I move:
That Dáil Éireann approves the following Regulations in draft:
Health Boards Regulations, 1970 a copy of which Regulations in draft was laid before Dáil Éireann on 8 June, 1970.
This motion arises under section 4 of the Health Act, 1970, which requires the Minister for Health to make regulations specifying the number, constitution and functional areas of the health boards which, under that Act, will become responsible for the administration of the health services. For the convenience of the House I have, as undertaken during the debate on the Health Bill, circulated an explanatory memorandum outlining the details of this proposed change in the administration of the health services.
So as to give the whole picture, this explanatory memorandum also refers tentatively to the proposals under the Act for setting up certain other bodies—Comhairle na nOspidéal and the three regional hospital boards —which will be specially concerned in the efficient organisation and development of hospital services. However, the motion before the House now does not relate to these special hospital bodies: separate regulations on them will be submitted later, after the details of their constitution and functions have been the subject of consultation with the hospital authorities, the teaching bodies, and the other interests which will be affected by them. Accordingly, I will not in this statement refer further to them, but will treat solely of the establishment of the new health boards.
The Act requires that, before the regulations setting up the health boards are made, the Minister must consult the Minister for Local Government and also each county council and county borough, corporation and the Dún Laoghaire Corporation. In addition, consultation with the National Health Council is required by section 41 of the Health Act, 1953.
All these statutory consultations on the draft regulations have now been completed and in the case of Dublin City, the formal consultations with the corporation, in the person of the commissioner, were supplemented by informal discussions which I had with some of the Dublin City Deputies. I have also consulted a number of other bodies, including those representing various professional interests. Many bodies and hundreds of persons have taken part in these consultations. I would like to place on record my appreciation of the interest which they have shown in the proposals and the work done by them.
I will present to the House the result of these consultations, but before doing so I should, perhaps, say some general words on the considerations underlying my design of the areas and constitutions of the health boards.
In choosing the functional areas of the health boards, I had to have regard first to what would be a reasonable area for administrative purposes, without having the centre of administration too remote from any large sector of the people served. Clearly, in modern times this requirement can be met by having far larger administrative areas than when transport depended on the horse. There was, of course, no hard and fast rule which we could follow but a practical consideration which was borne in mind was that the areas should be sufficiently compact so that a board member could attend a meeting without an overnight stay and also that staff could travel out from the headquarters to the rest of the area without spending too much time on travelling.
I had also to consider whether county boundaries should be followed in all cases or whether some counties should be split between two boards. Tradition more than logic can be said to govern the lines between counties and there was a strong temptation to be logical in designing the health board areas at the expense of county integrity. North Carlow is, perhaps, orientated most towards Dublin, parts of Kerry and South Tipperary towards Limerick and North Roscommon and the "panhandle" of Cavan might best be administered from Sligo.
On closer study, however, I decided that such apparently logical moves would be unwise. Each county is now a unit in the health services administration and it is better to build by combining these units and accepting whatever anomalies there may be in the boundaries. This has the further decided advantage that it will ease the quite considerable transitional problems affecting the staffs of the present health authorities.
I think that my decision to stick to county boundaries was generally welcomed by the local authorities. Of course, this will not mean that, for hospital services for example, each health board area will have to be self-sufficient. There is nothing to stop arrangements being made for, say, North Roscommon patients to go to Sligo or for Carlow patients to go to Dublin.
In choosing the particular areas set out in the draft regulations, I had regard also to existing regions for other purposes. There are regional systems at present for local government planning, for Bord Fáilte, for the Electricity Supply Board and for some other purposes. In general, the pattern of these indicates that the number which I have chosen, eight, seems about right. In particular, I tried not to depart from the local government planning regions except for very good reasons. In fact, the health board areas differ from the planning regions only in that Roscommon is associated with the west rather than the midlands, that Meath is associated with Louth, Cavan and Monaghan rather than Dublin and that Donegal, instead of forming a separate region, is associated with Sligo and Leitrim.
The proposals for the constitutions of the health boards have, perhaps, given rise to more interest and controversy than the choice of the eight areas —understandable controversy. I should mention, seeing that all involved were anxious to obtain the greatest possible representation. Local authorities wished their members to form a substantial majority on each of the new boards, while the medical profession pressed for strong representation. Representation was sought too by a large number of para-medical groups. If I had agreed to meet fully the wishes of all interests, each board would have blossomed in numbers into a mini-Dáil.
Now, one cannot state a hard and fast rule for the ideal number of members for a board, but a body which is an executive agency, such as the health boards will be, becomes less effective if its membership is too big. I took the pragmatic view, therefore, that if the members of the board were to form an effective body, they should not exceed about 30 in number. This decision meant that I was unable to accede to requests from many quarters for representation or an increase in representation but, after considering the various views expressed on the constitution of the boards, I did manage to make some concessions which I will refer to in my detailed comments on each of the areas.
The National Health Council and a number of the county councils made the point that there should be provision for the professional representation on the board to be spread equitably over the constituent counties. I sympathise with this point of view and intend, in the constitution of the first board and in the regulations governing election to subsequent boards, to see if I can meet it to some extent. However, any exact geographical distribution of professional representation will be difficult to achieve, seeing that, in the appointment of professional representatives, the main endeavour will have to be in getting a good spread of doctors among the different categories of the profession and in securing the professional people best qualified to act on the board. It should be borne in mind, too, that the Minister, in choosing his three nominees to each of the boards, will have a chance to redress or reduce any geographical imbalance which results after the appointment or election of the professional representatives.
I will now refer briefly to the proposals for each of the boards. I should mention that, while the statutory consultations with local authorities took place in the months following the enactment of the Health Bill, I had already had informal contacts with representatives of all the local authorities concerned, before the Bill was passed, on tentative proposals which I had then circulated. What was said during those informal discussions was borne in mind and a number of changes were made in the draft regulations before they were sent out for the purpose of the formal consultations. Hence, the scope for further changes arising from the statutory consultations was limited but I did manage to make some further concessions to local points of view.
The population to be covered by the proposed Eastern Health Board—— 921,000—is by far the largest and the constitution of this board presented, perhaps, the greatest problems. Clearly, if local representation on this board were to be in proportion to population, then Dublin would have had such a preponderant number of members that Kildare and Wicklow would have an insignificant say in the work of the board. In relation to this area and others I took a pragmatic line that representation of each county or borough could not be in simple proportion to its population, but that, where there were big differences in population, the larger authorities should have some additional weighting in their representation.
My original proposal was for a somewhat smaller number of members than the 35 proposed in the draft regulations. I have accepted an increase in the total number beyond what I would regard as the optimum in an endeavour to reach a compromise with the local authorities. I should mention that, in this area, the five authorities concerned took a commendable initiative in meeting to agree among themselves on their representation on the board. They agreed on a total representation of 23. I did not fully accept this and the total local authority representation of 19 which I propose is a compromise between this and my original proposal for a total of 16.
Kildare and Wicklow each pressed very strongly for four members, instead of three. Wicklow County Council mentioned the peculiar geography of the county and thought that their representatives would have to number four if members of the public were to have a reasonable chance to contact them. In refusing these requests, I had regard to the relatively small populations of Kildare and Wicklow Counties when compared with Dublin, and to the fact that each of the counties will have a local committee on which many of the councillors will serve and maintain contact with the operation of the services.
The four county councils concerned in the Midland Health Board—Laois, Longford, Offaly and Westmeath— were reasonably satisfied with the proposed representation, although Westmeath County Council would have preferred to have five nominees on the board, having regard to its expectations of growth in population in that county. The present population of Westmeath is about the same as that of Offaly. If this proportion changes in the future, there could be an adjustment in the representation on the health board but there is no present justification for giving Westmeath higher representation.
In the mid-western area, I had proposed to the local authorities that Clare County Council should nominate four members, Tipperary (North Riding) County Council should nominate four and Limerick City Corporation and County Council three each. Limerick County Council made a strong recommendation that, on the basis of its population vis-à-vis Clare and North Tipperary, it was entitled also to four members. I conceded this, bearing in mind that the total representation of seven from the Limerick area would still be below the total for the other two counties. Clare asked for an additional member also, but I could not see my way to agree to this, bearing in mind the populations served by each of the three county councils concerned.
The four counties concerned with the North-Eastern Health Board— Cavan, Louth, Meath and Monaghan —have expressed themselves as satisfied with the proposals in the draft regulations. This, I might mention, is one of the areas where there is a departure from the local government planning regions. I decided that it was more appropriate that Meath, instead of being associated for health purposes with Dublin, should be associated with Cavan, Monaghan and Louth, particularly having regard to the existence of the major hospital centre in Drogheda. The Meath County Council agree with me in this.
For the North-Western Health Board, it is proposed to allocate six members to the Donegal County Council and four each to the Leitrim and Sligo County Councils. Donegal represented to me that at least 50 per cent of the membership of the board, including the professional and other representatives, should be from Donegal. While this might be justified on the basis of the populations of the three counties—Donegal's population is 109,000, as against a total of 82,000 for Leitrim and Sligo—I do not think that it would be desirable that any one county should have an overall majority in the membership of any board. I accordingly regret that I cannot meet the wishes of Donegal in this respect. Sligo and Leitrim, I should mention, showed uneasiness that, in the selection of professional representatives, Donegal would achieve a preponderance and, as I mentioned in my general comments, I am considering how this could be avoided.
The constitution of the board for the south-eastern area, which includes five counties and the City of Waterford, presented special difficulty.
I should mention that, in the first place, Carlow County Council wished to opt out of this area and be associated with the Eastern Health Board. I met a deputation from the county council on this matter and explained to them that I could not accept this change. The reasons for this were that the population served by the Eastern Health Board as at present proposed was so big that it would be undesirable to add to it, and that Carlow, by reason of its small population, would have very little say if it were in the eastern board. This county is in rather an unusual position, in that the town of Carlow and its environs are at least as convenient to Dublin as they would be to, say, Waterford but, if one rejects the solution of splitting Carlow county, I think that the logical place for it is in the south-east. As I mentioned earlier, there will be nothing to stop an arrangement being made for Carlow patients to continue to go to Dublin hospitals.
In their views on the draft regulations, Carlow County Council indicated that they were agreeable to go into the south-east only on the understanding that the major hospital for the area would be in Kilkenny. I am afraid that I could not give any undertaking about this, as a decision on the major hospital areas in the country must await very full examination of the merits of the different possibilities.
Each of the other local authorities concerned in this area have asked that their representation on the board be increased beyond the figure which I proposed. I have examined their representations very fully but I do not think that the representation for any one authority could be increased without adjusting those for the others and, if they were all adjusted, the total membership of the board would go far above the figure which I regard as the optimum. I have not, therefore, found it possible to make any concession to the views of the local authorities in relation to representation on the board in this area. It is a fact of geography that the south-eastern area as we now propose it is a logical administrative entity; it is accepted as such as a local government region and by Bord Fáilte. The small representation from each county on the health board for the area derives from the fact of there being so many local authorities in it and I can see no way of constituting a viable health board for the area except by having but a few from each county.
The area of the Southern Health Board will cover Cork and Kerry. Kerry County Council had first proposed that there should be two boards, one for each of the counties, but I could not accept this, as I would not regard Kerry County as having a population sufficient to justify its having a health board of its own. Suggestions were also made that it would be more appropriate for North Kerry to be associated with Limerick than with Cork, but I rejected any idea of splitting County Kerry in designing the areas for the health boards. For one thing any such split would have made the proposition for having a large general hospital in Tralee, which is now proceeding, a doubtful one. Looking at the picture as a whole, I think that it is better that the whole of Kerry should be associated with Cork rather than with Limerick. The Tralee hospital must become intimately involved with the large general hospital which is being planned for Cork and this can best be done by having the two counties together within the one health board.
I originally proposed representation on this board of four for Cork Corporation, six for Cork County Council and five for Kerry County Council. This would have given none of the local authorities an absolute majority, but would give Cork city and county which have a population of 340,000 as against Kerry's 113,000, a two-to-one majority on the board. Cork Corporation asked that their representation should be increased from four to five members and Cork County Council requested an increase in representation from six to seven members. Kerry asked that their representation should equal the total for Cork city and county. I have increased the Cork representation to meet the views of the two local authorities there and have increased the Kerry County Council to six so as to keep the proportion of representation the same. I could not agree that Kerry is entitled to equal representation with Cork, having regard to the respective populations. Kerry County Council also asked that the Tralee Urban District Council should be entitled to representation on the board. There is no provision for this in the Act. They asked, too, that four or five of the doctors on the board should come from Kerry. I agree that Kerry should have its fair share of the medical representatives and, as indicated earlier, propose to arrange accordingly, but I see no reason why this county should have a majority of the medical representatives, as the county council have proposed.
The Kerry County Council asked that the chief executive officer of the Southern Health Board should be from Kerry. I would, of course, be in no position to comply with this request, even if I agreed that it was reasonable. The selection of the chief executive officer for the board will be a matter for the Local Appointments Commissioners and Kerry must take its chance on what county the person selected by the commissioners will be from—just as the counties within the area of any other health board must take their chance on whether a person from Kerry or elsewhere is appointed as their chief executive officer.
Following the informal consultations, I had increased the local authority representation on the Western Health Board to six for Galway, five for Mayo and four for Roscommon. Galway and Roscommon accept this but Mayo have asked that they should have six representatives. I do not think that this would be reasonable, seeing that the population of Galway is considerably bigger than Mayo and that it has the major hospital centre of the area. Mayo and Roscommon made some points also in relation to the medical representation on the board. I will bear these in mind.
I would like to repeat what I stated during the debate on the Committee Stage of the Health Bill, that, while the county and county borough council representation on the health boards is, of course, democratically sound, I feel certain that, once established, all the members of a board will think collectively for the general good of the whole area served. I confidently expect that the contributions of local authority and professional members alike will be positive and not negative, in the sense of trying to weaken the health structure in any part of the board's area.
The local advisory committees, which will examine the actual record of health services, current and developing in their areas, should be the spurs for any promotional policy required to maintain the principle of fair shares in the development of health policy. I also expect that, through the delegation of day-to-day administrative matters and by the formation of executive committees, the health board's operations will be discharged more efficiently.
This then is a summary of the views expressed by local authorities on the proposals in the regulations. I hope from what I have said that the House will accept that the points made in each area have been very fully considered and that what is now presented in the draft regulations is the best compromise I can offer between the local views and the essential needs of the new administration.
Deputies, I feel sure, will agree with me that almost any appeal for augmenting the number of local authority representatives from one county would be contested by other local authorities in the area and this would result in stalemate.
I can report that the National Health Council, when consulted on the draft regulations, expressed agreement with them. There was also statutory consultation with the Minister for Local Government who has offered no objection to my proposals.
A number of the authorities expressed views on other local matters arising under the Health Act which do not relate to the draft regulations before the House. I have not as yet had an opportunity to consider all of these points but will do so and communicate with the local authorities.
The draft presented represents what I, following the very full consultations which I have outlined above, consider to be the most effective pattern at this point of time for the administration of health services in accordance with the 1970 Act. What is now proposed is not inmutable and, if the administrative needs of the services change, new regulations can be brought in at a later date, when the full effects of the change in administration can be seen in perspective. For the present, I would ask that this House should approve of the draft of the Health Boards Regulations as now presented to it.