Seanad Éireann debate -
Wednesday, 28 May 2008

Vol. 189 No. 20

Health Services: Motion.

Senator Phil Prendergast

I move:

That Seanad Éireann:

notes the continuing problems and regular crises in the management and operation of our health services, and believes that the HSE is not working;

further notes that the HSE has failed to meet any of the original objectives set by the Government, namely, to make the system more responsive to the needs of patients, to make the system more accountable, and to provide better value for money;

believes that rather than improving, the situation is in fact getting worse, and that we now have a monolithic system, distanced from the patient, divorced from ministerial accountability, and driven by budgetary concerns rather than patient need.

Accordingly, Seanad Éireann calls on the Government to initiate without delay a recovery plan for the HSE consisting of the following six steps:

1. establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making devolved to local level as possible;

2. make the Minister for Health and Children answerable to the public through the Oireachtas for all aspects of health service policy and delivery, and make the Secretary General of the Department the Accounting Officer for the HSE;

3. offer a voluntary early retirement, redundancy and re-deployment scheme, as part of the rationalisation of management structures;

4. give each hospital and each community care area autonomy to spend its budget, allocated according to national norms. Require each hospital to establish a management board;

5. accountability to the public through local and national public representatives should be at network and community care area rather than regional level and regional structures should be abolished; and

6. each hospital and community care area should be required to establish a patient liaison programme in accordance with recommendation 11 of the HIQA report on Rebecca O'Malley's case.

I wish to extend a warm welcome to the Minister. However, I do not believe she will be feeling quite so warm towards me when I have concluded my contribution.

For the past three years we have watched with keen anticipation the workings of the Health Service Executive, HSE, which was established with reference to the Health Act 2004. The latter provided a legal framework for the establishment of a body to assume responsibility for the management and delivery of health services from the various regional health boards that were then in place. We were informed that the HSE pledged "to use the resources available to it in the most beneficial, effective and efficient manner to improve, promote and protect the health and welfare of the public". This is a noble and ambitious challenge, in respect of which, unfortunately, the HSE has already failed. Since January 2005, the HSE was supposed to manage all the varied aspects of the health service in a co-ordinated and cohesive manner in order to ensure better quality of care. Consequently, this was to ensure that the health of all members of society would be enhanced in a whole-of-Government approach to health care.

Unfortunately, the reality of our ailing health service is a far cry from the brainchild conceived by the Minister. Services are being cut and relocated in a unilateral fashion, with no meaningful discussion with interested parties such as front-line employees and those availing of the service. In south Tipperary, breast care services were transferred in a heartbeat to Waterford Regional Hospital and, while this matter was no doubt discussed at length, the final decision was announced as a fait accompli to the people of Tipperary when the service had already been transferred. There was no opportunity for a local public perspective on the issue. The experts had made their decision, regardless of the disruption this brought to women who were experiencing serious health problems and who were undergoing invasive and stressful treatment. Consideration was not given to the distances their concerned families would be obliged to travel in order to be present to support their loved ones.

Waiting lists are spiralling out of control to such an extent that many essential services are now only partially available to those lucky — I use the word advisedly — enough to have a place on them. Even then, there is no guarantee of the level of service that people will finally receive because there is a concerted effort to simply clear the waiting lists through one-off assessments and referrals to other services. This will undoubtedly lead to even more waiting. Many waiting lists have been temporarily closed due to the inability of the health service to provide the necessary resources.

The HSE has already overspent by €95 million in the first four months of this year. As The Irish Times and other newspapers have reported, the situation is becoming worse on a daily basis. The executive’s attempt to address this problem through staff embargoes, limiting recruitment in particular areas to the financial constraints that apply in those areas and cutting vital services has simply resulted in further difficulties and nationwide dissatisfaction. All those who work in front-line services are feeling the brunt of these decisions. Morale has been badly affected, sick leave has spiralled and, given that the size of the workforce in the health area has been dramatically reduced, staff are finding it impossible to deliver the desired level of care and service.

The Labour Party has studied the difficulties associated with the management of the health service and acknowledges that reversing the current position will pose a considerable challenge. We are, however, convinced that the six-point plan I will outline will have a positive impact and return this service to the core values required to provide an equitable and responsible health service that will serve the needs of the people. To implement the plan, it is essential the Government and the HSE recognise the need to address core issues such as the need to increase bed capacity and, as a matter of urgency, to finalise the consultants' contract.

The six steps in the plan are: to establish clear lines of authority, responsibility and reporting within the HSE, with standard-setting at national level and as much day-to-day decision making as possible devolved to local level; to make the Minister for Health and Children answerable to the public, through the Dáil, for all aspects of health service policy and delivery and to make the Secretary General of the Department Accounting Officer for the HSE; to offer a voluntary early retirement, redundancy and redeployment scheme, as part of the rationalisation of management structures; to give each hospital and each community care area autonomy to spend its budget, allocated according to national norms and to require that all hospitals establish management boards; accountability to the public through local and national public representatives should be at network and community care area level rather than at regional level, and regional structures should be abolished; and each hospital and community care area should be required to establish a patient liaison programme in accordance with recommendation 11 of the HIQA report on the Rebecca O'Malley case.

To deliver effective health care, we must start with the patient. This means we must consider the available budget and ensure there is a fair allocation of funds to all areas of the country and that these funds are spent in a meaningful way at local level. Local management teams must then be allowed to take charge of this money and direct it into the services required. There is no doubt the local management teams in our hospitals are best placed to decide the level of funds to be allocated for the range of services provided. A degree of autonomy will undoubtedly result in better management of funds. Local managers surely have the wherewithal to assess the service needs, prioritise spending and ensure the continuation and development of core services. There is no necessity for a three-tier system of management because, as a result of the level of devolvement, this ultimately leads to complete confusion and a marked lack of personal responsibility for budgets.

The structure of the HSE, as it stands, is a source of great confusion. Decisions are made and nobody seems to know who was responsible for them. Again, simple decisions that impact locally should be discussed and made at ground level, with the necessary accountability built into the system. Once the bulk of local decision making has been delegated to the direct management, more time and energy can be given by the leadership of the executive to developing standards that will facilitate the effective implementation of the policies of the Department of Health and Children. This will ultimately result in a transparent, accountable and responsible health service.

At present, it is almost impossible to obtain a direct answer on any issue from the Department of Health and Children. This is largely due to the way the HSE and the Department work hand in hand. It was initially envisaged that the Department would be responsible for the formulation of policy, while the HSE would oversee the implementation of such policy, However, there is so much overlapping between both structures that there are no clear lines of definition. This is an enormously grey area, with the Minister involving herself with the implementation of policy and, equally, the management of the HSE wandering into the area of policy formulation.

The HSE and the Department need to work as separate and individual entities which complement each other but which also allow each other to advance their own areas of responsibility in an independent manner. Consequently, each entity must be separately accountable for the decisions made and should be available to justify these policies and decisions to the Members of the Oireachtas. The Minister for Health and Children must ensure that budgets for new development and policy focus, as recommended in the document A Vision for Change, should be specifically earmarked for this purpose and not redirected to address budgetary deficits. If the overall standard and delivery of care by the Department and the HSE is to be improved and refined, these funds will have to be protected to ensure development of new and innovative strategies.

The next point is the offering of a voluntary early retirement, redundancy and redeployment scheme. The original formation of the Health Service Executive brought together many different strands involved in the management of the health service. However, all the pre-existing levels of management were simply brought forward into the HSE, with much duplication of responsibility and the resultant layers of administration that prevent the development of a streamlined organisation. It is clear that in the interests of removing unnecessary inherited layers of administration, an agreeable redundancy package must be introduced. While there will be an initial outlay associated with this redundancy package and early retirement scheme, the long-term benefits not only will leave additional funds in the coffers for essential services but also ensure each respective layer of administration can work efficiently and in a productive manner.

The next point is the strengthening of decision making at local level. Once again, the present structure of the HSE removes decision making from those who invariably implement the decisions locally. Independent administration of the annual budget by a committee made up of members of the multidisciplinary team in each hospital will make for a personalised approach to spending where each member has a vested interest in prudent spending to maximise the returns from funds, and it will facilitate the prioritisation and development of important resources in each of the separate areas. It is recommended that these committees would also liaise with other hospitals, forming a regional network, and with representatives of primary, community and continuing care.

Labour favours the introduction of universal health insurance as part of the overall reform of the health service. For universal health insurance to work effectively, it is necessary to strengthen local management and decision-making structures, and to enhance corporate governance at hospital level. These kinds of reforms, therefore, will contribute in the long run to a more effective use of resources in the health service.

The next point is the restoration of local accountability. Labour is proposing that the present regional structures in the HSE be abolished and replaced with a new system of accountability. In respect of hospitals, this would be located at the hospital network level and would involve local and national public representatives who would meet regularly and have the power to insist that health officials attend meetings and answer questions. The focus would be on delivery of services. In respect of social services, there would be a structure in each community care area which would similarly invigilate the delivery of social services and where public representatives could hold local social services to account, again within budgets set out by the HSE and according to national norms.

The next point involves a patient liaison programme which each hospital and community care area should be required to establish in accordance with recommendation 11 of the Health Information and Quality Authority report on Rebecca O'Malley's case. We are all aware of the repeated failures in patient diagnoses over recent years and a way forward must be put in place to ensure such systems failures do not recur. What has emerged arising from these incidents has been the urgent need for a strong clinical governance procedure and also for the development of a patient liaison programme. This was identified by the HIQA in the report on the Rebecca O'Malley case and forms one of the key recommendations.

Labour advocates the appointment of an independent advocate as well as a hospital-appointed dedicated patient liaison person as part of a complaints procedure. This will ensure patients will have somewhere to go should they have any concerns. It is essential that this recommendation be implemented as soon as possible primarily to ensure patients' health risks are reduced and also to restore public trust in the effectiveness of our health service.

Senator Alex White

It is my pleasure to second this motion and welcome again the Minister for Health and Children to the House. I am interested to hear her response and those of our colleagues opposite in respect of the proposals we are bringing forward. I am bi-locating somewhat this evening as I am also attending the Joint Committee on the Constitutional Amendment on Children. My absence during the debate is not from a lack of interest as I find myself having to be in two places at the one time.

I will repeat a challenge I threw down to the colleagues opposite yesterday. Hardly a day or week passes without one or other of our colleagues opposite coming into this House and quite correctly criticising an aspect of the health services that has come to their attention. Time and again they make the point about the system being dysfunctional and there being a lack of clarity in terms of responsibilities and management lines. They express their frustration in this House in respect of particular problems that arise and, more seriously, the inability to obtain clarity and answers to genuine issues which arise.

The picture inevitably painted by colleagues on all sides of the House is of an almost Kafkaesque system which is impenetrable to public representatives, to say nothing of members of the public or citizens who seek to make sense of it. The frustration people have in trying to make sense of it has been echoed at the highest level in Government, as we know. A number of the Minister's colleagues have reflected this in recent months.

There is a fundamental difficulty to be addressed and we do not bring this motion forward to have a go — as might be suggested — or level criticism in a gratuitous way. We approached this issue genuinely and my colleague in the Lower House, Deputy Jan O'Sullivan, has brought forward these proposals in a genuine attempt to have the chaos which characterises much of the operation of the health services addressed in a meaningful and practical way.

I repeat my challenge to my colleagues opposite, including those who raise these issues every day. I am disappointed with the response by way of the amendment to the motion. I, along with others, yesterday indicated our proposals and if there are specific aspects with which the Government has a problem, it should amend them so we can have a realistic and meaningful discussion. What we have instead is the usual response, which is to delete everything in the motion after "Seanad Éireann" and insert something entirely different that does not address the issues we are attempting to deal with.

If colleagues are frustrated and believe the system is dysfunctional, they can see a practical answer in the first paragraph of our motion in respect of establishing clear lines of authority, responsibility and reporting within the HSE. That issue is not dealt with in the amendment to the motion. There is a reference in a bullet point to yet another review. It may be there is a need for ongoing reviews in all organisations but we seem to be in a permanent state of review in the case of the HSE. The matter is not dealt with.

A second issue is the frustration people feel in respect of accountability for delivery of services, for example. We know we have the model of the Minister dealing with policy and the HSE dealing with implementation and delivery, as Senator Prendergast pointed out. At least, that was the vision at the outset, but it has not worked. The Minister has found herself having to deal with everyday issues and it appears the HSE, almost inevitably, strays into the policy area. How could it be otherwise?

If people feel, as I do, that the matter should be addressed, one would imagine it would be addressed in the amendment. It is not, apart from a generalised acceptance that the Minister accepts full accountability. There must be accountability at the core as the Minister must constitutionally be responsible to the Houses for what happens under the rubric of her brief. There is no real everyday and meaningful accountability. There is a proposal to deal with it but there is no response from the other side.

For example, with regard to the HSE, the motion points to the fact that there is a statutory requirement on the HSE to manage its budget within its approved Vote. This is the constant response one gets the whole time. This gives rise to a genuine belief in many people — not just those on this side of the House — that the HSE is driven more by budgetary concerns than it is by real patient need. To corral into the HSE not just the responsibility for doing the everyday job but to be the Accounting Officer for its own funding is quite wrong. There is a democratic issue in this also. It is unprecedented that a body the size and importance of the HSE, which is tasked with the health services of the country, would have the power of answerability for its budget. There must be an issue at the core of these problems that we should examine.

It was a spectacle when Members of the Oireachtas, both Senators and Deputies, gathered in the restaurant downstairs and vied to put questions to the head of the HSE and his staff. Putting up one's hand in the hope that one can ask a question is not serious accountability in any real democracy or constitutional system.

People sometimes say the Department of Health and Children was too weak before the HSE came about to make its writ flow, as it were. The answer to that was to strengthen the governance in the Department of Health and Children and the way it managed the system rather than removing the power and corralling it within the HSE along with all its other responsibilities.

If the Members on the other side of the House are concerned about staffing, the two constant refrains one hears about the health service, whether it is on radio, television, in this House or outside it, is that it is overstaffed and that we are throwing money at it and getting nowhere. This is the conventional wisdom one hears every day of the week but let us consider it. If the executive is overstaffed and the Minister believes it is, we should take an honest approach to the problem and go with a redundancy programme. We should see the case in that regard. People might find it odd that the Labour Party is advocating that but we do so in the sense that if there is a need for redundancies, we should have them. Let us see the case made and have consultations, as Senator Prendergast said. We should do it instead of maintaining the criticism of the health service that it is overstaffed. If it is overstaffed we should address the problem. At that stage we will see whether there is a need for redundancies and if there is not a need, that argument should be left aside. It either is or is not overstaffed.

The second point is that we are constantly throwing money at the HSE. The notion has found its way into the public discourse that money is being thrown at the HSE and we are not getting anything back. We have had very little discussion about outcomes. All the discussion is about costs, as somebody said on the "Prime Time Investigates" programme the other night, but there is little about what we are achieving. We do spend a great deal of money on our health services. We are right to do that and the Minister should defend that.

One of the most remarkable observations made in the course of the "Prime Time Investigates" programme the other night, and it told a major story, was that fine doctors and medical people were seen to leave the public sector and go into the private sector. What is the reason for that? It must be partly due to the perception in the system that the action is in the private sector. We must get the action back into the public sector. We should favour and privilege the public sector and try to reform the current system by way of this motion, which is a set of sensible proposals that could easily be backed by any Member on the opposite side of the House if they were honest about what they were saying.

Senator Geraldine Feeney

I move amendment No. 1:

To delete all the words after "Seanad Eireann" and substitute the following:

"—supports the fundamental objective of the Government in health policy, that is, the achievement of best clinical outcomes for all patients throughout the country;

affirms its confidence that this objective is best supported by setting national standards and applying them consistently; by the establishment of the Health Service Executive, HSE, as a unitary national health authority; and by the effective use of resources for the benefit of patients and service users;

endorses the many confirmations by the Minister for Health and Children that she and the Government fully accept political accountability for the health services and affirms that this is the position in the Health Acts;

welcomes the review under way in the HSE of its internal organisation structure to improve the effectiveness and efficiency of the organisation, by streamlining its management structures, clarifying roles, responsibilities and reporting relationships and strengthening co-ordination, governance and accountability;

acknowledges that a voluntary redundancy scheme for staff of the HSE would best be implemented in the light of the outcome of that review, in dialogue with the relevant staff representative associations, and with the potential for redeployment of staff having been fully identified;

underlines the importance of the statutory requirement on the HSE to manage its budget within its approved Vote;

supports management actions within the HSE to allocate and manage budgets at the appropriate hospital and community service levels;

affirms the importance of management accountability within the HSE for its own sizeable budget and expresses its confidence that this objective is supported by the chief executive officer of the HSE being the statutory Accounting Officer in relation to the appropriation accounts of the Executive;

acknowledges the steps taken in the Health Act 2004 to provide for and encourage local responsiveness of the HSE; and

welcomes the recent initiative taken by the Minister for Health and Children and the HSE in encouraging greater patient involvement in a wide range of health services."

I, too, welcome the Minister to the House. The Health Service Executive was established in 2004, before the Minister's time in office, under her predecessor, the Minister, Deputy Micheál Martin. In budgetary terms it is an enormous organisation with a budget in excess of €15 billion. The HSE is the biggest organisation in the country and everybody would agree it is a work in progress rather than a finished article.

There are approximately 112,000 employees in the HSE. The complexity of dealing with the nation's health needs is frightening, to say the least, and in the past year an enormous amount of the HSE's time has been taken up dealing with the well-entrenched elites of consultants and pharmacists. It appears that agreement is slowly being reached in both cases, which I welcome.

We all know the HSE is not perfect, and the system is not perfect either. We all have our own particular gripes, whether it is specialist centres of excellence for cancer care or overcrowding in accident and emergency departments. We must give the HSE, under the management of Professor Drumm, time to improve those areas. When considering this issue earlier today I made a reasonable analogy and compared the health services today with the progress of a supertanker. The latter cannot suddenly stop and turn in a small area, and an organisation as large and as complex as the HSE cannot be asked to do the same.

I was interested to read in the medical supplement in The Irish Times yesterday a short piece outlining a lecture held in Dublin City University on Monday night on information systems in health planning. Professor Anthony Staines, who is a professor of public health in DCU, referred to he and his colleagues coming together last year and issuing a report that found that public satisfaction with the HSE is much greater than the perception given in the media. It is easy for the media to ignore good news. Professor Staines stated that the reason it is ignored by the media is because it conflicts with their master narrative. Bad news is always better than good news. Sensational headlines are what is important to the newspaper business.

The common finding throughout Europe was that most people in Europe are happy with their health services. Professor Staines went on to state that if we were to abolish the HSE it would be disastrous for us as a nation and it should be stoutly resisted. If we consider the experience in the United Kingdom with the NHS, it found that changing such structures can often be counterproductive and paralyse the staff for several years while changes take place.

It is wrong of Members to come into the House and criticise an organisation such as the HSE without giving any consideration to the staff who work in it. I have family members working in the service and they tell me they are often embarrassed to say they are working for it. They put that down to the media bashing the HSE is getting currently. They are proud of where they work but they get embarrassed when they read the way they are perceived by the media.

I wish to highlight two points in the amendment. It states that the Government welcomes the review under way in the HSE of its internal organisation structure to improve the effectiveness and efficiency of the organisation by streamlining its management structures, clarifying roles, responsibilities and reporting relationships and strengthening co-ordination, governance and accountability, while at the same time acknowledging that a voluntary redundancy scheme for staff of the HSE would best be implemented in the light of the outcome of that review, in dialogue with the relevant staff representative associations, and with the potential for re-deployment of staff having been fully identified. Regarding what Senator Alex White said earlier, overstaffing is being addressed in the review under way. He would know that if he had read the amendment to the motion.

A national organisation such as the HSE is preferable to the old health board system. Modern research and science tells us that certain health treatments and services must be provided on a national rather than a local scale. Similarly, negotiations with health service providers, whether they are nurses, doctors or pharmacists, must be dealt with at national rather than local level.

We all know the problems families face, and they were discussed in the House some months ago, with the treatment and education of children with conditions such as autism. Again, the improvements we make in dealing with those problems will be better if dealt with nationally rather than locally.

As a nation we are living longer and are now healthier than ever before but as we age our medical needs become greater and more costly. That is an enormous challenge for all western countries, including Ireland. Given the limits of our national finances, we are particularly sensitive to that. I believe in a national organisation such as the HSE providing our health care. I am not naive enough to believe everything the HSE does is perfect or even acceptable in some cases but I reiterate that the HSE is the equivalent of a child in its early days in education. It is work in progress and it must be given the necessary time. I refer again to the points made by Professor Anthony Staines, the expert in the field of health planning.

Senator Frances Fitzgerald

I am pleased to have the opportunity to speak on this Private Members' motion and I commend the Labour Party Senators on submitting it and providing the time to debate it. There is urgent need to address this issue, to examine how the HSE is performing, how it delivers services and the relationship, in terms of responsibility and accountability, between the HSE and the Minister in her Department. All these issues emerged in a number of reports last year as being key to the delivery of health care services. There have been two serious investigative programmes by "Prime Time" in recent weeks, one on the delivery of services to young people at risk, the other on the pace and rate of delivery of primary care teams. Both programmes were critical of the delivery issues.

It is not, of course, only on television programmes that we hear such things. We also learn from the direct experience of clinicians and patients. One of the key issues that comes up repeatedly, which is not addressed by the Government amendment, is that clinicians feel alienated from HSE structures. This is not about bashing the staff of the HSE. I agree with Senator Feeney on this matter. A great number of people in that organisation want to do their very best. It is about how services are delivered and the experiences of people. It is clear there are major problems. I am not alone in saying this. The Fitzgerald report, which was commissioned by the Minister to analyse this, stated that doctors described the HSE as a "low trust" organisation concerning relations between clinicans and administrative officials.

We must admit this is happening if we wish to change it. I spoke to a clinician today who told me that when he goes home at night it was not the patients that are on his mind in terms of pressure, nor is it the services he is trying to deliver. He said what is on his mind is how he will deal with the bureaucratic structures within which he must work and how to get across to the administrators the needs of his front-line job. Those words came from a person who is trying to give service in a very disadvantaged area. In his experience, the relationship between clinician and administrative back up is highly problematic. A number of people to whom I spoke today said they do not believe anybody is listening to them. As clinicians, they feel very strongly that their experiences go unheard within the present structures. This is a very serious issue and I believe it is real. People are not imagining such things.

Yesterday the Joint Committee on Health and Children heard representatives of the Muscular Dystrophy Association. I found it traumatic to listen to them because their needs were so great and the lack of delivery to them was extraordinary. They talked about the need for more personal assistants in order that they might be independent. In the health service right now, despite all the money available, these people do not get what they need. To take that group alone, one would have thought that after 11 years of the Celtic tiger, it would be automatic and routine that they would have personal assistants. These people are in dire need and what they need is not available to them. We know also that patients from the National Rehabilitation Hospital cannot go home at present because they cannot get enough home-care packages. I raised this at the Joint Committee on Health and Children.

The Minister knows, I know and everybody in this House knows we could quote example after example. Something is seriously wrong. What disturbs me about this amendment is that it contains denial. There are two ways of looking at it. The Minister is asking us to welcome the review of the organisation to improve its effectiveness and efficiency by streamlining its management structures, clarifying roles and responsibilities, reporting relationships, etc. It is an indictment of the Minister, the Department of Health and Children and of the HSE that after four and a half years of an organisation that was meant to deliver, the Minister comes here to tell us a review of its basic roles and responsibilities is taking place. It is an admission of failure that such measures are needed. The reports have stated clearly that these things must be done. Every report has identified this. What has gone wrong? What is the Minister's explanation to the House that an organisation she set up is not delivering ? Why has it gone wrong? Who has been in charge? How has this been allowed to develop? Why, after four and a half years of the HSE, are such measures needed?

The other side of the coin is that for 11 years we have had a Government made up of Fianna Fáil and the Progressive Democrats which has had more money for delivery of services than any other Government. We have a population that approaches 4 million and we have not been able to organise our health services.

I have no doubt that very serious questions will emerge about the public private partnerships that have been so popular with this Government. It is clear from the experience in England, for example, that there has been huge spending over budget on many such projects. This will emerge here too. I heard somebody say at the weekend that if one wishes to know where the money has gone that should have been providing front-line services in England, he or she should look to the waste in public private partnerships. It is questionable to assume that these structures deliver the best front-line service in health. This model has been used.

I am disappointed there is a need for this debate. It is distressing for people in every sector. I could go into detail on all of them but will mention just two where delivery for the patient has failed. At the end of the day patient care is what we are here to talk about, not about structures for the sake of structures. We are here because we want the structures to deliver care to patients.

There should be an inquiry into the outbreak of the C.difficile infection in Loughlinstown Hospital where 16 people died in order that we can learn from the mistakes made. The Minister will have seen what happened in Maidstone in England. This is an incredibly serious infection with devastating results. We have had a very serious outbreak with 16 people dead.

The other area I will mention is mental health and the decision to locate the Central Mental Hospital beside a prison. This is against all international best practice. I ask the Minister to reconsider that decision, which I assume was made by her and that she will take responsibility for it.

The Government amendment shows a degree of complacency in that it does not inject any urgency into the crisis in the health service.

Minister for Health and Children (Deputy Mary Harney)

It is always a pleasure to come to the Seanad notwithstanding the fact that some of its Members think I have no accountability here. It is unusual that I do not as I am here so often. I always enjoy attending debates in this House.

If we do not get the basic facts right, we will not have an informed debate. I want to tell Senator Fitzgerald that the HSE is not four and a half years in existence, nor even three and a half years. The HSE was established in January 2005 after a prolonged period of analysis carried out by prospectors and others and after widespread consultation with a number of stakeholders. The reason for advancing a unified organisation for Ireland was that, with a population of 4.3 million, we had 11 health boards with 273 members covering very small populations. It was not possible to provide quality assured services with such a small population. I advance the view again that it would not have been possible to have implemented the cancer control programme if we still had the old health board regime. The midland health board has no cancer centre, the north east and north west are similarly without specialist cancer centres. When the health plan of former Minister for Health, Deputy Michael Noonan, was put into effect by the health boards, all the evidence backed up this point. In the midlands, for example, each hospital got a slice of the action and this meant patients did not receive a quality-assured service. Consequently, a unified service is right for Ireland. It is right in terms of delivering effective quality-assured services and ensuring that we minimise the cost associated with their delivery.

Another myth suggests that since I became Minister and the HSE was established, the level of bureaucracy increased greatly at the expense of front-line staff. Since the HSE was established, there was a reduction of 423 staff in its own corporate headquarters alone. There has been an increase in front-line hospital staff in the order of 6,000. There has been an increase of just under 6,000 staff at community and primary care level and a considerable increase in the number of therapists. This is not understood. I constantly read articles and hear references in both Houses to the effect that there has been a growth in bureaucracy since the HSE was established and since I became Minister. We have increased the number of physiotherapists by 20%, the number of occupational therapists by 45% and the number of speech and language therapists by 28%. The number of consultants has risen by 18%.

On the issue of clinical involvement, I am a strong fan of clinical leadership. The cancer control programme was recommended to the Government by a group of 23 people, 17 of whom were medics. The success of that programme is very much dependent on clinical buy-in. With a view to implementing the programme, Professor Keane, a medical oncologist, has recruited to his team Dr. Arnie Hill, a breast surgeon from Beaumont Hospital, Dr. Donal Hollywood, a radiation oncologist, and Dr. Maccon Keane, a medical oncologist from Galway. These three clinicians are working part-time with Professor Keane on the implementation of the programme and there is considerable buy-in from doctors around the country. Only recently Professor Keane addressed up to 200 surgeons in the Royal College of Surgeons in Ireland. I know from many sources that when he left that meeting, virtually nobody in the room disagreed with what is happening. Individuals in particular circumstances may not like what is happening but, by and large, there is considerable clinical buy-in, bearing in mind that there is never unanimity.

The new contract of employment for consultants, which was agreed recently by the Irish Hospital Consultants Association, which represents 80% of practising consultants, was favoured by 80% of consultants while 20% were against it. An important feature of the transformation of doctors' working practice is the idea of working on a team with a clinical director. At present, consultants work as individuals, or lone rangers, within hospitals. There are a few exceptions, as in St. James's Hospital, where there is a clinical directorate model that works very well. Some consultants tell me they work "in the hospital and not for the hospital".

Lead clinicians must work in teams to provide cover in the hospital and to provide the excellence and expertise we require. The clinical director will be responsible for ensuring there is structured cover by consultants when the hospital requires it, be it on Saturday, Sunday or in the evening. There will be two directorates — a medical directorate and a surgical directorate.

It took so long to agree on the consultants contract mainly because of the issue of access to private practice in public hospitals. Senator Fitzgerald referred to doctors not being very enthused by the problems that arise. They do not go home worrying about their patients, apparently; they go home worrying about the bureaucracy.

Irish doctors are the best paid in the world.

Senator Frances Fitzgerald

I did not say it was bureaucracy.

Deputy Mary Harney

I believe the Senator stated "by administration".

Senator Frances Fitzgerald

Professionals.

Deputy Mary Harney

Irish doctors are the best paid in the world by a long margin, as are all health care professionals. As I stated previously, pharmacists are paid, on average, €100,000 more here than in Northern Ireland, yet we cannot get support for the reforms we are introducing. Under the new regime, we will ensure that as a result of the high public salaries, there is greater concentration on access based on medical need rather than private insurance or financial means.

In the public hospitals, nearly half of the patients of some clinicians, some of whom are not great fans of mine, are private fee-paying patients. I used to be a great fan of universal insurance but the reality of universal insurance in Ireland would be that we would simply be paying consultants a couple of hundred more million euro to see the patients they are supposed to see to justify their public salaries.

I have just come from a meeting of the Cabinet sub-committee on health involving the HSE, the Minister for Finance and the Taoiseach on aspects of the transformation agenda. Among the changes are the measurement of performance, including the number of patients being seen at outpatients departments. There are many measurement requirements in the public health system. One thing is certain, if one does not measure, one cannot succeed in managing. The reality is that there is a great disparity between the number of patients seen in each outpatients unit of the same specialty.

In the other House recently I referred to Dr. Tubridy, a neurologist in St. Vincent's Hospital in Dublin. As a result of changing the way the neurology department operates, he was able to double, in the course of 18 months, the number of patients being seen in a calendar year. The doctors were able to devote twice the time to each patient on foot of the appointment of administrative support staff. No further resources were required.

In the physiotherapy department in St. James's Hospital, 18% of patients did not turn up for outpatient appointments. This clearly implies the slots are not available to other patients. However, as a result of patients being able to make their own appointments in St. James's Hospital at times that suit them, and as a result of texting and other simple measures, the hospital has enjoyed a 50% reduction in the number of patients not showing up for appointments. The hospital intends to decrease the figure to a negligible level of 1% or 2%. I salute these kinds of initiatives.

The change under way involves measuring performance. As I stated, 18% of patients do not show up for outpatient appointments. We know that for every one new patient seen, there are almost three repeats. There should not be repeats in that with a few exceptions, they should be seen at general practitioner level. Very often the patients do not see the consultant but might see the consultant's registrar.

Measuring what is happening is essential to changing performance. I accept that some do not like this. Some doctors have said to me they are independent, which is true for clinical matters, but this does not mean that we cannot measure what is happening in the public health system with a view to improving performance. This is happening across the system and will happen also at the community and continuing care levels.

Central to the reforms is ensuring that those who are accountable for spending the money and delivering the service are accountable to the Oireachtas. We should not confuse accountability for the Vote or the finance with the responsibility of the Minister. Nobody would suggest that the Minister for Justice, Equality and Law Reform is not responsible for law and order and matters concerning crime and justice, yet it must be borne in mind that the Garda Commissioner is the Accounting Officer. Similarly, Professor Drumm is the Accounting Officer in the health system. He gets the money voted for the public health service by the Oireachtas and attends meetings of the Committee of Public Accounts, as he will do tomorrow, to account for how it is spent. That, in my view and that of anyone who has considered management systems and the need to ensure responsibility for service delivery, is very important. It was not good enough under the old regime when the Secretary General of the Department of Health in Hawkins House was the Accounting Officer for every single health board in respect of how they spent their money. Clearly, this does not make sense.

The Secretary General is not involved with every HSE area or hospital. He is not involved operationally in the delivery of services on a day-to-day basis. To expect him to be accounting for the spending of every single penny does not represent good management, nor does it lead to a very close link between the money and the performance in respect of its allocation.

Since the HSE was established, it received an increase of €5 billion, which is more than the amount spent running the entire health service in 1996. That puts what I am saying in context. Health care is expensive. Those who work in the health service are generally well paid, as they should be, and are highly skilled professionals. Given that we pay them good salaries, we are entitled to ensure the best possible outcome. It is a question of outcomes and nothing else. It is not a matter of driving budgets, although everybody must live within his budget, as used to be the case under the health boards. It is a question of ensuring the allocated budget is spent as wisely as possible in delivering enhanced quality-assured care to patients and service users.

I do not believe that making hospitals responsible at a local level to local communities will work. However, I am a major fan of patient advocacy and every group appointed by me has included people solely with a patient advocacy role. For example, last week I was pleased to meet the new Medical Council, which now has a lay majority. While it will not take effect until next month, its members held a three-day induction course in a County Wicklow hotel from Thursday to Saturday of last week and I was pleased to meet them. Ms Margaret Murphy was one of those whom I appointed. I met her through a patient safety conference in the United Kingdom organised by its chief medical officer. She had come to his attention because she had been obliged to litigate to establish the reason her son had died in a hospital in Ireland as a result of an adverse incident and no one would give her an answer. That era is over and patients are not obliged to litigate to find out what happened. Inquiries will take place, lessons will be learned from them and there will be a change in respect of how patients are handled.

Only three weeks ago, Professor Drumm and I launched a new patient involvement strategy, which must be devolved to the lowest possible level at hospital, community and nursing home level. For example, many nursing homes now have user councils whereby those who live in such nursing homes can put forward their views on how they operate. It could pertain to simple matters such as the presence of a coffee bar. I learned of a case recently in which the residents observed they had nowhere to meet someone to have a cup of coffee. While these are simple matters, they make a great impact on the quality of service that can be supplied.

I wish to deal with the rate and pace of the establishment of the HSE, which has been mentioned. Prior to the passage of the legislation in 2004, an interim board was established in 2003. However, the interim board had no statutory backing and it was impossible for it to do certain things. It was necessary to create a body that had legislative backing to take forward the agenda. At that time, it was not possible to decide what staffing levels should be. It was much more effective to launch the organisation, put in place a new chief executive office and management structure and then allow the new management structure to decide what staff ratios were required. Recently, a consultancy called Empower has carried out a review of clerical and administrative staff within the HSE. Believe it or not, the HSE is on a par with the Scots, the Welsh, the British, the French and so on in respect of the numbers of administrative and clerical staff in the organisation. However, huge discrepancies exist between one region and another arising from the old health boards.

It is important to perform such exercises and to have the experience of trying to manage before deciding on redeployment and voluntary redundancies. The State has operated very few voluntary redundancy programmes. However, many people observed, of the last such programme, that the wrong people left, some of whom then returned as consultants to the system. I do not want that to happen. If a voluntary redundancy programme is to be carried out in which it is known exactly who is needed and where, it must be based on ensuring the required skill sets are retained in the organisation and that those who have a skill set that may not be required in a particular area are encouraged to move on by way of voluntary redundancy. While I believe this to be possible, it must be done carefully and properly.

Moreover, McKinsey & Company has performed a review with Professor Drumm and the board of the HSE's management structure regarding positions and accountability and whether to keep two pillars, that is, a primary care or continuing care pillar and, for example, a hospitals pillar. The failure to integrate is an issue at local level in particular and these issues must be examined in the context of an organisation that at least knows what it is about. One cannot do such things with an interim board with no statutory backing. This is a mission that has never been embarked on in Ireland previously, in either the public or private sectors. This is something that has been attempted only in very few public systems around the world. No one has ever sought to perform this kind of change on the scale being attempted in Ireland through the HSE with more than 100,000 people, many of whom work in voluntary organisations that are funded, but not owned, by the HSE. Virtually no acute hospital in this city is owned by the HSE, contrary to the popular view. Such hospitals are funded by the HSE but are in the voluntary sector and are owned by others. Ireland has a strange structure and we must ensure, as we move forward in respect of the organisation of our public health system, that we do so in a way that makes sense.

Senator Fitzgerald mentioned the issue regarding Clostridium difficile. Until May of this year, it was not measured and was not notifiable. Consequently, making it notifiable naturally gives rise to headlines outlining the number of outbreaks that have occurred. There were no outbreaks previously because no one was responsible for notifying them to anyone else. Sometimes, positive developments, such as requiring a hospital to notify, are seen in a negative context. Hospitals now are required, because of enterprise liability, to inform the State Claims Agency of all adverse events that take place. This has been perceived by some media commentators as a highly negative development, with reports of so many adverse incidents in this hospital or the other. Worldwide, 10% of hospital experiences are adverse but thankfully, only 1% are fatal while the other 9% are non-fatal. This statistic obtains in Canada, New Zealand, the United States and in many European countries. Unless such events are reported, we certainly will not learn from the experience and will not improve matters from a patient safety perspective.

As for our population and home-care packages, I accept we have a long way to go to put in place the requisite home supports for older people. However, we started from a base of virtually zero a couple of years ago and now have 11,000 older people being clinically supported at home with the various therapies that facilitate them remaining at home rather than going into residential care. Moreover, Ireland has an extremely young population. It has the second youngest population of the approximately 40 countries in the OECD. Ireland has the youngest population of the 27 member states in the EU with 11.1% being over the age of 65. The equivalent percentage in Italy and Germany, for example, is 20% and I understand it is approximately 16% in France and the United Kingdom. Ireland has an extremely young population but often does not get the benefits of that young population. Our health spending at 9% of national income is the average across the OECD.

My point is that health reform is in its infancy. I personally believe strongly that a corner has been turned. I see this every day. The health awards took place a few weeks ago and I could not believe the kind of examples of innovation that were happening, in many cases without any new resources, simply by people thinking outside the box and being encouraged to view matters differently. In particular, measurement drives performance. Senator Quinn, who is present, is a businessman and I am certain he used to measure how his staff performed. I always saw him on the shop floor any time I went into the Superquinn in Lucan or into any other Superquinn branch. It seemed to be that he was present in all the Superquinn branches at once.

Managers who measure can manage and those who do not, cannot. Members are aware that some people who give the impression of working hard sometimes do not produce many results. A new era of measuring has arrived. It will involve, as noted previously, measuring outpatients and what happens in the community sector. As for contracts of employment, negotiations have yet to take place with the general practitioners and others. The remuneration of those who give a better service, work longer hours and so on, as many do in rural areas, should support and incentivise this. Sometimes in the past those who shouted loudest and complained most got the resources.

Individual cases, which always are very sad, in which services do not match expectations always will arise. There always will be the potential to improve and the health service is no different in that regard. Perhaps it never will be different as no health system is. There will be constant issues because democracy means that citizens are concerned about their health and naturally they will make their public representatives aware of when things do not happen. Equally, there are huge numbers of positive developments. Senator Prendergast mentioned moving the breast services from Clonmel to Waterford. That has happened and, as she is aware, I visited South Tipperary General Hospital only two weeks ago, where I visited the oncology ward and spoke to a number of women who had undergone breast surgery in Waterford. They were extremely satisfied with the service they received and were particularly pleased to be able to have their oncology treatment in South Tipperary General Hospital. This also will be the case in counties Sligo and Mayo and everywhere else.

Ireland is one of the best performers in the world in respect of the treatment of children's cancer. The service is centralised in Crumlin and chemotherapy is delivered in 16 hospitals through a protocol throughout the country. It is known that Ireland performs extremely well with children's cancer. It does not do well with other cancers because of the fragmentation of the service. We must learn from this and must be sufficiently courageous to inform ourselves, examine the best international practice, consider all the evidence available to us and then implement it because sometimes we have fallen down on implementation. When doing so, we do a great disservice to patients and to ourselves and that era is over. Members of the public are up for the kind of change that is under way and are patient enough to wait for it, notwithstanding the fact that it causes heartbreak and difficulties when services cannot be provided as quickly as we would wish. Improvements in accident and emergency services are a fine example of this as they are 70% better than in 2003. Comparing this month to the same month in 2003 shows a huge improvement in waiting times and we must do better. At present an average waiting time of 12 hours is the target and we aim to half that later this year. The target time, from when one presents to when one is admitted or discharged, will, hopefully, be no more than six hours. If we can adapt these targets on an incremental basis we will have a public health service of which people can genuinely be proud. Hopefully countries will look to our public health services in the way they have looked to our economic performance in recent years.

I am pleased to be in the House to deal with this motion. I compliment the Labour Party on putting forward proposals and some of them are already happening. There must be clear lines of accountability and responsibility. It would be nice to press a green button in order that they could happen instantly but that is not possible. However, they are going on as we speak and the internal restructuring of the organisation is happening at great pace. A new human resources director in the HSE starts on 9 June and we have seen the huge effect of the estates manager, Mr. Brian Gilroy, on leveraging the values of properties to invest in the capital programme. I believe that as the summer passes and the organisational structure is put right due to the HSE's internal analysis, some of the issues referred to in the Labour Party's motion will be addressed.

Senator Feargal Quinn

I welcome the Minister to the House and appreciate that she comes here regularly. She answers our questions and seems to have figures at her fingertips that she does not have to read from a prepared script. On her last visit here, very recently, I expressed my support for her objectives.

Some seven or eight years ago I visited a number of hospitals to inquire how we will get around the big problem facing us. This long predates the Minister's current situation and responsibilities. I am a great believer in delegation and passing responsibility to where the action is and where customers, in this case patients, are located. I came to the conclusion at that stage, as did the Minister, that health boards were not the solution because every town, community and county wanted its own hospital and centre of excellence. I support the Minister's moves in recent years to try to achieve her goal in this regard and the national cancer strategy, announced last autumn, is an example of this.

The national cancer strategy indicates that breast cancer services should be centralised in eight cancer centres based on clinical excellence and the number of newly diagnosed breast cancer patients per year. The logical assumption is that smaller units will close and services relocate to a larger unit. A figure of 150 new cancer cases per year is the minimum for a designated cancer centre.

Let me take one instance of a concern my attention was drawn to in Cork. The situation in Cork is unique in that two hospitals, Cork University Hospital and the South Infirmary — Victoria University Hospital, currently provide breast cancer services. The newly built and recently opened BreastCheck unit is located adjacent to the South Infirmary — Victoria University Hospital unit and is effectively an integral part of it. The breast cancer unit in the South Infirmary — Victoria University Hospital is currently the largest unit in the country and handled 220 newly diagnosed patients last year. This year it is on target for somewhere between 300 and 320 patients, excluding BreastCheck patients, who make up another 100. The South Infirmary — Victoria University Hospital has a well organised multidisciplinary team and is one of the few units in the country to meet the Health Information and Quality Authority, HIQA, standards with good, well-established data collection for quality assurance. The Minister has often mentioned that numbers equate to quality. Cork University Hospital deals with about 80 newly diagnosed cases per year and has only one breast surgeon. It is the regional trauma centre and the wards are often full of trauma and fracture patients. Other surgeries, including cancer surgery, get cancelled or postponed.

I welcome the Minister of State at the Department of Health and Children, Deputy Barry Andrews, to the House as he has not been here in my time. Our problem is that Cork University Hospital has been chosen as the designated breast cancer centre for Cork and that services will cease at the South Infirmary — Victoria University Hospital. The consultant medical staff in the Cork hospitals would be happy with this if a purpose-built facility adequate to cope with the clinical workload of around 500 new cancer cases per year existed in Cork University Hospital but it does not and would take years to plan and build. A unit dealing with 500 new cancer cases may even be too big, given the multidisciplinary meetings and outpatient clinics that would be associated with this workload.

Professor Tom Keane came to Cork recently and, while previously he had indicated he would be data driven, to use his term, in his implementation of the cancer strategy, he subsequently backtracked on this and is going to implement the strategy to the letter of the document. He indicated that all breast cancer services would be relocated to Cork University Hospital by May next year, which I believe to be an impossible timescale as there has been no engagement with any clinicians in the process.

Moving a large unit into a smaller one is bizarre, to say the least, and patient care will be adversely affected by moving services to Cork University Hospital. The service would be better located at the South Infirmary — Victoria University Hospital in the short to medium term while a longer term, properly resourced strategy is put in place.

I apologise if I have concentrated on a particular instance and I hope it is an exception, rather than a typical example of what may happen elsewhere. The amendment to this motion supports the fundamental objective of the Government's health policy, which, it says, is the achievement of the best clinical outcomes for all patients throughout the country. We will assume that Cork achieves that fine objective. This case may be only one instance but the figures that have been brought to my attention suggest that if this is happening elsewhere the matter needs immediate attention. I assume the case in Cork is the exception to the rule. I have great admiration for what is taking place and I believe the HSE is getting on top of this. Last time she was here the Minister gave us figures and judging from her words today I believe she is confident that she and the HSE are getting on top of this. I have used the case of Cork and ask to be excused for concentrating on one instance, but if it is an example of what is happening elsewhere it needs serious attention. If it is something that is an example of a unique exception the Minister may be able to handle it.

The objectives of the HSE and those mentioned by the Minister today are supported by all of us. The manner of achieving those objectives is crucial and I believe the Minister is confident we will succeed, though we need the support of everyone in the country to do so.

Senator Ciaran Cannon

I second the Government amendment to the motion and welcome the opportunity to contribute to this important debate on the management and operation of our public health service. This is a matter of concern not only to all public representatives but to all members of our society. I agree with the Minister that the Labour Party's motion was tabled in that spirit of concern.

The fundamental objective of the health policy of this Government is to achieve the best clinical outcomes for all patients across the country. This is a central tenet of the health service reform programme.

The reforms are aimed at helping to deliver a health system that is more responsive and adaptable and that more effectively meets the needs of the population at an affordable cost. The principles underlying the Government decision in June 2003 to establish the Health Service Executive as a national health authority are as valid today as they were four years ago, namely, to improve patient care, to provide a new national focus, to reduce the fragmentation of the health service and to improve budgetary and service planning. Nobody, I believe, is suggesting that we should go back to a time when we had a plethora of health boards operating almost independently of one another. In a small country of 4 million people it made perfect sense to move towards a centralised and more efficient model of health care and this continues to be the case.

It is important to clarify the current governance and accountability frameworks, both within the HSE and between the HSE and the Minister, as there appears to be a small amount of confusion about the precise position. The board of the HSE is accountable to the Minister. The CEO is accountable to the board and has responsibility for the implementation of the board's operational policies. The CEO is also answerable to the Oireachtas in his capacity as Accounting Officer for the appropriation accounts of the HSE.

The annual service plan, which sets out the quantum of services to be provided in any financial year by the HSE from the resources allocated to it, is the primary vehicle through which the Minister and her Department monitor and evaluate the performance of the executive against the targets set out in the plan.

Ultimately, the Minister and the Government are politically accountable for all aspects of the health services. The Minister, Deputy Harney, has confirmed this many times. The specific political accountability of the Minister under to the Health Acts is quite clear, and I do not subscribe to the theory that the establishment of the HSE has in some way diluted her political accountability or that of the Government collectively. Senator Alex White mentioned the issue of political accountability and previous suggestions of a democratic deficit in the way the HSE is operated. My experience at local level in Galway is that we have accountability and a democratic input into the operation of the health service. I and other Members of the Oireachtas have regular meetings with our local health manager and we are her eyes and ears on the ground in that we funnel to her the concerns and needs of the people we represent. I do not know whether there is a similar process in other areas but there should be.

The budget for the HSE for 2008 is €14.2 billion, or almost €10,000 for every taxpayer in the country. This amount is more than a quarter of Government current expenditure and is nearly the equivalent of total estimated income tax receipts. Given the sheer scale of this budget, it makes perfect sense that those who have responsibility for managing and delivering services out of the budget should be also accountable for it. Senator Prendergast mentioned in her speech the wisdom of granting real powers to local management and suggested that these bodies should be given real autonomy in running their local health services. A welcome development this year is the assignment by the HSE of budgets, approved employment ceilings and service delivery commitments to named individual budget holders at both hospital and community service levels. These managers are being held accountable throughout 2008 by means of the HSE monthly performance monitoring reporting system. This represents real and tangible accountability and it is being delivered by the Minister.

The HSE was formally established on 1 January 2005 and, some three years later, the current review of its internal organisational structure is timely. The objective of this review is to improve the effectiveness and efficiency of the organisation. The Minister for Health and Children agrees that a properly planned and managed voluntary redundancy scheme could have an important role to play in helping to streamline management within the HSE. This should result in an improvement in the delivery of health services to patients. Such an initiative would mean the numbers involved in senior management should become integrated and streamlined. There will need to be much greater clarity in terms of roles and accountability. Absolute clarity will be also necessary on the staffing requirements of any revised internal organisational structure based on the review I mentioned earlier.

The issue of safety in the delivery of health services lies at the heart of any care system which has the confidence of the people using those services. Although the health sector is one of the most complex areas of activity in any country, it must by its very nature command the confidence of those who use it. Patient safety and quality of service are at the heart of the Minister's agenda. The Health Information and Quality Authority, which was established in May 2007, is responsible for setting and monitoring standards across health institutions and services in the public sector. Its functions also include the undertaking of investigations, the evaluation of the clinical and cost effectiveness of health technologies and the evaluation and setting of standards for information on health services and the health and welfare of the population. There are still some services that are not operating to the highest standards, and errors have been made. However, the new system of checks and balances is working, as demonstrated by HIQA investigations and other service reviews being carried out by the HSE. We must now ensure that we learn from these events by improving the service and maintaining a higher standard.

Earlier this month the Minister for Health and Children launched the national strategy for service user involvement in the Irish health services, which is one of the most exciting and interesting developments in the reform programme. The strategy was developed by her Department in partnership with the HSE and will drive service user involvement in our health services. As a result of this strategy, new primary care teams will work with their patients and local communities to develop models of service provision that will meet their needs. Older people and their families will have the opportunity to speak about the quality of their community care provision. Mental health service users will be able to work with service providers to tailor their health care appropriately to their specific needs. Through this strategy, service user involvement will enable the health services to anticipate problems and avoid complaints and it will guarantee that service users will be at the centre of efforts to drive up the quality and safety of service provision.

The Minister for Health and Children has only had one interest at heart since her appointment to that role, and that is the interest of every patient who accesses our health system. She has taken total responsibility for providing a world class health service. In my short time in this Chamber I have seen no other Minister appear before us so often. I have seen no other Minister with such a command of his or her brief and such a commitment for far-reaching and meaningful reform. She is accountable and committed, and with all our support she will succeed in making that reform happen.

Senator Alan Kelly

I welcome the Minister of State to the House.

I am disappointed that some of the Senators who have been criticising the HSE for the past nine months have not shown themselves in the House today. I would like to hear them repeat some of the comments they made during the year about the HSE.

There is a philosophy in the HSE of budget management rather than demand for services. That is the reality I see every day. It is there in the answers I receive to my questions and in what people tell me. I agree with Senator Alex White, who summed it up better than me when he said that the body should not have the power of answerability over its own budget. It is true. When we ask a question about the health service and hear the phrase, "This is a matter for the HSE" in the reply, the reality is that the HSE is not accountable, despite the efforts of the previous speaker to outline his version of the lines of accountability. It is not accountable in a similar way to any other agency in the State, which, given that we are talking about people's lives and health, is shocking. That is why the second point in our motion states that we want the HSE to be accountable to the Oireachtas. This is an imperative.

While speaking I will dip in and out of various areas, mentioning in particular the area from which I come, the mid west, and specifically north Tipperary. I wish to mention the future of acute hospitals, particularly smaller hospitals. Last week in my area of Nenagh — not to be too parochial about it — two of my colleagues, Deputies Lowry and Hoctor, were falling over themselves, as usual, to announce a new surgical and endoscopy service and a sterile unit in Nenagh hospital. When the HSE gets its act together this will cost €15 million, as there are various components to be put in place. This is fantastic news and it is very welcome. However, it does not in any way suggest that the existence of this hospital and its services will be prolonged. Using it as an example of a small acute hospital — it is one of the smallest although it has a large geographical area — it can be seen that despite the large geographical area and the 15,500 people who use the accident and emergency department, it is constantly under threat.

We have an elderly care unit that is much in demand but is sporadically closed down, despite the fact that it is in the backyard of the Minister of State with responsibility for older people. As everybody in the House is aware because it has received national attention, we have a CT scanner that has been sitting in bubble-wrap for a year and a half while people are ferried to and from Limerick for scans. In addition, the bed capacity is continually being cut. This is the reality of what the HSE has done to small acute hospitals. This hospital is underfunded, like many other small hospitals, despite the small — or minute — increase in funding it received this year. Medical inflation and national inflation are raging. The manager is left in the impossible situation of being forced to sign off on budgets with which he or she is unhappy in order to meet the demands of the HSE which, as I said at the beginning, manages its services based on budget rather than need.

Where are the Teamwork reports and why have they not been published? They were promised in February, March and April, but we are nearing the end of May. I am unsure as to whether they will be published because they are too politically sensitive. The Hanly report recommendations were implemented by stealth and it looks like the Teamwork recommendations will be also implemented by stealth. Many believe we will get what Professor Drumm outlined in a number of public utterances concerning small acute hospitals, namely, he will turn them into day hospitals. He stated that there were too many unsustainable accident and emergency units. If a unit with the geographical basis of my area is unsustainable, the health service has a serious problem.

The ambulance services, a pet subject of mine, sometimes get a raw deal and have been negatively affected by the changes administered by the HSE. In many cases, the work of ambulance crews is so vital that, without them, we would be in serious trouble. Many of those involved work long and unsociable hours and shifts, on which they must double up due to a lack of qualified staff. There are not enough emergency medical technicians or advanced paramedics, a situation affected by last year's embargo. Neither is there enough capacity, but this is due to a lack of ambulances rather than the change to single-bed stretchers in ambulances. The confusing protocols should be addressed.

The concept of primary care is worthy, but it has different meanings to many inside and outside these Chambers. Before we get rid of the old system, we need to bring in the new. We have not even reached the 50:50 point. Several years ago, the budget between acute and community health care was divided 70:30, but that ratio has become 40:60. This is not necessarily good. There are problems in a number of areas. For example, the number of home help hours offered is a joke in some cases and there are long waiting lists for occupational therapy. In my area, some 693 children are awaiting speech and language therapy. I do not believe the staff recruitment issue and the number of years they must work prior to getting their jobs comprise the sole problem. Half of the therapist posts in the north Tipperary-east Limerick area are vacant.

Many point to the success of the NHS in Britain and claim that community driven care can work. We each must consider our own circumstances and there is no such thing as best practice. The glue that holds together acute and community care is the GP service. The difference is that GPs are not under the HSE whereas they are under the NHS in Britain. Hence, the same model will not fit Ireland.

In many ways, some good people in the HSE's management are not treated well and some of the criticism is unworthy. As many of the HSE's managerial positions are temporary, people who make decisions watch their backs. I have an issue with the PR policy of the HSE.

Senator Mary M. White

Does the Senator believe the positions should be permanent?

Senator Alan Kelly

No. There is an inconsistency in that their roles and job specifications are not defined. At a public affairs level, the management and corporate policy of the HSE is the worst of any public body. This is not good enough from an information point of view because we are entitled to better. As evidenced in this week's "Prime Time Investigates" programme and as has been stated by Senators during the past six to nine months, the numerous examples of information flowing from the corporate level of the HSE and the aggressive attitude it and its PR department have assumed in response to simple questions are unacceptable.

Senator Ivor Callely

I wish to share time with Senators de Búrca and O'Malley.

An Leas-Chathaoirleach

Is that agreed? Agreed. The Senators have eight minutes in total.

Senator Ivor Callely

Will the Leas-Chathaoirleach inform me when two minutes have expired?

An Leas-Chathaoirleach

Yes.

Senator Phil Prendergast

The Senator's time is up.

Senator Ivor Callely

I am happy to participate in this debate. I noted the Labour Party's motion and listened with interest to its Members' contributions. I support a number of the points made, as they were fair, legitimate and realistic in so far as we have experienced many of the situations outlined. I also noted the countermotion.

I have the height of respect and regard for those who work in the health services. I commenced my career in wholesale pharmaceuticals and dealt with pharmacies, doctors and hospitals. Due to my interests, I became a member of a health board after first being elected as a councillor and worked with the various systems and structures. Later, I worked in the Department of Health and Children. I welcome some of that Department's officials to the House. I worked well with them and it is welcome that they are continuing their good efforts. I am one of the few people who have been in everything from the back of the shop to the front. My family is involved in the pharmaceutical business. I have worked at the front door, the back door and every other door of the hospital system and I have worked with management and health board structures.

There are benefits and problems and we could do better than we have done, but the solution is probably not to be found in either the motion or the proposed amendment. When the health board system worked, it worked well. I was approached about whether I would participate in changing the health board structure in the greater Dublin area to allow a regional authority to come into being. My colleagues and I, rather than a single Minister, considered the proposals on structural change. One of the Minister of State's officials could pencil a note correcting me if I am wrong, but I believe the Minister of the day was the current Leas-Cheann Comhairle, Deputy Howlin, of the Labour Party. Other Ministers, including Deputies Noonan and Martin, were involved.

Some of the structures put in place in the greater Dublin area worked. For example, shared services proved significantly beneficial. The health boards' muscle allowed them to do a great deal to improve services in certain respects, such as administration and purchasing. The boards were able to use the purchasing power or muscle of those involved to implement a wage system or to make purchases. We brought together the voluntary, statutory and charitable sectors, a considerable and unprecedented breakthrough.

The HSE is too great a step. The Minister referred to 11 health boards, but I believe that we had 14. We went from 14 to one, a step too far. I ask that Senators not tango over this issue and that we achieve a unity of purpose to try to find the right model.

We should not do so on a Twenty-six Counties basis. We achieved success in the greater Dublin area by finding a model that worked. Everybody agrees there must be change. As I said, I have not dealt with the specifics of the motion or the amendment.

My time is up but I hope to have another opportunity to engage in a thorough debate on this issue.

Senator Déirdre de Búrca

As I was not aware I was sharing time, I will have to pare back what I intended to say. It is difficult to make a meaningful contribution to a debate on the health services in four minutes. However, I will do my best.

I welcome the opportunity to debate the Labour Party's motion. It is a welcome motion because it reflects most aspects of the public's concern about the Health Service Executive. Rather than merely expressing those concerns, the Labour Party has offered a series of constructive proposals for reforming the HSE. However, I also take on board the point made by the Minister for Health and Children, Deputy Harney, regarding the changes and improvements that have been achieved in the health service. The HSE has been in existence for only three years and many of the improvements that have taken place are not recognised by the media. Negative headlines always make better stories. Many of the new statutory reporting requirements have enhanced the perception that there is only bad news and problems in the system. That tends to distort the picture.

The truth is somewhere in between. The process of reform is beginning to take effect. However, many of the concerns raised by Senators in this debate are valid. The greatest problem with the HSE is the lack of accountability. It is difficult to identify individuals within the organisation who are responsible for different aspects of its functioning. The task of bringing more coherence to the HSE is probably the greatest challenge facing the Minister. The establishment of the executive involved the merging of all the previous health boards. In such cases, it always takes some years before there is a sense of coherence and orientation.

New structures will have to be put in place. I use the example of the national cancer control programme as a model of the type of coherence that can be brought to bear if a particular service is delivered with the right type of clinical governance and leadership. Professor Tom Keane, who recently briefed members of my party on the national cancer control programme, strikes me as a good example of an identifiable person heading up the process of change within a defined area of the health service. He has both clinical expertise and experience in change management. He is bringing to bear that experience in putting in place the right structures.

Regional specialist centres are recognised as the most appropriate way to deliver some of our cancer services. One of Professor Keane's greatest criticisms of our existing cancer services is the emphasis on hospital and inpatient care.

Senator Jerry Buttimer

The problem is the shortage of beds.

Senator Déirdre de Búrca

His vision for the future delivery of cancer services involves a greater reliance on ambulatory and community based services, along with specialist centres. That is the type of model we should look to for the HSE generally. Over time, we can expect to be able to point to discrete areas of the health service with clear figureheads.

The Leas-Chathaoirleach has indicated that I have used up my four minutes. I did not think I had.

Senator Jerry Buttimer

Senator de Búrca is on eco-friendly time now.

Senator Liam Twomey

We are keeping a close eye on her carbon footprint.

Senator Déirdre de Búrca

I was only getting started. I regret that I do not have sufficient time to make all the points I hoped to make. While I welcome the Labour Party motion, I also acknowledge the many positive developments that were highlighted by the Minister.

Senator Liam Twomey

I propose to share time with Senator Buttimer.

An Leas-Chathaoirleach

Is that agreed? Agreed.

Senator Liam Twomey

The problem with these types of debates is that Government Members have to support the Minister no matter what happens and regardless of the chaos in our health services. The road to ruin is paved with good intentions. That adage is appropriate when one considers some of the developments arising from the establishment of the Health Service Executive. I do not blame the Minister, Deputy Harney, for most of these problems. It was her predecessor, the current Minister for Foreign Affairs, Deputy Martin, who is responsible for the mess in which we find ourselves.

The setting up of the HSE was a rush job from the beginning. Most of those responsible for that process were concerned it was happening too quickly. However, the then Minister, Deputy Martin, wanted the executive to be up and running on 1 January 2005 for the purposes of public relations spin, knowing he would be well gone from that office when the true extent of the mess became apparent. It is interesting that when people were being recruited to head up the directorates within the HSE, nobody in the private sector in this State — which boasted, at the time, the most successful economy in the world — was considered adequate to run any part of the HSE. All of those who secured senior positions were previously employed in the former health boards. Within 12 months, however, half of them had either resigned from their roles or were moved because they were found to be incompetent.

The management structure of the HSE, as announced on 1 January 2005, had been already amended by 1 June 2006. By 1 June 2007, the structure was being amended again in line with the original formation as at 1 January 2005. I do not know what the situation is now. This constant state of flux is causing problems for staff further down the line, including those in local and middle management who do not know to whom they should report. That sense of incompetence at the senior level of the reform process means that problems with the delivery of services are inevitable. No matter how good the staff in middle management and in clerical and front-line roles, these problems lead to inefficiencies and wastage of resources. That is what this motion is about. The management structure of the HSE must be changed in order that the organisation can work efficiently.

The Minister, Deputy Harney, has given inadequate policy direction. She made reference to Dr. Donal Hollywood in connection with the cancer strategy report that she claims will lead to great improvements for patients. Dr. Hollywood produced a report on radiotherapy services to which the Minister reacted badly when it pointed out the mistakes that were made. However, perhaps she was big enough at least to acknowledge that she was not as wise about radiotherapy services as she should have been and that it was a mistake to wait five years before changing policy in this area.

The Minister is now saying we must restrict the number of facilities offering cancer care services. At the same time, however, the Government is offering tax breaks to small operators for the purposes of setting up small clinics at any location throughout the State to provide the types of services we were told should be provided only in centres of excellence.

I regret I do not have sufficient time to make all the points I wish to make. Will the Minister of State, Deputy Barry Andrews, ask the Minister, Deputy Harney, what has become of the Tribal Secta report which was published in January 2006? Where are all the great improvements we were told would flow from that report?

Senator Jerry Buttimer

I commend my Labour Party colleagues on tabling this timely motion. Members may be familiar with the film, "There's Something about Mary". There is certainly something about the Government's health policy. Government Members speak ad nauseam in this House about the failings of local hospitals and other aspects of the health service. There is a lack of political courage. We get fine rhetoric and empty talk but no political testosterone. I encourage Government Members to abandon their idle chit chat on the Government benches and to join us in voting with their conscience. They should vote for the people of Ireland. Patients are not consumers or statistics but people.

At a time of economic challenge, with €16 billion per annum being spent on health in the past ten years, people's health is being jeopardised because of the deficiencies in services delivered by the monolithic organisation that is the HSE. I do not blame the Minister, Deputy Harney, bur rather her colleagues at the Cabinet table. Fianna Fáil, the Progressive Democrats and the Green Party have abdicated responsibility. A quarter of all Government expenditure goes on health but we are not getting value for money or efficient delivery of services. There are grave implications in this for our aging population.

The Government amendment is one of the weakest I have seen in this House. What is the Government's fundamental objective for the health service? What is its overarching philosophy? Is it about care and service? It is not; it is about the core Fianna Fáil-Progressive Democrats slogan of privatisation and co-location. I challenge Senator de Búrca, the Green Party and Senator Callely, who are not members of this privatisation gang, to vote against the Government. They should vote for the people and the patients.

We need accountability. I agree the old health board system did not work properly but there was accountability. The new regional health fora are a joke. The Minister of State, Deputy Barry Andrews, should go back to the Minister and to the Department and urge that the regional health fora be given teeth to deal with issues. Currently, they have none. Management is playing ducks and drakes with the councillors, who have no power to question, interrogate and get answers. Reform in that regard is necessary.

There also must be accountability on the part of top and middle management of the HSE. Last week, Deputy James Reilly spoke in the Dáil about delivery of health services and the management of the health service. The legacy of this Government and the policy it supports is closure of local hospitals, growing waiting lists for operations, a freeze on recruitment, reductions in the number of home helps and care packages and the debacle in the children's hospital in Crumlin, where 120 staff are to be let go because of bad management. What does that say to the children and patients in this country? This Government does not care and shields itself with the HSE. Shame on it. It is not dealing with consumers or figures on a page but with people who deserve dignity and care, which they are not getting from this Government.

Senator Fiona O’Malley

It is a great pleasure to welcome the Minister of State, Deputy Barry Andrews. I wish to share time with Senator Mary White.

An Leas-Chathaoirleach

Is that agreed? Agreed.

Senator Fiona O’Malley

I am pleased the Labour Party has put down this motion. What is important about it, and the Minister alluded to this earlier, is that it puts forward solutions for debate. It is regrettable that other business has prevented Senator Alex White being present for the full debate. We need to focus on solutions. All Members are concerned about the care administered to the patient, regardless of our political ideologies. None of us could accuse another Member of not having the care of the patient at the heart of the policy initiatives they espouse.

Senators Alex White and Kelly questioned whether it was right that Professor Drumm be the Accounting Officer for the executive. Like the Minister, I consider it vital that this be the case, when one is making the choices and decisions. The policy is decided in the Department but when one is making the choices on its delivery one must have responsibility to ensure that if savings are being made in one area, good practice can be provided in another. I hate to sound like a broken record but I consider the Minister, Deputy Mary Harney, an inspiration. Her most admirable trait is that she never loses focus. Yes, it is a difficult job, particularly when it involves life and death issues in people's lives, but she remains focused on the task. That is highly commendable.

Like Senator Feeney, I heard Professor Anthony Staines on the radio during the week. I listened to the programme again this afternoon on the Internet and it is particularly good. Professor Staines runs the health system research in DCU and I hope Professor Drumm and the Minister are familiar with him. In the interview he said that systems are not really important, nor is changing the system we have at present, particularly if it involves turning round a process of reform mid-stream. The Minister is utterly convinced she has turned a corner with the reform, and it is important that we see results on that front. What is the point in changing the system? As Professor Staines said, it may not be the perfect system but it is the system we operate. What is important is how services are delivered, how medical personnel, such as doctors, nurses, physiotherapists and so forth, operate within the system and the latitude and capacity they are given, and take themselves in terms of initiatives, to deliver better patient care.

What the Minister told us about neurology services is important. We should reflect on it. As the Taoiseach said this morning in response to the Labour Party Leader, it is all very well for the Opposition to be exclusively concerned about the patient without reference to a budget. I disagree with the point that the HSE is driven purely by budgetary concerns. That is not the case. It seeks to provide best delivery of patient care but it must operate within a budget. In neurology services it was able to double outcomes with no extra money, purely through a change in work practices. That is something we should consider. Staff morale is a problem but we need to examine where this works and how it can be replicated in other areas.

Senator Mary M. White

I agree with Senator O'Malley that the Minister, Deputy Mary Harney, is an inspiration as a leader in the evolution of the health service into the 21st century. She is the most focused person I have ever encountered. In the six years I have been a Member I have seen and heard her perform. She has the most extraordinary focus and all of us can learn from her.

I do not agree with the Opposition's criticism of Professor Drumm and the Minister, Deputy Harney. It is absolutely puerile and infantile. The organisation was only established a short time ago. The Minister and Professor Drumm are brave people. Two people were considered ahead of Professor Drumm and they would not take the job. Professor Keane told us today that he was asked to take up the job. People are not rushing to take up these positions.

Senator Jerry Buttimer

No Fianna Fáil Deputy would take the ministry.

Senator Mary M. White

I believe people are too hasty in criticising the organisation. The Minister said she would like to see the HSE develop in the same way the economy developed into the Celtic tiger. For 30 years the IDA spearheaded economic development by encouraging inward investment in Ireland. It was a major architect in the development of the Celtic tiger. If the HSE is left alone, Professor Drumm has the courage and understanding, having been a professor in Crumlin children's hospital, to change the culture in the health sector.

An Leas-Chathaoirleach

The Senator has one minute left.

Senator Mary M. White

There are negatives. I believe we got our economy right but we seriously neglected the health service. I watched the "Prime Time" programme last Monday night. The way the young child with diabetes had been treated was reflective of a Third World country. As I have always said, I do not agree with a two tier service of public and private health care. I do not agree with putting a public hospital and a private hospital side by side and I do not understand——

Senator Paudie Coffey

So the Senator will vote for the motion.

Senator Mary M. White

I will not vote for it. The Senator can forget about that.

Senator Jerry Buttimer

The Senator is for co-location.

Senator Maurice Cummins

The Senator is talking out of both sides of her mouth.

Senator Mary M. White

I do not care what the Senators say. I would be fired.

Senator Jerry Buttimer

You cannot back two horses.

An Leas-Chathaoirleach

Senator White without interruption. The Senator has only half a minute left.

Senator Jerry Buttimer

She must pick one horse or the other.

Senator Mary M. White

I do not agree with co-location.

Senator Maurice Cummins

Stand in the middle of the road and you will be knocked down from both sides.

Senator Mary M. White

I said in the House last week that I visited Crumlin hospital for the first time in my life a month ago. Given the neglect I witnessed, I cannot believe that the hospital was not rebuilt 30 years ago.

Senator Jerry Buttimer

It is like watching "The Waltons".

Senator Mary M. White

I would like to hear from the Minister for Health and Children if it is carved in stone that the proposed national children's hospital will be built in Dublin city centre, which would, I believe, be wrong. There is no breathing space and no parks available.

Senator David Norris

Hear, hear.

Senator Mary M. White

The idea of the metro bringing people in and out makes no sense. Who uses the metro to go to hospital?

Senator Jerry Buttimer

Hear, hear.

Senator Mary M. White

Everybody uses cars and people want to go where parking is available——

Senator Jerry Buttimer

Try waiting for the metro while in labour.

Senator Mary M. White

——and where it is possible to take walks around the grounds. I would like to hear more from the Minister on this matter. The problems result from the neglect of the health service since the foundation of the State.

Senator Jerry Buttimer

What about the Celtic tiger years?

Senator David Norris

It is a measure of the great interest and the seriousness with which Seanad Éireann takes this matter that there are so many people wishing to speak and so many have requested to share time. I am one of them and I wish to share time with Senator Pearse Doherty.

An Leas-Chathaoirleach

The Senator has just less than eight minutes.

Senator David Norris

Senator Doherty said that two minutes would be enough.

Senator Jerry Buttimer

That would be generous.

Senator David Norris

I am not going to argue, because I wish to get on with this and if I am finished early the Senator can make use of the time.

An Leas-Chathaoirleach

Is that agreed? Agreed.

Senator David Norris

Given the degree of interest in this matter it is a pity there is not a supplied script from the Minister of State at the Department of Health and Children, Deputy Barry Andrews, which I would have welcomed. It would have been helpful to those of us who, because of pressure from other sources, were not able to be here to hear the Minister of State's speech. I am sure there was no disrespect intended, but I hope it will not happen again as we are entitled to a ministerial script in such a serious debate.

I fully support universal health care provided by the State. I know that the concomitant of that is increases in taxation and I would be happy to campaign for that, because it is the most basic human right.

Senator Mary M. White

Hear, hear.

Senator David Norris

I do not like the public versus private model. It was appalling that the woman in County Kilkenny was sentenced to death for the crime of being poor, which I have said before. That is my principled stand. I find there are elements with which I agree on both sides of the debate. For example, regarding step No. 4 in the motion, I agree with most of what the Labour Party put down, but I do not agree that each hospital and each community care area should be given autonomy to spend its budget. That is madness and will lead to NIMBY syndrome. Everyone will want their own hospital and I do not believe it will work in that way. We must have centralised control.

There are concerns, however. I listened to a very distinguished professor on the radio and he said that he could have been an adviser and made money out of continually advising on re-organisation of the service. However, he went on to say, continual re-organisation would involve throwing money at it all the time, but there would be no increase in service delivery and we must face the existing problems. That is the reason, I believe, step No. 2 in the Labour Party motion, namely, making it clear that the Minister for Health and Children is responsible to the Oireachtas and appointing a named officer which may be the Secretary General or may be Professor Brendan Drumm, is a way forward that is useful. I do not believe the proposal is answered by the bland waffle with which the Government responds. The Government has said these officials are already responsible which is not an answer to a direct and specific question. That is what is wrong and it is the reason I will vote with the Opposition.

There are so many problems. I had a woman who campaigned for specific medical treatment to be made available. That was agreed. Managers were appointed and, at that stage, the Civil Service recruitment freeze was imposed. There was no medical staff, no delivery of services and the HSE is left with the managers and is still paying them. That is the reason step No. 3 of the Labour Party motion proposing an offer of voluntary early retirement, redundancy and re-deployment scheme is vital to progress. However, it must be focused, cut out the flab and get rid of surplus people. There is no point getting rid of the people who deliver the service. We must go further in our efforts, focus on change and make clear where it should be.

Regarding step No. 6 which says that each hospital and community care area should be required to establish a patient liaison programme and so on, it quotes a specific case which is one of the problems. We all find these heart-wrenching individual cases. However, I do not believe we should endlessly regurgitate them.

Senator Mary M. White

Hear, hear.

Senator David Norris

The Minister for Health and Children cannot be made responsible for each individual case. The greatest political friend I ever had in my life was Mr. Noel Browne and I salute him, because he single-handedly broke through the curse of tuberculosis. He broke the piggy-bank of the sweepstakes and established hospitals everywhere. If Mr. Noel Browne was in this House or the other House demanding that we respond to every individual case it would have impeded delivery of the programme. This is the reason we must avoid the Joe Duffy radio programme route. We betray ourselves as politicians when we do take it.

We can all agree, however, that we have all been touched by the hospice movement. It is unparalleled in the humane treatment of people who are terminally ill. Yet, we have a situation which is ludicrous, where there is a budget allocation made for a hospice, for its development and to continue its work and then at the end of the year, it finds it has not been given the money to spend. The money has been re-allocated to make up a deficit in another area. This is wrong and we must be focused and prioritise. We must stop messing around and playing politics with this issue. We must take seriously our responsibility to the citizens of Ireland and deliver a decent health service. Given a choice between the two sides, on balance, having previously supported the Minister for Health and Children, who is courageous even when she is wrong — I do not know whether she has testosterone and I am not a sexual expert on this matter, she may or may not have — I will vote with the Opposition tonight.

Senator Pearse Doherty

Gabhaim buíochas leis an Seanadóir Norris as ucht a chuid ama a roinnt liom. Táim ag tacú leis an rún atá molta ag Páirtí an Lucht Oibre. Glacaim leis go bhfuil fadhbanna leis na seirbhísí sláinte agus nach bhfuil siad ag obair mar is ceart. Caithimid díriú ar na fáthanna nach bhfuil siad ag obair mar is ceart.

It is not enough to say that the HSE is overly bureaucratic, was established in haste and completely lacks democratic accountability. All of that is true and must be addressed. However, the problem is more fundamental. The problem is Government health policy, which is based on the retention of our two-tier, public-private, apartheid health system. This is the core problem. The problem is the Government's failure to deliver on primary care, making us over-reliant on our over-stretched hospitals. The problem is the lack of commitment on the part of Government to putting patients first and to treating patients on the basis of need and need alone. It puts book-keeping before life-saving, as we see in the current cutbacks being imposed by the HSE at the behest of the Government. We all know these cuts are having a significant effect. Today we learned of staff lay-offs in Our Lady's Children's Hospital, Crumlin. There is no doubt that sick children will suffer if that is allowed to go ahead.

I will give as an example an individual case, even though Senator Norris gave me the time and he does not like citing individual cases. However, it lends a human side to the story. It is important to note, as other Senators have said, that these are not statistics, they are real people. Today, the office of my colleague, Deputy Caoimhghín Ó Caoláin, was contacted by the family of a 70 year old man who had to attend Our Lady of Lourdes Hospital in Drogheda yesterday for an X-ray on his arm which was broken some weeks ago. He had to wait eight hours for the X-ray. He could not gain access to the toilet because of long queues and could not help urinating as he sat in the chair in the overcrowded accident and emergency department.

Senator Jerry Buttimer

It is scandalous.

Senator Pearse Doherty

That man is frail with lung and other health problems. I ask every Government Senator who is thinking of voting on this motion to consider if this was his or her father or mother. This is not a direct result of the work of the Minister, Deputy Mary Harney, or Professor Brendan Drumm, but the system failed that man.

Senator Mary M. White

It is not as simple as that.

Senator Pearse Doherty

It is, because unfortunately——

An Leas-Chathaoirleach

I ask the Senator to conclude.

Senator Pearse Doherty

Unfortunately, we all know of such cases and it is not right to put one case above another. We all know of the injustices and indignities that people face at the hands of the two-tier health system. This needs to be addressed and we need the political will to do so, which is not present on the Government side of the House.

Senator Phil Prendergast

In the interest of not interrupting Senator Feeney earlier I remained quiet when she remarked that she felt there was a criticism of HSE staff implied in the motion. I worked for 23 years as a midwife and nurse in the health services. My husband has given 30 years of service. On the basis that, as a couple, we have given between us 53 years of service I can speak with some degree of authority on the HSE and the way it functions. At no time did I imply the staff of the HSE were not working to the best of their abilities. Every day and night of the year, regardless of whether it is Christmas night, Easter or any other holiday, that service is provided by nurses, clerical officers and other staff who give out the cups of tea and clean the hospital wards. I have the highest regard for the way those frontline staff deliver services. I appreciate that the Minister feels put out by what she describes as constant criticism, but programmes such as "Prime Time" do not manufacture evidence.

The stories I have heard from Senator Doherty and others and the support I received from the opposite side of the House gives me a glimmer of hope that we will get support for this motion, although I am aware the Government side will in reality vote against these proposals. By offering solutions to some of the deficiencies in the health service, we might achieve a positive result. I have respect for the Minister, who does her best, but I am critical of a system which was established to replace 11 health boards but is not coping or delivering meaningful interventions. It was claimed that the reduction of waiting times to 12 hours is an improvement on what existed ten years ago, but the system has not improved if a patient cannot access a toilet or if the condition of a person suffering diabetes is exacerbated.

Tonight Crumlin hospital is short of 24 neonatal nurses and a further 120 jobs may have to go in this tertiary referral centre. Difficult decisions will have to be made on where the service will be cut. Will the jobs be taken from the neonatal unit, child oncology services or education support roles? I have been in that situation and I know it is not easy but we have put forward our proposals in the hope of introducing a degree of accountability and making a positive intervention.

I am not here to criticise the Government because I want to think we can work together. I am heartened that several Government Senators supported me tonight, including Senators O'Malley, de Búrca and Callely. I hope that support will continue when the House votes on this motion. I thank the Minister of State for attending tonight and my colleagues on this side of the House for their contributions and support.

Question put: "That the amendment be made".

The Seanad divided: Tá, 26; Níl, 22.

Tá

• Boyle, Dan.
• Butler, Larry.
• Callely, Ivor.
• Cannon, Ciaran.
• Carty, John.
• Cassidy, Donie.
• Corrigan, Maria.
• Daly, Mark.
• de Búrca, Déirdre.
• Ellis, John.
• Feeney, Geraldine.
• Glynn, Camillus.
• Hanafin, John.
• Keaveney, Cecilia.
• Leyden, Terry.
• MacSharry, Marc.
• McDonald, Lisa.
• Ó Murchú, Labhrás.
• O’Brien, Francis.
• O’Malley, Fiona.
• O’Sullivan, Ned.
• Ormonde, Ann.
• Phelan, Kieran.
• Walsh, Jim.
• White, Mary M.
• Wilson, Diarmuid.

Níl

• Bradford, Paul.
• Burke, Paddy.
• Buttimer, Jerry.
• Coffey, Paudie.
• Coghlan, Paul.
• Cummins, Maurice.
• Doherty, Pearse.
• Donohoe, Paschal.
• Fitzgerald, Frances.
• Healy Eames, Fidelma.
• Kelly, Alan.
• McCarthy, Michael.
• McFadden, Nicky.
• Norris, David.
• O’Reilly, Joe.
• O’Toole, Joe.
• Phelan, John Paul.
• Prendergast, Phil.
• Ross, Shane.
• Ryan, Brendan.
• Twomey, Liam.
• White, Alex.

Tellers: Tá, Senators Déirdre de Búrca and Diarmuid Wilson; Níl, Senators Alan Kelly and Alex White.

Question declared carried.

Motion, as amended, put and declared carried.

An Cathaoirleach

When is it proposed to sit again?

Senator Donie Cassidy

Ag 10.30 maidin amarách.