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Dáil Éireann debate -
Thursday, 31 Jan 2013

Vol. 790 No. 3

Health Service Executive (Governance) Bill 2012: Second Stage (Resumed)

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

I stated last night that the Minister for Health, Deputy James Reilly, had made his own bed, and it is not a bed of roses in the Health Service Executive, HSE. There was no need to make any promises before the last election but he made so many that he has been in a tailspin ever since trying not to fulfil them.

We know the way the governance in the HSE was set up. There are nothing but problems in it. It is top-heavy with administration. There are many good people trying to work on the front line and in administration, but there is a lot of dead weight, inertia, unhappiness and unease. If anyone knew the HSE inside out it was the Minister because of his profession and his skills in negotiating with it in the past on behalf of his profession.

This short Bill is a cop-out. There is no intention to tackle the HSE or disband it. With righteous indignation the Minister and many others in opposition were tabling parliamentary questions and getting back replies from the HSE that the matter was not one for the Minister. That is a cop-out and an abdication of powers. That is probably the reason the HSE was set up, but the Minister promised to banish all of that. He said he would deal with it, cut out the dead weight, get answers and be accountable, but what happened? We know the way he handled the board and what happened with the chief executive officer. Last week we found out, thanks to an RTE freedom of information request, how projects in my region, the south east, were fast-tracked at the expense of others because, as the Minister proclaims, the money follows the patient, but the money here is following the Ministers. They were trying to save their seats by ensuring that money was spent in their constituencies, and the CEO of the HSE, Cathal Magee, and Brian Gilroy, who was always a very good public servant, did not know anything about it. They heard this had been done before the board even met. What we are doing in this Bill is tinkering with the system, but it will not make any tangible difference.

The Bill is intended to provide for a transitional measure, but that is the problem. There has been too much transition and not enough action in the HSE since 2004. The former health boards were accountable. I would love to know who drafted the Bill because it is couched in language that will continue to confuse. We will continue to have inertia and a lack of accountability in the HSE, and it will continue to be a monstrosity that is not serving the well-being of the people.

Accountability is referred to in the Bill, as are new posts. Separate from the Bill, but in support of the new directorate and administrative structure, the HSE has already initiated the process of putting in place the new HSE directorate management and leadership team. "Management team" and "leadership team" have become buzzwords, certainly in the past ten years, and these people are leading like sheep out of a gap. There is no vision or proper thinking on their part. We have reports from the Health Information and Quality Authority, HIQA. As I said last night, I was very disappointed with my local hospital, which was criticised because of the levels of dirt. There is no excuse for this. They can have all the leadership and management teams they want - bed managers, ward managers and floor managers, which they never had in the past - but there is no excuse for dirt in a hospital. When matrons were in charge of our hospitals, that did not happen. I am glad HIQA found that problem because it is not fair to patients or the public.

There is another issue in the hospital with patients on trolleys, the pressure of intake on the wards and the pressure the staff work under day in, day out. Front-line nursing staff, junior doctors and consultants are treating patients on beds in corridors. They should not be expected to work in those conditions. The European working time directive is being flouted in this case, yet in other areas EU directives are being implemented to the letter of the law. The staff in South Tipperary General Hospital are under too much pressure. They cannot cope with beds in corridors. They do a tremendous job for which they are constantly praised, but I blame that part of the HIQA report on a lack of resources, funding and support from the HSE nationally and regionally.

What happened last week undermined the basis of what we are doing in the south-east region - that is, working towards a centre of excellence in Waterford Regional Hospital. The Minister of State has one in his region, and there are eight in the country. Many of us bought into that process reluctantly, but we sat down with the consultants, the nursing staff, the domestic staff, all the clinicians and the senior officials in Health Service Executive South, with whom I have had major issues and many of whom I distrust. I hate saying that, but they will tell one something in a meeting only for one to find out later that something different was done a week beforehand. That is the kind of spin that is going on. We bought into that project only to have a bombshell dropped before Christmas when Kilkenny tried to align itself with Dublin. That would undermine the basis for our centre of excellence in Waterford Regional Hospital, because we would not have the numbers.

The Taoiseach, in reply to my questions the other day, stated that conditions in St. Luke's General Hospital, with portakabins and so on, were appalling and that people were practically working in tin huts. That is not true. Issues arise in every hospital where portakabins and prefabs are used, but to demonise the situation in Kilkenny and Wexford - I have never been in Wexford General Hospital - is wrong. It is simple spin because the Minister was caught napping. He was caught engaging in cronyism of the worst kind, when we are dealing with people's lives. I will say no more on that, but we are awaiting a report from Professor Higgins, whom I was accused recently of maligning. I did no such thing. I merely stated that he is working out of Cork and, naturally, the more throughput he can get for that area, the better. I am sure he will do an independent report but the games being played and the brinkmanship being engaged in by the HSE are wrong. We have too many layers of management and, sadly, many of them have nothing to do but make work for pen-pushers and everyone else. We do not have the front-line staff where we need them, and this Bill will not change this.

I refer to the new posts. The five new national directors will be responsible at national level for the delivery of services in each service domain - that is, hospitals, primary care, mental health, social care, and health and well-being. It should be all about health and well-being; we can forget about the first four. They know what they have to do. We must get value for money from the hospitals and faster throughput. If the consultants want to use the public hospitals for their private practices they should be charged for that. When I was only a ladeen I recall Barry Desmond saying he could not understand why the consultants - and many of them were eminent people - should be allowed use public hospitals and charge enormous rates while veterinarians set up their own practices, bought their own equipment and so on. That is farcical, and the Minister is one of the people who subsequently negotiated some of those packages. It was from that time that the rot set in. Public hospitals should be for public patients, and if the consultants want to operate in private hospitals, let them do so, and they should give value for money.

The cost of health insurance is a rip-off. This morning we heard that VHI intends to increase premiums by 6% on top of what it got earlier. People cannot keep paying those premiums, and that will put more pressure on public hospitals. The charges VHI applies are immoral. I refer to ambulance services alone. I had need of one 20 years ago when I travelled the same distance as from here to Grafton Street. I could have walked it but I did not; I needed an ambulance, for which I was charged £500. It was daylight robbery. A case was recounted to me last week in which an ambulance that arrived to take a patient from Clonmel to Waterford came from Sligo. What is going on? That is mismanagement and bungling, because it is an eight-hour journey from Clonmel to Sligo, and that ambulance may have been needed elsewhere.

We are told that all of the new positions will be above board because the Public Appointments Commission will choose the candidates. I will tell the Minister about the Public Appointments Commission. He might be aware that in the previous Government the then Minister, John Gormley, in his wisdom, set up the Inland Fisheries Board and decided that the commission would choose the candidates. There was an advertisement process and I was chair of the interview board. We arrived into the Public Appointments Commission to interview the candidates who had been short-listed. I met a lady from the commission who told us the way the process would run for the day. There were three Oireachtas Members on the board: the then Deputy Peter Kelly, the then Senator Noel Coonan and me.

She went on to inform us that she had short-listed the candidates because it would be too hard for us. First, I wanted to have the interviews take place here on a sitting day, but they had to be held on a Monday at the Public Appointments Commission. I got an insight into what went on at these interviews. The number of former county managers and retired officials on the list was sickening. Every one of the first 20 was either a retired chief superintendent, a retired chief medical officer or another official who already had a big pension. I turned the list upside down and said we would start from the bottom up. I was looking for the candidates involved in fisheries and there were many such eminent people. We picked the three candidates and the lady involved in organising the interviews did not get her way, a point about which she was not too happy.

This is the charade that takes place across the country, which is why the country is the way it is. It is being plundered by officialdom; there are jobs for the boys and there is cronyism. I am not referring to political cronyism but inside cronyism, with no command over officials. No Minister will take on the officials because Ministers are afraid of them. I saw it happen with the late Brian Lenihan and see it going on in the Department of Finance. The officials who got us into the mess are still there, except those who were promoted to position in the European Union. They would not even see a hole in a wall and because they are so long in the system they are suffering from fatigue. I have no faith in the Public Appointments Commission because of its shenanigans. Those involved look after themselves and their friends in high places.

In the case I described the candidate list was filled with the names of this and that retired chief. It was as if they did not have enough in their pensions and pay-outs, while ordinary people who had applied were kept off the list. The same has happened in the case of the NewERA project in which people who applied for advertised positions did not even get a response. They are waiting for the Minister to choose, but we have seen what happened with the Minister for Justice and Equality. Their own cronies will be chosen again. If we do not break that system, we will not fix the country or sort out the mess that is the health system.

To whoever drafted this legislation, it is a pious and useless document. It is only a stop-gap measure and just playing the game. It is said it is a great game played slowly, but it is too late for that. The Minister for Health promised change, but he has no intention of sorting out the health service. This holding Bill to buy more time is a farce.

I wish to share time with Deputies Liam Twomey and John Paul Phelan.

I welcome the opportunity to speak on the Health Service Executive (Governance) Bill 2012. Like other Deputies, I questioned previous health Ministers on the management and delivery of health services in my constituency. Of course, I got the usual reply that the Minister was not responsible but the Health Service Executive, HSE, under the Health Act 2004. That Act imposed structures on the HSE which have not worked, while allowing previous health Ministers to hide behind it. There was no integration, no clarity, no direct accountability between the HSE and the Minister. It important that the HSE is accountable to the Minister, as well as to the Dáil.

The Bill is an interim measure. In the long term the Minister for Health, Deputy James Reilly, is proposing to abolish the HSE in favour of a new system of directorates headed by a director general. This is a brave step by the Minister and will bring accountability and transparency to the sector.

As part of the reform of the health service, the reconfiguration of acute hospitals in the mid-west region is under way. The role of Ennis General Hospital has changed substantially. We are fortunate that a good manager took over in 2010 and under his stewardship, with a dedicated and loyal staff, the hospital has been given a new lease of life. Up to €2.5 million has been invested in the endoscopy unit. The hospital won first place in the national health care innovation awards for the provision of radiology services last year, boosting confidence in the hospital and eliminating X-ray waiting lists. A new €15 million state-of-the-art 50 bed wing has opened and it is the first health facility in the country that is SARI - strategy for the control of antimicrobial resistance in Ireland - compliant. I look forward to the Minister officially opening the facility in the near future. As the hospital manager has moved on, I hope the range of services he introduced will be maintained. The framework for the development of smaller hospitals will be published shortly. It will help to define the role of hospitals, including Ennis General Hospital, in the mid-west regional hospital group. I understand it will focus on enhancing and growing services rather than downgrading them.

In the past the Opposition sought to question the role of the local emergency centre at Ennis General Hospital, which is glaring hypocrisy in view of the track record of the previous Government. I remind the Opposition that the outgoing manager of the hospital said 90% of accident and emergency cases could still report to Ennis General Hospital, even when the new system was put in place. Every patient wants and deserves the best treatment and he or she must have confidence that if he or she needs to access this service, it will be available.

Since taking office the Minister has worked hard to improve patient outcomes. He has set up the special delivery unit, made significant progress in reducing waiting times and set clear targets which the HSE has to meet. This year the HSE service plan aims to have 95% of all attendees at accident and emergency departments discharged or admitted within six hours of registration.

According to the Irish Nurses and Midwives Organisation, INMO, there are 22 patients on trolleys at the accident and emergency department at the Mid-Western Regional Hospital in Limerick. As the number of attendees at accident and emergency departments fluctuates at this time of year owing to flu etc., the current delay at the hospital is causing upset for patients, their families, as well as the nursing and medical staff. I hope the matter can be resolved as soon as possible.

Ireland has the 36th highest suicide rate in the world. Suicide prevention is an issue which the Government has prioritised. Today new guidelines were issued for schools in an effort to stem the problem. The Minister of State, Deputy Kathleen Lynch, is committed to transforming mental health services in line with A Vision for Change and many positive steps will be taken to improve the quality of mental health care. I concur with other Members that unused moneys allocated for health services should be diverted to plug the hole in mental health services.

The Minister is driving reform which is necessary and will lead to better patient outcomes. I compliment him on his work in this regard.

I was a Member when the HSE was established and, at the time, we had high hopes for what it might achieve. Unfortunately, the former Minister for Health and Children, Mary Harney, did not have great clarity of purpose as to what she wanted the HSE to achieve. The HSE ran into several problems in subsequent years which the then Minister was able to deal with by increasing the budget by €1 billion a year. However, she never dealt with the basic problems.

As a general practitioner and having worked with people in the HSE, I know there is no lack of commitment and drive at every level. This legislation will be the start of the changes we have proposed to make in the HSE. However, I am under no illusion as to what could go wrong with this and that there will be people who will try to obstruct what we are trying to do in the health service.

This legislation adds to the picture by making the health services responsible to the Houses of the Oireachtas again, which is important.

Another important aspect of the legislation is the statutory audit committee. I am a member of the Joint Committee on Finance, Public Expenditure and Reform. Recently, we wrote to the Minister for Finance, Deputy Noonan, and the Minister for Public Expenditure and Reform, Deputy Howlin, with regard to ensuring that the way we in the Houses of the Oireachtas legislated for spending was realised. All too often we make a reduction to a Vote, or we direct that certain services should be reduced in health or education, but the directions are not carried out and cuts are made to some other service without the approval of the Minister or these Houses. This ends up with the public believing we are heartless and uncaring because of the cuts made by the HSE. There is a need for strengthening to an even greater extent what is planned under this legislation and the way in which the money the House has voted for is spent to ensure that if reductions are to be made in administrative sections of the HSE, then that is where the reductions will be made, rather than cuts to home help or carers.

The Minister has acknowledged that this is the first step in a range of changes that will take place within the HSE. It is important that this debate is widened as much as possible because there is an absolute need for clarity with regard to what we do with the HSE. Thus far, it is crystal clear that the HSE is an organisation for the delivery of health services. If we are to change the overall mission statement of the HSE, it is important that we clearly outline what those changes will be. At issue is the administration of €15 billion which we spend on health services.

Often we hear from contributors who are keen to get a soundbite. It is easy to demonise the HSE as a faceless organisation, but there are many aspects of the organisation that work well and many aspects that do not work well. For the ordinary man or woman on the street the major issues include what will happen to small hospitals, hospital groups and primary care, how to integrate the HSE with the work of general practitioners, how to genuinely look after patients in the community, how to deal with chronic care and how to set up all the associated structures. All of these questions are vital. These are the tangible questions that patients in the community understand. How to pull all of this together is relevant for the administration of the health service and how we deal with it in future.

It is not possible within ten minutes to go through everything, because we must untangle some of the remarkably inefficient reforms made during the history of the HSE. The HSE is not all bad. In the beginning, because of the way the organisation was thrown together, staff did not really understand their function, and there was poor leadership coming through many levels of the organisation. This gave the sense that the whole organisation was chaotic. However, I have found that a corporate structure has begun to evolve within the HSE such as one would expect of any organisation. It is important that we keep the best parts of what has been evolving and get rid of the worst parts. There is still too much management. Many management structures were created not only within the HSE as an administrative organisation but also within hospitals and at primary care level. Many management structures were set up almost to provide a career pathway, mar dhea, for people involved in the services rather than actually providing efficient management of our health services. It will be difficult to unpick many of these superfluous layers of administration and management during the coming years without affecting front-line services, and it will require remarkable clarity of purpose not only from the Minister but from everyone who provides health services or who is involved in or has an interest in health services in the country. No one is under any illusion about how difficult this will be.

I call on the Minister to clearly state, as far as he can, what is going on. A constantly changing structure without any clear plan relating to what is going on will increase the confusion and fear and this does not get people to buy into what is going on. That is what happened during the establishment of the HSE. Communication will remain vital. We must clearly outline to people what changes are coming about in the health services. Given the reductions in pay for those who work in the health services, the expected efficiencies and the reduction in staff numbers, there is, no doubt, reduced morale within the health services. There is a need to communicate at every level with people in the health services to keep people on board and working with us for the betterment of the patients we are looking after.

It is important that not only those who are delivering health services but those who will benefit from any changes to health services are fully aware of the changes we are bringing about, and we must communicate fully with them. This will be a difficult task in the coming years. The HSE, as it was first established, went through a remarkable number of rapid changes. I recall when Professor Drumm was in charge. At the time the HSE published changes to the management structures and the various pillars it used to deliver health services in the country. The executive changed the structure so often that when we sought information from staff in Professor Drumm's office in Naas, they often provided us with an old structure which was out of date. The people there were so confused about what was taking place that they gave out-of-date information about their own organisation. Such rapid change and messing around with the system reached the point at which I could see the stagnation present at the lower, county level. People were becoming afraid to make decisions and were unsure about the type of decision they could make, which had a negative impact on health services at the time.

This legislation will make the HSE accountable to the people again, which is important. The changes include the setting up of a statutory audit committee, which must be robust to keep the checks and balances in place with regard to how taxpayers' money is spent in the health services. We need to communicate in a crystal clear way to everyone who requires health services and everyone who works in health services about the next steps we must take with the HSE, not only with regard to the gross administration but also with regard to everything else, including small hospitals, hospital groups and primary care. I wish the Minister the best of luck in this regard because it is a remarkably difficult task.

I echo many of the sentiments expressed by the previous speaker, Deputy Liam Twomey. I, too, was a Member of the Oireachtas when the HSE was established. At the time of its establishment there was considerable belief among the public as well as among Members and those who worked in the health services that there was a need to overhaul the structure of governance that existed in our health system. There was a belief that the HSE would deliver successfully on the need to overhaul these services. It is fair to say, from my perspective and from that of customers or consumers of the HSE - the people and citizens who use the service - that much of the governance structure established by the HSE has not been an improvement on what went before under the old health board system. Deputy Liam Twomey referred to the old system and how, under the health boards, people were more empowered to make decisions locally. They had perhaps a better knowledge of the individual circumstances in which individual users of the health service found themselves.

On the establishment of the HSE, that power was removed. There was also a removal not just of oversight by the Oireachtas, but of the ability of Members to obtain information for people. The fact that public representatives deal with individual queries of constituents is much maligned but it is a reality that we are an interface between all aspects of the public service and the public. I have found the HSE structure to be most difficult to get information from for ordinary users of the health service. In fact, it is perhaps the single most positive step in the Bill that it makes the HSE accountable through the Secretary General of the Department of Health to the Minister for Health. It is a step which was committed to in advance of the last election and subsequently in the programme for Government. It is now being delivered in the legislation.

I agree with Deputy Liam Twomey about the continuous change which occurred in the early years of the HSE. Quite often, users of the service as well as staff on the front line felt that the management structures and systems which were put in place were unclear. I welcome the initiative in the legislation establishing directorates under clear headings and the creation of a direct chain of command, for want of a better term, regarding their operation. The HSE is a mammoth organisation in which approximately 100,000 people still work and has been a by-word for bad governance, politically and administratively, since its establishment. I welcome the provision in the Bill for an audit committee. It is imperative that public funds are fully accounted for when used. It is one of the great failures of the HSE as established by Deputy Micheál Martin when he was Minister that many promised savings and efficiencies were not delivered. There was quite often duplication of services across the country. Much of what was promised did not happen because of the system that was put in place in the transition between the health boards and the HSE.

I want to make particular reference to funding for mental health, a subject to which Deputy Pat Breen referred at the conclusion of his comments. The Government has, correctly, committed to ring-fencing funding to make extra provision for mental health services. Notwithstanding the current straitened and difficult economic circumstances and the fact that his hands are tied in many respects, in particular in terms of the budget at his disposaI, I urge the Minister to ensure the funding is not only protected but actually spent on mental health services.

I welcome the legislation. It may be an interim measure, but it is certainly a step in the right direction.

I am glad to have an opportunity to speak on the legislation. One must ask what the purpose of the Bill is because it is not clear. While there has been a lot of talk about different aspects of the health service in press statements and in some of the contributions to the debate in the House last night and today, it has not specifically been about the Bill. It is important to ask why the Bill is before us today.

There has been a lot of talk about the manner in which the HSE organises its services. I certainly do not carry a flame for the HSE and am very conscious of its shortcomings as an organisation and the flawed structure it has been. From the very start, it was clear that the body was established by people with very little understanding of how the health service worked and what its needs were. We have a huge, amorphous body with no clear lines of responsibility, no clear demarcation between service areas and a lack of transparency in its functions and as to how funding is handled. One often gets the impression that the HSE is a kind of black hole into which money disappears.

It is very difficult to get hard information on the numbers of staff employed in different parts of the service and where exactly the funding is going. There is no doubt about the need to reform the administration of the HSE and to put in place separate directorates. While there are flaws and dangers in creating the directorates, they are necessary. There is also a need for greater clarity as to the different aspects of the HSE. Like most Members, I am concerned about that issue.

Legislation is not necessary to improve the organisation of the HSE. Deputy Liam Twomey made very sound points which displayed a very good understanding of the health service. All of the things he referred to could have been done by now and can be done at any stage without legislation. They concern good administration and the operational and service structures within the HSE. We should be doing those things to make the HSE much more responsive to the needs of citizens and patients.

As an organisation, the HSE has two elements. It has an operational structure and a governance structure. The governance structure is the legal basis on which the organisation spends money, employs people and provides services. It is of critical importance that the HSE's governance structure is soundly based. It must be borne in mind that the HSE is the premier public body in the State. It is responsible for a budget which is larger than the combined budgets of several other Departments. It employs approximately 100,000 people and has a budget of €13 billion. It is the major public body which is why it is critical that its corporate governance structure is a proper one which adopts good practice and, from a legal perspective, is soundly based.

It is normally the case that a public body has a chief executive and senior management team and, separately, to ensure the proper checks and balances are in place, an independent board which oversees its operations. This is the general corporate governance structure to which we are used and which is in place in most public bodies. This structure keeps the operation of a public body at arm's length from the political system which is very important to ensure we do not have political interference. It provides an assurance that there is a certain level of accountability and transparency in an organisation.

There is a serious corporate governance problem in the HSE as it is. The problem has arisen owing to the actions of the Minister for Health, Deputy James Reilly, at an early stage in his ministerial career.

We remember what happened on 28 April 2011. Where there are serious problems in the health service, a Minister will naturally look to blame somebody for those shortcomings. The difficulties in the HSE make it very easy to blame it for everything and use it as some kind of whipping boy. We remember the spectacle of the Minister marching down to the HSE in April 2011 and demanding the resignation of the board. He sacked the board, an act that could be regarded as a media stunt. He never explained why he sacked the board, which was made up of very public and well-known people who were of good standing. We are still waiting for an explanation as to why he sacked the board. That then caused the problem whereby we had a major public body with no board. The Minister had to appoint an interim board, which was a very strange board made up of seven senior people from the Department and four senior managers from the HSE. The HSE needs a proper governance structure but it was denied this because of the actions of the Minister. The HSE needs an independent board but to turn around and appoint one now would be an admission of the folly in which the Minister engaged in April 2011. In many respects, this legislation is a face-saving exercise for the Minister. This gets to the heart of what this legislation is about. It is not about reorganising the HSE or making it more responsive. It is about putting in place a corporate governance structure which the HSE does not have as a result of the Minister's action.

What is being proposed in this legislation is that instead of a board, which most public bodies would have, the HSE is to have a directorate. This directorate will be made up of the director general and between two and six directors who will be appointed by the Minister. The director general is to be recruited in accordance with the Public Service Management Act, which is standard. It is also important to highlight the fact that the first director general can be appointed by the Minister and, of course, that is what has happened. The Minister has appointed a director general designate in advance of this legislation. I want to be clear that the point I will make in respect of that is no reflection on the present incumbent but relates to the procedures followed in this regard and the procedures provided for in this legislation.

It is important to cast our minds back to how this situation arose and recall that on 18 July 2012 the Minister published this legislation. Section 7 proposes to insert Part 3A into the Health Act 2004. Section 16C(4) of Part 3A allows the Minister to appoint the first director general without regard to the normal recruitment procedures. There was understandable criticism of this provision when the Minister published the legislation in July. What has been given far less attention is the fact that the Minister, in seeking the approval of his Cabinet colleagues on 17 July 2012, sought and received approval for this power while withholding from them the fact that the incumbent chief executive of the HSE, Cathal Magee, had already tendered his resignation. Allowing a Minister to appoint his own man to one of the most senior public offices in the country is wrong to begin with. Allowing the Minister to provide for this in law when he failed to reveal news that was material to the content of the Bill he was presenting to his Cabinet colleagues is highly questionable. It should never have been allowed to happen and sets a very dangerous precedent. Of course, a pattern has been developing. Many of the senior people appointed by the Minister have been appointed without open competition. That applies to very senior people who were brought in under quite unorthodox employment arrangements to take up very highly paid posts and indeed other posts were created. Three new posts are provided for in this legislation where there is no clarity about the recruitment process. Again, this is a very dangerous and unhealthy system to allow from a corporate governance perspective. It is simply not following proper procedures.

The new governance raises significant concerns. We have a director general and directors and the number of directors depends on the whim of the Minister who can appoint between two and six directors. In respect of the corporate governance structure of our premier public body, we do not know how many directors will be appointed. The legislation provides for two, three, four, five or six in addition to the director general. All of those people are appointed by the Minister. The only real stipulation in this legislation regarding the appointment of the directors is that they will be drawn from the pool of national directors within the HSE. These are the people who are responsible as national directors for service provision. Those five posts have yet to be filled. Obviously, that provision has implications for the existing national directors with which I will deal.

Under this legislation, the Minister will appoint the directors. Therefore, we will have a new governance structure within the HSE and the composition of that directorate will be a director general and directors, all of whom are appointed by the Minister. I have a serious concern about this structure in respect of the circularity of the corporate governance involved, which is highly questionable. With a normal governance structure, the management team reports to the CEO and the CEO reports to the board. In the very unusual arrangement regarding the governance of the HSE, the director general is answerable to the directors in the boardroom of the HSE but when they go outside the board room, the accountability is reversed because the appointed directors are part of a management team and are answerable to their director general. It is absolutely unworkable because it is one way inside the boardroom and the reverse outside it. It is not only unworkable but unacceptable and highly unorthodox. We are told that this is only a temporary arrangement. We are talking about a significant upheaval in the governance structure and what has been said about reorganising the way in which the services are operated. Deputy Liam Twomey outlined very clearly the significant problems caused in the transition from the old health boards to the new HSE. In any major change like that in an organisation, one is talking about a four to five-year period before the thing is bedded down. The Minister is proposing to introduce major change and upheaval in the HSE and for what? For one year? When he published the Bill, he also published a number of diagrams, including this extraordinary diagram which is the timeline for the abolition of the HSE. It shows this arrow jumping from the end of 2012 to 2014 when the HSE will be abolished. Over next year the Minister is proposing to have all of this significant change take place within the HSE in order for it to be abolished at the end of that process.

Does anybody in the Cabinet or on the Government backbenches know what will happen to the health service in 2014? What will be the delivery structure if the HSE is being abolished? It is easy to say the HSE should be abolished; we all know serious problems have arisen with it, but it is difficult to build a meaningful structure to replace it.
A pattern is developing whereby in the absence of a clear vision for the health service or the structures that could deliver a responsive and fairer health system, there is scapegoating of the people working in the service. The Minister decided to abolish the board and replace it with this strange directorate. Then he sacked the CEO and put his own man in the post. Now he is proposing to abolish the HSE next year, followed by what? My real fear is that the experimentation in which the Minister is engaging in the absence of a clear roadmap for the coming few years will, in effect, dismantle the health service as we know it without providing clarity on what is to replace it. I am concerned that he is engaging in an exercise which will completely dismantle the public health service and send it into free fall.
How are primary care and hospital services to be delivered? How are the hospital groups to be constituted? Will a paid board be appointed for each of them? How will we deliver primary care services if the HSE is abolished? How are public health nurses going to function? They are the mainstay of the health service, performing the critical functions of looking after older people, supporting families and providing vaccination services. They are on the front line of the health service. Who is going to employ public health nurses or the 100,000 health workers in 2014 after the Minister abolishes the HSE? We do not have the answer to any of these questions and I firmly believe the Minister does not have the answers either.
The second purpose of the legislation is to give the Minister direct control over the operations of the health service. His role will no longer be specifically confined to policy direction but will include operational matters. This might be acceptable if the Minister's directions were to relate to principles such as setting out citizens' rights to health services or criteria for prioritising the provision of health services. We know from bitter experience, however, that neither the Minister nor his Cabinet colleagues operate on the basis of transparency and prioritisation when it comes to health spending. From a funding point of view, the €13 billion Vote for the HSE will transfer to the Department of Health next year and the HSE will no longer be answerable for that money. The Minister will have complete control over the health service and its €13 billion budget. There will be no checks and balances in ensuring proper procedures and good governance arrangements.
I oppose the Bill because, whatever about transferring powers when the Minister and the Cabinet display sound judgment and prioritise the patient in health spending, in current circumstances it would be the height of folly and highly irresponsible for the House to give these wide-ranging and unfettered powers to a Minister whose track record already concerns many of us.

While listening to the previous speaker, I was reminded of the question: how does one eat an elephant? The answer is bit by bit. I am not saying the HSE is an elephant. It consists of many good people who are doing their best in an unworkable system which was handed to them on a plate several years ago. The HSE structure welded together 11 health boards which, while not without their own challenges, were working at a local level.

It is important to remind the House of who presided over the change in structure. The HSE was set up by the current leader of Fianna Fáil, Deputy Micheál Martin, while he was Minister for Health and Children. He spent €16.8 million on reports during his four years in that office. These reports included a value for money audit which was produced in 2000 and, ironically, cost taxpayers €616,000. The absence of a real attempt to save money gave rise to the ridiculous situation where councillors from County Donegal had to attend meetings in Galway. They were eager to reflect the concerns of people in their jurisdiction, whether at primary health care level or in Letterkenny General Hospital, but became frustrated at the lack of opportunities to do so. I recall the cryptosporidium outbreak in Galway which presented a serious health concern for the people of that city. Councillors told me that they had attended meeting after meeting in Galway at which the issue was discussed. It was an important issue, but others also needed to be addressed. In stretching from Malin Head to north Tipperary, the HSE became unworkable. As all politics is local, people want to know what is happening in their own area and representatives need to reflect the issues on the ground.

It is welcome that the Bill sets out new arrangements for the delegation of functions by the new director general. A key principle of the new structure will be that the authority will make operational decisions delegated as closely as possible to the point of service delivery. That is a welcome development. We have a plethora of people engaged in positive and proactive work, from carers to home help organisations. They need an integrated plan at a local level, with greater communication and interconnectivity among them. I welcome the sharp focus on how services can be managed and delivered at a local level.

When I was on the hustings and doorsteps during the election campaign, people asked me why the Minister for Health, Deputy James Reilly, wanted to take responsibility for health services, given that the job was a crown of thorns or a poisoned chalice. Difficulties will arise and people will get upset in bringing about change. When the Minister attempts to restructure areas of the health service, there will be turf wars and personality clashes. The reality is that human beings do not like change and change comes slowly. Two years into his term of office he has brought about change that is not really reflected in the public domain. There are positive news stories that do not get mentioned such as the reduction by 24% in the number of patients on trolleys nationally - there were 20,352 fewer patients on trolleys in 2012; a reduction of 98% in the number of adults waiting more than nine months for inpatient and day case surgery; a 95% reduction in the number of children waiting more than 20 weeks for inpatient or day case surgery; and a 99% reduction in the number waiting more than 13 weeks for routine endoscopy, to name but a few. However, that does not get mentioned because it is not good enough fodder for the media as it comes in a positive framework.

I want to make reference to the work the Minister is doing on a cross-Border basis. He has built up a strong working relationship with Mr. Edwin Poots, MLA, his health colleague across the Border. I would like to compliment Mr. Poots, who - along with many of this colleagues, even in his own party, the DUP, such as Mr. Jim Wells, MLA - has a pragmatic approach to cross-Border shared services. At a time when efficiencies and cost-saving measures are introduced in the health services in both Northern Ireland and the Republic of Ireland, there is a pragmatic approach to joined-up thinking in shared services.

If we are looking at the community trust hospital model - I know the Minister is looking at different possible permutations, such as which hospitals naturally cluster together - I ask him to keep thinking on the same road in regard to reaching out across the Border. There is a natural alliance between regions such as Sligo and Letterkenny, where there are two hospitals that will form a natural cluster, but we should also be looking at ad hoc cross-Border relationships between Sligo, Letterkenny and Altnagelvin Area Hospital in Derry. There is already sharing of resources between Derry and Letterkenny, and the Irish Government has contributed €19 million to the development of a radiotherapy centre with three linear accelerators at Altnagelvin. That is an example of how we can work together mutually for the benefit of people in their respective regions. Another example of how synergies can lead to win-win situations is in regard to ambulance services. There is no reason we cannot have a shared air ambulance shared service encompassing Enniskillen, Letterkenny, Altnagelvin and Sligo.

For counties such as Donegal and Sligo, the temptation is always to do a mapping exercise in which we look at Ireland on the basis of the Twenty-six Counties. While it is a 26-county jurisdiction from a Republic of Ireland point of view, the Minister has to continue on the road he is travelling with respect to shared services. He is already doing so in his positive and proactive engagement in regard to the children's hospital, for which I compliment him. However, he should not go down the road of being tempted by lines on a map and the way counties happen to be situated in the Twenty-six Counties.

While I have the opportunity, I will reference the Higher Education Authority, which is looking at third level colleges, including institutes of technology. However, it is looking at them on a 26-county basis, which is wrong. Underpinning every policy decision we make, be it for the north-west or on a cross-Border basis, is the Good Friday Agreement, to which we all signed up nearly 15 years ago. Within that was the north-west gateway initiative, which was signed up to by both the British and Irish Governments in order to work on synergies and close co-operation between the two.

I welcome the opportunity to contribute. This important Bill seeks to abolish the board structure of the HSE and provide for a directorate to be the new governing body of the HSE in place of the board, headed by a director general; it provides for further accountability arrangements for the HSE; and it provides for related matters, including a number of technical amendments to take account of the replacement of the board structure by the directorate structure. I welcome the Minister to the House. After 14 years of seeing money thrown at a problem without addressing it, the Minister, Deputy Reilly, has taken the bull by the horns and is effecting change, with a much lower budget, in the way we deliver health services in this country.

I come from County Roscommon. I have had to deal with the ups and downs of innuendo, of lies and of people coming out with completely mad suggestions. I will say this: shame on RTE, shame on TV3, shame on most of the radio stations and shame on the people who constantly carry on with lies in regard to what is happening in Roscommon Hospital. I want to put on the record that Roscommon town has a population of 5,000 people and County Roscommon has a population of 50,000. Where I live, in Boyle, and throughout north Roscommon, the people have always gone to the accident and emergency department in Sligo. In south Roscommon, the people have always gone to the accident and emergency department in Ballinasloe. Roscommon town has 5,000 people and a consultant at the hospital wrote to state that it could not oversee a safe accident and emergency department because the throughput was not available. We were told 14 days before a vote here a year and a half ago, by none other than Dr. Tracey Cooper of HIQA, that she could not allow an accident and emergency department in Roscommon Hospital because there was not sufficient throughput. Fewer than 30 people a day used it. They called it an accident and emergency department but it had no cardiac surgeon, nobody to intubate, no paediatric surgeon and no anaesthetist cover overnight. It is not the accident and emergency department I would expect if I were in difficulty. If a person has a serious heart attack or is in a car accident, that person will be brought to an accident and emergency department. We have now put in place an air ambulance service, based in Athlone, which is saving people's lives and which has carried out over 120 missions since it was put in place as a pilot scheme. I hope that service will be continued because it is saving lives. We also have paramedics driving about. Whereas at one time, following an accident, patients were brought to an accident and emergency department such as that at Roscommon to be stabilised and then brought somewhere else, now they are stabilised at home or at the side of the road following an accident, and are then brought to a real accident and emergency department. Lives have been saved and I want to put on record that no lives have been lost despite the innuendo and the untruths that have gone out.

What really gets me is that on Tuesday night I saw a constituency colleague of mine on "The Vincent Browne Show" on TV3. Seven times he mentioned my name and said I did not do anything. I tell him to get down off his high horse. He should go in and see what is happening in Roscommon County Hospital and what is happening under the Minister, Deputy James Reilly. What is happening is that we are allocating resources and ensuring people's lives are saved. It is happening on the ground. Even if the newspapers and media outlets do not want to know, it behoves them to call in and see what is happening.

Outpatient attendances for Roscommon County Hospital in 2012 were 14,855, some 2,000 more than in 2011. The number of day cases was 5,127, which was 1,400 more than in 2011. The number of inpatient discharges was 1,889, whereas the target for 2012 was 1,620. The number of urgent care centre attendances, including the minor injury care unit, was 5,940. Roscommon hospital is leading the way as an example of the role a small hospital will play. The smaller hospitals framework will set out the range of services that can be performed in smaller hospitals. If I might tell my colleague what has happened in this regard, examples of service development in the hospital this year include plastic and reconstructive surgery, led by Dr. Deirdre Jones, which commenced at the end of 2011 and is now extended to two days a week. This service is growing, with 50 patients booked for each day of the clinic - 100 patients per week - and access is significantly improving, with decreasing waiting times. Sleep studies, led by Dr. Imran Saleem, commenced in Roscommon hospital in March last year and 132 patients have already been assessed. Urology services commenced at the hospital in May. The radiology project, upgrading the X-ray system to allow doctors to view electronically and share X-rays quickly and easily, went live in August.

This means that Roscommon Hospital can offer increased diagnostic services to patients from Roscommon who attend consultants based in Galway. In addition it means that Roscommon now provides CT scans for suitable patients on the waiting list for scans at Galway University Hospital. It is another example of how all the resources of the group are used to facilitate best patient care. An application has been made for planning permission for the endoscopy suite. This will be a €3 million development construction of which will commence in the last quarter of 2013. The unit will have JAG accreditation. Roscommon Hospital will become a centre for colorectal screening under the governance of the National Cancer Screening Service in mid-2013. It will provide a new dental service for patients with special needs while under general anaesthetic commencing in September. The nursing initiatives include nurses prescribing, X-ray prescribing, nurse-led clinics, colorectal clinical nurse specialists, Bord Altranais assessment and productive ward initiatives. The group inpatient list target has been exceeded in Roscommon Hospital.

A few nights ago someone on "Tonight with Vincent Browne" asked "who is Frank Feighan?". Frank Feighan attends a meeting in Roscommon Hospital and in the Department of Health every week to ensure that I deliver for the people of County Roscommon but most important, to ensure that the people of Roscommon are safe. We do not have innuendo. The consultants in Roscommon Hospital wrote a letter before that famous decision to say that they could not stand over a safe service. The consultant in the hospital stated to me that the accident and emergency department was safe only if an accident occurred within a mile and a half of the hospital. In that case lives may be saved. Otherwise it was unsafe. Virtually all the doctors in Roscommon and other places sent their patients to Sligo, Galway, Dublin or Athlone. Only 9% of the people who went to hospital from Roscommon, which has a population of fewer than 50,000, went to Roscommon Hospital.

The people and the doctors of the county drove at speed to get away from the accident and emergency department in Roscommon. Now they are shedding crocodile tears, coming out with lies and innuendo stating that it is safe and they want it. They will have a hospital of which they can be proud. It will be five times busier and twice as big but there will be no accident and emergency department because it is unsafe, not through lack of money or political will but because it cannot comply with the HIQA standard. The Opposition have talked about the money that went to hospitals in Kilkenny and Wexford. The same amount of money effectively went to Roscommon in 2004. Fianna Fáil spent €7 million on building an accident and emergency department, then set up HIQA with terms of reference that closed it down.

Debate adjourned.