I move:
That Seanad Éireann approves the following Regulations in draft:—
Health Boards Regulations, 1970
a copy of which Regulations in draft was laid before Seanad Éireann on 8th June, 1970.
Health Boards Regulations, 1970: Motion.
Section 4 of the Health Act, 1970 requires that regulations be made by the Minister for Health specifying the number, title, functional area and membership of health boards which will be responsible for the administration of the health services in the State. The section further requires that before the regulations are made, the Minister must consult with the Minister for Local Government and with each county council and county borough corporation and Dún Laoghaire Corporation. The Minister is further required by section 41 of the Health Act, 1953 to consult with the National Health Council about the regulations. Having completed this round of consultations, I am now asking this House to approve of the draft regulations which I have recently laid before it.
In order to help Deputies and Senators in their consideration of these draft regulations, I have had published an explanatory memorandum which deals generally with the changes in administration of the health services to be made under the Health Act, 1970. I considered that it would be helpful to explain in the memorandum not only the changes which arise from the establishment of the health boards but to sketch in broad outline the type and functions of the other bodies to be established under the Act and to set out the inter-relationships between these bodies and the health boards. The explanatory memorandum deals very tentatively with the bodies which will be established for the co-ordination of hospital services. I recognise that Members of the House will naturally want further elucidation about the roles of these bodies.
For that reason I want to make it clear to Members of the House at this stage that the draft regulations dealing with the establishment of Comhairle na nÓspidéal and the three regional hospital boards will be the subject, not only of a separate debate in each of the Houses of the Oireachtas, but of considerable consultation between now and the time the draft regulations are finally laid for consideration by the Dáil and the Seanad. In fact, at this time, a preliminary draft of these regulations together with explanatory material is being prepared in my Department and I would hope to circulate this as a basis for discussion to many interested bodies fairly soon but, in order to keep these bodies informed of developments, I have circulated to them copies of the explanatory general memorandum which I have circulated to Members of the Oireachtas and made it clear that I will be having a separate round of consultations with them about Comhairle na nÓspidéal and the regional hospital boards.
I would ask Senators to avoid the understandable temptation to deal at some length with the hospital bodies during the course of the debate on this motion and to concentrate as far as possible on the content of the draft regulations dealing with the establishment of the health boards. There will be plenty of opportunity later for everyone to make his views known to me about the hospital bodies before the regulations are made.
I would now like to outline some of the reasons which influenced me in proposing that there might be eight health boards with the functional areas set out in the draft regulations. I aimed at having each health board responsible for providing services for at least 200,000 people while at the same time ensuring that each board's functional area would be reasonable from the point of view of convenience of administration. I also had in mind that distances from an administrative centre for the board to other parts of the area would not be too great and I decided, early on, that counties would not be split for the purpose of forming a functional area of a health board. Naturally I had regard to the way in which the country has been divided into regions for other purposes, for example for tourism and planning. Generally speaking, I found that I could keep pretty well in line with the planning regions and, where I did depart from them, there were reasons specifically associated with the problems of health administration in so doing.
In deciding not to divide any county for administrative purposes, I had regard not only to the traditional reasons for leaving county boundaries undisturbed but also to the practical consideration that the county is the basic unit for local government administration. It will considerably ease the transitional difficulties which we will almost inevitably encounter if we continue to avail for some time of the close links which exist between health and local government at county level at present. The changes we are making in the administration are substantial by any reckoning and where it can be avoided there would be little point in adding further to the transitional problems.
If I am to judge by the reaction of local authorities to the proposed grouping, then the criteria on which I have based my proposals must have been reasonably valid. Most of the local authorities accepted the suggested groupings but there were one or two instances I might mention where alternative suggestions were made.
During the informal consultations which I had with local authorities during the passage of the Bill, Carlow County Council indicated that they were not entirely happy with the proposal to include them in the South Eastern Health Board as they felt that because of their almost total dependence on Dublin for the provision of general and maternity hospital services they would prefer to be associated with the Eastern Health Board. I had a very satisfactory discussion with a deputation from Carlow County Council about this matter, and I put it to them that it was, in my opinion, in their best interests to be associated with the South Eastern Health Board as they could not reasonably expect, in view of their size, to have any considerable say on the Eastern Health Board. I accepted that the county was in a rather unusual position in so far as the northern part of the county tended naturally to look towards Dublin rather than to any centre in the south east and that because it does not have a county hospital of its own it was very much dependent on Dublin for its hospital services. I explained that there would be nothing in the new arrangements to stop Carlow patients from continuing to avail of the services in the Dublin hospitals, and in acknowledgment of the special situation which existed for Carlow in relation to hospital services I have undertaken that the county would have a special representative on the proposed Dublin Regional Hospital Board.
When Carlow County Council submitted its formal views to me on the draft regulations it stated that it would be agreeable to forming part of the South Eastern Health Board area provided that the major hospital for that area would be located in Kilkenny. I could not at this stage, in respect of this or any other area, give any undertaking or guarantee about the siting of the major hospital as this is something which will have to be examined fully in consultation with all the bodies and interests concerned and it would be totally premature for me at this stage even to voice an opinion as to where the major hospital for any area might be. Having regard, however, to the fact that Carlow can continue to avail of hospital services from Dublin and that it will have a reasonable representation on the South Eastern Health Board, I propose that Carlow should be included in the functional area of that board.
At my meeting in Cork with representatives of the constituent local authorities of the Southern Health Board, the representatives of Kerry County Council suggested that there should be a separate health board for each of the counties of Cork and Kerry. I did not accept that the population of Kerry justifies its having a separate health board. It was also suggested to me that part of North Kerry should be associated with the Mid-Western Health Board in view of its proximity to Limerick and the extent to which it avails itself of hospital services there. Again, I had to reject this as, apart from the fact that I had decided that counties should not be divided for administrative purposes, it seemed to me that most of the population of Kerry regarded Cork as the most convenient regional centre. Furthermore the splitting of a county's representation between two boards would weaken its voice in regard to its health services since each part of the county could hope to have only a very small number of representatives on the health board for its area. In the case of Kerry, there was still a further consideration, in so far as the plans to provide a new general hospital at Tralee is based on the assumption that it will cater for the population of the whole county.
There were a number of other suggestions made to me during my discussions with local authority representatives about possible changes in the proposed grouping but these suggestions were not formally taken up by the counties concerned. I think that, generally speaking, county councils are happy with the proposed set-up and I am sure that the counties now brought together for health administration will willingly work together for the ultimate betterment of the service.
One of the major difficulties which I have had in this whole exercise is in trying to reconcile the need to give adequate representation on the health boards with the desirability of keeping the boards to a size where they will have a reasonable chance of being effective in carrying out their work. I stated fairly early on in the discussions on the changes that as far as possible I would try to keep the size of the boards to about thirty and while there is nothing magical about this figure I am convinced that once this number is exceeded the chances of ending up with an ineffective board are increased. I was, therefore, forced to turn down many requests for representation or for an increase in proposed representation and where I have exceeded this figure of thirty I have done so only on the understanding that the likely benefit arising from increased representation will outweigh the possible disadvantages of having an unwieldly board.
I have deliberately curtailed the size of the boards in order to ensure that they would be effective instruments in the discharge of the functions with which they are being entrusted. There is the danger that in a major reorganisation such as we are undertaking here, sight can be lost of the fact that all the changes are essentially and primarily designed to improve the service which will be available for the recipient. The point has, I think, been made in this House during discussion on the Health Bill that the patients will not be concerned with the actual administration of the service but with the quality and intensity of the service provided. This, of course, is quite true but the quality of the service is very much dependent on the effectiveness and efficiency of the organisation administering the service.
In the re-organised health service administration, the health boards will, as I have said before, be the essential nuclei of the service. I would hope to see each board operating as a corporation which has been given the task of providing the best possible health services for the people within its areas in so far as its resources permit and of ensuring that the resources which are made available to it are used in the most effective manner possible. I think it was Senator Alexis FitzGerald who said during the Second Stage debate of the Bill in this House that we can all benefit from discussion if we listen to one another and it will be of vital importance that members of a health board, irrespective of the capacity in which they serve on these boards, be prepared to listen to the other members' contributions and accept that they can benefit from them. The local authority member, the hospital consultant, the nurse, the dentist, the pharmacist— each of them will have his or her own particular contribution to make and the board as a corporate entity will then, by various processes, come to decisions based on a wide spread of advice and experience. This is how I hope to see the health boards working and I am sufficiently optimistic to believe that this is how they will work.
This brings me to deal with the question of the balance between the local authority and the professional representation on the boards. A considerable number of the local authorities indicated to me during consultations that they felt that they should have a greater majority than that which I have proposed on each of the boards. On the other hand, the professional organisations felt that they were entitled to a somewhat greater say on the boards. I have said before that I do not think there will be many occasions on which there will be a clash of interest between the local authority members and the other members of the board. On each of the boards there will be one dentist, one pharmacist, one general nurse and one psychiatric nurse. When, therefore, there are suggestions that the professional representation is excessive it boils down to considering the representation which is being given to the medical profession.
Once it has been accepted that the profession should be represented on these boards, then that representation must be sufficient to allow the major branches of medicine to be represented, while at the same time allowing the members of the professions democratically to select, for appointment, people in the profession whom they consider have a definite contribution to make in their own right. I am quite sure that the members of the medical profession appointed to the first boards will be conscious that they are part of a very significant sociological development and that while they have a definite contribution to make because of their professional expertise, they can receive very valuable help and guidance from their fellow members representing local authorities who have the advantage of having been associated for many years with the administration of health and local government services. This fusion of administrative and professional experience can hardly fail to produce very worthwhile results and I am sure that all the members appointed to the first boards will, above all, try to ensure that the development in the administration which we are pioneering in this country will be successful in maintaining and improving the services which are now provided.
A number of local authorities and the National Health Council recommended to me during my consultations with them that steps should be taken to ensure that professional representation is fairly evenly distributed among the constituent counties of each health board. I fully accept the validity of this suggestion and I am hoping that in requesting nominations for the first boards and in making the regulations governing selection to subsequent boards, I may be able to do something to meet this point. However, I could not accept that this should be a primary consideration in selecting professional representatives to the boards as we must first of all try to ensure that there is a good spread of doctors among the many categories in the profession and that, as far as possible, the best qualified people are appointed to each board. I will take up this point with the nominating bodies and I will have regard to it when I am making my own appointments to health boards.
In the draft regulations, I have proposed that the Minister appoint three members to each health board. There have been some suggestions, not very many indeed, that this was a disproportionate number for the Minister to appoint. I cannot accept this view, particularly when, taking into account the contribution made through the agricultural grant, as well as the health grants, the State is bearing, over the country as a whole, up to 75 per cent of the cost of health services. I think that I should also make it clear that no officers of my Department will be appointed to the health boards. In making my appointments, I would have to be influenced by a number of conditions which may arise, including the possibility that some particular vocational or area interest might not otherwise be represented. I have indeed already received a considerable number of representations on behalf of people who wish to be appointed to these boards and I have consistently replied to these representations on the lines I have just mentioned.
In giving their views on the draft regulations which are circulated a number of local authorities raised points which were not directly related to the draft regulations now before the House. I have not as yet considered all these points but I shall do so in due course and I will then have replies sent to the local authorities concerned.
I have had a very long round of consultations on my proposals for these health boards, and I want to take this opportunity to thank everyone who made a contribution during these consultations. For many reasons, some of which I have outlined during this opening statement, I did not find it possible to accept all the suggestions that were made to me, but no one should think that because their suggestion did not lead to a change in my proposals it was not worthwhile. Every such suggestion made forced me to look with a more critical eye on the proposals which I had made.
What I am now putting before the House for consideration is what I believe to be, having had the benefit of all this constructive criticism and advice, the best administrative structure for our health services now. What is now proposed need not forever be regarded as unchangeable and, if it is considered necessary, new regulations can be introduced when we have had an opportunity of seeing how this new system is operating in practice. I would, therefore, ask the House to approve of the draft of the Health Boards Regulations which I have put before it.
I appreciate the memorandum in explanation that the Minister has given us. It is certainly far more elucidating than the memorandum we received on the International Health Bodies (Corporate Status) Bill. The Health Act was before us as a Bill and we spent many days going through it. These regulations pertain in particular to section 4 of that Act.
I do not know whether the Minister had in mind the actual constitution of the Dublin Health Authority when he decided to establish eight regional health areas. From our experience of the work of the Dublin Health Authority, we can say that he was right in bringing eight regional health areas into the Act because the Dublin Health Authority have been a complete success. Though many people may say otherwise when they receive their rates demand, those of us who have worked on the Dublin Health Authority realise how successful they have been. I believe that the Minister has used this authority as a prototype for his regional health areas.
In fact the Eastern Regional Health Board is only increased by the addition of Counties Wicklow and Kildare— not a big increase in population but a big increase in area. I notice that in forming the Dublin health area the Minister has compromised between population and accessibility. One must agree with the Minister on this to some extent. It may be that one would like to see representation on the basis of population. At first sight it may appear that this is as it should be but there is also a case to be made for accessibility and the distances that must be travelled. In this connection, I am not talking about doctors but about patients.
I shall take up one or two points in succession. I do not know as yet what the Minister has done about resolving the representation for Dublin city. I read in the Dáil Debates that he said he had consultation with the various Deputies from Dublin city. I cannot remember his exact words but they were to the effect that there was a tentative agreement that persons should be appointed by the commissioner on a proportional representation basis. It was mentioned somewhere also that the various Deputies representing Dublin city might well be nominated by the commissioner to act on the Eastern Regional Health Board. I do not know what the Minister has decided but when he is replying I should like him to be specific as to how he intends the representation of Dublin city to be on the Eastern Regional Health Board. This is something that everybody especially the people of Dublin city want to know.
Could I elucidate for the Senator?
Certainly.
Nobody else need raise this particular question. I have got agreement from the Minister for Local Government that he will make arrangements under his powers to appoint seven people. Of course, they will have to be politically on a fair representative basis. One of the ways of doing this is actually to appoint Deputies and I imagine that is how it will be done. Anyway I can assure the House that the Minister for Local Government has agreed in respect of the Eastern Health Board that persons will be appointed to represent Dublin Corporation on a fair and equitable basis. It will be the Minister for Local Government who does that.
I accept what the Minister says but who is going to appoint them?
The Minister for Local Government under his own powers under the Act.
Will the Minister for Local Government appoint them to the health boards?
Yes.
I do not know if this will be equitable in many ways. I am not suggesting that the Minister for Local Government or the Minister for Health will do anything wrong. I am just looking at the principle here and not personalities. This is the first intimation I have had of how this will be done. I will reserve judgment on that for the moment. There is a reference in either the last statement of the Minister or in the memorandum we received about County Carlow objecting to having the headquarters in Waterford. I am not taking sides in this but it seems to me that Kilkenny would be a more accessible centre than either Wexford or Waterford and that it would be more central to the board itself. This is only a suggestion I am making and I do not think it is of great import if the centre is in Waterford. This matter must be taken into consideration with the general hospital which will be in Waterford. In arranging the centre for the South Eastern Health Board, one should consider Kilkenny. However, this brings up the question of the regional hospital board which will be in Ardkeen, Waterford. I would like to bring to the Minister's attention the accessibility of the capital of each health authority. Normally it should not be on the coast. It should be as central as possible.
As far as I know the Minister has made provision to allow a local authority which he is putting into one particular health area to opt out of that area and join another area after some experience. This is a very good provision. I also want to compliment the Minister on having a preponderance of local authority members on the health boards. When one speaks about health one always speaks about doctors, surgeons and physicians and certain people may feel they should have a preponderance of representation on those boards. In fact, it is better and fairer—the Minister has agreed with this—to have a preponderance of local representatives on the health boards because those are the people who are accountable to the public. The doctors, surgeons and physicians are accountable in a different way to the public. They are accountable for their skill but they are not accountable for administration to the public. Therefore, it is correct that local representatives should be in a preponderance on health boards.
I would like the Minister to state what is the duration of the appointment of representatives on the health boards. I can understand the duration of the appointment of local authority members on health boards would only be from local election to local election. What about the duration in the case of the other representatives on the health boards? Do they cease to be members of health boards when the local authority members cease to be members?
I want to refer now to the representation of various local authorities on the health boards. I allow the Minister certain latitude in his digression from population by appointing members from local authorities on the basis of accessibility but to me his digression from this point is far too great in many places. Take, for instance, Dublin city. I am open to correction on this but I think there are only seven representatives for Dublin city. I feel that is too low. The population of Dublin city is almost 700,000; Wicklow has 60,000 and Kildare about 66,000. It seems to me that the representation for Dublin which is only twice the representation which Wicklow and Kildare are getting is too low a representation. I also think that four for Dublin county is too low. In the allocation of membership of boards throughout the country one can bring points to the Minister's notice about the inequality of representation from the constituencies and rating authorities on the various boards. I have given the Minister one particular example where I consider there is inequality and I would like the Minister to reconsider this if possible. The Minister's reply will depend on whether we are going to oppose those regulations or not. As long as I have seen the Minister before us in this House he has always been co-operative and in no sense has he tried to be vindictive. I am sure that he could be co-operative now.
Notwithstanding many of the misgivings which many of us might have with regard to the various provisions of the Health Act which we discussed in great detail some months ago we should all accept at this stage that the Bill we discussed then has now been passed by both Houses of the Oireachtas and has become law. We must accept it and make the best of it. I should like to join with the Minister in the latter part of his speech where he asked the people involved in seeing to the formation and getting off the ground of the new health boards that they should approach it in this light and should give of their best.
One of the main apprehensions many of us had, and I hope it will prove to be unfounded, was that members of the board might concentrate more on pressing their own local issues or their own specialist field of medicine or allied fields rather than on trying to view the overall development of the health services in their area. I hope the various people appointed under these regulations, whether they are from the local authority or, appointed on the recommendation of the representative group in the medical field or in its allied fields, will approach their appointment to the board in the proper spirit, looking at it from the point of view of the development of a proper modern health service in their own functional area without any overemphasis on one particular part of that area or another or any particular field of the health service.
In a way it is rather a pity that we must discuss these draft regulations while not having before us the draft regulations which would set up the other boards which the Bill envisages —the regional hospital boards and Comhairle na Óspidéal. I appreciate the difficulties involved in this but I feel it would have given to this House and presumably to the other House and to the many people involved in the health services at present a far clearer picture of what was in the Minister's mind in the implementation of the proposals if they knew what was in the Minister's mind in regard to the hospital boards also and Comhairle na Óspidéal. However, presumably these regulations will come before us in the near future and we will be able to discuss them at least in the light of our experience having discussed the regulations for these health boards. It might have been a useful thing if we had been able to discuss them side by side.
The Senator is absolutely right. Perhaps I could explain to the House that it is simply a question of timing and the resolution in regard to the regional hospital boards and Comhairle na Óspidéal will come before the Oireachtas in November or December. I can say, as an excuse, that legalistically, as those who have studied this Bill know, the health board could go into operation without ever having a regional hospital board or Comhairle na Óspidéal. They are additional bodies and the entire operation could proceed without those additional bodies so that at least there is some logic in that situation.
I appreciate that and I do not want to press it. I do not want to drift away into fields which are not directly related to the regulations. In regard to the business of staffing it would have been far more healthy if the staff had seen the proposals for the regional hospital boards as well.
May I discuss briefly again the proposals for the eastern region which is to have a board of 35 members to serve a population of 921,000 people? It will be the area at present served by the Dublin Health Authority plus the counties of Kildare and Wicklow. All of us who are members of the Dublin Health Authority were rather pleased that the Minister agreed to increase, even to a small extent, the amount of representation from the local authority members but I am rather upset by the Minister's reliance on this magical figure of 30 which he spoke about so often when he was discussing the Bill and which he still seem to be intent upon as being the only real figure to provide effective administration by a board. He has allowed the Eastern Health Board to grow to a figure of 35 members whereas, in fact, if he agreed to the eventual proposals put forward to him by the local authorities from all the areas which will go to comprise the eastern region, he would have a board of 39.
I thought it was rather a good thing and I was sure it was something the Minister would have welcomed very much that representatives of Dún Laoghaire Borough, Dublin Corporation and Kildare, Wicklow and Dublin County Councils got together at the suggestion of the Dublin Health Authority and thrashed out the pros and cons of the new eastern board and eventually agreed on behalf of each of their local authorities on a figure which they would accept on the new health board. That figure would have given us a total of 23 local authority members. The Minister's proposal at that time was 16 and presumably following receipt of our suggestions he increased the local representation from 16 to 19. There are some obvious words that come to mind to describe the idea of going from 16 to 19 but not as far as 23 but I shall leave that be. It is just a pity that when there was this degree of co-operation, which I thought augured very well for the initial success of the eastern board, the Minister did not feel himself in a position to agree to these proposals.
If one looks at it on factual grounds, the grounds of population and area in square miles to be served by the Eastern Health Board, one discovers that it will serve a population of 921,000 in an area of 1,800 square miles. The nearest proposed health board in square mileage to that is the North-Eastern Health Board with an area of 1,950 square miles, 150 square miles larger but which will serve a population of 237,000 people, approximately one-quarter of the number served by the eastern board. Yet it will have 16 local authority members and the Dublin board, serving four times as many people, will have but three more. It is as well to bear in mind that the eastern board will cover five different local authority areas, so there are 19 members from between five local authorities whereas the north-eastern board covers only four local authority areas and will have 16 members serving a population only one-quarter of that served by the eastern one.
Bearing all these things in mind, I would have thought that our suggestion should have been acceptable to the Minister. I presume that at the stage at which we now are there is no hope of the Minister changing his mind in this regard, so I do not suppose there is much point in discussing it further but it is as well to let him see that some of us are still a trifle disappointed.
The Minister probably will not welcome this very much but I should like to hark back again to the position regarding Dublin Corporation. There is a certain amount of uncertainty here. We can accept that the Minister for Health is approaching the problem of Dublin Corporation's representation on the Eastern Health Board in a spirit of goodwill and we hope that he has persuaded his colleague, the Minister for Local Government, to approach it in like fashion.
Our apprehension at the Minister's reply in another place and here again this afternoon is that the representatives appointed might all be members of different political parties representing the Dublin area. A large number of members of Dublin Corporation have never sought election to the Dáil and have no desire to do so but they had a definite and real interest in serving the people of Dublin city even though they had no wish to go into politics. They were content to give of their time and energy to the corporation and its constituent bodies like the health authority.
If members who do not belong to a particular political party are to be excluded from the board it will be a great pity. Speaking from memory I recall that out of the 45 members of Dublin Corporation 15 members belong to the Fianna Fáil Party; 13 belonged to the Labour Party—one of those members has since died and another has joined the Fine Gael Party—and the Fine Gael Party had 11 members. One of our members also died but we have recently had this addition from the Labour Party. The Ratepayers, who have quite a strong voice in the affairs of Dublin Corporation, had three members and there were three Independent members. One of the ratepayers' representatives was the most diligent and hard working member of the health authority. He was obviously a man interested in the health services of the city and he was prepared more than most of his colleagues to give of his time to attend meetings and visiting committees in an attempt to provide a better service for the community. In recent months we have invited ex-members—everyone knows why they are ex-members—of the health authority to come back and serve with us on the visiting committees of various hospitals and this particular gentleman was the first to answer that request. As far as I can recall he has attended every meeting of the visiting committee since he was appointed.
According to the suggestion outlined by the Minister this man would automatically be excluded from being a member of the board because he has never had any interest in standing for election to Parliament. I would find a system where it was possible for non-Parliamentary members to become representaives on this board far more acceptable. I feel sure such members would work far better for the new Dublin Corporation which we all look forward to seeing very soon. Fianna Fáil had three-ninths, Labour had almost three-ninths and Fine Gael had almost three-ninths. Seven places are to be given to each of the parties and one place is being given to an Independent.
As we all know, the eastern health region comprises of the greater Dublin area, Kildare and Wicklow and manages to take in County Meath. It has been stated that the reason why County Meath has been included is that Meath runs out along North County Dublin as far as the coast and the development of Dublin Airport has inevitably involved Meath in major proposals in regional road and rail networks. We believe that the eastern health region is too big without having Meath included in it. Government Departments will find it more and more difficult as they attempt to rationalise their services to provide greater efficiency by having services on a regional basis. They will discover that what is thought to be a suitable region from the point of view of health services does not coincide with or suit the arrangements for regionalisation which another Department is trying to make.
This brings me back to a pet topic of mine which I spoke about during the Second Reading of the Bill, that these new health boards, or indeed any Department which is attempting to rationalise its operations, do not have to rely on county boundaries if one can believe what was said by a former Minister that county boundaries were of no consequence and were not respected by the people living in them; they were imposed upon us by an alien dominion and should not therefore be respected by the Government. I would not go so far as to agree with that, but Government Departments in future will have to decide what the most effective region would be without taking into account things like county boundaries but instead taking into account features such as rivers, mountains and road and rail networks.
I have considerable difficulty in seeing how members of the south-western region appointed from County Kerry and County Cork will manage to travel to a meeting and get home again on the same day. A man who had to travel from the Dingle Peninsula to Cork city for a meeting, then have lunch and attend another meeting would find great difficulty in getting home that night. That is one obvious difficulty which is bound to cut across any attempt at getting new boundaries or delineations. Once we accept the fact that the Minister was basing his assumptions on existing county boundaries the regions are the best we can hope for.
I should like to inquire, because the regulations do not mention it in any way, as to the effective date of the operation of the new health boards. I know that it is envisaged that they will be established on 1st April next and, as it were, effectively come into being without executive power on 1st October next, but the difficulties which the 19 elected representatives and the 16 appointed representatives on the Eastern Health Board will obviously have in gradually assuming power and taking over the lines of control from the three different health authorities in authority at present are difficulties which are very much in the minds of all those people at the moment. I think that everybody throughout the country, and not just here in this House, would be extremely interested and not a little relieved to hear what suggestions the Minister has to make as to how this might most smoothly be carried out.
This obviously applies also in the matter of making new appointments. We all realise that this is, under the present process, taking a considerable length of time. It does not involve the Minister directly, but it is one of the things giving rise to some concern and which we would all like to see expedited by whatever means is possible.
The last thing on that particular point is the question which I do not think any public representatives are sure about, and that is, who is responsible for the preparation of the estimates for the financial year 1971-72? Will it be the existing health authorities or the new members as proposed under these new draft regulations? If it is to be these members how effectively can they make an assumption in an accurate way about an area over which they have no control, and if it is to be the existing members how can they effectively work out what the amount might be for a board that they in fact will be replaced by?
Looking at the set-up, the comparison between public representatives and others on the various boards, it is, of course, gratifying to notice that the Minister did accede to the strong representations made to him that the public representatives should be given a majority, but on some of these boards the majority they have been given is of the barest and shakiest nature. I think I would not be mistaken if I said that on more than half of the boards the public representatives coming from three, four or five local authority areas will have a majority over the others of one. Taking into account that you may have absences due to illness or people being out of the country or on holiday the effective working majority in that case is absolutely nil. On the other hand, as I began by saying, I sincerely hope that we will very rarely have a situation where there is a confrontation between the collective public representatives and the collective others. It would be a deplorable state of affairs, if any of the health boards were to operate in this way, and I sincerely hope that the approach will not be of this nature.
As I look down the various health boards I see that there will be nine doctors on the eastern, seven on the midlands, six on the mid-west group, seven on the north-east, six on the north-west, and eight on the south-east —it seemed to begin with seven but another was sneaked in after the explanatory memorandum was printed —and seven in the west. One thinks of the approximate 2,500 or 3,000 doctors in the country. Those doctors must feel tremendously grateful to the Minister for this representation that he has given to them on these new boards— nine out of 35 on the eastern, eight out of 31 on the south-eastern. This is very generous representation, and I hope it will be representation that will be approached in the proper manner by the appointing bodies when they come to appoint their representatives to the board.
In comparison with these figures the representation afforded to nurses, that long forgotten branch of the health service, is fairly skimpy. On each of the boards there will be one general nurse and one psychiatric nurse. Yet, in any health service or in any hospital the number of nurses and their contribution is always for greater than the contribution made by any of the rest who are involved in the service. If, heaven forbid—I know that there are others who would quarrel with me about this, but I agree with the Minister on it—the Minister should ever decide to increase the number of "others" rather than public representatives on the health boards, the field he should look to to give increased representation is our nurses, and I would say increase the representation of general nurses.
Might I again mention to the Minister and to the House that it is a pity that, again presumably for very understandable reasons of difficulty touched on by the Minister in his speech, the Minister was unable to give us in fairly clear terms the administrative centres from which each of these health boards will operate and the centre in which each general hospital will be. Obviously this would have improved our knowledge——
The health boards will have the first decision as to their centres, and I cannot make a decision. As far as the hospitals are concerned this has nothing to do with the Health Act, which merely makes it possible to build general hospitals and which did not mention the location of the general hospitals. It is not related to this. The health boards will have their own choice as to their centres. If they cannot make up their minds then I will choose a centre for the health boards.
I must say that this is an aspect of the Act which I did not realise: that it would be up to each board to choose their own administrative centre, but I would presume that the centre for the eastern board would be in Dublin, and I was given the mistaken impression from listening to conversation between people from some southern counties that there was a controversy as to whether the administrative centre would be in one of the deeper southern counties or in one of the more northerly ones, and I thought that the final decision rested with the Minister. Perhaps what they had in mind was that he would have the final decision in the event that they were not going to get agreement.
In his speech the Minister set out the idea, which was a very laudable one, that each health board area would cover a population of at least 200,000 irrespective of the square mileage or the area involved. This is a good thing and is more or less in line with what is a generally accepted standard as to what the functional area of a health board should be, but the only thing that the Minister did not mention in his speech—and that would have been far more interesting to the members of the eastern health board area—was the simple fact that if you are specifying a minimum or anything you obviously must presume that there should also be a maximum. The Minister did not define the maximum, and to my mind the maximum here, which is at present about 921,000, quite obviously will in the next 10 or 15 years run to 1,250,000 or perhaps more, and, if so, there will be extreme difficulty in carrying on in an effective way. Recently what I thought was a very interesting suggestion was made to me, that consideration should be given to the idea of actually dividing the city of Dublin in two, basing one health area on the northern side with some adjoining area, County Dublin, perhaps, and Meath as well, and another area which would include south Dublin, Dún Laoghaire and perhaps part of Dublin county. It is obvious that this would have created vast administrative difficulties for the existing authorities and for the Department in endeavouring to sort out this type of situation but if one is to have regard to the continuing expansion in the population of Dublin city and county, perhaps one would agree that it might have been the bravest and, in the long term, the most clever step to have taken. However, this has not been done and we must accept that, but I say to the Minister in all sincerity that the eastern health board area is very large, population-wise, and all the indications from the planning officers of Dublin Corporation and Dublin County Council are that the population will increase rapidly during the next ten or 15 years. Therefore, the size of the eastern health board area in relation to population ought to be taken into account by the Minister's Department in future years.
Finally, while there were many parts of the Bill with which I did not agree, I agree in principle with these draft regulations. All of us must support the idea of regionalisation and the endeavour to have a more effective, a more efficient and a more modern health service for all our people. On that aspect, we are in agreement on the principle of the need for rationalisation. We may not always have been in agreement with regard to the number of representatives from any particular area but, presumably, it is a healthy sign when suggestions are put forward from one side of the House and when they can be opposed and debated from the other side.
I am intrigued by the idea that a board cannot function properly if it is composed of more than 30 members. One often reads in the newspapers of 79 or 80 people meeting for hours to discuss some matter. I do not see why the eastern health board cannot, if they so desire, have upwards of 79 or 80 members. However, we must accept that we have 35 members. I would hope that some Members of this House as well as of the other House will be among those 35 and I would hope, too, that the seven representatives in the Dublin Corporation area will not all be either from the other House or from the other House combined with this House.
For my part. I wish the measure every success and I shall do all in my power to assist the eastern health board to get off to a good start. I sincerely hope that it will result in the provision of a more efficient, more modern and more effective health service for our people.
I welcome these regulations implementing the Health Act of 1970. I should like to refer to the composition of the health boards and to what has been said about the proportion of professional and the public representatives on the boards.
I agree with the Minister when he says he does not think there will be any occasion on which there will be a clash of interests between the two types of representation. I recently had the experience, with Senator Boland, of serving on a body in the eastern region of Dublin. This body was set up for the purpose of reaching some conclusions on a matter not very far removed from the objectives of the Health Act of 1970 and on that body there was almost 40 per cent medical representation out of a membership of almost 30. We have not had many meetings so far but it is quite clear that there will be close co-operation between the medical and the other representatives. I can see no reason why there should be any confrontation between the interests of the two parties. I never cease to be intrigued by what would appear to be a conflict in the minds of certain people about the effectiveness of doctors as representatives on bodies like that.
People blame doctors for not taking sufficient interest in pressing forward improvements in health services and for not advancing the interests of the public in health matters but, on the other hand, when the question arises of giving them an opportunity for doing this, it usually meets with less than the same amount of enthusiasm. Perhaps there is some explanation for this conflict but I cannot understand it.
At the moment, I have the pleasure of supervising a student in a dissertation on the effectiveness of doctors in making changes in health services and in improving and developing these services. It has been part of my job to ensure that this student was put in touch with various medically qualified persons who are interested in politics and in public administration. This student has been amazed at the enthusiasm with which doctors whom she has visited want to be involved in these matters but it was also apparent that the opportunity for crystalising their ideas has not always existed.
These boards with a relatively high but not too high a proportion of professional representation will provide an opportunity for this type of crystalisation. It will encourage doctors to take an interest in these matters and this, in turn, cannot be anything but good for the development of the services.
The trouble is that the training of a doctor is defective in this particular regard. Primarily, a doctor is an individualist. He does the best he can for individual patients, one at a time, and the concept of the greatest good for the greatest number is not part of any medical curriculum. He starts his professional life as an individualist and it requires a good deal of moulding of his particular kind of character to make of him someone who will press forward on an administrative basis and who will endeavour to put matters on a broader front—someone who will keep the interests of all the people prominently in mind.
Among these representatives I welcome the appearance in each medical group of at least one medical practitioner who is working in the field of preventive medicine. This is very important. As I have said before in this House, it is important to involve preventive and social medicine in the health services.
There will also be another satisfactory dividend from this type of involvement and that is in relation to the training of doctors both as students and as graduates. This brings me to the last point I wish to make and that is that in three of these regions, the eastern region, the southern region and the western region, there are medical schools. In the eastern region there are indeed three medical schools. I hope somehow or other when the machinery is arranged for those people to be appointed to serve on the board representatives will be found who are involved in teaching and training doctors, both at the undergraduate and at the postgraduate level. The type of person who has this involvement brings to his service on a board like this a different type of experience and a different type of outlook from someone who has not got it. This is an improvement in the general working of the body. It also has the reverse effect of preventing the people who are involved in this section of medical education from being in an ivory tower, from getting themselves separated from the general applied aspects of the subjects which they teach. It is very easy if you work inside what is sometimes referred to as the cloistered atmosphere of an institution like that to get away from the practical application, particularly of many of the scientific subjects. We cannot afford to do that now and the more we can involve people who have this sort of expertise in making this available by letting them serve on boards like this the better. I welcome those regulations.
Senator Boland told us that in general the provisions in the draft regulations had already been discussed at length when we discussed the Health Bill some months ago but then he proceeded at length to give the same speech he gave then. I have no intention of doing that. I am glad the Minister has reassured us that those regulations and those regions are not so sacrosanct that they will remain for all time and if experience and time prove that they must be changed he is prepared to make the necessary changes.
When the Minister was in the Cork region North Kerry asked him to put North Kerry in with the Shannon area. He explained to us the reason why this could not be done and we accepted his reasons and explanations. We are quite sure that when the time comes if we are not in the correct region he is quite prepared to let us switch. We are prepared to take the present region as a basis for working. Time may prove that the Minister is right and we are quite confident if the region and the regulations do not suit the medical world they will be changed by the Minister.
I should like to say a few words on the regulations. First of all, I want to begin, not unnaturally I suppose, on a parochial note and to protest most strongly at the under-representation of Limerick city on the proposed mid-western health board. As the Minister is aware, like every other county borough, Limerick city does not enjoy any abatement of rates and therefore the ratepayers in Limerick pay the full amount for health charges. The Minister, who, to give him his due, has taken into consideration geographical and population considerations has, as far as I can see, completely ignored financial considerations. Furthermore, the city of Limerick which now has 60,000 people and will, according to Professor Lichfield and Mr. Buchanan, have another 15,000 to 20,000 by 1985, is entitled to at least equal representation with the county of Limerick, the part county of North Tipperary and Clare County.
I should like to thank the Minister for increasing the representation of Limerick County Council which was grossly under-represented in the original proposals but I would like to ask him even at this late stage at least to bring the representation for Limerick city up to the same as that enjoyed by the contiguous counties with which it will be working, namely, County Limerick, County Clare and Tipperary North Riding.
I would like to agree with the other speakers in that I do not think any conflict of interest will arise in the discussions which the various health authorities will be carrying out from time to time. It might be inferred from that possibly, although I would not like to infer it, and I am sure the Minister would not wish it to be understood, that there was any conflict of interest in the four existing joint health authorities because the medical and other professions were not represented on those bodies. As a member of the Limerick Health Authority for the past ten years I should like to pay tribute to the manner in which the public representatives—as the Senators know it was only the public representatives who were on those boards—worked together in the general interests of all the people in the area they served and to the very happy relationship which existed between the public representatives and the unrepresented medical and other professions. If I were to express what is probably a lone view, if I were in the Minister's shoes I would have been inclined to build on the existing joint health authorities and to continue the existing arrangement which had been proved over the past ten years. However, the Minister in his wisdom has decided, and obviously he has been strongly supported by the medical and other professions, to give representation to the medical and nursing professions and on balance I think this will prove to be a good idea.
The Minister has agreed to give a majority on each of the health boards to public representatives but the majority, in some cases a meagre one, would hardly be regarded as overgenerous. During the debate on the Health Bill recently in this House I suggested a fair division of representation would be two-third public representatives and one-third medical, nursing and other professions. The idea appears to have got out that the public representatives want to have an over-riding majority because they want to use it to vote against the medical or professional representatives. I do not think that situation will arise.
There is another consideration in this which the Minister has apparently overlooked. The success of those boards rests very largely on the dedication, the hard work and the co-operation of unpaid public representatives who are prepared to give their time and their efforts to serving the public. Many of those men on various boards throughout the country, and I am sure the Minister will agree with this, have given this service down the years at no cost to the public or local exchequers. The only thing I regret is that the Minister did not accept the proposition that the widest possible representation for the public representatives would ensure that the boards would work in closer harmony with the people they serve.
I can see in the case of Limerick city now where we are asked to nominate only three representatives on to the mid-western board that there will be extreme difficulty in electing those representatives, particularly in the present political composition of the Limerick City Council. I hope the Minister will agree, even at this late juncture, to bringing the level of representation of Limerick city up to the level of the contigous counties.
I should like on the whole to join with the other speakers in supporting the idea of regionalisation. In this day and age we must accept that the larger unit is more likely to give an efficient service to the people in the groups it represents. It is a very welcome change in Limerick because we had the extraordinary situation there where a certain institution in Limerick was prohibited from taking into the institution patients who happened to live in one of the contiguous counties, say, County Clare, which is only two or three miles from the institution concerned. These institutions will now be open to people living in Limerick city and county, North Tipperary and Clare. That is a very welcome development.
It is possibly a little outside the regulations which, I understand, strictly speaking, are the only matter under discussion and the Minister in the Dáil resisted any efforts to speak on anything else, but perhaps he would give some indication in his reply as to how it is proposed to appoint the key figures in these health boards—the chief executive officers. Will they be recruited from the staffs of the existing health authorities?
An Leas-Chathaoirleach
The Senator should not tempt the Minister into irrelevancy.
He was very helpful in his introductory address when he referred to the fact that in the Dáil certain irrelevant proposals and suggestions were made and he promised to deal with all of them. So, I hope he will extend the same charity to me. I shall not trespass any further on your co-operation, a Leas-Chathaoirleach. I should like strongly to urge the Minister again, in the interests of harmony and efficiency, to increase the representation for Limerick city.
The Minister is sticking to the magical figure of 30 or about 30 members for these regional boards. That is rather poor representation for the ratepayers in one area at least. Nineteen elected representatives on the eastern board means one elected representative in respect of 48,000 people, whereas in another area there is one elected representative in respect of about 11,000. I know it can be argued that the eastern area is a more compact area but nevertheless one representative for 48,000 people means that the unwieldiness of which the Minister was afraid at the top is coming in at ground level. A board to cater for a population of approximately one million, an area which has more people than the next four boards on the list, should be well in excess of 30 to 35. The Minister should have seen to that. These nineteen representatives should not be expected to look after such a huge number—to make representations on behalf of individuals in respect of hospital bills and for families who claim general medical service cards.
I am glad to see the Minister has indicated that the professional representation on these boards will be based on the areas they represent as far as possible because in different areas because of the population set-up different problems may arise and need attention. A county which is being depopulated always has a high percentage of elderly people. That question arose some time ago in Cavan when representations were being made about a grant to provide a hospital to cater for the aged. The county has an inordinately high percentage of elderly people on account of the emigration of the middle age group and of people in their early 20s. I feel it is absolutely necessary to have professional representation to cater for the various classifications of population within a regional area.
The Minister gave as the reason why he must have three representatives on the regional board that different Departments contribute 75 per cent of the total cost of health. That would lead one to think that the Minister feels that the nominees will, in fact, be able to look after the official end but on the next page the Minister goes on to state his intention of ensuring that vocational areas that might not otherwise be represented are, in fact, represented.
I take it the Minister is aware that great attention will be centred on his three nominees. If the Minister is lucky enough to make three appointments in each case which are accepted by the people as being evidence of the Minister's desire to ensure that the best possible set-up is brought about the Minister will have gone a long way towards getting the regional board off to a good start. If, on the other hand, people are dissatisfied and feel these people were appointed for reasons other than their devotion to health it might get the board off to a rather bad start.
I am prepared to concede, from the progress the Minister has made with the Bill from the beginning, that he is doing his best. I am sure the Minister will give great attention to the selection of the three nominees for these boards.
Senator O'Brien referred to the number of local authority representatives in relation to population and he also referred to the representational work that they would naturally do. Of course, I explained in the House before that the members of the local county advisory committees are perfectly entitled to make appeals for people who they think are not getting adequate service. In fact this is one way in which they can exercise their guardianship in respect of any particular county. It is one of the things they can do. In fact anybody can make representations. Deputies can make representations and members of county councils or local authorities who are not themselves members of a county advisory health committee or a health board can make representations. Therefore the opportunity to make representations, while I hope it will be largely centred on the members of the health board and the county advisory committee, is there for others too, and in that way I think there will be adequate representation for everybody.
Senator J. Boland referred to the transitional problems. They do not directly arise on these regulations but perhaps the House and Senator Boland would like to know that the new boards become responsible for the services on 1st April, 1971. A transitional arrangement will be required and there will be a liaison committee of county managers working with the chief executive officers who by that time will have been appointed for the purpose. County councils will act on an agency basis for the time being in order to provide what might be described as a transitional service. The estimates will be initiated at a very early date. In fact preparation of the 1971-72 estimates is already being done by the staff of the existing health authorities. They will continue with this work until the health boards are set up. The finalising of the estimates will be a joint operation up to the 1st April, 1971 for the health boards and the existing authorities.
Senator Belton referred to the position of Carlow. Carlow did not object to the headquarters of the health board being situated in Waterford if the health board so choose. They only made the point that the general hospital, if there was to be one as suggested in the FitzGerald Report, should be in Kilkenny and not in Waterford. I do not need to tell the House how difficult the choice of the midland hospitals will be. One can jump from Monaghan to Cavan, from Mullingar to Tullamore and from Kilkenny to Waterford. If the FitzGerald Report is accepted representations will be made from the other excellent general hospitals and if one accepts their suggestions then the rest of the FitzGerald Report recommendations must go. It is a kind of game of chess which I do not look forward to playing at all. Each local authority will have its own point of view and they will probably be in contradiction to each other.
The period of duration of the health boards will be five years. The second election of the health boards will be in 1972.
Does that include non-local authority representatives also?
Yes. Senator Belton and Senator Boland asked about the position of the Eastern Health Board. It is fair to say that 35 members for the Eastern Health Board with a population of 929,000 does not compare too badly with the 27 members on the Dublin Health Authority which at present serves 795,000 people. I know that kind of statistical comparison can be challenged but all I can say is that I did my best. I did not want to go up to 40. I agree there is no magical number. Senator Boland and Senator Belton also spoke about the necessity of having to work the Eastern Health Board through a number of committees with a considerable derogation of authority to the chief executive officer. Senators will admit the whole administration is extremely complex and cannot be related only to the number of members; it has to be related to the method of administration.
If it is felt that the numbers are too small in order to perform effectively there is nothing to prevent a health board, if they get my consent, from forming a committee to which certain powers can be derogated. These committees can include people who are not members of the health board. This is a very valuable provision because it provides flexibility. One would have to make quite certain it was not misused because it could cause confusion and bring about inefficiency but if it is used wisely it means that a health board of 35 or 32 can have some of their work conducted by people whom they appoint on a sub-committee. These may include people who are not members of the health board but are expert in some particular field and to whom some minor powers can be derogated. I shall have to see how that works out and use my discretion in agreeing to that in order to make sure that it is in consonance with efficient organisation. Senators also spoke about the fact that I did upgrade the number of represenatives from counties of low population.
Senator Jessop spoke about the valuable contribution which could be made by the medical profession and I quite agree with him. A number of the medical profession are already interested in administration as I know from the 30 consultative boards of one kind or another attached to my Department. I have found the medical profession able to speak clearly about a situation and able to make suggestions about how to develop a particular service. I look forward to the contribution they can make. I agree with Senator Jessop that they are inclined to be individualists. I am very glad that Senator Jessop in a totally different capacity from being a Senator is working for a greater teaching of social medicine to undergraduates so that when a doctor receives his degree he knows far more about social medicine and social behaviourism as a whole in relation to the health services.
Senator Ahern referred to the position of Kerry on the Southern Health Board. I want to make sure their position is taken care of and that they do not suffer through being a small partner on a big board. I do not think a Kerryman would ever admit he is small in stature compared with a Corkman even though the numbers may be smaller.
Senator Russell referred to the numbers of representatives of Limerick proposed under the regulations for Limerick Corporation. It is fairly easy for three people to represent a city the size of Limerick. I have examined the position very carefully. I have increased the number for Limerick County Council and I am afraid that is all I can do. I would also inform Senator Russell that the advertisements for chief executive officers who are to be appointed entirely by the Local Appointments Commission have already been appointed. We hope the chief executive officers will begin to operate some time in October or November so that they can take part in the changeover from the health authority to the regional health boards and make sure that the administration can work satisfactorily. They will be working for the health boards from October onwards in a consultative capacity only. They will not become legally operative in their new function until 1st April, 1971.
Senator Boland was right when he said that the health boards had not been designed so that everybody could travel from home to a meeting and return home on the same day. I did my best but I cannot do anything more. Senator Boland said he thought the majority of local authority representatives may be too small but he countered that statement by saying he hoped there would be no confrontation between local authority representatives and the professionals and I hope so as well. So far as absences are concerned, there may be absences on both sides. The Senator also referred to the work of nurses. I should like to have appointed representatives from the various groups but I found it impossible to do so. I should like to say that although it is not a matter related to these regulations I hope everybody concerned with health on the local authorities will encourage the formation of a committee in every hospital where nurses can give advice on the running of hospitals so far as the nursing profession is concerned. This is not to be found in a great many hospitals even in the year 1970.
Some Senators have referred to the growth of Dublin. That will be taken care of by future amendments to the regulations when required. I think I have dealt with all the points raised by Senators.
Question put and agreed to.
Business suspended at 6.10 p.m. and resumed at 7.30 p.m.