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Seanad Éireann debate -
Wednesday, 7 Nov 2018

Vol. 261 No. 2

Health Service Executive (Governance) Bill 2018: Report and Final Stages

Before we commence, I remind the House that a Senator may speak only once on Report Stage, except the proposer of an amendment who may reply to discussion on the amendment. Each amendment on Report Stage must be seconded.

Bill recommitted in respect of amendment No. 1.
Government amendment No. 1:
In page 7, to delete line 17 and substitute “(c) 8 ordinary members.”

For the information of Members, by agreeing to the motion to recommit the House allows a Committee Stage-style discussion on the amendments only. In other words, Members may speak more than once on each amendment. Amendments Nos. 1, 6 and 14 to 16, inclusive, are related and may be discussed together by agreement.

I propose to speak on amendments Nos. 1, 6 and 14 to 16, inclusive, as they are concerned with increasing the size of the new HSE board and with related consequential amendments. The Committee on the Future of Healthcare concluded that an independent board for the HSE needs to be put in place in order to strengthen and improve governance, leadership and accountability within the organisation. This Bill translates that policy directly into legislation.

As the House will be aware, a chairperson-designate, Mr. Ciarán Devane, of the board has been selected and the Public Appointments Service is currently undertaking a process to identify other potential board members. The board will help to drive accountability and transformation. I cannot underline more strongly how important it is to get the right calibre of people with the appropriate mix of experience to serve as members of the board. Given the nature of the role, the associated time commitment envisaged and the range and breadth of competencies required, the Minister for Health has carefully considered the overall size of the HSE board. He has taken into account the fact that the HSE is our biggest State agency, with a budget of €17 billion in 2019, and a significant workforce. An agency of this size generates a huge volume of work - often complex - for its governing body. As a result, it is important to ensure that the board is of an appropriate size, with overlapping skills and competencies, and that collective decision-making is supported and strengthened.

The Bill, as published, provides for a nine-person board. With these amendments, the Minister proposes to increase the overall size of the HSE board from nine members to ten. Amendment No. 1 increases the number of ordinary members from seven to eight. The other two board members are the chairperson and the deputy chairperson. The other amendments are consequential and relate to the quorum for meetings moving from four members to five and to the minimum number of board members required to call a meeting moving from five members to six.

I hope Senators will support these amendments and acknowledge that it is not just about the important work that this new ten-member HSE board must undertake, it is also about reiterating our commitment as public representatives to supporting the new board in its work.

I agree with and welcome the proposed amendments. I had the privilege of sitting on a State board, the board of the Port of Cork, as the nominee from Cork City Council for ten years. The board had great responsibility at the time. The Minister is right. This board will have a budget of €17 billion in real terms. It is important that we get the right people in there and that they are able to do the job of managing. We must remember that over 111,000 people work in the HSE between the hospitals and all of the support services that are provided by the health service. It is important that not only do we have a very good chairperson and deputy chairperson, but that we also have very good board members who can manage and help to roll out a very competent health service into the future. I welcome the proposed changes.

I, too, welcome the proposed changes. I am glad that the Minister was here for the Second Stage debate. He took on board the suggestion of having two members as patient advocates. I thank Senator Ruane for tabling an amendment to the same end. It is important that suggestions that arise during Second Stage debates are taken on board. In fairness, I have noticed that, in this and the Lower House, Ministers take on board positive suggestions.

Amendment agreed to.
Bill reported with amendment.
Government amendment No. 2:
In page 7, line 18, to delete “(2) The chairperson,” and substitute “(2)(a) Subject to paragraph (b), the chairperson,”.

Amendments Nos. 2 to 5, inclusive, and 7 to 12, are related and may be discussed together by agreement. Amendment No. 4 is a logical alternative to No. 3.

Again, I thank colleagues for their comments. I appreciate their support. The Minister, Deputy Harris, specifically asked me to start by thanking all of the Senators for giving him the time to reflect on this important issue and to bring forward these amendments in order to ensure that at least two members of the new HSE board will have experience and expertise in advocacy in the context of matters affecting patients. From the outset, he has clearly stated the Government's commitment to implementing the recommendations of the Scally scoping inquiry in full.

On behalf of the Government, I thank Dr. Scally for such a careful, compassionate and considered report. In his report, Dr. Scally asks the Minister to consider seriously the appointment of two patient advocates to the proposed new board for the HSE. This is what the Minister has done.

The Public Appointments Service has a robust process for the selection of candidates for membership of the new HSE board. This process will see candidates being appointed to the board based on the skills and experience they bring to the board and their ability to engage in collective complex decision-making. From the outset, patient advocacy was identified as a core skill and expertise needed in board members. It was always the intention of the Minister for Health to ensure that this experience and expertise would be found in the board. However, he has listened carefully to the concerns expressed in previous debates and believes that we should meet Dr. Scally's recommendation by amending the Bill and providing for a requirement for all future Ministers for Health to ensure that there is patient advocacy experience and expertise on the board of the HSE. On his behalf, I am proposing to amend the Bill to provide that at least two members of the HSE board have patient advocacy experience or expertise. This is done in amendment No. 3.

The other amendments are consequential. Amendment No. 7 relates to the term of office of the members of the first board and is intended to ensure there are always members with advocacy experience or expertise on the board. The remaining amendments in this group are technical drafting amendments. I hope the Senators can support them.

The Government's amendment arises on foot of the amendment I tabled - on the basis of the Scally report - on Committee Stage. I thank the Minister and his officials for taking on board the essence of the debate on Committee Stage. I wish to make a few observations. Obviously, I will accept the amendment and not press mine. However, it is important to put on record what a patient advocate is and should look like. It is not something additional but the priority of the role. I have had some conversations over recent days with the Irish Platform for Patient Organisations, Science and Industry, IPPOSI, and the organisations under it that do a great deal of work on patient advocacy. They have been in contact with the Department so, hopefully, some of their recommendations can be taken on board.

I will outline some of their concerns and some of the values and roles they believe a patient advocate should have. They say in their communication that the text of the vacancy notice would preclude many patient advocates from applying. Candidates should have a career history at a sufficiently senior level in a complex organisation of scale or equivalent experience, board level experience, a proven track record of organisational management and organisational improvement, experience in transformational change and reconfiguration in complex environments and a track record in implementing major system wide reform. They feel it is unlikely that patients, their families, carers or their representatives who have been involved in patient advocacy would be able to apply under the high-level criteria in the vacancy notice. Perhaps with regard to the two patient advocates we should consider broadening some of those terms so we truly get to the essence of what a patient advocacy role would look like.

The text of the proposed amendment referring to the opinion of the Minister concerns them. They indicate that recruitment for State boards that is ongoing could be directed, overridden or vetoed by a ministerial appointment because in the Minister's opinion the person has worked in different sectors for a long time, perhaps has been involved with the HSE and has somehow displayed patient advocacy throughout that time, even though it has not necessarily been a central part of the person's profession. They are worried about what the phrase "in the opinion of the Minister" means. The Ministers of the day change and so do opinions, so it is important to come to an understanding of what a patient advocate is so the opinion does not change from Minister to Minister and we end up with something that does not resemble a patient advocate at all. Given the context they believe that of the eight members due to be recruited from the applications following the recent vacancy notice two positions should be reserved for genuine patient advocates so the patient's voice can be heard meaningfully at the board. In identifying these two individuals, real patient advocacy experience should be prioritised over the vacancy notice requirements which call for senior management board level experience, organisational change record and so forth.

I will outline the values the group believes should be central to the role. As a patient umbrella group, it believes that public and, more particularly, patient confidence in the HSE is of paramount importance. It maintains that patients are priority partners and that trust is best achieved through working together in partnership. In the group's experience meaningful patient partnerships should be initiated as early as possible in the design stage of the proposed initiative, and in this regard it has reached out to the Department on these matters. Its members believe that one of the primary functions of the HSE board should be to promote the development of a more patient centric health service and that current HSE patient involvement mechanisms are not fit for purpose. They must be replaced by a modern, representative and active patient involvement infrastructure. The group believes the board should be tasked to oversee the development and implementation of a national patient involvement policy and that the policy should call on national directors, clinical leads, regional directors, hospital group CEOs and community healthcare organisation chief officers to strengthen patient involvement across the HSE at all levels.

Some of the issues the group has identified regarding patient advocates relate to the shared purpose. It says the HSE should facilitate discussions between stakeholders to identify each other's values, expectations and objectives and to identify how patient advocates can influence the direction of the HSE. The group refers to respect and accessibility. It recognises that the patient advocate role often can be difficult and a lone voice among professionals. It asks that all board members, particularly the chairman, receive training on patient centricity so all members can act as patient advocates in the broadest sense of the term. With regard to representativeness and diversity, the group underlines that patient advocates at the oversight level must be able to speak on behalf of the broader patient community, rather than from their condition-specific perspective. It recommends that patient advocates have extensive personal or professional experience of representing, communicating for and defending Irish patients. In the interests of giving a voice to patients who are seldom heard in healthcare prioritisation the group feels that consideration must also be given to the gender, age, ethnicity and socioeconomic background of patient advocates. Regarding the responsibility of that role, the group maintains that the patient advocate role on the HSE board must have clearly agreed and, ideally, co-created responsibilities which will be established upfront and in writing and will be revisited regularly.

On the capacity and capability for engagement, the group believes that the level of knowledge and resources that patient advocates have access to as part of their role will determine the meaningfulness of the engagement. The IPPOSI is happy to offer its extensive experience in this area to help build the capacity of new patient advocates. It also supports the fair remuneration of patient advocates for time and expenses. On transparency, communication and documentation, the IPPOSI recommends that steps be taken to open the HSE board meetings to the public. It suggests that, at a minimum, meeting schedules, agendas, minutes and accompanying documents should be published in a clear and timely manner on an easily accessible section of the HSE website.

In the context of continuity and sustainability, the group states that at least two advocates should be appointed to the role, as will be the case. In addition, alternative patient advocates must be identified to ensure representation during times of absence or illness. It correctly points out that where a vacancy arises due to personal circumstances or death it should always be filled within three months so the patient advocate role is consistent and sustained and has continuity.

I felt it was important because our latest discussion on Committee Stage was on what a patient advocate looks like, what their role should be and what the essence of their responsibilities are in order that it is not caught up in the higher level running of the board and that it is truly representative of patients. It was important to put some of these points on the record as these are the organisations that are working on building the capacity of patient advocates. I am happy to resend any of that information on to the Department.

I thank Senator Ruane and will allow other Senators to come in now before I bring the Minister of State back in. I call Senator Burke.

I remind Members that we are dealing with amendments Nos. 2 to 5, and 7 to 12, inclusive.

I agree with my colleague on the importance of patient advocates. It is also important to realise that this board will manage a budget of €17 billion. Many of these boards often rely greatly on advice from management, particularly from the chief executive. A board member needs to have the capacity to challenge and to make sure that the information that he or she is getting from the management team is correct and accurate. It is important that people have those skills.

Some of those decisions can be difficult because if one decides to progress one area, one might have to make a decision not to progress another area. It is important that one has people who have the skills to help everyone to work together. One of the problems that we currently have with the HSE is that everyone is defending their own part of the system and people are not working together. Whoever we put on a board should be able to work with, and challenge, management to ensure the correct decisions are being made.

While I have no difficulty in holding certain aspects of meetings in public, I am concerned about having all meetings in public, in particular, when decisions are being made that may not be what the public may want to hear. When one is managing a system like this, difficult decisions have to be made that people will not like. They have to be made, however, in the best interests of developing the proper and best level of healthcare that can be provided in this country. I am not satisfied.

We have reached a budget of €17 billion, which has increased substantially over the past three to four years. I stated this morning on the radio that we have an extra 12,000 people working now in the HSE compared with December 2014. That is greater than the entire workforce of the Army, but I am not clear that there was an overarching strategy by the HSE over the past four years regarding the key areas to deploy people.

A board, likewise, will have to make policy decision on the areas that need to be prioritised when bringing in new skills and how to help to co-ordinate management in ensuring that decisions are made in a timely manner. This is not the position now. I find that I go from A to B to C to D to try and get a decision. Some 18 months later, I find no decision has been made.

I had an interesting meeting in the past week concerning a facility, Cuan Mhuire, which cost €2.1 million in 2007. This brand new facility was purchased to provide a service and 18 beds are available in a house that was refurbished and fully equipped. For eight years, it has been lying idle because the HSE cannot make up its mind. There has been a failure to reach agreement about how we go forward. This is exactly what we are talking about. A sum of €2.1 million has been tied up since 2007, without anyone benefiting from that expenditure. That is exactly why a new board is so important to making decisions in a timely manner and ensuring that everyone down the line also makes decisions. It is not a case of passing from one section to another. We need to get into the entire health service to ensure that we can deliver the type of care that we require in this country.

We welcome the Bill which we have discussed at length in this House on different occasions and it is about time that changes take place in the HSE. The two patient advocates is a great idea but I take on board Senator Ruane's point about whether the high standard of professionalism omits and disqualifies others from being a member of that board. It is prudent and best practice to have these advocates with their core skills and expertise in knowing what it is to be and to represent patients at the core of what we do within the health service.

It is a pity to have to state that the HSE did not respect the wishes of Seanad Éireann when we wanted to put patient advocates on their steering, policy and decision-making boards. This will modernise our health service and it will happen. It is inevitable so why not just do it now? Is the Minister of State in thrall or are his hands tied by the HSE's adamant, stubborn decision not to allow patient voices at this and different tables throughout the tiers of the executive where they are much needed and where confidence in the HSE is at rock bottom? If there is any at all, it has been severely dented. It has cost the HSE its credibility and cost women their lives in the recent scandals that have affected us.

We will support the Bill, as Sinn Féin believes it is timely and much-needed. We will continue also to push for a voice for the ordinary, wonderful HSE workers at the coalface who know what they face and have practical experience on a day-to-day level and who liaise closely and are advocates for their patients as well. We will push that aspect on Committee Stage in the Dáil but, overall, we welcome the Bill as it is.

Fianna Fáil also supports this Bill and believes that it should be enacted as a matter of priority.

On Senators Ruane and Devine's comments regarding the patient advocacy, I would be interested in knowing what process would be used in selecting these two patient advocates. Like Senator Ruane, I would like a "patient advocate" to be clearly defined because, as she correctly pointed out, that is open to interpretation. This would be helpful and I am in total agreement with her on this point.

I thank the Senators for their contributions on this issue. I fully understand the points raised and I give a commitment that proper consideration will be given to all of the issues raised. The documentation Senator Ruane raised will be gone through by the Minister for Health, Deputy Harris, and the Department of Health as there are some constructive proposals in it. The Government has proposed an amendment in this regard.

The other point raised by Senator Burke regarding the capacity and skills issue at board level is very important as well. The Government amendment will ensure that at least two members of the new HSE will have experience or expertise in advocacy in respect of matters affecting patients. This is in line with the Scally report. I hope the Senators will understand why we are taking this approach.

On the broader issue of patient advocacy, important points were made about carers and high-level criteria and as the debate was proceeding I was thinking about something I did before the summer. We have a group in my disabilities portfolio called the national platform for self-advocates. These are people with intellectual disabilities and I took them on over the summer as consultants on the disability sector. They are a valuable group because they are outside the professional ranks. They are people with disabilities themselves and they have fantastic contributions to make.

The debate about genuine patient advocates is very important. Important issues were touched on relating to trust and the patient partnership. Regarding Senator Devine's comment, I am not in thrall to anybody in the HSE and I will push the reform agenda.

In reply to Senator Wilson, the chairman designate, Mr. Ciarán Devane, has been selected and the Public Appointments Service is undertaking a public process to identify the other members of the board. The board will drive accountability and transformation and I cannot underline more strongly how important it is for us to get the right calibre of people and the right mix of experience among board members. Given the nature of the role, the associated time commitment envisaged and the range and breadth of the issues, the Minister for Health has carefully considered the overall size of the HSE board.

The key issue is to ensure we have two people at board level who are voices for patients as well as being competent board members.

Amendment agreed to.
Government amendment No. 3:
In page 7, between lines 23 and 24, to insert the following:
“(b) At least 2 of the persons appointed under paragraph (a) shall be persons who, in the opinion of the Minister, have experience of, or expertise in, advocacy in relation to matters affecting patients.”.
Amendment agreed to.

Amendment No. 4 cannot be moved because amendment No. 3 was passed.

Amendment No. 4 not moved.
Government amendment No. 5:
In page 8, line 1, to delete “(selected in accordance with subsection (8))”.
Amendment agreed to.
Bill recommitted in respect of amendment No. 6.
Government amendment No. 6:
In page 8, line 4, to delete “3 members” and substitute “4 members”.
Amendment agreed to.
Bill reported with amendment.
Government amendment No. 7:
In page 8, to delete lines 6 to 11.
Amendment agreed to.
Government amendment No. 8:
In page 8, line 12, to delete “(9) Subject to subsection (10)” and substitute “(8) Subject to subsection (9)”.
Amendment agreed to.
Government amendment No. 9:
In page 8, line 15, to delete “(10) A person” and substitute “(9) A person”.
Amendment agreed to.
Government amendment No. 10:
In page 8, line 16, to delete “subsection (9)” and substitute “subsection (8)”.
Amendment agreed to.
Government amendment No. 11:
In page 8, line 18, to delete “(11) A member” and substitute “(10) A member”.
Amendment agreed to.
Government amendment No. 12:
In page 8, line 22, to delete “(12) The Minister” and substitute “(11) The Minister”.
Amendment agreed to.
Amendment No. 13 not moved.
Bill recommitted in respect of amendments Nos. 14 to 16, inclusive.
Government amendment No. 14:
In page 28, line 3, to delete “Any 5” and substitute “Any 6”.
Amendment agreed to.
Government amendment No. 15:
In page 28, line 6, to delete “5 members” and substitute “6 members”.
Amendment agreed to.
Government amendment No. 16:
In page 28, line 12, to delete “4 ordinary members” and substitute “5 ordinary members”.
Amendment agreed to.
Bill reported with amendments.
Bill, as amended, received for final consideration and passed.
Sitting suspended at 3.35 p.m. and resumed at 5 p.m.