I join previous speakers in welcoming the Minister. In a debate during Private Members' time in this House last February the Progressive Democrats called on the Government to take early and decisive action to reform the management structures and financial accountability of the health service. I am delighted that the Minister has responded in such a positive way and congratulate him on the decisive action shown in the health service reform package announced last week by the Government.
This is the largest single reform package any Government has ever undertaken. It is only the start of a process of reform, a process designed to put patients first and at the centre of health care reform and investment. This is about patients before politicians, boards and structures. It is a decision which signals that the way we have always done things cannot be the way forward.
Everyone will be asked to accept change – politicians, public servants, doctors, pharmacists, administrators, etc. Everyone in the country wants change for the sake of patients. No one is exempt from change if we are to get the best possible services for patients and value for public money. We must all put patients first.
From now on, the debate about health will centre on reform. We are making the investment; we now need the reform. After an increase of more than €5 billion in current spending on health since 1997, no one can credibly argue that all would be right in health if all we did was to spend more. Even the Labour party now accepts this. The Government asked last week to be judged by reforms and results. There will be continued additional funding for health, so long as we keep the economy working well, with high levels of employment, more economic activity and growth. The biggest ever expansion of health care investment was put in place by the Fianna Fáil and Progressive Democrats coalition Government. Now, the biggest ever reform of health is under way, also led by the Fianna Fáil and Progressive Democrats coalition Government.
Unfortunately, political debates on health seem to concentrate on health boards. The Progressive Democrats' manifesto last year staed our management structures were not yet organised to deliver the best results for patients. We signalled that: "The health strategy provides for an early and clear report on health agencies and management structures", and concluded: "It is vital to all our people as well as all working in the health services to have health management structures that are tuned to delivering quality services and care for all".
The programme for Government made a commitment to produce a full analysis and rationalise our system. The Fianna Fáil and Progressive Democrats coalition parties stated:
We will seek the completion of the report on health agencies and management structures by the end of 2002 and will move forward on the principle of removing unnecessary overlap of functions and minimising delays in implementing service improvements.
That is the Prospectus report which, with the report of the Brennan commission, has set out a clear agenda of change in the management of the health service. The Government has accepted the need for the wide-ranging reforms recommended. It has decided there will be a single health service executive for the whole country, with its own board and chief executive. It will be accountable to the Minister for Health and Children. The chief executive will be an Accounting Officer and, therefore, answerable for the executive's budget to the Oireachtas.
With regard to democratic accountability, the health boards have been in place since the Health Act 1970. Now is the time for change. We should agree they are no longer appropriate for the governance, planning and delivery of health policy. This debate is not an attempt to blame health boards or question the integrity of their members. It would be unproductive in the current debate either to blame or exonerate any one group. We could go on forever analysing and decrying past mistakes and failures, sharing stories from our own experience and localities. It is the job of the Government to move forward, propose solutions and get on with implementing them.
Health board chief executives have welcomed the reforms, even if some health board members seem less willing to embrace change. In response to the points raised by Senator Feighan, we should have political accountability and democratic control over health services. We need national policies to work locally. Expenditure on health represents nearly one quarter of all current Government spending. With 166 Deputies and 60 Senators, I do not believe we also need 263 health board members to ensure political control. We have a small population of 3.9 million people and are already very well represented politically. When international analysts say local decision-making can help in public health care systems, they are envisaging local populations in the millions rather than the hundreds of thousands, as has been the case for some of our health boards.
The health service executive will not be remote from people and will have plenty of input from Oireachtas Members, consumer groups and the public. The creation of the new executive will allow a better focus on consistent service levels and budget management across hospitals, primary care and community health services. The creation of a national hospitals office as part of the executive will give a welcome national focus to hospital service planning and management. It is the only form of management and governance that can hope to address the issues that will be raised in the forthcoming Hanly report on medical staffing and hospitals.
The Government will also be reforming the terms and conditions under which hospital consultants work. The Brennan commission of 12 independently minded and public spirited individuals underlined the importance of the common contract for hospital consultants for achieving hospital services managed to achieve best value for taxpayers. They said: "The key question is, how can the health services contract with individual clinical Consultants make it possible to negotiate with them, in a systematic way, the resources they need for their practices without interfering in any way with their clinical independence in the treatment of patients?"
The reforms proposed address this question of involving consultants in management responsibilities. Hospital consultants are absolutely central to the effectiveness of health services. They set excellent standards of care and control who is seen, when they are seen and the resources used in treating them. The terms under which they are contracted by the State are also important to ensure we get equity and clarity in the public-private mix.
The whole point of the Brennan commission recommendations was to align incentives with desired public service outcomes. To do this, we need much better data and management of information on what many people do in health services, consultants included, as well as tighter contractual terms.
There have been many contentious points raised for and against consultants since the Government's announcements last week. Part of the reason there is such contention is that there is very little, if any, hard data on how consultants spend their time, for better or worse. This is part of the management vacuum. It would surely be better if we could debate and make policy on the basis of hard facts, not make deductions about how consultants respond to incentives implicit in their common contract. We do not know what consultants are doing. Many are doing superb work, well beyond what the common contract requires. Some are using the laxity of the contract to their advantage. How much time are they spending with public and private patients? We just do not know the answer.
A consultant contracting with the State is not, in essence, much different from a public servant, even if the consultant is technically self-employed. We require teachers to turn up for a certain number of days and hours. We do not allow them to delegate teaching to others, allowing them to give private grinds during school hours, even if many would not use that option. It is not anti-teacher to make this stipulation nor is it anti-consultant. There is a role for delegation but there is also a limit to it. It is simply common sense public management which, I believe many consultants will accept.
I was pleased to see Dr. Colm Quigley, president of the Irish Hospital Consultants Association, writing that consultants "are open to any set of proposals regarding amendments to the current contract". He said he had only one stipulation, that any new contract should be available to all consultants. We shall see what comes out of the negotiations with the Government. What is important is that a new contract should be negotiated and put in place as quickly as possible.
With regard to the cost of drugs, I will declare an interest because I own a pharmacy. The Government will also be implementing the Brennan commission recommendations on controlling drugs costs. We will be reforming the way we pay for drugs; where a generic drug is available, the Government will pay for it but not the high cost of branded drugs, just for the sake of having a brand. This is a sensible reform which has been proposed by my party colleague and Minister of State, Deputy Tim O'Malley, for which I congratulate him.
The cost of drugs is escalating internationally and there is an obvious public interest in tight cost management here. The OECD report stated:
The increase in public and private spending on pharmaceuticals has been one of the main drivers of rising health expenditure in many OECD countries in recent years, reflecting the introduction of new and more expensive drugs. Pharmaceutical spending rose by more than 70%, in real terms, between 1990 and 2001 in Australia, Canada, Finland, Ireland, Sweden and the United States. Pharmaceuticals now account for more than 10% of total health spending in nearly all OECD countries, and over 20% of health spending in France and Italy.
In Ireland, for example, the cost of the drugs payment scheme has doubled since it started. It cost €140 million in 2000 and is budgeted to cost €280 million in 2003.
The Brennan report puts the cost of pharmacy claims in the GMS at over €700 million in 2002. We cannot but try to control drugs costs. Pharmacists will have to recognise the public interest in controlling drugs and prescription costs. The Government will negotiate with them but if change is to affect everyone, pharmacists will have to be part of the equation.
There will be many others affected by the reform agenda such as civil servants, general practitioners, health board management and staff and local representatives. I do not underestimate the scale and scope of the agenda being undertaken by the Government. It is big but the public deserves nothing less. It expects the Government to govern and lead. Taxpayers are paying public servants generous increases under benchmarking and Sustaining Progress. With nearly 40% of the public service working in the health area, the quid pro quo must be visible in health service reform. Everyone involved in the health service has the opportunity to show that the investment in benchmarking and Sustaining Progress by society will pay off in better management, flexibility and responsiveness to public needs. That is where the challenge lies. If any one group asks to be exempt from change, nothing can work. If all work together to embrace change, everything can work.