Dáil Éireann debate -
Wednesday, 16 Jan 2019

Vol. 977 No. 5

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

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

Deputy Eugene Murphy

This House has spent a considerable period of time discussing health issues today. Many nurses were present for this afternoon's debate on pay and conditions in the nursing profession. The number of staff nurses has decreased by more than 1,700 in the last ten years. This is symptomatic of the difficulties that have arisen under the HSE. Every day, we hear justified criticisms of aspects of work and things that are not being done. I want to state clearly that there are many good staff in the HSE. A great deal of good work is being done by the HSE. It would be wrong to paint everybody with a negative brush just because the system under which the HSE has operated has not been very successful. It is the system that is the problem, more or less. The board of the HSE was abolished in 2012. To be honest, we have had many difficulties and problems in the six years that have elapsed since then. We have spent a long time trying to fix this problem. According to the Sláintecare report:

Good leadership and governance are critical functions of any health system. The Committee strongly believes there is a requirement for clearer clinical and managerial accountability and governance throughout the system. This includes clarity at all levels, from the Minister for Health, the Department of Health, the HSE and healthcare providers.

It must be in everybody's interest to ensure all the work that was done on Sláintecare is implemented as quickly as possible.

We have problem after problem within the system. It is bizarre that waiting lists seem to get worse and worse. When I looked at some figures as part of my research on this issue in advance of tonight's debate, I learned that over 5,000 people are on outpatient waiting lists in the CHO 2 area, which covers counties Roscommon, Mayo and Galway. It is bizarre that waiting lists in virtually every area of healthcare are growing and growing. It emerged recently that inpatient and outpatient waiting lists have grown by approximately 50,000. That is a shocking indictment of any system. This problem is not confined to the CHO 2 area; it is found all over the country. We need to have change. We have to bring that change around as quickly as possible because people out there are frustrated and annoyed. Sláintecare proposes "that the HSE be reformed into a more strategic national centre, with an independent board and fewer directorates". The Sláintecare report continues:

Recognising international evidence on the negative impact of system re-organisation or merger, the Committee believes structural change should be as simple as possible, and only what is needed to meet the requirements of integrated care. The HSE strategic national centre will be supported by regional care delivery through regional bodies, recognising the value of geographical alignment for population-based resource allocation and governance to enable integrated care.

It is vital that these changes are made and brought forward as quickly as possible.

I would like to refer to another indictment of the system. It was mentioned earlier today that many people, particularly nurses, are leaving this country. They are finding themselves unable to work within our system, mainly for reasons of pressure and conditions. We must acknowledge the outstanding commitment of front-line staff who deal with unbearable situations every day. We have to remember that people in queues who have been waiting a long time for assistance sometimes complain. When people are in pain, they get into bad form. Nurses and front-line staff are required to deal with all of that. It can be seen right through the system that this particular problem has been getting worse year after year.

Sláintecare explicitly recommends that the Minister for Health should appoint "an independent board and Chair" to the HSE "at the earliest opportunity...following a selection process through the Public Appointments Service" and that the membership of the board should reflect "the skills required to provide oversight and governance to the largest public services in the State". We should remember that over €15 billion, which is a lot of money, is spent on the health service each year. The director general of the health service will be accountable to the board. This Bill provides for the establishment of a nine-person board for the HSE. The board will be the governing body for the HSE and will have the authority to perform the HSE's functions. The board will be accountable to the Minister for Health for the performance of its functions. If there is one word I have heard time and again in recent years, both during my time as a local councillor and since I was elected to Dáil Éireann in 2016, it is "accountability". We all know that people regularly talk about the lack of accountability in the system.

I welcome this Bill, behind which Fianna Fáil will throw its support. As I have said, the abolition of the board by the former Minister, Senator Reilly, was a mistake. It was abolished and it was left there. We have moved on six years. Things have worsened over those six years. It is beyond time for the Members of this House and the Government to pursue this particular change. In my view, we should make the change happen as quickly as possible. We have enormous mountains to climb as we try to improve the health service. I stress that in no way am I making any derogatory reference to the many good people who work in our health service day and night, 24-7. As I said, they do a lot of good work within the health service. We owe it to the staff and the public to make the changes that are necessary. That is why Fianna Fáil is supporting this Bill.

Deputy Fergus O'Dowd

This important legislation attempts to change the face and the modus operandi of the HSE. I am speaking personally when I say that, regretfully, it is like changing the deckchairs on the Titanic at this stage. The good ship HSE will continue to sail on without accountability or transparency, both of which were mentioned by the previous speaker. I have many examples because my constituents have come to me with them. I have been told by people from outside my constituency that the HSE is not working and is not accountable. I will give a few examples.

In November 2012, a patient died after being brought in a very serious condition from Cherry Orchard Hospital to St. James's Hospital, where he passed away. He should not have died. He was in such a disgraceful condition from a medical perspective when he arrived at the accident and emergency department at St. James's Hospital that the receiving doctor who met him there expressed serious concern to the members of his family who accompanied him to the hospital. When he asked them why they had not looked after him in his home, they informed him that he had not been in his home, but had been in a HSE hospital for a long time. He was a victim of AIDS. When the AIDS ward in Cherry Orchard Hospital was closing because people were thankfully living longer, people within the health service recommended that he be sent to the St. Doolagh's facility on the north side of Dublin city. That option was refused to him and he was kept in Cherry Orchard Hospital in a geriatric ward to which he was not suited. They had no training, no knowledge, no concern and no care for this man because he had AIDS. That is an absolute tested fact. It is known.

The facts are that the family was deeply concerned about that and they contacted management in the HSE and fought like hell to get an inquiry. The inquiry was set up. No doctor was put on the inquiry team to examine the medical issues which were of deep concern to the family. The family rejected the finding of the first inquiry. They came to me and we got a second inquiry set up. The second inquiry commenced into the death of this person and a doctor was put on the team but in the middle of the process the doctor left the inquiry and it collapsed because there was no medical person on it. We insisted on a third inquiry. The HSE tried and was unable to get a doctor anywhere in this country to sit on this board for almost a full year. It requested the medical association to nominate somebody to examine this situation, which is appalling and deeply concerning. No one stepped forward. Eventually, it had to get a private company to do it and then - this was almost four years later - the family got the truth of the death of their loved one and the reasons that person died. It had to do with a lack of management in Cherry Orchard Hospital, a lack of accountability and many other issues. The family has not left it at that because they are looking for a final relief of the burden on them because of the death of that man and the way he was treated by the HSE. I rang the family today and was told they are being challenged in the courts not by the HSE but by its legal advisers. That poor man died in 2012 and they still have no closure. There is no accountability within the HSE for this. It goes on and on. The only people who have suffered are the poor person who died and his family.

That is not the end of the story in Cherry Orchard Hospital. During the course of our inquiries, freedom of information requests and parliamentary questions, we discovered there were two other deaths at the same time in that hospital. Three people died in Cherry Orchard Hospital over a very short period of time in 2012. I do not know, I cannot get and I will not be given the details: I do not want to know their names but I want to know what the outcomes of those two other separate inquiries were. When we met the third inquiry team we were not told that it was looking into the other two deaths. I want to know what the hell was going on. What was happening in Cherry Orchard? Why did they not tell us what the outcomes of those two other inquiries were? We still do not know if anybody has been suspended. We do not know what has happened or what the outcomes were.

This goes to the heart of what this reform should be about. It should be about transparency of process and accountability. One of the issues concerns the medical profession. As a result of a discussion I had with people in the HSE, I believe we need an independent board - obviously there would have to be due process before a case would go to it - that will examine and investigate deaths and other medical issues that have arisen. We have heard of other people who have died tragically since, namely, Emma Mhic Mhathúna. Vicky Phelan is fighting very hard and she is shining light into the darkness of the HSE and its operation. We need now, and on Committee Stage, a better decision to be made other than to change the names of the people who sit around that board. Putting two people on it who have public knowledge all sounds very well and grandiose but it means nothing unless the HSE is accountable.

We need a body that will invigilate and examine what they are doing separately and that when people die tragically in hospitals or there is a significant medical misadventure that there would be an automatic referral to this body, which would have medical expertise provided by the medical professionals. They are remiss in not coming forward and doing their duty of care to people who were mistreated in our medical service. They are afraid to go forward. How in the name of God can they stand over their oath, if they, as an ethical body, will not say that they will nominate people who will investigate and examine the reason a person died or was badly mistreated by this system, which is unaccountable and rotten in many respects in this area? It is an outrage. It annoys me. When people come to me with cases like this one, I tell them I will do my best for them, but we are only voices here, we make our speeches and they waft off into the air. Nobody gives a damn, or do they care? I challenge them to do something about it now. I challenge my Government to step up to the plate and make sure there is a proper independent, scientific and medically based process in place, backed by the medical profession, that ensures that where these issues arise, they are dealt with clearly, openly, transparently and accountably and that people are fired for not doing their job. Nobody gets fired in the HSE. One cannot find out if there is even an investigation under way in some cases. It is not good enough.

The other issue that concerns me about the HSE is that of transparency and how can we improve it and accountability. I was sitting in my office one day and I got a telephone call from a person who told me that they found a medical record from a hospital somewhere in Dublin lying in a ditch on the side of the road. The medical records of patients were found on the side of the road in Baltray in County Louth, not once, not twice but on three separate occasions. I advised the person to bring them directly to the Garda station, which is the appropriate place to bring them. The person told me there was no hospital name on the documents but they did contain the names of the patients and their treatments. It is appalling those records were found on the side of the road.

The reply I got from Beaumont Hospital stated:

Dear Mr. O'Dowd,

A recent incident occurred whereby personal healthcare information on patients who attended our Emergency Department was found outside of Beaumont Hospital. [It was found on the side of the road in County Louth.]

On review ... the source of the information has been identified as an Emergency Department summary clinical handover report used by nursing/medical staff during shift changeover. [They were changing shift and suddenly a sheet of paper fell out, landed on a car or whatever and ends up on the side of the road.]

As a result of this incident all Emergency Department staff have been directed to use the confidential bins provided for such reports prior to leaving the hospital.

As well, I have written to all of the patients personally outlining the cause and details pertaining to the information breach and apologised on behalf of the hospital.

That happened three times on three separate dates over a period of time. That is not good enough. The way they treat serious significant confidential information in a cavalier way is unacceptable. Somebody should be held accountable for this. I do not know who they are and we will never find out because they are not going to do anything about it.

I welcome the interest of the Minister of State particularly in this matter because she has visited the town of Drogheda on three separate occasions at least to deal with the issue of drug abuse and the medical issues pertaining to that. The context of drug abuse in County Louth is clear with the appalling situation we have with the drug barons, the criminals, the violence on our streets, people being shot at in houses and people being intimidated. A woman who called to my office this week told me that her son was told that if he did not pay his debt, this was the knife - which they showed him outside a supermarket - with which they were going to cut her. Would my colleagues believe that? That is the truth. That is what happened in my office last Monday morning. We have the proceeds of crime, the criminality and all of that is going on.

On the medical side of it, I have information on the number of significant drug users, the use of syringes and so on. It is a quarterly measure of the amount of heroin and other substances that are being injected in County Louth. The figure is shocking. It is 11,000, on average, over a three-month period in County Louth.

The Minister of State, other people and I have tried to get a needle exchange programme and recognition for a top-class voluntary organisation, the Red Door Project in Drogheda. It does not have a proper outreach service because it cannot afford it. When Senator Nash, who is not in this House right now, and I made representations to the Minister, the official involved wrote a letter naming me and Senator Nash as using our political position with Red Door to get it funding and asking what she should do. Nothing happened. The project got no funding and has not got it to date. Almost €500,000 of health board money has gone into another location in Drogheda to additional services, which is very welcome. One of these services is drug outreach, which is welcome too. There was no consultation with Red Door, the Garda or anybody. The HSE is not accountable and it is not helping where it is critically needed to deal seriously with the drug problem in Drogheda by engaging, participating, sharing and working together with community groups. What better thing could be done than that?

Looking at the HSE and its CHO areas, the CHO area of Louth is different to the acute hospital area. There is one administrative area for community services and a different acute hospital area. They are not joined up in their thinking but they set up a group of counties which have nothing in common. Louth and Meath have a lot in common but we have nothing in common with Laois, Offaly, Westmeath and Longford but they are all in one area. It does not make sense. Louth, Meath, Cavan and Monaghan would make sense as an area. That is how it used to be. A lot of thinking needs to be done and on Committee Stage of this Bill, I hope to table some amendments to challenge the system, not the Minister, and the HSE to be accountable and to look again at making a better health service which would work with involvement, support, and more time for the community. I acknowledge all the good work, as the acting chairman has, of the tremendous nurses, doctors and staff. They are fantastic. There are some excellent top class administrators. The inquiry relating to Cherry Orchard Hospital would not have taken place if not for two very good HSE officials when we insisted at the end in getting full transparency.

How much does it cost to change the name of a hospital? The HSE, in its wisdom, has decided that Our Lady of Lourdes Hospital in Drogheda which was built in 1950 by the people of Drogheda and elsewhere in the country, when everybody bought a brick and supported it, should have a name change. The ethos of the hospital changed some years ago, rightly so, when the health board took it over. The order of nuns, the wonderful Medical Missionaries of Mary, no longer have any role to play in it but people like the name - the Lourdes hospital - which is what they know it as. I like where I live, a place called St. Mary's Villas. One of the main streets in the town is called St. Laurence Street. I like that and St. Laurence's Gate. I do not want to change the names. We like names such as Peter Street or St. Laurence Street. They are historic and part of what we are. The Lourdes hospital's name is being changed and there has been no consultation with the people, who are angry about that. Many of them protested it. One might ask what a name change is. It is a fundamental thing for people to show respect for what is there. I am talking about the name, not the ethos, which has changed and I fully support a secular health service and complete separation of church and State. I do not think it is a good idea to change willy-nilly the names of institutions that have been there for a long time. Will the name of St. James's Hospital change? If it did change, what would it cost?

I believe there is a total lack of sensitivity and awareness on issues like this and of understanding of people who respect and like what the hospital means to them. Changing the name is rubbish. I would like to talk about many other things although I know my time is getting short. If a hospital in one's county closes, one is in trouble but one would have no say in that and there is no forum to complain about it. The only place to deal with health in this place is in the Chamber, with the Minister or in the Joint Committee on Health. I have a significant interest in health. I am not on the Joint Committee on Health and if I went in, I am sure 20 others would be ahead of me. We are talking about regional accountability. One thing the Minister should consider is that there should be a regional health forum that Members of the Oireachtas would attend. It should be quarterly, based on their acute hospital grouping or CHO. I do not mind which it is. There would be an agenda which would be made known in advance. One would ask for reports at it but not interfere with decision-making. One could ask why something was done, what is happening in a certain situation or how one could help. That debate and knowledge do not exist.

The HSE is a bit like the Kremlin. I will be visiting Russia fairly soon and it is probably the last place I would like to be. One cannot get answers, cannot find people and will be put through the hoops if one submits a freedom of information request. Moreover, one must request meetings. The problem with the HSE is that it is not interactive with the political system. The political system, in a way, is afraid of that responsibility. The Minister will face responsibility every day if anything goes wrong but he has no say in what is happening and this Oireachtas has no say. There is no real understanding or effort to get a better system to make it better for ordinary people. It is not good enough when people such as those I am dealing with lose loved ones in appalling, disgraceful, shameful and unacceptable circumstances and are still fighting for justice six years after a person died. This has to change.

Deputy Catherine Connolly

While some of what the previous speaker said echoes with me with regard to my personal experience, I totally disagree with him in certain respects. I agree about lack of accountability and reviews not being carried out properly. It merges with my own experience. I have raised some of those matters in the Dáil. When he extends that to say that politicians or the Government have no responsibility, I have to fundamentally disagree with him. We are here to re-establish an independent board as a monitoring mechanism over the Health Service Executive and I support that. One has to ask why there was no board and for how long has there been no board. The previous speaker, who has left the Chamber, was part of the Government that made the decision in 2012 to dissolve the independent board and to replace it with civil servants. I will address some of the consequences. Why are we re-establishing that board tonight, almost seven years from the time it was dissolved? There are three reasons, two of which are interconnected. One is the Scally report, which clearly outlined the consequences of bad governance, especially the lack of board representation.

The second is the Sláintecare report which includes the input of members across parties, reflects a new Dáil and a new type of politics. I am still innocent enough to believe in new politics, even though my cynical side tells me that we are going nowhere. I will stay with my innocent side tonight and the Sláintecare report which clearly states we need an independent board. That is one of the reasons we are here. I would like to think we are here because the Government has learned something and will state it made a terrible mistake at the time and that the then Minister, Senator James Reilly, thought he was doing the right thing but that it was not good. However, I do not hear that being said.

The third reason is the Scally report, from which I will quote because it is important. I contributed to the debate on it. It concerned cervical cancer screening, what had happened, the patronising attitude and the failure to give information. That is what it was about: the failure to give information to women to empower them and let them make decisions. The report which I have read closely is scathing, albeit in very moderate language, about the absence of governance. In fairness to the CervicalCheck programme, another point is noted, that within a few days of the launch of the cervical screening programme, there was the bank guarantee:

Staff recounted how the Irish bank guarantee occurred three days after CervicalCheck was launched nationally in September 2008. As the financial crisis contributed to an economic recession, public sector programmes and organisations saw a reduction in the level of resources afforded to them, with CervicalCheck no different. As its budget was reduced, CervicalCheck struggled to adequately replace departing staff.

That was the background. The reason I mention this in the context of this debate is that even with these difficulties, it struggled on gallantly until it was put back within the remit of the Health Service Executive in 2010. Dr. Scally states clearly, "Since 2010 ... CervicalCheck has not had a single, accountable senior person responsible for the delivery of the programme on a full-time basis." At that point there was an independent board, but we were in trouble with CervicalCheck because there was no accountable person. On top of this, the then Minister, Senator James Reilly - I do not wish to personalise the matter but he happened to be the Minister at the time - walked in and dissolved the board in 2012. Therefore, the level of accountability that was supposedly there in theory was also taken away and civil servants were put in charge.

In 2013 a Fine Gael and Labour Party Government introduced legislation that copper-fastened the absence of monetary accountability and of a means of holding the system to account. What did they put in place? There was a director general going into a room to be answerable to other directors of services and when he came out of it, he was answerable to himself and, ultimately, the Minister. All of this was done in the context of debates in which it was said this was to bring more openness and greater accountability. The Minister of State is as aware as I am of the many mistakes made from 2013 to date. My own family has suffered. I will not go into it here, but I have alluded to it on a number of occasions and will come back to it when I speak about the failure to carry out an independent review when something happens. On this point alone I have asked a simple question of the hospital in Galway: how many reviews have been carried out independently within a certain period? By whom were they carried out and what was the cost involved? An answer has been given to the effect that it has no system in place for recording this information. That is the official reply to a Dáil question. Again, this will be relevant when I come back to the board we are going to re-establish. The first hurdle is the board; the second is ensuring it functions adequately, that it has adequate data, help and research facilities and so on.

I will quote Dr. Scally because balance is important and I want to balance some of the things I said at the time:

Changes to the overall governance of the HSE itself had a significant impact. In March 2012 the Board of the HSE, which had consisted of an external, non-executive Chair and Board members, was removed and replaced by a Board consisting of civil servants and HSE officials. This change from the accepted good practice of having independent Board members in an oversight role, and involved in a committee structure beneath the Board, was a major move away from the established norms of good governance of public bodies. It is difficult to see who, under this configuration, was representing the patient and public interest.

Again, this is something to which I will return, if time permits. Talking about putting patient representatives on the board is not sufficient to represent the patient. Much more is necessary to have an independent board. I will continue with Dr. Scally what he said for the moment:

In the case of civil servants appointed as Board members, it raises the question of whether they are acting in their civil service capacity, supporting Ministers to carry out Government policy, or are there to administer a major public body in the interests of the public it serves. This was further compounded by senior civil servants at times fulfilling two roles, one in a senior executive position in the Department of Health and the other within the top-level governance structure of the HSE.

Again, Dr. Scally is clearly illustrating the difficulty at the time. It is something to which I will return when I speak about appointments and conflicts of interest on any new board. The report continues: "In 2013, legislation changed the nature of the governance of the HSE entirely, replacing the Board [as I said] with ... a Director General and [other] Directors". This was supposed to be part of the beginning of the abolition of the Health Service Executive, which never happened. However, no politician or member of Government came back and said, "The Health Service Executive has not been abolished, so we need to put back in place an independent board to monitor it." It has taken Sláintecare, Dr. Scally's report and the loss of lives, including of someone close to me, to realise we need an independent review board, not for the purposes about which Deputy O'Dowd was talking because they are for independent reviews. That is an entirely separate matter and he confounded and conflated issues in his emotional address to the Dáil, which I fully understand. However, the independent board has a different function.

The net effect of removing the board by legislation, supported by a majority of the House and led by Fine Gael and the Labour Party, was to remove an external independent input into the running of the Health Service Executive at its highest level. There was absolutely no independent input or monitoring. That is the way we have progressed and I make my contribution in the context of a health service that is very much struggling. So far this year there have been 73 children on trolleys and we are barely two and a half weeks into 2019. I hope the time will never come when I accept this as collateral damage in a thriving economy. I certainly do not accept it now and do not think one can have 73 children on trolleys and at the same time talk about a thriving economy. We have thrown out all of the other figures. Last year, in Galway alone, there were 8,750 patients on trolleys, chairs and other contraptions in wards. The hospital in Galway distinguishes itself, despite the best efforts of staff, by having the most appalling record for the number of patients on trolleys. It should be borne in mind, as I said, that Dr. Hickey, the brave consultant that he is, has repeatedly pointed out that every year there are between 300 and 350 premature deaths as a direct consequence of the time spent on trolleys by patieints. We are having this debate in the context of the Government's appeal to nurses not to strike because of patient care issues, but we are missing the point - the very reason they are promising to go on strike is that they are concerned about patient safety and that patients are dying as a result of inadequate care because there are not enough staff and many mistakes are being made.

For the second time tonight, I thank the Oireachtas Library and Research Service for its very detailed report. It is important to compliment staff when they do an excellent job. The service has given the history, with Dr. Scally. Thanks to its report, I now have the language to address something that has always jumped out at me. The report refers to the characteristics or qualities essential for a good board. It examined international literature, simplified it for us and provided the key characteristics of a good board, namely, transparency, accountability, participation, integrity and capacity or TAPIC. Many boards are caught considering financial issues and key performance indicators given by government. The literature tells us that one of the better characteristics of a board is to have consideration of patient safety placed on the agenda of every board meeting.

The initial hurdle is to set up an independent board. The second is to make sure the board is representative, has gender equality and has members who have the capacity to absorb knowledge, ask questions and hold the system to account. That is the role of an independent directorate. I re-read with fascination the comments of the former director general of the HSE which were given great prominence in The Sunday Business Post and found myself agreeing with some of the things he said. I found others extraordinary, however, including his comment that shit only went one way, namely, uphill to him. He spoke about the abolition of the independent board but did not consider its consequences for himself. He also commented that on one day in 2012, the very year the former Minister for Health, now Senator Reilly, got rid of the board, the HSE lost 5% of its staff. It lost all that experience and wisdom because of cutbacks.

Those cutbacks were made before the Minister of State took office. I was on a health forum in Galway at the time. In 2007 and 2008, only the language used was different. When we asked why beds were empty or wards closed, the reasons given were cost-containment measures and bed refurbishment measures. During all that time the privatisation of the service was intensifying. Now Fine Gael repeatedly talks about how wonderful the National Treatment Purchase Fund is. The NTPF was to be a temporary measure, not a permanent one. The opposite happened and we ran down the public system.

I welcome the Bill and hope it is implemented as quickly as possible. The selection of board members will be extremely important, as will be the services provided to the board. Gan aon amhras, tá gá le daoine le Gaeilge. Tá dualgais reachtúla ar an Rialtas agus ar aon bhord an Ghaeilge a úsáid agus a chur chun cinn. Glacaim go mbeidh Gaeilge ann, ar aon nós. In addition, there has to be expertise and research available. There has to be clear evidence that the people appointed, men or women, have the ability to ask questions, are not afraid and that patients are first on the agenda.

In respect of conflicts of interest, the former director general of the HSE saw no problem in taking a position in a certain pharmaceutical company. This is public knowledge. In addition, apparently the Government did not see any difficulty in the fact that the chair of the pharmaceutical company in question was also chair of one of the hospital groups. I view that as a conflict of interest, although perhaps others disagree. That is the type of thing that in a small country we have to be particularly aware of.

The final point that emerged from the research done by the Library and Research Service was about oversight of the independent board. We know this on the Committee of Public Accounts, PAC, membership of which is both a prison sentence and a privilege. What comes out every week are the difficulties arising from lack of governance, and even when governance procedures are in place the failure to monitor those. We get tied up with all of these governance words but the consequence is that patients suffer and die. In respect of other groups that come before us, the whistleblowers and employees suffer, and the public purse suffers because of inquiry after inquiry. In my two years as a member of the committee, I have lost count of the number of independent inquiries there have been - separate from health - on the vocational educational colleges, universities and technological colleges. They are costing us a fortune because we have not managed to implement good governance. Even when we do so in theory, we do not ensure it is implemented on the ground and that costs us more. I welcome the Bill and look forward to further discussion on Committee Stage.

Deputy Michael Harty

The Health Service Executive (Governance) Bill 2018 is extremely important and I welcome it because it is at last introducing real structural health reform. It reflects one of the main recommendations of the Sláintecare report which was published on 30 May 2017. It has taken 20 months to introduce legislation to reappoint the board. It is very disappointing that it has taken almost two years to bring the legislation forward. That is indicative of the slow pace of implementing Sláintecare reforms which is disappointing given that Sláintecare has cross-party support. Nevertheless, it is a welcome start.

The Bill is a significant reversal of Government policy which was initiated in 2012, as Deputy Connolly so clearly explained, by Senator Reilly, the then Minister for Health, who disbanded the HSE board on a whim. I think it was his intention to disband the board within 100 days of being appointed Minister for Health. This intention to replace the board was never realised and the structures put in place, the clinical directorates and the civil servants who replaced the board members, never really worked. That has contributed to the demise of our health service that we are experiencing today.

A Programme for Partnership Government published in May 2016 which underpinned this Government included a commitment to continue to dismantle the HSE and replace it with a new structure. Thankfully, that new structure has not appeared. In the Oireachtas Joint Committee on Health's deliberations on Sláintecare we were advised by many experts in change management that if we were to reform our health service, we should do so with the minimum structural change possible because once major structural changes are made, it takes years to implement them. The recommendation was to reconstitute the HSE board and work from within the HSE to reform the health service, rather than setting up a new body. The report made an important recommendation, which I hope the Minister will progress, to decentralise the HSE, not down to health board level but to regional bodies where the hospital groups and community health organisations would be merged. These merged entities would have one budget and the independence to deliver services in their respective region as the regions need these services. As such, we would not have the unwieldy centralisation that we have in the HSE at the moment. I hope the appointment of a HSE board is the start of that process.

We have seen how chopping and changing in our health management structures has inhibited real health reform. It has resulted in chaotic and fragmented health services. It allows for excellent and adequate care in some areas but unfortunately there are many areas in our health service that are extremely stressed and do not deliver optimum care. We have incoherent policies and a management structure that is almost impossible to navigate. We are all aware of the problems with our waiting lists and today we had 535 patients on trolleys, which in an average winter is now almost acceptable. Of course it is not acceptable. Trolleys are just a symptom of wider problems within our health service. We know trolley numbers will vary from one period of a year to another. If there is only one person on a trolley, it is an indication we have capacity issues with regard to staff and beds.

The present structure of the HSE is not fit for purpose. The management processes were put in place with 18 clinical directorates and a group of civil servants who must have had a conflict of interest in being civil servants and members of the board. The system became completely unwieldy and not fit for purpose. It was intended to be a temporary arrangement initiated by the then Minister, now Senator James Reilly, while he put some other structure in place. We were never quite sure what that structure would be. The replacement structures, which are not fit for purpose, are still there seven years later. That system has inhibited health reform, integration and structural reform in our health services.

One of the main difficulties in our health services at present is the lack of integration. People are in silos. They are in separate offices, directorates and divisions. They have separate budgets and do not speak to each other. As a consequence, much inefficiency and unmet need build up in the system. The HSE has had three directors general in the past eight months. We have failed to fill the position. We are now engaging in another interview process to try to find a candidate who has the skills and expertise to lead an organisation which has 135,000 people working for it. The person with the skills and managerial experience to fill that post will be very difficult to find. I believe there will have to be an extremely attractive package to attract somebody who can run a service like that. It would be money well spent because we waste so much money in our health service. We waste millions of euro. Look at what happened with the budget for the children's hospital. It has now increased by a factor of two or three, depending on what figures one believes. If it is going over budget by up to €1 billion, we must pay somebody an attractive salary to run an organisation to stop that kind of waste. It is very important that, apart from appointing a new HSE board, we have a director general of the HSE as soon as possible who has the skills and expertise to manage it. That person will be responsible to the board. As Deputy Connolly stated, it is very important because Tony O'Brien admitted he was reporting to himself. For several years he was reporting to himself. He had responsibility to the Minister but it is important we have a proper managerial structure in place.

The Scally report resulting from the cervical screening controversy highlighted in stark terms the deficiencies in accountability and transparency that exist in the health service. Deputy Connolly was quite right that accountability and transparency are absolutely essential when we constitute this new board. It has to be independent but it has to be answerable. It has to explain its decisions. When a political decision is made that affects our health service and which is incorrect or wrong, it has profound implications for the delivery of health services. We talk about clinical responsibility. If a doctor, nurse or health professional makes a mistake they are accountable to their professional bodies and if they are found to be negligent they will suffer the consequences. We make political and corporate decisions willy-nilly in our health service which has profound negative effects on it, yet nobody is held responsible. Nobody puts their hand up and says it was a wrong decision and if it had gone a different way many millions of euro could have been saved, the health of our patients could have been improved and lives could have been saved. Corporate decisions are extremely important and should not be underestimated.

Ciarán Devane has been appointed chair designate of the yet-to-be-constituted HSE board. He will have a very important task. First he will be part of the interview panel to appoint a new director general to the HSE. He will also have influence on the people who are appointed to the HSE board. It is very important the board is a slimmed down board from the previous board and that it has particular skills in change management. It is very important. When we look at the Sláintecare report and how it has to be implemented, we must have experience on the HSE board of change management and implementing reform.

The new HSE board will have important functions. It will have to ensure the HSE engages with the Sláintecare reform programme and engages with Laura Magahy, the director of the Sláintecare implementation office, to ensure that Sláintecare reforms are deeply embedded in HSE service plans year on year for the next ten years and for many years after that so that reforms are put in place to improve patient services and outcomes. The essence of a health service is to improve patient outcomes and deliver a service. I was impressed with the HSE service plan delivered at the end of December 2018 because for the first time it has embraced reform. References to Sláintecare are widely scattered throughout that report. There is an intention and recognition in the HSE that Sláintecare has to be delivered. There is a greater recognition within the HSE than there is within the Department of Health of the importance of delivering on Sláintecare.

The board must also build on accountability and transparency in managing and making decisions. I have said bad corporate decisions have a profound effect on population health. Deputy Connolly referred to the retirement of very senior people in 2012. The HSE lost a raft of experience as a result of a change in pension arrangements. It was not intended but it was a consequence of those pension arrangements. We lost a significant amount of corporate knowledge as a result. Look at the corporate decision on the children's hospital, the length of time it has taken to deliver it, the controversy over its location, the cost of construction and eventually the cost of commissioning which we learnt in the health committee this morning will cost €300 million. That moves the cost from €1.4 billion to €1.7 billion and we are four or five years away from the first child gaining access to that hospital. There are many corporate decisions that have profound effects on patients and unless those corporate decisions are correct, we will not have proper delivery of services.

The new board must also build trust in the health system in patients. Unfortunately, there are many patients who do not trust the health service. They do not trust the HSE to deliver the service. Many patients are afraid to go into hospital now because of previous experiences or those of friends or family or because of listening to the news every day which reports there are 400, 500 or 600 people on trolleys. We have to build trust, not only in patients but also in staff. If we do not build trust in staff who feel fulfilled going to work and have job satisfaction, we will lose them and we are losing them. We are losing our graduate doctors, nurses and therapists who are going to other systems that function properly and give them job satisfaction. We must build trust. We should not underestimate the importance of morale. I remember when the Minister for Health took up the position, I told him in the Dáil that the first thing he could do which would not cost a penny was to try to improve the morale of the staff working in the health service.

Unfortunately, I do not think he has been able to manage to do that yet.

The new board must also build a relationship with the Department of Health. Looking at the interactions between the Department of Health and the HSE in the Committee on Health over the past two and a half years, there is palpable tension between them. Perhaps that is a good tension but there is a lot of negativity while there is not a proper process of engagement between the Department and the HSE. There often tends to be a blame game. There needs to be an honest and forthright interaction between the two to support new and innovative models of care. The models of care we have at the moment are not working because there is a lack of integration and because our health system is built on models of care that were okay 40 or 50 years ago. Health technology and health management have moved on but the structures underpinning our health service are still the same. New, innovative models of care mean integration between primary and secondary care and vast improvements in communication between those looking after people in the community and those looking after people in our hospital services. They are in silos and separate and there is very little communication.

One of the major problems is that we do not have an IT system or ICT to manage a modern health service. We do not have a unique patient identifier or an electronic patient record. Those two things are the drivers of health reform. Not only will they deliver efficiencies but they will also give us data. We cannot manage a health system if we do not have data. Data are king. Data are money. If we do not have real-time data on what is happening within the health service, our planning will not be optimal. The new board will have to concentrate on all those things.

The board must drive integration of our hospital services between the community and consultant and hospital-led services. It must expand bed capacity. There is no point in denying that we have a huge deficit in bed capacity. The bed capacity review suggested that if we engage in full-bodied health reform where we change structures and change our models of care, we will still need 2,600 beds over the next ten years. If we do not engage in health reform and keep doing what we are doing while expecting to get a better result by magic, we are going to need 8,000 beds. What chance have we of getting 2,600 beds, let alone 8,000? One of the major reforms also recommended by Sláintecare is that we have elective-only hospitals where patients coming in for elective care are not continually being displaced by people coming up from casualty. There is a whole range of things that the HSE board needs to concentrate on and it is a huge task.

We must make Ireland a magnet for health staff. We are repelling our graduates, nurses, doctors and therapists. They are going away to health services that work, that can give them job satisfaction and job progression. It is not all about money. It is about being allowed to deliver a level of care to the maximum of their training. It is about their will to provide a health service, and there is great will in our graduates. They want to deliver a health service but they find, having trained in the service here, that they cannot see light at the end of the tunnel. They have low morale and they go elsewhere where they get better job satisfaction.

I hope this new board will achieve all of the items Deputy Connolly and I have mentioned. Unless we innovate, change and reform, this health service is going to continue to deteriorate.

Minister of State at the Department of Health (Deputy Catherine Byrne)

I thank the Deputies for their contributions and for their overall support for the Health Service Executive (Governance) Bill 2018. I have listened carefully to the speakers and share some of their concerns and experiences. I do not agree with some of things that have been said. I believe we have a health service where there is transparency and accountability. We might need a little bit more of it, but every day I see people working through the HSE and many good people contributing widely across all the services throughout the country. I visit many of them. We cannot paint everybody with the one brush.

The central purpose of the Bill is to establish a board governance structure for the HSE and this is, of course, in line with the view of the Oireachtas Committee on the Future of Healthcare. By way of further background, the Minister for Health in fact raised the issue of current governance arrangements for the HSE during his appearance before the committee in March 2017 and indicated his intention to review arrangements, subject to the committee's final report. As Deputies know, an independent board for the HSE was subsequently recommended by the committee and is an action for delivery under the Sláintecare implementation plan. I am glad to hear Deputy Dr. Harty talk about Sláintecare. It is an amazing document which was put together by all Members of this House. I hope it will continue to be a document that everybody can support.

Yesterday, the Minister of State, Deputy Jim Daly, on behalf of the Minister for Health, underlined the importance Ministers place on the re-establishment of the HSE board and the opportunity it provides to strengthen governance and oversight of the HSE. To follow on from what Deputy Connolly said, at the time when I was a councillor and was on the boards of the Eastern Regional Health Authority, ERHA, and the Eastern Health Board before that, I was always in awe of the work done by the members of those committees, including public representatives and people working in the health service. In general there was real openness and transparency whereby we were able to go into a meeting and ask questions and come out with answers. I found great satisfaction in that. Maybe we need to look again at approaching it in a different manner like that.

I again underline the important role for the board in strengthening collective decision-making. As the Minister for Health has indicated, the establishment of a board for the HSE is the first step on a journey of reform in our health services towards a shared version of a health service that provides the right care at the right place to patients. Sláintecare gives the blueprint for this. Reflecting on what has been said in the debate, I emphasise the importance of this report around Sláintecare and the importance of the role of the new board. I look forward to our continued work together on the Health Service Executive (Governance) Bill 2018 as a crucial step on this journey of transformation of our health services. On behalf of the Minister, Deputy Harris, who cannot be here, I stress that we all have a duty of care to work on behalf of all our citizens. In some of the contributions it is very clear that the public representatives in this Chamber are singing from the same hymn sheet. A strong board can make a great difference to Sláintecare and to how we go forward with our health services. I thank Members, the Leas-Cheann Comhairle and the Ceann Comhairle for the work that has been done in allowing the Bill to be brought to the House.

Question put and agreed to.