Health Service Executive (Governance) Bill 2012 [Seanad]: Second Stage

Minister for Health (Deputy James Reilly)

I move: "That the Bill be now read a Second Time."

I note there is no member of the Opposition present but so be it. I welcome the opportunity to bring the Health Service Executive (Governance) Bill 2012 before this House. There was a good debate on the Bill in the Seanad and I am sure it will be similarly debated in this House.

The programme for Government commits to the most radical reform of our health services in the history of the State with the goal of a single-tier health system, supported by universal health insurance. That reform programme requires significant change across the entire spectrum of our health system not only in structures but also in attitudes and cultures. A core element of the process overall is to identify the building blocks that are necessary to bring us from where we are now to where we want to be in terms of our vision for a new health system. The vision which springs from the programme for Government is set out in Future Health: A Strategic Framework for Reform of the Health Service 2012-15. It charts the Health Service Executive (Governance) Bill as one of those building blocks.

I am taking a hands-on approach to transforming the health service and that is delivering real results such as 3,706 adults who were waiting more than nine months for inpatient and day case surgery at the end of 2011 now having that list reduced to just 89 adults. That is a reduction of 98% in a single year at a time when we were told by Deputy Caoimhghín Ó Caoláin that we would not be able to maintain a safe service because of the reductions in numbers of staff and in the budget. There were 1,759 children waiting over 20 weeks for an inpatient or day case surgery at the end of 2011. Within a year that list has been reduced to 89 children, which is a 95% reduction in a single year. There were 4,590 patients waiting over 13 weeks for a routine endoscopy procedure at the end of 2011. Within a year that waiting list was reduced to 36 patients. That waiting list has been cut by 99% in a single year. These are real and measurable results, and we reduced the number of people lying on trolleys by over 20,000 but more needs to be done, and it will be done. This Bill is an integral part of that.

Deputies will be aware that the programme for Government envisages that the Health Service Executive, HSE, will eventually no longer exist as its functions move elsewhere under the health reform programme. The HSE is a large, complex organisation providing services that are of fundamental importance to the individuals who receive them. Accordingly, its abolition as an entity will take careful planning, sequencing and complex further legislation. It must be done right and at each step it will be crucial to ensure that there are robust governance, management and accountability arrangements in place to drive, manage and monitor implementation of the reform programme.

It is important to remember that the HSE was formed under Deputy Micheál Martin's stewardship of the Ministry of health. It certainly was not formed in a manner that was remotely ideal. The welding together of 11 different health boards and a shared services unit, ensuring that everybody not alone kept their job but stayed in the same job as part of the conditions, was always destined for failure because no attempt was made at real reform. No opportunity was taken in those years, when the country had money, to reorganise the health service, reorganise the administration and grow the necessary management.

This Bill is intended as a transitional measure. It does not abolish the HSE or change its legal status under the Health Act 2004 which established the executive. Its main objective is to bring greater focus on service delivery and ensure more accountability during the time the HSE continues in existence. While it is a transitional measure, it is nonetheless fundamental as a key step in the reform process. To correct any misapprehension, the board of the HSE has not been abolished but this legislation will abolish it.

Under the Health Act 2004, the HSE board is the governing body of the HSE. In 2011, I made changes to the composition of the board designed to facilitate greater co-ordination and integration between the senior management teams in my Department and the HSE. I believe this has facilitated a greater unity of purpose. That unity of purpose between the HSE and my Department will continue. However, when making changes to the board, I signalled I would be introducing legislation to abolish the board structure and establish new governance arrangements for the HSE, pending its eventual dissolution. These changes are in the Bill now before the House.

The Bill abolishes the board structure of the HSE under the Health Act 2004 and provides for a directorate, headed by a director general, to be the new governing body in place of the board. This new structure is designed to help prepare service delivery for the next phase of the health reform programme. The Bill's other purpose is to provide for further accountability arrangements for the HSE. In line with health reform policy, the Bill is intended to make the HSE more directly accountable to the Minister for Health, who in turn is accountable to the people through the Oireachtas.

Several necessary technical amendments are also being made to the Health Act 2004 to take account of the replacement of the board structure by the directorate structure. The HSE has legislative responsibility for the organisation and delivery of health services. Under the Bill, as the governing body, the directorate has authority to perform the HSE's functions. The directorate will consist of a director general and other directors. A director is appointed to the directorate by the Minister and is known in the Bill as an appointed director to distinguish him or her from the director general. To offer flexibility and allow the size of the governing structure to adapt to changing circumstances, the Bill does not specify a fixed number of members for the directorate but instead provides for a maximum of seven and a minimum of three members, including the director general, who is automatically a member and the chairperson of the directorate.

The Bill provides that other members of the directorate - the appointed directors - must be HSE employees in the senior grade of national director. To clarify, this means that appointed directors may be drawn from among any HSE employees holding the position of national director, irrespective of when they took up that grade. My officials and the director general designate are exploring whether the membership of the directorate might be widened to include other members of senior management, such as the chief financial officer. Such a proposal, if adopted, would have no financial implications.

Separately from the Bill but in support of the new directorate structure and new administrative structure, the HSE has already initiated the process of putting in place the new HSE directorate management and leadership team. The recruitment process for five new national directors has now commenced through a competitive process to be run by the Public Appointments Commission. The five new national directors will be responsible at national level for the delivery of services in the relevant service domain for hospitals, primary care, mental health, social care and health and well-being. They will lead the development of national service plans associated with their sector, manage performance and, in time, develop strategic commissioning frameworks for their areas as appropriate. In addition, arrangements are being made to establish three other key senior positions: chief operations officer, chief finance officer and director of shared services.

The HSE will continue to have operational responsibility for running the health service, but accountability is strengthened. The Bill provides that the directorate is accountable to the Minister for the performance of the HSE's functions and its own functions as the governing authority of the HSE. The process will be that the director general accounts on behalf of the directorate to the Minister through the Secretary General of the Department. In this way, the HSE will be required to account for its actions and decisions. This adds to existing accountability arrangements under the Health Act 2004 for service plans, annual reports, codes of governance and the provision of information to the Minister.

The Bill also strengthens accountability arrangements in the 2004 Act by providing that the Minister may issue directions to the HSE on the implementation of ministerial and Government policies and objectives relating to HSE functions where the Minister believes the HSE is not having sufficient regard to such objectives or policies in performing its functions. In addition, the Minister will be able to specify priorities for the HSE to which the HSE must have regard in preparing its service plan. The Minister may establish performance targets for the HSE in regard to these priorities. However, directions, priorities and targets may not be specified with regard to individual patients or service users.

As is the case currently for the chief executive officer, the Bill provides that the director general will be the accounting officer for the HSE. This is a temporary arrangement, as my intention is to return the Vote to the Department of Health from 1 January 2014. At that point, the director general will no longer be the accounting officer. This will require further legislation to disestablish the HSE Vote and fund the HSE through the Vote of the office of the Minister for Health. In the meantime, the Bill has new provisions for a statutory audit committee, which will report in writing to the director general and provide a copy of that report to the Minister.

Part 1 contains the standard provisions dealing with the Short Title, commencement and definitions. It also provides for the repeal of those parts of the Health Act 2004 providing for the board and chief executive officer structure. Part 2, sections 4 to 22, inclusive, contains provisions to amend the Health Act 2004 to reflect the new directorate structure and accountability arrangements. Some of the key elements are sections 5 to 7, inclusive, 12, 14 and 17. Section 5 amends section 10 of the Health Act 2004, dealing with directions from Minister. The section in question currently allows the Minister to give general written directions to the HSE regarding the Act. The Minister can give specific directions in regard to the submission of reports and the submission of information on the performance by the HSE of its functions. That section is amended to provide that the Minister may also give general written instructions to the executive concerning the implementation of any policy or objective of the Minister or the Government which relates to a function of the HSE, where the Minister is of the opinion that the HSE is not having sufficient regard to such policy or objective in the performance of its functions.

This new power in section 10(1)(c) balances the Minister's responsibility for policy with the HSE's responsibility for operational matters. The HSE has responsibility under the Health Act 2004 for the provision of health and personal social services. However, the HSE also has a statutory obligation to have regard to ministerial and government policies and objectives when performing its functions. Directions under section 10 may not be made for individual patients or service users.

Section 6 inserts two new sections, section 10A, setting of priorities by Minister, and section 10B, limitations on the exercise of power under section 10 and 10A, into the Health Act 2004. Under section 10A, the Minister will be empowered to determine priorities to which the HSE must have regard in preparing its service plan and also to establish performance targets for the HSE. Before specifying priorities or performance targets under this section, the Minister must have regard to best practice for the service that is the subject of the priority or performance target, outcomes for patients and recipients of services likely to be affected by the priority or performance target, and the effect that specifying the priority or performance target would be likely to have on other services provided by or on behalf of the executive. Again, priorities and targets will not apply to individual patients.

Section 7 inserts a new Part 3A into the 2004 Act to provide for the establishment of the new governing authority for the HSE, the directorate. This new Part will form sections 16A to 16M, inclusive, of the Health Act 2004. Section 16A provides that the directorate will consist of a director general and other persons referred to in the Bill as appointed directors.

Section 16B sets out the detail relating to the term of office of an appointed director. The term of office for a member appointed to the directorate is three years and he or she may be reappointed by the Minister for a second or subsequent term. I have outlined that appointed directors will be drawn from employees in the grade of national director in the HSE. An appointed director will cease to be a member of the directorate if he or she ceases to be a national director in the HSE.

Section 16L makes arrangements for the appointment of a director to the directorate on a temporary basis to cover the extended absence of an appointed director, because of illness, for example. As the Bill stands, if the national director for hospitals was an appointed director and he or she was on extended absence owing to illness, the Minister would not have the flexibility to appoint that national director's second-in-command to act as a temporary member of the directorate under section 16L, even where it made sense to do so for the duration of the absence. I will table an amendment on Committee Stage to address this issue.

Section 16C sets out the role of the directorate which will have collective responsibility as the governing authority for the HSE and the authority to perform the HSE's functions. Subject to directions of the Minister, the directorate may delegate HSE functions to the director general. The section also sets out the accountability arrangements to the Minister, to which I referred.

Section 16D sets out eligibility requirements for appointment and reasons for removal from office of persons appointed to the directorate. These are similar to the provisions in other legislation on board appointments and removals.

Section 16E provides for the appointment by the Minister of the director general. Under section 16E(4), the first director general is appointed by the Minister and subsequent directors general will be appointed by the Minister following a recruitment process under the Public Service Management (Recruitment and Appointments) Act 2004. Section 16F sets out the eligibility requirements for appointment as director general and the circumstances whereby the director general may be removed from office.

Section 16G provides for the general functions and role of director general. These include managing and controlling the business of the HSE. In the operational aspects of his or her role, the director general is answerable to the directorate as the governing authority of the HSE. On a day-to-day basis, national directors, even if appointed as members of the directorate, will be accountable to the director general for the performance of their functions as employees of the HSE.

Section 16H sets out the arrangements for the delegation of functions by the director general. This will be subject to directions from the directorate. A key objective of the new HSE governance arrangements is to facilitate a system whereby authority to make operational decisions is delegated as close as possible to the point of service delivery. To that end, delegated functions may be sub-delegated, as set out in section 16H.

Section 16I provides for the attendance by the director general before Oireachtas committees. Other aspects of section 7 deal with procedural and related matters for the directorate.

Section 12 amends provisions in the 2004 Act with regard to service planning. Currently, the HSE prepares a service plan in line with certain requirements, adopts the plan and submits it to the Minister for approval. The Minister must either approve the service plan or issue a direction to amend it if requirements are not met. The 2004 Act is being amended to provide for the HSE to prepare a plan in line with current criteria and take account of priorities determined and targets set by the Minister. While the Minister may direct the HSE to amend the plan if requirements are not met, the Minister may now amend the plan following consultation with the HSE also. Section 14 provides for the 2004 Act to be amended in order that the Minister may direct the HSE to take specified measures on implementation of the plan.

I have referred to section 17 which provides for the director general to be the accounting officer and sets out provisions for a new statutory audit committee. Other sections in Part 2 deal with technical amendments to the Health Act 2004 consequential on the establishment of the directorate.

Part 3 has the standard provision for savers following the repeal of sections relating to the board and chief executive. There is express provision in the Bill for the Minister for Health to consult the Minister for Children and Youth Affairs before specifying priorities or performance targets in respect of functions of the executive that relate to the functions of the Minister for Children and Youth Affairs. There is also reference to the Minister for Children and Youth Affairs in the provisions dealing with service planning. These are transitional provisions pending the establishment of the Child and Family Support Agency and the transfer of certain HSE functions to that agency.

At the beginning I spoke about building blocks. The Bill is only one element of a major legislative and administrative reform process under way aimed at ensuring a better health service for everyone. Ultimately, the reform programme is about the patient and a health service that delivers quickly and effectively for that patient according to his or her needs. As long as the Oireachtas keeps the focus on the outcome for patients, we will not go too far wrong in our aspirations to realise the health service to which we all aspire, one in which every service user can feel safe and of which every worker can be proud. I commend the Bill to the House.

Deputy Billy Kelleher

I welcome the opportunity to speak on the Bill. Discussion has taken place in the Seanad where we did not oppose the Bill on Second Stage. However, having read it and given what has occurred in the intervening period since the Seanad debate and the position in terms of the provision of health care, I have some concerns. There was an issue with budgets last year involving a failure to address a budget deficit early in the year. This allowed an escalation to occur to the point where there were cuts to the numbers of home help hours and personal needs assistants. There was then a reversal of some of these cuts. However, everything that flowed from this leads me to being concerned about bringing responsibility for the delivery of health care services back into the Department under the Minister. I have grave concerns for several reasons.

I accept that any Minister of Health and the Government have an obligation, a duty and a right to set policy and the broad framework for health care provision. However, I am concerned that there could be politicisation of the delivery of health care services. This is an issue of concern for several reasons. Every Member in the Chamber will advocate for his or her constituents and those in surrounding areas; that is his or her duty as a representative. However, let us consider cancer care services and the national cancer strategy. It received political support, but it was not political in its implementation. Strategic decisions were based on best advice, best practice and best clinical outcomes. There was strong opposition in the Chamber and among the Government parties that supported the policy. Ministers held strong views on the matter. However, responsibility for implementation of the policy was taken from the hands of politicians, something about which I have major concerns. Now, it appears we will politicise the delivery of health care services rather than the policy, something which could have a detrimental impact on health care provision. What will happen? On several occasions the Minister has stated it is his right and entitlement and he can argue the case, but whoever is sitting opposite will have extensive powers in deciding on health care provision, where services should be located and the funding of same. This is an issue is of concern in the context of the Bill.

The Minister has stated this is a transitional arrangement, which I accept. He has referred to the abolition of the HSE in 2014 and subsuming the service into the Department and to a system of universal health insurance flowing from this. He has spoken about hospital trusts to be established, to be underpinned by the small hospital framework and universal primary care access. However, we are two years into the life of the Government.

The basic foundation block is funding, which we have yet to put in place. There are many legislative changes being made to subsume the HSE into the Department of Health, but we are no clearer on how the process will be funded. After two years, we have still not seen the White Paper on universal health insurance. The Minister made commitments on the Dutch model, which was in his view the ideal arrangement to fund health care. A cursory look at the Dutch model reveals that it is under significant stress with significant funding issues beginning to emerge. We have seen a drop in the number of health insurers and a concomitant reduction in competition. Insurers are finding it difficult to fund and provide primary care. We are deciding to go headlong into the stacking of building blocks without having laid the foundation of funding. It is to put the cart before the horse. If we were to support the legislation, it would have to be on faith in respect of many of its provisions.

The Minister alludes always to his mandate. He has had a mandate for many things. He had a mandate to introduce universal health insurance and, equally, free universal primary care. He had a mandate to maintain Roscommon County Hospital and Our Lady's Hospital, Navan. He had a mandate to abolish the prescription charge. While the Minister has decided to row back on certain of his mandates, he is rushing headlong in respect of others without outlining how they are to be funded. Funding is clearly the issue in respect of which I have significant concerns.

The legislation gives the Minister sweeping powers. The director general will be subservient to him. While it is right and democratic that the director general should be accountable to the House, the Minister will have sweeping powers over the implementation of policy, which will be politicised. Many people are concerned about that. If we had politicised the cancer care strategy, parts of which the Minister opposed in Opposition and parts of which he welcomed, it would not have been brought to fruition. While people in Letterkenny and Sligo have concerns about it, it was implemented with political support and without political interference. The Bill is in direct contrast. Not only does it provide sweeping powers to the Minister to decide policy, it empowers him to dictate the implementation and delivery of health services.

Deputy James Reilly

That is not true.

Deputy Billy Kelleher

It is true. Section 16 provides for powers of appointment and for setting policy and makes the director general accountable and answerable to the Minister in all cases except in respect of individual service providers and patient outcomes. The Minister will have absolute power to decide the location and funding of services. It was only last September that the House had a debate which saw a Minister of State resign because the Minister decided, as he said was his right, to put two primary care centres in his own constituency. The Minister had no credible reason to do so other than that it was his constituency. If Deputy James Reilly was the Minister for Transport, all trains would go to Balbriggan and all buses to Swords as a result of his parochial thinking.

Deputy James Reilly

They were already in the plan, as the Deputy well knows.

Deputy Billy Kelleher

That is the issue about which I have a concern, as do many other people. We have also seen what happened in respect of St. Luke's Hospital and Wexford Hospital. I highlight these cases to show that as matters stand, politicisation takes place. The Bill creates circumstances in which the provision and location of services will be fundamentally in the gift of the Minister. Such decisions will not always be based on best clinical outcomes or strategy, but on political reasoning. We are creatures of politics who think about votes when we make decisions in the House. The national cancer strategy would have been torn to shreds had it been left to the House to decide where services should be provided. Notwithstanding that there are concerns among people in Letterkenny and Sligo, most people will accept that the national cancer strategy under Professor Tom Keane was very successful. It has delivered positive clinical outcomes and used resources effectively and efficiently because it was not politicised. In his short time in office, the Minister has politicised the delivery, funding and location of health care services. It is there for all to see.

The legislation represents a transitional arrangement following which the HSE will be subsumed into the Department in its entirety. We continue to await the White Paper on universal health insurance. I hope the Minister will indicate when it will be published. It is of critical importance. While the Minister claims to have a mandate to provide for universal health insurance, we still do not know how much it will cost. We have no idea what measures the Minister will propose. The structures being put in place are based on something about which the Minister does not yet know anything. It is something about which no one knows anything and regarding which we will have to have a very long think. The Minister is talking about not only a restructuring but a fundamental shift in the way we fund health care services.

Only today, the VHI announced it will increase the cost of private health insurance cover by 6%, which may cost the average two-parent, two-children family up to €300. The Minister may talk about universal health insurance, but his policies to date have acted as a counterweight to its introduction. The Minister should seek to make private health insurance more affordable to encourage people to take it up. We made the point in the context of debate last year on the Health Insurance (Amendment) Bill that no policy is emanating from Government to negate the massive inflation in the cost of private health insurance to make it affordable. Families are being put under enormous pressure to sustain private health insurance and in some cases are dropping out. The figures demonstrate this trend. It will put further pressure on the public health system as those people will have to be treated in any event. An income stream is being diminished and further pressure is being put on the public health system.

If the White Paper were published, it would be a starting point to stimulate a debate on how health provision will be funded in the years ahead. We have seen officials travel to Germany, Holland, Canada and the United States of America. They have been all over the place seeking to find a universal health model which fits the Minister's view and is suitable for implementation in Ireland. We are two years down the road and making legislative changes to fit the model without having put in place the foundations on which can be placed the building blocks of the Minister's reform projects.

It was the first time I ever heard about a benchmark position whereby the Minister decided 13 weeks would be the benchmark.

Acting Chairman (Deputy Terence Flanagan)

The Minister can respond later.

Deputy Billy Kelleher

Talk about inventing lists he knew he could easily get rid of. A period of 13 weeks was never the benchmark in the first place in respect of waiting for that procedure.

Deputy Jerry Buttimer

We will set up a committee like Deputy Martin did.

Deputy Billy Kelleher

I am trying to point out that in terms of the delivery of health care in this country, a lot has been said but, unfortunately, a lot of things said are now being unravelled completely. Eligibility for medical cards must be addressed urgently.

Deputy James Reilly

There are more medical card holders now than ever before in the history of the State.

Acting Chairman (Deputy Terence Flanagan)

We will allow the Minister to respond.

Deputy Billy Kelleher

The service plan for this year is very light where last year's plan was far more detailed. The reason more people have medical cards is because more people qualify on the basis of financial need. It is not because the Minister or the HSE are more generous in granting medical cards. These people are getting them by right based on a means test. What is happening in the meantime is that people who need medical cards for life-saving treatments are being denied them.

Deputy James Reilly

They should not be. There is a discretionary medical card group staffed by doctors to ensure people get discretionary medical cards on the grounds of medical condition.

Deputy Billy Kelleher

They are being denied them. That is the point I am making. That is a key area that needs to be addressed because it is not working. Another man who came to me recently is on chemotherapy and had undergone surgery for bowel cancer. He cannot get a medical card. I know well that he is not a very wealthy man. He is on little more than a social welfare payment and an occupational pension but he cannot get a medical card. Means tests are carried out but there are many refusals on the grounds that the applicants have financial means.

Regardless of what may be said about our time in government, at least people who were receiving treatment for or recovering from cancer were granted medical cards on medical grounds. That is something the Minister has to address. He speaks about universal access to free GP care. That is fine, but in the meantime we cannot give medical cards to people. That is distasteful, to say the least.

Deputy Jerry Buttimer

We pumped €28 million into the medical card scheme.

Deputy Billy Kelleher

I do not want to argue with the Deputy across the floor, but, as Chairman of the Joint Committee on Health and Children, he should know the reason for the increase in the number of medical cards. It has increased because applicants are qualifying for them on financial grounds. However, they are being denied on medical grounds. That is the key issue I am trying to raise. I have raised it repeatedly in the past year, but the position is certainly not improving for the people who attend my clinics and I am quite sure, Deputy Buttimer, the same can be said for those who attend your clinics.

An Leas-Cheann Comhairle

I ask the Deputy to speak through the Chair.

Deputy James Reilly

He was speaking through a different Chair.

Deputy Billy Kelleher

I am getting confused by all the Chairs around here. We will, of course, examine the Bill in finer detail on Committee Stage. It provides for the abolition of the board and the CEO structure which will be replaced by a system of directorates headed by a director general. The Minister has outlined his decision, although he has not necessarily outlined the logic behind it. This directorate structure will be an interim measure until further legislation is introduced in 2014 to underpin the move to universal health insurance and the establishment of hospital trusts. We are still awaiting a clear position on universal health insurance and the funding for such a system.

In announcing the changes the Minister described the HSE as a self-serving system rather than a patient-centred service. That was a cracking phrase which reminds me of my earlier comment about his stewardship and decision-making. The primary care centres were self-serving.

Deputy James Reilly

Rubbish.

Deputy Billy Kelleher

On the issue of accountability, we had a taste of so-called accountability here yesterday in the course of the Topical Issue debate. This is very relevant to the Bill before us, because it is about the relationship between the HSE and the Minister. This Minister, like his predecessor Mary Harney, hides behind the HSE when it suits and pushes the HSE aside when it suits. He hid behind the HSE when it made the announcement last August of a further €130 million in health spending cuts, cuts for which he and his Government colleagues were directly responsible. These cuts included the cuts to personal assistant services for people with disabilities, which the Government was embarrassed into reversing by disabled people camped outside Government Buildings. Well done to them.

The Minister pushed the HSE aside when he fast-tracked hospital capital projects at the behest of his Cabinet colleagues Deputies Howlin and Hogan. The explanatory memorandum for this Bill claims it is essential that the HSE be properly accountable to the Minister for its performance. We are all for more accountability from the HSE, but what about the accountability of the Minister to the people and to the Oireachtas? Yesterday, the Minister was asked repeatedly by me about how the decision was made on the capital projects in Wexford and Kilkenny, but he doggedly refused to reply to the questions I posed. He refused to account for the fact that the Ministers in these constituencies, Deputies Phil Hogan and Brendan Howlin, announced the commencement of the hospital projects before the HSE board met or before the board was even aware that these projects were going to leapfrog others. The Minister simply ignored my question about what contact he had with his two Cabinet cronies before they so confidently made their announcements. It may be a case of "If there is no written record, it did not happen." However, I believe accountability requires that the Minister respect the words he put on the record of the House this evening when introducing this Bill, when he spoke about accountability to the people through the Oireachtas. Those are the words he used. He said the Minister was accountable to the people through the Oireachtas. However, we have no evidence of any acceptance, let alone adherence, to the spirit - never mind the letter - of the words he uttered here this evening.

I hold no brief for the HSE and its current structures - quite the opposite. It is top-heavy and over-bureaucratic. The passing of the HSE board under this legislation will be lamented by few and I will not oppose its abolition. However, the hospitals controversy raises an important question. It came to light because journalists were able to obtain minutes of board meetings under the Freedom of Information Act. Will the new directorate appointed by the Minister have the same transparency and accountability?

Section 12 of the Bill gives the Minister increased powers to amend HSE service plans. In principle that is not objectionable but, based on all the evidence over the past two years, we have no confidence in how it will be used in the hands of the Minister. The issue is not the procedure for formulating the plan; what is important is its content, the strategy and the policy that guide it. In the case of the Government, it is the fundamentally wrong economic strategy of austerity and the fatally flawed health policy of Fine Gael which clearly hold the whip hand as far as health is concerned in the coalition.

On 10 January the Minister approved the HSE's national service plan, which I have described as a plan for slashing services. The plan implements the savage cuts to public health services imposed by the Fine Gael-Labour coalition in budget 2013. Of the total of €721 million in cuts in this plan, a massive €323 million is cut from primary care. This makes a mockery of the Government's so-called reform programme, which allegedly has primary care at its centre. The Minister has signed off on a plan that will deprive a further 40,000 people of medical cards in 2013, and many more thereafter as the income criteria for receiving a medical card are changed. This is a further attack on people on low incomes. It is scandalous that the plan imposes a cut to disability services of 1.2%, which is four times what was expected by the sector. There should have been no cuts to this sector, but it was expected that cuts of the order of 0.3% would be made. There was a shock when the real figures were revealed. These cuts will severely affect disability services, which are already reeling from cuts in previous years.

The plan also implements the increase in medical card prescription charges and the reduction in the monthly subsidy for medicines under the drugs payment scheme. I have put a parliamentary question to the Minister on this issue. I now have evidence of double-charging for prescription items. Patients are not just being charged €1.50 for prescription items but in many instances are being charged €3. This is happening because the prescribed items are not available in the milligram amounts prescribed by the general practitioner, so two tablets must be prescribed to meet the prescription. Hence, people must pay twice. This is absurd. These are people on medical cards and very low incomes. The Minister must address and correct this issue if he is not prepared to abolish the prescription charge entirely. The plan also implements the reduction in the monthly subsidy for medicines under the drugs payment scheme.

This plan will deepen the staffing crisis in public health services. The HSE admits in the plan that in the light of the staff reductions of recent years and given that a further 4,000 staff are due to be cut this year, the planning of services is "particularly difficult in 2013". That must be the understatement of the year. The staffing crisis will be compounded by the Government's decision to attempt to introduce a cheap labour scheme for nurses which has been rejected by the nursing unions and the overwhelming body of newly qualified nurses. I emphasise that the nurses in question are qualified. It almost beggars belief that the Minister is proposing to extend this yellow pack scheme to other professions in public health services, even though it is so grossly unfair. Given that the boycott by the nursing unions is being widely adhered to and has broad public support, it is clear that the scheme is a hopeless failure from the Minister's point of view. I call on him, once again, to withdraw this totally unacceptable scheme and sit down at the table with the nursing unions which have proposed alternative ideas for savings which would respect the existing salary scales of nurses and midwives.

I invite the House to compare the slashed salaries the Minister expects graduate nurses to work for with the salaries at the top of the HSE. The Bill will not address the issue of excessive salaries in the top-heavy upper and middle management layers of the HSE. Some 129 managers and administrators receive salaries of over €100,000 per annum. That is obscene at a time when older citizens' home help hours and home care packages which were already inadequate have been cut again this winter. Bureaucratic change of the kind set out in the legislation is meaningless in the absence of real policy change and a change in the culture of privilege at the top. The resignations of the former chief executive of the HSE, Mr. Cathal Magee, whose departure I greatly regret, and the former Minister of State, Deputy Róisín Shortall, exposed the deep dysfunction at the top of public health services. There are three aspects to this problem - the unsuitability of the Minister for the office he holds; the fundamentally flawed policy approach of the Government, as evidenced every day on the floor of the Dáil; and the unreformed structure of the HSE and the health service.

Nothing the Government is doing in the Bill equates to reform. Last year marked the centenary of the tragic sinking of Titanic. The Bill represents no more than a rearranging of the deck chairs in the context of the crisis in public health services which are struggling from day to day. Even before cuts of €721 million were announced in budget 2013, public health services were reeling from the cuts of €130 million announced last August, the €750 million cut announced in budget 2012 and the €1 billion cut imposed in 2011. Last week the Joint Committee on Health and Children heard from nurses - front-line service providers - who described the reality of reduced services and increased risks in hospitals as a result of short-staffing. The recruitment ban, the further restrictions on overtime and the hiring of agency staff are having a dire effect. The increased flexibility and potential productivity from hospital consultants achieved in last year's talks were welcome, but all of this could be scuppered by these other cuts. If an insufficient number of nurses and other staff are on duty, insufficient theatre time is available and insufficient inpatient beds are open, many consultants will not be able to provide the extra treatments and perform the extra operations and procedures required of them.

The Minister's lack of transparency and accountability is central to the issue of governance addressed in the Bill. I raised his failure to fill 64 vacancies on nine boards within his remit, including the Food Safety Authority, during a Topical Issue debate last week. Twenty-five people applied under the new open procedures for a position on the board of that authority. The Minister continues to hold off on these appointments, even though, according to reliable information we have received, an overwhelming number of the applicants are suitably qualified and eminent to take on any position of responsibility required by the board. All of this raises questions about the future of the various authorities and boards and undermines public access to the appointments system. People can hardly have much faith in this so-called new approach. It is clear that the Minister is refusing to address their concerns. When I raised this matter last week, the Minister of State, Deputy Kathleen Lynch, was sent in to reply in the absence of the Minister and it was clear that she was embarrassed. The Minister can take a look at the tape if he does not believe me. The Minister of State admitted her view was that the reply she had been given to read did not shine "any light on the question raised." So much for accountability.

I want to mention an important issue that has been raised by Mental Health Reform regarding the Bill. The organisation in question has welcomed the Government's intention to improve the accountability of the HSE through the Bill, but it has expressed concern that the current draft does not ensure a director of mental health with the competence to drive implementation of the Government's mental health policy will be appointed. I ask the Minister to note this most seriously. Mental Health Reform is concerned that the Bill limits the recruitment of the new directors of the HSE to those who already hold the position of national director within it. It believes the appointment of the best person for the job, whether that person is internal or external to the HSE, is vital. The new director for mental health must have a proven track record of leading change in mental health services and competency in the recovery ethos that underpins A Vision for Change. This is extremely important. I urge the Minister and the Government to introduce appropriate amendments to rectify this matter, or to support amendments that may be tabled by me or other Opposition voices to achieve that end.

I look forward to having an opportunity to address improvements to this legislation that might be possible on Committee and Report Stages. I accept that the Bill will make its way through the Houses. While it falls far short of what we really need in terms of reform, it is all we have to work with, at least for now.

Deputy Seamus Healy

I would like to share time with Deputies John Halligan and Maureen O'Sullivan.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Deputy Seamus Healy

A number of key criteria must underpin the provision of a proper health care service for the people. A quality service must be delivered on the basis of medical need. We must have a service that is democratically accountable and controlled. The delivery of the service must be transparent. The service must be delivered in a fair manner devoid of political interference. There must be real and meaningful consultation with stakeholders and local communities. The Bill does not fulfil these criteria.

In fact, if it goes through as it is, we will lose the opportunity to reform the system and, in particular, a situation where there is no democratic accountability and no democratic control of the health service. As we all know, the HSE was established by Fianna Fáil to specifically avoid accountability - accountability to this House, stakeholders, local communities and those interested in the delivery of health services. What we got was a bureaucratic monolith which was operated from an ivory tower, with absolutely no contact with stakeholders and local communities, and intent on avoiding such contact and consultation.

The old health boards were certainly not perfect. However, from the point of view of democratic input, they were far ahead of the undemocratic HSE we have today. At least, elected public representatives were represented on them, as well as staff representatives and ministerial nominees. Meetings were held regularly and they were transparent, open and public, and could be accessed by both stakeholders and local communities. We also had local health committees at which local councillors in every county could make their views known to the health boards and ensure their voices and those of their communities were heard. We now have a situation where even parliamentary questions on health matters cannot be responded to in the House and are referred to the HSE, from which we receive no satisfaction. While we have this opportunity, we should ensure there is proper reform, democratic control and accountability, not just to the Minister, the House or stakeholders but also to local communities.

There is a further problem in that there is no meaningful consultation or negotiations between the HSE, stakeholders and local communities in furthering any of its initiatives or plans. I have been through a number of such plans, including the so-called reconfiguration of hospital services in the south east and the closure of the acute psychiatric unit at St. Michael's Hospital in Clonmel. The fact is that the HSE has absolutely no interest in consultation or negotiations. It decides what it wants to do and drives a coach and four through everybody - stakeholders, staff and local communities. It does not want to listen and has no intention of listening to stakeholders. That simply has to change. We should even go so far as to ensure there will be a legal obligation on the health service to consult stakeholders, local communities and staff.

In regard to the situation on the ground, staffing levels have been decimated by cuts in numbers and funding; there is a moratorium on the employment of staff; some 2,500 additional staff reductions are proposed in the next year to 18 months; and there is the proposed reduction in the budget by a further €2 billion in the next two years. All of this puts huge pressure on staff who are already working above and beyond the call of duty and each of whom is now doing the work of two or three individuals. In these circumstances, there is no doubt that, despite their very best efforts, things will go wrong. I have huge sympathy for staff who are unfairly placed in this position. Last weekend, for example, in my local hospital, South Tipperary General Hospital, there were 26 patients on trolleys in the accident and emergency department, side rooms of the accident and emergency department and the corridors of the hospital. Six of the patients were left beside the vending machines in the atrium of the hospital. As I said, this was despite the best efforts of staff who were working above and beyond the call of duty. It is a disgrace. The reductions in staff numbers and the moratorium have to be reversed because they are totally unacceptable. The service the public is getting is not and cannot be described as a quality service while these cuts are taking place.

It is a pity the Minister has left the Chamber. I call on him specifically to fulfil the commitment he made to the committee of the Community Hospital of the Assumption in Thurles which met him in November 2011 and again in April 2012. He gave a commitment that he would reopen the 22 beds which had been closed in the hospital. His Fine Gael colleague from north Tipperary gave a similar commitment just before Christmas. I ask the Minister to immediately reopen these beds and ensure provision is made for this in the HSE West service plan.

I refer to the question of medical cards. As I have said in the House previously, the centralisation of the medical card system was a complete shambles and remains so. In particular, the issuing of medical cards to applicants on medical grounds is at an unacceptable level. By way of parliamentary question, I brought to the attention of the Minister a situation where an applicant had been awaiting a medical decision since last September. It is not unusual to find such cases every day. It is taking too much time for medical applications to be dealt with.

I concur with Deputy Billy Kelleher who indicated, correctly, that, in respect of medical applications in cases involving persons suffering from a very serious illness such as cancer, whereas medical cards had been granted automatically in the past, this was no longer the case. Moreover, the most insensitive of letters are being sent to applicants and their representatives. This must change. The Minister must intervene to ensure this happens.

We must take the opportunity in this Bill to ensure we will have a democratically accountable and controlled health service which operates through consultation and agreement.

Deputy John Halligan

My first question to the Minister is whether the Bill will prevent a Minister for Health from accelerating projects in specific areas without due consideration for due process. If many of us received copperfastened guarantees that this would be the case, it might be worthy, but somehow I doubt this will be the case.

I was a city councillor in Waterford when the HSE's predecessors, the health boards, were in place. For years I witnessed the most disgraceful waste within the health boards. However, the single agency established to replace them, if it did anything, very quickly created more senior roles in the health sector than ever before.

The HSE's inadequate financial management infrastructure was born of a legacy system from the old health boards. We are all brutally aware of the financial mess the health sector is in as it inefficiently grapples with the €750 million taken out of the health budget in 2012 and the €1 billion taken out in 2011. Many would say with hindsight that the abolition of the health boards and the creation of the HSE was counterproductive. The structure of the HSE is a shambles. Many people have little belief in it; many even have contempt for it, despite their respect for the health professionals working within the HSE, including the nurses and doctors coping day to day with the recruitment ban, restrictions on overtime and cuts in services.

I thank the Deputy. I recall the times when maybe 50 or 60 councillors would turn up, and the staff from the HSE. The councillors got their travelling expenses. Everything was crammed into a two-hour meeting during which nothing could be achieved. If ever there was a waste of money, time and procedures, it is the health forums. The Minister should really examine them. If they were abolished we would save millions of euro.

When it was set up less than 14 years ago, the HSE was intended to move the health service away from the control of local vested interests that dominated under the regional health board system, but, as the cases of Wexford General Hospital and St. Luke's General Hospital revealed last weekend, this was not achieved. I welcome the principle behind these reforms. Without question, the HSE, its structures and its governance need to be changed now. We need far greater clarity in tracking the health budget, but I have serious concerns about how the proposed system will work in practice. As I read the Bill - I may be wrong - it proposes that we give responsibility for the health budget of €14 billion or more to the Department of Health, thus giving the Minister of the day the authority to specify priorities which must be followed in preparing service plans. Every one of us would have difficulty with that because my reading of the Bill suggests that this is a very general power and there is little information on the type of direction the Minister may make. This needs to be clarified in the Bill. For instance, people will ask whether we are giving the Minister and his Cabinet colleagues carte blanche to accelerate projects in their own constituencies to the detriment of other areas. That is a reasonable question. We need clarification on the specific authority the Minister would have. The legislation needs to state how and where a Minister may make directions. That is a reasonable request. If such an amendment is tabled, the Minister should consider it carefully. What we set in statute here may remain for another four, five or eight years. The present Minister may not be in government then and may well tell the next Minister for Health that he has too much power. We need to state specifically how and where the Minister will make directions because we need accountability in all aspects of the health service.

The Minister has also indicated that the new directors will be appointed following a competition from within the health service, which leads me to wonder whether the Minister will merely be shuffling deckchairs in making these appointments, because this happens when we reappoint within a working system. Giving each director the power to establish his or her own committee for assistance and to advise the Minister is creating another bureaucratic layer of outside advisers. Do we need this? We have enough of them already. I do not understand why are we going down that road, which adds another cost. There is also a general lack of clarity about how the new integrated care agency, which is a separate purchaser and provider of arrangements for health care, would operate in practice. That is a big issue for many people. I have gone through the Bill in detail and it appears to me that a great deal is left unclear.

I do not know what advisers put the Bill together, but my few points are reasonable recommendations. We need clarity. It is not always the case that those of us in Opposition want to oppose everything. Sometimes if simple amendments were tabled we would find it easy to support Bills. I would appreciate if the amendments that I am sure various Members will table are accepted.

When will the Minister introduce free GP care for those with long-term illnesses? He advocated this strongly when he was in Opposition. I do not see his White Paper on universal health insurance being delivered as promised. I do not see the free doctor scheme going anywhere. I have spoken to many doctors and they say they have not even been contacted. No discussions have taken place. The Minister has had two years in government. That was one of the big promises he made to many people. I spoke about this during Leaders' Questions last week. The cost of going to a doctor is huge, and if one subsequently goes to a chemist one can pay a total of €100, a third of the earnings of some people who do not qualify for a medical card.

The Minister should consider the amendments to this Bill carefully and be generous in assessing them. I listened to Deputy Ó Caoláin's excellent delivery. We have all put much thought and effort into this Bill to see how it would best serve the people. When we consider the amendments we might be able to support it.

Deputy Maureen O'Sullivan

When I was thinking about the health service, I tried to work out what word would best summarise it and I came up with "fraught". This is a service that has a massive budget yet it still has significant problems. It seems to totter from one crisis to another. I receive a considerable number of calls every day to do with health matters. This is not to take from the excellent care and service that health service staff provide to those who do get into the system. I am thinking particularly of the areas of cancer, heart, post- and neonatal care, and gerontology, all at a time when health service staff salaries are being cut and staff are not being replaced. Workloads are increasing and budgets are being reduced.

I can remember the old health boards, which came from the belief local authorities, which had been overseeing most health services, were not suited to the task owing to the much wider trends in health care development and increasing costs. As the health boards had elected representatives and representatives from the health care professions, they had a democratic element, as Deputy Healy mentioned. Then the view emerged that the health boards had to go and the HSE was born to manage the services as a single national entity. Now we are on the move again.

Health care is the largest spending programme after social protection, accounting for 27% of total Government expenditure. In 2011 the cost was over €13 billion, with 37% spent on hospitals and 34% on community services. When one takes that into account, with our relatively small population, it is incredible that we do not have a state-of-the-art health system with easy access for those in need of services, regardless of their personal circumstances and ability to pay. I was struck by one statistic in the 2011 annual report and financial statements that over 75% of the population availed of services through 425 primary care teams.

This seems to suggest ours is a very unhealthy population. Without being too simplistic about it, we are not paying enough attention to prevention measures. I will give two examples. We know the medical and health issues associated with obesity, two being diabetes and heart problems, yet when a suggestion was made that there be a tax on sugar which might have gone some way towards addressing the problem, we took it no further. We know all about the health problems associated with addiction, particularly alcoholism, yet when there was mention of and support for minimum pricing of alcohol, with related advertising mesures, it went no further.

I refer to an article in the health supplement of The Irish Times yesterday which confirms what we already know, namely, the effect of poverty and unemployment on health. The article quotes Professor Kennedy who spoke on the Irish Cancer Society's strategy statement, 2013 to 2017 - Towards a Future Without Cancer. The point is made that people living in disadvantaged communities have a far greater risk of having cancer and dying young because they are twice as likely to smoke, eat too much poor quality food and be physically unfit. Professor Kennedy mentions particular cancers that are much more common in areas of high unemployment and deprivation. These health inequalities have been evident for far too long, as confirmed by one report after another, and in different parts of the world. The point is made that social injustice is killing people on a grand scale. People living in areas of high unemployment and deprivation engage in unhealthy behaviours because of the feelings of powerlessness they experience, exacerbated by the lack of educational attainment. These massive inequalities are not being addressed and the problem continues.

There has been much criticism of the HSE, some of which is justified, some not. The criticism which is justified relates to the general lack of integration and cohesion across the organisation, insufficient openness and transparency and the specifics of the relationship with the Departments of Health and Children and Youth Affairs. We are now moving to a transitional structure, with another to follow in two years time. Is anybody convinced, however, that this will address the health needs of the nation? The programme for Government contains a grand plan for a health reform programme to bring about a universal, single-tier health service based on universal health insurance. It would be great to think the Bill would contribute to this. There are serious issues, some of which relate to recent decisions, that could be aided by the Bill and give more authority to the Minister. However, we know what happened in the case of the primary care centres. One area I represent, Summerhill in the north inner city, one of the most disadvantaged areas in Ireland, is still waiting for a primary care centre, although there is a move in the right direction. If transparency is an issue, is giving more oversight powers to the Minister and the Government the answer? I remember what Mr. Cathal Magee stated to the health committee, namely, that the financial system environment in the HSE was not fit for purpose. Another statement was made to the Committee of Public Accounts concerning a financial deficit of €500 million at the end of last year. It is good that the Bill provides for an audit committee and sets out various functions, including reporting.

I refer to the position of director general. The Bill provides for the putting in place of between two and six directors. Media reports have considered seven directorates - primary care, mental health, hospitals, social care, child and family services, health and well-being and corporate services. However, the Bill does not provide details on the administrative structure and how the particular service areas will be assigned among the directorate. I make a special plea for a directorate for addiction services. During the years we went from having no one in government having responsibility for this area to on a number of occasions having a full Minister, then no one, followed by a Minister of State on a number of occasions but only with it forming part of a much wider brief. We need a directorate with responsibility for this area because addiction encompasses so many aspects. The Technical Group introduced a Private Members' Bill last October. We asked the Minister to prioritise addiction services as a health rather than a criminal issue. It is positive that the issue of drug addiction comes within the responsibility of the Department of Health, but then one looks at the wide range of addictions and the associated mental, physical and emotional problems and illnesses, including suicide, homelessness, imprisonment, sexual violence and rape, as well as the socio-economic aspects. If I take the first six directorates, primary care, mental health, hospitals, social care, child and family services, health and well-being, addiction is related and relevant to each of them. The importance of addiction services will be further disjointed if they are covered by six bodies. There is a need for us to take this issue on board and address it.

I turn to the area of mental health and there is no doubting the need for a directorate. It is welcome that this job was advertised earlier this month. I presume that the position of mental health director will be prioritised if the Minister opts to have only two. The Bill should state as much. There are questions to be asked. What will be the relationship between the new director of mental health and the regional directors? It appears these have not been mentioned before but are now being mentioned in the booklet which outlines the job description of director of mental health. There are also questions about budgetary control. The new director is crucial in this regard. It is recognised by everybody, especially those working in mental health services, that this function is needed to implement mental health policy.

In July 2012 the Technical Group made a submission on the Bill to the Minister. The first point we made was on the need for a strong framework for the sustained improvement of mental health services, with increased transparency and accountability in mental health service expenditure. We know what to do and have known this for a long time; it is all more or less contained in A Vision for Change, particularly the need to shift the balance of care from long-stay to community services.

To date, there has been poor accountability in the case of the budget. In 2008 almost half of the €51.2 million in government funding intended to support implementation of A Vision for Change was diverted to meet deficits in other areas. The 2009 report highlighted the absence of timely and detailed data and information. There was no real assessment of progress in capital investment or current expenditure. The 2010 report showed gaps which prevented financial accountabilty for the allocation of funding to support delivery of recommendations made in A Vision for Change. One reason is that the HSE does not track expenditure by care group, including mental health services. As a consequence, the HSE cannot state accurately how much is spent on mental health services. The 2011 report found that there was no system of performance indicators in place to enable monitoring of progress on the policy. That report, from Trinity College Dublin, stated establishing a national mental health service directorate was urgently needed, a body that would have the authority to control both existing and new resources. In budget 2012 €35 million was not spent, while in budget 2013 there is an additional €35 million. It is like Lannigan's Ball - one steps in and out with this figure of €35 million. Some 477 new posts were included for mental health services, as well as the 414 promised in 2012. Of this figure of 414, 58 had taken up positions by 31 December. In 2006 the programme under A Vision for Change estimated the need for an approximate 1,800 new professionals to implement reforms in mental health service provision. There is a caveat in the 2013 service plan, namely, that actions will be carried out "subject to affordability", which, of course, rings alarm bells.

I support the mental health reform coalition which identified two urgently needed measures to ensure accountability for delivering policy, one being the appointment of an empowered competent director of mental health with a statutory duty to implement A Vision for Change. The functions of that director should be outlined in the Bill, as well as the provision that he or she consult users of mental health services, their families and other stakeholders.

An Leas-Cheann Comhairle

We now move to the 20-minute speaking slots. Deputy Jerry Buttimer will be followed by Deputies Regina Doherty and Paul Connaughton.

Deputy Jerry Buttimer

The Minister for Health, Deputy James Reilly, has left the Chamber, but I will respond to Deputy Billy Kelleher's remarks. There are 1.8 million people with medical cards, the highest ever figure. As chairperson of the Oireachtas Joint Committee on Health and Children, I give the Deputy an assurance that we will invite HSE personnel with responsibility for medical cards to attend. We will discuss the issues of discretionary medical cards and doctor groups and examine how these personnel adminster the scheme to provide medical cards for those who require them. I share the Deputy's views and concerns, in particular that patients with cancer should not have to endure hardship, suffering and pain of being told by the HSE they cannot have a medical card. As the Deputy knows, committee members have been to Finglas and will return there. We will bring in the relevant personnel to discuss the issue with them.

There were a good few press releases.

Deputy Jerry Buttimer

Absolutely. The Deputy is good at issuing his own.

Acting Chairman (Deputy Michael McCarthy)

Deputy Jerry Buttimer to continue, without interruption. I must inform the Deputy that his time is almost exhausted.

Deputy Jerry Buttimer

I have a great deal more to say.

Acting Chairman (Deputy Michael McCarthy)

The Deputy has 50 seconds in which to say it.

Deputy Jerry Buttimer

We must ensure we get matters right in the context of the creation of the new child and family support agency. I hope the Minister and his Department will, in conjunction with the Joint Committee on Health and Children, consider how we should proceed in that regard. The proposed new directorate of mental health is most welcome.

The Minister is in charge of his brief and wants reform to be achieved. People should join him in that task, rather than criticising him.

Deputy Regina Doherty

I would hate to see how Deputy Jerry Buttimer would react if he was really upset by our colleagues across the floor.

I welcome the opportunity to contribute to the debate on the Bill. It is no secret that the Government inherited a health care system in crisis. The health care system is engaged in an ongoing process of change and transformation at every level. The key focus is to ensure all our resources are directed towards better services for the population. This programme of transformation of health services calls for a change in not only what we do, but also in how we do things and work together to deliver integrated patient-centred services. As we continue to make progress, guiding and leading change across the entire system is a key challenge for everyone in the health service. The Government is committed to meeting this challenge and continually seeking ways to improve the way things are done.

The magnitude of what lies ahead requires a robust infrastructure for deliberation and decision-making. Establishing that infrastructure is the purpose of the legislation before the House.

The new structures within the Health Service Executive (Governance) Bill 2012 will allow us to redesign the system to place the needs of the patient at the front and the centre. In order to achieve a new degree of transparency, accountability and efficiency prior to its abolition, the HSE will be reorganised along service lines. The new directorate structure involves the identification of clear areas of priority and the establishment of responsible directors for these service lines. This programme of reform replaces the HSE with six new directorates to be overseen by a director general. It will also allow the reorganisation of services to prepare the way for the wider introduction of the money follows the patient principle and the ultimate introduction of universal health insurance.

The purpose of the new directorate team will be twofold. It will run the health services as they operate and prepare for the transformation required in the move to universal health insurance. The clear identification of the seven directorates or service lines will provide considerable clarity in the delivery of the relevant services under the responsibility of the directors and for greater financial transparency and accountability in assessing these services. It is proposed that the persons who will take up the directorates will be a combination of existing HSE directors and persons to be identified by internal competition. The new directorate system will give us clear sight of budgets and where the money is being spent. The Minister for Health, Deputy James Reilly stated, "For too long the treatment of patients in health services has had to conform to the needs of the system, whereas this new directorate structure in the HSE will allow us to redesign the system to put the needs of the patient at the front and centre." The patient is the key stakeholder.

Change has become an ever-present feature of our work environment and the management of the continuing changes is a key challenge for all managers in service delivery. The policy of administrative control within the health service has changed little in the past decade, despite the advent of a national strategy, planning legislation and structural reform. The Bill alters all of this, with the key to the change being governance. Governance needs to be at the heart of health sector reform. It is vitally important that as we move towards new operating models, there is due diligence in the way we make the transition in order that patient safety is maintained. Governance is an essential element for success in improving quality and safety performance, reducing costs or collaborating with the medical profession to participate in new forms of care provision. Governance requires a unique set of policies which must be supported by structures and mechanisms that facilitate collaboration. The engagement of people is a defining factor.

Together with governance, accountability has become a major issue in the health care system. The Bill will bring about a health care system which will be accountable on roll-out, delivery and maintenance. It will build internal capacity to conduct organisational assessments, communicate effectively, motivate and lead change and create an open environment that will allow people to reflect on and learn from their mistakes and failures. These initiatives add value for the community and other stakeholders. From now on there will be clear and unambiguous section by section delivery, with transparent outputs and outcomes. We have learned a lot of lessons from our predecessors on how to do things in the wrong way; we are going to learn how to do it in the right manner.

Deputy Paul J. Connaughton

The abolition of the current board structure of the HSE and its replacement with a system of directorates, with a provision for the Minister to give policy directions to the HSE, is most welcome. I acknowledge that the directorate structure is an interim measure pending dissolution of the HSE, a policy to which the Government committed as part of the move to universal health insurance.

Under the provisions of the Bill, the director general will be accountable to the Minister through the Secretary General of the Department of Health. The Minister may issue written directions to the HSE on policy implementation if he or she believes insufficient regard is being paid to a policy or objective. It also allows the Minister to give specific priorities to the HSE which must be taken into account in the service plan. An audit committee will advise the director general on financial matters and this report must be provided for the directorate and the Minister.

In many respects, the HSE, established in January 2005, has proved to be a runaway train. It is hoped the Bill will provide welcome direction for the executive in terms of priorities and make the HSE more accountable. In too many instances, important decisions are being taken by middle management within the HSE without proper recognition being given to the long-term impact on the service. When the HSE was established, it was hoped a centralised service would prove more competent than the individual health boards which it replaced. The Brennan and Prospectus reports in 2003 criticised regional decision-making and called for the health service to be managed by a single entity. The setting up of the HSE in January 2005, on foot of legislation passed in 2004, reflected the recommendations made.

Much criticism had been levelled at the holding of health board meetings which took place around the country. However, these meetings provided an opportunity for public representatives to hold health service personnel to account for decisions. The regional health fora which replaced the old health boards were given representative rather than executive functions. They became toothless bodies and thus an important element of regional accountability was lost.

The per capita spend of the HSE has been reduced by 11% in the past two years, a very significant sum. It is increasingly important that every cent spent in the health service is spent wisely for the benefit of patients, be they in hospital or the community.

A key mistake made at the time of the creation of the HSE concerned the lack of action in amalgamating management positions. This resulted in hugely increased management numbers and a bloated and costly bureaucratic set-up which hoovered up millions in budgets, without providing real benefits where they were needed most, at the coalface. Successive Governments have failed to grasp this nettle and until such time as the numbers of administrators in the system are reduced, we will continue to have an overly bureaucratic system in which too much of the salary cost is associated with administrators as opposed to doctors, nurses and other front-line health care staff.

Issues also arose in the context of transparency. Politicians of all hues have found it very frustrating in their efforts to obtain answers from the HSE. Unlike all other State bodies, the HSE has proved virtually opaque in getting answers to even the most simple of questions. I hope the regime to be ushered in with this legislation will allow public representatives to have questions on health matters answered in a more timely and constructive fashion.

The issue of the money following the patient is also an important part of Government policy which will be implemented through the new governance structures, an important element of which is the measure that HSE hospitals will become autonomous providers of care.

I acknowledge the changes in County Galway where four hospitals have been merged - Merlin hospital, Portiuncula hospital, UCHG and Roscommon County Hospital. This change was implemented by the Minister and the Government. The four hospitals are now more cost-effective and working more efficiently, with more patients. I commend the staff of the hospitals and Mr. Bill Maher, the chief executive officer of the hospital network. It is a case of allowing hospitals to do what they do best. UCHG is a status four hospital; Portiuncula hospital is a status three hospital; while Roscommon County Hospital and Merlin hospital are status two hospitals. This reform has been implemented in the past two years and is very welcome. The hospitals are working better together and this process needs to be replicated in other areas.

I sincerely hope the regime ushered in through this legislation will result in a more coherent and cohesive health service, where important elements of Government policy will be acted upon and the service plan will reflect the priorities of those appointed by the people to steer the country on a particular course.

Deputy John McGuinness

I wish to refer to Deputy Jerry Buttimer's contribution-----

Acting Chairman (Deputy Michael McCarthy)

The Deputy must speak to the Bill.

Deputy John McGuinness

-----and his reference to St. Luke's Hospital in Kilkenny. For many years Oireachtas Members on all sides worked with Garry Courtney and the leading staff members in the hospital. They determined what was needed and we pursued it politically. We had many achievements because we all worked together. The hospital serves not only Kilkenny but also Carlow and the region beyond. I commend Garry Courtney's imaginative work in the health service which is noted all over the country. There was a collective input into what happened at the hospital, but that is not the question which was raised by Deputies Billy Kelleher and Micheál Martin. They questioned how it was fast-tracked and dealt with, which is a different issue. We welcome the development at St. Luke's Hospital, as I am sure, the people of Wexford do. The other issue raised concerned governance.

Deputy Paul Connaughton raised another issue of concern to me which also relates to the Bill. I wish to deal with it separately before I make general comments on the Bill. I refer to the system for dealing with parliamentary questions. We are forced to table parliamentary questions about individual cases, HSE expenditure or its future plans which are generally not known in detail.

When one recieves a reply, it is almost too late for the individuals concerned because the action asked about has or has not already been taken, or the information sought on medical card applications has been lost. The parliamentary question system would serve us well if it were used correctly, but the Department of Health simply ignores it. The HSE ignores the right of Members of this Parliament to ask questions about individuals or the system within the health service or those organisations supported by section 39 grants. It would be an important and reforming step if the Minister were to say that, as and from 1 February, all parliamentary questions on health matters, be they about individuals or organisational issues, had to be answered within the specified three-day period. One could even allow a few more days to answer the more difficult questions. To receive no answer or receive a standard reply stating the matter in question is not one for the Minister but for the HSE is not acceptable. On asking a question, one must wait a number of weeks, if one is lucky, to receive a very poor response. This is unsatisfactory. To receive no response is a damning comment on the HSE and the Department.

Let us not ignore the fact that we let this happen. When Deputy Emmet Stagg was in opposition, I used to hear him talk about parliamentary questions and their importance. Now that his party is in government, it is business as usual and scant replies are given to parliamentary questions. This is not satisfactory and it could be corrected at the stroke of a pen if the Minister were of a mind to do so.

The Bill has been referred to as legislation bringing about reform. It is about the appointment of a director general and two to six other directors. It is not reforming legislation and to say otherwise is nonsense. To confine the competition for the job of director general and the other directors to those currently employed in the HSE is simply asking those who could not reform the organisation to date to deliver the necessary reform under a new title. This is a contradictory approach which will not impress those engaged with the administration of health services on a regular basis. It is not reform. I ask the Minister to reconsider this part of the Bill and allow the positions to be subject to open competition. Anybody within and outside the HSE who believes he or she is qualified and has something to offer should be allowed to apply. Instead of having an open competition, the Minister started incorrectly by appointing the current director general designate. It was a political appointment which he should not have made. Why did he not allow an open competition or follow the pathway of reform about which he spoke while in opposition? Why did he not declare that, as a first step, there would be a open competition at arm's length from the Minister and the HSE, as it stood? After this, he could have driven the governance reform that he envisaged in the context of the Bill. I ask him to implement change in this regard first. The people in the HSE who could apply for the positions in question stood over the activities raised by Deputies in the House. I refer to the medical card system, for example.

Officials from the medical card section appeared before the committee chaired by Deputy Jerry Buttimer. They spoke about medical cards at the Committee of Public Accounts also. Certain improvements were made, but it is still the case today that a person with cancer whose time on earth is limited cannot obtain the medical card that is so necessary for him or her to see out his or her last days with dignity. It is wrong that, on proving one has cancer, one should be subjected to the type of questioning engaged in by the medical card section in order to obtain a medical card. This questioning occurs, despite the medical evidence being in favour of the patient. It is simply wrong and the Minister could change it at the stroke of a pen.

Every Deputy will be aware of the number of people coming to his or her constituency office because of the cutting of home help hours. These individuals' home supports from the HSE have been cut and, in some cases, withdrawn completely. The Minister says he will examine each case and ensure that, where one is deserving, one will have one's home help hours or supports restored. Every single reply my constituency office receives from the HSE is the same. There is not one word that is different except for the name and address of the person on whose behalf one is making representations. All replies are negative.

I have received an e-mail that is representative of the e-mails we all receive. It is written by a neighbour on behalf of an 87-year-old woman who cannot make her own bed, dress herself, wash herself or look after her basic needs. Her home help, amounting to two hours a week, has been withdrawn. Nobody could agree with this. None of us in this House wants to see this happen, yet it is happening under the watch of the Minister who said every case would be examined genuinely. It is occurring under the watch of each of the people who will be seeking appointment as one of the two to six directors. This simply is not right.

Let us consider the section 39 grants and the recent decision to withdraw the financial supports and advisory services for childminders. There are 33 officers in all throughout the country. They were told only last week that they were out of a job because there was insufficient money available. This is after we have held a referendum in which we said children would be to the fore and that policy would look after them. The childminding services on which children rely so much are being withdrawn. The basic rights of children are being affected. This is happening under the watch of the Minister and those who will apply for the jobs to which I referred.

There are many other examples of a system that is simply failing the patient. While Deputy Jerry Buttimer's point that the patient was failed by the last Government and its predecessor is correct, this is happening under the watch of the Minister who spoke so much about reform. I am asking that basic steps be taken in the process of reform. I ask for accountability in the parliamentary question system. I seek honest answers to questions to the HSE about elderly patients represented by Members. It is a basic right to be given access to the relevant information. It is the right of every Member of Parliament to be given full information in response to a parliamentary question. These reforms could be achieved easily to everyone's benefit.

Having achieved these reforms, one could consider structural reform. In this regard, one should consider the commitment that every Member of this House would be brought before the HSE locally to deal with all relevant issues. The local HSE committees have been criticised in this House as the process is a complete sham. It involves a number of officials and bureaucrats meeting Members in an office with one intention, that is, to whitewash any point raised by these Members. It is a case of giving them a bum steer and wasting their time.

The greatest amount of time and money is being wasted by the group of officials that attend those meetings because they have no intention of giving the Minister the answer or the information required. That is so much the case that a question I tabled to one of those officials regarding an autism nurse resulted in a response coming to the office stating that the information was being gathered. I was only asking about an appointment, therefore, the information is a simple "Yes" or "No" or the giving of a date. They cannot even do that much for one because there is a culture of secrecy and an unwillingness to co-operate within the HSE and until that culture is broken we will be badly served by that organisation. This legislation will not break that culture because it is relying heavily on those currently employed in the HSE and it is not opening its doors to young people coming in with imaginative management ideas who can solve some of those problems. I need only point to the recent meeting between the Committee of Public Accounts and the HSE. It was nothing short of a disgraceful performance by the Secretary General of that Department and by the Director General Designate of the HSE but it tells one something about the organisation and if dogs resemble their masters, in this case we are in real trouble.

I refer to the audit committee that is to be appointed according to this legislation. I have seen audit committees appointed to boards and agencies within the control of the State and it is amazing to see the names that crop up on those audit committees and their qualifications. One will find very few auditors or accountants but one will find the safest pair of hands one could ever meet. They will not go astray or go off message, and they certainly will not audit. It is down to the Comptroller and Auditor General to audit the HSE to ensure we get accountability and transparency in the context of that audit. I would like to see the Minister spell out clearly in this legislation who should be on the audit committee, their responsibilities and roles because that clarification is absolutely necessary.

I turn to general public accountability. In a debate here to which the Minister of State, Deputy Kathleen Lynch, responded I asked that we would investigate as a matter of urgency and in a public way the death of Niall Comerford. He was a young 22 year old man who went into hospital for a simple procedure and died within days. I was promised, as were his parents, Walter and Joan Comerford, that the national incident unit would investigate this matter speedily and that they would consult with the parents. I thought that was some sort of crack unit that would immediately go in and find out exactly what happened but not only are Niall's parents disappointed but I am disappointed because it is nothing short of more bureaucracy. All the family wanted was to find out what happened. All they wanted was to know the reason the information on deep vein thrombosis, DVT, was not made known to the patient before and after the operation. If it were made known, the chances are that young man would be alive today. They wanted no more or less than that but because of the actions of the HSE and the desire of the family to help others they are now being forced into a legal position either to sue the consultant or sue the HSE to get justice for their son and for other people who may be affected by that issue. It happens in the United Kingdom, and there is professional opinion that it does not happen here and that it should happen here. That sounds simple enough to me but it is being made mightily complicated by the HSE. That is the reason there are so many cases against the HSE. One will find very little humanity or compassion in the organisation, and I refer to the management of it as distinct from those who deliver the services on the front line because if the Minister were to listen to the people who deliver those services he would have it confirmed for him what is being said in this House by his own members of Government and by the Opposition.

I ask the Minister to consult again with the stakeholders, the patients, the doctors and those currently in a position within the HSE but who are fearful of speaking out because there is a bullying culture at certain levels within the HSE and they are fearful of losing their positions. He could learn so much from them. If he were to release them from that fear and take the time to listen to them he may learn a good deal about what needs to be reformed. He may learn a good deal also about the way he can better manage the €13.5 billion put at his disposal each year. That is €13.5 billion of hard-earned taxpayers' money, which is now very scarce.

I turn to the recommendations in a recent report from the Committee of Public Accounts. One of the recommendations refers to the recent report which was completed which examined the financial management capacity of the HSE and suggested that it should publish an implementation report which will outline the investment strategy on financial management infrastructure so as to ensure a robust and workable system for the management of the health budget. If we are to spend that much money on a health budget and drive it down towards the patient, which the Minister has said time and again is his intention, we must look at the costs associated with this Bill and with the change in management that is required. There is no reference to that in this Bill. The Minister can have all the reform and all the suggested change that he wants but if he does not have change managers put in place to drive the change that is necessary it will not be delivered for this Minister, the next Minister or the one after that. That is ignored in this Bill. There is no mention of it. The Minister should bring forward the appropriate amendments on Committee Stage to give greater accountability and access by the Committee of Public Accounts to section 39 agencies and to the private hospitals about which I have not spoken as I must conclude. I ask that these points be taken into consideration to ensure we have greater accountability, greater transparency and better value for the taxpayer and the patient.

Acting Chairman (Deputy Michael McCarthy)

I call Deputy Damien English who I understand is sharing time with Deputies Hayes and Harris. Is that agreed? Agreed.

Deputy Damien English

I welcome the opportunity to contribute to this debate on the Health Service Executive (Governance) Bill 2012. It is an important stepping stone on the road to this Government's commitment given at the beginning of its term to abolish the HSE.

I might not agree with everything Deputy McGuinness said but I certainly agree with his last comment about the change masters. I had a conversation with the late Brian Lenihan when he spoke about all the changes the Croke Park agreement would drive through and I made the very same point to him that Deputy McGuinness made. If we do not put in place the experts, the change masters and the cost accountants in every Department to drive the change we will not succeed. Deputy McGuinness is right in that. That is the same for this Government. There are a number of people in the Department of Public Expenditure and Reform who can drive this change but we probably need more in every Department. Deputy McGuinness is right in that regard and I strongly agree with that. Good managers were driving all the areas where the Croke Park agreement has been successful. It will not work unless it is driven, and we must stress that.

During 2004, both inside and outside this House, I and many others warned the Ahern Government of the potential dangers in creating such a massive bureaucracy as the HSE.

Sadly, little did I realise at the time how right I and others would be. Deputy Olivia Mitchell was Fine Gael health spokesperson when the Health Act 2004 was introduced. In the Dáil during the Second Stage debate, she stated:

It abolishes a framework of accountability within the system without giving us any idea of what will replace it or if it will be replaced. That is a leap of faith which Fine Gael is not willing to make. My main reason for opposing this legislation is that it removes all accountability from the system and fails to replace it with an alternative or even give us any idea if it will be replaced.

Deputy Martin was the Minister for Health and Children at the time. A few months later, after a reshuffle, Mary Harney was at the helm of the Department. Considering her previous portfolios, I thought this might have been good for the Department. She took up Deputy Martin's Health Act 2004 to establish the Health Service Executive and told the House it would be the be-all and end-all despite the fact that I and many other Members told her it would not. The legislation stated that the new chief executive officer of the HSE, which would deliver health services, could not question government policy. This was an illogical move. All the legislation did was to take away accountability to the House.

My experience working in the North Eastern Health Board in the late 1990s gave me some insight into how depressing and impeding a bureaucracy can be, even when staffed with good and well-intentioned people. Bureaucracy smothers innovation. It resents individual freedom and often cannot get its head around new methods and new ideas because these threaten the existence of the bureaucracy. Serving the system becomes the mantra rather than the system itself existing to serve others.

In 2005, with the establishment of the HSE, rather than a rationalisation and slimlining of the system of ten regional health boards, we got instead a very costly mutation. The then Minister for Health and Children became a token presence in the House because she and her Department seemed irrelevant to the day-to-day running of the health service. It was almost as if the health service train had been hijacked and she, like us, was one of its scared passengers. This is not just backbench blues talking; it was also the considered opinion of many external reports, including an OECD report in 2008 and the Ruane report of 2010.

The Health Service Executive (Governance) Bill 2012 is the first of many steps in putting the train back on the tracks. Like many Oireachtas Members, I used to dread the lack of any answers on the running of our health service during the Ahern and Cowen Administrations. We politicians and our constituents became all too used to the stock reply from the Minister that the matter raised was a matter for the HSE and the query had been forwarded to its headquarters in Naas. While nobody expects a Minister to be involved in every decision made in a multi-billion euro health service, they should at least be able to source the relevant answers for this Parliament whose Members vote through some €13 billion for health each year. I am hopeful this new Bill will increase the accountability of the HSE to the Minister and, through him, to this House.

I recently heard Deputy Martin on the radio talking about all he had done when he was Minister for Health and Children. He did not do much, in my opinion, apart from increasing the budget from €3 billion to €15 billion and doubling the numbers working in the health service, although not the outputs or services. It was not the people's fault but the system's. Deputy Martin brought in the HSE for him and his Government to hide behind. He and his successors would not answer basic questions in this House on simple matters concerning the health services.

I note in the Bill the establishment of an audit committee which will advise the new director general on financial matters. This committee will report in writing to the director general and to the Minister. I feel, considering the role of this House in voting through 27% of total current expenditure per year to the health service, that it deserves to see, review and debate this advice also. At the very least, its health committee or the Committee of Public Accounts should do so.

As someone who has called in this House for the focus of our health care system to move away from personal health crisis management and towards proactive care of good health that already exists, I note with interest the creation of a new national directorate on health and well-being, as indicated by the Minister, Deputy Reilly, on Second Stage in the Seanad last September. I hope this signals a greater emphasis on health promotion and general health screening. With our still growing but also aging population, this has the potential to save us many billions of euro in the future.

Mental health has often been described as the Cinderella of the health service. It is right and proper that it should receive a full national directorate also, as indicated by the Minister, Deputy Reilly, on Second Stage in the Seanad last September. Mental and physical health are essentially two sides of the one coin. We cannot have one without the other. With the recent death of our own colleague, Deputy Shane McEntee, and other tragic deaths across the country, we must redouble our efforts in suicide prevention. As my party colleague Deputy Neville often reminds us, we achieved a reduction in road deaths over the past decade, and we must now do the same for suicide.

The Minister for Health, Deputy Reilly, is a man with a vision who is on a mission. Universal health insurance is the destination to which he wants to take us. He wants to create a system in which money will follow the patient and excellence will be rewarded. It is a system that will allow smaller hospitals, such as my own local hospital in Navan, to find their niches and thrive. I welcome the significant investment in Our Lady's Hospital, Navan, in spite of much negative publicity. The money-follows-the-patient concept has worked very well for the orthopaedic unit there, proving it can be a major success.

Deputy Simon Harris

With this Bill, we take another firm step towards abolishing the HSE, on the basis of which the Government campaigned in the last general election. However, we cannot do the populist thing of abolishing the HSE in the morning and leaving a vacuum. The untangling of the bureaucratic mess that is the HSE must be done in stages, in a logical manner and over time. This is exactly what the Minister for Health, Deputy Reilly, has set out to do. Many Members and the media are so used to successive health Ministers failing and not delivering that everyone is ready to jump on every possible criticism of the Minister, Deputy Reilly, to claim he is not delivering. Tonight, we have concrete evidence of a further step taken by the Minister and the Fine Gael-Labour Party Government to abolish the HSE and replace that bureaucratic monster with a system of directorates that prioritise important health areas.

I recall a former health Minister and leader of the Progressive Democrats referring to the catastrophe of the HSE as being solvable in nine days. It has been a very long and expensive nine days for the people. We have seen the terms "cannot get answers", "black hole", "lack of transparency" and "no accountability" attached to the HSE in the public mind. We all remember that when Deputy Martin, then the Minister for Health and Children, was asked at a meeting of the health committee by my former constituency colleague Liz McManus whether he was responsible for the health service, he shrugged his shoulders and said he was not. That image symbolises the lack of accountability at political level in the delivery of our public health service.

As a member of the Committee of Public Accounts, I see how the health service has multiple financial systems all working on a different basis. When HSE officials attend the committee, what seem to be relatively simple questions are often not answered because the information simply does not exist. I recall asking how many people in the HSE earned increments above a certain level. It took weeks for the HSE to establish the answer because there was no system in place to deal with the query. Anything we can do to untangle the HSE is a vital and welcome development.

It is important to remember that our health service is not just about hospitals and trolley counts. Members and the media fall into the trap of thinking only about accident and emergency departments, when the service consists of far more than just hospitals. I am glad the new directorates that will be set up in the HSE recognise this fact. There will be directorates for hospital care, primary care, mental health, child and family care, social care and public health. We need to look at how we can treat people in their communities and provide health care at a more holistic level.

The development of the new child and family agency to prioritise child protection is very important. We know of so many instances in which the HSE did not even discuss the issue of child protection at board meetings when there were so many failings in our child protection systems. The creation of this new directorate has to be a welcome development.

It sends a message from the Oireachtas and the Government that when we hold a children's rights referendum, it is more than simply a referendum or a box-ticking exercise because it is being backed up with real and substantive policy change.

I welcome the fact that we will have a new directorate specifically empowered in the area of mental health. It was decidedly disappointing that the House and the Government, through the budget, could propose to ring fence €35 million, that the Oireachtas could vote that resolution through, that the Minister of State with responsibility in the area could declare in good faith on the Front Bench on this side of the House during a Topical Issues debate that she had the money in her back pocket, but then unelected HSE officials could manage to siphon off that money and put it somewhere where the Minister did not want it, where the Government did not intend it and where the Oireachtas did not vote it. If we are serious about real health reform and real political accountability then when the House takes a decision, when the Government puts forward a proposal that is accepted and when a Minister directs something to happen, we cannot allow a bureaucratic structure to do something else.

Deputy Robert Dowds

Hear, hear.

Deputy Simon Harris

I am pleased with the work of the Minister of State, Deputy Lynch, and her attempts to get back this money and send out a clear message to the effect that when we ring fence €35 million it should be spent on mental health services. There was cross-party support on this issue.

This reforming Bill is an important step towards the roll out of free general practitioner care. I compliment the new Minister of State, Deputy Alex White, on his stated intention to begin the process of rolling out free GP care this year. The Minister of State, Deputy White, and the Minister for Health, Deputy Reilly, are to be commended in this regard. I look forward to the continued development of primary care centres. There is a new centre due to go to construction in my hometown of Greystones next month.

When we are discussing the health service and public sector reform in general we should stop talking about it with unions and national politicians while ignoring the people who actually know how to reform the services. Those who know where the savings are and how to make the structures better are the people working in the health service. I appeal to the Government and to everyone involved in political life in this regard. By all means let us have national talks with union leaders and national politicians and doorsteps and "Six-one" news coverage, but we must also discuss the issues with the nurse on the ward and the dentist working in the primary care centre. We must consult them on where they see opportunities to save money, what they see in terms of waste and how they would run services. Despite all the discussion we have had about public sector reform, this element has been missing.

Deputy Peadar Tóibín

On 31 October 2010 some 10,000 people took to the streets of Navan in support of Our Lady's Hospital, Navan. It was probably the largest such rally in living memory in County Meath. The now Minister for Health, Deputy Reilly, was invited to speak on the day. Rightly, he decried Fianna Fáil for cutting surgery services from the hospital. He promised that they would be returned under a Fine Gael Government. Some months later in 2011 Fine Gael issued a newsletter to every home in the county stating that under Fine Gael services would not be cut in the hospital until the new regional hospital was built. Some of the Fine Gael candidates promised that in the lifetime of the current Government a new regional hospital would be built in Navan, County Meath.

We are approaching the halfway point of the current Administration. The cynicism of that pre-election promise has been laid bare because nowhere to be seen are there even plans for a new regional hospital in Navan at the moment. Following the election, the Minister for Health, Deputy James Reilly, distanced himself as much as he could from the Fine Gael promise made by several candidates who later became Members and who serve along with the Minister in government. We have also discovered that despite these promises the trajectory of Fine Gael and the Labour Party in government would be exactly the same as the trajectory of the Fianna Fáil Government.

In August last year it was announced that manpower supplied by agency staff for various duties, including overtime, to the equivalent of 200 staff members would be cancelled and not replaced in the Louth Meath area. These cuts have affected such places as Navan more than elsewhere. Over the years, because of the HSE desire for reductions at Navan, it has encouraged the relocation of staff from there to Drogheda. The posts in question have been backfilled by agency staff. Therefore, when agency staff are cut, it radically affects hospitals such as Navan a great deal more than elsewhere. We have seen cardiac technicians who provide front-line services being let go from Navan and not replaced.

The Minister present, Deputy Bruton, has some of his roots in County Meath. Does he not believe that a heart attack in County Meath deserves the same level of medical response as a heart attack anywhere else in the country? Typically, individuals who have had strokes in County Meath receive health care services from speech therapists, especially in an emergency situation where they are choking. However, speech therapists have been let go and not replaced in Meath.

The Minister should listen to the comments of a senior consultant on the effects of cuts to services in the Louth Meath region. He said they would lead to delayed admissions to intensive care units. He said they would lead to delayed emergency and cancer surgery, delayed cancellation of elective adult and paediatric surgery and cancellation of procedures for management of acute and chronic pain. Incredibly, a senior consultant stated in a letter to the HSE on the back of the cuts initiated by the Government that any cuts in the region would increase sickness and mortality rates for patients requiring surgery. Recently, I spoke with a surgeon involved in cancer surgery. He informed me that over Christmas due to the level of accident and emergency overcrowding he was forced to put cancer surgery on hold. Beds which were to be used for the recuperation of cancer patients were instead used to take the flow from the accident and emergency department. These cancer surgery patients are in chronic pain and immediate need of surgery. All this is a result of the cuts that have taken place. So bad is the situation that the Irish Hospital Consultants Association stated that its members will no longer be liable for breaches of patient safety as a result of these cuts and that responsibility now rests with the HSE.

Surgery services of which the Minister, Deputy James Reilly, spoke during the 2010 rally in Navan have not been fully returned to the hospital in Navan. So disgusted are the people of Meath at the evaporation of Fine Gael's pre-election promises that some time ago on a cold November day a second march was held. Between 6,000 and 8,000 people attended that march, the second-largest march in Meath in living memory. The campaign was phenomenal. Some 40,000 leaflets were distributed door to door. Some 8,500 people participated through Facebook. A total of 5,000 new petitions were signed, bringing the number of petitions signed on behalf of the hospital to 20,000. Up to 1,000 businesses and shops throughout the county erected posters in their shop windows. A total of 130 community organisations from Meath GAA down mobilised their members to join the campaign.

Our Lady's Hospital, Navan is in a critical position. People wait on trolleys every night while empty wards remain closed beside them. Serious front-line emergency services are gone despite promises. No consultation has occurred with staff or elected representatives in the county on the impending small hospital report.

Hundreds of millions of euro have been taken from funding for the HSE in recent years and the trend continues this year. Orwellian promises such as "universal health care" translate to the reality whereby medical cards are taken off people on low income. There is a palpable fear that the retrenchment trajectory of the Government will continue under this Bill and translate into further erosion of critical health services in Meath.

My plea to the Government is to focus on how critical health services are in hospitals such as Navan and to ensure that access to health care, which should be a right on the basis of need alone, is not taken from individuals in such a radical way.

On a regular basis I meet elderly people, perhaps with progressive chronic bone disorders, who are on waiting lists to join waiting lists. It is incredible to see these individuals, many of whom have paid taxes all their lives and who have contributed to society in every way they could, left in a situation where they cannot leave their houses.

They hobble around their homes waiting to see a consultant who can put them on a waiting list. I ask the Minister to uphold the pre-election promise that no services will be cut from Our Lady's Hospital, Navan, while we wait for a new regional hospital to be built in the town.

Deputy Robert Dowds

I am happy to support the Bill because I live in hope. I live in the hope that we can move towards an efficient health administration which serves patients and the community. I live in the hope that we can have a health administration which clearly accounts for the ways in which money is spent. I live in the hope that qualified accountants will be deployed effectively to ensure that is done. I live in the hope that we can have a democratically accountable organisation which provides elected Members with replies to queries as quickly as a Government Department.

The Minister has a lot of work to do given that health budgets are so much more difficult to come to terms with than those of any other Department. When one examines the figures spent in the education sector, which involves similar sums of money, one can follow reasonably closely where the money is being spent. Due to the way the HSE has been organised, it is very difficult to fathom where exactly money is being spent. It leads to scenarios like the one referred to by Deputy Simon Harris whereby money allocated to mental health ended up being siphoned off. Admittedly, it was replaced later. There is a real need to address this kind of issue.

The HSE is an example of the worst Fianna Fáil administrative practices. It was created as an extra wall between the public and the Government and as an organisation for politicians to blame rather than to take direct responsibility for services. It is vital that we move towards a more accountable structure. Ultimately, our aim must be to create a top-class, single-tier health service. It grieves me that the highly skilled doctors, nurses, occupational and speech therapists and orderlies by whom much excellent work is done in our health service are so ill served by the administration in place. If the Bill moves us towards a more satisfactory structure, we will be in a much better place. I wish the Minister well with it. Notwithstanding the criticism that is made of the health service, it is important to acknowledge the excellent work the professional and other staff do. They must be served by an effective administration. We have not had one to date. The Minister's actions are much to be encouraged.

The unresponsiveness of the HSE administration means we suffer from a lack of good primary health care and have a two-tier system which prioritises the rich over the rest. To this day, representatives receive serious complaints about waste. Deputy Simon Harris made a point earlier about consulting the people on the ground. It is important to do that because they are the people who can most easily point to savings which can be made. The two most recent complaints I received were in respect of a hospital in the north east and a blood clinic in a Dublin hospital. In the north east, the waste was in relation to stationery. It was pointed out that if the stationery had simply been sourced from Easons on the local main street, it would have cost less. I ask the Minister to indicate whether Deputy Brian Hayes's work as Minister of State with responsibility for public procurement will cover the health services. There is clearly work that needs to be done in that context. A person working in a blood clinic in a Dublin hospital told me she took samples from the same person three times over three consecutive days. She knew that the first sample would have been more than adequate. There was a waste of her time, equipment and testing facilities. Those two small examples will, unfortunately, be replicated across the country.

It is a tragedy - though no fault of the current Government - that we do not have sufficient money to spend on health. In that context, every cent must be used to great effect. I pay tribute to the great efforts of our many health professionals. If the Minister for Health, Deputy James Reilly, can reform the HSE, he will deservedly go down in the annals and have a proud place in history.

Deputy Seán Kyne

Of all Government responsibilities, health is perhaps the most significant. The provision of health services is a vital aspect of any functioning and compassionate society and one of Government's most important tasks. Everyone requires health care at some point in his or her life. Ensuring that all who need care receive it depends on careful planning, the allocation of significant resources and astute management. It is often overlooked that tens of thousands of citizens are successfully treated each day in our clinics and hospitals. People also overlook the fact that this year the Government will spend €13.5 billion on the health service which figure represents just under 27% of all Government spending. That one in four euro the Government spends will be spent on health is a clear measure of the importance Government and citizens attach to health care.

Providing health care is but one of the obligations placed on the Government. It also has a duty to ensure that the funds raised from taxpayers are spent as efficiently and effectively as possible. This is where the Health Service Executive (Governance) Bill comes in. Given the current financial situation, the goal of the Government is to cut costs but not the level and quality of care. This entails doing more with the significant investment which has already been made while ensuring that every extra euro spent goes further in tending to the health care needs of the people.

The efforts of the Minister and Ministers of State at the Department of Health and of the thousands of doctors, consultants, nurses and other staff are evident though not often reported. These efforts have led to exceptional improvements including a year-on-year reduction of 24% in the number of people on trollies in our accident and emergency departments. There has also been a substantial reduction in the number of adults waiting nine months and more for in-patient and day-care surgery from 3,700 in December 2011 to just 86 at the end of December 2012. There has been a 95% reduction in the number of children waiting more than 20 weeks for in-patient and day-care surgery and a huge reduction in the number of people waiting 13 weeks or more for routine endoscopy procedures from 4,590 in December 2011 to just 36 at the end of 2012. These vital improvements are the result of better use of the funding allocated to the health service. Improved management structures have gone hand in hand with the improved use of funding.

The announcement of the establishment of the HSE in 2004 seemed to herald a radical and bold departure from the health board system. Gone, we were told, would be the narrow, local focus while efficiencies and increased effectiveness would result from a new, businesslike approach.

Unfortunately, we know what happened. These much trumpeted plans never materialised properly. Instead we saw name changes, new titles and extra management layers, with little or no progress. The most valuable asset of all - the human resources - was not addressed in any meaningful strategic sense and merely transferred from one employer to another. Ultimately, the Government has inherited a brand in the HSE that has been damaged and does not inspire confidence among the people it is supposed to serve. For that reason, the Government has embarked on an ambitious programme of reform which will take time to implement but which will represent real change with visible results.

The Bill is part of that reform process. It contains an interim suite of measures that will provide the powers needed for decisive action and enable the Minister to more ably lead the way in reforming the health service. The new approach espoused by the Bill can already be seen in the much needed improvements in the work in the west with the new Galway-Roscommon hospital group under its CEO, Mr. Bill Maher. The group has seen significant improvements and results in the past year. The number of patients seen and treated was above the target set out in the service plan within the confines of a reduced budget and staff. Galway University Hospitals met one of the key targets of the Department of Health's special delivery unit in respect of inpatient waiting lists in 2012 - that no adult should wait longer than nine months, that no child should wait longer than 20 weeks and that patients requiring scopes should be seen within 13 weeks. Progress was also made in 2012 on the length of time patients had to wait for admission from the accident and emergency department. In February 2012 there was an average figure of 24 patients awaiting admission at 8 a.m. in Galway University Hospitals. This number was reduced to 12 in November. From talking to staff in the hospitals, one can see there is a newfound confidence that the Galway-Roscommon hospital group is working well with a reforming and efficient new CEO. It is great to see such progress. This is the model we want to see rolled out across the country with these results.

Deputy Áine Collins

The way the HSE was set up in the first instance - abolishing the regional health boards and amalgamating them into one huge bureaucratic nightmare - caused serious problems for the health service. As no steps were taken at the time to rationalise management structures and achieve efficiencies in administration, the result has been catastrophic. No savings were made and a monumental organisation was created. Overstaffed from a management and back office point of view, this resulted in a situation where it was very difficult to know who was responsible for what. No investment was made in processes and systems to measure efficiency and effectiveness. It is difficult to manage any organisation, be it public or private, without timely and accurate information. There were particular political reasons for this. The then Minister for Health needed day-to-day management to be at arm's length from the Department of Health. The Minister at the time did not have to take direct responsibility and was not directly responsible to the Oireachtas for the total mismanagement of the health service.

The Government came to power with an ambitious plan for the health service. It involved free GP care for all and a plan to introduce universal health insurance. One of the major obstacles to this plan was the hugely expensive cost of running the HSE and the inefficiencies associated with bringing it into existence in the first place. The Minister made changes to the composition of the board immediately which were designed to facilitate greater co-ordination and integration between senior management teams in the Department of Health and the HSE. At that stage, the Minister committed to introducing legislation to abolish the board structure and establish new governance arrangements for the HSE which would permit its eventual dissolution. Provisions to make these changes are included in the Bill.

The reorganisation of the health service is a significant task, made more so by the fact that previous Ministers for Health did not deal with the problem. They tried to protect themselves from problems that arose in the service by putting in place very complicated and extremely bureaucratic structures. This meant that, legally, the Minister evaded responsibility for being directly accountable to Members of the Houses of the Oireachtas.

The Minister is determined to abolish the HSE in order that he can implement the programme for Government, in particular, achieve the ultimate goal of having an efficient and effective health service. Very few realise the significant task facing him. He must unwind an ineffective system put in place by previous Ministers. This involves significant change management of staff. Retraining of staff needs to take place, which is time consuming and costly. There is no simple solution. For the moment the HSE will be responsible to the directorate headed by the director general. This directorate will be the new Government body in place of the board of the HSE. The Bill provides that the directorate will be accountable to the Minister for the performance of the HSE's functions and its own functions as a governing authority. The Minister will in time be accountable to the Oireachtas.

The Bill is only one step in dismantling the HSE and putting structures and processes in place that will allow the Minister to implement Government policy. It begins the process of returning responsibility for the health service to the Minister and the Oireachtas where it rightly belongs. It will be a long and difficult process, but the Minister is trying very hard to unravel a deliberately complex structure put in place to avoid a situation where anyone would have to take responsibility for their actions. The fact that this must be done in stages shows the complexity of the process. It should be noted at this stage that there are some very good people in management and administration in the HSE. The facts are that previous Ministers failed to face up to the changes that were necessary and did not provide the leadership and investment in new ways of management and technology that were required. The new structure is designed to help to prepare for the next phase of the health reform programme. More importantly, the Bill will make the HSE more accountable to the Minister for Health who, in turn, will be more accountable to the Oireachtas and the people. While the HSE will continue to have operational responsibility for running the health service, the Bill sets out parameters which will lead to a more integrated care system and governance with a clear line of responsibility from the HSE to the Minister.

In his concluding remarks in the Seanad the Minister continued to use statements reflected in the programme for Government, stating the reform programme was about the patient. He also believes these changes will make sure the patient is at the centre of the service and that the health service will be reminded continually about its obligation to serve the patient. Despite the continuing criticism of the health service, it should be noted that, as Senator Colm Burke said in the Seanad, much progress has been made in outpatient care services. The number of appointments has increased from two million to 3.5 million in the past ten years. The number of day case procedures has increased dramatically. These increases have taken place because of the reforms and reorganisation in the HSE that the Minister has already undertaken. As money is extremely important in the current economic environment and the Minister's theme is that the patient comes first, it is essential that the taxpayer also gets value for money.

I wish the Minister the best of luck in this necessary and difficult programme and his endeavours to drive reforms which will lead to measurable outcomes. I have every confidence that owing to the willingness of the many great people who work in the health service, this programme is achievable and commend the Bill to the House.

Deputy Peter Fitzpatrick

The programme for Government commits to the eventual dissolution of the HSE as the health care reform programme advances. It will be replaced with a system of directorates headed by a director general. The directorate structure is intended to be an internal measure pending the ultimate dissolution of the HSE which will require further legislation. The Bill is, therefore, intended as a transitional measure designed to prepare the health system for the changes ahead, while also making the HSE more directly accountable to the Minister for Health who, in turn, will be accountable to the people through the Oireachtas.

The Bill does not change the legal status of the HSE under the Health Act 2004. It amends the Act by abolishing the current board of the HSE and replacing it with a directorate structure comprising a director general and other directorates. To offer flexibility and allow the size of the governing structure to adapt to changing circumstances, the Bill does not specify a fixed number of members for the directorate but instead provides for a maximum of seven and a minimum of three, including the director general who will automatically be a member and the chairperson of the directorate.

Under the Bill, the directorate will have the authority to perform HSE functions. However, the Bill does not provide the details of the administrative structure of the directorates such as how particular service areas ought to be assigned among the directorates. The HSE will continue to have operational responsibility for running the health service. The broad structure of accountability is built on existing provisions in the Health Act 2004, but the Bill contains provisions which will extend the Minister's powers to direct policy and clarify parts of accountability. In particular, the director general should account to the Minister and the Secretary General of the Department of Health. The Minister may issue written directions to the HSE about policy implementation if he believes insufficient regard has been paid to a policy objective. These directions may not relate to individual service users. However, the director must inform the Minister about what measures have been taken to comply with ministerial directions on policy implementation.

The Minister can specify priorities which the HSE must take into account when preparing or amending a services plan. The Bill provides for the establishment of an audit committee which will advise on financial matters and report at least annually to the director general and the Minister.

Health care in Ireland accounts for 27% of total government current expenditure. After social protection, it is the largest spending programme. The HSE's expenditure for 2011 was €13.588 billion, of which 37% was spent on hospital services and 34% on community services. At the end of 2011 it employed 104,392 whole-time equivalent staff, a reduction of 3.3% compared to the end of 2010. Of these staff, 46.7% worked in hospitals and 47.6% were in community settings. More than 75% of the population, or 3.4 million people, availed of services through 425 primary care teams. Some 1.694 million people were covered by medical cards, representing a net increase of 78,254 people since December 2010. Over 370,000 emergency admissions were made to acute hospitals over the year, which was 3,000 more than during the previous year.

The programme for Government commits to a programme of health reform aimed at achieving a single tier health care system based on universal health insurance. As part of the reform process, the Health Service Executive will cease to exist and its functions will return to the Minister or be taken over by the universal health insurance system. In December 2011, Government approval was given for drafting this Bill as part of the reform process culminating in universal health insurance. Provision is made for the Minister for Health to consult the Minister for Children and Youth Affairs before specifying priorities or performance targets in respect of functions of the executive relating to the functions of the latter. These are transitional provisions pending the establishment of the child and family support agency and the transfer of certain HSE functions to that agency. The legal status of the HSE under the Health Act 2004 does not change under the Bill and HSE employees will remain the employees of the HSE.

Deputy Mattie McGrath

I am delighted to have an opportunity to speak on this proposed legislation. The Minister stated:

I have followed the debate on my monitor and in the Chamber and, while I do not want to disagree with my colleagues, I only wish I could have their faith and enthusiasm.

As a medical practitioner with vast experience, the Minister should have understood the ramifications of the many, varied and somewhat desperate promises he made before the election. They were ridiculous in the extreme because anybody could have told him that the previous Government was departing office speedily and had practically disintegrated. He did not need to make any promises but that would not do for him. Whether due to a rush of adrenaline or for some other reason, he had to tour the country, including my own county, and make promise after promise. He must have realised most of his promises could not be fulfilled. They were aspirational, unnecessary and overly zealous.

The Minister inherited a structure which was created in 2004 to bring all the health boards together. Bad and all as the health boards were, at least they offered local accountability. He complained on a daily basis about the then Government's failure to issue replies to his parliamentary questions. Questions were disallowed because they were matters for the HSE rather than the Minister for Health and Children. He promised reform of the system, with universal health care and free GPs for all. I think he referred to the Danish model but I may be wrong about the country. He knew it could not be done unless there was radical reform. I do not know who drafted this Bill but it is another cop-out. It shies away from the political decisions required to deal with an out of date and outrageous organisation. Many good people work in the HSE on the front line and in back offices but it is not fit for purpose as a working vehicle for delivering modern health services. It was cobbled together without the loss of a single job.

As a small businessman I am aware that a business is not viable if wages comprise more than 50% of its costs. It is unviable and unworkable and, with the way the Minister is going, it is going to be unfixable. I would love to have the enthusiasm of the backbenchers who commended him on his actions. At the rate we are going we could be here in 2030 and this monstrosity will not have been dismantled. It has grown into a monstrosity and many good people are striving day in and day out to provide services for sick people. On Monday evening I attended a funeral in Clonmel. The family of the deceased were loud in their praise of hospital services. When one is able to get into hospital the services are very good, but the bureaucracy and pen pushers surround all this.

A nun retired recently from a small hospital in my county. Her name was Sister Áine and she was one of the last remaining matrons. She ran the hospital not with an iron fist, but with authority and respect. There were no instances of MRSA or the disappointing HIQA reports that were published on my own hospital in south Tipperary, which I will not discuss until I find out the facts. One could see that when one walked into the hospital. We have lost the system where one person had authority. When a patient entered hospital and the matron was in charge, there were no bed managers, ward managers or risk assessment managers. We have a manager for this, that and the other. In many cases they have nothing to manage. The problem is there are too many layers. Many people use the system to climb to positions of authority. It is a shame that the system was allowed to grow when the HSE was established by the previous Government in 2004 without ever weeding out the dead wood. The contract cleaners and everything else then came in. This is where the problem began. When a matron was in charge there were no contract cleaners. The blessed medal was put under a statue and someone was called in to explain why the cleaning was not done properly if the statue was not moved. There were no cases of dust on window sills, telephones or computers. The work was carried out with respect and dignity for those who went before.

The Minister has a hard job but he created the hardest job for himself. He created so many expectations and made so many promises that he cannot fulfil them. He should have known that because he negotiated on behalf of his former colleagues with previous Ministers. Nobody was in a better position to assess the problems but his lust for power was too much. He was going to wave the wand and everything else. I will never forget the day he came to Clonmel. I waited two and a half hours for him to arrive and a further two hours while he launched a project in St. Luke's connected to Limerick Institute of Technology. He was to meet Oireachtas Members as a common courtesy but he ran out of the place faster than Cromwell was hunted out of Clonmel. He nearly knocked the patients from their trolleys such was his indecent haste. He ran up and down the wards, then jumped into his car and departed like the flight of the earls. He has not returned but he is welcome to leave us and the model we are working towards in south Tipperary and the south east alone.

Debate adjourned.

Dáil Éireann debate - Wednesday, 30 Jan 2013

Health Service Executive (Governance) Bill 2012 [Seanad]: Second Stage

Dáil Éireann debate -
Wednesday, 30 Jan 2013