I move:
That Dáil Éireann approves the following Regulations in draft:—
Health (Hospital Bodies) Regulations, 1972—a copy of which Regulations in draft was laid before Dáil Éireann on 11th May, 1972.
Health (Hospital Bodies) Regulations, 1972: Motion.
Agreed? We go back to Social Welfare.
On a point of order, would the Minister explain in a little more detail? He just cannot move it in the House and leave it hanging like that.
The House has already decided to approve of it.
No.
I take it the Minister is referring to the health regulations?
Which were discussed with the Estimate.
I wonder are Members aware of what is taking place, that the regulations are now being put before the House by the Minister?
Yes, so they are. I would point out that the motion is being debated with the Health Estimate and that any Deputy who has already spoken on the Estimate and the motion may not speak again.
Is it not the situation that we were speaking on Estimates plus regulations.
On both, yes.
But we were taking them in the aggregate. Now, they have been separated and are people who spoke on the aggregated subjects now to be debarred when there is quite a new motion before the House?
It is not a new motion.
Debarred is not the proper word because they were allowed to speak on the motion and the Estimate but they would not be allowed to speak now when I am putting the question on this motion.
To remove any misunderstanding, it must be stated that we are not agreeing to these regulations.
(Cavan): I take it that any Deputy who has not spoken is entitled to speak?
I have put the question.
There are members of our party who have not yet spoken on this. Will they not be given an opportunity to speak?
The discussion on the Estimate will continue.
But if these regulations are being taken now, members should have an opportunity of speaking before the Minister speaks.
I have already put the question.
(Cavan): I am offering to speak on the regulations briefly. I have not spoken on the Estimate.
I have put the question and I took it that the House agreed.
No.
I shall give the House an opportunity of deciding on that question.
I think this is sharp practice because the Members of the House did not realise what was happening.
It was made perfectly clear by the Whips.
This has been agreed to by the Whips. It is not a matter of the Chair putting the question without the knowledge of the House.
(Cavan): My understanding of the Order of Business was that after Questions the order would be interrupted, that a discussion would take place on these regulations and that when we had finished that the order would be resumed.
When I asked the Minister for Health to move the motion I took it that there was no further discussion and some Deputies said they would wish to divide on this.
But the Minister did not move the motion.
I did move the motion.
He was quite silent.
You took No. 5. Members of this House are being gagged by the Chair and by the Minister for Health.
(Interruptions.)
That is a very unfair allegation.
It is a fair allegation. This is being done simply and solely because everybody is opposed to the regulations.
(Interruptions.)
(Cavan): I would like to make a submission. First, I take it it is not suggested there was an agreement that there would be no discussion on these regulations? I submit that, in accordance with the practice of the House, if a Minister rises to conclude or if a question is about to be put and if there is any question or any doubt as to whether somebody is offering to speak, the benefit is given to the person offering to speak.
Before the Deputy resumes I should like to make it clear to Deputy Clinton and others that there is no question of gagging by the Chair. This was agreed to by the Whips of the various parties.
That is not the impression of the Opposition parties.
It was not agreed by the Whips that there would be no discussion on the health regulations. They were being taken separately. They were separated from the Estimate of the Department of Health. There was no such agreement and it was a complete misunderstanding.
May I ask the Ceann Comhairle if the Whips' agreement to which he refers precludes discussion of these health regulations at this time?
Only by those who have already spoken on both the Estimate and the motion. They may not speak again.
I should like the Standing Order supporting this to be quoted.
There is no Standing Order.
I am challenging the right of the Chair to rule in this way.
There is no Standing Order; it is a question of common sense.
This is a complete change of outlook simply and solely because we do not want these regulations.
(Interruptions.)
If Deputy Fitzpatrick wishes to speak on the motion I shall permit him to do so. I have not seen anybody else offering. I cannot speak for the others. When I called the motion nobody offered.
Will we be allowed to contribute?
Nobody who has spoken already will be allowed to speak again. Deputies will not be allowed to speak twice on it.
I will not be speaking twice on this motion. We spoke already on a joint motion.
Deputy Andrews stated that the two items should be divided and I wish to record that our understanding was that though they would be divided there would be a discussion.
The discussion is being allowed.
The way those people speak with authority about agreements.
In view of the fact that the motion was not moved until a few moments ago, how could a point be reached when those who have spoken on the Health Estimate——
There can be only one motion before the House at one time. Both motions are tied up and may be discussed together.
(Cavan): I do not intend to take up the time of the House for very long in opposing these regulations but I do not think I would be discharging my duties to the people who elected me if I did not speak on them. The regulations proposed involve the establishment of Comhairle na nOspidéal, being a body referred to in section 41 of the Act. My serious objection to the composition of that body is that they are heavily loaded in favour of the medical profession and I ask the Minister to consider the advisability of handing control of the hospitals in this country to a board composed entirely, practically, of the medical profession.
I understand the Minister will appoint all 23 members of the board and it is stated in the regulations that not fewer than 12 of them will be registered medical practitioners engaged in a consultant capacity in the provision of hospital services. I do not wish to be unduly critical of the medical profession or of any professional body but it appears to me that each of these consultants will have a vested interest in the running of a hospital. The danger is that they will be guided entirely, perhaps, or to a large extent at any rate, by the interests of the medical staffs of the hospitals.
I think that on such a board it would be necessary to have medical people in an advisory capacity, in a position to tender advice on the running of hospitals, on the appointment of medical staff and that sort of thing, but I think it is entirely wrong and a dangerous departure to constitute those boards in such a way that the medical staff will have control. That is what we are proposing to do.
I know that people are of the opinion that the health boards which have been set up are entirely bureaucratic, that again in that case they are being handed over to the medical profession and associated professions. That is a retrograde step. I think the majority on those boards should be elected representatives, people who would have to answer to those who elected them. The result then would be that in most cases, certainly in medical matters, the board would always be guided by the professional members of the board. Then, in matters of principle not concerned with the staffing of hospitals or the treatment of patients, the views of the elected representatives would prevail.
It is very easy for any professional man to see things only through his own professional eyes. It is very easy for any member of a profession to believe that the rights and privileges of his profession relating to certain matters should prevail, and it is very easy for any of us to be irritable and short tempered with people who put forward views with which we do not agree.
No matter how long I speak I could not improve on the points I have been trying to make. It is simply that I think it is fundamentally wrong that in something so important to the people who are ill in hospital and to their relatives as the running of our hospitals control should be handed over to a body who have a vested interest. I say that because, without being unduly critical or offensive, the staffs of these hospitals are, in effect, the officers or servants of the public. They are there to serve the public on, I immediately concede, reasonable conditions.
I am a great believer that the medical staffs of our hospitals should work in conditions as nearly ideal as possible. For instance, I do not believe it is possible for a surgeon to operate with any degree of comfort in a one-surgeon hospital. The days of such hospitals have gone. There will have to be larger staffs and conditions will have to be improved to such an extent that doctors, whether general practitioners, specialists or consultants, will have reasonable hours off, a reasonable number of days off, weekends off, but I do not concede that it is prudent to hand over the complete administration or control of hospitals to people who have a vested interest in one point of view. I say that is not prudent. I am not seeking to cast any reflection on the medical profession. They are human beings. They are subject to the shortcomings of human nature. But that is exactly what I fear. The regional health boards have not been, as I said, very long in operation, but the general feeling is that they will be run in a bureaucratic fashion right from the top down. Even in this House we now have the Minister refusing to answer questions and saying that such and such is a matter for the health board. That is a development I do not like. It has come since the establishment of the health boards. After the boards were first set up it was possible to get an answer from the Minister on health matters.
I have refused about three questions. The Deputy need not start flogging that one.
Notice taken that 20 Members were not present; House counted and 20 Members being present,
(Cavan): I was, Sir, pointing out that I do not approve of the regional health boards' method of operating and I feared there was a trend towards bureaucracy creeping into the administration of the health services. I made a point that the Minister is not prepared to answer questions relating to administrative matters. The Minister resented that and told me I need not flog that horse.
After the health boards were set up the Minister freely answered questions relating to my region. I can think of one question which was very effective, a question relating to the placement of a mentally retarded child. That child was placed within a matter of weeks. However, when I put down further questions, the Minister took the attitude that the matter was a matter for the regional health board. Was that, I wonder, the Minister's own idea or is this the attitude of the health board? Is it their attitude that they cannot be bothered supplying information to the Department for transmission to Deputies in Leinster House? If that is the way in which this attitude towards questions arises, then I deprecate it very much.
It is not.
(Cavan): Then I would ask the Minister to review his attitude and to preserve democracy here. Any questions I put down were put down only because the child could not be placed for seven years.
It has nothing to do with these regulations anyway.
(Cavan): I am making a comparison between the attitude which prevailed under health boards and the attitude I fear will prevail under the board we are setting up now. If you have a board loaded in favour of the administrators of the hospital, and if you have a Minister for Health who will not answer questions here relating to the administration of that hospital, but will rather refer one back to the hospital board, a board which is loaded in favour of the administrators, then where does democracy go? What becomes of the rights of the citizens? How is a citizen to make a complaint? How is he to get his rights? This is something about which I am fearful.
The hospital board, so-called, consists of 23 people and at least 12 of these must be consultants. I understand all of them will be appointed by the Minister. The chairman and vice-chairman will be appointed by the Minister. On the discussion on the Health Act here we nearly had a standup fight in order to get the concession that a majority of the regional health boards must be elected representatives. I remember a very long debate and the Minister yielded; he conceded that a majority, 17 out of 32, would have to be elected representatives. When you come to the regional hospital boards you have the same thing again.
There shall be thirty-two members of the Dublin Regional Hospital Board, made up of—
(a) four persons appointed by the Eastern Health Board, four persons appointed by the Midland Health Board, four persons appointed by the North-Eastern Health Board and four persons appointed by the South-Eastern Health Board—
then you have 16 persons appointed by the Minister.
I should like the Minister to tell us now, while we are considering these health regulations, what type of person he intends to appoint, what type of appointees will make up the 16 persons he will appoint. Will they be elected representatives? Will they be members of the medical profession? This is important. It is very important in relation to the little interlude we had before I rose to speak because a ruling was made that people who had spoken before would not be allowed to speak again since they had an opportunity to put their points when the Health Estimate and these regulations were being debated as a package.
It was very significant that the Minister was prepared to allow these regulations to go to a decision of the House or a vote of the House without answering any of the points that must have been made by Deputy Clinton, Deputy Begley and other Deputies who spoke on the package. That is why I say there is a tendency to steamroll things through the House and to show a sort of resentment at the questioning in the House of decisions by regional health boards.
My fundamental objection to these regulations is, first, that there are too many boards and, secondly, that the boards will be loaded in favour of the medical profession. We already have regional health boards. We are setting up regional hospital boards and a national hospital board. These boards will be tripping each other up. It will be very hard for a person to know where he should go for his rights and who is in control of what.
The Minister must realise that he is asking us for a blank cheque. He is asking us to hand over the administration of our hospitals to a board to be set up here and he should not expect to get that authority without a full discussion and a full debate in the House. Before the voting on this matter this evening he should answer the questions that have been put. He should tell us how he can justify writing into these regulations that out of 23 members of Comhairle na nOspidéal 12 shall be registered medical practitioners engaged in a consultant capacity in the provision of hospital services. I want him to deal in particular with that. That is my fundamental objection to these regulations.
There is one general and one specific topic to which I should like to refer in the discussion on these draft regulations and statutory instruments. The general topic is the topic of democracy in the selection of personnel, democracy of control of the hospital services. We all pay lipservice to the word "democracy" but we are inclined to think it means the opportunity of electing a Government or local authorities every so often.
In historical terms democracy is a new growth, a fragile growth and a partial growth. If it is to be more than a word which is uttered by every party as something everyone agrees about at election times, systematic efforts must be made to introduce democracy into all aspects of our lives: into education which I will not pursue; into industry which I will not pursue; and into the control of our health services. It is a fundamental question of answerability.
Health services become more and more expensive with every passing year, and properly so, because knowledge is exploding and because people's desire to avail of the best current knowledge is also increasing rapidly. Society has decided that it is prepared to spend much more money than heretofore on the provision of health services, medical services and hospitals. In the end, however, we raise this money, it comes from the public. It comes from the public just as much if it is dropped in 10p pieces into cans on street corners as if it comes from a local authority or from a national Government.
In the matter of membership of the single national council—and I am now referring to the draft regulations —we find in the section on membership, section 5, that all persons appointed to the council shall be selected for appointment by the Minister. This is to operate for a period of 3½ years from now, or a period of three full calendar years from the beginning of 1973.
I am not a doctor but as a veterinary surgeon I am a member of a profession which has some minor similarities. As I think everyone in this House does, I profoundly admire the individual action of very many dedicated doctors, but I cannot say that I admire the collective action of the medical profession as a whole in the same unreserved way that I admire so many individual doctors.
Very often the doctors themselves show a contempt for democracy. They are a clique. They are, in the old-fashioned term, a mystery. They despise the ability of the public to apprehend their mystery and they desire to keep the public at arm's length, in ignorance and out of the way as much as they possibly can. This attitude is bad medicine. It belongs more in the last century than in this. Not only is the knowledge of the public rising rapidly, but the responsibility of the medical profession to explain to the public what they are about, and the way in which they are discharging their public duty, is increasing all the time.
Yet the tendency among leading doctors, among what one might call the politicians of the medical profession rather than the day to day journeymen, the GPs, who are admired and respected by everybody, is to hand down the succession from man to man, to favour the chap they like, to go on gathering the chosen few into this select band, this special élite, the people known as consultants and specialists.
It has been suggested that beginning in 1976 we may have some other method of selection, one would hope a democratic method of apointment but, by the time 3½ years have elapsed, individual cliques will have dug themselves in, and then we will have the possibility of a self-perpetuating oligarchy contemptuous of democracy and not willing to be answerable to the people who in the long run are putting up the money, that is, the public at large. That is my general objection.
This is my general objection, but when one comes to consider the actual sections of the draft regulations, there is a more specific and particular objection relating to appointment. We have an historical distinction in this country between local authority and voluntary hospitals and I want to make a distinction in my attitude to the voluntary hospitals as I made a distinction in my attitude to the medical profession as a whole as distinct from the attitude to particular doctors. There is admiration of the services to the nation from very many voluntary hospitals. This will be shared—there will be no possible disagreement on that. Yet to the extent that many of them have roots in the past, many have a strong tradition, many have a specially entrenched position, they are unwilling in the changing circumstances where the vast majority of their money comes not from voluntary collection but from the public purse to change their control into a democratic form of control where they are answerable to the public.
I would refer to sub-article (4) of page 6 of this statutory instrument which sets out that regional hospitals shall exercise the function of appointment, which is referred to in section (k) of sub-article (8), and then sets out that this function of appointment by the regional boards shall be exercised only with the consent of the body or bodies responsible for the administration of the hospital or hospitals concerned. That is fine in relation to hospitals where there is a measure of democratic control, local authority hospitals, but in my view, it is not fine in relation to voluntary hospitals. What is built into what I have quoted is a veto on the power of selection of the already not sufficiently democratic regional boards. Already on the National Council, Comhairle na nOspidéal itself, I am disappointed to see that of the 23 persons, 12 shall not just be registered medical practitioners—that is perhaps arguable—but they shall be registered medical practitioners engaged in a consultant capacity and this is already building the strength of what I call a self-perpetuating oligarchy, a self-perpetuating élite. They already have too much power given to them in the composition of the boards, but when that has been done first, they then hand away a veto to an even more elitist and self-perpetuating oligarchy running very many of our voluntary hospitals.
The net outcome of this is that the maverick doctor, the doctor, perhaps, admirable medically but with strong social attitudes, the man who is outraged—this is hypothetical obviously —possibly by what he sees in certain areas, the man who has very strong opinions on contraception as certain doctors have—there is a veto against that man being handed away against a man who from his professional viewpoint has expressed outrage at housing standards, who has possibly expressed outrage at nutritional standards, dental care, the treatment of unmarried mothers—a whole lot of these areas in which the most humane, the noblest of the medical profession do express concern and a sense of their own responsibility, of their own outrage.
The debate will be perpetuated if we are now to debate what will come before the House as a second set of regulations, namely, the selection procedure, if the Houses choose to give it to Comhairle na nOspidéal. It does not arise in this debate and I made it absolutely clear that Comhairle na nOspidéal will itself have to be formed and start to study how in relation to consultation with other bodies and with me, it would select so that the question of not selecting somebody who is a socialist doctor simply does not arise. They have only the power of withholding or granting sanction for the post of a consultant and I, from my financial control, will have the ultimate decision in every case, withholding or granting sanction for the making of an appointment in the consultant field in this country. They have no selection procedure, so that although I am very interested to hear what the Deputy says, it does not arise on these regulations. It will come before the House later and we can then discuss whether the system of selection is likely to preclude socialists or people interested in housing.
The Minister is appallingly wide of the mark and he knows it. It says "Only with the consent of the body". He should not try to pull the wool over our eyes.
If I am in error, it is a genuine error on my part and I apologise if I am wrong. The Minister introduced the word "socialist". I was expressing a category of doctors who have a sense of profound concern and outrage at what they see in our society. They generally are socialists but it is not an invariable one to one correspondence. While I take the Minister's point, I cannot agree that it represents the situation, unless I misunderstand the documents we are now considering. I take it that his point is that he has the ultimate right of appointment, but what I am worried about is not the power of appointment by the bodies responsible for the administration of the hospital or hospitals. Let me be more precise about it What I am worried about is not the power of initiation of appointment but the power of veto on appointment by the boards of voluntary hospitals, and that unless I misunderstand it entirely, does come up under these regulations. Because it is divided into sections and subsections (a), (b) and (c), I may be unclear because I am not absolutely happy in my own mind how I should name each of these subdivisions in order to be understood.
I hope the Deputy will take my word for it that when these regulations are passed, neither the regional hospital board nor Comhairle na nOspidéal will thenceforth select a doctor for any purpose and we will have to wait until new regulations come before the House when the Deputy can argue about whether the voluntary hospital concerned should have the right of refusal—whether doctors selected to work under the regional hospital board and not the hospitals—whether that is a right course or whether I should amend it in ensuing regulations. All that can be argued and I hope the Deputy will take my word for it that no selection procedure is at the moment envisaged. He can argue all these points when I come before the House as I hope by about next February or March to complete the powers of Comhairle na nOspidéal to deal with the question of selection procedure.
That is not true and the Minister knows it is not true. The Irish Medical Union have a memorandum before the Minister pointing out that they do not accept his interpretation.
The IMA and IMU are accepting the general postponement of the selection procedure.
The Minister is misleading the House because I have a memorandum from the Irish Medical Union before me which completely contradicts him.
The normal procedure when a Minister gives such an undertaking is that the House accepts his statement.
He should amend the regulation.
I am quite happy to do this, but quite genuinely we are at cross-purposes because I was not entering my doubts about the mechanism of selection of Comhairle na nOspidéal. I was entering my doubts about the veto which is here being given to the boards of the voluntary hospitals. Perhaps we could resolve this if I asked the Minister a very brief and direct question. If it is answered satisfactorily, I shall sit down immediately. Am I wrong in thinking that article 8 (4) on page 6 of the statutory instrument confers a veto on the boards of voluntary hospitals if they wish to exercise such veto. Am I wrong in that understanding?
It is correct that we had a difference of a point of view between some consultants and the voluntary hospitals, so what we had to put in this regulation was that if and when there is a selection procedure devised it is unlikely that a consultant will be appointed by the regional hospital board to work under the regional hospital board unless he worked for more than one hospital. Most of the hospitals seemed to feel that if the doctor was going to work solely for one hospital he should not receive the type of contract that would be given to him by a regional hospital board. None of that is of real significance because the regional hospital boards have no power to select in this regulation. The whole of that matter has been postponed and we could even get an agreement between the voluntary hospital authority, the regional hospital boards and myself that it would be possible to appoint a consultant without the consent of the voluntary hospitals. All that can be discussed again when we have the selection procedures before the House.
I shall not take up much more of the time of the House except to say that what the Minister has said does not satisfy me. It seems to me that there is a real point here. I entirely accept that the method of selection has not yet been worked out but it does seem to me that a veto is being handed to groups that are what I have called self-perpetuating oligarchies, that the operation of real democracy in this matter is being inhibited. The Minister's explanation, far from removing my objections, has strengthened them. I want to read that on to the record and reiterate my dissatisfaction.
I believe these draft regulations are very dangerous. It looks to me as if the people are handing away their rights in regard to their hospitals. It is important to consider the method by which the health boards have been set up. I think this is relevant to the regulations. I want to point out the numbers comprising the health boards in the country.
We are not dealing with the health boards.
May I help the Deputy? Neither the regional hospital boards nor Comhairle na nOspidéal, as I have already indicated both on the occasion of the Health Bill and in my speech introducing these resolutions, is going to run the hospitals. The regional hospital boards have a budgetary assistance function in relation to the budgets of the voluntary hospitals as they come before the health board and to me. They have a research function on the future of the hospitals and they have a function to encourage better management in the hospitals. They do not run the hospitals, either the voluntary hospitals or the health board hospitals. Neither does Comhairle na nOspidéal run the voluntary hospitals. They have a function solely of recommending or withholding sanction for the appointment of a consultant. They do not run the hospitals. I hope the Deputy understands this.
(Cavan): The Minister has told us who does not run these hospitals; will he now tell us who does run them?
The health boards run some of the hospitals. The voluntary hospital boards manage the rest of them.
(Cavan): Then the health boards do run some of them?
Yes, but I hope Deputy Enright understands this. No doubt he has not had time to go back to the Health Act speech.
May I raise a point of order? When this discussion came up this evening I was claiming my right to speak because of the fact that this was not before the House until now as a separate issue. In fact, it was not moved until now. The Minister just muttered from his seat but that was his way of moving it. I could not have spoken to a motion that was not moved and therefore I claim at this stage that I have the right to speak on the motion which was only moved at 4 o'clock.
I moved the resolutions with the Health Estimate.
The ruling of the Chair is quite clear in regard to this. Originally the Health Estimate and the regulations were discussed together. Any Deputy who spoke on that occasion had the opportunity then to deal with the regulations as well as the Estimate. That was the time for Deputies who have spoken to deal with these regulations. Therefore, a debate on these regulations at the moment is confined to those who have not taken part in the debate.
On the same point of order, am I correct in saying that the motion was not moved until 4 o'clock this evening?
Originally the Health Estimate and the regulations were moved.
Is it right to say that the regulations were moved?
They were moved.
If they were moved why were they moved again at 4 o'clock this evening?
For the simple reason that on this occasion there has been a division of the two. When the Estimate was dealt with there was also a section dealing with the regulations.
Is it not a fact that you cannot have two motions before the House at the same time?
They were discussed together.
You cannot have two before the House at the same time?
Discussion can take place, as in the case of amendments. Those who have already spoken are precluded from speaking again.
Would the Leas-Cheann Comhairle explain why it was not necessary for the Minister to reply to the regulations, to all the arguments that were put up on the regulations in relation to the health services generally, and why he has interjected half a dozen times since this discussion started at 4 o'clock.
The Chair takes it that the Minister will reply to points raised. All the Chair is concerned with at the moment is the actual position. The present occupant of the Chair was in the Chair when these were being debated together. Quite a number of Deputies took part in the discussion on that occasion and had the opportunity to refer to these regulations.
I am satisfied that a dirty trick was carried out on the House and it was most unlike the Minister for Health to be part of it.
I am extremely worried about this. Assuming that I now speak on the regulations, will the Chair prevent me from speaking on the Estimate?
No. The Deputy will have his opportunity when the Estimate is resumed of speaking on the Estimate but not on the regulations.
I must be extremely dull because I cannot understand this.
The fact is that Deputy Clinton and other Deputies were speaking on a composite business before the House which included the regulations which are now under discussion separately. This is a separate motion.
To me it is a trick.
Far be it from me to contradict a man such as the Minister for Health but I shall quote some points from the regulations. In regard to the functions of the regional hospital boards, it is important that we should look at article 8 subsection (1) (c). Some of the functions of a regional hospital board shall be:
to consider any proposal of a health board or other body referred to in paragraph (a) for—
(i) a change in the user of a hospital maintained by it,
(ii) an extension of such hospital, or
(iii) the discontinuance of such hospital.
It appears that the regional hospital boards will have authority in regard to the regional hospitals that will be set up. Am I correct on that point?
It is not for the Chair to say.
I am asking the Minister.
The Chair would point out to the Deputy that we are discussing health boards. We are dealing with the Health (Hospital Bodies) Regulations.
If we are dealing with regional hospital boards——
But we are not dealing with hospital boards.
Would you look at section 8?
(Cavan): On a point of order, these regulations propose to establish regional hospital boards and clause 8 of the document which Deputy Enright is dealing with proceeds to set out the functions of these hospital boards and some of them are particularly alarming when you consider that they will be handed over to the people who are employed in the hospitals.
I have explained to the Deputy. The Deputy is right. They will have these powers but they will be recommending powers. First, very definitely, the county advisory committee would have to be consulted in regard to any change of function and, secondly, they can make no ultimate decision because any decision they could make about the closing of a hospital or changing the function of a hospital would involve a financial decision on my part, so that I am ultimately responsible and they will not have overall control. They are bound to come back to me and I would have to take full responsibility, with the consent of the Oireachtas, for the decisions they make in that regard. That applies to virtually every change in the health service. It requires my consent because, first of all, I have a national health policy which I will continue to operate and my successor, whoever he may be, will continue to operate and I also have financial control. So, the Deputy can be sure that the regional hospital boards will not be able to make decisions making radical changes in the characteristics or the functions of hospitals without its coming before me and, therefore, before the House.
There is one very serious point which is completely relevant to clause 8. We hope that the regional hospitals will be built. As to the functions of the hospital boards, the Minister says there will be no change, that they are completely under his authority. That is fair enough. I agree on that. In regard to the building of hospitals or factories, when questions are asked about the building not being proceeded with we are told that it is due to sufficient capital not being available and so on. That is very dangerous. There will be 23 members of Comhairle na nOspidéal, 12 of whom will be medical practitioners engaged in a consultancy capacity. The Minister has the power of appointment of the others also. In other words, he has complete power of appointment.
In the Cork Regional Hospital Board there will be 16 persons, four persons appointed by the Mid-Western Health Board and four persons appointed by the Southern Health Board and eight persons appointed by the Minister. It appears that the Minister will have complete and unfettered control of the regional hospital boards and of Comhairle na nOspidéal. This is a very serious matter for everybody in the country. The Minister will have control over the question of whether regional hospitals will or will not be built.
There are many county hospitals which are—I hesitate to say being scaled down—at the very most maintaining the status quo. I am giving the Minister the benefit of the doubt in saying that. County hospitals in the health board area in which I am situated will be maintained barely at existing levels. The people in the area agree to this in the hope that a regional hospital will be built in Tullamore. The Minister will have sole discretion as to whether or not the regional hospital will be built. It is a very dangerous situation that we have to depend completely on the Government having the money available to build these hospitals. Deputies can be put off indefinitely on the plea that the capital is not available.
I have the financial control now, with the consent of the House. The Deputy must get his sights right about this. The health boards and other consultants will be able to give advice but I have absolute financial control now, with the consent of this House. The Deputy does not understand that.
The Minister will not accept responsibility for the health boards even to the House here.
We are discussing the regional hospital boards.
Will the Minister accept full responsibility for them?
Of course, I am responsible for them.
Will he answer Parliamentary questions?
I have only refused to answer three.
The Minister refused to answer six of mine.
I told the House the other day that I was so confused about what kind of questions I should answer and what I should not answer that I decided to answer everything. The Deputy need not introduce this argument as a red herring.
It was not a red herring to people who had no medical card.
The Minister states that he has financial control at the present time. A question may arise as to whether a hospital is necessary in an area and it may be the case that money may be needed for something else. It is dangerous to allow this to happen. The Minister mentioned that no changes would be made with regard to the scaling down of hospitals until consultation had been held with the county councils' advisory committees. I have been a member of Offaly County Council for five years and it is my opinion that the submissions of county councils have not received the recognition to which they are entitled.
With regard to the matter we are discussing, too much power will be vested in the Minister. From what has been said it appears that the Minister will have financial control over the building of regional hospitals. When the regional hospital boards at Dublin, Cork and Galway are set up, the Minister will have complete control over them. In Comhairle na nOspidéal there will be 23 members of whom 12 will be medical practitioners engaged in a consultant capacity in the provision of hospital services. Deputy Keating made the point, with which I agree, that the consultants will not be in close touch with the ordinary people to the same extent as would general practitioners. Medical practitioners should have as decisive a voice in this matter as consultants.
The Minister also has power to appoint the remainder of the board and this is not a good thing. This House should not hand over all of its authority. In addition, the county councils contribute by means of the rates. It is not good that complete authority should be taken from the local representatives. The health schemes are becoming too remote from the people and this is not desirable. If this should happen we would have a dangerous situation—I use the word "dangerous" advisedly.
There are 30 members on the Midland Health Board, 16 of whom are public representatives. Members of the Midland Health Board form part of the Dublin Regional Hospital Board. On the latter board there are 32 members consisting of four from the Eastern Health Board, four from the Midland Health Board, four persons appointed by the North-Eastern Health Board and four from the South-Eastern Health Board. The Midland Health Board comprises four counties and there will be one representative from each county. When one considers that out of the 32 members 16 will be appointed by the Minister one realises what is involved. On the Dublin Regional Board only 16 persons will be answerable to the people; the other 16 are appointees of the Minister and do not have to answer to anyone but to him. It is my opinion that representatives on the board should have to answer to the people.
In his explanatory memorandum, the Minister has stated that the chairman and vice-chairman of Comhairle na nOspidéal will be selected by him from among the members. In this instance the Minister is taking too much responsibility and I do not think it is wise. In view of the fact that the regional hospital boards will be answerable only to the Minister, it is alarming to read that the discontinuance of any hospital will be a matter for the regional hospital boards. I could not vote for this regulation if this is allowed.
In the midland health area we have agreed that a regional hospital will be set up at Tullamore and I am prepared to stand by that decision. However, there will only be one representative from each of the four counties on the Midland Health Board. Many of the people in the health boards have grave misgivings about this regulation. The public representative is being cut out completely in Comhairle na nOspidéal. He will not have any voice in that council. The 23 members will not be responsible to anyone but to the Minister. The regional hospital boards are so rigged that they will be answerable only to the Minister. This is a very dangerous practice. The matter almost slipped through the House this evening without there being any opportunity for a frank discussion of it.
Yesterday the Local Elections Bill went through the House. We have now allowed the postponement of the local elections. If important issues are allowed to go through the House without being opposed, the 144 members who comprise this House are letting democracy slip from their grasp. In conscience I could not vote for the regulations before the House because as the boards are set up they are too far removed from the people who will be using the hospitals and these are the people who have a right to a say in the running of their hospitals. They should have the right to elect people to the administration of their hospitals and if the boards are not running the hospitals properly, they should be answerable to the people who use the hospitals. From these regulations we can see that there will be no consultant in the country who will be answerable to the people. Neither will the other people appointed to the boards be answerable to the people and neither will the 16 persons appointed by the Minister have to answer to the people.
I would agree with these regulations if Comhairle na nOspidéal were a democratic body on which public representatives would have a 50/50 say. They should have a casting vote but I would go along with a 50/50 representation. There is not sufficient public representation on the Dublin regional hospital boards. I am sure there will be grave misgivings throughout the country when the people realise what are to be the functions of the regional hospital boards.
Normally I do not speak on health matters but when anything of this particular nature comes before the House I am inclined to contribute. This is a piece of specialised bureaucracy of the type that the Minister in particular is very fond of. These regulations are based entirely on the premise that the Department of Health are all important in this matter and that nobody else has any say. The introductory section of the regulations is contrary entirely to what is normal practice in statutory instruments. This reads that:
The Minister for Health. . . . hereby makes the following Regulations as respects which, pursuant to the said section 41, a draft has been approved by a resolution passed by each House of the Oireachtas.
It goes on to describe the regulations. When the Health Act of 1970 was going through the House, I presumed to rise on Committee Stage to ask a question of the Minister but the Minister became very angry with me. Months afterwards I had to help the Minister out in relation to that Bill. On the second occasion, many months later, the Minister's attitude towards me was very different when I asked him a question. In the meantime he had been put through the mill by the House. According to the regulations, Comhairle na nOspidéal shall consist of 23 persons all of whom are to be appointed by the Minister and the majority of whom are to be consultants. There is a special provision that biochemists, top grade, and senior registrars shall be prescribed officers. In other words, they also may come in but nobody else may. This is a real example of the top echelons of staff only being entitled to be appointed by the Minister to Comhairle na nOspidéal.
The regulations go on to deal section by section with the Dublin, Cork and Galway regional hospital boards and, eventually, in section 8 to define the functions of each board as distinct from the special functions which are embodied in the earlier sections of the regulations. Let us take the Dublin Regional Hospital Board. We are told that there shall be 32 members of this board made up of:
(a) four persons appointed by the Eastern Health Board, four persons appointed by the Midland Health Board, four persons appointed by the North-Eastern Health Board and four persons appointed by the South-Eastern Health Board and
(b) sixteen persons appointed by the Minister after consultation with, or on the nomination of, such bodies representative of persons concerned with the provision of hospital services and such other bodies (including bodies engaged in medical education) as he considers appropriate.
In other words, the Minister can appoint anybody he wishes as one half of the members of the board. The Department of Health become a dictator and can do what they wish in relation to a matter of this nature which concerns the people for whom the services are being provided under the Health Act of 1970.
We come now to the functions of the regional hospital boards which, fundamentally, are to operate the regulations under which the hospitals are conducted and to lay down the rules under which appointments are made. There is one particular function that I shall refer to at some length. I refer to 8 (1) (f) which says: "to advise hospital authorities in its area." What does that mean? What is the significance of that in regulations which are supposed to deal with administrative matters? Regulations are administrative law and according to article 8 (1) (f) the functions of a regional hospital shall be to advise hospital authorities in its area. What significance has this?
Does the Deputy wish me to reply now?
I should be grateful if the Minister would.
This means that regional hospital boards, because they would have consultants from voluntary hospitals which the health boards do not run, would be able to advise the health boards how better the voluntary hospitals in an area could co-ordinate with the health boards in an area to provide better service at possibly less cost and utilise all available beds. It is advice in relation to the combination of voluntary hospital beds and health board hospital beds in the area. That is fairly harmless.
I agree. That is the very point I was making, that, in fact, it is harmless.
There is nothing sinister about it.
I am not suggesting there is. I am suggesting that it is worthless, that it should not be there. It is not administrative law. Giving people advice is not administration and has no relation to it. Administration is the doing of things, getting them done, but giving people advice is not getting things achieved. Giving advice is very like debates here: it is literally useless to talk in this House——
Oh, dear.
——because, in fact, the Government in no circumstances will accept an amendment to any Bill or give any standing whatever to the Opposition parties. It is no wonder that after 15 years in office they would become arrogant. This is the reverse of that, because advice is something you give people if you cannot coerce them. The remainder of the article is to the effect that the regional hospital boards shall do this and that—"advise the Minister . . . to make appropriate representations . . . to govern . . . to examine . . . to allocate . . . to control the expenditure of capital funds allocated by it under paragraph (i)." The Minister himself under these regulations has control of major capital expenditure. He will not give these hospital bodies constituted by himself responsibility for major projects; he wants to keep that under his own thumb even though these boards are composed of senior people. He is giving them no real control over expenditure.
No wonder the cost of hospital services has gone sky-high and that the cost of a hospital bed in a voluntary hospital in this city today is £75 a week for a private patient. If anybody is unfortunate enough not to be in the Voluntary Health Insurance scheme he may suddenly wake up to find himself a bankrupt or the equivalent of a bankrupt if he has to stay in hospital for a number of weeks.
Article 8 (1) reads:
to organise advisory services on management for hospitals.
This is the old game of the Government getting in consultants wasting the people's money. The Government have never stopped this game of throwing money around—McKinsey and Co. and all the others. The result is that the value of money is down in this country and we have no option when Britain allows the £ to sink but to allow the Irish £ to sink with it.
Article 8 (2) says:
In considering a proposal referred to in subarticle (1) (c) (i) or (iii) of this article, a regional hospital shall request and have regard to the views of the relevant local committee established under section 7 of the Act and the views of any other hospital authority . . .
I know a good deal about the business of providing that so-an-so shall consult with somebody else. This is of no significance whatever. When it is provided that one Department shall consult another Department they write to the other Department and the other Department say: "We do not think you should do this." The first Department then write back and say: "You can say what you like about it. We shall do it in any case." That is the end of the game if the second Department have any common sense, particularly if it is the Department to which I was attached. If it is provided that such-an-such a Department shall consult the Department of Finance and if they stand on their hind legs they can tell the Department of Finance to jump in the Liffey. And this is done. If the Department of Finance have any sense they say: "Very well. You have consulted us. You have done what you are bound to do under the regulations." And that is the end of it.
"Shall have regard to the views . . . " All they need say if any rumpus arises is: "Yes, we had regard to their views and we decided to do such-and-such." This whole business is gobbledegook of the first order and has no significance in regard to genuine administration.
Regulation 11 says:
Any reference to a health board in sections . . . shall be construed as including a reference to a regional hospital board.
This is the kind of omnibus clause that Ministers and their advisers love: "such-and-such a thing shall be held to mean something else." As I said before: "Two shall be held to be equal to five," any way you like to talk about it. John O'Donovan shall be same as the chairman. This kind of thing is done. I am not drawing a long bow. This kind of thing has gone completely out of hand in this country. There is literally no restriction any longer on what the Executive may do. They continually put clauses into Acts enabling them to do what they like and if anybody says that is not good enough they refer, as the Minister did a while ago, to the Act and say: "It was in the Act". And the House has authorised the Act. So if the House chooses to give away the democratic rights of the people this is an occasion when the Houses of the Oireachtas are within their rights to do wrong, and once they have done wrong nobody can catch up on them, nobody can do anything about it.
These regulations are brought in on the second last day of the month and are to come into operation at the end of the month. In other words, the House is put under pressure to push these regulations through at a moment's notice. The printers' mark on the last page is 5/72, the month of May, yet here we are at the end of June discussing whether the Minister is to have power to make these regulations. This is the kind of action by the Executive that makes people worry about democracy, and the next general election will be about democracy and nothing else. It will be about whether you can have democracy when you have this so-called administrative law, which is not administrative law at all but the absolute control, the dictatorship, of the Executive.
On a point of order, earlier the Ceann Comhairle held that I had no right to speak because I had spoken earlier on the Health Estimate and the regulations. Can the Chair tell me the position of Deputy Murphy who was speaking on the composite situation of the Estimate and the regulations when the debate on the Estimate was adjourned? Is he to be regarded as having spoken on the regulations, or what is his position?
I was not here at the time and it is not for me to say. Deputy Murphy was in possession and he was not here to carry on.
He could not carry on on something that was not introduced or moved. He was in possession on the Health Estimate and the regulations jointly. The Minister decided to separate them for his own reasons and he moved this motion at 4 p.m. today.
Acting Chairman
According to the information that has been transmitted to me, nobody is to be permitted to speak twice.
Deputy Murphy would be debarred even though he was not allowed to complete his speech——
Acting Chairman
I am under the impression that he was not here to complete his speech.
Does the Chair agree with me that it is an extraordinary situation and an extraordinary ruling?
Acting Chairman
That may be so but I cannot adjudicate on it because I was not here at the time.
Would the Deputy who was in possession when progress was reported be in order, on resuming on the Health Estimate——
Acting Chairman
I am informed that the Health Estimate is being dealt with at a later date.
Can the Chair tell me whether Deputies who have spoken on the regulations will be allowed to speak later on the Estimate?
Acting Chairman
I cannot take these decisions, but the information that has been transmitted to me is that the debate continues now only on the regulations and anybody who has spoken before cannot speak again.
I have 29 years experience in this House and this is the first time that the unusual circumstances have arisen in which a Minister has moved a motion at 4 o'clock in the afternoon and a Deputy who has spoken on the Health Estimate is not allowed to speak on the regulations because he is said to have spoken already on a motion that was not before the House until 4 o'clock this afternoon. I do not know how that ruling came to be made but it is not in accordance with the democratic principles of this House.
I take grave exception to whoever made that ruling. I was present in the House at 4 o'clock this afternoon when for the first time the motion was moved, after Questions. A Deputy then presented himself to speak and was told he could not address himself to the motion because he had spoken on it previously. I do not like to challenge the Chair's ruling but I find it hard to understand how any Deputy could be ruled out of order as having already spoken on a motion which was not moved until 4 p.m. today. It is something on which the Ceann Comhairle should express an opinion because it concerns the rights and the liberties of every Member of the House. One thing that is rich and precious to us all is the right to address Parliament in compliance with the rules and order of procedure. Deputy Clinton has been treated most unreasonably.
Acting Chairman
The position as put to me is that anybody who spoke before cannot speak again. The only discussion at the moment is on the health regulations. With regard to any comments to be made on Deputy Clinton, I wish to point out that there was a ruling by the Ceann Comhairle, it was discussed here and finalised, and I should be obliged if the Deputy would continue to discuss the regulations only.
I will comply with the Chair's wishes but I heartily compliment myself on not having spoken on the Health Estimate because if I had I presume I would not be allowed to address the House on the regulations. I presume that when Deputy Clinton spoke on the Estimate he was under the impression that when the motion came before the House he would be permitted to speak on it. I would feel extremely disturbed had I spoken on the Estimate and was thereby deprived of the right to address the House on the regulations.
The regulations are of a type one would expect to be presented by Fidel Castro. They are not democratic or in line with the principles of the Health Act on which the Minister has been so vocal in the House and the country.
I want to compare now the powers exercised by health boards in the past and the powers to be exercised by the health boards set up by the Minister in the last 18 months. I recommend strongly that these proposed regulations be rejected by the House. Under them, not alone will the teeth be extracted, so to speak, from regional health boards but the very limbs will be amputated. What is in the Minister's mind? There is more behind these regulations than would appear on the surface. They are, in my opinion, evilly conceived. There is a close resemblance here between Health and Education. Health and Education are two of the most vital Departments in any democracy. An attempt is being made to remove education from the religious orders and from private sectors and now we see an attempt being made by the Department of Health to take control of the hospitals out of the hands of the religious orders and out of the hands of the voluntary hospitals. We owe a deep debt of gratitute to these institutions. These are institutions which have earned public confidence. Outstanding work has been done by St. Vincent's Hospital out in Elm Park, by the Mater Hospital, by the Richmond Hospital and by all the other hospitals here in this city and throughout the country. Very few institutions enjoy the respect and confidence that these hospitals have earned. It was in these hospitals that many people were restored to a new life as a result of the care and attention bestowed on them as patients in these hospitals.
When the Health Bill was under discussion here we were not told that the thin edge of the wedge would be inserted through the medium of regulations to deprive those responsible for the running of these hospitals of the right to run them. As in education, we find here the icy grip of bureaucracy on health. These regulations are being introduced for no good purpose and for no good reason. The only purpose is to channel health into the hands of the civil servants and the Minister. These regulations confer extraordinary powers and, whilst the House has every guarantee of integrity with the present Minister in office, there is no guarantee for the future. But it would be quite wrong for Parliament to confer such far-reaching powers on any Minister for Health. It is all very well for the Minister to tell the House that he is quite satisfied and, if the House gives him the authority, he will administer these regulations with integrity and with impartiality. What guarantee is there for the future? In five, ten or 15 years time there may be a Minister for Health who will use these regulations for party political advantage. He may fall the victim of some clique which may want greater control over our hospitals. It is wrong to give the kind of powers sought in these regulations to any Minister for Health.
I want to give this House the reasons why I have such strong opposition to these regulations. The Minister is well aware that many of us in this House have been associated with the old health boards for many years past. Many of us have also been associated with local authorities. Our primary concern was the welfare of the aged, the ill and the disabled. As public representatives we devoted our energies and time to the building up of a good hospital structure.
If these regulations are passed tonight they will completely undo the valuable work done by members of the health boards, members of the old boards of health, members of local authorities and hospital committees. They will undo the valuable and useful work performed in the voluntary hospitals such as St. Vincent's Hospital, Elm Park, the Mater, the Richmond and other outstanding hospitals that have gained not only national recognition but international recognition for their care and attention and devotion to duty.
These regulations have been put into print and circulated. Will the Minister tell us what were the views of the Government in general when he was seeking approval to have these regulations printed and circulated? At 4.5 p.m. today it was his intention and the intention of the Government to sneak these regulations through the House without notice, without discussion, without debate, in order to pull the wool over the eyes of Members of the House who are keenly concerned about the future of the entire hospital structure.
The Deputy should not be unfair. We discussed the general functions of these boards and Comhairle na nOspidéal during the passage of the Health Act. If the Deputy looks at section 41 of the Health Act he will find that the main concept is there so this was discussed at very considerable length during the passage of the Health Act. I just want to mention that to the Deputy. There is nothing new in the general concept of these three boards and Comhairle na nOspidéal. The Deputy, of course, is entitled to say what he thinks.
I want to assure the Minister that I read the Health Act line by line and section by section. It is true that there was a vague reference to Comhairle na nOspidéal and that there were other vague references, but it is only now that we have got the orders and the regulations. This House should not be too hasty in passing regulations of this kind without knowing what they are doing.
As I have said, there is a terrific similarity between these regulations and the trust deed associated with the community schools. The same principle is involved. We can deal with the community schools on another occasion. As I have pointed out, this is an attempt by the State to monopolise and completely take over education and health. Through these regulations the health services will go out of the hands of the health boards and out of the hands of the elected representatives.
It is stated: "The Regulations shall come into operation on 1st day of July, 1972." They will come into operation at the end of this week. The Minister has not satisfied the House as to why they are necessary. They are an expression by the Minister and the Government of no confidence in the regional health boards set up under the Health Act 18 months ago. I should like to hear from the Minister in clear and simple terms what will be the functions of the regional health boards if we take away from them control of the hospitals, administration of the hospitals, administration of hospitals staffs and the planning, development, design and extension of hospitals. Everything connected with hospitals will fall into the hands of Comhairle na nOspidéal.
I am a member of a health board. We discussed this matter and passed a resolution unanimously asking the Minister to defer putting these regulations into operation. I should like to hear from the Minister how many health boards have petitioned him to defer putting them into operation. Having considered the notice given by the Department about the making of these regulations, all the health boards submitted resolutions to the Minister pointing out that before regulations of this character were made the health boards should be given an opportunity to prove themselves in relation to hospital planning and hospitals in general. Only 18 months ago the Minister addressed the health boards and pledged co-operation and support. He expressed sympathy and asked for co-operation between the health boards and himself. The first major issue to arise was the taking away from the health boards of the management of the hospitals, the planning of future hospitals and the staffing of the hospitals under these regulations.
All the health boards asked the Minister to do was to postpone the introduction of the regulations so that they would have an opportunity of studying, reviewing and planning, and of examining the financial aspects of future hospitals and health policy. Is it not correct to say that practically no regional health board is in agreement with these regulations? Is it not correct to say that practically all the health boards asked the Minister to postpone them?
I should like to know from the Minister what is the urgency? Why can he not comply with the unanimous request of so many health boards? Why must 1st July, 1972, be the date? Has he entered into any commitments for hospital borrowing from any international source by reason of which he must give that source a guarantee that Comhairle na nOspidéal have been set up or are about to be set up? There must be reasons for it because no sane Minister who wants to co-operate with newly-established health boards would act in this fashion against the wishes of the health boards who asked that these regulations be deferred. Therefore, when I read that these regulations shall come into operation on 1st July, 1972, I believe that there must be an extraordinary urgency associated with them. I ask the Minister if the urgency is a financial one? Must he give to some hidden, concealed hand a guarantee that the Last Post has been sounded over voluntary hospitals?
No Last Post.
The Minister says that no Last Post has been sounded. I put it to him that if these regulations are passed, if the House agrees to them, that in itself is the Last Post, the flag at half-mast and, in my opinion, the requiem for voluntary hospitals. Nobody knows that better than the Minister but I think he knows what is the urgency associated with these regulations.
Reading the draft regulations further, we see that during the period ending 31st December, 1975, all persons appointed to Comhairle na nOspidéal shall be selected for appointment by the Minister. We are now in 1972 and these regulations cover the period to 31st December, 1975. "Shall be selected by the Minister"—I ask is that a democratic process? Does this not give the Minister full say and full control over the very creation and birth of Comhairle na nOspidéal? Of course it does, and he is going to put on Comhairle na nOspidéal people who will do exactly what he wants in relation to expenditure, to planning of hospitalisation, to the setting-up of hospital extensions. In the making of these appointments, there are to be 12 consultants, 12 people who are already associated, or will be in an official capacity associated, with the working and management of hospitals. I do not dispute for one moment their integrity. The medical profession have an extremely high standard, but I ask the House is it right or proper that the Minister should give this power over to 12 consultants, together with 11 other people appointed by him alone—not by the health boards, not by the local authorities, not by a Committee of this House and not by the Government collectively but by the Minister himself. I put it to the Minister that he will know the minds of these people. He will have already sounded them and he will know the material of which they are made, and unless they are prepared to implement his policy in relation to expenditure on future hospitalisation, these people will not be appointed.
Comhairle na nOspidéal do not control hospital expenditure.
I put it to the Minister that this will be an occasion on which appointments by the Minister in relation to this matter will be similar to all other State appointments made by Ministers of this Government when, on practically all occasions, they appointed people who carried out their wishes. Whether it was right or wrong, black or white, no matter what the wishes of the Minister's were, whoever they so appointed blindly carried out their wishes. I strongly object to the extraordinary powers the Minister is taking unto himself, not, may I say, that I am overwhelmed with suspicion of the present Minister but that I fear some reckless individual who may yet occupy the position the Minister holds may seriously abuse the power this House is now giving. Now is the time for this House to show its disapproval by deciding that they will not trust even the present Minister with this power and authority in relation to these appointments.
Proceeding further, we find that the regulations set out that there will be three hospital boards, Cork, Galway and Dublin. I am interested in the Dublin Hospital Board because it is the board which will be responsible for the area of the Midland Regional Health Board. The Midland Health Board will have their representatives on the Dublin board and we will then be in the extraordinary position—I put this to the Acting Chairman as a representative for Longford-Westmeath—that the hospitals in that constituency, in Longford and Mullingar, will be in the same board area as the major hospitals of Dublin and if there is to be hospital reorganisation, extension, development and planning, the majority of the members of this board will not be from Laois-Offaly or Longford-Westmeath but from the greater Dublin area. Despite the fact that the FitzGerald Report recommended that a regional hospital be considered favourably for Tullamore in County Offaly, I venture to say, while not setting up to be a prophet, that when these regulations are passed and when the Dublin Regional Hospital Board have full control, whatever development takes place will not be in Tullamore, in Mullingar or Longford. That is why we view this with the greatest concern and alarm. I distinctly heard the Minister for Health tell the Midland Health Board, and other health boards assembled for the purpose of hearing his address, that the location of a regional hospital would be a matter for the boards themselves. Now we find that the boards will have no say in this. When the Minister was addressing the health boards he consoled and gave confidence to members that in planning future regional hospitals the health boards which he was bringing into being on that date would have this responsibility. Now we find they have not this responsibility at all. Who did the Minister think he was fooling? Is it not true that all the health boards have been fooled, that they thought they had power and authority and that they were responsible for health administration and hospitalisation? Now they find that that is not so, that the Minister is appointing what can be described as a ghost team who have no responsibility whatever to the public, who will not have the confidence of the public, who will be brought into being by the Minister and the Minister alone. The electorate, the ratepaying community, will have to foot the bill but they will have no say in this matter. Therefore, the health board which covers the area of the Acting Chairman will now have no say in the location of a midland regional hospital.
Yes, they will. The regional hospital board cannot decide the issue. I explained that during the passage of the Health Act.
That is not in these regulations. If there is a regulation which gives authority to the health boards to decide on the location and the establishment of a hospital in any of the health board areas I would like to see it in writing but I cannot find it in these regulations. Perhaps the Minister has a different copy of the regulations. Perhaps the Minister is dealing with the conditions that have been laid down by international financiers for the lending of money or the granting of money for hospitalisation. I do not know. That is what we are trying to get information on. That is the purpose of the debate. That is the reason why Deputy Clinton was not allowed to speak this afternoon. Some of us must have the right and the courage to stand up and ask these questions and to insist that the Minister should not treat the House with silence or contempt but should give us all the information which the ratepaying community are entitled to.
The Dublin Regional Hospital Board will be made up of four persons from the Eastern Health Board—that is four persons from the present Dublin Health Boards—four from the Midland Health Board—of concern to the Acting Chairman and of major concern to myself as a member of that board— four persons appointed by the North-Eastern Health Board and four persons appointed by the South-Eastern Health Board. If they had the say there would be some element of democracy in operation but these will be "16 persons appointed by the Minister after consultation with, or on the nomination of, such bodies representative of persons concerned with the provision of hospital services and such other bodies (including bodies engaged in medical education) as he considers appropriate". This gives the Minister power to appoint 16 persons and these 16 persons will be carefully scrutinised by the Minister. Their views will be well known in advance. There will be discussions and recommendations. We are told there may be nominations submitted to the Minister. The Minister will not appoint anyone who will cause any degree of embarrassment to himself, to his party, or to the Health Act. He will appoint 16 people who will bend the knee to the crack of the whip of the Minister for Health. I have no confidence in a set-up of this character.
The regulation covers the establishment of the Dublin Regional Health Board. Further on we see that the Cork and Galway boards are similarly appointed. Let us come to the question of the function of a regional hospital board. They shall be:
to consider and keep under review the general organisation and development of in-patient and out-patient services in the hospitals administered by health boards or by bodies in its functional area which are engaged in the provision of services under the Act, with a view to promoting the organisation and development of these services in an efficient and satisfactory manner.
Does that mean that the present health boards are not carrying out their duties in an efficient and satisfactory manner? Is this not, in plain language, a slap in the teeth for the health boards appointed only 18 months ago? Is it not correct to say that the functions of the regional hospital board will be the very functions of the health boards at present? Can the Minister deny that at this moment the duty of the CEOs and of our regional health boards is to keep under review the general organisation and development of the in-patient and out-patient services in hospitals administered by the health boards? That is what they are doing at the moment. This regulation is to take from the health boards functions which they thought they would have for an indefinite period and give them to a new board being established by the satellites of the Minister for Health, appointed by him and by him alone.
I want to warn the Tánaiste that when these regional hospital boards are set up, members of the existing health boards will lose interest. Their functions will have been minimalised. Forthwith, on the passage of these regulations the hospital boards will be redundant. Is it not correct to say that at the moment the hospital boards administer the hospitals? The hospital board of which I am a member administers the county hospitals in Portlaoise, Tullamore, Mullingar and Longford. The development of in-patient and out-patient hospital service will be the responsibility of the regional hospital board when these regulations are passed. It means that the Minister for Health, without giving any reason or excuse, without giving the boards a fair chance, without giving them even an opportunity of failure —they have not been in existence for a sufficiently long period to have failed—without giving them the test of time, is taking from them the right to administer the hospital service.
Who does the Tánaiste think he is fooling in relation to this matter? I hope every hospital board will hold a special meeting or two to deal with these regulations. I put it to the House that the CEO and his recently appointed highly expensive staff will all be declared redundant so far as the health board is concerned and will become the servants of the new hospital board to be appointed by the Minister and by him alone.
The Minister did not appoint all the members of the health boards. County councils appointed some members. The Minister made certain appointments. He administered a very bitter pill in a sweet, attractive, chocolate coating. The real snag is appearing. The real test is coming. The health board which the Minister established in a semi-democratic manner are now being rendered powerless by the dictatorial establishment of a board that will have no responsibility whatever to the people or from the people, that will have no obligation whatever towards the ratepayers who will foot the bill. All that the ratepayers will be asked to do is to pay up and shut up. The votes of ratepayers will not enter into the appointment of members of these boards. It is the strength of influence with medical organisations, the strength of political pull with whatever Minister may be in office that will be responsible for the administration of hospitals and of these hospital boards. This comes about because of the distasteful, disgraceful and undemocratic manner in which these boards will be appointed by one man to administer millions of pounds of the taxpayers' money. The taxpayers and the ratepayers will have no say as to how the money is spent.
The money will be spent on the recommendations and advice of the hospital boards, none of whom will be elected by the ratepaying community. We are buying a pig in a bag. The ratepaying community will blindfold themselves, put out their wrists to be handcuffed and their ankles to be chained. The Minister will appoint his colleagues and his friends to spend millions of pounds of the taxpayers' money while the elected representatives on the health boards will have no say whatever.
I am not concerned with any other explanation the Minister for Health may give. I am concerned with what is here in black and white. There is nothing in these regulations to indicate that in the development of in-patient and out-patient services in the hospitals administered by health boards the health boards will continue to have responsibility. On the contrary, the regulations indicate that there will be a transfer of these powers and responsibility from the semi-democratically elected health boards to the dictatorially appointed hospital boards on which the elected representatives, the general public or the ratepaying community will have no say whatever.
Draft regulation 8 (1) (b) says that the functions of a regional hospital board shall be:
to make such recommendations as it thinks fit arising from the consideration and review under paragraph (a) to the Minister, to a health board or to any other body concerned.
Here we find a most extraordinary situation. The hospital board appointed by the Minister will make recommendations to the health board on which there are elected representatives. This is a reversal of the normal procedure. The elected representatives on the health boards are familiar with local requirements. They know what is required by way of in-patient and out-patient service, maternity service, dispensary service. Should not the health board make the recommendations to the hospital board instead of the hospital board make a recommendation to the health board? The draft regulation is ill-conceived and designed for a purpose. This is not a consultative set-up; this is dictatorship. This is part of the Government policy. Eventually this House will have no influence. It is slowly becoming a mere talking shop and it will become a mere county council. To pass a regulation of this kind is not in the interests of our health services or the general organisation of our hospital services. I disagree with the Minister's appointees making recommendations to members of the health boards who were elected by the people. The health boards must levy the charge, they must get the money from the counties they administer. If they have to pay the bill they must have some say as to how, when and where the money is spent but that will not happen if this regulation is passed.
This regulation says that people who have no authority from the public, a group of consultants already employed by the health boards, will be made masters. They will tell their masters how much will be required, how much must be levied, how and where it is to be spent. If this is called democracy, let us describe it as Fianna Fáil democracy. It is not democracy by the people or for the people. This is the worst type of planning for the future, it is bad management and it will not produce good results.
The Minister may have fancy ideas about the future of these boards but I fail to see them. I do not understand why he has taken this step. The character of the regulations worries me. It is stated that the functions of the regional hospital boards shall be to consider any proposal for "a change in the user of a hospital maintained by it". I put it to every Deputy that this is a most serious regulation.
I want to warn health boards that this regulation will give power to the newly instituted hospital boards to downgrade or close hospitals in order to suit the hospitals with which the consultants, who are members of the board, will be most prominently associated. This is bordering on what might be described as a corrupt practice. It will have serious consequences for the country. I can foresee that many of our county hospitals will be downgraded or closed down as a result of this regulation. Do the surgeons, the sisters, the nursing staff, the porters and all others associated with hospitals, realise that hospitals can be closed down by direction of a body that has no responsibility to the people? They will be able to downgrade, to close the doors of any hospital——
They will not have any such right.
The Minister is in for a rough evening. Look at what he has let himself in for.
I have never heard such nonsense. They will have no such right.
Perhaps I am dull, but I am reading the regulations as would a lay man. Article 8 (1) (c) (i) states that the functions of a regional hospital board shall be to consider any proposal for "a change in the user of a hospital maintained by it". It is stated clearly in the regulations and there cannot be any doubt about the matter. Article 8 (1) (c) (iii) states that the functions of the regional hospital board shall be to consider any proposal of a health board for the discontinuance of a hospital. To me "discontinuance" means an end, a full stop. As a member of a health board, I read this as meaning that if the regional hospital board decide to close a hospital in my area there is nothing I can do about it if this regulation is passed.
Nonsense.
The Minister may say this is nonsense but there is nothing in the regulations which tells me it is nonsense. I am only reading what is set out in black and white. If this ministerially appointed hospital board decide that Portlaoise County Hospital, that Tullamore, Mullingar and Longford Hospitals must be discontinued, what can I, as a member of the Midland Health Board, do about the matter? I cannot tell the CEO of the Midland Health Board that the Minister has said that all this is nonsense. The regulations set out plainly what can be done. I will not vote for regulations which put the hospitals in my constituency, whether at Tullamore, Birr, Abbeyleix, Edenderry, Mount-mellick or Portlaoise, in danger of being closed as a result of the power and authority which the regional boards will have.
The most serious aspect of this is that these faceless people, mainly consultants and existing employees of hospital boards, will advise the Minister on hospital policy in so far as it affects the functional area of the board. Not only that, but they are to make appropriate representations to Comhairle na nOspidéal on matters referred to in section 41 of the Act. This is a very serious situation for every hospital in the country. As a result of the passage of this regulation numerous hospitals will be closed. Instead of services improving they will become further removed from the people. I hope that there will be sufficient members here to reject these outrageous proposals which the Minister thought would go through the House unnoticed and with speed and efficiency. He thought that all these defects would be concealed. It is only right that there should be a frank debate on the proposed regulations.
These powers are very wide. We see that the functions of the regional hospital boards shall be to govern the numbers and types of officers and the employment in such hospitals and, except in so far as the Minister has the function, the remuneration of such officers. Have the trade unions been consulted on this matter? Have the nurses organisations been consulted? Have all grades of employees in hospitals been consulted in relation to this new departure? Already health boards and CEOs have the right to deal with questions of remuneration. We find now that in accordance with these proposed regulations the health boards will govern the numbers and the types of officers. The Minister is now taking away from the health boards and health authorities the right to decide rates of pay. It will be the function of the hospital boards to determine the numbers of nurses, doctors, ward attendants and, perhaps, ambulance drivers and helpers to be employed.
That means simply what I said during the passage of the Health Act: that the regional hospital boards will do the work being done now by the Hospitals Commission which are a body whose board are appointed by the Minister. The Hospitals Commission's work will be done by the hospital boards on which the health boards will be represented so that they will have more authority than they had before to deal with the salary matters which are now being dealt with by the Hospitals Commission in Dublin for the voluntary hospitals. I hope the Deputy will not exaggerate the meaning of this. I have given him a clear picture. Granted, it is not clear in the section but the Deputy need not worry about that.
I take it that the Minister wished to have that on record but the regulations before us do not contain that. This matter is very serious. I say this because we have ample evidence to indicate that there are numerous medical card holders who cannot obtain the services to which they are entitled because of the manner in which the Department are dealing with the medical profession. I have here a letter that I received from an outstanding specialist. In this letter he referred to a patient he had seen at a clinic and said that he pointed out to her family doctor that there was a long waiting list of adult female tonsillitis cases. He said that during the previous two weeks he had spent eight hours operating on two ear cases and as the patients concerned were medical card holders he would receive remuneration of approximately 5s per case or 1s 2d per hour. He continued that having spent four hours on such a case in that week he was unable to spend all his time operating on patients who were medical card holders. He suggested that I might use my influence to have the patient concerned taken to some other hospital. Is this the way medical card holders are being treated by the Department? I have great sympathy for this surgeon. I cannot think of any circumstances in which any professional man would be expected to work for such rates of remuneration.
Lest the Minister did not clearly understand I repeat the last paragraph of the surgeon's letter:
As these are medical card holders I shall receive remuneration of approximately 5 shillings per case or 1s 2d per hour operating on them. Having spent four hours on a case such as this this week I am unable to spend all my time operating on patients with medical cards. Perhaps you could use your influence to get her into some other hospital.
Is that not a very serious situation for any professional man and is it not more serious still for the medical card patient who is being pushed from Billy to Jack because the surgeon can only afford to operate on two such cases in a week because the local authority will only pay 1s 2d an hour for operating? Is there not better pay for road scavengers?
Would the Deputy please relate his remarks to the proposed regulations?
Certainly. I presume the learned Cathaoirleach has the draft regulations before him. Does the learned Cathaoirleach see page 5? Page 5 says——
Acting Chairman
If I may interrupt the Deputy, I can tell him that the learned Cathaoirleach has seen it and noted that while reading it at (g) he did not read all that is there.
I am not responsible for what the Cathaoirleach did not read. I am only responsible for what I read. Thank God my eyes have not yet failed me and what I see here is that the function of a regional hospital board shall be, among other things, to govern the numbers and types of officers and employment in such hospitals and, except in so far as the Minister has the function, the remuneration of such officers.
Acting Chairman
I was indicating to the Deputy that what he is reading is an extract from (g) and not what appears at (g).
What I have here is Statutory Instruments, Draft of Health (Hospital Bodies) Regulations, 1972, and I presume my copy is no different from the others. As different people take different meanings from the Bible I presume the Cathaoirleach and the Minister will take their own meaning from what they read. I must be guided by my intelligence. Being blessed with reasonably good eyesight, assisted by high standard spectacles, that conveys to me that "the remuneration of such officers" means their pay or monetary reward.
I was quoting the case of this surgeon who must work for 1s 2d an hour and can only do two medical card cases in the week. I want to ask the Minister if he thinks that rate of pay encourages the medical profession who have given such outstanding service and are sincerely devoted to their calling. The medical profession, particularly our surgeons of the highest standing who are under their lamps for the greater part of day and night in many cases, are owed a great debt of gratitude by the public. I shall not go beyond saying that present rates of pay are insufficient. This is the function of health boards at the moment but, according to my reading of this, it will now be passed over to the hospital boards.
More serious still it will become the function of these boards to control the expenditure of capital funds allocated by them under paragraph (i). This completely takes the skin off the health board and leaves a very poor and feeble skeleton. That is why I resent these regulations and look on them as a severe intrusion on the rights of the public and a serious blow to democracy. These regulations should be expounded at every church gate. Have the people adopted the attitude that they will accept anything from Fianna Fáil? These regulations go too far.
Article 10 says:
(1) A body established by these regulations may appoint such and so many officers and employ such and so many servants as the body may, from time to time, think proper and in appointing any officer or employing any servant the body shall comply with any directions given by the Minister relating to the procedure to be followed.
(2) Every officer of the body holding office in a permanent capacity shall cease to hold his office on attaining the age of 65 years.
(3) The body shall determine the remuneration and conditions of service of each officer and each servant.
Are these not most extraordinary powers presented to Parliament as mere regulations which the Minister proposed to the House at 4 o'clock and expected to have passed at five minutes past four? Did the Minister think none of us knew what was going on or did he think he was pulling "a fast one" and that Parliament would not have the opportunity of discussing these regulations?
Article 10 also says:
(5) The Minister may, whenever and so often as he thinks fit, declare that any of the powers conferred on a body by this article shall be exercisable only with the consent of the Minister, and whenever any such declaration is in force, the said powers may, in relation to any officer or employment to which the declaration applies, be exercised only with such consent.
This gives additional power and authority to the Minister.
This matter is far too serious for the Minister to stand up here and tell us that the regulations mean one thing while he says another and to refer us back to what he said on the introduction of the Health Act some years ago. The fact of the matter is that he is depriving health boards of all responsibility and permitting a select few, mainly of the medical profession, consultants whom he will appoint, to spend millions of pounds and to put into effect their own views and opinions in relation to the entire hospitalisation of the country. I want to object very strongly to these regulations. I oppose them strenuously. I think they are bad and should be rejected by this House because we are handing over rights which public representatives should be slow to hand over to people who have a vested interest, a financial interest, in hospitalisation.
I want to place on record my deep appreciation of the fine contribution the voluntary hospitals have made and to salute the outstanding work of the Sisters of Mercy and the Sisters of Charity in St. Vincent's Hospital, Elm Park, the Mater Hospital and all those responsible for the Richmond and the other voluntary hospitals which have not alone been a credit to this city but have rendered outstanding service to the entire country. I am sorry that these regulations are not in the interests of these hospitals. I feel they should be rejected and I trust that every effort will be made by health boards to voice their loud and strong opposition to the manner in which the Minister has treated them, that is, with contempt, disrespect and distrust, and above all, by showing his lack of confidence in those who have given their time freely and voluntarily day after day in the service of the general public, the welfare of the aged, the invalided and the sick, with a serious devotion and love for the maintenance of a very high standard of hospitalisation.
These standards are now at risk. Inexperienced people far removed from rural conditions are now to be equipped with extraordinary powers and authority to deal with every aspect of this serious matter. I hope that this House will see fit to reject these evilly-disposed and ill-conceived regulations which are not being brought in in the interests of health, of a better service for the public or the promotion of a better hospital service for the people but for a reason which is in the back of the Minister's mind, a reason which has not been disclosed but a reason on which the public can use their own common sense, intelligence and imagination.
The Minister has had one assurance from Deputy Flanagan, that is, that he is in good health, if one can judge by the strength and length of his contribution this evening. One can say that he has spoken a good deal of sense about the operation in particular of the regional hospital boards and the duplication of which many of us are quite fearful. Deputy Clinton in previous contributions has expressed very considerable reservations about the likelihood of an overwhelming bureaucratic apparatus being set up by the Minister, I think, somewhat unwittingly but, nevertheless, he is now proceeding to do it, under the 1970 Act, and I am quite fearful, and I share the reservations of Deputy Clinton that the duplication of work between the various eastern health boards, the Southern Board and so on, the health boards in the country and the regional hospital boards and the area boards now being set up will lead to an appalling administrative confusion and an unnecessary administrative expense, and indeed, inevitably will lead to conflicting policy decisions developing between staffs employed by the respective authorities.
I submit that the arguments put forward by the Minister, originally on his Estimate and during this discussion, have not been strong enough, in the sense of bearing in mind the original FitzGerald Report and the new consultancy advice available to his Department, to hold water as he suggests in relation to the regional hospital boards and the intermeshing of functions with those of the health boards themselves. I think the Minister should seriously have another long look at the administrative structure he is now setting up and I say this as one who strongly supported here the regionalisation of the health services. I think we needed regionalisation of our health services and I supported the setting up of the health boards as such, but I am afraid we are now building another edifice on that, an edifice which could result in a future Minister having to unscramble an appalling confusion of function and identity of purpose. That is my criticism on that aspect and I propose to pass on to deal very briefly with the second criticism.
The Minister stated earlier on that the FitzGerald Report recommended quite clearly that all consultants should hold their contracts from the regional hospital boards, and as the Minister is aware, a specific provision in this regard was contained in section 41 of the 1970 Act.
I am aware from statements I have received from the Irish Medical Union and from other interests directly involved that the Minister has now come up with a proposition which is wholly unsatisfactory to everybody concerned but which seems to meet the wishes of the voluntary hospitals. At the moment about half the hospital beds in the country are in the voluntary hospitals. I am afraid the Minister, in relation to the appointment of consultants, having taken about five steps forward, has now taken about ten steps backwards. In article 8 (4) of these regulations it is stated:
A regional hospital board shall exercise its functions . . . only with the consent of the body or bodies responsible for the administration of the hospital or hospitals concerned . . .
I must charge the Minister that under pressure exerted on him by the vested interests and in the power struggle that went on he has ignominiously caved in and given way to pressures which are not of themselves fully democratic. We are now going back to the old class distinction in hospital appointments whereby some consultants will hold their contracts from the regional hospital boards in good faith and in full understanding; others in the voluntary hospitals will hold them subject to a veto by the boards of these voluntary hospitals. That, in 1972, is not good enough. It is no consolation for the Minister to say, as he has said, in a very ambiguous context, that it seems likely that the authority employing the consultant will remain as at present, that is, it will be the health board or the voluntary hospital body concerned. What was the purpose of having common contracts of employment? Was it not to break down the appalling public disgrace of the cream of consultancy appointments and the cream of the power of the land ruling the roost exclusively for almost all time to come with total consultancy appointment power within their hands, a relatively small group in the medical profession holding that exclusive power in their hands within the operations of the voluntary hospitals while those who were not in the swim, those who were not well got with certain people on certain boards of voluntary hospitals, took their chance in the ordinary local authority hospital for consultancy appointment? I think the Minister is in many ways an excellent Minister for Health, probably the finest Minister for Health this country has had, but in relation to the appointment of consultants and these regulations the cave-in by the Minister is a rather ignominious cave-in.
The Minister is aware that the medical organisations concerned generally wished to retain the concept of the regional hospital boards holding the contract. They had one reservation, that is, that people should not be chopped around from one regional hospital to another without their consent. The Minister is equally aware that the Dublin voluntary hospitals more or less, to use an unparliamentary phrase, told the Minister to get lost, that as far as they were concerned the contracts of consultants would be between them and the consultants and while the appointment system could come through the regional bodies they were retaining that power exclusively to themselves. I do not think that is good enough. I do not think it is possible because what we now have proposed in these regulations is a very simple thing. We are now, in effect, putting into statutory form, putting into a statutory instrument, the handing over of an exclusive power of veto to such organisations, which is undesirable. This is a right worked hitherto in a voluntary manner. It worked sub rosa, with the acquiescence of the Department of Health, but when we embody it in a statutory instrument I think the Irish Medical Union are right in saying, as they have said to me, that it is the most inglorious cave-in they have ever seen by a Minister. It perpetuates in statutory form the handing over to voluntary hospitals of their veto of appointment of consultants. This is discriminatory and within the medical profession it will perpetuate the class divisions which are rampant within that profession. Talk about trade unionists, you could cut the class divisions within the medical profession with a knife. We are now building up again the old inbreeding system, the old power struggle system, of the boys who are well in and the boys who are not. Certain consultancy groups who virtually control appointments in certain voluntary hospitals will once again crack the whip if they do not like the colour of the hair of a particular consultant.
These are my two reservations. I have waited about three hours to speak. It is no way out for the Minister to state that all the consultants would be operating under a common form of contract under the regional hospital boards and he wanted them to be assignable to hospitals within the region. The Minister is right in putting that up for consideration. He pointed out originally that the advantage lay in having great flexibility in the organisation of consultancy services. It also meant that a consultant could be appointed to a local authority hospital or to a voluntary hospital. What happened? Overnight the Dublin voluntary hospitals told the Minister what to do with his proposals and they have now successfully retained all power. I do not think that should go without protest in this House.
I would urge the Minister to have a very sharp look at the general concept of regional hospital boards. I am afraid the functions outlined here are so omnibus, so open to conflicting interpretation by the various CEOs, that all I can see happening in my health board area is holy administrative warfare between the Dublin Regional Hospital Board and the Eastern Health Board. I think there will be maythem. There were many members of my party who completely opposed the setting up of the Eastern Health Board and I opposed them. I think the idea is quite excellent, very necessary, but I would have taken the bull by the horns and put the hospital administrative system under fairly substantial control of the Eastern Health Board in the Eastern Health Board area rather than hiving it off in a manner which will make it impossible to administer. Four almost anonymous individuals, unknown to one another, from the Eastern Health Board, four individuals appointed by the Midland Health Board, most of whom would never have seen one another, four persons appointed by the North-Eastern Health Board, four persons appointed by the South-Eastern Health Board, are to come together with 16 persons appointed by the Minister, many of whom may not know one another, to form the Dublin Regional Hospital Board. It will take them ten years to discover what political party the members support. Usually, that is discovered within a matter of hours.
I submit that the administrative apparatus proposed by the Minister is extremely cumbersome, unnecessary and unlikely to be helpful to the health services. The Minister should rationalise it. Of course, on the consultancy side, he should withdraw the regulations and if he wants the support of the House he will get it, in telling certain vested interests that, in running the health services, we have an overriding national responsibility. We have a responsibility to the medical profession. We have a responsibility to prevent them from perpetuating the class divisions that they have already built up, which most of them detest and want amended. We have a responsibility also to, for example, the Irish Medical Union who have opposed this regulation, who have asked me and a number of other Deputies to oppose it. If the Minister does not take it back for re-examination, we will vote against these regulations this evening and, if we are given the opportunity, after the next general election, we will willingly amend the regulations and make them more rational and more democratic.
I do not think I should deal with a great deal of what Deputy Flanagan said. He quite obviously misunderstood the import of the regulations. First of all, I must put in perspective the underlying reasons for establishing these regional hospital boards. I indicated the reasons absolutely clearly in the course of the debate on the Health Act, both on the Second Stage and on Committee Stage. I spelled out to the Dáil and in the Seanad the general functions of the regional hospital board, the general functions of Comhairle na nOspidéal and how I saw their relationship with the health boards and with myself as Minister. So, when I spoke on the occasion of introducing the Estimate and, later, the regulations, I did imagine that most Members of the House would either re-read what had been said before on the occasion of the debate or would remember the general import of what lay behind the proposals which are now before the House finally in the form of a specific statutory instrument.
Would the Minister tell the House why he himself employed McKinsey to tell him how this could work?
I am getting down to that, if the Deputy will give me a chance. As the House knows, between 65 and 70 per cent of our total health expenditure relates to hospital services and you have this position obtaining: we need a real effort to plan the hospital services on the basis of these following facts—that the percentage of acute care beds provided by voluntary hospitals as distinct from health board hospitals is 83 per cent in the Eastern Health Board area; 33 per cent in the North-Eastern Health Board area; 30 per cent in the Southern Health Board area; 18 per cent in the Midland Health Board area; 15 per cent in the Mid-Western Health Board area; 13 per cent in the Western Health Board area; 10 per cent in the South-Eastern Health Board area and 8 per cent in the North-Western Health Board area and, in contradistinction to that, the percentage of patients who go to Dublin for hospital treatment, including maternity services, is 24 per cent in the case of the North-Eastern Health Board; 4 per cent in the case of the Southern Health Board; 25 per cent in the case of the Midland Health Board; 10 per cent in the case of the Mid-Western Health Board—one in every ten— 10 per cent in the case of the Western Health Board; 25 per cent in the case of the South-Eastern Health Board and 22 per cent in the case of the NorthWestern Health Board.
So, there is a complicated situation of a very considerable number of voluntary hospitals in some areas, fewer in other areas, and a very considerable movement of patients from the country to Dublin in order to be cared for in relation to various specialities and, in some cases, maternity services. I suppose I should also mention that 29 per cent of the patient beds in the voluntary hospitals of Dublin are occupied by persons from outside the area, 18 per cent of the patient beds going to the Western Health Board coming from outside the area of the Western Health Board. I will give one other figure, what are defined as local specialities in relation to treatment represent about 82 per cent. Then there are specialities in treatment covering a regional area which amount to 9 per cent and then there are the great national specialities where one can have treatment in only one or two hospitals. These amount to 9 per cent of the cases treated.
That gives the background to the general position. What is the best way of planning the future hospital services, bringing together and co-ordinating the voluntary hospitals and the health board hospitals and making the best use of the beds, allowing for the regional characters, the regional problems involved and allowing for the special position of Dublin to which go so many patients and where 83 per cent of the beds are provided for acute care by voluntary hospitals.
We need, quite obviously, as much specialised knowledge as we can get, as much guidance as we can receive from the interests concerned. It was the recommendation of the FitzGerald Report, not in the same form—it is the recommendation in the Devlin Report on the Civil Service—that, whereas it is absolutely true that the officers of my Department can do very excellent planning, in relation to this kind of planning, why not have regional hospital boards which represent in part the health boards on which there are representatives appointed by me who are skilled in these matters? They will tease out these questions, examine these problems, make use of the powers that will be given to them in this statutory instrument, knowing that I will have the ultimate responsibility, that I as Minister for Health, or whoever replaces me, have first of all to announce a national health policy and to get consent of the Oireachtas for that. Then I have to provide every health board and every voluntary hospital with the necessary finances to carry on both current and capital and extended development. Thirdly, the Minister for Health of the day, whoever he may be, has to ensure that standards are kept uniform.
So, the idea that the regional hospital boards could be huge Parkinsonian empires that are able to make decisions irrespective of what this House might like, or of what the Minister might like, from my point of view, is entirely wrong. They will not be able to do any such thing. They are bodies with special functions, trying to see how far we can get the voluntary hospitals and the health board hospitals to work together and to provide the greatest possible variety of services in an efficient way.
I think most Members realise that there is growing specialisation in medicine. Within the next 15 years we will reach a stage where all operations in relation to vascular surgery for children under ten years of age will be carried out by one specialist. We will reach the stage where no longer will any genito-urinary surgery be practised by general surgeons but will be practised entirely by specialists. Inevitably this means more teamwork in hospitals and more specialisation. The only way we can deal with this is for the regional hospital boards to have the kind of staff and facilities whereby they can examine the detailed survey of the patient workload of every hospital which is gradually accumulating as a result of the work of the Medico-Social Research Board. This will be able to tell the regional hospital boards the nature of the maladies of every patient in every hospital, how long it took to observe the patient, and how long he was in hospital. We are beginning to understand the meaning of specialisation in relation to future developments and we will be able to plan the integration and co-ordination of voluntary and health board hospitals on a better basis.
I have said all this before; there is nothing new in what I am saying this evening. The Department of Health, with the consent of the Oireachtas, control the financial expenditure of the whole hospital system in this country, except for those who pay privately as patients in the hospitals and in relation to the private funds of the voluntary hospitals. We have to give consent to all major construction and reconstruction of hospitals. That remains in the power of the Minister for Health with the consent of the Minister for Finance and, finally, with the consent of this House.
We need to have the means of ensuring that when the budget of a health board is examined there should be some relationship between the increase of expenditure that can be afforded each year over and above the increase of costs and the increase of user, as between the voluntary hospitals and the health board hospitals in the area. There should be a regional board that could consider this on the basis of what is required in the health board area and the relationship of hospitals in a particular health board area having regard to the fact that many patients may go outside the area and come to Dublin. They should consider what can be done about the planning of facilities when there are two different types of hospital operating in an area and it is necessary to plan as well as possible for the future development of the hospital system.
We must face the inescapable results of specialisation. It will come whether we like it or not. Everybody, even those in Dublin, will agree that if we can keep patients out of Dublin by being able to afford intelligently-organised specialist services in the regions that would be a good thing. Obviously certain types of patients will always have to go to Dublin or Cork, for example, for neurological services, but there are a number of other specialist services that are provided only in Dublin which perhaps could be provided in the regional areas outside Dublin. This might be possible provided we know about the patient workload from the Medico-Social Research Board and provided research is undertaken by the regional hospital boards where they can get the health boards and the voluntary hospitals in the area to consider the proposition, for instance, if we can afford more genito-urinary surgery in Cork, Galway or Waterford, or wherever it might be proposed. I made this clear to Members of the House when we were discussing the Health Act.
The regional hospital boards will be concerned with examining the proposals in the FitzGerald Report. There is no need for the regional hospital boards or for the Minister to follow rigidly the proposals made in that report. I accept the general ambit of the report because I know there will be more specialisation. I know that in about ten years it will be difficult to get a single-surgeon hospital to perform any operation but what is described as the cold, absolutely simple surgery. Therefore, I know that the general concepts in the FitzGerald Report are valid.
The regional hospital boards will not override the wishes of the health boards with regard to the change of functions in the hospitals or to the closing of any hospital. The regulations say that the regional hospital boards shall consider the proposals made by health boards in relation to changes in the function of a hospital or the discontinuance of a hospital. I made it clear that this would be the result of combined discussion between hospital boards and the health boards, that the county advisory committees will have to be consulted.
Finally, I, or the Minister for Health who succeeds me, will have the responsibility. It is literally impossible for either Comhairle na nOspidéal to make any sensational proposals in relation to the withholding or granting of consent for the appointment of consultants in an area, or for the regional hospital boards to make any proposals for changing the function of a hospital or for closing a hospital without financial changes being necessary —either transferring money from one health board to another or having to provide money for beds in a large regional hospital that will take the patients who are now looked after in a single-surgeon hospital. The Minister for Health will have absolute personal and financial responsibility. He will have to come to the House for money and to get his Estimate through in respect of any major changes that are going to take place in relation to the proposals made in the FitzGerald Report. I am not shuffling off the responsibilities of the Minister for Health by appointing enormously expensive regional hospital boards which would take away responsibility from me and crush the efficiency and sense of well-being of the health boards as was suggested by Deputy Oliver Flanagan.
I accept entirely everything that has been said by Deputies in regard to their fears as to how the regional hospital boards will perform. I am getting proposals for the procedures of the regional hospital boards, for the method of their communication with the health boards, for their staffing, for the connection between the regional hospital boards, the health boards and my Department, for the co-ordination that must exist between the regional boards and Comhairle na nOspidéal when Comhairle na nOspidéal make a decision recommending the appointment of some new specialists in some areas. I must have recommendations as to how best I can ensure that this will not be what Deputies fear—a bureaucratic structure which will simply mean a great number of new institutions making a series of decisions with the Minister for Health having to examine a series of different decisions made by different bodies, all taking time and all involving unnecessary and expensive staff time. That must be avoided. I have had consultations in a preliminary way with the firm of McKinsey who, I say without fear of contradiction, made very good proposals for the upper staff structure of the health boards, for the support staff. Indeed, these proposals have been accepted without demur and without much criticism by the majority of the health boards. Therefore, they have established a reasonably good reputation for setting up the administrative structure of the health boards.
The same people have talked with representatives of many of the voluntary hospitals. They have talked with people concerned with health boards and they are to propose to me a structure which will ensure that this operation will be carried out properly, that the communications will be all right, that there will be no multiple decision-making of the wrong kind and that, above all, these boards will not simply be duplicating the work of my Department. My Department's functions will have to change to some degree because of the decentralisation process that will take place in relation to the operation of these boards.
I wish to say one thing in that connection which will be of particular interest to those concerned with the Eastern Health Board. I recognise what Deputies Clinton and Desmond said about what would appear to be an inadequacy in the structure of the Dublin Regional Hospital Board because of the fact that, whereas some 22 or 25 per cent of the patient load comes to Dublin from other health board areas for specialisation, in Dublin where 83 per cent of the beds are provided by voluntary hospitals, there is a special situation and obviously there must be a long-term examination of the whole work of the voluntary hospitals system in Dublin, the health board system, the establishment of two new regional hospitals and the continuing moving ahead of the Blanchardstown and St. James's hospitals. Therefore, I assure Deputy Clinton that I have asked the firm of consultants to suggest to me some form of committee work procedure in relation to the regional hospital board of the Dublin area that will ensure that the Dublin problem can be examined in a meaningful way and that there can be a right kind of relationship between the Dublin Regional Hospital Board and the Eastern Health Board so that planning can be conducted properly. I will go further and say that if this does not work I will have to come back to the Dáil and admit to Deputy Clinton that he was right, that the Dublin Regional Hospital Board was an unwieldy structure.
I would have to come back and amend the structure and if I have the privilege of continuing to be Minister for Health, I would be prepared to do so. I believe that I can devise a committee procedural system which will enable what Deputy Clinton fears to be avoided, the fear that there is a very special situation where there is a large number of people attending hospital in the Dublin Regional Hospital Board area. There are also the outlying areas all of which have to be looked after and, equally, there is the considerable number of patients coming from all parts of the country to the Dublin Regional Hospital Board area for specialisation.
A great deal will depend on the method of administration of these bodies and how they work with the health boards. Most responsible Deputies paid tribute to the way the health boards were beginning to operate although, as yet, many of them have not got their full staffs and some have not even got their programme managers. A number of responsible Deputies, too, were of the opinion that this new structure was better than the old county council structure because of the growth of specialisation and the fact that so many people moved outside the county council areas to go to hospital in Dublin. If we have as much success in relation to the operation of these boards as we have had in relation to the health boards, we will be making progress. I would say to Deputy Desmond that we intend going ahead with the new regulations for the selection of consultants in voluntary hospitals. I am aware that the most responsible consultants in this country and a great many members of the boards of voluntary hospitals accept that this is the best course to follow but I will not be deterred by any pressures exercised on me to prevent this happening. I have said that already in this House. I intend to go ahead and it will be possible for me, if I can get the right kind of co-operation, to go back on the arrangements made in this statutory instrument and arrange for the possibility of consultants working through regional hospital boards and they will work to them even though they may be working for one hospital. I will discuss that again with the bodies concerned.
It is my opinion that the major value in a consultant getting a contract from a major hospital board is in the case where he works in a specialist function for a number of hospitals. I do not think it is very valuable if he works for one hospital except that you get standard terms of appointment, some standardisation of salary and that at times also a consultant will agree to being obliged to work for the Dublin Regional Hospital Board or whichever regional hospital board he is appointed for and that he must be obliged to move from one place to another if he is appointed by the regional hospital board as a whole. The medical profession did not like that part so I have had some difficulty. Nevertheless, if I can get a selection procedure agreed for the consultants employed in the voluntary hospitals, we shall be making progress. This is not to criticise the boards of the voluntary hospitals who have given splendid service but knowing how successful we have been with the Local Appointments Commission, if we apply the same kind of principles to the appointment of consultants in voluntary hospitals we will be making more progress in securing the best talent possible.
I could answer many detailed questions but the answer to most of the questions is given by me when I say that I admit these boards will not carry out the purposes for which they were created unless the management-communication-co-ordination structure between them and the health board, between them and Comhairle na nOspidéal and between all three and myself are intelligent. Of course, I will be answerable to the House for everything that is being done by these boards and there can be no secrecy about the method they operate. I could not spend an hour attempting to answer a series of questions that were put to me but I think I have said enough now to assure the House that I have no conspiracy in mind to take away the authority of the health boards, as was suggested by Deputy Flanagan. I can assure the House that the people whom I will appoint will be people of the most eminent character. They will represent certain specialities. They will represent geographical areas. They will be people who are beyond reproach and no one will say that any appointee of mine, either to Comhairle na nOspidéal or to the regional hospital boards, was appointed with the idea that I had some project in mind of forcing an action which was purely for political party purposes. They would have to say that they would be people of the very highest skill and reputation and it would be impossible for any Member of the House to say that my appointees were appointed because I had some low motive in mind of a party political character. The idea is ridiculous. No matter who is Minister for Health, when it comes to matters such as the conduct and administration of hospitals with all the boards operating and with their tradition over a long period, the idea that any Minister for Health would appoint people who would act for corrupt reasons to that Minister's personal advantage is inconceivable.
I appreciate very much the trouble the Minister has taken to reply but could he tell the House what he will do if the firm of McKinsey come back to him and say: "We think the setting up of the regional hospital boards is a crazy concept and they should not be there at all."
I just hope they will not.
As these are regulations as distinct from a Bill there is no possibility of submitting amendments in regard to them and so I should like to put one point to the Minister in regard to article 8 under which the health board may refer to the Minister a change in the user of a hospital, the extension of it or the discontinuing of it.
The Deputy may only ask a question.
Would the Minister consider adding to article 8 (d) which says: "to advise the Minister on hospital policy in so far as it affects the functional area of the board" the following: "but this shall in no way interfere with the proposals in regard to the building of the regional hospitals which shall be built within a period of a certain number of years"? The Minister is Minister now but, in fact, there will be changes over the years and it might be better to have this written into the regulations to prevent changes which might occur. It is not necessary to elaborate as to why changes may occur but changes could occur which would change the whole concept of the FitzGerald Report in regard to the setting out of hospitals. Therefore, I would ask the Minister to consider making this addition to article 8.
I regret that I cannot amend the regulations at the moment but the Deputy may be assured that the whole question of the implementation of the FitzGerald Report in relation to the midlands, north and south, will require very great care. There are a great number of conflicting interests and the Deputy will find himself involved in these. The idea that in some way the regional hospital board could ride rough-shod over a health board and make decisions, or put me in the position of making decisions, without proper consideration of these matters is quite untenable. This would be quite impossible and I can assure the Deputy of that.
Question put.
The Dáil divided: Tá, 53; Níl, 44.
Tá
- Andrews, David.
- Barrett, Sylvester.
- Boylan, Terence.
- Brady, Philip A.
- Brennan, Joseph.
- Briscoe, Ben.
- Browne, Seán.
- Burke, Patrick J.
- Carter, Frank.
- Carty, Michael.
- Childers, Erskine.
- Colley, George.
- Cowen, Bernard.
- Crowley, Flor.
- Cunningham, Liam.
- Davern, Noel.
- Delap, Patrick.
- de Valera, Vivion.
- Dowling, Joe.
- Fahey, Jackie.
- Fitzpatrick, Tom (Dublin Central).
- Gallagher, James.
- Geoghegan, John.
- Gibbons, Hugh.
- Gibbons, James.
- Gogan, Richard P.
- Haughey, Charles.
- Healy, Augustine A.
- Herbert, Michael.
- Hillery, Patrick J.
- Hilliard, Michael.
- Hussey, Thomas.
- Kenneally, William.
- Kitt, Michael F.
- Lalor, Patrick J.
- Lenihan, Brian.
- Lynch, Celia.
- Lynch, John.
- McEllistrim, Thomas.
- MacSharry, Ray.
- Meaney, Thomas.
- Molloy, Robert.
- Moore, Seán.
- O'Connor, Timothy.
- O'Kennedy, Michael.
- O'Leary, John.
- O'Malley, Des.
- Power, Patrick.
- Smith, Michael.
- Smith, Patrick.
- Timmons, Eugene.
- Tunney, Jim.
- Wyse, Pearse.
Níl
- Barry, Peter.
- Begley, Michael.
- Belton, Paddy.
- Burke, Joan.
- Burke, Liam.
- Burke, Richard.
- Burton, Philip.
- Byrne, Hugh.
- Clinton, Mark A.
- Cluskey, Frank.
- Collins, Edward.
- Conlan, John F.
- Coogan, Fintan.
- Cooney, Patrick M.
- Cosgrave, Liam.
- Coughlan, Stephen.
- Creed, Donal.
- Desmond, Barry.
- Dockrell, Henry P.
- Dockrell, Maurice E.
- Dunne, Thomas.
- Enright, Thomas W.
- Esmonde, Sir Anthony C.
- Finn, Martin.
- FitzGerald, Garret.
- Fitzpatrick, Tom (Cavan).
- Flanagan, Oliver J.
- Governey, Desmond.
- Jones, Denis F.
- Kavanagh, Liam.
- Kenny, Henry.
- McLaughlin, Joseph.
- McMahon, Lawrence.
- Malone, Patrick.
- Murphy, Michael P.
- O'Connell, John F.
- O'Donnell, Tom.
- O'Donovan, John.
- O'Hara, Thomas.
- O'Leary, Michael.
- O'Sullivan, John L.
- Taylor, Francis.
- Timmins, Godfrey.
- Tully, James.
Tellers: Tá, Deputies Andrews and Meaney; Níl, Deputies Cluskey and Timmins.
Question declared carried.