Last night in the few minutes at my disposal I made reference to some of the statements contained in the Minister's speech to the Seanad. I should like to take up from there. The Minister made certain very important references in his statement to the operation of the four extra bodies which it is now proposed to bring into operation arising from section 41 of the Health Act, 1970. These four bodies, as he has stated, comprise in the first instance of a national body to be known as Comhairle na nOspidéal, which will have overriding responsibilities for co-ordinating the hospital and community services throughout the State. The three other bodies are to be known as regional hospital boards to be based on the university centres in Dublin, Cork and Galway.
It should be remembered that these four bodies—the national body and the three regional hospital boards—will be in addition to the eight regional health boards already established and now in operation for about 15 or 17 months. We, therefore, have a situation where under the proposals contained in the Health Act of 1970, we will have a three-tier system of administration for hospital and community services throughout the State. This service will operate under the Minister's own Department and with the Minister in final control of policy and, indeed, of the operation of the various boards.
It might be helpful if at this juncture we would cast our minds back a little to the development of the administration of health and community services over past years. I am long enough a member of a local authority, as other Senators are, to recall the days in which the local authorities, the city councils and county councils were responsible for health services within their areas. I remember that in Limerick city and county we had one chief medical officer for the two areas. He had his assistant who was responsible for the TB services in both areas.
We have advanced considerably since then, not alone in the Limerick area, but also in all areas throughout the State. It is right that we should be critical of some developments in regard to the health services, but we should also pay tribute to the successive Ministers for Health and to the local authorities for the developments that have taken place. These have taken place, not always with the cooperation of existing vested interests in the fields of health and social welfare. I had some experience of that myself in a sector of the health services, so I speak with some experience.
The next major step taken was the development of joint health authorities in certain areas, but not in all. Limerick city and county were joined together in a Limerick Health Authority which functioned for almost 11 years, up to the time of the recent legislation introducing the health boards. The Minister would be the first to admit that the Limerick Joint Health Authority gave splendid and efficient service for more than a decade.
The service was so good and the public representatives of the two areas, which were not always in complete harmony, worked so well together and gave such an efficient service that many of us took the view that it was a retrograde step to break up the Limerick Health Authority and to establish the wider Mid-Western Health Board. That feeling still persists to a degree, but the general opinion is that the new health board should be given an opportunity to function to see if they can provide the services for which they are responsible.
There was, of course, a vast difference between the composition of the Limerick Joint Health Authority and other joint health authorities in the country and the present eight regional health boards. The most significant point was that almost half the members of the new health boards are now composed of non-elected representatives. They represent the various sectors of the medical profession, psychiatry, nursing, social welfare and other interests.
The Minister, during the course of his tour around the country consulting with representatives of the councils which would compose the various health boards, accepted what was, for us anyway, an important concession. He agreed that the forthcoming Bill would provide for a majority of the members of the health boards to be elected public representatives; secondly, that the health boards would have the right to elect their own chairman and vice-chairman. It may appear to some of the Senators here, who are not members of local authorities, county councils, city councils, or other local councils, that it was not a very important concession, but to those of us who are members of local authorities it was an important concession and one which we appreciated having secured from the Minister.
While some of us may still have misgivings about the composition of the new regional health boards, we feel that in fairness to all concerned they should be given a reasonable opportunity to function effectively in the interest of the patient. The comment I have made—"in the interest of the patient"—should form the basis of any type of organisational structure which the Minister or his advisers may decide on as best for the country. The fact that we are dealing with larger boards as compared with the smaller joint health authority or single health authority boards of the past to a certain extent divorces the elected representative from the people whom he wishes to serve in his area. These boards are by their very nature more technical. Professional men are represented on them. The staffs are larger. There is no longer the same sense of intimacy or contact between the public representative and the patient, or those needing medical or social care as there was in the past within the smaller unit. Maybe that is the result of the larger unit but the tendency among public representatives so far has been not to have the close contact with their constituents which they had under the smaller bodies.
So far the new health boards have tended to confine their principal impetus to adding extra staff and increasing the cost of administration. I do not share the views of those who say that, because extra staff are employed, costs must rise, or that the boards must necessarily be more expensive generally or less efficient. I am, however, concerned at the rapidly increasing staffs in all health boards, not only confined to the Mid-Western Health Board and at the enormous increase in costs which are spiralling at a frightening rate in every area; an additional burden is being placed both on the taxpayer and ratepayer. In the final analysis, it is the man in the street who must pay the bill.
I hope this organisational period may settle down shortly and that we will have our health boards adequately staffed and efficiently run at reasonable cost to both the taxpayer and the ratepayer. In regard to the costs to the ratepayer, I hope the Minister, in the coming 12 months, will be able to further relieve the ratepayer of a greater part of the charges of the national health and community services. It is quite wrong, in principle, that national services, such as health, education, Army or police, should be a direct charge on the local ratepayers. It is only right that local taxation should pay for purely local services, but national or regional services should be paid for on a different system. I have sufficient experience in public life to appreciate the fact that all these desirable changes cannot be accomplished by the wave of a magic wand, or by any Minister of Finance, or of Health. If one accepts this principle and agrees to work towards it, then a better system, in which the burden is more equitably distributed, can ultimately be found.
One essential requisite must be retained if the new health boards are to be successful and carry out effectively the duties assigned to them. They must be run economically, subject to an overall co-ordinating and policy-making national body. This national body will function under the control of the Minister for Health and his Department. I will develop this point clearly at a later stage. The best organisation would consist of eight regional health boards with adequate autonomy, finance and staff, all working in harmony to provide the best possible services for the people living within their designated areas.
The only other body which I consider necessary is some form of national body which would co-ordinate the activities of the eight regional hospital boards and which would be responsible to the Minister for overall policy. There is no possible argument in favour of the introduction, between the national body and the eight regional health boards, of the proposed three regional boards. They will only serve the purpose, which the Minister does not wish, of overlapping, increasing costs and causing friction between the three hospital boards and the eight regional health boards. This is inevitable, from the point of view of the functions of the proposed three hospital boards.
I should like to quote article 8 of the draft of Health (Hospital Bodies) Regulations, 1972, which was circulated to all Senators and Deputies.
The functions of a regional hospital board shall be:
(a) to consider and keep under review the general organisation and development of in-patient and outpatient services in the hospitals administered by health boards or by other bodies in its functional area which are engaged in the provision of services under the Act, with a view to promoting the organisation and development of these services in an efficient and satisfactory manner.
I would regard that as, almost word for word, the responsibility of the regional health boards. The regulations continue:
(b) to make such recommendations as it thinks fit arising from the consideration and review under paragraph (a) to the Minister, to a health board or to any other body concerned,
(c) to consider any proposal of a health board or other body referred to in paragraph (a) for—(i) a change in the use of a hospital maintained by it, (ii) an extension of a hospital, or (iii) the discontinuance of such hospital,
(d) to advise the Minister on hospital policy in so far as it affects the functional area of the board...
(e) to make appropriate representations to Comhairle na nOspidéal on the matters referred to at section 41 (1) (b) (i) of the Act.
(f) to advise hospital authorities in its area,
(g) to govern the numbers and types of officers in employment other than those referred to in section 41 (1) (b) (i) of the Act in such hospitals and, except in so far as the Minister has the function, the remuneration of such officers,
Subsection 8 (1) (i) reads:
to allocate to hospital projects (including projects for equipment) in its area the public capital funds made available by the Minister...
(j) to control the expenditure of capital funds allocated by it under paragraph (i)...
(1) to organise advisory services on management for hospitals.
Maybe I am reading more into this than should be read into it but perhaps the Minister can reassure myself and others who think on the same lines that there is no possibility of a clash between the regional hospital boards and the regional health boards. As I see it, there is a very distinct danger that what is going to happen is the very thing the Minister is desirous of avoiding, that is, an overlapping of functions and authority and an overlapping and an increase in costs. I believe this is inevitable under the three-tier system.
I do not know if this idea was sold to the Minister by some foreign consultants, of which we have had quite a plethora in this country employed by various Ministers of State, or whether it is that we have some power-conscious backroom gentlemen in his Department who see in this an opportunity of giving apparent devolution of control to the hospital boards but, at the same time, ensuring that overall control remains in the Minister's Department. One cannot have it both ways. If we want regional hospital boards to operate effectively and to operate in the interests of all concerned, with goodwill among the elected members, medical and otherwise, we have to give them a degree of authority. We have to encourage their enthusiasm to work for the good of the people in their area.
The people of which those boards are composed, whether they be public or professional representatives, do this work without remuneration. This is unpaid work and they give their time in the interests of this social and medical work. They may be paid in their individual professions but they give that time out of their professional or business occupations in the interests of the people who live in their area. To encourage the right type of individual to take part in that service we must give them the feeling that they have not only the responsibility but the autonomy and the power to do what they think best.
That is the reason why I am absolutely opposed to the injection of these three hospital boards into the system. I think they are completely unnecessary. I note from the Minister's speech that it is proposed to transfer some of the responsibilities of the Hospitals Commission to the regional hospital boards, but I think that could have been transferred to the national body, Comhairle na nOspidéal, which seems to me a much more appropriate body to take over these functions.
Furthermore, I see a distinct danger of a clash of interests between the two bodies notwithstanding the fact that there will be representatives from the regional health boards on the regional hospital boards. Let us take the case of the Mid-Western Health Board, of which I am a member. That board caters for a population of approximately 260,000 or 270,000 people and it will have four representatives out of 16 on the Cork Regional Hospital Board. Half the members of that board will be appointed by the Minister. In other words, public representatives will comprise half the board and the other half will be nominated by the Minister.
The Minister, in his consideration of his nominations, will undoubtedly— and I think, from his point of view, quite rightly—ensure that medical and professional interests are adequately represented. But he has gone on to make a change and has decided that he will appoint the chairman and vice-chairmen of the regional hospital boards. He has departed in two instances from the policy which he agreed to with regard to the regional health boards. He says that there will not be a majority of elected public representatives unless he himself puts them on the boards—certainly they will not have the right to be elected on the regional health boards—and he has also taken away from them the right to elect their own chairman and vice-chairmen. In fact, as I see it—and I hope that I am not being a Jeremiah in this regard—you are imposing on the eight regional health boards three regional hospital boards to which the Minister will have the right to appoint half the membership and will also have the right to appoint the chairman and vice-chairmen.
