The meeting has been convened for the purpose of consideration of Committee Stage of the Health (Eastern Regional Health Authority) Bill, 1998. I welcome the Minister for Health and Children, Deputy Cowen, and his officials to the meeting. I suggest that we consider the Bill until 6 p.m. and that if we have not concluded it by then, a further meeting will be scheduled. I also suggest that we suspend proceedings from 1 p.m. to 2 p.m. Is that agreed? Agreed.
Health (Eastern Regional Health Authority) Bill, 1998: Committee Stage.
I wish to complain about the fact that Deputy McManus and I have just been handed a letter which indicates that a substantial number of amendments tabled by us are out of order. I challenge that ruling because I find it difficult to understand how a number of these amendments, including amendments Nos. 6 and 8, are out of order. I have not had an opportunity to go through some of the other amendments. It is extraordinary that they have been ruled out of order when they are only seeking to ensure that the Eastern Regional Health Authority does what is already done by the Eastern Health Board. Amendment No. 8 seeks to ensure that arrangements previously agreed are complied with.
Have these amendments been ruled out of order on the advice of the Department of Health and Children or a lower officer? It seems that amendments of substance tabled by Deputy McManus and I have been emasculated and Committee Stage is being rendered largely irrelevant. I would like clarification on this issue.
This is a serious matter.
I will try to explain the reasons these amendments were ruled out of order when we come to each amendment. While they have been ruled out of order on financial grounds, it will be possible for Deputy Shatter and Deputy McManus to speak to the amendments, although they cannot be moved.
I appreciate that you are in a difficult position, Chairman, but the reason an extraordinary number of amendments have been ruled out of order is given in the letter we have received. It states:
We regret to inform you that amendments Nos. 5, 7, 9, 14, 19, 23, 24, 25 and 26 tabled by you must be adjudged out of order as they involve a potential charge on the Revenue.
I contest that statement. I understand it may apply in certain cases but it does not apply in all cases. I will speak on each amendment as it arises.
I cannot accept that extra costs are necessarily required when a management structure employs people and various areas of responsibility are included in its terms of reference. That presumption by the Department of Health and Children is unsubstantiated. We are working to ensure this Bill and the structures it sets up are the best possible and it is unsatisfactory that our points are dismissed on tenuous grounds which I contest.
It is almost ludicrous that some of my amendments have been ruled out of order on the grounds of involving a potential charge on the Revenue when they seek to clarify the terms of reference and responsibilities of the new boards and authority. If we want clarity in this Bill, we must debate it seriously rather than allowing Deputy Shatter and I to make speeches but not to move the amendments. We will only be whistling in the wind if we cannot move them.
"Involving a potential charge on the Revenue" is a catch-all phrase which is often used on Committee Stage but in this case it is wrong to rule certain amendments out of order and not to allow us to debate them in the normal way. We are making a laugh of the process.
The ruling stands. The detailed reasons each amendment was ruled out of order will be given when we deal with them.
I insist on a reply to the question I asked. Fine Gael's stance is to co-operate with the Minister in the passage of this legislation. We should not emasculate the legislative process. We are taking Committee Stage here in lieu of in the House. What is now happening makes a mockery of the powers of the Oireachtas and I question the constitutionality of what has occurred.
I have a view about the way the Department of Health and Children does its business. I want to know if the letter we received from the Chairman of the committee is as a consequence of the Department of Health and Children seeing the amendments, trying to evade addressing them and advising the Chairman of the committee they are out of order on the grounds given. If that is the case, I will seek to terminate this meeting and intend to call a vote to that effect.
We should seek the advice of the Office of the Attorney General before proceeding further. This committee is entitled to seek submissions on any Bills. I will formally propose that the committee be furnished with the advice of the Attorney General on this matter and, having received such advice before proceeding any further with Committee Stage, the committee should be at liberty to obtain independent legal advice if it is required. When amendments are ruled out of order, it is not my normal practice to create undue difficulty but I am deeply concerned about the blanket nature of what has happened and its potential impact on our legislative process.
From where does this advice emanate? The Chairman of the committee has signed a letter and, with respect, I assume he is acting on advice. I have always and will always treat the Chairman with great respect. I do not want anything I say to be construed as a personal attack on him.
The advice that these matters were out of order was given to me by officials of the House. It did not come from the Department of Health and Children.
I propose that we adjourn this Committee Stage debate and seek the advice of the Office of the Attorney General on the contents of the letters of 31 March 1999.
Is that a formal proposal?
It is.
I support the proposal fully. We cannot proceed on this basis and function effectively as a committee of the House.
I will need to have the proposal in writing.
Will the Chairman give us a moment to do that?
Yes.
It is very unfortunate that assumptions are being made about my Department when it has not had any involvement in the matter. Members are free to ask me about rulings on an amendment at any time. The normal circumstances applied in this matter; advice was offered to the Chairman by the officials of the House.
I have no wish to have an argument with the Minister about this issue. I accept what he says but I am deeply concerned about the precedent this sets for dealing with a Bill of this nature. It undermines the functions of the Oireachtas that these amendments are dealt with in this way, particularly in the context of this Bill. The committee should seek advice on the issue. I intend to provide the Chairman with the wording of the motion I am proposing.
I accept the Minister's comments, which I believe reinforce the point made by Deputy Shatter in regard to the seriousness of this situation. Amendments which are tabled in good faith are being ruled out of order in an unacceptable manner. Many of the amendments tabled cannot be ruled out of order on the basis of a cost element. That is not a sustainable argument.
Is the Deputy saying the amendments are unsustainable because there is a cost element involved?
No, I am saying there is no potential cost involved.
It is my prerogative to rule Deputy Shatter's motion out of order but I believe it would be more appropriate to vote on it.
In the context of the motion I have tabled, I am anxious that we adopt a constructive approach to this Bill. I acknowledge that the Minister may have been unaware of the contents of the letters received prior to us receiving them. Rather than viewing the motion as a party political issue, I urge members to agree to it in order that we can obtain advice.
The Minister has an essential interest in ensuring the Oireachtas does its business in a constitutionally correct fashion. It is in everyone's interest and in the interest of the future work of this committee to obtain such clarification on a Bill of this nature. I accept fully that on occasion, Opposition Deputies, table amendments which involve substantial charges on the Exchequer - the Minister would have done so himself when he was in Opposition. However, I do not believe that arises in regard to these amendments.
The wording of the question is "That this committee adjourn to obtain advices from the Attorney General's Office as to the contents of the letters of 31 March 1999 received by Deputies Alan Shatter and Liz McManus and reserves unto itself the right to reserve to seek any additional advices deemed appropriate".
I should have said " That the committee adjourns its consideration of the Health (Eastern Regional Health Authority) Bill, 1998" because we are not adjourning permanently.
Question: "That this committee adjourns its consideration of the Health (Eastern Regional Health Authority) Bill, 1998, to obtain advices from the Attorney General's Office as to the contents of the letters of 31 March 1999 received by Deputies Alan Shatter and Liz McManus and reserves unto itself the right to reserve to seek any additional advices deemed appropriate" put.
Question put.
The Select Committee divided: Tá, 7; Níl 8.
Tá
- Bradford, Paul
- Clune, Deirdre
- Connaughton, Paul
- Gormley, John
- McManus, Liz
- Neville, Dan
- Shatter, Alan
Níl
- Ahern, Michael
- Cooper-Flynn, Beverley
- Cowen, Brian
- Dennehy, John
- Keaveney, Cecilia
- Kenneally, Brendan
- O’Keefe, Batt
- Wright, G.V.
Question declared lost.
SECTION 1.
I move amendment No. 1:
In page 3, subsection (2), line 27, after "1996," to insert "the Health (Provision of Information) Act, 1997,".
This amendment adds an extra line to the Bill and there are ink and printing costs involved. I hope the committee will not disallow it because of that. It is a simple technical amendment to ensure there is no ambiguity. I ask the Minister to accept it to make it absolutely clear that this Act which relates to the Data Protection Act is included in the Bill.
I accept the amendment.
Amendment agreed to.
Section 1, as amended, agreed to.
SECTION 2.
I move amendment No. 2:
In page 4, subsection (1), between lines 25 and 26, to insert the following:
" 'registered dentist' means a person whose name is entered in the Register of Dentists, other than a person temporarily registered under section 28 of the Dentists Act, 1985;
'registered dispensing chemist and druggist' means a person whose name is entered in the register of dispensing chemists and druggists maintained by the Pharmaceutical Society of Ireland;
'registered medical practitioner' means a person whose name is registered in the General Register of Medical Practitioners, other than a person provisionally registered under section 28 of the Medical Practitioners Act, 1978, or temporarily registered under section 29 of the Medical Practitioners Act, 1978;
'registered nurse' means a person whose name is entered in the register of nurses maintained by An Bord Altranais under section 27 of the Nurses Act, 1985;
'registered pharmaceutical chemist' means a person whose name is entered in the register of pharmaceutical chemists maintained by the Pharmaceutical Society of Ireland;
'registered psychiatric nurse' means a person whose name is entered in the psychiatric division of the register of nurses maintained by An Bord Altranais under section 27 of the Nurses Act, 1985;".
The amendment inserts into section 2 the definition of the registered professions entitled to serve on the authority. The Bill as initiated does not define these professions as it was my intention that the definitions, rules and procedures which apply in existing legislation to the registered professions in health boards would apply to the new authority. I am advised, however, that in order to avoid confusion it is best to spell out the definitions in the Bill. The definitions of the registered professions in the amendment are the same as those which apply in the health board regulations currently in force, but they are updated to take account of recent legislation.
The representation of the registered professions on the authority is spelled out in section 10 and is the same as that which currently applies in the Eastern Health Board. My intention is that the members of the registered professions will be directly elected to the authority by their peers in the same manner as currently applies to health boards. Amendments which I have tabled to section 22 will ensure this is the case.
The Minister points out correctly that the definitions of the different people or professions interrelates with later sections and are also relevant to the composition of the Eastern Regional Health Authority. Amendments relating to these issues tabled by Deputy McManus and I have been ruled out of order.
I wish to draw the Minister's attention to certain matters. First, it seems that "registered medical practitioner" as referred to in the Bill does not include non-consultant hospital doctors. Provision is not made for their representation on the regional health authority or the area boards. Despite the fact that a large number of social workers are employed by the Eastern Health Board, no provision is made for their representation on the authority. Social workers, who do substantial work at the coal face and who deal with many very difficult issues, should be recognised given that other professions which are providing services in the health board area are given recognition, albeit poor recognition in some cases.
Will the Minister clarify why social workers are effectively excluded from membership of the Eastern Regional Health Authority and are not given any specific entitlement to have a member or members on the authority? I also ask the Minister to clarify why no place has been provided for non-consultant hospital doctors and why provision is only made for one general nurse and one psychiatric nurse. There are more nurses than doctors working in the hospital service. I am not saying that consultants and medical practitioners in general should not have representation - of course they should. However, the level of representation provided for registered nurses is appallingly low and will not even allow for one nurse to serve on each of the area boards, something which is essential.
The amendment on non-consultant hospital doctors can be discussed. With regard to representation, I am seeking to achieve a consistency of approach in the context of the task force recommendations which are the result of consultation dating from the health strategy of 1994. This is the end product of much discussion and consideration of all the relevant issues. It is difficult to achieve unanimity concerning representation. However, on the basis of the majority representation of public representatives and consistency with other health boards, my intention is to follow the recommendations of the task force. I have views on how we might deal with area boards and ensuring attendance at certain meetings, something which will be raised on the relevant sections.
I do not wish to anticipate discussion on non-consultant hospital doctors. However, the main reason they have not been part of previous legislation concerning health boards is, probably, the transient nature of their work given that they do not have long contracts in that health board area. A case can always be made to include a range of people, but I want to maintain a consistency of approach in terms of the existing health board structure. I want to follow the recommendations of the task force which are the result of much consideration. The Deputy will be aware that the task force's recommendations on representation were framed on the basis of the previous administration's proposal, with which I agree, namely, that there should be a majority of public representatives on the boards. As a result of that direction being given by the previous administration, the task force, following much discussion, made its proposal.
One would need the wisdom of Solomon to solve all the problems or issues which arise, something acknowledged by everybody on Second Stage. A couple of issues arise on the relevant sections as to how these matters can be dealt with. I have not tabled an amendment on Committee Stage in order to give the committee an opportunity to air its views on these issues. I do not wish to anticipate discussion on other sections.
Amendment agreed to.
Amendments Nos. 4 and 28 are related to amendment No. 3 and they may be discussed together by agreement.
I move amendment No. 3:
In page 4, subsection (1), line 37, to delete "mental handicap" and substitute "intellectual disability service".
Amendment No. 28 is related. These amendments are based on using more modern understanding and language to describe the service being provided and the persons who benefit from it. The concept of mental handicap in general terminology is being replaced with that of intellectual disability and the legislation should reflect the desirability of using a description which is regarded as more appropriate than that which applied in the past.
While the term "mental handicap" is still used widely, a number of other terms have also come into general use in recent years. One of the more widely used terms is "intellectual disability". The report of the review group on mental handicap services, needs and abilities which was published in 1991 recommended that an alternative term to "mental handicap" be agreed by consensus. One of the possible alternative suggestions was "intellectual disability". Since the publication of that report my Department has encouraged debate to endeavour to achieve a consensus for the most appropriate and acceptable terminology and whether to continue to use the term "mental handicap" or use one of the alternative terms. To date, there appears to have been no consensus regarding one or other terms.
However, I have no difficulty in accepting in principle the Deputy's amendment for three reasons. First, the term "intellectual disability" was one of the alternatives suggested by the review group in their report. Second, it is one of the more widely used alternative terms within the field of mental handicap and, third, it is already used by my Department in relation to the intellectual disability database.
It has not been possible to check with the parliamentary draftsman's office in the time available as to whether Deputy Shatter's amendments have any implications which would require further amendments to this Bill or to existing legislation. Therefore, with the committee's agreement, I propose to explore this matter further with the draftsman and to bring forward suitable amendments on Report Stage.
My amendment is of a technical nature and seeks to insert a missing word. It's purpose is to ensure that the term which is defined in section 2 accurately reflects the terminology used elsewhere in the Bill. I propose that for the purpose of maintaining internal consistency in the Bill that it should be agreed to today.
I thank the Minister for his constructive response. I have read through the Bill and my amendments are the only ones required. I invite him to accept my amendment. The review he is talking about can be done between now and Report Stage and if other inconsistencies are discovered during the course of that review then it can be addressed on Report Stage. I ask him in the spirit of his response to accept the amendment. I accept that he may come forward with more amendments to ensure the Bill is consistent when the matter comes back to the House.
Amendment agreed to.
I move amendment No. 4:
In page 4, subsection (1), line 37, after "handicap" to insert "service".
Given that amendment No. 3 has been accepted, amendment No. 4 has been rendered irrelevant.
Amendment agreed to.
Section 2, as amended, agreed to.
Sections 3 to 6, inclusive, agreed to.
SECTION 7.
Question proposed: "That section 7 stand part of the Bill."
Do the Freedom of Information Act and the Ombudsman Act still apply to the authority?
Yes.
Question put and agreed to.
Amendments Nos. 5 to 10, inclusive, not moved.
SECTION 8.
Question proposed: "That section 8 stand part of the Bill."
Amendment No. 5 in the name of Deputy McManus has been ruled out of order because it provides that the authority shall oversee the regulation of private hospitals in its functional area. To put in place a regulatory system for such hospitals would potentially involve the provision of additional resources to the authority. Therefore, the amendment involves a potential charge on the Revenue and must be ruled out of order in accordance with Standing Order 142(3).
This is like being a eunuch in a harem. However, I will take this opportunity to speak since I can do nothing else.
I would like to hear the Minister's views on this question of private hospitals. Private hospitals are increasingly becoming service providers, particularly within the Eastern Health Board region. The development of private hospitals does not seem to be connected with the Department or the local health board in a structured fashion. The argument can be made that these private hospitals are privately funded and, therefore, should be left to get on with their own business. However, the reality is different. The public indirectly subvent these private hospitals because private health insurance is open to tax relief - 41 per cent of the population now has private health insurance and many people avail of the services provided by private hospitals. They are part and parcel of service provision, particularly in the Eastern Health Board region. We cannot continue without a structure that ensures some regulation and links between the Department, the local regional authority or the health boards and the private hospital.
I will cite a topical example. At a time when we have serious waiting lists and when such a large proportion of the population has private health insurance schemes, it is extraordinary that a private hospital in Dún Laoghaire, operating at 50 per cent of its capacity, is about to close its doors because it is not sustainable. Unless the Minister or the health board acts then the site will probably be used for property development purposes. The health board is reported in today's newspapers as being unable to say if it needs this hospital. This highlights the disjunction between the health board and the range of service provision that is available within its jurisdiction. My amendment was an effort to make that connection. From time to time public patients are being treated in private hospitals under the waiting list initiative. I do not have any great ideological problem with that. A friend of mine who is a postman underwent his bypass operation in the Blackrock Clinic. It is sensible to avail of bed spaces where they are available.
At present there is a private hospital closing in an area of County Dublin that is crying out for beds. If the health board had a certain responsibility for private hospitals and had links with them I do not believe the current situation would arise. I ask the Minister to indicate what he intends to do with St. Michael's hospital.
Under the waiting list initiative there is a clear requirement to deal with the bed blocking that is occurring at present, which the Minister has raised as a legitimate issue in terms of the waiting lists and the increasing problems associated with them. This is his opportunity to deal with the issue. I ask him to respond to my points because they are of grave concern to the people of south Dublin and the people in my constituency of north Wicklow. We cannot stand aside and let hospital beds that are urgently and desperately needed disappear in front of our eyes.
Some of the matters raised by Deputy McManus would be more appropriate to a Dáil question but the Minister may respond in general terms.
I agree; they would be more appropriate to a question in the Dáil.
St. Michael's hospital was referred to in today's newspapers. However, I cannot give any commitments on its future at this meeting.
The proposed amendment sought to incorporate the private hospital sector under the aegis of the Authority. This is not envisaged, nor is it possible. If the intention of the amendment was to incorporate the private hospital sector into the system for the purpose of guaranteeing service and quality, etc., there would be other ways of doing this. An accreditation system is being piloted at the moment in the major teaching hospitals, which are public hospitals. The private hospital sector is also progressing towards the institution of an accreditation programme. The Independent Hospital Association of Ireland, the representative body for 18 private hospitals, has declared its commitment to the development of an accreditation system for its members. The aim of this is to develop standard benchmarks for a nationwide system of grading for private hospitals.
It is clear that the interests of patients and of the hospitals will ultimately be best served by a common or joint approach to the development of hospital accreditation measures. This is one of a number of issues of common concern between the public and private systems in the hospital sector which would benefit from a joint examination and development in the context of the forum of health care providers, both public and private. I expect the formal establishment of such a forum to be given additional impetus in the context of the forthcoming White Paper on Private Health Insurance.
Given that there are wider national issues involved, I do not think the idea of incorporating a private hospital system into an authority covering the eastern region, without reference to the position in the other seven health board areas, makes sense under legislation which seeks to set up an authority which will give a more streamlined service under the present statutory and voluntary sectors within the confines of the Eastern Health Board area.
I challenge the Chair's ruling in relation to the additional cost to the State. The Minister said that the accreditation system, which is a good idea, is developing through his Department in co-operation with the private hospitals. Given that this work is being carried out by the Department and it involves only the transfer of responsibilities there is no additional cost. There would be no additional cost given that the work would be devolved from the Department to a regional authority or local boards. From the point of view of the Chair's decision on the matter, it raises the question of why the amendment is being ruled out of order. What the Minister says with regard to the private hospitals - that there are national implications and it would not be appropriate to devolve this to a regional authority or local board - applies to the voluntary hospitals. This is taking place in the context of the voluntary hospitals and, therefore, it is illogical and inconsistent to say that the same cannot be done in the context of the private hospitals.
On that point, the Health (Eastern Regional Health Authority) Bill will be a model which will apply throughout the country in due course in terms of setting up service agreements between the boards and the voluntary hospitals, while recognising the independent ethos of the voluntary hospital in allowing them to do their business in a normal manner. I hope this will be a model for service delivery throughout the country in due course. The reason this has come to the fore relatively quickly in the Eastern Health Board area, rather than in other health board areas, is because of the contribution the voluntary sector makes to the delivery of hospital services in the east vis-à-vis the remainder of the country and the need to plan strategically in an area which now covers 1.3 million people to have proper monitoring and evaluation to allow the service to be delivered in a more localised manner. That is the thinking behind the Bill.
On the issue of the cost to the Exchequer, there is a big difference between accreditation and regulation. Accreditation is a self-regulating mechanism, based on objective standards that are objectively transparent and can be applied and considered. The Deputy is suggesting expanding the role of the State in the whole private hospital sector. This would result in an increased charge on the Exchequer vis-à-vis the State’s role in regulating that sector. In seeking to meet the Deputy’s proposals, I am pointing out that accreditation is another means of achieving the same ends without an expansion of the State’s role.
Amendment No. 6 has been ruled out of order under Standing Order 142(3). Deputy Shatter may wish to address the issue.
Amendment No. 6 sought to insert in the Bill a series of additional functions to be exercised by the Eastern Regional Health Authority. It did not seek to get the authority to do any more than the Eastern Health Board is currently obliged to do across a broad range of services. It is my view that section 8 of the Bill, which amendment No. 6 seeks to amend, is far to imprecise in setting out the functions to be exercised by the authority. These functions in particular areas should be spelt out to a greater degree because we should be conscious that this authority, like the Eastern Health Board, is there to serve the people within whose catchment area it operates. It is not there for its own sake. There should be a touchstone against which we can judge the quality of the services provided by the authority across a broad range of areas. I do not believe that the Bill, as presently constituted, has that touchstone.
It is ironic that some of the proposals which I seek to include in the Bill do no more than to set out the current stated objectives and commitments of the Eastern Health Board. The suggestion has been made that the inclusion of these proposals would place an additional charge on the Exchequer. By including the proposals to which I will refer in a moment, all I seek to do is to ensure that the Eastern Regional Health Authority lives up to the obligations that the Eastern Health Board currently has. In some areas the Eastern Health Board falls short of providing the services it is obliged to provide, partially because the Department of Health and Children has not properly funded it.
I wish to refer briefly to what should be included in section 8 of the Bill. It is important that the Bill expressly states that the new authority would ensure that essential medical and psychiatric care of the highest standard is provided in its functional area to those who require it without undue delay. The problem at the moment is that there are growing waiting lists in the Eastern Health Board area for in-patient hospital care and for a variety of medical procedures. There are waiting lists of those referred by their GPs to consultants for an initial consultation, although the numbers involved are not known because no accurate information is maintained. Those who look to the public system for medical and psychiatric care are entitled to such care without undue delay. There have been debates in the House about whether it is unacceptable for adults to wait 12 months or longer and for children to wait six months or longer for a variety of medical procedures. In some cases people must wait 18 months to three years for various medical procedures.
It is important that this authority is required to provide health care within a regulated timeframe and that the funding provided by the Department of Health and Children is guided by that. At present, discussions take place between the Department of Health and Children and the Department of Finance about the overall health expenditure. The sums allocated to health boards are not based on the needs of patients or on the provision of a variety of procedures within a maximum time period. Financial allocations are designed to fit specific numbers of procedures being undertaken without any guarantee that waiting times in a number of areas will not only be reduced but will be permanently reduced on a long-term basis. That is one of the proposals contained in this measure.
There is also substantial concern about the Eastern Health Board meeting its obligations under the Child Care Act, 1991, to promote the welfare of children and to ensure that children at risk are provided with proper protection. It is believed that the family circumstances of approximately 1,000 children who are reported as being at risk or the possible victims of abuse have not been fully and comprehensively investigated. The Department was not fully aware of the numbers involved at the end of 31 December 1998. In a reply to a parliamentary question tabled by me on 2 March, the Minister did not have information about how many reports of children being at risk of abuse or neglect had been fully investigated or if the children's welfare had been assessed. Perhaps he could give me that information today. It is deplorable that the Eastern Health Board has difficulty collating this type of information and the Department of Health and Children has difficulty supplying it.
We have already conferred obligations on the health boards under the Child Care Act, 1991, and our adoption legislation. I want to insert in section 8 a provision which ensures that in "performing its functions, the authority shall ensure that the child care and adoption services for which it is responsible in its functional area under the provisions of the Child Care Act, 1991 and the Adoption Acts, 1952 to 1998, are of the highest standard and are provided without undue delay". I do not understand how that imposes an additional charge on the Exchequer or why the Minister would object to its inclusion. Perhaps he does not object to the inclusion of some of these functions in the Bill.
As regards assessing couples and individuals for foreign adoptions, the Eastern Health Board has a huge backlog of cases and its unacceptable delays are creating difficulties for many couples. The standard of the service currently being provided is under serious question. We have a duty to ensure that a better service in the child care and adoption areas is provided by the new authority. However, it must not be a mirror image of the service provided by the present authority.
I am not being critical of any social worker or individual in the Eastern Health Board who works in the child care area. They are working under extreme and difficult circumstances with limited resources. This new authority must be put in place and it is important that its obligations to this House are fulfilled. Perhaps the Minister could respond to these two areas before I discuss the other areas which should be referred to under this section.
I understand the Deputy has tabled amendments for the purpose of discussing certain issues. I emphasise that the purpose of the Bill is to set up the new organisational structure and to outline the functions of the new authority and its relationship with the area health boards and the service providers generally. I want to maintain a consistency of approach when setting up this authority because it is part of a national framework and a health board system throughout the country. If we were not setting up this new authority and we were just discussing issues relating to the health board structure, for example, we would not be suggesting that we treat one health board differently from another in terms of the legislative provisions that apply to it.
We all agree with many of the aspirations and sentiments in Deputy Shatter's amendment. There are legislative requirements under the Health Acts, the Mental Treatment Acts, the Adoption Acts and the Child Care Act, 1991, which cover these issues. These Acts confer statutory obligations on health boards and on this authority because the functions of the Eastern Health Board will be transferred to it when this legislation is enacted. The authority will then delegate reserve and executive functions to the area health boards where necessary. It will maintain many of the reserve functions and it will be responsible for co-ordinating services and bringing about the improvements Deputy Shatter and others would like to see.
We must address the inadequacy of the organisational structure and bring about the improvements referred to in this section in terms of the enhancement of health policy issues in any area of the service. For that reason it would not have been possible for me to accept the amendment. We should not incorporate specifics in this section given that the authority will be subject to the same broad statutory obligations which apply to the Eastern Health Board.
The purpose of the Bill is to set up the new organisational structure, outline the functions and service agreements, ensure transparency, set out the relationship between the new authority and the three boards and deal with the representation issue. The monitoring, assessment and strategic planning, which everyone agrees is essential to improve the health service in the eastern region given the number of people it seeks to serve, will be dealt with by the new authority. That strategic focus will be available through the authority.
The members of the authority will be on the area health boards which will provide a localised service. This interaction will ensure the democratic accountability about which everyone speaks. For that reason, I would not have been in a position to accept this amendment if the Deputy had been allowed to move it. It is not that I disagree with its sentiments but we must be mindful of the purpose of the Bill so that there is no confusion about a different level of statutory provision being applied to it than applies to other health boards throughout the country.
I understand what the Minister is saying, that perhaps there should not be more elaborate provisions for the Eastern Regional Health Authority than for the health boards. However, where there are difficulties with a service or a good service which he wants to ensure is preserved, what we are doing is providing a new, but to some extent fragmented, structure. We are entitled to ensure that certain standards are complied with in the context of previous legislation when establishing a new structure.
We have seen in the context of waiting lists that there is an inadequacy in the provision of medical care for patients who rely on the Eastern Health Board. In the context of the child care services, the Minister and I cannot guarantee that we will not learn in eight or ten years that more tragedies were being acted out which replicate what happened to the McColgan family in the early 1980s. These were being acted out because of the health board's inability to intervene. We have a duty to ensure that this new authority intervenes and takes action where necessary.
In the context of other issues referred to which arise under section 8 which I sought to deal with in my amendments, one of the proposals I submitted is that in performing its function this new authority should ensure that "appropriate special residential accommodation and services are provided within its functional area for those children who require such services and who can no longer be accommodated in their parental home and who are not suitable or eligible for foster care or adoption". The reason I raise this issue is that we know there are about 70 children at present in the Eastern Health Board area who require either containment, high support or special residential accommodation because their parents cannot cope with them. They cannot live in their homes and currently there are no facilities for them. This is an issue which the courts have addressed on many occasions.
I want to put on the record one particular comment by Mr. Justice Peter Kelly - he is not the judge who is currently the subject of some controversy but one who has been a judge of the High Court for some time. When talking in July 1998 about these children for whom the health board and the State have been held to have an obligation, the judge said in the context of the lack of facilities that it is no exaggeration to characterise what has gone on as a scandal, that he has had evidence of interdepartmental wrangles over demarcation lines going on for months, seemingly endless delays in drafting and redrafting legislation, policy that appears to be made only to be reversed and a waste of public resources, for example, going through an entire planning process for the Portrane development only for the Minister to change his mind thereby necessitating the whole process being gone through again.
He said in July 1998 that addressing the rights of young people with whom he has to deal appears to be bogged down in a bureaucratic and administrative quagmire. The judge, in dealing with another young child, repeated his views in December 1998. Just last week, yet again, he was confronted with this problem. It is important that there are provisions in this legislation to ensure that the Eastern Regional Health Authority meets the obligations which the courts have stated are upon it in the context of providing special accommodation for young people.
It is also important that we no longer have children, who require accommodation outside their family homes, put in hospitals as social admissions. Last year in the Eastern Health Board area 96 children were admitted to hospital as social admissions and in excess of 1,900 hospital bed days were lost. There were some children who found themselves as social admissions in hospital for eight, nine, ten or 11 months. It is outrageous.
In dealing with this Bill, the Minister needs to tell us what assurances he is giving the House that when the Eastern Regional Health Authority comes into being it will properly fulfil its functions in this area and that we will not see a continuing plethora of court cases because the State, the Department and the health board are failing to act to provide proper residential care for young people who require it.
On other issues which I have sought to raise to ensure that a range of support services are provided for the elderly and those suffering physical and intellectual disability, my amendments are a mirror image of the current objectives of the Eastern Health Board as set out in its most recent published programme.
That it is in the programme does not mean it must be in the Bill.
No, but the amendments are designed to ensure that what is currently an aspiration or a statement of policy which is desirable for those who look to the health board for particular services is something which is met and complied with and not just rhetoric. That is the reason I tabled those amendments. I would be interested in the Minister's response, not just on those matters but particularly in dealing with the issue concerning young people, which has been in and out of the courts for some years and which gets little attention in the House. It was to be addressed in the Children Bill, 1996, which has been hanging around for three years and has not progressed beyond Second Stage.
We are touching on wider policy issues as distinct from the Bill. This is fair enough as it gives me an opportunity to answer some of the queries. Deputy Shatter voted for the Health (Amendment) (No. 3) Act, 1996, and so did everyone else. That is the basis on which we deliver and fund health services. It will always be the comfort of any Opposition spokesperson to refer to gaps in the health services or to the fact that the services are inadequate in some respect in relation to some individual case or groups of cases. However, the fact of the matter is that we do not fund the health services on the basis of some objective need which has been assessed which we will fund regardless of cost. That is not the reality of the situation and Government cannot give that commitment.
In one of the few instances in relation to health policy when the whole House showed a bit of common sense, all parties agreed with the accountability legislation as being the only practical way in which we can, year on year, improve the health services, increase the number of procedures and the level of activity, and not end up from year to year wondering whether we can maintain and sustain services because we do not know whether we can continue to afford to produce that level of funding in any given area. That was, is and will be proven to be the right way to go. Let us get that matter out of the way.
We cannot, as I have said a hundred times, fund infinite expectation with finite resources but we can plan, prioritise and deliver services with available resources. The boards have new reserve functions in relation to that matter under the 1996 legislation which is giving that sort of decision making to local boards rather than, as occurred in the past, asking simply that they rubber stamp money from the Department. That was the whole idea of the strategic management initiative.
When we come to implementing these issues, on which everyone is in agreement, the fact is that with responsibilities come duties and obligations as do privileges and rights. The health boards now have, as I have said to them on many occasions, the opportunity to prioritise in a way they have not before. The Oireachtas has given them that opportunity. It is for the boards to meet those responsibilities and, working with their executives, they are meeting them admirably in many cases. I am not aware of any board which is walking away from its responsibilities now that it has been given more. That is a good example of the further devolution of power to the regions and localities. This Bill is further localising decision making and ensuring that we get better quality decisions by giving more responsibility to people operating at lower levels.
With regard to the specifics of the service issues to which the Deputy referred in respect of children who are out of control and those with emotional difficulties, it is true that policy in this area was not developed properly in the past. When I took office I was surprised that the Department's child care unit comprised four people and was totally under-resourced. However, I appointed a Minister of State with responsibility in this area and he has been given the money and additional resources necessary to beef up the section considerably.
I am aware of the court cases to which the Deputy referred. The Eastern Health Board has identified the need for a total of 60 special care, high support places. Funding for the development of two units to meet that need has been included in my capital programme, which is much enhanced. The building of a special care unit providing 24 places has recently commenced at Ballydowd in Lucan and the planning of a second 24 bed high support unit, which will be built at Portrane, is at an advanced stage.
The Deputy said earlier that perhaps a single large unit might be built at Portrane but certain concerns about and objections to that proposal have been raised. As a result of a great deal of consultation, discussion and with the assistance of local representatives in the area to ameliorate people's concerns, which were unjustified in terms of what they believed was being proposed, that proposal is now going ahead. I accept that there have been some delays but we are obliged to deal with issues raised by local residents. However, the matter is now progressing and I can say that my Department is investing resources in this area.
In the interim, a step-down unit providing five beds is being developed which will ensure an efficient use of the existing 12 beds by freeing up beds more quickly. A number of special arrangements for children requiring special care and high support have also been put in place, pending the coming on stream of the new developments - including intensive family support projects, alternative care through specialised fostering, etc. That is only the beginning. This phenomenon is part of the social change taking place which we must try to address from a policy perspective. We are doing that. Members can use this debate to raise certain problems in the health service and I will do my best to respond.
In relation to the adoption assessment procedure and the historically long delays involved, the Department received a draft report of the independent consultant's review of the foreign adoptions assessment procedures last week and it is being examined by the advisory committee set up to assist us with that project. The report, which is extremely comprehensive, contains a detailed overview of the current assessment procedures in health boards and it proposes a standardised framework for the carrying out of future assessments which accords with best practice in the field and delivers the service in the most efficient and sensitive manner possible. We intend to examine carefully the recommendations in the consultancy study and to take appropriate steps to implement those recommendations. We expect to receive the consultants' final report later this month.
These are ongoing issues and, regardless of whether it is done by an authority, a board or three area health boards, I take the point that they must be addressed. However, the purpose of the Bill is to facilitate an organisational restructuring. All of the obligations placed on service providers in relation to the issues raised are subject to existing legislative supervision. We are always concerned with ensuring that legislation makes sense and that it is properly formulated.
As a legislator, I do not believe it is correct to begin injecting various pieces of other legislation into specific Bills of this sort. Service providers are subject to general legislative provisions, regardless of the organisational structures that are in place. That is understood and accepted and the Child Care Act, the Adoption Acts and various other items of primary legislation cover those areas. However, the Bill before us deals specifically with the implementation of task force recommendations which resulted from long discussions in respect of reorganising structures. For that reason, I would like the Bill to deal solely with that issue and those involving functions, relationships and representation. To start inserting specific amendments from other legislation in the context of putting forward aspirations and sentiments with which everyone agrees, does not add to the Bill.
Amendments Nos. 7 and 9 in the name of Deputy McManus and Nos. 8 and 10 in the name of Deputy Shatter have been ruled out of order. I am asking, therefore, that section 8 stand part of the Bill.
Before proceeding in that regard I wish to bring to the attention of the Minister section 8(4) which relates to Tallaght Hospital and states:
Nothing in this Act shall be construed as prejudicing the performance by the Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital of its functions under its Charter.
The Minister said previously that he has no intention of undermining the independence or ethos of the new hospital. He also acknowledged that the charter under which the hospital was opened will be honoured. The amendment I tabled simply seeks to substitute a new subsection (4) which would ensure that that was so by stating:
Nothing in this Act shall be construed as affecting the independence and ethos of the Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital under the terms of its Charter or shall be construed as prejudicing the performance by the hospital of its functions under the Charter and the Authority shall be enabled to fund the hospital to fulfil its objects as set out in its Charter.
As matters stand, the level of funding with which Tallaght Hospital is provided is decided on by the Minister and the Department following direct discussions between the board of Tallaght Hospital and the Department.
I have no wish to discuss the history of Tallaght Hospital and the difficulties associated with it. However, there are concerns on the part of the hospital's authorities that in the future they will be obliged to seek funding from the Eastern Regional Health Authority, which in turn will deal with the Minister. Effectively, the issue of the hospital's funding will have to be addressed by an additional administrative group. What the Eastern Regional Health Authority ultimately provides for Tallaght Hospital, will largely be determined by the financial allocation of the Department.
I do not understand how it can be suggested that amendment No. 8 represents an additional charge on the Exchequer. In my opinion it reflects what I understand to be the Minister's position. I would like the Minister to clarify whether he would be willing to accept amendment No. 8. I realise it has been ruled out of order and cannot now be accepted on Committee Stage. Is the Minister be willing to bring forward a similar amendment on Report Stage to replace the existing subsection (4) in order to address concerns on the part of individuals in Tallaght Hospital? I suggest this course of action to the Minister to ensure that another element will not be added to the Tallaght "pot" which will cause unnecessary worry or difficulty for the Department or the hospital authorities.
I would like to hear the Minister's response to the substance of my proposal that, on the basis that my amendment was ruled out of order for alleged financial implications, he will bring forward a similar amendment on Report Stage. There will be concerns at Tallaght Hospital if, as suggested, the amendment has financial implications. The amendment seeks to ensure that commitments already given to the hospital are honoured. The suggestion that it has financial implications could lead to the conclusion that it is not the intention to honour those commitments.
I wish to refer to amendments Nos. 7 and 9 which were tabled in my name and which have been ruled out of order. Amendment No 7 puts forward a much simpler proposal to that in amendment No. 6, which as the Minister said was too detailed and, in effect, contained in other legislation. I accept there are difficulties with having detailed specific objectives written into the Bill, but amendment No. 7 comprises a general principle which has already been set out in the health strategy and incorporates the two key points that must be the core values of our health services - the principles of equality and quality. I am interested to hear what the Minister has to say - I cannot say the Minister has rejected the philosophy behind the amendment.
There are not necessarily cost implications. For example, the charter of the Adelaide, Meath and the National Children's Hospital, sets out the ethos and principles which have to be lived up to. In the same way, while the Bill essentially deals with reorganisation, we need to set out the guiding principles, with regard to the work of the new organisation. It seems to be possible to do something similar to the charter, but I presume the Minister will say it is not possible to do it in the general way set out in my amendment.
That raises the question of the health strategy. What is its status? What is it for if not to be given legislative effect? Will the Minister comment on the health strategy? Is it simply pleasant rhetoric to be dragged out when he is making speeches?
I will refer to amendment No. 9, regarding Tallaght Hospital, on Report Stage. Will the Minister reflect on the position being taken on this amendment and consider how he might meet the need expressed by the Adelaide Hospital Society to respect and underpin the independence and ethos of Tallaght Hospital. We should not underestimate the importance of this issue, which extends to the work being done today in Northern Ireland, in the context that the pluralist ethos can be respected and nurtured in the South.
Concerns have been expressed about the independence and ethos of the hospital being respected in the future. If this has financial implications I would like to know precisely what they are. I know the Minister is not responsible for this amendment being disallowed, but I urge him to look at the issue carefully. When speaking on North-South Bodies in the House recently, he referred to the need to build connections between healthcare services North and South, and this is an indirect connection that can be made easily. More significantly, if it is not made it will be interpreted in an undesirable way.
Perhaps amendment No. 7 is considered a charge on the Exchequer because it refers to equality of access. Equality has a specific legal meaning - equity is about fairness, equality is an absolute term about equivalence of service. Trying to promote equity is what drives the health strategy and that is why we are seeking more funds for the public hospital system. Whether one considers it a relative success or failure probably depends on what side of the House one is on. We are promoting equity in the system all the time. Issues such as access to procedures have been raised and this is one of the reasons we are beefing up the one public patient centred initiative in the health service, that is, the waiting list initiative.
The amendment tabled by Deputy Shatter concerning the Adelaide Hospital Society is very similar to a proposal from the Adelaide Hospital Society, the Adelaide being one of the constituent parts of the Tallaght Hospital. The society is concerned that section 8 of the Bill as drafted requires to be strengthened to enable the authorities to fund services provided by the hospital in fulfilment of its charter. The society's grounds for this proposal is that it feels the authority is limited to its functional area by section 8(2) and, therefore, requires an enabling power to fund the services provided by this hospital to a national minority community as they see it. However, when this point was put to me by the Adelaide Hospital Society I sought legal advice from the Office of the Attorney General. The advice from the Office of the Attorney General was that section 8 (2) does not debar the authorities from providing services within its functional area to persons who normally reside outside its functional area and that would be the case with any hospital in the country.
There is nothing in this section which could prevent the authority from funding the services provided in Tallaght Hospital to members of "the national minority community". My firm intention is that the current practice whereby doctors can refer patients from anywhere in the country to a hospital in the eastern region, if they decide that such a referral is in the patient's best interests, will continue. The costs of treating such patients will be taken into consideration in the normal course of discussions between the hospital and the authority regarding the annual service plan. In the light of the advice received from the Office of the Attorney General I consider this amendment unnecessary.
I will indicate the reason we put in the subsection in the first place. Section 8(3)(e) asked the authority to have regard to the right of voluntary bodies who provide services to manage their own affairs in accordance with their independent ethos and traditions. I am anxious to maintain and respect the independent ethos and traditions of all hospitals, regardless of the ethos and tradition. I am a great believer that pluralism is about equality, treating everybody equally which is certainly my intention. That is the legislative intention. It is not about special pleading or making exceptions, but about recognising differences and treating all equally.
Subsection (4) is what I would regard in legal parlance as a saver. The board of the Adelaide and Meath Hospital, incorporating the National Children's Hospital, had expressed concern that the provisions of the charter that governs the hospital might be adversely affected by the Eastern Regional Health Authority. The charter, which was ratified by the Dáil in July 1996, enables the three base hospitals to come together to form the board of the new hospital at Tallaght Hospital and this provision has been inserted to ensure that none of the provisions of the Bill will affect the performance by the board of the Tallaght Hospital of its functions under the charter. Concern has been expressed by some other voluntary hospitals that this section confers an advantage on the Tallaght Hospital over other hospitals in the eastern region. However, the Attorney General's office has confirmed the Department's view that the provisions as drafted do not confer any new power or advantage on Tallaght Hospital. The intention is that the hospital will be funded by the authority in exactly the same manner and under the same rules as the other major acute hospitals in the region and there is nothing in the subsection or, indeed, elsewhere to suggest otherwise.
Question put and agreed to.
Section 9 agreed to.
The sitting of the Select Committee was suspended at 1.05 p.m. and resumed at 2.15 p.m.
NEW SECTION.
I move amendment No. 11:
In page 7, before section 10, to insert the following new section:
"10.-(1) The Authority shall put in place systems, procedures and practices to enable it to monitor and evaluate——
(a) the services provided by the Authority, and
(b) the services provided by each Area Health Board,
and shall publish an annual report detailing such services and describing any gaps or deficiencies that require redressing.
(2) The Authority shall no later than the 1st day of October in each year, by advertisement in such national newspapers as it determines, seek submissions from the general public on the services provided by the Authority and each Area Health Board to be received no later than the 30th day of November in that year.
(3) The annual report shall be published no later than the 31st day of March in the year immediately following the year of such report and shall be laid before Dáil Éireann.".
This proposal is that the new authority ensures that up to date information is available concerning the demands being made for various services, on waiting lists and that there is ongoing monitoring of services by the authority. It will enable it to set out in a report most of the positive aspects of its services and the perceived gaps. It will also ensure the authority is aware of any difficulties being experienced by the consumers of the services provided by the authority.
The provision concerning public submissions will give feedback to the authority which will make it aware of perceived difficulties on the part of the public with the services it provides and will motivate the authority to address them.
I am conscious of the difficulties which successive Ministers have experienced in securing information on waiting lists. The Minister for Health and Children told the Dáil a few weeks ago that he had to insist he had final figures by the beginning of March from some of the health boards to enable him to respond to a parliamentary question. In the context of waiting lists, the authority should have an on-line system which indicates the number of persons on waiting lists in each area and it should be programmed to state the length of time an individual has been on a waiting list and detail the nature of the waiting list each consultant has for individual specialities and the consulting waiting lists. This information should be available to the Department of Health and Children and to GPs. There is no reason it should not also be available to the general public.
We need to ensure that systems are in place for the Department to be able to develop policies based on up to date information, not on information which is three, six or 12 months old.
In the child care area the Department and successive Ministers have been inhibited in developing policy. Issues have frequently been dealt with when it was too late, because the basic background information on the manner in which the services are functioning was not available.
On the Department's website, which could be greatly improved in the provision of information, some three or four weeks ago, the latest statistics the Department was able to give about children in care nationally was to the end of December 1996. In January of 1999 that is completely inadequate. I am still waiting for information from the Eastern Health Board concerning child care issues.
I am anxious to ensure that up to date, modern technology is maintained and a proper business approach is adopted to the maintenance and dissemination of information and that this authority reports at the end of the first quarter in each new year on the services provided by it in the previous 12 months.
I am conscious that each of the health boards is required to produce annual reports on their services. The difficulty is that these reports are often produced after long delays. We should set down the latest date by which reports should be received.
The authority does not provide services as such. For that reason the proposed new section 10(1)(a) is inappropriate. Section 10(1)(b) is covered by section 8(3)(c) where the authority has a statutory requirement to make sure that it evaluates services being provided to the area health boards, the bodies within the Bill which will provide the services.
It is important that the authority has up to date monitoring and evaluation services to do the job and for that reason significant money has been allocated in preparation for this move to ensure that the services provided are closely monitored and evaluated. There are sophisticated information systems which have been commissioned at an overall cost of £10 million which will be put in place over the next 12 months.
The monitoring process will focus on the key elements of service agreements identified in the task force report. These are the quantum of service to be provided, effectiveness, efficiency, equity, quality, access, appropriateness of care and responsiveness to the public. These are the criteria under which monitoring and evaluation will take place.
The authority is already obliged under section 15 of the Health (Amendment No. 3) Act, 1993, to provide an annual report. Each health board must produce its report by June 30 and we should use that as the date for the production of reports by the authority and individual boards.
Those are our responses to the proposed section. Section 10 (1)(b) is covered by existing provision. Section 10 (1)(a) is not relevant to the extent that services as defined in the Act are services which are provided by the area health boards. The practicality is that the need to monitor and evaluate effectively is in hand and significant resources are being made available for it.
Will the report which will be produced by the authority at the end of June each year detail what it has learned as a result of monitoring and evaluation of services? Will it clearly set out where there are service deficiencies which need to be addressed? Does the Minister agree these reports would have greater value if they did not just consist of the authority or health board commenting on itself but if the authority was actively required to seek submissions annually from members of the general public on aspects of the service with which the public is having difficulties? There should be some consumer input into the health service on a more localised basis.
The existing statutory requirement under section 15 of the 1996 Act requires an annual report to include a statement of the services provided by the authority, in this instance, in the preceding year and such other particulars, including financial statements, as the board considers appropriate or as the Minister may specify. The authority and area health boards will provide annual reports and there is common membership on both. It will not be a case of asking the membership of an authority not involved in the area health boards to produce a report not relevant to the three area health boards. Public representatives represent the consumer in a far better way than people who nominate themselves as representatives of the consumer. It is, therefore, the job of those on the board to insist that the authority reports adequately on the issues it regards as important, whether the reserved or executive functions of the authority.
Section 15(2)(b) of the 1996 Act refers to the annual report, including such other particulars as the board considers appropriate or as the Minister may specify. In addition to the normal annual reporting mechanism, the authority might usefully report to us. I take the point that if it has a valuation and monitoring role, it should be able to detail how it believes the boards are doing. Common membership on both would benefit health boards in that the authority would give a view to the area health boards on how it believes they are doing.
The authority will operate differently from the other seven health boards and will have an overview function of the area boards. I am conscious that at present if an individual has a difficulty with a health board and if there is a belief a health board is not providing an adequate service or there is a gap in its services, they may turn to TDs or to the public representatives who are members of the board or they may make a complaint to the Ombudsman.
Over the years the Ombudsman has dealt with a large number of complaints in other areas and has forced Departments to address issues not previously addressed properly. The Ombudsman is now discovering difficulties with some health boards. This may not be an appropriate mechanism to do so and a ministerial direction may be appropriate in the context of the other health boards as well the Eastern Regional Health Authority, but if the health boards put in place a structure through which complaints about a service provided would be channelled, it would give the health board an opportunity in its annual report to address those issues, not necessarily in the context of replying to individuals but in particular areas in which difficulties have arisen which are generating serious complaint. It would be good if the area authority or a health board placed its view on the record, acknowledged there is a problem and indicated in its annual report how it proposes to address it.
Over the years the Adoption Board, in its annual report, has tended to comment on gaps in the area of adoption which need to be addressed. Some of this comment has resulted from pressure on the board - for example, in the area of origin tracing by people who seek services from the board which it is not legally or administratively in a position to provide. Highlighting the need can act as catalyst to problems being addressed.
The Eastern Regional Health Authority should have a type of self-critical section to address issues which need to be addressed. Because it is now performing a different function from that of the other health boards, it should be able to address difficulties brought to its attention by members of the public as regards the functioning of the area boards.
I take the point at which the Deputy is driving. It is important to recognise it is not the function of an authority or a health board to comment on the policy pursued, as that is a matter for us in the Oireachtas. We may have arguments about whether there are gaps in the service or whether we should put more resources into it. Like Secretaries General and others, those who come before this committee from the authority will have to address the exercise of their executive functions, but they cannot suggest there should be an alternative policy. That is not their function; their job is to implement policy on which the Oireachtas decides. The reporting mechanism should not be used by them to deal with an area of activity which is not properly within their remit - nor would they want to get into it. That would not be beneficial or right, in the same way as we cannot exercise the executive function we delegate to them on a day to day operational basis.
I will come back to this on Report Stage, but I take the point on the type of issues to which the annual report of the authority might advert and what is envisaged. Rather than it being strictly a financial statement, the authority should use it to let us know if area health boards are not implementing existing policy as envisaged and if the strategic focus of the authority is being frustrated in terms of the implementation of existing policy. We need to know that and the authority needs to be able to confirm it. I do not believe that should be the case since there is a common membership on all boards. I take the general point that we need to contemplate the areas on which it will report. I do not accept it should be a case of them saying it would be great if they had more money to do this and that. That is not their function, it is for us to decide.
Amendment, by leave, withdrawn.
SECTION 10.
I move amendment No. 12:
In page 7, subsection (2)(a), line 24, after "Board" to insert "being an arrangement which in each case ensures equivalent comprehensiveness of service as between the three Area Health Boards".
The reason I tabled this amendment is that I am concerned about equality between the three area health boards. Looking back historically at the Eastern Health Board region, there are differences of service which go back further than the establishment of the health board and probably relate - as I am sure the Minister is aware - to the difference between an urban and a rural county service, as in the case of County Wicklow which has traditionally been a rural county. Perhaps people's expectations were not as great in terms of services from the health board.
Whatever the reason, there are differences and anomalies within the system currently will. One simple example relates to vermin control. People living in Dublin can get a more developed service than those in County Wicklow and presumably in County Kildare, although I do not know how it applies there. Recently, I received complaints about services provided for the terminally ill at home. There are disparities between Wicklow and Dublin. The fact there are differences is something we need to address. These new structures will create an impetus to look afresh at what is provided and to iron out any historic anomalies.
There is also another separate aspect. We will have three area health boards which will inevitably have a different formation, a different set of services, to some extent, and differences between them. In the East Coast Health Board the profile is quite different and deficient in relation to paediatric services compared to the other health boards. I believe I am right in saying there is not even a consultant paediatrician in the East Coast Health Board area and there is certainly no paediatric accident and emergency unit. Such discrepancies are worrying, and I do not believe the Minister or anyone else would want us to end up with disadvantaged health boards as a result of this new structure.
There must be a conscious move to establish some type of equivalent comprehensiveness. Although I have used a very cumbersome term, I cannot think of a better one. I am sure the Minister, with the back-up in the Department, may have a better term. I believe he understands very clearly the point I am making. We must ensure that people are not disadvantaged because they live in one health board area rather than another. There is a danger this will happen if we do not have a base line. It is not that we do not have any experience from which to learn as we have inherited anomalies from the old district boards. The authority, whose job is to co-ordinate services, must ensure equivalent comprehensiveness of service in each area, otherwise, people will be at a disadvantage. The idea is to give people greater advantages. I do not want current difficulties exacerbated by the type of changes proposed.
It would not only be impossible to divide into equal thirds the level of services in the three area health boards but it would not necessarily benefit patients. That is not the function of the Bill. The Eastern Health Board provides a range of services under one structure. The problem in the delivery of services has been identified as the lack of a central authority to manage the situation. The present structure means the delivery of services is put at risk and the quality of decision-making is not as good as it would be if there were more localised structures. I know what the Deputy means but it is not correct to suggest that the Bill is geared for that purpose.
Although this authority deals mainly with urban areas, there are rural areas under the Eastern Health Board and existing services in existing facilities. We are trying to ensure that a central authority delivers those services in the same way to everyone in the health board area through better co-ordination. Successive reports and experts who have studied this area have stated that the absence of a single authority with responsibility for the planning of all statutory and voluntary services is the reason people feel disadvantaged within the health board region.
Proximity to services is relative. All services in the Eastern Health Board region are closer to the people than in other rural health board regions where the geographical distance from the availability of services is greater. Because of the way the health services have developed over the decades, national specialities in the main are located here. Services, particularly national specialities, are closer to people in this region than they are to people in Cork or Donegal who may need such tertiary treatment at some stage.
I cannot accept the amendment on the basis that it would seek to give an impossible mandate to the authority to have equal thirds in the three health board areas. That is not the purpose of the legislation. If, on the other hand, the Deputy's concern relates to the consistency of approach in the administration of services across the three health board areas, an assurance can be given under section 17(8). All area chief executives are required to exercise their functions subject to the general directions of the regional chief executive. The purpose of this provision, therefore, is to ensure that the approach of the regional chief executive is uniform and consistent across the region as a whole.
We are not interfering with the services as they stand in this Bill. When the authority is set up, any proposals to provide a better co-ordinated service will be dealt with by it and subsequently by the area health boards. Any changes required will take place in that forum but they will not be prescribed by me in this legislation because it is only setting up the new organisational structure under which those issues can be discussed and successful solutions found.
I am not making much headway with the Minister. As regards advantage and disadvantage, I accept that people living in the greater Dublin region are at an advantage in terms of national specialities compared to someone living in Donegal. However, I am talking about services provided by the health board or hospitals in Dublin which are not considered national specialities.
The Minister must appreciate that the type of counselling service needed by someone who lives in Tinahely and whose son commits suicide, for example, is difficult to access. It will take a mother over an hour and a half to take her young daughter to Our Lady's Hospital for Sick Children in Crumlin from a rural part of County Wicklow. It is extremely difficult to access health board services which should be easily accessible and which make a vital difference to people. Someone living in the southern end of County Wicklow is at a great disadvantage in terms of accessing treatment and counselling for child abuse. I have already mentioned the terminally ill where there is a clear disparity between the two counties.
I am concerned that we will maintain in a new form the disadvantages which exist at present. I understand there must be economies of scale in terms of national specialities and that it is difficult for the Minister to fight that battle. However, that is not the issue. I am talking about health board services with which people in rural areas of the current Eastern Health Board region are having difficulties. Unless this is recognised when these new structures are set up, I am afraid the disadvantages will be institutionalised into the future. This is an opportunity to ensure that does not happen.
Living in Tinahely or Carnew is different from living in the inner city where there may be a different type of deprivation but where access to hospital and health board care is easier. I am concerned about the counties outside Dublin which are part of the Eastern Health Board region. The Minister said he cannot accept the amendment but I ask him to ensure that the authority looks at this carefully so that there is equity for the thousands of rural people under this new structure. It is important not to forget that this is not a city structure but a city and rural structure.
I accept the Deputy's point. The experts who have studied this believe that if we want to improve the situation for people on the periphery of the region who feel they do not have the same access to services as people closer to the urban centre of the region, we must have a radical overhaul of the organisational structures within the Eastern Health Board area which serves 1.3 million people. It is impossible under present organisational structures to do that. It is to meet that reality that the East Coast Area Health Board will be based more locally and will help to provide services for the people of Tinahely which are more relevant to their needs rather than asking them to travel to Crumlin or to the Eastern Health Board opposite Heuston Station for counselling after a family tragedy. I accept that we need more localised services but this Bill simply seeks to radically overhaul the organisational structures. It is far more likely for that to happen under the new set up than under the present set up. That it is not happening under the current set up is the criticism. The authority's role is to ensure that the three area health boards providing that more localised service do so in a way which avoids duplication, which is efficient and so that people are not let out of acute hospital beds without provision for sub-acute care or nursing home care. These are the issues which arise continually. We are trying to address those issues.
Part of the anomalies go back to prior to when the health board was set up. Setting up a new structure does not necessarily mean that it will sort out all the problems.
It is more likely. Experts back that view.
I favour this development and I support it, but we need to be conscious of what needs to be done.
It would be extremely helpful if the headquarters of the east coast health board was located in Bray, County Wicklow. I hope the Minister will consider that as a gesture of good faith.
Amendment, by leave, withdrawn.
I move amendment No. 13:
In page 8, subsection (5), lines 9 and 10, to delete paragraph (a).
This matter was the subject of debate as to whether the responsibility should lie with the area health boards in relation to the organisations in the voluntary hospitals or whether it should, as the Minister determined, stay with the authority. It would be wiser to delete this paragraph. It will give more room for manoeuvre to the authority to decide the powers to be delegated downwards.
I have heard convincing arguments why the health boards should have this power and these arrangements rather than the authority. There is a concern that the authority will be bureaucratic because it is large, that it will end up making the decisions and the health boards will not have real authority. I would have thought that it makes sense for the Minister to simply delete this paragraph and allow things to develop more organically. If the authority comes to the point of deciding that arrangements can be made with the person specified in the Second Schedule which will make the system work more efficiently and be more accountable, why not allow it? However, if the Bill states that the authority is prevented from making that movement forward, it will not be considered and the opportunity will be lost. I do not suggest that they must do it but that the Bill be silent on that. I do not see why the paragraph must be in the Bill. The Minister is adding unnecessarily to the top heavy nature of the structure.
I cannot accept this amendment, as the basis on which we achieved an agreement to reform the delivery of health services outlined in this Bill was a consultative process and a respect for the independence of the ethos and traditions of the voluntary sector, about which we spoke with regard to another amendment. It is on the basis of guaranteeing that they will have their funding dealt with through the central authority that we have got the voluntary sector on board in the overall reorganisation of the services in the region.
To accept this and take away the Second Schedule and the idea that they would not have to deal with the central authority would undermine the basis on which they agreed to participate. It would undermine the task force recommendations. This is the basis on which we achieved agreement and, therefore, we must respect that agreement.
It is open, under the provision of the Bill, for bodies in the Second Schedule to opt for direct funding from the area health boards if they so wish. That will require their agreement and consultation. We must deal with them on that basis. If we were to accept this amendment and state that voluntary bodies outlined in the Second Schedule will now take their funding from the area health boards, this Bill would not receive the co-operation we need.
Amendment, by leave, withdrawn.
Section 10 agreed to.
SECTION 11.
Amendments Nos. 14 to 27, inclusive, and amendments Nos. 29 to 31, inclusive, deal with the number of members and the composition of the membership of the Eastern Regional Health Authority. These amendments have been tabled by either Deputy McManus or Deputy Shatter and, in the case of amendment No. 24, by both. Both Deputies have submitted amendments which would increase the total number of members of the authority.
Deputy McManus has submitted amendment No. 14, which would increase the total membership to 59 from the existing level of 55, and Deputy Shatter has submitted amendment No. 15, which would increase the total membership to 57. Amendments increasing the numbers of members of a health board - for the purposes of the Bill the authority is construed as a health board - involve a charge on the Revenue. The reason for this is that members are paid travel and subsistence expenses in respect of their attendance at board meetings and these expenses are ultimately funded by the Exchequer pursuant to section 32 of the Health Act, 1970. In the circumstances, amendments Nos. 14 and 15 are inadmissible.
In addition, amendments Nos. 19, 23, 24, 25 and 26 from Deputy McManus and amendments Nos. 18, 24 and 27 from Deputy Shatter have also been ruled out of order because in each case the amendments propose consequential increases in the number of members.
Although the Deputies have tabled amendments reducing the number of representatives from particular sectors, these do not offset the total increase. I am required to rule out of order all amendments which involve an increase in the membership of the authority.
Amendments Nos. 14 and 15 not moved.
I presume amendments Nos. 16 and 17 will be taken together.
Yes. Amendment No. 17 is consequential on amendment No. 15. Amendments Nos. 20, 21, 22 and 29 are related. We will take amendments Nos. 16, 17, 20, 21, 22 and 29 together by agreement. Is that agreed? Agreed.
I move amendment No. 16:
In page 8, subsection (2)(a), line 25, to delete "30" and substitute "28".
I appreciate that there is not a perfect solution to the numbers who should be on the health authority. I came to this Bill with a view that 55 members was too many and that if possible it should be reduced. There would be great difficulty for an authority of 55 members to meet a minimum of six times in the year and function. I was also conscious of the difficulties of the Minister and the background to all of this in that it is important that the authority has a reasonable representation from public representatives of each of the different local authorities. The report on this matter recommended that there should be a majority of public representatives on each area board. With regard to the broad range of services provided by health boards, it is also important that, in addition to consumers, the professionals providing such services have adequate representation.
The Minister stated that public representatives represent the consumers of the services. However, on further examination, there is concern that some groups are not represented at all or that their representation is minimal. In the context of the membership of the Eastern Regional Health Authority, it is important that the area boards include a representative of particular professions. In that regard, the Bill provides for the appointment of 30 public representatives by the local authorities. I propose that this be reduced to 28 and that the number of members from Dublin Corporation be reduced from ten to eight. That would reduce the total membership from 55 to 53. The initial proposal is to adopt that approach, the intention being to provide for additional membership.
Amendments Nos. 24 and 27 have been ruled out of order. Deputy McManus and I propose, in amendment No. 24, that the number of nurses who should be appointed by election from the ranks of registered nurses should be increased from one to three. In my opinion there should be a registered nurse on each of the area health boards. That should happen as of right, not by the courtesy of a local authority making such a decision. The reduction in the number of members appointed from Dublin Corporation is not proposed to simply reduce its representation, it is aimed at creating a gap and maintaining a measure of control over the numbers serving on the board.
The other amendment that has been ruled out of order is designed to make provision for social workers to be represented on the board. The health board employs an increasingly large number of social workers who provide a wide variety of services. Perhaps the Minister might, if he has the information in his possession, indicate the total number of qualified social workers working for the health board. The people involved in this profession do a great deal of work, provide a wide range of support services and are aware of the difficulties the health board is experiencing in delivering those services. In establishing a new authority, it is anomalous that it should include representation from the ranks of doctors, nurses, dentists, pharmacists and the various voluntary organisations which deal with disability. However, the social workers who will work for the area health boards will not be represented.
It is clear the committee cannot increase the numbers from 55 to 59. However, if we were to adopt my proposal the numbers serving on the area health authorities would be reduced from 55 to 53. If that occurred, the two amendments ruled out of order, which were designed to increase the numbers of nurses serving on the authority or to provide for participation by social workers, would no longer be out of order. If we reduced the numbers from 55 to 53, both proposals could not be adopted but one could. Alternatively, an amended version could be adopted to provide for the appointment of one social worker and one additional nurse which would maintain the authority's membership at 55.
I do not intend to propose that we simply reduce the number of members appointed from Dublin Corporation without ensuring additional nursing representatives and representatives from among the ranks of social workers employed by the authority are appointed. I will be interested in the Minister's reply in that regard.
Is the proposal that deals with non-consultant hospital doctors also under discussion?
Yes.
Section 11(2)(b) makes provision that, of the 13 members of the registered professions - effectively, these people are medical practitioners - appointed to the board "9, including not less that 2 consultants in general hospitals, not less than one consultant psychiatrist, not less than 2 general medical practitioners and not less than one registered medical practitioner with special knowledge or experience in preventive medicine, shall be appointed by election". However, there is no provision for representation from among the ranks of non-consultant hospital doctors.
The Minister stated earlier that one of the reasons for not including such representation in the past was that their term of contract is relatively short and it was not envisaged that a full term would be served on a health authority by a non-consultant hospital doctor. I put it to him that some of the contracts now being offered to non-consultant hospital doctors cover longer periods than they did some years ago and hospital registrars may remain in their posts for longer than heretofore. A number of hospitals have already begun to appoint specialists to operate below the grade of consultant. One of the policies the Minister is attempting to pursue - I support him in this regard - is to gain recognition of the need within the medical service to provide for a specialist grade below that of consultant in particular areas of speciality. If such a grade were established, the specialists appointed would be non-consultant hospital doctors with a far longer term of contract than is the case at present.
Non-consultant hospital doctors play a substantial role in keeping hospital services in operation. In my opinion, their representatives could play an important role on the board of the authority. In that context, I urge the Minister to take on board the amendment I proposed because it would at least guarantee that one doctor acting in a non-consultative role in the hospital service would become a member of the authority.
I echo the view that 55 is a high number of members for any authority. Proposing that this be increased to 59 would not make a blind bit of difference in terms of the excess baggage involved.
I tabled these amendments because I am concerned about the effectiveness of the authority. The more the authority evolves, the more work it will take on and the less the health boards will be involved in decision making and streamlining the service. At present, very clear arrangements are in place regarding the various people serving on the health board - be they chemists, nurses, doctors, etc. Everyone agrees that the system covers too large an area and must be reformed. However, if we are going to establish three health boards and lose that kind of cohesion at health board level, the decisions that should be made at health board level will be made at authority level. If, as at present, various representatives, such as nurses, doctors, chemists and dentists, are not involved, at least two health boards, probably three, will not include representation from among those areas of expertise.
It appears the new structure will involve a great deal of expense but not much expertise. There is a danger of duplication if health boards, which can make decisions and debate issues, are obliged to refer matters to the authority for resolution. Chemists are an obvious example in this regard. In my experience a methadone treatment programme of any kind cannot happen unless chemists are involved. Chemists have been one of the major blockages in terms of getting a full methadone treatment programme consistently in all areas. They are vital to the anti-drugs strategy. There will be at least two health boards where the chemists will not be participating or involved in any way because they will not be represented. That is a grave loss and a fault in the system.
One of the major complaints in the Eastern Health Board region is about dental services. All TDs in the Eastern Health Board region are weighed down with demands from parents about orthodontic treatment, etc. It is important they are included. They need to hear what the public representatives are talking about. I accept the Minister's point that the public representatives represent the public interest and represent, in effect, the consumer and patient. If the professionals are not involved in the discourse and debate, the public representatives will be talking to each other. That is not very productive when an alternative is possible. It may appear unwieldy having three of everything but we have three health boards and we need to recognise that fact when the various disciplines are being represented.
It is important the non-consultant hospital doctors are represented. I hope the Minister will accept that point.
I am not.
I thought he was; I thought he was going to come up with a magic solution. I am disappointed if this is not the case. While the junior hospital doctors are transient due to the nature of their work - health board and local authority officials are transient as well, the nature of the beast is that there is movement in particular aspects of the health services and local authorities which has to be recognised - they are well organised and can be represented even if the individuals move round the system. The actual cohort can be represented very effectively. There are various central issues, one of which I will raise later. There are pressures on junior hospital doctors in relation to working time.
Major concerns have been expressed this week by some Fianna Fáil members of the Southern Health Board about the extent junior hospital doctors are being exploited and are, in my view, creating risks from working all the hours expected of them. This has been raised by the profession itself and is an issue that will become more serious and acute as the demands on doctors grow. It is important that the Minister look again at this issue. If he will not include any provision for junior hospital doctors, then I have misread the signals and I will raise this matter again on Report Stage. The public patients see the junior hospital doctor, not the consultant. They need to have confidence that the junior hospital doctor is not being worked to death.
The Deputies have outlined some of the problems in how we try to square a circle. Everyone is agreed that there should be a majority of public representatives on the board. If we try to accommodate every profession, not just the registered professions as at present but non-registered professions and socio-medical professions - you can talk about non-hospital doctors, occupational therapists, physiotherapists, social workers and a whole range of people working in this service in relative numbers terms - to maintain the principle of majority public representation you will end up with an unwieldy number that would not be feasible. If you accept the principle of majority public representation being the issue, then you have to be prepared to acknowledge that to achieve that, everybody cannot be represented on a board. Someone could claim they should be represented on a board because of their profession.
My next point is often missed by many who are appointed to boards. When a person is a appointed to a board he or she is not there simply to represent a profession, they are there to do a job, bringing their expertise and abilities as board members and have a far wider remit than protecting vested interests. Unfortunately, many of the people made are under the mistaken belief that without representation on the board their interests cannot be protected because it is only the interests of those represented on the board that are catered for. That is a wrong assumption and certainly not a premise upon which one should try to address this problem. Otherwise we would need the Seanad Chamber every week to have an Eastern Health Board or public authority meeting and it would not stop at 60 members. That is the reality.
Consistency of approach needs to be shown here. As with other boards we do not want to create a sui generis situation. There is an argument for and against how we should address this problem generally where, under the Health Acts, the people who are represented on boards - and I do not make the point that they are representing their profession but the people who have access to become board members with this wider view of what their role is - are only members of registered professions. Non-registered professions do not have that statutory favour. That is a more general issue to which people might want to address their minds. We must ensure that everybody addresses his mind to that issue without us ending up with just bloated boards all over the place. It would require give and take, consultations would have to take place and a very detailed process would have to be entered into to see if some people who are at present not available for membership of a board could be accommodated. That is a wider issue than this Bill.
To come back to my basic point, if we believe in majority public representation, as I do and as the previous Administration did, then we must be prepared to acknowledge that we cannot accommodate all the professions. We have to remind these professions on a board that their job is not to protect their own interests, but to give of their expertise generally in the public interest. That is what public representatives do. If a person were to say there should be fewer with special expertise on certain boards, it might not necessarily be a bad thing in some cases. I am not saying that is what we should do. In my opinion many of those with the most common sense are the public representatives who have the customer and consumer focus more to the forefront of their minds than people who know a lot more about medicine who happen to be on the same board. One should never generalise or be unfair. I am not being unfair to anybody. I have seen many instances in my political career where the people who were most political were not the public representatives who took the harder decisions and would have to knock on doors after rationalisation. The people who were opposed to rationalisation in many instances were those who felt that their particular fiefdoms were being set upon. That is a more general point.
How do we try to accommodate these concerns? I do not agree that we should reduce the number on Dublin Corporation because it has the biggest population to look after; they have ten representing 500,000 people. On Second Stage, Opposition colleagues felt very strongly that now there was an opportunity for the city of Dublin to be better represented on the authority because the numbers of public representatives were what they thought they should be. None of us are members of Dublin Corporation and a reduction in its representation on the authority by two will mean that we will not make many friends in the corporation area, although I recognise what the Deputy is trying to achieve.
I also recognise the fact that because certain aspects of his overall proposals have been ruled out of order, it is hard for him to cut and paste within those constraints. However, I acknowledge that having only one representative of a profession on a central authority creates a problem in the context of the three area health boards. I have given the matter considerable thought since it was raised on Second Stage but I did not table specific amendments in regard to it because I wanted hear people's views. A possible solution is that each professional representative on the board could have observer status on the two area health boards of which he or she is not a member. If this were considered too great a workload for an individual, we could look at providing, on an administrative basis, for a deputy to attend on behalf of the member.
A similar situation currently pertains with regard to Eastern Health Board committees and such a system could be put in operation by the authority on an administrative basis but because there is one psychiatric nursing representative and one general nursing representative, if an individual votes with one, he or she could be in trouble with the other. However, it could be arranged that they are present at meetings with observer status. As a result they will know what is going on and have a sense of participation.
Will they have speaking rights?
Yes, but they would not have voting rights on the board to which they are assigned. That would apply to the member of the authority, which is envisaged under the Bill anyway. That may be the best way forward. I am speaking to people affected by this who feel that they are professionals and this may provide the best solution in a difficult situation. The matter can be discussed further if the Deputy wishes. However, I reiterate that when one tries to accommodate one side of the argument, one ends with a gap on the other side. We already accept and acknowledge that 55 is a difficult number. Many minds will be applied to this and that may be the best practical solution I can find to the problem.
I agree entirely with the Minister's view that representatives of a specific profession on the authority or the area board are not there to protect the interests of their professions but to offer their expertise, insight and knowledge. In that sense, it is important that there should be a nursing representative who can attend meetings of each area board and this led to the proposal that there should be three nursing representatives on the authority rather than one.
I agree with Deputy McManus that there should also be a representative of the dental profession on each board and if a way can be found around this which does not increase the size of the authority, it would be desirable. We retain serious reservations about its size and capacity to do work. If all its members are very active, the agendas for authority meetings could be so extensive that most issues would not be discussed. Of course, if a large number of members are inactive, it will not serve its purpose. Therefore, size is a problem.
If the problems of dentists and nurses can be addressed in the manner suggested by the Minister whereby observer status would be granted to members of those professions on each area board, expertise would be available. I urge the Minister to consider the position of social workers and I am aware that various other professions within the health board could also be represented. I am conscious that within the current health board structure that there is no specific provision for social worker representation. One reason is that there has been so much difficulty with child care services - the Department has not done enough over the years and it seems to take years to change anything because there is a lack of information from people working at the coal face. Social workers should be represented on the authority and there should be at least one representative on each of the area health boards. They can bring expertise to meetings and help the boards to focus on the inadequacies of their child care services and the measures which need to be taken to address them from an internal perspective.
At present, nobody represents the experiences of social workers to Eastern Health Board members in order to discuss their problems. Of course, the administrative staff of the health board can do so at meetings, but there is a role to be played by social workers. However, they have not always pushed their role. The large number of social workers currently employed together with the increased number of recruits makes it essential for such expertise to be brought to bear in the deliberations of area boards or the authority if they are to operate effectively. The Minister has not yet responded on the non-consultant hospital doctor issue in terms of whether he is willing to accept my amendment or that of Deputy McManus.
I welcome that fact that thought is being given to this matter by the Minister. I wish to refer to the question of professionals and his view with which I will not argue. I do not doubt that professionals are nominated to boards and defend their patches, although public representatives are also good at that. However, one group is not necessarily more principled that the other. The defence of their patches by professionals occurs anyway. I refer again to chemists as an example because it is better to have them on the inside and, if necessary, defending their own patch and sometimes the indefensible, particularly in terms of their role in combating drug addiction and the drugs menace. They have the capacity to transform a community but very often refuse to participate and get involved.
The Minister should look closely at this and begin throwing his weight around in terms of how dispensing chemists approach the issue of distributing methadone. Drugs are an issue throughout the Eastern Health Board area and I would prefer if an individual were on the board who could deal with the issues related to dispensing - the advantages, disadvantages, fears and staff losses. They would be addressed democratically rather than having professionals outside the system making decisions without any connection with the needs of communities. It is important that these people are on the inside and are brought in because many of them provide the key to good health. I cite chemists because they seem to create the logjam in certain circumstances at present, but there are other examples.
My proposal regarding pharmacists being available throughout the area health board in terms of attending and speaking at meetings is something to which we are trying to apply our minds. The same applies to general nurses, psychiatric nurses and dentists. They are the people we are trying to get on to the boards.
The non-consultant hospital doctors issue has wider ramifications. Were we to do it in the eastern health authority region, we would be asked to do it everywhere else. There is a wider issue involved.
We are making a new start in the Eastern Health Board area.
The Minister has told us that he wants to extend this.
We want to extend the model of the delivery of service, not the representation on the boards. We are trying to marry the statutory and voluntary sectors so they are in tune and not delivering services in isolation from each other. That is the important work. This is a logistical problem and we know that we cannot represent everyone. I understand the Opposition has a job to do in putting forward these amendments, discussing these issues and seeing how to solve them. At the end of the day, however, I have the responsibility of making it all add up and it is not a simple task.
There is a wider issue - membership of boards is restricted to registered professions. We may have to look at that but we can require registered and non-registered professions and existing health board personnel to work this out. We cannot be expected to accommodate everyone, ending up with far too many people which then effects the efficacy and good running of the board because they feel we have met their particular request. We must make a decision.
There is no point creating a precedent which extinguishes one fire and ignites many others. That will only solve the problem in respect of the people who made the representations on this issue but when one accommodates social workers, for example, occupational therapists will come in the back door for a chat. Making flesh of one and fish of another will lead to trouble. We cannot make everyone happy - that is the bottom line. I have gone for majority public representation and that means so many others can get on the board. It is done in the same manner for other boards. I propose to stick by that and look at the single professions in terms of getting them access to the three area boards without affecting the overall number. I cannot solve every problem by doing that but it is the only logical way to goand I cannot add to it until we return on Report Stage.
Aside from the other professions where I can see there would be open-ended problems, the Minister is talking about creating a structure where everyone apart from junior hospital doctors will be involved. The junior hospital doctors have more contact with the patients than any doctor, apart from the GPs. They are a significant part of the overall medical profession and they are not represented. The Minister is tilting the balance in favour of the consultants who are guaranteed places against the non-consultant hospital doctor who will not be included.
I am making provision that the same category of medical doctors is represented on this board as is represented on all other boards.
There should be a balance.
There are wider policy issues which would have to be addressed in the general context of all boards, otherwise it is a totally inconsistent approach.
In the circumstances of the Minister's response and in the context of my amendments, which seek to extend the nurses' representation from one to three and to allow for social worker representation being ruled out of order, I will not press the amendment.
Amendment, by leave, withdrawn.
Amendments Nos. 17 to 20, inclusive, not moved.
I move amendment No. 21:
In page 8, subsection (2)(b)(i), line 40, after "consultants" to insert "and 1 non-consultant hospital doctor".
Amendment put and declared lost.
Amendments Nos. 22 to 27 not moved.
I move amendment No. 28:
In page 9, subsection (2)(c)(ii), line 24, to delete "mental handicap" and substitute "intellectual disability".
Amendment agreed to.
Amendment No. 29 not moved.
Amendments Nos. 30 and 31 are related and may be taken together. Is that agreed? Agreed.
I move amendment No. 30:
In page 9, subsection (2)(d), line 31, after "Minister" to insert "to be representative of patients in the functional area of the Authority".
There is provision for three members to be appointed to the established authority by the Minister. I propose that the amendment be made to provide that the three appointed by the Minister shall be representative of patients in the functional area of the authority.
I also propose an additional provision in amendment No. 31 whereby "a person appointed by the Minister as provided for in paragraph (d) shall not be a member of a local authority, Dáil Éireann or Seanad Éireann". There is specific representation provided for public representatives on the authority and it is important that the people appointed by the Minister should be representative of the patients' interests in the context of the health services.
If the Minister is not willing to take that amendment on board, we should ensure that those appointed by the Minister are persons other than public representatives. That provision would provide some flexibility to the Minister to address some of the issues previously discussed. It would be open to the Minister to appoint additional nursing, dental or social work professionals or other interests to the board.
In relation to the existing local politicians who would be on the area boards, if they do not represent patients, who do they represent? This amendment suggests that I would appoint representatives of patients in the functional area of the authority. I would contend that the public representatives are representatives of patients in the functional area of the authority and have a greater mandate in that area than anyone else.
We talk about democratic institutions but have problems recognising that we are the people who are the manifestation of them. I forcibly reject the idea that there is any person who can say he represents the patient to a greater extent than a public representative. No such person exists. Every member of the public represents himself. In a representative democracy the local public representative unequivocally represents the public. I do not buy into the other argument and it is my opinion that it has done much damage to professional politics to suggest it has any validity.
With regard to the second amendment, I do not accept my discretion should be fettered here, just as it is not fettered anywhere else. I can genuinely say to the committee that I have not put my mind to this issue and that it is one to which I will put my mind once an enactment takes place. In the same way as it need not necessarily be a public representative, it should not be part of this legislation that it cannot be. At the end of the day, ministerial discretion should mean just that - the discretion of the Minister and not of local authorities or the Oireachtas suggesting to the Minister. These are ministerial discretions which are unfettered. It is for the Minister, in his judgment, to use that discretion properly in so far as he can. That is a judgment which will never be unanimously accepted. For that reason, the ministerial appointees to this authority should be no different to those to any other authority under my aegis and which is unfettered.
I would like to respond to that in the context of the first amendment. There are groups who represent patients' interests outside the political system, such as the Patients Association and the various organisations representing people with disability, all of whom play a role representing patients' interests. They play a distinct and separate role to that played by public representatives. It is only right that such groups have representation. Some of the groups representing those with disability may have representation under other subsections of this section.
This proposal sought to ensure that people other than those delivering the services and public representatives are represented on the area health authority, which is a reasonable suggestion. Of course, public representatives represent patients' interests but they also represent their political party interest. For example, where a particular party holds an overall majority in the context of membership of a health board, it is not always in the interests of patients but rather in the interests of protecting Government policy, if it is the Government of the day which has a large number of supporters on a health board. We should not be naive about this.
The Minister made speeches when he was Opposition spokesperson on health but he is happy to say the opposite now that he is Minister. As his colleague, the Minister for Public Enterprise, Deputy O'Rourke, said in the past, what one says on one side of the House does not matter and that once one is Minister, one can have a completely different view. Let us not be naive.
Public representatives might represent the position of patients but they also represent their parties and on occasion do not represent the consumers of health board services because they have a different party political agenda. Just as the Minister might suggest this proposal undermines the role of public representatives, public representatives come to these roles with their own baggage and interests to represent. That applies to all parties - it is not a particular critique of Fianna Fáil.
There are groups representing patients' interests which play a constructive role in the health service, constructively produce critiques of it and which have contributed to the development of policy over the years. It is not unreasonable to suggest the Minister's discretion should be fettered to some degree. On the basis that the Minister is not willing to accept that amendment, it is not unreasonable for the Bill to contain a provision which says these positions are not open to Members of the Oireachtas or members of local authorities. There is a plethora of legislation in force in which we have created a variety of different positions over the years from which Members of the Oireachtas are excluded.
I am concerned to ensure the appointments where ministerial discretion is exercised are based on the needs of a particular health authority. Let us take a theoretical example and assume the Minister's party is in Government and only has a majority in the Dáil with the support of a certain number of independent Deputies - a scenario which may be familiar to the Minister. Let us assume one or two of the Independent Deputies on whom the Coalition Government is dependent happens to be based in the area of the Eastern Regional Health Authority, which strangely and by coincidence happens to be the case at the moment. What happens when it comes to appointing members to this authority and the one or two Deputies - at present, it is one Deputy - whose support the Government requires to stay in office demands a position on the Eastern Regional Health Authority? Is it not likely, based on everything we have learned over the past 18 to 20 months, that the Deputy seeking that role will be put on the authority not for reasons relating to the health system or the authority but for reasons which will ensure the Government's majority is maintained in the Dáil?
In the context of appointing this authority, there should be certain parameters determining who can be appointed. As we have already seen, this Government was willing to produce a proposal for European funds which was shot down for including Counties Kerry and Clare, a proposal which the Minister and I know was produced for nothing other than reasons which would ensure the Government maintained the support of the Independent Deputy from Kerry South. I do not know if the Independent Deputy from Wicklow might now demand a place on the Eastern Regional Health Authority.
It seemed to me that the Minister might have welcomed this proposal as a legislative prophylactic against unreasonable demands being made by Independent Deputies whose support is required by the Government. The Minister should not be put out by this proposal which ensures that no Minister, whether in a minority or majority Government, can be put under pressure by a Member of the House to secure a place on the health board so the Government has support and the Minister maintains his position in office, or put under pressure by the competing demands of colleagues in a political party for a place on a health board.
This is not contrary to the interests of public representatives or the Minister but ensures that a difficulty which could arise and might undermine the credibility of ministerial appointments in this area does not arise. It ensures that Ministers cannot be put under pressure by colleagues or Independent supporters to give them positions which should, in the Minister's better judgment, go to different people with particular qualifications or representing particular interest groups, such as a patients' group. I will not press amendment No. 30 in the light of the Minister's comments but will press amendment No. 31.
Some political colour has been added to the debate. I assure Deputies that I have no intention of filling any vacancies until such time as they arise. The Deputies were supportive of Ministers and Governments which sought to appoint 24 people to eight health boards when vacancies had not arisen. I do not have to take lectures in relation to what political exigencies demanded. Two Ministers of State, if I recall properly, from your health board area, Chairman, sought to become members of a health board while they were still Ministers of State let alone Members of Dáil Éireann which, as the Deputy will know, is a total disqualification from membership of a health board. That was tried under the Administration of the Deputy's party.
I recall the Minister of State at the time suggesting on national radio that I would be hearing from his lawyers. I do not know if he is a client of the Deputy's but I received no correspondence, writ or summons of any description, apart from the fact that the outgoing Minister called me a blackguard for having the audacity to send a letter immediately one had been received from him on his last day in office asking why and how they could take up membership of a health board when vacancies did not exist until the following week. Legislative prophylactics were not used in the demise of the last administration.
We have learned from the history of prophylactics that if one takes precautions a first time it is always good to do so a second time.
It is a pity the outgoing Minister did not hear the cautious and prudent approach of Deputy Shatter at the time. I can assure the Deputy it did not deter me from doing what I had to do to ensure the integrity of my tenure was upheld. Any vacancies arising during my time will be filled by me and any that arise after my time can be filled by my successor. That principle seemed to have lost itself somewhere in the dying days of the last Administration.
Is the Minister saying Deputy Fox will not be appointed to this authority?
I will consider everybody on their merits.
Amendment, by leave, withdrawn.
I move amendment No. 31:
In page 9, subsection (2), between lines 31 and 32, to insert the following:
"(e) a person appointed by the Minister as provided for in paragraph(d) shall not be a member of a local authority, Dáil Éireann or Seanad Éireann.”.
Amendment put.
The Select Committee divided: Tá, 7; Níl, 8.
Tá
- Bradford, Paul
- Clune, Deirdre
- Connaughton, Paul
- Gormley, John
- McManus, Liz
- Neville, Dan
- Shatter, Alan
Níl
- Ahern, Michael
- Cooper-Flynn, Beverley
- Cowen, Brian
- Dennehy, John
- Keaveney, Cecilia
- Kenneally, Brendan
- O’Keeffe, Batt
- Wright, G.V.
SECTION 13.
I move amendment No. 32:
In page 10, lines 33 to 36, to delete subsection (2).
This amendment proposes the deletion of subsection (2) of this section which states "In the performance of his or her duties under this section, the Regional Chief Executive shall not question or express an opinion on the merits of any policy of the Government or a Minister of the Government or on the merits of the objectives of such a policy".
The regional chief executive runs the regional health authority. At a time of greater openness in our public service, someone who has the calibre to be appointed to this position and who has the obligation of managing the new Eastern Regional Health Authority should not be muzzled. I can see no reason for muzzling someone in that position and preventing him from expressing comment or criticism on the merits of a policy which might give rise to a difficulty for the authority. If the authority produces a report which comments on an aspect of policy which creates difficulties for its delivery of service, the chief executive would have a duty to reflect the views of the members of the authority. If he did so, under this provision the regional chief executive would find himself acting in a manner contrary to his statutory function.
Under the provisions of the legislation the chief executive is accountable to the Dáil and it is quite possible that the chief executive could be asked questions before a Dáil committee on health policy issues which impact on the delivery of service. If a chief executive before a Dáil committee is criticised by a Member for a defect in service and the defect is a consequence of a policy decision by Government or spending restrictions imposed by Government, the chief executive could not properly or truthfully respond to a question asked of him. In those circumstances I believe subsection (2) should not be contained in this legislation and I propose it be deleted.
I cannot accept the Deputy's contention that this involves muzzling; rather what is involved is maintaining the impartiality of our public administration system. This impartiality has served this country well and is essential for continued good governance of the public administration system.
Questions of policy are matters for individual Ministers and politicians. The regional chief executive is being put in the same position as others, for example, Secretaries General. This is a standard provision. There is no question of an official being muzzled when he appears before a committee, for example, the PAC. The official is there to give detailed accountability in respect of the implementation of policy, not on whether he thinks the policy is the right one. That is a matter for the Minister. That principle serves us well. For that reason and on the basis that it is a standard provision - it is found in all legislation relating to appearances by public officials before the Public Accounts Committee - I do not understand why an exception should be made in this case. The Deputy has a view on this matter and that is a different issue. However I am not prepared to delete a standard provision of accountability for the regional chief executive. One would not propose that the Secretary General of a Department should have removed from his remit appearances before committees on this basis. The rule of thumb has applied for many years in relation to appearances by secretaries of Departments before the PAC.
The subsection which the Deputy seeks to delete is directly modelled on section 19 (2) of the Comptroller and Auditor General (Amendment) Act, 1993, under which Secretaries General of Departments appear before the PAC. As I have stated, section 13 which the Deputy is seeking to amend, is essentially an accountability measure. The regional chief executive will appear before the Public Accounts Committee to account for the expenditure of the authority and for his stewardship of the authority in implementing Government policy. The regional chief executive, no more than any other official, cannot be put in a position where he is involved with the Minister in making the policy he is supposed to implement. For that reason, I cannot accept the amendment.
Under the Committees of the Houses of the Oireachtas (Compellability, Privileges and Immunities of Witnesses) Act, 1997, civil servants cannot make a statement on the merits of policy.
Amendment put and declared lost.
Section 13 agreed to.
Section 14 agreed to.
SECTION 15.
I move amendment No. 33:
In page 11, between lines 39 and 40, to insert the following subsection:
"(6) Sections 3 and 4 of the No. 3 Act of 1996 (as amended by section 24) shall apply to an Area Health Board as if it were a health board and references in those sections to a chief executive officer shall be construed for the purpose of this subsection as including references to an area chief executive.”.
Sections 3 and 4 of the No. 3 Act of 1996, more commonly referred to as the Accountability Act, define the reserved functions of a health board and the executive functions of a chief executive officer. Reserved functions are exercised by the board and specified in legislation. Executive functions are carried out by the chief executive officer and are defined as functions which are not reserved functions. The intention of this amendment is to apply the concept of reserved and executive functions to the relationship between an area health board and its area chief executive. This type of relationship is already implied elsewhere in the Bill. For example, section 9 allows the authority to delegate reserved functions to an area health board and section 17(5) provides that wherever a reserved function is delegated to an area health board, the corresponding executive functions shall be deemed to have been delegated to the area chief executive.
The experience of health boards since the introduction of the reserved and executive functions in late 1996 has been that the distinction has worked well and has served to improve the efficiency and effectiveness of the work of the boards. It is important the nature of the relationship between the area health boards and their chief executives be made explicit by way of this amendment so all parties are aware from the outset where their respective roles and responsibilities lie.
Amendment agreed to.
Section 15, as amended, agreed to.
SECTION 16.
I move amendment No. 34:
In page 11, subsection (1), line 41, after "Board." to insert "Where the Minister proposes to make regulations under this section, he or she shall cause a draft of the regulations to be laid before each House of the Oireachtas and the regulations shall not be made until a resolution approving of the draft has been passed by each such House.".
This relates to regulations which the Minister will introduce regarding membership of the area health boards. I cannot see any reference in the Bill to the overall size of the board. We know there must be four people on it, how often it must meet and that the fixed term of membership is five years but we do not know the overall numbers of the board.
The intention is to follow the recommendations of the task force.
That is not written into the Bill and I am concerned about it. This also applies to other Bills which have passed through this House where regulations have a significant impact on the outcome of the Bill. However, the regulations are never debated in the Dáil. The mechanism whereby regulations go through is in the form of a negative because it is up to people to raise the issue rather than being in the form that the Minister draws up regulations, allows it go to the Houses of the Oireachtas and then they are implemented. I would have thought this to be a sufficiently important measure for it to be open for debate and for voting on if necessary. I do not imagine there will be any problem with it but there could be. I remind the Minister that there have been instances where regulations were brought in by Ministers in other areas andwere found to be legally faulty. In one case the regulations went to court and were found to be deficient. That illustrates how important it is that regulations are put into the arena for public and democratic scrutiny.
In this instance the Minister will have the power to define the area health board which will replace the Eastern Health Board and will be responsible for thousands of people, yet we do not know what size he is talking about. He will say he has to comply with the task force recommendations but tomorrow he could have a rush of blood to his head - it happens to Ministers - and choose whatever size he likes. That is how I interpret this amendment. It is not set down in the Bill that we can say this is good or deficient or that this is the way to go. Unless we deal with it here or in the way I propose, where the regulations will be subject to scrutiny, I do not believe that is acceptable.
The Minister makes great play of accountability and representing the public but this Bill is deficient under those criteria and under his own criteria. It is not adequate for him to say that he will follow the task force recommendations.
Why?
Because we are dealing with legislation.
I know that.
Since we are defining everything else in legislation we should also define the overall numbers and the profile of the health board.
We are setting up a new authority which will take over the functions of the Eastern Health Board; we are giving statutory effect to that. The proposal in the Bill by way of regulation is to set up the area health boards as set out in the task force report. I have stated on Second Stage that that is my intention in making the regulations required under this section. As I have said, I will follow the recommendations of the task force which provide the following representation on each of the three area health boards. A northern area health board would consist of ten public representatives - six from Dublin Corporation and four from Fingal County Council - five registered professions, one from the voluntary hospitals, one from the voluntary mentally handicap sector, one from the voluntary bodies and one ministerial nominee, totalling 19. In the south-western area health board there will be 12 public representatives - four from Kildare, one from Wicklow, four from south Dublin, three from Dublin Corporation - five registered professions, one voluntary hospital, one from the voluntary mentally handicap sector, one voluntary body and one ministerial nominee, totalling 21.
The east coast area health board will consist of eight public representatives - four from Dún Laoghaire/Rathdown County Council, three from Wicklow County Council and one from Dublin Corporation. It will also consist of five people from the registered professions, one from the voluntary hospitals, one from the voluntary mentally handicap sector, one from the voluntary bodies and one ministerial nominee, totalling 15. That is what will be laid out in the regulations setting up the three area health boards which will be operating to this authority and that is given statutory basis here.
With regard to the regulations being brought before the Oireachtas, the standard provision which applies to regulations under the Health Acts is provided in the Bill. I do not see any reason the positive resolution suggested by the Deputy would be required particularly as section 16 clearly specifies the criteria for membership of health boards.
Is the amendment being withdrawn?
No. There is a precedent for my amendment. Under certain aspects of the Freedom of Information Act there is an allowance for this. It is unacceptable for the Minister to say he is going to do these things when they are not written into the Bill itself. These are not minor matters but significant proposals. This is similar to the earlier issue about who appoints people to health boards. Whatever the individual Minister says is not of parallel significance to what the Bill says because it is the Bill that will become an Act and will have a statutory basis whereas what the Minister says does not. The Minister may say he will allow 15 people from one county to sit on a health board but tomorrow that provision could be changed because it is not specified in the Bill. I am concerned about that. I am not questioning the Minister's good will or authority with regard to the Bill but I believe this proposal should be written into the Bill and the normal checks and balances should be provided. They are provided in other legislation where you can refer regulations back into the Houses of the Oireachtas. This is not the first time the Minister has been asked to make such a provision because I have raised this issue on many occasions in other contexts and I do not see why he cannot do it now.
Section 4 provides that the regulations shall be laid before each House as soon as possible after they are made. Again, it is the standard provision. For resolutions annulling the regulations passed by either House within 21 days will have been laid before the House the regulation will have been annulled but anything done before that date will remain valid. That is provided for statutorily in section 4. The Deputy is seeking a positive resolution rather than a negative one but this is a standard provision with regard to the Health Acts. In order that there is some uniformity in the way we do business I believe the same should apply to this board as any other board. I put forward my opinion because I do not believe this amendment is required because this is part of a wider health legislative framework. That is also the way it was done in the past. I believe in consistency and conformity. I do not believe in changing things just for the sake of it. I know the Deputy would disagree with me but I do not see a good reason for doing other than what we are proposing here.
Amendment put and declared lost.
Section 16 agreed to.
Section 17 agreed to.
SECTION 18.
I move amendment No. 35:
In page 14, lines 1 to 11, to delete subsections (2) to (4) and to substitute the following subsections:
"(2) An Area Health Board shall prepare annual financial statements in accordance with the accounting standards specified by the Minister for the purposes of section 11(2) of the No. 3 Act of 1996 and shall submit such financial statements to the Comptroller and Auditor General for audit on or before the 1st day of April in the year following the year to which they relate.
(3) Upon completion of the audit referred to in subsection (2), the Comptroller and Auditor General shall draw up a report in writing in relation to the financial statements and shall submit a copy of the financial statements together with his or her report thereon to the Authority, which shall submit them to the Minister.
(4) The annual financial statements of an Area Health Board shall form part of the consolidated annual accounts of the Authority.
(5) The consolidated annual financial statements of the Authority shall be prepared in accordance with accounting standards specified by the Minister and shall be adopted by the Authority and submitted to the Comptroller and Auditor General for audit on or before the 15th day of April in the year following the financial year to which they relate.
(6) Subject to subsection (5) , the consolidated annual financial statements of the Authority shall be audited in accordance with section 6 of the Act of 1993.
(7) The annual financial statements of the three Area Health Boards, together with the reports of the Comptroller and Auditor General thereon, shall be appended by the Minister to the annual financial statements of the Authority (as submitted to the Minister by the Comptroller and Auditor General in accordance with section 6 of the Act of 1993) and the consolidated annual financial statements of the Authority (as submitted to the Minister by the Comptroller and Auditor General in accordance with subsection (6) and section 6 of the Act of 1993) and laid before each House of the Oireachtas.".
The new eastern regional health authority will have a budget of over £1.2 billion. Each of the three areas health boards will be responsible for expenditure in the region of £300 million per annum.
It is of the utmost importance that the arrangements for accountability regarding the expenditure of these public funds are as clear and unambiguous as possible. This section sets out the accountability arrangements which will apply to the three area health boards. It also provides for the authority to produce consolidated accounts which will combine the accounts to three area health boards with those of the authority to provide an overall picture of expenditure for the region.
Following extensive consultations between officials in my Department and the Office of the Comptroller and Auditor General I decided to amend this section to clarify the arrangements for the audit of the accounts of the area health boards and the consolidation of the accounts of the authority. The section as originally presented was open to different interpretations and could have led to difficulties with audit procedures in the future. This amendment provides that the accounts of each area health board will be audited by the Comptroller and Auditor General and submitted to the authority which will forward them to the Minister. It also provides that the accounts of the area health boards will form part of the consolidated accounts of the authority which will be adopted by the authority and submitted to the Comptroller and Auditor General for audit. The authority itself being a health board will be governed by existing legislation relating to the accounts of health boards.
Subsection (7) of this amendment provides that when the Minister has received all the relevant sets of accounts - that is the accounts of the authority itself, the accounts of the three area health boards and the authority's consolidated accounts - he will submit them as a package to the Oireachtas. This procedure will enable the Oireachtas and the Committee of Public Accounts to obtain an overall picture of the expenditure in the region.
In line with section 13, the regional chief executive will be the accountable person for all the expenditure in that region. He/she will appear before the Committee of Public Accounts to account for the expenditure assisted by the area chief executives as required.
I have no problem with the principle of this amendment but can the Minister guarantee that when Members of the Oireachtas are presented with the accounts they will be able to see the separate elements in the package? The Book of Estimates does not necessarily reflect what is going on. It is important that each health board is treated separately because if you consolidate all that information there is a danger that it would be very easy for things to get lost or combined and no one could establish where the faults are in the system. Can the Minister guarantee that that will not be the case if this arrangement is adopted?
Members of the Oireachtas will receive five sets of accounts - the accounts of the central authority, the accounts of the three area health boards and the consolidated accounts.
Amendment agreed to.
Section 18, as amended, agreed to.
SECTION 19.
Question proposed: "That section 19 stand part of the Bill."
Section 19 provides that, on the establishment date, the Eastern Health Board should stand dissolved. There are various provisions to ensure the health board's obligations are transferred to the eastern region health authority but I am concerned that there is a gap in this provision. Some years ago I represented a couple where there was an allegation that a child had been abused. Wearing my legal hat I represented them in court proceedings brought against the Eastern Health Board. It was said that the allegations of abuse were untrue and there was a variety of grounds on which a care order was challenged. In the ultimate Supreme Court judgment the care order was set aside. By then any concerns that the health board had that the child was abused had been satisfactorily addressed. They were no longer concerned that the child was a victim of abuse at that stage.
The Supreme Court order set aside the original care order for a number of reasons. First, the courts determined that the Health Act, 1970, which created the health board structure had not conferred a status on health boards to be granted the care of children pursuant to fit person orders, despite the fact that the courts had been making these orders for many years which placed a child in the care of a health board. As a consequence emergency legislation had to be pushed through this House to protect the legality of a variety of fit person orders taking children into care who required to be retained in care because the Supreme Court judgment undermined the validity of all orders made since 1970.
I refer to that precedent because I am concerned that the provisions in this section may not adequately address one particular issue. At present, child protection orders are made under the Child Care Act, 1991, in favour of health boards but now we are dissolving the Eastern Health Board. Before Report Stage, can the Minister look at whether he is satisfied that a specific provision is not required in this legislation to protect the validity, or continuing in force following the enactment of this legislation of child care orders made under the 1991 Act in favour of the Eastern Health Board?
There is no specific provision in this legislation addressing the issue of the Eastern Health Board. Arguably under the 1991 Act and the fact that this new authority is replacing the Eastern Health Board and then we have area boards, the courts may take the view that existing orders made in favour of the Eastern Health Board are now transferred to apply to either the Eastern Region Health Authority or the area health boards. There is a need for clarity here. I presume that in future where care orders are being sought under the 1991 Act they will be sought be the area boards and not the authority. There is a need to clarify in the context of care orders that are already in force in favour of the Eastern Health Board in which board is a child in care following the enactment of this legislation. Is it one of the three area boards or is it the Eastern Regional Health Authority? I do not think we envisage it should be the Eastern Regional Health Authority. I think the Minister envisages that it should be one of the area boards. I presume when court proceedings are brought under the Child Care Act, 1991, they will be brought under the legal title of one of the area boards. Perhaps it is intended to be the area authority. It is important that this issue is addressed. It would be a disaster if this legislation came into force and a child taken into care who needs that protection had to be released by the courts from care because section 19(1) dissolves the Eastern Health Board and the courts took the view that following its dissolution it is unclear which board or authority would continue to care for the child. I appreciate that this is a technical and difficult issue but it is a real issue that could affect almost 3,000 children in care. It is an issue we need to be careful about and it should be clarified.
Second, section 7 clarifies that, where legal proceedings are pending on establishment day "to which the health board is a party shall continue with the substitution of the name of the authority for that of the Eastern Health Board". If there are existing proceedings there may not be a problem but there does not seem to be an interaction in this legislation containing specific reference to the Child Care Act, 1991. There is a need to clarify this area.
I take the point made by the Deputy and I will look at the matter between now and Report Stage. Would subsection (8) cover this? It states: "any resolution passed, order made or notice served by the Eastern Health Board" and that means served by or on the Eastern Health Board.
I have carefully examined this. As this is a technical issue I decided to raise it with the Minister and give the Department an opportunity to examine it rather than bring forward a series of amendments that he has not had the opportunity to consider. There does not seem to be a specific provision here that says child care orders made in favour of the Eastern Health Board shall continue in being as if made in favour of either the authority or the individual boards. There is a need to specifically amend the Child Care Act, 1991, to clarify where child care proceedings are brought, whether they will be brought in the name of the area boards or the authority.
Question put and agreed to.
SECTION 20.
I move amendment No. 36:
In page 15, between lines 18 and 19, to insert the following subsection:
"(2) Where, but for this section, the Organisation of Working Time Act, 1997, would not prevent the Authority or a Board from entering into or approving a contract of employment which provides for hours of employment (including training and on-call periods) of more than 52 hours per week in any week, averaged in accordance with that Act, no such contract of employment may be made with or approved by the Authority or a Board.".
With this new structure it is important that basic principles are laid down. One of them would be that workers would not be exploited in the way junior hospital doctors are at present. There are serious questions about standards when we reach a point where interns are working 150 hour weeks as has been reported. The medical profession has expressed concern about this situation. Last week I attended a conference organised by the Medical Council where these points were raised. The conference dealt with the whole issue of ability to practice and performance of doctors. Unfortunately, the Department of Health and Children was not represented at the conference. The extent to which junior doctors are expected to work very long hours over long periods is worrying.
The circumstances today are different to those in the past when interns worked long hours and it was seen as part of the job. Nowadays, there are more acute demands on junior hospital doctors than in the past. Patients' expectations are also higher, which create their own pressures and stress. We must be conscious of that.
My amendment lays down the basic rules. I appreciate the working time Act does not cover doctors at the moment, although I believe it should. I understand Commissioner Pádraig Flynn argued very strongly about protecting junior hospital doctors. However, I think the health boards can play their part in protecting the health worker and, more importantly, the patient.
The Organisation of Working Time Act sets out statutory rights for employees in respect of rest, maximum working time and holidays. These arrangements apply by law set out in the Act, in regulations made under the Act or through legally binding collective agreements. Employees working in the new authority will be covered by such arrangements and their interests, in relation to working time, are adequately dealt with under such legislative arrangements. It would be inappropriate to attempt through this legislation to put in place arrangements in relation to working time which would be more properly dealt with under the Organisation of Working Time Act, 1997.
It is assumed that the principal concern of the Deputy is the working hours of junior hospital doctors. This group is not currently covered by the rest and maximum working time rules. At the moment, collective bargaining agreements incorporate various methods to deal with the issue. The contract for non-consultant hospital doctors, which came into effect on 1 January 1997, arose from detailed discussions with the non-consultant hospital doctors representative groups and includes agreement on the number of approved rostered hours, the arrangements in relation to unrostered episodic hours, a mechanism for dealing with persistent unrostered hours and payment arrangements for hours in excess of 39 and Sunday work.
It should also be noted that the European Union Commission has brought forward proposals to amend the Working Time Directive 91/104/EC. Discussions are ongoing in the Commission in relation to the implementation of the working time directive for "doctors in training" and other excluded groups. These discussions have underlined the complexity of the issue of excessive hours and the difficulties in implementing the working time directive for this group. The Commission's proposals and the resultant discussions have already raised issues concerning definitions as well as questions regarding reference periods and transitional periods.
The amendment does not recognise these complexities and, therefore, would not be implementable given the existing structures of medical manpower and the operation of rosters at hospital level. Moreover, it would be neither practical nor appropriate to attempt through this legislation to bring in arrangements which would cut across the ongoing discussions at EU level dealing specifically with this issue.
This might not be the appropriate legislation to deal with this issue. However, I agree with the view that the pressures under which junior hospital doctors are working are unacceptable. They create genuine concerns about the capacity of junior doctors, working completely unacceptable hours and dealing with modern medicine and technology, to always fully address the needs of patients attending hospitals. It is a very serious issue to which we need to return, even if it cannot be addressed in the context of this Bill.
Amendment, by leave, withdrawn.
Section 20 agreed to.
SECTION 21.
Amendment No. 41 is cognate with amendment No. 37 and amendment No. 38 is related. Amendments Nos. 37, 38 and 41 may be discussed together by agreement. Is that agreed? Agreed.
I move amendment No. 37:
In page 16, subsection (4)(b), line 12, after "direct" to insert "following consultation with each health board".
I am very concerned about the setting up of the health boards executive. I am not against it in principle as I understand there are arguments for co-ordination across the health board and practical reasons for the setting up of such an executive. However, I am deeply concerned by the lack of accountability inherent in the structure which I find totally unacceptable. This executive is accountable to its own members, who are unelected, and the Minister only.
If the Minister is serious about devolving power and all the nice things he said about public representatives up to now, it is flying in the face of that to establish an executive with considerable powers to raise money, buy property, accept money, carry out works - which are undefined at this stage but will inevitably have a bearing on the work of the health boards - and anything the Minister may require of it from time to time.
In a sense, we are talking about a shadow organisation to the health board structure. I do not have a problem with that in principle but I do with its execution. We must put in safeguards so that the Minister and the executive confer on a regular basis with the health boards which, if they are kept out of the loop, will not know what is going on and will probably be responsible for adding to the existing deficiencies with which this executive is supposed to deal, such as differences of practice between health boards. The health boards must be part of what the executive is doing and must be consulted.
If, for example, county managers and the Minister were determining major policies and making major decisions without the involvement of the local authorities there would be uproar. I am not saying the Minister or the chief executive officers would be at fault but if asked about this, a chief executive officer will say that his or her loyalty or allegiance is to his or her health board. However, the reality is that they cannot live up to that automatic pledge of allegiance if they have to be accountable to an alternative structure which is headed by the Minister or the other executive members.
There must be links. The links I am proposing are that there would be consultation by the Minister with the health boards and reporting on an ongoing basis, and not just the standard annual report which does not always tell us very much about any organisation.
There must be recognition of the hard work done by health board members. I fully support the points made by the Minister in regard to councillors and members of health boards. It is often thankless, hard work and increasingly so because of the reduction in status of public representatives. However, this is not helping to prevent the reduction of the status of public representatives. I ask the Minister to look at this.
The issue raised by Deputy McManus is important. It is a defect in the Bill to have the chief executives meeting without reporting obligations. It suggests that an administrative cabal will be running the show and it will be left to their discretion how much they tell the members of the boards. The proposed requirement on the executive to report to each health board on its activities not less frequently than once every three months is important. In addition, the executive member from each health board area should report to his or her health board on the activities of the health board's executive. The overall chief executive should report to the health authority on the decisions and activities taking place. That should be an item on the agenda of each meeting.
Under the legislation, area health boards must have nine meetings each year and the authority must have six. I see no reason for not having a report made to the relevant board or authority at each meeting on any decisions made or proposals emanating from the health boards executive, so that there is a constant flow of information and a positive consultative process. This would guard against the health boards executive reaching a decision and springing it on the elected and nominated members of the individual boards, which could impact on the provision of services in their area.
The Minister should look at Part V again and tease out further the reporting and accountability obligations of the health boards executive when it meets as an executive.
The entire concept of the health boards executive was questioned and criticised by Deputy McManus, particularly on Second Stage. I wish to take this opportunity to clarify the intentions behind this proposal.
The chief executive officers of the eight health boards have been meeting regularly and co-operating on a voluntary basis for many years. Since 1996 they have been required by legislation to have regard to the need for co-operation and for the co-ordination of their activities.
Acting jointly on a voluntary basis, the chief executive officers have already spearheaded a number of innovations, including the joint procurement and development of information systems for the health boards, for example, new financial systems and personnel payroll systems, joint advertising campaigns during the winter months to reduce pressure on accident and emergency departments, anti-smoking initiatives, such as the campaign aimed at discouraging shopkeepers from selling cigarettes to under 16s and joint purchasing of equipment and other supplies.
The group of chief executive officers also meets on a regular basis with senior management from the Department of Health and Children. They have worked jointly with the Department in recent times on a number of important issues, including developing guidelines to ensure consistency of treatment across health boards with regard to entitlements such as medical cards, helping to resolve difficulties regarding the respective roles of district health nurses and general practitioners in the child immunisation programmes and developing a new system for making refunds under the community drugs schemes.
There is significant potential for further improvement in ensuring uniformity and consistency of treatment and standards across all health board areas. There is also great potential for achieving cost savings through increased co-operation and collaboration in areas such as procurement.
The chief executive officers of the health boards have indicated to me that they want to take action in these areas but they are hampered by the fact that they have no legal powers to act jointly as a group or to employ staff or office space to further their co-operative ventures. The establishment of the health boards executive will give them these powers and will put their current activities on a statutory basis so that they can continue and expand their co-operation.
During the debate on Second Stage it was suggested that there may be sinister motives for the establishment of the health boards executive. I hope the explanation I have given demonstrates there is no such motive behind the proposal.
Deputy McManus also argued that this proposal for a health boards executive was not signalled in advance. While that may have been her view, those who have been involved in, or observing, the health services for many years were aware of the need for such a structure and of the proposals to address it. My Department's statement of strategy for 1998-2001, published last May, clearly signalled on page 15 the intention as follows:
An important development in the coming year will be the establishment on a statutory basis of a joint executive agency for the health boards, so that they can co-operate and co-ordinate their activities more effectively.
It also signalled on page 23 the list of steps to be taken, that is, "the introduction of legislation to establish a joint executive agency which would assume responsibility for co-ordination of executive functions relative to health boards".
Deputy Dennehy stated on Second Stage that no one wants to return to the days when health board chief executives competed with each other so that one board's gain was at the expense of another. Partnership, co-operation and collaboration are at the heart of this proposal. Everyone agrees this is the way we should be going in the health services.
Much has also been made about an apparent lack of democratic accountability in the health boards executive. I do not accept the assertion that the executive will be unaccountable to the health boards. It must be emphasised that it is only in respect of the executive functions of chief executive officers that the proposed health boards executive will apply. The distinction between the reserved functions of the board and the executive functions of the chief executive officers is very important. Under the provisions of the Health (Amendment) (No. 3) Act, 1996, which was enacted under the previous Administration, the members of health boards cannot issue directions or take decisions in relation to executive functions. What is being suggested in these amendments would curtail the powers of the chief executive officers in a manner which is contrary to the 1996 Act.
However, there is no question of the members of health boards being kept in the dark about what the executive might do. The 1996 accountability Act already requires health board chief executive officers to keep their boards informed in relation to the exercise of their executive functions. I also draw the Deputy's attention to section 21(15) which provides that where a chief executive officer of a health board requires the executive to perform a function on his or her behalf, he or she shall inform the health board of the fact as soon as possible.
I do not accept these amendments. I am satisfied the section, as currently drafted, already provides for adequate accountability to the health boards, taking into account the 1996 legislation.
Is the Deputy pressing the amendment?
I am. It is very disappointing that the Minister is not recognising that these amendments are not interfering with the structure of the authority or with the executive functions of a chief executive officer. The Minister must recognise that. The terms used are "consultation and information".
I meant that in relation to executive functions. There is not a requirement for a chief executive officer to consult with a board in the exercise of executive functions. The 1996 Act demarcates the functions reserved to the board; functions not reserved to the board are executive functions. Therefore, a requirement for them to consult with the boards before exercising executive functions under the health boards executive mechanism is a restriction on chief executive officers which is less than what they have available to them under the 1996 Act at the moment and what is available to them administratively.
We are often asked to put certain administrative arrangements on a statutory basis when the opportunity arises. That is simply what we are seeking to do here. It is simply using this part of the Bill, which is not relevant to the main purpose of the legislation, to put on a statutory basis, in a transparent way, a health boards executive which is already in existence and working. We are asking three area health boards to work under one statutory authority to co-ordinate and improve the delivery of services, and this is simply just another mechanism which will allow us to do that, where it is appropriate, on a national basis. I have outlined some of the areas where they have been able to co-operate; procurement is a very serious area.
The consultation process is already built into the 1996 legislation. No one is working in the dark. Section 21(15) confirms the position in relation to this executive.
The amendments refer to the decisions made by the Minister and the need for him or her to consult with the health boards in terms of setting out the brief. The proposed requirement for reporting to the health boards is to ensure there is a flow of information.
When I was Minister of State with responsibility for housing I learned more about local authorities in three months than I had in 20 years as a member of a local authority. It is not easy for elected members to get information on how the system operates and how decisions are made. As public representatives, we should make sure the system ensures rather than presumes information is available. This structure is being established not on a voluntary basis but on a statutory basis. Until now a chief executive officer was able to make decisions according to what his or her health board wanted. This new structure could mean decisions may conflict with what his or her health board wishes. Most chief executive officers are trying to work with health boards, although they may have the power to make executive decisions. I will press the amendments.
Amendment put and declared lost.
I move amendment No. 38:
In page 16, between lines 14 and 15, to insert the following subsection:
"(6) The Executive shall report to each health board on its activities not less frequently than once every 3 months.".
Amendment put and declared lost.
I move amendment No. 39:
In page 16, between lines 34 and 35, to insert the following subsection:
"(9) Upon completion of the audit under subsection (8), the Comptroller and Auditor General shall draw up a report in writing in relation to the accounts and shall submit a copy of the accounts together with his or her report thereon to the Minister, each health board and the Area Health Boards, and the Minister shall, as soon as may be, cause a copy of the report and a copy of the accounts to which the report relates to be laid before each House of the Oireachtas.".
Amendment agreed to.
I move amendment No. 40:
In page 16, subsection (9), line 35, to delete "30th day of June" and substitute "31st day of March".
Amendment agreed to.
I move amendment No. 41:
In page 17, subsection (13), line 34, after "may" to insert "following consultation with each health board".
Amendment put and declared lost.
Section 21, as amended, agreed to.
SECTION 22.
I move amendment No. 42:
In page 18, between lines 10 and 11, to insert the following:
"(a) the insertion in Rule 5 after 'section 4(2)(a)(ii)' of 'or section 11(2)(b) of the Health (Eastern Regional Health Authority) Act, 1999,' ".
The purpose of the amendment is to ensure that the regulations which apply at present to the election of members of the registered professions to health boards will also apply to members of the authority.
Amendment agreed to.
Amendments Nos. 43 and 44 are consequential on amendment No. 45. Amendments Nos. 43, 44 and 45 may be discussed together.
I move amendment No. 43:
In page 18, paragraph (b), line 23, to delete "and".
I am happy to agree to these amendments. I want to draw to the Minister's attention the fact that amendment No. 45 refers to the "insertion in Rule 17 after 'an officer or servant of the board' of 'or an employee of a voluntary hospital, voluntary mental handicap service provider or voluntary service provider' ". I propose that the reference to "voluntary mental handicap service" be replaced by "voluntary intellectual disability service", if that is consistent with earlier amendments.
I will bring that forward on Report Stage.
Amendment agreed to.
I move amendment No. 44:
In page 18, paragraph (c), line 26, to delete "1998,'." and substitute "1999,', and".
Amendment agreed to.
I move amendment No. 45:
In page 18, between lines 26 and 27, to insert the following:
"(d) the insertion in Rule 17 after 'an officer or servant of the board' of 'or an employee of a voluntary hospital, voluntary mental handicap service provider or voluntary service provider'.".
Amendment agreed to.
Section 22, as amended, agreed to.
Sections 23 and 24 agreed to.
First Schedule agreed to.
SECOND SCHEDULE.
I move amendment No. 46:
In page 21, after line 34, to insert the following:
"Cheeverstown House Limited
K.A.R.E.
Peamount Hospital
Sunbeam House Services".
Amendment agreed to.
Second Schedule, as amended, agreed to.
Title agreed to.