Amendments Nos. 1 and 2 are related and may be discussed together by agreement.
I move amendment No. 1:
In page 4, subsection (1), after line 43, to insert the following:
"(b) the need for co-operation with voluntary bodies providing services, similar or ancillary to services which the health board may provide, to people residing in the functional area of the health board,".
Since the publication of this Bill I have received a number of representations urging that section 2, which requires health boards to have regard to the need for co-operation with other health boards, local authorities and public bodies, should impose a similar requirement in relation to co-operation with the voluntary sector. The voluntary sector makes an enormous contribution to the provision of health and social services, whether it be general hospital services, services for the mentally and physically handicapped, child care, the elderly and other vulnerable groups. I am happy to give statutory recognition to that contribution by imposing on health boards a duty to have regard to the need for co-operation with voluntary bodies providing services to people in this area. This underlines the Government's commitment to the role of the voluntary sector. I hope it will promote greater co-operation between health boards and the voluntary sector in the delivery of our health services.
This is the exact point at issue in Deputy Geoghegan-Quinn's amendment No. 2. In effect, I am accepting the principle and spirit of her amendment. However, we are recasting it in the manner of my amendment for technical reasons. I thank Deputy Geoghegan-Quinn for formalising this because there was quite an amount of representation from Deputies on the matter. In the new arrangements we will have with the voluntary organisations when we move from the vertical relationship which the Department of Health now has with them to the horizontal relationship they will have with health boards in future, it is proper that the obligation of the health board to co-operate with them should be a statutory one. That is the essence of both amendments but I stress that there is no difference in either intent or content.
I thank the Minister for his remarks and I will withdraw my amendment on the basis of his generous response in moving amendment No. 1. The Minister is correct when he says that Deputies of all parties received many representations from various voluntary bodies, particularly from county associations for the mentally handicapped. Even though in most health board areas voluntary bodies have a good relationship with health boards, they were concerned that if other bodies were recognised in the Bill and voluntary bodies were omitted, that kind of relationship might be put in jeopardy. They were also concerned that in health boards where they have been experiencing problems with officials, such tendencies would be removed. Now there will be a statutory obligation and duty on health boards to co-operate with voluntary bodies.
When we see tremendous work being done by voluntary bodies we must acknowledge that they provide services which health boards themselves cannot and are also capable of raising substantial amounts of money by way of private fund-raising.
No health authority could provide 100 per cent of all services required by every single individual within its jurisdiction. Therefore, we must encourage all the voluntary bodies involved. There are a number of others besides the ones I mentioned. They were equally concerned that there should be a definite obligation by way of statute on the health board to co-operate with them. I am pleased the Minister has recast my amendment in a form which we are happy to accept and I thank him for his generosity.
I wish to be associated with the thanks expressed to the Minister for bringing forward this amendment and I thank Deputy Geoghegan-Quinn for her own contribution in this regard. The key statement made by the Minister relates to giving statutory recognition to the voluntary sector. There has been regional variation in the involvement of the voluntary sector. I am not being critical of the health boards. Sometimes it may have appeared to the voluntary sector that their contribution was not fully recognised, not just by one board but by one region within a board. It is good that the Minister has now made a move to give them statutory recognition, which spells out the health boards' firm responsibility to co-operate with the voluntary bodies. It also puts an onus on the voluntary bodies to co-operate properly with the health boards. This is an important issue which the voluntary sector will have to be conscious of in the future, precisely because of this amendment.
On the basis of Deputy Flood's last comment, I would like to give the Minister some indication of the difficulty we have as public representatives and members of health boards. We see substantial moneys allocated to voluntary bodies without any recourse to a health board. This occurs not just in the health area but cuts across a number of other areas of activity in the State. Along with the statutory recognition for voluntary bodies in this Bill, which I welcome, there must be a level of accountability associated with this recognition.
A small number of voluntary bodies may occasionally have difficulties in terms of funding arrangements and how they spend their money. Public representatives, members of health boards, and members of local authorities have an enormous difficulty in finding out the truth in relation to how this money is spent because they have no direct linkage at local level. In the context of devolution, which is the "in" word in local government, what is the Minister's view in relation to how voluntary bodies would link more into the health board and local authority system, in order to ensure the proper spending of money and accountability to the local democratic system?
This is an important amendment. I concur with Deputy Hogan's comments. Voluntary bodies do tremendous work and get angry with health boards because they rely almost entirely on them for the provision of many services. The net effect of this is the development ofad hoc services in, for example, the child care area. Critical areas are then unmet if a voluntary body does not fill that niche.
I welcome this amendment. It is desirable as we rely, depend on and value the work of voluntary bodies. It is an important amendment and I congratulate the members of the Opposition and the Minister on it. There are still huge issues to be resolved about the responsibilities of the health boards in providing services and how they fill gaps. Voluntary bodies will only meet needs they identify and set as their priority, which may not be the crying national or local need at the time. I think the health boards over-rely on voluntary bodies, particularly in relation to child care services in Dublin. As a result, courts have ordered local health boards to make certain provisions which they have not made. One of the problems has been the over-reliance on voluntary bodies, which is going too far in one direction. That is a debate for another day.
This is an important issue. It is significant that voluntary bodies are being given recognition for the first time, through the Houses of the Oireachtas putting a statutory obligation on the health boards to co-operate with them. I presume this will go through on Report Stage and become part of the way things are done.
In the past, services were inadequate in certain areas and there was much unmet need. Voluntary groups, particularly relatives and friends of the handicapped, tried to put a service in place when it was not being provided by the health boards. Over a period of different administrations, services have obviously improved. A system has developed where health boards are given block grants for budgets for certain health and social services. Voluntary groups have strengthened their position but their relationship in terms of policy and funding is ultimately not with the health board, which controls services in its area, but with the Department of Health. This is obviously an issue in the area of mental handicap — we are all familiar with the county organisations. In this area, for example, an important role is played by the Brothers of Charity, who have many schools around the country. This relationship is with the organisation nationally, rather than the subdivision of the organisation in the particular health board area. The Department negotiates budgets with the Brothers of Charity who get funding which they reallocate to different institutions.
Voluntary hospitals are a bigger issue. For example, hospitals like the Mater, St. Vincent's, Portiuncula, St. John's or the Bons Secours in Cork are institutions which are effectively run by voluntary bodies. They have massive budgets. Their relationship in terms of funding or policy is not with the local health board but is vertical to the Department of Health. It is a fundamental part of the health strategy that this should be changed. There are over 66,000 people employed in the country's health service, with about 320 employed in the Department of Health. This is a tiny executive. In the proper management of the health services, the role of the Department of Health should be in policy formation and the measurement of outcomes. There should be a system in place to ensure that not only is policy being implemented but that we can accurately measure its effect. This cannot be done if phone calls are being taken from the Mater Hospital, dealing with every crisis a big voluntary hospital might have, and where there is no devolved layer to deal with those issues.
The fundamental change taking place is that of the funding relationship between the Department of Health and the voluntary bodies. In future, the money will go to the voluntary bodies and hospitals through the health boards. Obviously it follows that good relationships will have to be developed on the horizontal level rather than the vertical. This is the tip of the iceberg and it will take a long time to put in place. We are making a start on it.
Preparations are ongoing in the Southern and Mid-Western Health Boards in respect of mental handicap. Mental handicap organisations are in discussion with these health boards to see if we can take the first step in changing the funding for voluntary bodies from the Department of Health to the health boards. Obviously, because voluntary bodies have good relationships with the Department and we are conservative when it comes to proposals for change, there is a tendency to hang onto the old relationship rather than form a new one. There is concern that voluntary organisations might be disadvantaged when the link is broken with the Department of Health and the new link is established with the health board. This is why we are moving slowly and there is such a level of representation provided for in this amendment. Because of the establishment of the new relationship, voluntary organisations want to ensure they have some statutory protection. The statutory protection provided in this amendment is the obligation on the health boards to co-operate. They are co-operating anyway, although there is no statutory obligation on them to co-operate. A whole web of new relationships will have to be built up. This has major advantages because, as in any devolved system, if the calls are being made out of Hawkins House for what is needed in Connemara or west Limerick, the people making the calls are at a distance, whereas if the calls are being made by way of service plan in the local health board where there is local representation, the problems are likely to be addressed with more focus, unmet needs are more likely to be prioritised and met needs are not likely to be duplicated. The transition will be difficult and it will require all the skills of management in the health boards and in the voluntary organisations to establish the new web of relationships which will bring that about.
The money involved is of a different order of magnitude when it comes to making that switch in the case of the voluntary hospitals. The vast majority of the voluntary hospitals which are household names are in the Eastern Health Board area in Dublin and, particularly with the very big hospitals, it will not be possible to establish that relationship with the Eastern Health Board without restructuring. That is where the restructuring of the Eastern Health Board falls into the policy agenda. Dublin Deputies could recite many reasons for restructuring the board, but the changes are absolutely essential if we are to improve the relationship between the Eastern Health Board and the major voluntary hospitals that provide the bulk of the hospital acute services in the Eastern Health Board area.
I welcome the fact that Deputy Geoghegan-Quinn has pressed this matter. It looks like a small issue in the context of this Bill but it is an indicator of a very major issue in terms of health policy and changes which we are trying to put in place with the co-operation and goodwill of everybody.
This is a very important section, as the Minister will agree. There are difficulties emerging as between health boards. I am glad that for the first time we are enacting in legislation the need for health boards to co-ordinate their activities and to co-operate with each other. During the summer I had the opportunity to travel to most of the health boards. I have been very impressed with the way certain health boards handle particular areas of policy, but in other health boards the way the same policy is handled is not good. Each time I have asked what level of co-operation there is, for example, between programme managers, between individuals dealing with specific areas of policy. I asked whether they meet on a regular basis, whether when they come across a problem which they need to deal with they ring a colleague. I have discovered that unless there is a personal friendship between individuals in different health boards there is very little co-operation or co-ordination of policy.
The Minister has heard me say on many occasions in the Dáil that great policies are being administered by health boards but that those policies are administered and implemented differently in different health boards. I appreciate that there has to be scope for flexibility, but where criteria are laid down and a policy or a programme is there to be implemented for the good of the people, it must be applied uniformly in each health board. That is not the case at the moment.
I understand that there are different policies or implementation schemes in regard to the new immunisation programme for children. As public representatives we all encourage parents to have their children immunised. In this case the Western Health Board scheme and the South Eastern Health Board scheme are aligned. The immunisation programme should be the same throughout the country. I am not asking the Minister to respond directly to specific issues today but I am making the point in the context of this very important section 2(i)(b) of the Bill before us.
There is tremendous concern in relation to child care policy and the Minister shares that concern. There have been many cases of child abuse in all health board areas but the only cases we hear about publicly are those in which the system has broken down. I am not sure what the learning curve is. Is there a learning experience? Do people share information? Is there a formal way in which that can be done in the same way as it is done by the Garda where there is a very straightforward way of reportage and training, where one individual is assigned to co-ordinate all the services in each division? We need that level of close co-operation and co-ordination of services in the health boards because the health board is normally the first port of call for most people.
We have had some criticisms in a number of public reports because of the lack of a speedy response to cases which have been reported. I know there are difficulties in relation to that but where national policy is being implemented by the health boards, surely it is not too much to expect an adequate level of co-operation and co-ordination of activities so that where one health board is operating a particular area of policy very effectively, other health boards can learn from that. We should not have eight independent republics.
I would like to see this legislation pursued by each health board. It would give equality and would have the benefit of making health boards accountable for the various schemes they administer. There is a tendency for the various programmes run by the health boards to compete with each other for the amount of money available. For instance, in the case of the Western Health Board which services County Galway, County Roscommon and County Mayo, there is a tendency not to look at the needs of each county independently. Instead, the various programmes compete with each other for the amount of money available. As a result, we do not get the level of service or accountability that the Minister feels is necessary. I would like to see section 2 becoming a very live section of the Bill and one which the Department would be very scrupulous about implementing in each health board.
Deputy Geoghegan-Quinn has raised a number of very important and interesting issues. The Garda Síochána is a centralised national agency working under the Garda Commissioner whereas the health boards have a devolved system like local government. Not every Deputy was a member of a health board but most of us were in local authorities at some stage and in the same way as there are differences between the level of and manner in which services are delivered at local authority level there are differences between services in different health boards.
When sharing experiences of the local authorities, some people will say, for instance, that the planning office in their county council is very efficient and others will say that their planning office is not. The same would apply to the housing or roads section of local authorities. If you look at the divergences of the manner in which the county roads problem has been dealt with in the various local authorities and the cost per kilometre of road repair on county roads and the wide differences between local authorities you will see one of the problems of a devolved system. However, if you have a centralised system the difficulty is that there will never be an opportunity for change by enthusiastic local people who measure the manner in which they deliver services to the needs of the locality.
Take the Northwestern Health Board, for example. It has done some interesting things which have been a model for the rest of the country but if we had a centralised grip on it, the board would not have had the opportunity to do that. What we need is an arrangement where people are free to pilot new programmes and at the same time establish what is best practice. The health board chief executive officers meet the Secretary of the Department of Health once a month and would meet me individually or together occasionally and set up the office of health gain on a non-statutory basis. It is an office people have not heard much about as yet. There was a major meeting in Athlone yesterday in that context. The purpose of the office is to share experiences with the view to everybody adopting best practice once it is piloted in one particular area. It is working well and the Department of Health has begun to look at the possibility of putting it on a statutory basis. It is moving forward and I agree with what has been said but I do not want the dead hand of the Minister to be put on the service nationally and that there will only be one way for things to be done, that is, follow the directions issued by the Department. That would be a retrograde step.
On the other hand, when one sees a high-flying programme manager, who is very effective in an area, we would like that programme manager in our area to move up to best practice. The office of health gain is probably the way to do that.
Best practice may be fine in one situation but best co-operation is another. There seems to be less and less co-operation among the health boards at present. They all seem sensitive about their budgets. Where we had better co-operation we had previously in services seems to be deteriorating at present.
There might be best practice in one health board area but there would not be co-operation on the ground.
Is the Deputy referring to the Mayo-Sligo fault line?
That is where the Deputy is talking about.
The corridor is still there. We have better North-South co-operation than we have Northwest and West.