of gross national product and the magazine states Ireland is number one with regard to quality of life. However, we know from bitter experience that does not apply to the health service. When one visits France, Spain, Germany or any of our other European partners, their health care systems are definitively superior to ours. That is an appalling failure of will by Fianna Fáil in particular.

I commend the Tánaiste for having the courage to take charge of the Department of Health and Children. Her own party played a full role in the savage cutbacks of the late 1980s, which the Ceann Comhairle will recall since he was Minister at that time. Those cutbacks had a disastrous and ferocious impact on the people I represent. The Progressive Democrats have been the ideological driving force in health administration since 1997, together with Mr. Charlie McCreevy, the leading PD, so to speak, a member of Fianna Fail who has now departed for Brussels. The party has also been the force behind the cynical and brutal failure to deliver on the promises of the 2002 election.

Seven and a half years after the summer of 1997, the Minister for Justice, Equality and Law Reform, Deputy McDowell, seems to be preparing an exit strategy from the Government. Despite the Taoiseach's intentions, we may not reach the early summer of 2007. Deputy McDowell is enamoured with the evolution of Irish politics along the lines suggested by Mr. Frank Flannery, where those of a democratic persuasion, including the Progressive Democrats, will be on one side and Fianna Fáil and other parties will be the other. The Tánaiste may not have two and a half years to deliver any kind of change under this Bill.

In 2001, before the last general election, the then Minister for Health and Children, Deputy Martin, issued the health strategy entitled, Quality and Fairness — A Health System for You. We are now halfway through the development of that strategy, which accompanied developments in the Prospectus and Brennan reports. The key elements of the strategy were better health for everyone, fair access, appropriate care in the appropriate setting and a high-performance system. The Bill before us seeks to develop a high-performance system on the basis of organisation. However, while I commend Deputy Martin for introducing the smoking ban, the other three elements of the strategy have not been delivered. We still do not have fair access; we have the opposite. We still do not have appropriate care in the appropriate setting. The amount of funding set aside by Deputy Martin for primary care was derisory, as stated by general practitioners who visited me in Dáil Éireann and made representations to other Deputies.

With the exception of yesterday's excellent news regarding smoking statistics, we are still waiting for better health for everybody. In terms of a general approach, the health strategy had some merit with regard to a framework for change of primary care, acute hospital services, funding, human resources, organisational change and information. However, apart from this Bill on organisational change, three and a half years later we are still waiting for the development of the strategy.

One can contrast this with the programme put before the electorate by the Labour Party in 2002. Its fundamental driving force was to achieve an integrated health system for everybody which did not depend on a person's wealth. People would not have to go to their GP and enter into the long waiting system, where one waits to get an appointment to wait for another appointment. The Minister, myself and other Deputies have to put up this virago of nonsense week in, week out as we try to encourage and assist people to seek appropriate medical care.

The fundamental problem which remains is the gross inequality of our health system. This was well-illustrated a few months ago in a report by the Public Health Alliance of Ireland entitled, An Unequal State. The report showed quite dramatically that in terms of cardiovascular disease, cancer and infant mortality, those who are unemployed or have a manual job or are on the borderline of family income are far more likely to die prematurely than those working in professional fields. That is based on information we have. The Bill does not advance public information with regard to health statistics. Ireland is a decade behind the British in terms of the provision of a proper data bank of health statistics. However, the Public Health Alliance of Ireland report bluntly showed how unequal our society is with regard to health provision.

There are currently 70,000 to 80,000 medical cards in the system. The Public Health Alliance of Ireland's report pointed out that if a person is unemployed, working for the minimum wage or on borderline income, they will not get a medical card from this Government. The report indicated, across a range of indices, that we are still a grossly unequal society in terms of health provision.

In an article the Professor of General Practice at Trinity College Dublin, Dr. Tom O'Dowd, demonstrated, across the range of primary care provision, how people on low income and senior citizens are also left in a vulnerable situation.

The key problem in this is the conservative alliance in this House which has prevented the creation of an egalitarian and fair health system. The ongoing cynicism of the Government in regard to the health strategy and the promise of 3,000 additional beds, an end to waiting lists in two years and 200,000 medical cards is breathtakingly unbelievable and will have to be severely punished in 2006 when we will probably go to the polls.

Apart from the political problem, the other major problem is that of the controllers of the political process, represented especially by the consultant class. The best recent example is in regard to orthodontic treatment. Members have spent much time in the past decade making repeated representations to health boards, the Minister for Health and Children and various interests in the medical profession to try to deal with the spectacular waiting list for orthodontic treatment. Some months ago, some 21,000 children were waiting for treatment, with 11,500 further children on a treatment waiting list.

During the past three years, I received repeated replies from the former Minister for Health and Children, Deputy Martin, with regard to his plans. A report he presented to me in January 2004 is typical of many such reports in regard to orthodontics. The Minister's report refers to the establishment of a grade of specialist in orthodontics in the health board orthodontic services. At that time, there were 13 trainees for the public orthodontic service in addition to six dentists who commenced their training in 2001, making a total of 19 trainees. However, this came years after another former Minister, Deputy Noonan, had set in train a similar development for the training of consultants.

The former Minister, Deputy Martin, ignored the advice of a number of orthodontic professionals. I think in particular of Dr. Ted McNamara, who presented many Members of the House with an unbelievable story of how collusion between the Department of Health and Children and vested interests in the dentistry profession had prevented the creation of a public orthodontic service. Not alone did they do this but they basically smashed a service which already existed and was working well in the Mid-Western Health Board and Western Health Board regions, to such an extent that distinguished public servants resigned from the board of the Dublin Dental Hospital in protest at this disgraceful behaviour. The reports of Dr. McNamara and other professionals in orthodontics represent a shameful story and one to which I hope we will not have to return in the context of a tribunal of inquiry or an investigation by the Garda bureau of criminal investigation, given that it is alleged that serious damage was done to the teeth of the children and teenagers of Ireland due to collusion between the Department of Health and Children and vested interests in the orthodontics profession.

The net result is that anguished parents are still asking Members to assist with teenagers who have waited up to eight years on the A or B list but have been moved to the third list, which seems no longer to exist, and who have received a tough lesson in the provision of health services in this country. The Minister should reconsider this area because it seems a spectacular and clear case of vested interests, allied to incompetence and lethargy in the Department of Health and Children and the political conservatism of Fianna Fáil and the other conservative parties in the House, preventing the development of a modern health service.

The Bill is welcome. It is interesting that it is being taken at this time as we read yesterday of the collapse of a crazy and narrow decentralisation, or non-decentralisation, programme. Like you, a Cheann Comhairle, I believe profoundly in local and regional development. I believe Cork people are the most suited to run Cork, Munster people the most suited to run Munster, Connacht people the most suited to run Connacht and, in the same way, Dublin people are most suited to run Dublin. One of the Dublin's problems is that most of the time Dublin people have not run Dublin. Despite the Taoiseach putting on a blue shirt on occasion, on many matters he has let down badly those he makes out to be his own people, nowhere more so than in regard to the crazy decentralisation programme outlined by the former Minister for Finance, Deputy McCreevy.

For example, instead of locating the Department of Communications, Marine and Natural Resources in Rossaveal or-——

We are moving well away from the Health Bill.

I am talking about centralisation and it is a centralising Bill. Instead of locating a section of the Department of Communications, Marine and Natural Resources in Rossaveal, Howth, in my constituency, Castletownbere or one of the five national ports, it is located in Clonakilty. Other sections of the Department are located throughout the country. However, the Health Bill is an example of re-centralising. It tries to set out a simplified version of a national administration for a modern health service for 4 million people and to the extent it achieves this, I welcome it.

My major disappointment with the Bill is that there is not a more detailed section on information and health statistics. According to the health strategy, a separate board will provide us with basic information. However, the statistics available to our counterparts in the House of Commons enable them to know precisely, for example,cardiovascular death rates in any town in Britain, such as Manchester, which, although distinguished in other ways, has a terrible reputation in regard to health and is bottom of the league across a series of indices. We do not have access to such information and the Bill will not help to improve this. It will not help with regard to some of the fundamental problems in the Irish health services to which I referred. However, it may be a start in trying to achieve a more modern organisation and, to that extent, I welcome the Bill.

I wish to share my time with Deputies Finian McGrath and Kehoe, by agreement.

Is that agreed? Agreed.

The Tánaiste when introducing the Bill talked of it as historic legislation and of the original Health Act 1970 as ineffective. As the 1970 Act was introduced by a Fianna Fáil Government, I wonder what her colleagues in Government thought of this. Perhaps the Tánaiste was saying that changed times and circumstances mean we must reconsider the administration of the health services, a fact about which there is little argument in the House. However, the Tánaiste in surprisingly choosing to accept the position of Minister for Health and Children, which is seen as having the potential for political success, could also be looked upon as acting with some degree of political arrogance. She seems to think her particular brand of economic theory can work upon every type of social problem. The experience on this side of the House and of many others outside the Chamber is that the policies to which the Tánaiste refers often cause further inequality and divisiveness.

We therefore need to look critically at what is being proposed and why. The Tánaiste is wrong to accept from the previous Minister for Health and Children an emphasis solely on administration. If we are concerned about health care we must go back to first principles. We have to talk about greater degrees of health education, improving the lifestyles of our people, engaging in preventative and primary health care, and then talk of the investment needed in secondary, tertiary and other types of health care. Unfortunately the balance is all askew and that creates many of the current inequities in the health system.

The curious element of the Tanáiste's approach to the ongoing health crisis is that her proposals seem to suggest that the problems of what we recognise as being a two-tier health service can be solved by turning it into a four-tier health service. We will now have categories of people who rely totally on health insurance, others who rely neither on health insurance nor access to medical cards, another category which will have medical cards entitling them to doctor-only service but not to medicines or hospital care. We will also have people entitled to the full medical card service. That is the nature of the health care service proposed by the Tánaiste. She is choosing this particular administrative model to implement this in a manner which will worsen rather than improve public access to, and confidence in, our health care system.

The issues of accountability are paramount in this area. Most of the areas of health care I have listed from a health hierarchy point of view can and should be best dealt with at a local level. This Bill proposes a top-down approach to health care services. That is necessary only for the largest type of capital expenditure and the broadest type of policy initiatives. The Government is choosing to travel the big bang road towards dealing with our health crisis. Unfortunately it is not willing to back that up with resources. Inper capita terms we still rate lower than most European countries and the problems in our health service are about access, not necessarily about administration.

The most disturbing aspect of this Bill is that not only is the chief executive of the Health Services Executive wholly reliant on the political will of whoever the Minister for Health and Children is at a given time, but the parliamentary role of this Chamber in making that person accountable is being undermined in terms of how this person can and should be give evidence to Oireachtas committees. This is of particular concern with regard to the Committee of Public Accounts, of which I am a member, which has powers of compellability. The Comptroller and Auditor General has concerns as to how this Bill is currently worded in terms of the compellability to give all the necessary information on how public money is to be used by this new agency. That might be compromised unless changes are made. I look forward to seeing the Government critically examine the Bill to ensure that the tiny level of accountability in this Bill can be made more real by the time it comes to Report Stage.

I thank the Ceann Comhairle for the opportunity to speak on this new and important legislation. I welcome the debate on the urgent need to reform our health service and I enter the debate with an open mind. I recognise the need for change, reform and investment. If this Bill means reform plus investment, I am interested in being positive and constructive in the interests of patients, staff and the taxpayer. I am not merely going to use our health service as a political football or an issue to score points if I have a serious input into changing and improving the service. That is my bottom line — change, improvement and investment.

I hope that the health service can deliver more effectively and I am not one of those who say that we can do nothing about the hospitals, our accident and emergency units, our elderly, those with disabilities, and other issues related to the health services. It is a question of choices and priorities. Are we serious about making health a top priority and are we prepared to make tough decisions to fund the health service? These are not easy decisions and may not be popular, but if anyone comes up with constructive proposals or ideas to deal with these important matters, I am open to their views, and this debate can thus be very positive.

I cannot accept that after seven years in power, and massive wealth in our society, people should have to wait in trolleys and chairs in accident and emergency units. An immediate problem is the shortage of 300 beds. That is why I welcome the decision in the Estimates to provide an extra 300 acute hospital beds and to free up of another 100 beds. That is a start but the momentum needs to be continued. I also welcome the extra €20 million to be spent on reducing hospital waiting lists. We all support those ideas, but can the Minister deliver on the promises? That is the test, and a marker for the new Health Services Executive. These improvements should take place within about three months; if not, this Bill means nothing. People are fed up with excuses and with waiting. Our citizens are fed up with all the talk and debate on the issue.

Looking at the details of the Bill, it provides for the reform of the health service management structures. This is a welcome development and something that needs to be done. Out-dated practices must change. Two days ago a number of my constituents receiving speech therapy services in the Drumcondra area received letters from the Northern Area Health Board informing them that those services would be suspended on 30 November. They were horrified and shocked by this treatment because of a row about premises. When I raised this matter in the Dáil yesterday under Standing Order No. 31, and issued a statement, the health board climbed down within a few hours and has now guaranteed the service, which will continue in Whitehall and in another venue. The handling of this issue by the management of the Northern Area Health Board and the threatened suspension of the speech and language services at the Drumcondra location were disgraceful. It is good that the families involved received individual letters at their homes this morning and that the board apologised for the inconvenience caused. I raise this matter because it is relevant to the reform of our health service and the formation of the Health Services Executive.

Looking at the broader issues, when Imelda Marcos was the first lady of the Philippines she had a dream. She wanted to turn her country into the world capital for heart transplant operations, an admirable aspiration. The problem was that to achieve her ambition she proposed to divert almost all of her country's health budget to finance the state-of-the-art facilities. As a result the budget for primary health care for the entire population would have been on a par with Imelda Marcos's personal shoe budget. Her grandiose plan had to be shelved on foot of the tidal wave of outrage generated by her proposal. It was almost universally accepted that treatment for the privileged few should not be at the expense of the impoverished many.

There is an ongoing tension in the health care system between the right decisions from an economy viewpoint and those from an ethical viewpoint. Successive Ministers for Health and Children boast about the amount of money spent on our health service. Although most civilised societies espouse the concept of equality for all, this ideal rarely corresponds with the reality. Issues in the allocation of resources for and within health care are arguably the most difficult issues facing us today. As a former teacher I am acutely aware that we also have major allocation decisions to make in education if we are to ensure that our education system is to be an instrument of equality. In health care and in education, situations present themselves in which decisions must be taken and alternatives selected which will bring advantage to some and may leave others disadvantaged. A political ideal or a constitutional right might assert that every person has an equal claim to health and education but this aspiration is not always realised in Ireland. Choices must be made about which patients and treatments are to be given priority, and which students will go to university. In a situation where there seems to be a contradiction in making certain choices, then in order that fair treatment may be given to all it is essential that we consider, however tentatively, the ethical grounds on which to make such choices. There is both an economic and an ethical dimension to the problem of allocation. This Bill has the potential for change. There are many aspects of it that can be developed to improve the services but the bottom line is, there is no point establishing a Health Service Executive if we do not introduce change along with investment. Trying to introduce change in the health service without any investment will do nothing for the patients on trolleys and chairs.

I welcome the opportunity to speak on this important Bill. We owe it to the citizens to provide them with an extremely good health service, which this Bill has the potential to do. However, it is up the drivers behind the Bill to ensure changes are made to improve the lives of everybody. Despite the Hanly report and the plans the former Minister, Deputy Martin, had for hospitals throughout the country, poor people are being left behind when it comes to health care. People are now waiting to get on waiting lists while those on waiting lists must wait three to four years for treatment.

An old lady with cataract problems came into my clinic two or three months ago. She had been waiting for an operation for the past two years and had a very genuine case. I pursued her case, made representations and we finally got her into hospital. However, when that poor lady got into hospital, it was too late and, as a result, she will have dysfunctional eyesight. She will be unable to look at television and read the newspapers because her operation was too late. If she had been seen perhaps four or five months earlier, it might have been a different story. If this Bill had been implemented a year ago, would this lady be in the same position? I believe she would be.

The Government talks about the great economy, the Celtic tiger and the boom years yet our health service has not got any better. We all know the amount of money pumped into the health service since 1997 when this Government first took office. It has spent millions of euros, which I do not deny. However, will the management structure proposed under this Bill protect the rights of citizens and will it be able to spend the money wisely as it has not been spent to date?

I have one major problem with the Health Service Executive. When I ask the Minister for Transport a question about the National Roads Authority — I use the NRA as an example because previous speakers mentioned it — he states that he has no direct responsibility. I hope the Tánaiste, or whoever is Minister for Health and Children in the next couple of years, will not state that he or she does not have day to day responsibility for the health service and that it is up to the Health Service Executive to make the call.

The chief executive of the South Eastern Health Board, Mr. Pat McLoughlin, has met Oireachtas Members from the south east twice a year. However, I will not have that same opportunity to meet the new Health Service Executive twice a year to discuss what is happening in the South Eastern Health Board area. That is not good for the health service.

In the late 1990s or early 2000, Wexford General Hospital was promised a 70-bed unit under the national development plan. Some 19 beds were to be fast tracked because they were needed as soon as possible. However, we are still waiting for those 19 beds. Will the chief executive of the new Health Service Executive be able to provide those 19 beds? I do not believe he or she will. That is the type of issue the Government will face in the next couple of years. Will this Health Bill deliver? I do not see it doing so. The Government has a great opportunity and has been making plans and it is up to it to deliver.

I thank the Deputies for their contributions on this important legislation. The Tánaiste pointed out in her opening speech that the legislation provides for the complete reform of the organisation and management structures of our health services — the first substantial and fundamental reform for more than three decades.

We do not accept that the legislation is being rushed through the Houses without consultation. The Government announced the reform programme 18 months ago and the need for this legislation has been well signalled in the intervening period. This Bill is the second of two Bills to be brought to the House this year in regard to the Government's plans for structural and organisational reform of the public health services.

As recently as April and May last, the House discussed the Health (Amendment) Bill 2004. As Deputies will recall, it was an interim measure to fast track the reform programme. That 2004 Act is part of the legislative arrangements necessary to underpin the reforms. In that context, the then Minister went into considerable detail about the reform process and the arrangements to be put in place going forward. He specifically informed the House of plans for further legislation, such as that before us, which would: establish the Health Service Executive; make provision for improved governance, accountability, planning, monitoring and evaluation; introduce a statutory framework for the handling of complaints and provide for democratic participation at regional and local levels under the new structures. The Government is not springing any surprises on the House under the Health Bill 2004. The changes involved have been well explained and communicated publicly and have been specifically previewed in this House.

Communications and consultation have been at the core of the health reform process going back to the national health strategy, Quality and Fairness, in November 2001. Immediately after the Government decision on the health service reform in June 2003, the Secretary General of the Department briefed political parties on the proposals.

From the beginning, the process has involved an open discussion. The Prospectus and Brennan reports were published in June 2003 and laid before the House. At that time, 100,000 copies of an explanatory booklet entitled The Health Service Reform Programme outlining the reforms were issued, especially to those working in the health system. The then Minister for Health and Children, Deputy Martin, and the Secretary General of the Department visited each health board area to meet and discuss the reforms with the staff. Simultaneously, an extensive consultation and communication process was under way.

Following this initial process, the Department commissioned the office for health management to conduct an information and consultation exercise reaching as many people and agencies as possible. More than 20,000 staff were directly engaged over the summer months and into September 2003. This included staff and representatives of the ERHA and health boards, the voluntary hospital and disability sectors, the community and voluntary pillar, the trade unions and the Department of Health and Children itself. The office of health management produced a detailed report of this process that was published earlier this year.

The meeting of the national consultative forum in November 2003 focused on the health service reform programme. Other communication and consultations included publications on the health reform website and steps taken by the interim Health Service Executive to inform health service staff of developments as they occurred.

It is inaccurate to state that this Bill does not provide for accountability by the executive. A key objective of reform in the health system, as identified in the Prospectus and Brennan reports, involves the separation of policy and operational responsibilities. The result will be greater clarity, transparency and accountability around who is responsible for doing what in the health system. The establishment of the Health Service Executive, as a single entity with statutory responsibility for the management and delivery of health and personal social services, is the central plank in this important process.

The Tánaiste is very strongly of the view, as am I, that the executive should be as widely and directly accountable as possible for its decisions, plans and actions in regard to its statutory functions. Such an approach is central to ensuring the highest standards of service are achieved and maintained. It is the Tánaiste's intention that this should be reflected in the quality of service that the executive will provide to Members of the Oireachtas in responding to queries and providing information about the management and delivery of health and personal social services, whether at national, regional or local level. This is an important aspect of the executive's work and represents a key element of the vibrant, high-quality customer service arrangements required.

In that context, the executive must establish an effective system of rapid response to inquiries from politicians and the public, establishing systems capable of reaching down into the organisation and rapidly retrieving the necessary information from the authoritative source. This is only one of the potential benefits of streamlined administrative arrangements under the reform process. It is an aspect in which both the Tánaiste and I have a particular interest, not just in the context of the Bill or as a Minister or Minister of State, but as a public representative.

Deputy Ring asked what form the answer to a parliamentary question will take in the future. There will be no change with regard to the practice of parliamentary questions. As matters stand, it is frequently the case that the Minister for Health and Children refers the questioner to the chief executive officer of the relevant health board.

It often takes six months to get an answer to such an inquiry. That is the problem.

There will be no change in the format of replies to parliamentary questions, as Deputy Ring seemed to fear.

This does not represent reform.

I emphasise the Tánaiste's commitment and mine to ensure, as part of this reform process, the new executive provides speedy responses to the queries of public representatives.

I have raised Deputy Ring's question to illustrate the nature of the difference that the Health Service Executive will make. Consider, for example, the current situation of a Deputy who has the privilege of being elected in this city. He or she must transact business with a significant number of authorities to acquire any information about the health and social services in the city. The streamlined administrative arrangements provided for in the Bill will effect a fundamental transformation in this arrangement.

The interim executive is aware of, and making plans for, the proper and effective discharge of its serious responsibilities in this area. Earlier this month, it announced that the overall structure of the executive would include an office of the chief executive officer and a corporate affairs directorate, and that responsibility for the important function of managing parliamentary affairs would be assigned by the CEO to one of these central governance areas. As we move forward, the operation of the executive's arrangements will be monitored closely and reviewed as necessary.

The provisions of section 10, which provides that the Minister may give directions to the executive and that the executive shall provide any information and statistics required by the Minister, and the provisions relating to the production of service plans by the executive, are strong accountability provisions. The Minister is politically responsible for health services to the Oireachtas. In line with the recommendations of the Brennan and Prospectus reports, the executive will be responsible to the Minister for the management and operation of the health services. The Department will be responsible for supporting the Minister and the Government in all policy matters. The lines of accountability are clear and transparent and do not leave room for non-accountability at any level.

The Bill establishes regional forums which will comprise members of city and county councils. These forums will have an important role within the new structures. They will afford local public representatives the opportunity to make a major contribution in the development of services within their region.

They will also afford them the opportunity to claim expenses.

The advisory panels are critically important as they will allow local communities and other groups to be involved in shaping a client-centred service. Such advisory panels were recommended in the health strategy, which also recommended that they should be set up on a more structured basis.

A number of Deputies raised the issue of the membership of the board of the HSE. As the Tánaiste recently announced, the current executive chairman of the interim executive, Mr. Kevin Kelly, has been appointed as interim CEO of the executive from 1 January 2005 and until a new CEO is appointed. Consequently, Mr. Kelly will step aside as chairman of the interim executive and the Tánaiste has requested the board of the interim executive to bring forward recommendations regarding his successor. Subject to the foregoing, the existing members of the interim executive will be invited to act as appointed members of the board of the HSE.

The Tánaiste shares Deputy McManus's view that the issues of information and quality standards are critically important to these reforms. This is why the establishment of the Health Information and Quality Authority was recommended in the reform programme. If we are to have accountability in the health service, we need access to information on the standards of services provided by the executive in order to ensure that we are getting value for the large amounts of taxpayers' money invested in the health services.

Why is this information not already available?

As already stated, the main reason we are proposing this legislation, and indeed the whole reform programme, is to ensure better outcomes for patients. We can only do this if quality is embedded at every level in the delivery of the services received by patients. The Health Information and Quality Authority will play a vitally important role in setting standards for the delivery of quality services. It will also have a pivotal role in implementing the national health information strategy that complements the national health strategy. The Tánaiste will bring forward further legislation early in 2005 to provide for its establishment and to address other issues arising from the national health information strategy. Mr. Pat McGrath has been appointed chairperson and arrangements are under way to establish an interim authority. The next step will involve the appointment of the other board members.

A number of Deputies raised concerns about the complaints framework proposed in the Bill. This framework conforms to the commitments in the health strategy. One of its most important features is that the Ombudsman and the Ombudsman for Children can still deal with situations where people are dissatisfied with the outcomes of their complaints or reviews. For that reason, the legislation must be compatible with the legislation underpinning the Ombudsman's office and the Ombudsman for Children's office. It is not possible, therefore, to provide for the investigation of clinical issues. These issues are, in any event, properly within the province of the Medical Council.

Deputy McManus contended that there is no specific definition of health and personal services in the Bill, but that the definition referred to a list of Acts in the legislation. All the Acts listed in Schedule 1 confer functions on the health boards. The significant number of Acts listed indicates that the functions and responsibilities of health boards are much more than just the provision of health services. Many of the functions under these Acts relate to important public health protection functions, such as those arising from the Rats and Mice (Destruction) Act 1919 which was mentioned by Deputy McManus. The functions and responsibilities under these Acts will now transfer to the executive on its establishment. It will be required to carry out those functions, including the public health functions, as part of its objective to "protect the health and welfare of the public".

That does not answer my question.

I have dealt with Deputy McManus's question.

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

This issue will be raised on Committee Stage.

Yes, it can be dealt with on Committee State as it is a committee point.

A contention was made that this Bill would not provide for extra services. The Bill is concerned with reform of the organisation and management structures of the health service. Regarding extra services, only last week the Tánaiste announced an increase of €950 million for health in the Estimates, bringing total spending on health to €10.5 billion, an increase of 9.9%. This funding will provide for more and better services which will be more effective because of the reform programme.

New units in hospitals will be opened and cancer services expanded. Waiting times for patients will be further reduced by additional funding provided to the national treatment purchase fund. Some 1,000 new front-line staff will be recruited next year to provide services to people with disabilities. Some 300 new beds will be available in public hospitals next year, in addition to those in the new acute medical units. The new management structures will support these extra services and increase their efficiency and effectiveness, which will deliver increased patient satisfaction and better outcomes.

I cannot agree with Deputy McManus's proposal that a national hospitals authority be established to deal with the hospital sector, and health boards be established to deal with provision of community care. This would inevitably lead to less co-ordination of services and this lack of co-ordination between the services has been the cause of numerous complaints over recent years. We are seeking, through the establishment of the executive, to move to a more co-ordinated service, not a less co-ordinated service. That is why one of the requirements being placed on the executive, under section 7, is the integration of the delivery of health and personal social services. I have previously considered the issue raised by Deputy McManus, which seemed a proposal worthy of examination. However, the general medical service, the primary care service and services for persons with mental health difficulties are all based in the community, under the authority of the health boards. It is difficult to draw the line between what happens in hospital and what happens with regard to health services in the community. For those reasons, the Tánaiste and previous Minister took the view that the best course of action was to have a unified administrative structure, encompassing the various health and social services.

I must clarify the issue raised by Deputy McManus regarding the filling of 22 posts by the health boards since March of this year. As the Tánaiste pointed out in her reply to Deputy McManus's parliamentary question, the 22 posts approved are either key management posts for the delivery of patient services or concern important areas of health services. It was considered necessary to fill these posts for the maintenance or the continuity and quality of service provision in the health services, in the context of the transition to the new administrative structures.

This is the first comprehensive reform of the structures of the health service for more than 30 years. It is not a reform that is being entered into lightly. The studies which were undertaken to arrive at the recommendations in the reform programme have been outlined to the House. Following the announcement of the reform programme, a comprehensive communications and consultation exercise took place to inform all those involved in or affected by the proposed reforms.

The Bill before the House represents a culmination of that process. It represents the beginning of a new era in the management of health and social services. We have had the opportunity with the legislation to put in place a modern and effective organisation and management structure which will provide for a health service to meet the needs of those who live in our country in the 21st century.

Question put: "That the words proposed to be deleted stand part of the main Question."



In accordance with an order of the Dáil of 25 November 2004, the division is postponed until immediately after the Order of Business on Tuesday, 30 November 2004.