Health Service Executive (Governance) Bill 2018 [Seanad]: Second Stage

Minister of State at the Department of Health (Deputy Jim Daly)

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

I am pleased to contribute on behalf of the Minister for Health. As we look forward in 2019, there are opportunities we need to grasp and challenges we need to understand and control. This Bill, with the re-establishment of a board for the HSE providing independent oversight, is a key enabler of accountability, improvement and transformation in our health services. The Minister for Health and I can think of no better moment than the start of a new year to work in collaboration with colleagues across the political spectrum to deliver on the commitment across this House, and as signed up to in Sláintecare, to re-establish the board of the HSE.

The HSE is our largest State agency, with a budget in excess of €16 billion in 2019 and a substantial workforce, delivering vital services. The transformation vision for health sector reform, as set out in the Sláintecare implementation plan, is an exciting change in our health services. However, with this opportunity also comes significant risk, responsibility and work for the HSE corporately. The HSE must be supported to deliver this work on the ground and, in the Minister's opinion, it is essential that a strong board be established to drive the strategic direction of the organisation, ensuring that appropriate systems for management and performance monitoring are in place, and to ensure accountability to the people of Ireland for decision-making processes in the HSE. The board will also support the HSE in its decision-making capacity to ensure transparent, collective, evidence-based decisions in regard to the range and breadth of health and social care services it provides across the country.

It is important, therefore, to outline the main objective of the Bill. A directorate governance system in the HSE was put in place in 2013. As the Minister said when bringing this Bill through the Seanad, this system allowed for co-ordination between senior management teams in the Department of Health and the HSE but, by its very nature and design, and by intent, this was a system that was always envisaged as an interim measure. The time has now come, in line with the Sláintecare recommendations, to establish an independent board governance structure for the HSE in place of the current directorate governance system.

This board will be the governing body of the HSE and accountable to the Minister for the performance of its functions. High standards of integrity and probity will be expected of the board. There are also central principles which must be at the heart of how the new governance model is implemented and which should guide the board. As the governing body, the board will support transparency and accountability of actions, benefitting decision-making and management performance in the HSE. Part of this will be for the board to challenge itself, as well as the HSE, to show how the HSE is getting value for the public funds it has been given. Part of this will be to foster a culture of continuous improvement in the HSE. The board will act collectively in order that all perspectives of patients, staff and the taxpayer will be taken into account, and will take decisions based on the public good. However, in acting on these principles of independence and inclusivity, the board must ensure that fundamental values of care, compassion, trust and learning are well rooted throughout all services for which the HSE is responsible.

Board members will be appointed by the Minister for Health following a Public Appointments Service, PAS, process for identifying suitable appointees. This process is a robust, competencies-based process and will result in candidates being appointed to the board based on the skills and experience they bring to the board and their ability to engage in collective, complex decision-making. The board will have strong competencies in key areas, giving leadership to guide, challenge and support the CEO and HSE executive team, ensuring accountability and delivering organisational transformation within our health service. The PAS process ensures that members of the board will have experience and expertise in one or more of a range of areas, including corporate governance; clinical governance; quality assurance and patient safety; patient advocacy; strategic planning and change management, business management skills, financial planning and management; strategic human resource management; and public communications.

From the outset, patient advocacy was identified as one of the core competencies needed in board members. The Minister for Health was also clear on the Government's commitment to implementing in full the recommendations of the Scally scoping inquiry into the CervicalCheck screening programme, including the recommendation in regard to advocacy and the new HSE board. This issue was also raised by Senators as the Bill passed though the Seanad. The Minister listened carefully to their concerns and reflected on the best way of delivering on the letter and spirit of Dr. Scally's recommendation. He, therefore, tabled an amendment to the Bill on Report Stage in the Seanad to provide that at least two members of the HSE board have patient advocacy experience or expertise.

The Minister would like to take this opportunity to update the House on progress with identifying board members. In September 2018, after a demanding public appointments process, Mr. Ciarán Devane was selected as the chair designate of the HSE board. He brings to that role a range of skills, experience and leadership from his extensive experience of the British Council, NHS England and as CEO of Macmillan Cancer Support.

The Public Appointments Service process to identify the other nine members of the board took place recently. The Minister hopes to be in a position to make an announcement on the selection of members shortly.

I turn now to the main provisions of the Bill. Part 1 contains a number of standard provisions including the Short Title and collective citation of the Bill. It also provides for the repeal of Part 3A of the Health Act 2004, which instituted the directorate governance structure.

Part 2 allows for the required changes to be made to the Health Act 2004 to reflect the structural changes proposed in the Bill. In essence, these changes include the establishment of an independent board, the appointment of a CEO to the HSE and the formulation of the values, principles and conditions to underpin this new structure.

Section 7 proposes to insert a new Part 3B, sections 16N to 16U, into the 2004 Act to make provision for the membership and role of the new HSE board. Section 16N(1) provides for a board of the HSE composed of ten members, namely a chairperson, deputy chairperson and eight ordinary members, all of whom will be appointed by the Minister for Health. As I mentioned earlier, at least two members must be persons who have experience of, or expertise in, advocacy in respect of matters affecting patients. The appointment and functions of the CEO of the HSE are covered by the insertion of a new Part 4A, sections 21A to 21G, into the 2004 Act. As Deputies will be aware, we are currently in the process of recruiting a new director general for the HSE. The successful applicant will become the new CEO of this important national State body under the legislation before the House. This will be a pivotal appointment in improving the management, performance and quality of our health and social care services.

The Bill also sets out the accountability structure between the CEO and Oireachtas committees. Under the new section 21E, as provided for in section 8 of the Bill, the CEO of the HSE will be required to attend before Oireachtas committees to give an account of the general administration of the HSE. The requirement for the CEO to appear before the Committee of Public Accounts is covered in the amendment to the Health Act 2004 proposed in section 17 of the Bill. Sections 9 to 29 provide for other amendments to the Health Act 2004, mainly consequential to the new board and CEO structure and take account of the move to a board and CEO structure from the directorate governance structure. Part 3 of the Bill consists of sections 30 to 34 and amends references to the director general in primary and secondary legislation.

The primary purpose of the Bill is to establish a board governance structure in the HSE to establish independent oversight. The Minister is also considering amendments to further strengthen oversight and accountability and to support a more structured and strategic performance dialogue between his Department and the HSE. I stress, however, that the Bill, including any amendments to it, is a first step. The Minister is committed to continuing this journey of reform outside of the Bill by means of ongoing work to review, refine and refresh the performance and oversight framework for the HSE. Sláintecare has placed the reform and transformation of our health services into a space that transcends party politics because the importance of what we are doing goes beyond our political affiliations or ideological standpoints. It is about providing the people with the best health service. The health service they deserve is one based on equity, professionalism and compassion which places the patient at the core of all that it does. The Minister believes re-establishing the board of the HSE is a key enabler of this and a fundamental building block to strengthen governance and oversight in our biggest State agency. I commend the Bill to the House.

Deputy Stephen S. Donnelly

When healthcare is discussed in politics and in the media, the focus is almost exclusively on what is going wrong. This relates to the numbers waiting to see doctors or to receive treatment, the number of people lying on trolleys in emergency departments, the number of people who cannot access mental health supports and the fact that the Government’s response to the crisis is all talk and no action. Patients, their families and their friends are exhausted. Many conclude that nothing can be done and that the problems they see in health are normal and inevitable. One regularly hears people say "Sure, is that not just how health care is?". As we look to 2019, it is essential to challenge this conclusion and demand better. These failures, waiting lists and cost overruns are not inevitable and they do not exist in other countries. They did not exist in the past in Ireland in the way they do now and there is no reason that they should exist in future.

In the 2000s, incredible progress was made. The nursing degree was introduced and the number of nursing student posts was doubled. The smoking ban was introduced and healthcare investment grew substantially. Some 53 separate healthcare bodies were consolidated into one, the national screening services were launched and 1,600 additional hospital beds were provided. The number of consultant posts grew by 40% and the Health Information and Quality Authority was established. There was a massive increase in home-care provision, the national cancer strategy was rolled out and so on and so forth. These initiatives supported our healthcare professionals to make extraordinary progress in patient care in Ireland. Waiting times fell from years to months and weeks. The rate of death from cancer fell by 11% over the past ten years, while the rate of death from stroke fell by one third in the same period. Infant mortality fell by a third while cardiovascular disease rates fell by 40%. Deaths from heart attack fell by half and three in every four eligible women were screened for breast cancer. These are amazing accomplishments, the credit for which belongs not to any political party here but to our healthcare clinicians who were able and were supported to do an extraordinary job. We have some of the best trained healthcare professionals anywhere in the world. The provide an outstanding level of care. They mind us, heal us and save our lives every day. They continue to make incredible progress to improve patient care in Ireland. What, then, is the problem? Why are there so many things on which we here, the media and patients focus?

Ireland has one of the highest healthcare spends in the world. In spite of that, we have, somehow, among the fewest hospital beds in Europe and the lowest number of consultants per capita. We have the longest waiting lists. During the 2000s, waiting list times were reduced from years to months but notwithstanding the many billions in additional annual funding now provided, those waiting lists have gone back up from months to years. Waiting times are longer than they have been at any time since we started to record them. In some areas, children with special needs must wait three and a half years for treatment. There are 35,000 people who have been waiting more than six months for a hospital appointment. It was less than one third of that in 2010. More than 3,000 children nationally are awaiting mental health appointments. Last year, the number of people on trolleys in emergency departments hit 10,000 for the first time in the history of the State. If one adds up the numbers on the lists of those waiting for appointments, therapy, diagnostics and mental health supports, one gets to 1 million. It had topped 1 million by September. Nothing like that has ever been seen before and nothing like it exists in any other European country. There are 72,000 people waiting for in-patient hospital treatment.

For every person who was waiting in 2010, when much less money was in the system than there is today, there are 16 people waiting at the start of 2019. That is how bad things have got. We compared the situation to that in the United Kingdom and found that when one accounts for population size, there are 200 people on waiting lists in Ireland for every one person waiting in the UK. We are 200 times worse than the UK at getting people treated before a year has elapsed. The current out-patient list stands at over 500,000 while the number of those waiting over one year stands at more than 150,000. That would fill the Aviva Stadium three times over. The one exception to this trend is where the national treatment purchase fund has been deployed. The Government talks regularly about the improvements that have been made and I do not blame it for that, but they are targeted. What the Government does not say, of course, is that the National Treatment Purchase Fund, which it resisted for years, came about on foot of the confidence and supply agreement. General practice is on its knees and nurses and midwives are looking at a national strike for only the second time in 100 years. There is an unprecedented recruitment crisis in the context of hospital consultants. Mental health services are falling apart in many areas. Health overruns are now consistently above €600 million a year, which never happened before.

The national children's hospital is an interesting case study. It was meant to cost less than €500 million but the latest figure is over €1.7 billion. In December, the Taoiseach told us the cost had risen to €1.4 billion and we have gone up by €300 million in the three or four weeks since.

How expensive is that? The most expensive hospital ever built anywhere in the world is the New Royal Adelaide Hospital in Australia. That facility was built at a cost of approximately €1.5 billion and has 800 beds. The new children's hospital will cost significantly more than the most expensive hospital ever built anywhere in the world, even though it will have a little more than half the number of beds. This means that when the national children's hospital has been built, the people will have paid approximately twice as much per bed as the cost of the most expensive hospital ever built anywhere in the world. That requires a staggering level of incompetence and systems failure to pull off.

What is going on? How is Ireland spending more public money than ever before on healthcare? We are spending more than most countries on Earth. At the same time, we are suffering from the longest waiting lists in Europe, the longest waiting lists we have ever had and a series of enormous overspends. How is this happening? How is so much valuable money being so badly wasted? Much of the blame rests with actions taken or not taken by this Government since 2011. It has managed to alienate pretty much the entire healthcare workforce, including general practitioners, consultants, non-consultant hospital doctors, therapists, nurses and midwives. The implementation of new initiatives like the national children's hospital has been incredibly poor, as have been the efforts to control costs.

The Government has wrought organisational chaos on the system. In 2011, it announced that the HSE was to be scrapped. It said that in the future, healthcare in Ireland would be funded by universal health insurance. That was the big idea. In 2012, in front of all the national cameras, the Government disbanded the board of the HSE. It marched the board out publicly in front of the cameras for everyone to watch on the news that evening. In 2014, the Government reiterated that it would disband the HSE and gave a date for this. The then Minister for Health and current Taoiseach, Deputy Varadkar, stated that the HSE would be gone by 2020. The Government had no idea what it would replace the HSE with. In 2016, the Government said it was no longer planning to abolish the HSE or to pursue the universal health insurance model of funding.

The only long-term strategy is not a Government strategy. An Oireachtas committee came up with the Sláintecare plan. The latter may have various flaws but is the only game in town. As a vision document, it is pretty good and quite ambitious. It was recommended in the Sláintecare plan that the board of the HSE should be put back in place. The Bill before the House has not resulted from a Government initiative. The Government did not wake up and realise that it should not have marched the board of the HSE out and destroyed governance in our healthcare system. It did not come up with the idea of bringing the board back. It was made clear in a report drawn up by this House that the biggest, most important, most complicated and most expensive system in our country self-evidently needs a board.

Unfortunately, every single Sláintecare implementation deadline has been missed so far. By my reckoning, approximately €20 million, in real terms, was allocated for Sláintecare in budget 2019. The Government said on budget day that €200 million was being provided for Sláintecare, but that was not the case. That money was being provided for various initiatives. The Government said that all of them were Sláintecare initiatives, but that was not the case. The money was being provided for doing a bunch of sensible things, like scaling up, as part of usual business. The actual money for Sláintecare in the budget was approximately €20 million. It is estimated in the Sláintecare plan that approximately €1 billion is needed for Sláintecare. Conservatively, it would probably be possible to get Sláintecare off the ground for approximately €500 million in any given year. It is probable that progress could be made on that basis. For every €1 that the Government has attributed to Sláintecare for this year, between €25 and €50 is probably needed. That is how seriously Sláintecare is being taken.

The former director general of the HSE, Tony O'Brien, appeared before various Oireachtas committees last year in the heat of the CervicalCheck scandal. He was under a lot of pressure from various Members of this House not just in respect of CervicalCheck but also on the performance of the HSE and on waiting lists. He repeatedly made the point that when he was hired by the Government in 2011 or 2012, he was instructed that his job was to dismantle the HSE. That is what he was told his job was. He said that he never received any further instructions. He was told that in the future, funding would be provided through universal health insurance. He never received any further instructions.

The Scally report pointed out the implications of the lack of a HSE board. It directly linked the lack of proper governance and the lack of a HSE board to the catastrophic governance failures that were a feature of the CervicalCheck scandal. Getting rid of the board was not just a mistake, it was an extraordinary mistake. The guy who was hired was told that his job was to dismantle the HSE. His board was taken away and he was not given any further instructions on the HSE. This extraordinary mistake has led to massive cost overruns, including an overrun of between €700 million and €750 million last year. Nothing like that had ever happened before. The spending overruns on the national children's hospital mean that this project is probably unlike any healthcare project that has been pursued anywhere in the world. We are going to pay twice as much per bed as the most expensive hospital ever built.

The lack of a board, coupled with this organisational chaos, goes a long way towards explaining how the same managers with the same doctors, nurses and other healthcare professionals, but with way more money, are providing a service that is much more difficult to access. It should not be more difficult to access. If the same doctors, nurses and managers are given way more money, they should be able to provide a more accessible service. Instead, chaos has been wrought throughout the HSE. Fianna Fáil will be supporting this Bill, which takes one small but important step towards reversing that damage by reinstating the board.

As we face into 2019, we should be under no illusions about the scale of the challenge before us. Organisational stability within the HSE has been lost. It has to be re-established. Financial control has been completely lost and must be regained. The HSE is on fire in terms of financial control. Our healthcare professionals - nurses, midwives, doctors and dentists - must be engaged with. They have been systematically alienated. They are not being engaged with. The Government is due to announce a new oral health strategy in the next two or three weeks. The Irish Dental Association made it clear in yesterday's newspapers that dentists have not been consulted on the upcoming oral health strategy. That is where matters stand.

This has to stop. Within the HSE, the Department and this House, there needs to be a culture of actively engaging with and listening to our clinicians. We should respect them and treat them properly, but that has not been happening. If we can stabilise the HSE as an organisation, if we can somehow get control of funding and financing, which has spiralled completely out of control, if we can begin to understand that the people who lead our healthcare system are the clinicians and if we can listen to, engage with and respect those clinicians, we can start to rebuild the healthcare system that patients, the public, clinicians and everyone working within the HSE deserve.

Deputy Louise O'Reilly

I welcome the opportunity to say a few words on this important legislation, some of which is technical in nature. It seeks to reintroduce a board to oversee the operations of the HSE. I hope this overarching premise means it will have beneficial ramifications for our health service.

It is interesting to look at how we got here. Before I was elected to this House, I had the privilege of representing workers. It was very interesting to hear Deputy Donnelly say that workers should be listened to. I represented workers when Fianna Fáil was in government. They were roundly ignored. I was sitting in Government Buildings when the Taoiseach of the day, in the face of industrial action by tens of thousands of healthcare workers, called a general election, suspended the talks and literally walked away from the table. Deputy Donnelly has told an interesting story, but the history of his party is one of ignoring front-line healthcare professionals. I hope it will change. I hope a lesson has been learned.

Just six years have passed since Fine Gael abolished the board of the HSE in favour of creating the office of HSE director general and conferring more powers on the Minister.

What the Minister exactly did with those additional powers is anyone’s guess because I do not know.

The dismantlement of the HSE was announced by the then Minister for Health, Senator James Reilly, who pushed strongly for what he called reform of the health system. It was not based on available evidence or on information from having talked to experts or front-line healthcare professionals but simply on the belief that he was right. The changes and the decision to scrap the executive were agreed in the 2011 programme for Government between Fine Gael and the Labour Party.

In the Seanad, the Minister had the temerity to say that the directorate governance system of the HSE introduced through the Health Service Executive (Governance) Act 2013 was by its nature and design, and by intent, always envisaged as an interim measure. The Taoiseach when he was Minister for Health went on to say that the executive would be fully dismantled by 2020. Unsurprisingly, that did not materialise and we find ourselves discussing this Bill and the board must return.

The new board will be a slimmed down, nine-person version of the former HSE board. Sinn Féin opposed the original legislation that sought to dissolve the board, not because we thought the board was perfect or was working well but because the legislation that delivered its removal was unclear, weakened the health service through the removal of the board for purposes of oversight, bestowed too much additional power on the Minister and did not give the Dáil additional powers of scrutiny or make the Minister further answerable to the Dáil. I do not believe there is another multi-billion euro healthcare body operating in the world without an appropriate board to provide oversight. It is welcome, therefore, that the Government has seen fit to reverse the decision of six years ago, but let us not fool ourselves, that was not the Government's decision. That was a recommendation of the committee that produced the Sláintecare report. I and others sat on that committee and that is from where it came. If pats on the back are being handed out, Deputy Róisín Shortall should probably get one ahead of anyone who sits at the Cabinet table.

It was important that amendments were made in the Seanad, which guaranteed that two of the people appointed under the section to support the board would have experience or expertise in advocacy relating to matters affecting patients. This followed the suggestions made by Professor Gabriel Scally in the scoping inquiry. It was unfortunate that the same accommodation could not be made to include worker representatives on the HSE board. We believe that workers should have some form of representation on the board, and that healthcare and medical professionals would be of major benefit to the board in its workings. The participation of healthcare workers would be an asset. It would help to ensure a deeper understanding of clinical issues, best practice, quality indicators and other issues related to the safety and quality of care and overall delivery of healthcare by the HSE. Sinn Féin had submitted amendments to this end, but they were ruled out of order. We will submit reworded amendments to this effect on Committee Stage and we hope they will be supported. There is nothing wrong with having healthcare workers represented on the board that oversees the operation of their workplace. More important, they have much to offer in terms of their membership of the board and the expertise they can bring to it.

The Government claims that the new board will restore public confidence in the HSE through a series of actions to strengthen the management, governance and accountability of the organisation. Those are grand claims but they are almost a photocopy of the claims that were made when the board was dissolved. The board had to be removed to have all this accountability and now the board has to be brought back to have accountability; perhaps it could stop reforming the structures and just focus on accountability. Only greater oversight and proper accountability of the board by the Minister of the day will ensure better governance, accountability and delivery of health services. It is a pity that was not the view six years ago. If the then Minister had the bit between his teeth and was interested in reform, then he probably could have done a better job six years ago.

There is no other multi-billion euro healthcare body operating in the world without an appropriate board and, therefore, I welcome the reintroduction of the HSE board because it is standard practice for public bodies to have an independent board, which operates at arm's length from Government and provides independent oversight, particularly in the context of the spending of public money and accountability to the taxpayer.

It was a sad state of affairs for the former Minister to do away with the necessary and important checks and balances. However, without radically altering how the board will operate in comparison with the previous regime and the previous board, then the Government is doomed to make the same mistakes again. It is important that the board has the right mix of talents and does not just comprise ministerial appointees who are appointed for political reasons. I do not believe the Minister would do that but he will not be the Minister forever. When we look at the Cabinet table I see people who have made appointments to boards which made as much sense as Caligula appointing his horse to be a Roman consul. These people will be tasked with an important job. We need to make sure that they are the right people who can deliver. It is a multi-billion euro organisation, a great deal of taxpayers' money goes into it and a great deal of accountability is needed.

We need to ensure against manipulation in appointing members to boards on one hand and ensuring the best and most appropriate people are appointed on the other. It is important that any member appointed to the HSE board is familiar with, and committed to, the implementation of Sláintecare. We have a unique chance to fix some of the problems in our health service, and that cannot be achieved if those on the board of the HSE are not committed to working towards that through Sláintecare. By that, I mean a commitment to public health service, to the delivery of healthcare on the basis of need and not ability to pay, and fully funded by the public purse, not through privatisation but through the public health system.

Progressive corporate governance reform at the highest level of the corporate body of the HSE is also needed. When the HSE board was dissolved in 2012, there was an opportunity to progressively reform the organisation to achieve the highest level of corporate governance. This was not done and amendments to strengthen the legislation at the time were not facilitated. That was one of the reasons we did not support its dissolution. We have the same concerns again regarding this legislation. We would like the provisions strengthened to make the Minister for Health and the new board more accountable to the Dáil. The board must also robustly hold the Minister to account, and the Oireachtas must be able to hold the chairman of the board to account. The re-establishment of the board cannot give the Minister the opportunity to hide behind or push aside the HSE when it suits. The HSE has been described as a growing monster by many but, in the main, that is because it has not been given adequate political direction by successive Ministers for Health. We need only note its initial foundation by the then Minister, Deputy Micheál Martin. He just amalgamated the old health boards. In saying that, I am being kind to him because he just shoved them together. It made no sense. Deputy Donnelly has treated us to a few of the greatest hits of Fianna Fáil in government but the ones I remember were the recruitment moratorium, privatisation and the first recorded overnight trolley wait.

Since the board was dissolved, there has been a sequence of bad moves and a lack of sensible direction. Sinn Féin welcomes the key fundamental principles, as outlined by the Minister, of independence, inclusiveness and compassion. At times, those principles are sorely missing, not on the part of nurses, doctors, healthcare professionals who, as we know, have them in abundance, but in the boardroom.

The board, as the governing body, must be independent, transparent and ensure accountability in its actions in order that people can have confidence in the decision-making and management processes within the HSE. Furthermore, it must be committed to a truly public health system. We cannot have members of the board who have conflicts of interest such as stakes in private hospitals, or video medicine systems, which for the avoidance of doubt are the antitheses of what it means to deliver public healthcare. While we need experience on the board, we do not need conflicts of interest. We need to see commitment to improvement, to the proper and prudent use of public funds, to combating waste and to ensuring direct health benefits and better outcomes for those who use the health service. If my memory serves me correctly, the HSE is the largest employer in the State.

In that context, an understanding of workers' rights and not simply human resource management is really important.

I welcome the appointment of Mr. Ciarán Devane as the chair-designate of the new board. I understand the Public Appointments Service process to appoint a chair was exhaustive. I know Mr. Devane has experience in health service provision from his time in Britain where he was chief executive of the charity Macmillan Cancer Support and served as a non-executive director of the National Health Service, NHS. Perhaps, in time, when we have Mr. Devane in front of the Joint Committee on Health, I will get an opportunity to ask him about his time with the NHS in England and see what his analysis is of the performance of the NHS during that period and of attempts by the Tories to privatise elements of the NHS. A huge job lies ahead for the new board, the HSE, the Department of Health and the Sláintecare implementation office, and I wish them well in their endeavours. I look forward to further debating this Bill on Committee Stage. I have outlined the type of amendments that Sinn Féin will bring forward and look forward to engaging with Mr. Devane.

In the few minutes I have remaining, it would be remiss of me not to mention the impending strike by nurses and midwives in our health service. One of the frustrating factors as a person who represented healthcare workers which is still true today is that one is often engaging with people who cannot make decisions. In the absence of the Department of Public Expenditure and Reform, one is talking to HSE and health service officials, but those people are not empowered to make that decision. That is extremely frustrating for healthcare professionals and obviously frustrating for nurses and midwives because they have found that they have no option but to take industrial action. We know that industrial action is the last port of call for any worker, especially nurses and midwives. I would like to see a situation where the HSE is empowered to make those decisions in the interest of the health service, to have the power to actively negotiate and engage with those healthcare professionals.

I heard Deputy Donnelly's view and that of Fianna Fáil about how well paid nurses are. I heard that view about how well paid nurses are in the Joint Committee in Health in July. I do not share that view because we are competing with English-speaking countries where nurses are paid more and their conditions are better. That is why our nurses are leaving. We need to have a health service that is empowered to deal with the front-line healthcare professionals we need, put in place strategies and know that it has the power to make good on any commitments that it makes at the negotiating table. I do not think that every person in this Chamber shares the Fianna Fáil view about how well-paid our nurses are and I do not think that we should be making comparisons between our nurses and healthcare workers in other jurisdictions except those that the nurses are going to, because we are competing with those.

Deputy Stephen S. Donnelly

Deputy O'Reilly just did.

Deputy Louise O'Reilly

When those people leave, we know that they are leaving to go to countries where the pay is better. Compared with those countries, they are not well paid. I hope that the new board has the opportunity to actively engage with healthcare professionals, learn from them and to be able and empowered to put in place strategies to recruit and retain key front-line healthcare professionals. That will be the challenge to meet the capacity deficit that we have for the new board and for the Minister.

Deputy Alan Kelly

I am glad to be in a position to speak on this Bill this evening. The Ceann Comhairle will be delighted to know that I will stick to the Bill. We will have other opportunities to deal with many of the serious issues raised by previous speakers in the next 24 hours. This legislation is important. It is concise. The Government was bounced into producing it because of the Sláintecare report, the committee which Deputy O'Reilly and I sat on for 11 months with Deputy Shortall as the Chair, which recommended this. As somebody who is into the detail of the cervical cancer debacle, it was quite obvious as a result of what many of us saw transpire at that time in the Committee of Public Accounts and the Joint Committee on Health, both which I am a member of, when speaking to HSE and Department of Health officials, that governance had collapsed and that an independent board was necessary. What was recommended in Sláintecare and the greatest example of why it was needed was before us in the cervical cancer situation.

I believe the decision to abolish the board in 2012 was foolish. The structures that were supposedly to be put in place never materialised. I looked back at the cervical cancer debacle and some of the committee hearings. I cannot remember whether it was at the Committee of Public Accounts or Joint Committee on Health - it was probably at both - and I remember questioning accountability and how this could happen. The national screening programme, which had been quite successful, had fallen down the organisational structure of the HSE. The history of how it fell down from the top tier of the management and directorate of the HSE, a number of years ago, is that a number of directors, working together, made a decision in a vacuum away from accountability to a board or anyone and it slipped down two tiers. As a result, the director in charge of it did not have a clue what was going on. At a management level, the directors speaking together at directorate meetings were obviously raising the issue and screening programmes were discussed. The audit which we all know about now never really reached the top table. No one was asking questions. Screening was merged into being part of the directorate in relation to wellness, so it was mixed up with that. It is very positive for that to be in the media and publicly known.

This is a very specific area and there was a lack of oversight and management structures that were decided by the HSE directorate, which I accept there is an element of need for, and there was no board to ask if and how something is working and other things that are necessary where boards are in place, including challenging a CEO or a management team, which is the directors in this case. As a result of that, the issues that we are going through did not get to the top and we would not have known if not for Vicky Phelan and everyone in this House knows that. To be fair and balanced, the CEO was left in this situation so I will not criticise them for that. There was a structure with a tier of directors and a CEO without an accountable board. It is an organisation with a budget of €17 billion or more, the largest number of employees of any State company in Ireland.

This Bill is small but it is incredibly important to ensure good governance, accountability and transparency. It is in tandem with other legislation which will go through the Houses, especially in the area of open disclosure. I wish the chair-designate the best. I also wish the new CEO the best, whoever that is, if we can find one. It is proving difficult to find one. Things that will have to happen in tandem are the psychological changeover in the HSE regarding open disclosure, honesty, transparency and how to deal with the public.

The establishment of the independent board and the putting in place of governance measures will not happen overnight. The board will be put in place, but the actual process by which it will do its work will have to be quite closely overseen by the Minister and his Department. We need to be very careful about the type of people who are appointed to the board. It is not that easy to get people onto boards any more - it is incredibly difficult - so we need to ensure that we get the right people across all the disciplines listed in the Bill, a matter to which the Minister referred previously. I welcome the fact that the Minister has changed the composition of the board in order to add two patient advocates. This is very positive. Dr. Scally referred to this matter. I want to be clear about one thing - and this must happen, particularly in healthcare but also, potentially, in the context of other boards - namely, that the members will have to be reimbursed. I do not mean travelling expenses, I mean full reimbursement in respect of loss of pay. Otherwise, it will not be possible to get a proper cross-section of society. I have raised this matter on half a dozen occasions. Let us consider the type of people we need to get on these boards. There is nothing wrong with one, but we do not want two retirees who can afford membership financially. We also need people with real-life experiences who have been through a lot. The majority of the families affected by CervicalCheck and related issues include young women. The best patient advocate when it comes to such a topic and cancer in general could come from that sector, but one of those people will not be able to go on the board because they will not be able to afford to give up the time from their job. I know this from the groups that have already been set up with the HSE in respect of CervicalCheck. Some of the people giving up their time on these boards will not be able to continue doing so long-term because they have jobs to go to and children to feed and cannot afford the loss of income. In that context, I plead with the Minister of State: if he takes away one small point I make, he should bear this in mind. It is something we need to ensure across Government and across politics.

The new board and chair designate need to set a new tone as to how they make the management structure and the management team accountable. Dare I say it, from an accountability point of view, Oireachtas committees have had to fill a void because of the fact that there has not been accountability at board level. What is happening at present is, because there is no such accountability, I and others, particularly members of the two committees to which I referred, are going into a level of detail which we probably should not need to go into because there is no board to do it. We are getting into levels of detail on medical and health issues, and also spend issues on other committees, because of the fact that there is no board. There is a vacuum and we are possibly not being consistent in targeting some of the main issues to the degree we should as a result of the level of detail we are having to get into. The new board, the new chair designate, can set a new tone in ensuring that the issues that need to be dealt with at that level are dealt with and that issues that need to be dealt with in here, at the highest macro level, will be dealt with in here as well.

As stated, the board must be inclusive and comprise a cross section of society with different skills. The patient advocates must represent a cross-section of society as well. It is also important that the new board fit in with the Sláintecare strategy. Some work has been done in this regard with the establishment of the programme office, the advisory group, etc. It is important that in setting this up we do not just think it will act in some way like other boards. There is a strategy in place here that is the only show in town and across politics. Any Minister for Health should glide into the slipstream of this because it is a strategy that has been adopted by an overall majority of the House. It is important that the new board understands that while the chair designate is accountable to the Minister, there is also the requirement to be part of this larger trans-politics, trans-time strategy because Governments and Ministers come and go. This is critically important as well and needs to be fitted in.

I wish to say a few words about the issue of regional alignment. This is a real bugbear of mine, and I know it is for some other Deputies. As part of the new structures, the whole alignment of the community healthcare organisations, CHOs, and the hospital groups must happen but in an organised fashion because otherwise the accountability chain up and down gets broken because people do not know who is aligned to whom geographically. All of us in this House deal with, as I call it, the acute side and the non-acute primary, community and continuing care, PCCC, side. I am lucky enough in the mid-west, where they are aligned. I would say it is the only place in the country where they are aligned. Well, most of it is aligned. Part of it in south Tipperary is not, but that is a different story. This causes real issues, so this alignment needs to happen relatively quickly and in tandem with the setting up of the new regional boards. Those boards are massively important and have the potential to be extremely effective because they will get into a level of detail that the national board will not be able to get into. There are specific issues that can then be dealt with at regional level. There are specific issues which are higher priority in the south east than they are in the north west and vice versa - one can pick any regions in the country - so those regional boards are critically important but they must happen following on from the alignment of the non-acute and the acute.

One issue that arises relates to the role of politicians at local level. I am not necessarily saying we should go back to the old health boards, but certainly when it came to accountability, common sense and a focus on the minds of regional health managers, they did not necessarily do that bad a job. Therefore, while not going back to that whole structure, we do need a format which is not just about the platitudes that happen in many regions at present whereby a couple of times a year there is a meeting and we are given presentations, etc. I obtain a great deal of information from our regional managers, but the point is that, in general, there is a role for politicians at the local level as well because there are cross-over issues that happen at local authority level - transport, environment and other issues - that need to be taken on board.

I welcome the Bill. I hope the Minister of State will take on board two or three of my comments, which I think are progressive. We will support the Bill. We will look at one or two amendments, potentially - not many. The HSE is too bureaucratic and too large. Dr. Scally stated in his report, "It [was] difficult to see who, under this configuration, was representing the patient and public interest". It is to be hoped that with the change in structures and the new chairperson designate, the new board, a new CEO, the new transparency, the new open disclosure, the new regional structures aligned and regional boards, that statement will become redundant. I fear, however, that it will take some time and much concentration to reach that point.

Deputy Mattie McGrath

I am happy to speak on the Health Service Executive (Governance) Bill 2018, as it is aptly or ineptly titled. It should probably be renamed the "Moving the Deck-chairs on the Titanic Bill". The Bill provides for the establishment of a nine-person board for the HSE and that board will be accountable to the Minister for Health in the performance of its functions. That is certainly a novel idea. The introduction of accountability into the HSE is as novel a notion as one will get anywhere. I do not say that tongue in cheek; I mean it from the bottom of my heart. It is novel that a system that has been to the forefront in lack of public accountability and near total failure at senior management level is going to hold anyone to account. I wonder what we think will be achieved by means of this Bill. Apparently, it makes the new board accountable to the Minister for Health. Imagine that: the board will be accountable to the Minister. My God, that is a new one - someone in the HSE will be accountable. What an insult to the people's intelligence. Those who drafted this Bill and the Minister who oversaw it should have a bit of cop-on.

This Minister has presided over the greatest levels of health system dysfunction in the history of the State yet he remains in place. He is accountable to no one and only remains in his position because, in all likelihood, the Taoiseach, Deputy Varadkar, is more than happy to sacrifice him as a public scapegoat for the catastrophic failures of the HSE. The Taoiseach got his litany today in answer to the question of how all the bad things happened when he was Minister for Transport, Tourism and Sport, Minister for Social Welfare and in respect of the national children's hospital. He knew nothing about the latter and did not want to know. I never heard such poppycock from a Taoiseach.

Let us see how accountable the Minister is and the HSE has been. There are record numbers of patients on trolleys and the Minister remains in his job. There are 498 people on trolleys today. A task force was set up eight years ago when there were 250 or so on trolleys. What did that achieve? Psychiatric nurses are at breaking point and are about to take to the streets but the Minister is still in his job and smiling. There is a €750 million overspend in respect of the national children's hospital - despite every warning being provided that this would happen - and the Minister is still in his job. He was warned that it the wrong site was designated. We had medical experts in here, people who had built hospitals in America and the UK, and he would not listen. It is the wrong location and will always be the wrong location. We cannot get nurses and in this case we cannot mind the nurses going to and from the hospital. People will not be able to park there and there will not be a helipad but the Minister is still smiling and in his job. The overspend is growing and the Taoiseach informed us earlier that we should continue to overspend because it is going to be a good project. Such logic baffles me.

There are chronic and unending waiting lists for children requiring assessment of needs, with no sign of the Government becoming accountable in that regard either. Children are waiting for orthodontic treatment and for scoliosis operations. My colleagues, Deputies Danny Healy-Rae and Michael Collins, are hoping that Brexit will not happen because they have booked buses - these are in addition to the 16 busloads they have already sent - to transport people to Belfast under the EU directive scheme in order to get cataracts removed and have knee and hip operations and many other procedures. The sad part is that we are paying for this out of our health budget in any event.

What little hope can we place in a Bill which merely seeks to create an alternative bureaucratic structure with a failing and sprawling organisation? The Bill seeks to make the new CEO accountable to the nine-member board. Was Mr. Tony O'Brien ever held accountable? No, he was not. Look at the cervical cancer scare. Were those who presided over the slow death of the health service ever held accountable? No, they were not. There was some accountability, as Deputy Kelly said, when we had the local health boards and locally elected politicians on them. What hope can we place in a Bill that is so very much like this Government, namely, all window-dressing and absolutely no substance? None whatsoever. I have no faith whatsoever in this legislation. It is both rubbish and ill-judged. We know that, no matter what happens, the Minister, even if he was to go out shooting people, would not resign. That is the chronic disrespect the Government has for this House and for the general public. It is a disgrace.

Deputy Michael Collins

I welcome the opportunity to speak on the Bill. The HSE was established in 2005. In 2013, a directorate governance structure was put in place for the HSE as a temporary measure until the latter's functions could be moved elsewhere. Under the health reform programme, this directorate structure has remained in place for longer than planned. The Government states that this is because of the complexities of the health reform programme. However, I argue that it is down to poor management of our health service by the Government.

The Joint Committee on Health recommended in its Sláintecare report that an independent board for the HSE be established. The Sláintecare report is intended to be a ten-year programme to transform our health and social care services. It promises to prevent illness in our population. Where can the Minister of State demonstrate that this is happening in our society? I have begged the Government to make the FreeStyle Libre device for people with diabetes reimbursable for all patients with the condition. I welcome the fact that the Government has listened to some of what I have requested and that this device has been reimbursed for diabetic patients between the ages of four and 21. This is not sufficient, however. It is estimated that over 15,600 people over the age of 80 suffer from diabetes. If the Minister were serious about promoting the health of our population, he would extend the current reimbursement for the FreeStyle Libre service to be included in the long-term illness scheme to all patients with diabetes.

I cannot go without mentioning the battle that children such as Ava Barry had to suffer to get access to life-changing medicinal cannabis. Medicinal cannabis has been legalised in more than ten European countries, in Canada and Australia and in 30 US states. We need to seriously consider legalising medicinal cannabis for sick children and adults in order to improve the quality of life of those suffering seizures and chronic pain. The battle that Vera Twomey had to fight in order to get medicinal cannabis for her daughter, Ava, was unnecessary. This mother had enough on her plate without having to fight the State and the Minister for Health.

The HSE claims to provide the majority of care close to home. Since I was elected, I have called on the Government time and again to address the serious issue of caring for our elderly either at home or in nursing homes under the fair deal scheme. Carers are waiting between three and six months, in some cases longer, to get their payments. It is outrageous that these people are expected to survive on no money until their payments finally come through.

West Cork is home to the largest population of elderly people in Ireland. These individuals are waiting to get into respite care. We need extra beds for respite and waiting times need to be reduced. I would love to see a system whereby care is provided on the basis of need. I do not see any semblance of this in our health system. I have advocated for years to keep Bantry General Hospital open. I and others lobbied the previous Government not to close the 24-hour accident and emergency department there. Unfortunately, it did not listen and waiting lists are now getting longer and longer. That frustrates me.

One of the key points of the Sláintecare report relates to the creation of a system whereby care will be provided on the basis of need rather than ability to pay. This is fooling the people into thinking that the Government will deliver on its promise. The Government is running the health service inefficiently and codding the people into thinking that it is trying to do better. I want to see real action and I want rural hospitals such as that in Bantry to operate to their full potential.

Another lovely promise that has been made relates to the provision of a service especially for those who need it most. How can members of the Government look people in the eye and expect them to believe that this will happen? We have been hearing promises of this sort for donkey's years but there is no real delivery in respect of them. In west Cork alone, many people have been waiting for cataract operations for up to five years. Many of these people are elderly. To date, Deputy Danny Healy-Rae and I have taken 20 busloads of people for cataract procedures. I have a list of up to 100 people in my office and I have spent most of the day working to try to get cataract, hip and knee operations and all sorts of other procedures for them in Northern Ireland. Those operations and procedures could be out at Bantry General Hospital. A cataract operation takes approximately 15 minutes. The Government is failing in its duty of care for people by allowing them go to another jurisdiction for these simple procedures.

The programme for Government promises "the most fundamental reform of our health services in the history of the State". The Government needs to face the reality that people and healthcare professionals do not believe our health system is working. Our nurses and psychiatric nurses are deeply unhappy, and with good cause. The Government needs to listen to these nurses because there is no doubt regarding the need for change in the health service. We need to see real action now.

Deputy Danny Healy-Rae

I am glad to get the opportunity to speak on the most important issue we have to deal with in the Chamber. Members are aware the HSE was put in place in January 2005. I and a lot of other people believe that since that happened our health service has deteriorated to such an extent that it is now in a total shambles. Nobody knows - I do not know - how it will be redeemed or retrieved or what will happen to give people confidence in our health system because they clearly do not have it at present.

There are four Ministers or Ministers of State with responsibility for health. We have a Government, Taoiseach and President but we do not have a health service. We do not have enough nurses and the nurses we have are not being properly paid. We do not have enough doctors or consultants. I know of one patient who has been waiting for three years for surgery. He cannot get it because he is a public patient and the consultant who was dealing with him at the start went into private practice and has not been replaced. The man has to sit in an arm chair half standing up. He cannot lie down and he cannot sit properly. He has to try to stay half standing. That is the way he is day in, day out. There is no accountability. That is what is wrong.

Kenmare community hospital has been opened four or five years now. I give credit to one man and no other. That is Jackie Healy-Rae who fought hard to get that community hospital for Kenmare. Lo and behold, it is only half opened. It is not even half open because 21 beds are still not open. It is the same story for the new hospital in Dingle. A local farmer gave the Government the land for the new hospital free of charge and only half the hospital is operating at present. There are offices in other parts of it. That is what is happening in Kerry. During the roasting summer there were 22, 23, 24 and 25 patients on trolleys day after day. That is what was happening down in Kerry. What will it be like before the springtime if the winter gets bad?

The big worry I have for the people of Kerry is we have been promised a new hospital for Killarney but if this children's hospital in Dublin is going to double its cost, will the funding be there for it? People have to wait six months for carers. Elderly people like to stay at home as long as they can. They would like to die at home. That is what they want. It is not fair that people have to wait six months to get carers.

Look at what is happening with private health insurance. When a patient goes into hospital someone comes to see if they are on private health insurance. If they are, their health insurance provider is charged over €800 for the stay in the hospital whereas it would only be €75 otherwise. What is that doing to private health insurance but driving the cost up and driving it beyond the reach of working people who would dearly like to have proper cover for their families? It is not attainable now because of the cost.

People are in pain and people are going blind. We are taking buses to Belfast week after week with people having operations for cataracts, hips, knees, tonsils and many different things. They can be done in Belfast and people can get the money back from the HSE when they come back but we cannot do them in our own hospitals in the South of Ireland. Why is it? I do not know if the Minister of State is listening to me or not. I do not know if he really cares because he made a statement a few weeks ago that in 20 years' time there will be no nursing homes in Ireland. Where are we going to go with the people then? What will we do with them? If we are going to close the nursing homes, what other place is there for them?

I have gone beyond my time. I am sorry.

Deputy Michael Healy-Rae

I appreciate the opportunity to speak on this very important issue. If one thinks back to dealing with the old southern health board, it was a board that had teeth. There were politicians, medical staff and consultants on the old southern health board. I was very privileged to have given many years with our late father, Jackie Healy-Rae, to sitting on the southern health board. It had teeth. When one went to a meeting, one had a say at the time of budget. It had to pass a budget the same as any local authority. They were meaningful boards but lo and behold a genius of a Government at the time thought it was right to do away with it and scrap it because it was working. The first HSE debarred politicians completely. When they realised they were making a right dog's dinner out of it, they decided they better bring the politicians back in. That was some bit of a help because we had politicians who were genuinely worried and concerned about their constituents and they worked on the new HSE boards. They are in no way related to what was there in the past and the structures that were there on the old health boards. When we talk about having confidence in the health service, how could we have confidence in a Minister or Department when one looks at what they are doing with the children's hospital and the massive overrun? What Deputy Danny Healy-Rae said is right. Somebody will have to pay for it. In other words, will the likes of the community hospital we are promised for the great town of Killarney be affected? The first thing that will happen is that other infrastructural projects that have to go ahead in the county of Kerry and throughout the rest of the country will be slashed and cut and will not be delivered on at all because the story will be that everything will be needed to pay for the overruns in the hospital they are putting in the wrong place. We have seen over the past number of years the difference coming into Dublin city in the morning. It does not matter whether it is 5.30, 6.30, 7.30 or 8.30 in the morning, one is choked coming into the town. Here we are telling people we have compounded it further by locating the new children's hospital in a place where a helicopter cannot land and where we will not be able to bring people by ambulance. It is absolutely insane. The overrun is totally insane.

I have to raise the fact that in County Kerry, we have two fine hospitals in Cahersiveen and Kenmare where they are crying out for more long-stay beds. We have excellent matrons and staff. Every one of them is operating to their maximum. At the same time the hospital is not because there are rooms and beds that have never been opened. The funny thing about it is when one talks about Kenmare there was an urgent situation where in the space of one day, upstairs had to open because of an eventuality. There was no problem. It was able to open in a day. It was filled but then it had to be closed again. There is total and absolute mismanagement and insanity by people in charge, not the local people on the ground. A massive amount of money is being wasted.

There is a new system in place now in the HSE which I want to tell the House about and put on the record. Before if one was operating in a community hospital, whether in Kerry or Donegal, when goods were delivered, one signed off for the goods. If ten boxes came in, whoever was responsible counted the boxes and signed for them. That does not happen anymore. The ten boxes are delivered. No one in the hospital can sign for them. A person has to travel out to sign for them. When I say "travel out", that could be 20 miles, 40 miles or 50 miles. The person has to travel from an office to sign for goods being delivered to a community hospital. It is a fact. I would not say it on the record of the Dáil if it was not a fact. It is more waste and insanity. The people working in our health service know it is happening and it is shocking. When will we see proper management? Money is being thrown at the health service but it is not being spent wisely. That is why I am asking how we can have confidence in what is happening.

Last Saturday, I saw 24 people from around Kerry who need to come to Dublin to have their cataracts removed. How can we have confidence in a health service when we cannot do that in the south and have to send them up to Dublin? We can give them the money back and they can avail of the service in the North but we cannot carry out the operations in the South. It is absolutely crazy that people awaiting hip operations and children waiting for tonsils to be removed have to be sent to the North. That is extremely unfair. There is discomfort on these people even though we have tried to make it as comfortable as possible. It is crazy to tell people in their 80s that they have to go to the North to have a cataract removed.

Deputy Bernard J. Durkan

I welcome the opportunity to speak on this important matter. Like a number of other Deputies, I spent some time on one of the original health boards - a lot of time, in fact - during which I learned something about the health services. I was interested to hear the various submissions. A comparison has been made between the old health boards and the current structure. I agree with that comparison. The thing that has been obviously missing for the past several years is proper connectivity within the system. The health services on the ground were remote from the HSE. When he was appointed in 2005, I asked the first chief executive of the HSE whether the structure of the organisation as set out was appropriate to facilitate the delivery of health services. He said he did not know. It was an honest answer but history has proven it was not the appropriate vehicle. Everybody has said it was wrong of a previous Minister to abolish the board of the HSE. I do not agree. It was unworkable. The problem was that a replacement structure was not put in place.

For my sins, I was also a member of the Sláintecare committee which met over a considerable period. I repeatedly asked that consideration be given to the reintroduction of a system somewhat similar to that relating to the health boards whereby there was connectivity, accountability, a chain of command and a continuous line from the patient right to the Department and the Minister. Nobody really wanted to take it up because they did not want to go back to the fact that the previous system was abolished.

Deputy Donnelly is a nice guy and I am very fond of him but he is wrong if he thinks that overruns in the health service only started when the current Government or that which preceded it came to power.

Deputy Stephen S. Donnelly

The data are there.

Deputy Bernard J. Durkan

During the 20 years I spent on the health boards, there were overruns almost every year.

Deputy Stephen S. Donnelly

There were not. That is factually incorrect.

Deputy Bernard J. Durkan

I was there so I know what I am talking about.

Deputy Stephen S. Donnelly

That is not what the data show.

Deputy Bernard J. Durkan

The Leas-Cheann Comhairle will recall the position at the time. What actually happened was that in the month of September, a diktat would come down from the Minister for Health which said "You are over budget, pull it up." We were to apply the hand brake and correct it immediately. That is what happened. That is why it did not go any further. That was lost.

Deputy Donnelly also alluded to a few other things. He referred to the long years of waiting lists. I am awfully sorry to disabuse him of that idea. He mentioned three and a half years but a wait of eight years was commonplace back in those days. I dealt with such matters. I was there at the time. An individual would ask if we could do something about his or her hip; maybe eight years had passed since it was determined he or she should have a hip replacement and he or she was in severe pain and came in asking if somebody could do anything about it. All that has been forgotten and it has been convenient to forget it. That is the way it was then.

For all the time I was on the health boards, we were always told by experts that politicians should not be involved at all and that it was a matter for experts. They had expert opinion and the answers to all the problems. Even though all the groups and professionals were represented there, the idea was to get politicians off the boards in order that proper management and the closure of some hospitals could take place. That is a quotation. We were repeatedly told that there were too many hospital beds in the country and that half of them should be closed down. Half of them were nearly closed down. That was at a time when we had experts telling us where we were going wrong. What we did have, to be fair to them - Deputy Kelly referred to this - were politicians at local and national level who were on the board. These individuals were not always right but they had a point of view and they were not shy of expressing it. Whenever they expressed their point of view, they represented the people. I am not sure whether the board structure we have in place now is the answer. There needs to be representatives of the professionals involved in decision-making at local and regional level. In the period from 2005 up to now, we have had separate bodies working in watertight compartments as it were, none wanting to concede to another. As a result we have had dissatisfaction. Many of the very good professionals working in the health services will tell us that readily. They will say their views are never listened to.

I hope that the Bill before the House will at least address the issue of the chain of command. That is essential. It must start with the patient, whose interest must be represented at all times. Everything else is secondary. I hate to be harping on but Deputy Donnelly also mentioned the Royal Adelaide Hospital. He is right. It is one of the most expensive hospitals in the world. It was opened in 2017 and was some years in preparation. It cost the Australians $2 billion and there are 800 beds in it. I am confirming that the Deputy was right about this because he was wrong in most of the other things he said. Time will tell when we find out what the original guesstimate was for the cost of the Royal Adelaide. I do not know but I am sure somebody out there does. Deputy Donnelly would have volunteered that information to the House if he knew it and I would encourage him to so do.

The theory is that a regional structure will be introduced. However, I am not so sure it is integrated in the plan to the extent it should be. If that regional structure does not apply, I do not think this system is ever going to work. Spokespersons on both sides of the House have addressed this over a long period. The Manchester formula was the one recommended in the 1970s, 1980s and 1990s when we had a different system. The idea of the Manchester formula was that, since the population of the greater Manchester area and Calderdale was similar to that of this country, it was quite obvious that the same costs should apply. This was absolute and total rubbish. It was a totally different system, particularly in view of the vast geographic expanse of this country and the compact area that one could virtually walk across in a couple of hours in Manchester. I had the occasion of visiting the system there as a former school colleague of mine, God rest him, was mayor in Calderdale. It was a case of chalk and cheese. We eventually determined that the single board we got in the form of the HSE was going to be the answer but it was not. That was obvious from the outset.

Constant dripping does not wear a stone in these particular cases. I cannot understand why it takes so long to get the message across, even for fools like me and other Deputies who were members of those old boards and know how they worked. If any kind of emergency that necessitated action occurred, we would have know all about it at the board meeting on the Thursday night. We were tipped off about it beforehand and we immediately knew what was going to happen. If it did not happen, there were problems. That was long before computers were available and there was considerably less technology, but it worked quickly.

I mentioned that all the professionals were represented on the old boards. Between the old health boards and the local health advisory authorities, every aspect of the health profession was represented. Everybody could contribute at meetings that were held regularly. Pharmacists, nurses, psychiatric nurses, special needs professionals, doctors, local GPs and the consultants were all there. They had the opportunity to exchange views on a one-to-one basis. They did not have to write them down or send emails. They did not have to wait for a fortnight or three weeks for someone to come back to them; they got the information there and then. It was laid on and ready to function.

I recall visiting a hospital where things were not going as they should have been. It is interesting how things have changed. It was obvious to those unfortunate members of what was then known as the health board visiting committee that things were not going right. We were advised not to cause too much disturbance because there could be a general and all-out strike as a result of our intervention. It must be remembered that we were only ordinary elected public representatives and we would not know about the niceties of these things. However, such was the severity and serious nature of the problem that we decided it would be better to have an all-out strike or a closure of the facility unless something changed. Amazingly, within 12 hours everything changed. The things that could not be done beforehand were all changed. Suddenly, all the neglect that had not been challenged before could be and was addressed.

We lack some of those things now. We are not as good at that as we were in the past, which is sad. Those self-contained compartments have grown up in the meantime. A walled system has developed and, as a result, we do not get the same interaction and transmission of authority. We do not get the same accountability or good governance. We do not get the same quality of response and delivery of services to the patient. This means that things are becoming increasingly expensive.

I hate to raise this matter. Deputy Donnelly kindly reminded me of something that amused me. In 2010, the number of patients on waiting lists was approximately one third of what it is today; that is true. However, the Deputy missed out on one thing. The country was bankrupt at the time - flat broke. Therefore the overrun was a bigger one than anybody thought about. I am sure he meant to mention that to the House, but he just stopped and I can understand how that would happen. I hate to mention these things-----

Deputy Dara Calleary

No, the Deputy does not.

Deputy Bernard J. Durkan

-----but Deputy Donnelly inspired me when he set about dissecting what happened in recent years. I could not resist the temptation because I had to make the comparison. There is no good in telling me that I was wrong; I was there at the time. The point is that the old lapse of memory is amazing. We tend to see things as they are and not to compare them with how they could or should be.

Deputy Dara Calleary

Deputy Durkan is doing that.

Deputy Bernard J. Durkan

Oscar Wilde once famously said “Duty is what one expects from others, it is not what one does oneself.” We need to recognise that a lot of water has gone under the bridge in the years since the HSE was set up. It did not prove itself to be what I thought it was. It proved to me what I thought it would not be and unfortunately I was right. It was decided way back that by taking politicians out of the system, party politics would no longer play a role in the delivery of health services. Party politics is part of the democratic system. It did not always fail in the past. The health boards were set up in 1970 by a Fianna Fáil Minister. The thinking behind that structure was sound. They needed to be improved and helped as time passed. They needed to take account of changing times and changed responsibilities, but they did not always do that. There were problems with the boards, but they had structures that could be operated and could be made to work effectively for the people.

I hope that the current proposals will work; I am not so sure. I hope I am not right, but in four, five or seven years or whenever, somebody may point out that we did not really do it right and that a different structure will be needed. How long can we go on like that? How long can we keep pointing out these things and asking ourselves when we will do it?

I had great respect for the previous chief executive of the HSE. I know that the CervicalCheck thing was a difficult situation that arose and he vacated the post somewhat before he was due to do so. I was not all that impressed with his swipe at the Minister on his way out the door. If we want to play politics with these things, we can all play politics. That applies to those both inside and outside the party political system. I have no difficulty with that and I am sure the Leas-Cheann Comhairle would have no difficulty with it either. One of the greatest things about the involvement in public life is that we still can and will continue to interact and make our views known at every opportunity that it is required.

Deputy Kelly and I have exchanged views from time to time. He mentioned one of the things that is required and the intention is to provide it. That is, very simply, good governance with the transparency, accountability and all that goes with it. I was once a member of a committee that carried out an inquiry into the banking system and deposit interest retention tax in this country. It was very beneficial to the State and raised approximately €2 billion for the State in an earlier time. After a six-month inquiry, the conclusion and recommendations were that there would be good governance, good fiduciary practice, accountability, and regular monitoring by different accountancy firms so that there would be no crossover and nothing would be missed. That was in 1999.

We can have all the good ideas in the world, but we need to be more effective than that was in terms of what should have followed - incidentally it was the only sworn inquiry that was concluded in the history of this House. I think it is effective. However, the problem was that when we finished and the personalities involved went off about their business, it only took them less than four years to unwind the intentions of what the committee proposed. We can have all the good intentions in the world, but unless what we recommend in this House is taken seriously, nothing will change and everything will continue as before.

Deputy Dara Calleary

I was due to share time with Deputy Eugene Murphy but I do not see him in the House.

I welcome the Bill, which is basically a legislative "mea culpa" on the part of a former Minister, Senator Reilly, whose bull-in-a-china-shop approach to health reform is now being reversed by this Bill. I listened to Deputy Durkan's homage to the past.

There was a lot of sense in what he said about the old health boards. When I was first elected to this House in 2007, the HSE held regular quarterly consultative meetings on a county-by-county basis, at which hospital and local HSE managers engaged with public representatives. They were very effective meetings but during the tenure of the former Minister for Health, now Senator Reilly, they too disappeared. The hospital groups were established and they considered themselves to be unaccountable to local elected representatives. The final vestige of involvement on the part of local representatives was fully cleared away and the aforementioned regular local meetings do not happen now. There is no longer any opportunity for engagement with local management.

The abolition of the board of the HSE was based on the then Minister's pursuit of the so-called Dutch model of healthcare, which was going to be the panacea for all of our wants, like some sort of classy beer. It was supposed to improve accountability and delivery by the HSE but it was never going to happen. Unfortunately, we have had so many incidents since which have proved that. The lack of accountability at the very top has spread right across the organisation. When one deals with local managers and local front-line staff, one sees their passion for the patient, which is fantastic and immense. However, as one goes up through the layers of the organisation, that passion gets lost.

One of the issues with this Bill is that it only provides for a minimum of two patient representatives on the board. That is too few. Everyone on the board should have the interests of the patient at heart. Everyone on the board should be able to live the patient's experience and the patient's journey. There should also be representatives of patient's relatives and parents who depend on the HSE for day-to-day services so that somebody around the board table can tell the story of cancelled appointments, of not being able to access physiotherapy, occupational therapy or home care packages. Someone needs to tell the story of being told on Tuesday that surgery scheduled for Wednesday has been cancelled. Those experiences need to be heard at board level. If HSE and Department of Health managers are unwilling to hear them from directly elected representatives, then we must ensure that in the design of this new board, the patient experience is central. We must also ensure that other issues and experiences take second place.

Ós rud é go mbeidh an bord seo i gceannas ar chúrsaí sláinte in Éirinn, ba cheart go mbeadh Gaeilge ag na daoine a bheidh ar an mbord. Níl aon rud leagtha amach sa reachtaíocht nua faoi chúrsaí Gaeilge. Tá a fhios agam go mbíonn cruinnithe ag coiste na Gaeilge - tá an Teachta Connolly i gceannas ar an gcoiste sin - faoin gá atá ann go mbeadh seirbhísí éagsúla ar fáil trí Ghaeilge. Tá sé an-tábhachtach go mbeadh Gaeilge ag gach duine a oibríonn sa chóras sláinte agus go háirithe ag gach ball den bhord.

We must look at the experience of the HSE since 2011 and the abolition of its board. We have had budget overruns which Deputy Durkan dismissed as an annual event that always happens but it should not always happen. It happens because there is no proper financial planning in place and no accountability when things go wrong. We have had so many controversies, both locally and nationally, that have impacted negatively on patient care and on confidence in the health service. Nobody is accountable for that. Nobody has paid for involvement in these controversies with his or her job. There is no sense of transformational change taking place which is what any new board must grasp and run with. We must ask whether by changing the board we are actually changing the culture of the organisation because that is the most important change. We are all committed to going down the Sláintecare path but that path must have at its heart a change in the culture of service delivery. We must put the patient first. We must make the required investment and put in place the proper legislative and regulatory framework required for primary care. Any investment in primary care must make it an attractive place to work. At the moment we are alienating our primary care professionals to such an extent that they are fleeing the country for Canada, Australia and other countries whose health systems are set up in such a way as to allow them to be general practitioners or physiotherapist rather than all that they are expected to be here. Instead of just paying lipservice to primary care, the new HSE board should place primary care at its heart because so many problems can be dealt with in that setting rather than the hospital setting. When patients attend hospitals, they must receive a timely service. They should not, depending on the time of year, have to wait on trolleys for hours. Primary care services must be available on a consistent basis across the country which is the not the case at the moment. Primary care services vary from area to area, from CHO to CHO, depending on the availability of therapists or appointments. Patients living in some parts of the country can access health services far quicker than patients living in other areas. A central board of governance of a national health organisation must be committed to consistency and continuity of care, regardless of geography. There is some care that cannot be provided locally, including specialist care. Tough decisions were taken in this House, in the context of the old HSE structure, on the reform of cardiac and cancer care services which were opposed by Members opposite at the time. Those reforms have delivered much improved outcomes but there must be a consistency in the delivery of services across the country. There must be a genuine understanding of the patient's journey in terms of the way that care is delivered and accessed and the board of the HSE must take on the responsibility in that regard.

The board must have teeth and HSE management must be answerable to it. Senior management in the HSE has not been held to account to any great extent. The Oireachtas health committee does a superb job but is limited in what it can do in terms of holding senior managers to account. Calling senior HSE managers before the Committee of Public Accounts on a crisis-by-crisis basis is not necessarily the best way to get consistent answers or reform. The new board must be entrusted with the responsibility for doing that.

The board itself must also be answerable to the people. Producing an annual glossy report full of staged pictures of people looking happy does not amount to responsibility or accountability. Members of the board must be accountable to this House in a different and new way. No longer will the standard procedures suffice whereby board members appear before committees of this House and spend hours at a time trying not to answer questions posed, having spent tens of thousands of euro of taxpayers' money on communications consultants who told them how to do that. That is not responsibility or accountability to the Oireachtas.

The Minister for Health has now decided to reverse the car that was driven through the health service by the former Minister for Health, James Reilly, without any concern for the damage caused. However, he needs to make sure that he is driving a new car and that the board of the HSE has the strength, capacity and skill set to represent the interests of patients, first and foremost and of communities. The board must ensure consistency and continuity of care across the country insofar as possible. Where services cannot be spread evenly across the country, the board must ensure that patients have access to care that is timely and that is delivered in a manner suited to their condition and respecting of their dignity as patients and citizens of this Republic.

The people who are asked to take on the duties of this board will have a very big responsibility. We will have to take that responsibility into account when considering the remuneration of board members. If we want the right people for this job, the standard way of rewarding them may not suffice. Thought will have to be given to the kind of person and the kind of experience we want around that table. Every single person who signs up to become a member of the board of the HSE must know from the beginning that his or her job is to represent patients. The people who are treated in our health service deserve representation and must know that if their treatment goes wrong or if they have a negative experience, there is someone at the board table who will stand up for them, for their community and for their health service.

Debate adjourned.

Dáil Éireann debate - Tuesday, 15 Jan 2019

Health Service Executive (Governance) Bill 2018 [Seanad]: Second Stage

Dáil Éireann debate -
Tuesday, 15 Jan 2019