Dáil Éireann díospóireacht -
Wednesday, 3 Mar 1999

Vol. 501 No. 4

Health (Eastern Regional Health Authority) Bill, 1998: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time."

Mr. N. Ahern

This Bill deals with the reorganisation of the health board, a mammoth job that has been talked about for many years. I have never been a member of the Eastern Health Board, unlike my colleague opposite, Deputy Shortall. Perhaps people who have been members, particularly those who have chaired it for a few years, know their way around it, but I have always found it to be an absolute monster in my dealings with it. I found it very difficult to tap into it. In my many dealings with officials over the years, I often got the impression that many of them did not know what was going on in their own organisation. I accept, therefore, the argument for change and reorganisation.

We had a briefing last year which Deputy Shortall organised. At the beginning of the briefing they talked about the number of locations of the health board, which was over 300. While I might criticise the health board for its lack of organisation, the number of locations in which staff are based puts some of my views in context. Obviously, it is difficult for an organisation of that size to know what is going on within it.

The Minister spoke about the need for a new organisation which would be more patient-focused. The health board is already a big authority and I am concerned that it might turn into an even bigger bureaucracy if we give it more functions. I have seen reorganisation occurring in other State and semi-State bodies; sometimes the original purpose of the reorganisation is forgotten along the line and it turns into the creation of more jobs for the girls and boys. In the midst of the petty squabbling which may occur, the basic service and client is forgotten. I hope the new authority will keep its real purpose in sight and realise it is not about the glorification of individuals within it.

I am pleased about the number of public representatives on the new authority. Although I have never been a member of a health board, some eight or ten years ago I was involved in local health committees which I found very beneficial. For the past 14 years I have been a member of a local authority which elects members to represent it on the health board. I do not hear from them in any formal way, although that may be as much my fault as theirs. The local health committees provided me with direct access to some health board officials. I would like to think public representatives who are not members of the authority would be consulted on a regular basis.

I have read the reports which have recommended change in the health board structure. However, one must be cautious when a group wants more control and power. I am concerned about health boards or health authorities trying to get their hands on the voluntary hospitals. I wonder whether that would be a good thing or whether we would be playing into the hands of control freaks. This Bill has been in gestation for many years and the groups it will affect have had plenty of time to reflect on what might happen to them.

The Eastern Health Board does some marvellous work. The Minister referred to the manner in which the health board has changed in the past 30 years to deal with the increase in population levels and social problems. In my constituency, the health board has been slow to deal with some of these social problems, such as drug addiction, homelessness, child care and so on, although it has become more involved recently. Perhaps funding was one of the problems, but it was not always the stated reason. The health board appeared to be rather bureaucratic at times in its failure to reach out to the community. Perhaps it did not receive the full backing of public representatives in many cases. However, even when such support was forthcoming, the health board was slow to reach out. Child care will be the major challenge facing it in the future. A great deal of taxpayers' money goes towards the funding of the health board and it is important that patients and clients are kept centre stage. I am concerned that the new authority will not be hijacked by people seeking to put themselves centre stage.

Concern has been expressed by voluntary hospitals in regard to some of the structures being proposed. Those concerns will have to be taken on board. Amendments could be considered on Committee or Report Stages to assure the voluntary hospitals that they are not being taken over. Voluntary hospitals have done a great deal of good work over the years and their concerns should be addressed.

I understand some specific concern has been expressed about section 8(3)(e) which states that the new authority, in performing its duties, should have regard to the rights of persons operating voluntary hospitals to manage their own affairs in accordance with their independent ethos and traditions. The phrase "have regard to" is considered by some to be very weak. Concern has also been expressed about section 8(4) which some people feel confers an unfair advantage on Tallaght Hospital over other teaching hospitals in the region. It has been suggested that one interpretation of the section could render it contrary to Article 44 of the Constitution which provides that the State shall not impose any disabilities or make any discrimination on the ground of religious profession, belief or status. These concerns have not been allayed fully.

The Minister has had his battles with Tallaght Hospital. He may feel he was too hard on it and, like a good gentleman from the midlands, wants to kiss and make up. Perhaps he is conferring a stronger status on it in the Bill than that enjoyed by other hospitals. That may put him into the good books with Tallaght Hospital and restore relations between it and the Department of Health and Children. However, in reaching out the hand of friendship to Tallaght Hospital is he being fair to the other voluntary hospitals? Is he bestowing on Tallaght Hospital a higher status than that given to other voluntary hospitals? We all know Tallaght Hospital has not been in existence for long and that it is an amalgamation of three hospitals. We also know it has difficulties and problems with its charter. Perhaps the Minister must be seen to try to make the administration there happy, but there is a concern that the legislation has gone too far and favours Tallaght over the other voluntary teaching hospitals. I would like to hear his comments in this regard and hope that if my comments are valid amendments will be considered. The time to consider amendments is on Committee Stage, not when somebody outside wishes to push the issue and when lawyers begin fighting in the courts, something which would cost us all a fortune. All voluntary teaching hospitals should be treated in the same way and none should be favoured above another.

There is also concern among some voluntary hospitals in relation to funding for their specialties. The Eastern Regional Authority will be concerned for the patients and clients within the region. However, the voluntary hospitals have pursued and been recognised as having national specialties in different fields. I often think they are more interested in expanding their specialties than in looking after patients in their casualty departments. Voluntary hospitals are very proud in this context and are always pushing out the boat in terms of their national specialties. There is concern that the status of these specialties may not be fully recognised by the new authority. I understand that the interim report examining the new authority discussed this issue, but I am informed it is not mentioned in the Bill. This is perceived as an omission which must be rectified.

Will the new authority say it is only interested in people if they come from Dublin, Wicklow, Kildare or Meath, and that those coming from Galway or Kerry are the responsibility of somebody else? Perhaps this has been thrashed out at length, but concern still seems to exist. There is a communication problem somewhere. I know we all fear change in certain respects, but there is nervousness and concern that if control is passed over to, for example, Dr. Steeven's Hospital, the national specialties of hospitals will not be recognised as they previously were.

Concern has also been expressed about capital expenditure. The Bill makes statutory provision for the payment of current expenses for services but does not provide for capital expenditure which is essential for delivering services in the future. These concerns must be addressed. Perhaps it is correct that the Department should control the purse strings in relation to capital expenditure and perhaps it will not hand full control to the new health authority. It may be necessary to make amendments on Committee Stage.

There are also concerns about the overall funding mechanism. Some people feel there is a conflict of interest on the part of the ERA as the purchaser of services is also ultimately responsible for the delivery of statutory services by the three area health boards. Perhaps the Minister will clarify the precise decision-making mechanism in relation to the allocation of funds. In particular I would like to know the decision-making process in relation to the allocation of funds by the Minister to the authority and by the authority to the health board areas and the voluntary sector.

The Bill includes the phrase "the resources available to the authority". Some people are asking that this be defined for the purposes of the Bill to ensure it includes those services being provided by voluntary bodies within the functional area of the authority. It is important that any such definition does not mean the service will only be provided to people residing in the functional area of the authority as this could run contrary to the mission of voluntary hospitals.

Similarly, there is concern that due recognition be given to the additional resources required by acute voluntary teaching hospitals to fulfil their teaching commitments. There is also concern that section 10 appears to delegate to the authority the function of determining future policy as to whether developments within the health services should be primarily in the voluntary sector, the institutions under the management of health boards, or in combination. Some voluntary bodies have obtained legal opinion. I am always dubious about legal opinion as I think one can get whatever legal opinion one wants depending on who pays for it. However, the time to sort out conflicting opinion, if such exists, is before the Bill is passed rather than having various bodies wasting time and energy and using taxpayers' money fighting a battle for control instead of dealing with the real problems faced by the health service.

There is also a request that the Bill include a definition of a voluntary body. Currently the Bill simply specifies a voluntary body for the purposes of the Bill.

These are some of the concerns of voluntary hospitals. I know these views have been submitted directly to the Minister and I am sure they are being studied in the Department. I like to think that an attempt will be made to keep everybody on board so that everybody can identify with the Bill, feel it is fair, claim ownership of it and look forward to a new structure for health services in the eastern region, and that it is not a case of bureaucracy or the control freaks winning.

In such measures where things are being drawn together some people will fear that they might be losing some authority over their patch. Every opportunity should be taken to reassure people in this regard, specifically in the context of Tallaght Hospital which I know has had a difficult birth. Some of the other voluntary hospitals have connections with Catholic orders and while the day of giving special recognition to one church may be gone, we should not be seen to be going in a particular direction in this Bill. The perception of some people is that Tallaght Hospital is being recognised and is receiving a status over and above that given to the other voluntary hospitals. It is a touchy subject and the Minister may be playing all sides against the middle and walking a tight rope, but I like to think that further work will be done and that some amendments will be brought forward to perhaps change some of the sections, thereby allowing all voluntary hospitals feel they are part of the new structure and feel happy within it.

Ms Shortall

I welcome the eventual arrival in the House of this Bill. As the previous speaker said, restructuring of the Eastern Health Board has been spoken about for many years and many promises were made, but it was not until 1996 that the Minister's predecessor, Deputy Noonan, made the formal announcement on the proposals to restructure – this time for real. Unfortunately, it has taken since 1996 to draft the Bill, publish it and debate it in the House.

I very much welcome the principles underlying this Bill, but it is merely the principles I welcome. I have very serious difficulties with much of the detail of the Bill with which I will deal later. I welcome the principle of devolving health ser vices to community level so that services can be more responsive to the consumers' needs and be more relevant to the local community. When the health boards were set up in the 1970s, Dublin was quite a different place. Eight health boards were set up and the Eastern Health Board was by far the largest.

Relative to the other areas, the east has grown substantially in terms of population. The Eastern Health Board caters for the needs of 1.3 million people with a budget of £500 million and a staff of 9,500. If we compare that to other health boards where the average population served is between 200,000 and 400,000 and with much smaller budgets and staff numbers, it is probably no wonder the Eastern Health Board has been seen by many as a monster, as Deputy Noel Ahern referred to it. It has been a large, unwieldy and, in many ways, unresponsive organisation.

This is partly due to the fact that the area is so large, the staff is so vast and that it has been trying to operate under the same type of programme manager structure which exists in the other health boards with much smaller populations. It stands to reason that an acute hospitals manager trying to serve the needs of 1.3 million people cannot be as responsive to individual needs as the programme manager trying to serve 300,000. There have been major problems of scale in relation to the operation the Eastern Health Board.

In areas outside the east, there is much stronger local identification with the local health board. The general feeling among people, particularly in the Dublin area, is that the Eastern Health Board is a large, unfriendly and unwieldy organisation somewhere in town. They do not have that local sense of being part of the health services, which certainly causes problems. It has also resulted in a situation where needs have not been sufficiently addressed.

I remember a couple of years ago when I was chair of the Eastern Health Board coming across a group of people in the Darndale area who had concerns about a number of social issues there. They came to meet me, as chair, and the chief executive officer. It turned out that this area of huge social need with a very large child population and all the attendant social problems in working class areas did not even have something as basic as a health centre. That struck me as quite extraordinary. It would never occur outside Dublin that an area equivalent in size to a reasonable town would not have basic health facilities.

I concluded the reasons for that were twofold. The first was that there were no public representatives from the Darndale area on the Eastern Health Board and, therefore, there was nobody fighting their corner. The other was that the senior executives in the Eastern Health Board were simply too far removed from local community difficulties and that the operation was delivered from town where managers were trying to take an overall view, cater for the needs of the entire area and did not have that hands on approach to local needs. It was another argument to restructure the Eastern Health Board to make it more sensitive to the needs of local areas.

The same point was made by Deputy Noel Ahern about the lack of responsiveness by the Eastern Health Board some years ago to the emerging drug problem. To a large extent, the health board has now got on top of that but there is no doubt this problem was overlooked or denied by senior management for years. That meant that a few years ago we were desperately trying to catch up with the neglect of the past. To a large extent, the same can be said about the child protection and child welfare services. Because there have not been senior people at local level, many of these problems have been overlooked and neglected for years.

I very much agree we need to restructure, to have smaller health boards which are closer to the people they serve with a narrower remit so that rather than having people from south Wicklow travelling to places such as Balbriggan and Lusk trying to come to terms with the local issues there, those people will be able to deal with their own matters and the people in the north Dublin area will deal with issues affecting their constituents. That is a much more satisfactory way to proceed.

We should have devolved boards. Because of the particular nature of the problems in Dublin and the fact it is a capital city, there is a definite role for a regional authority and the type of strategic planning required in a large capital city where there is much cross over between different board areas and where strategic decisions need to be taken in relation to specialising in the different areas of medicine and so on, where practical decisions have to be taken and where there is a need for an overview in relation to the health status of the population in the eastern region. I agree very much with the principles involved in that.

The other major measure under this Bill will bring the voluntary hospitals and agencies, particularly mental handicap agencies, under the umbrella of the health board. There is an unusual situation in the east which does not obtain in other health board areas where the bulk of health spending is done outside the health board. It is an incredible situation and very often the health board gets blamed for hospital waiting lists or inadequacies in hospital or mental handicap services when in fact the health board has no control over them. That is a fundamental flaw in the way our health services are delivered in the east.

By bringing the voluntary hospitals and other agencies under the one umbrella, strategic decisions may be taken at board level on the way health funding is spent. I am thinking in particular about decisions which need to be taken on spending in expensive acute hospitals, for example, compared to spending at community care level. It is not possible for those debates to take place at the moment because the health boards look after community care and the volun tary hospitals look after high technology expensive medicine. There is no forum in which that debate can take place. It is important to establish that type of accountability in the delivery of our health services.

The large voluntary hospitals in the Dublin area have operated as independent republics. Depending of the Minister of the day, one hospital might get the ear of that particular Minister in a more effective way than another and secure funding in that manner. That is, of course, highly unsatisfactory and means there is little or no accountability in the system. I welcome the proposals to bring together all the health agencies under one umbrella. A budget of £1.2 billion or £1.3 billion will be spent in the east.

On the role of the board and board members, as things stand the brief of board members is far too wide. We are dealing with the concerns of 1.3 million people. Not only is the Eastern Health Board on average three times larger than any other health board but there is a high concentration of all the social problems in the east which makes the work of board members much more difficult. There is insufficient time to give the necessary attention to many of the issues because of the volume of work with which members are asked to deal.

Many parts of Dublin have not had representation on the Eastern Health Board and are often overlooked. I welcome the proposal to improve the level of representation of people in the Dublin area. There is a tendency at official level to treat Dublin in the same way as Wicklow or Kildare, and that the three counties should be given the same level of representation. Dublin is 11 times bigger than Wicklow so there should be 11 representatives from Dublin for every one from Wicklow on a health board. That is the only way to ensure the issues that affect Dublin people are properly represented and that they get a fair hearing. This has not been the case and I am glad it is being rectified in this Bill. Those are the principles on which I support the Bill.

However, in practice the Bill is fundamentally flawed because of the manner in which it has been decided to constitute the membership of the area boards and the regional authority. The logical way forward is to ensure proper representation at area board level so that each of the three area boards has the full range of representation enjoyed by all other health boards. This would mean they would have representation from the full range of public representatives, GPs, consultants and other professionals. That is not going to happen. The representation will be inadequate because, for some reason, it was decided to start with a 55 member regional authority. The mind boggles when one thinks of 55 people in a boardroom trying to do business. Because this regional body will provide the membership for the three area boards, these boards will have inadequate representation on a number of fronts. This is a fundamental flaw in the Bill and the Labour Party will table amendments to correct this.

We should start with full representation at area board level and each board should have two or three representatives at regional level. In practice, this will mean professions such as general nurses, psychiatric nurses, pharmacists, dental representatives and so on will be represented on only one board in the eastern area. As a result, there will be two health boards without a representative of those professions. This is unworkable and the Minister will rue the decision to go forward on this basis. I have been in touch with a number of professional organisations and they are very annoyed at being squeezed out of the three new health boards. The Minister will hear many complaints from those bodies in the coming weeks. This is a fundamental problem with the structure proposed by the Bill.

I have seven years' experience as a member of the Eastern Health Board and two years as Chair. The board's remit is too big and unwieldy and there is not enough time to give adequate attention to many of the issues which arise. However, what is being proposed is that, in place of the existing board, we will have a 55 person board with two and a half times the existing budget. The staff will also increase by 250 per cent. A brief which was already too wide and onerous will be substantially increased. Being a member of this new authority will be the equivalent of a full-time job if it is to be done properly.

I expressed my concerns to the Minister on this issue some months ago and he stated that the legislation would be couched in terms which would prevent any operational matters being dealt with at regional level. It is impossible to preclude members from engaging in operational matters at regional level. That will not work. For example, the dental representative will be on only one board. Therefore, the only forum at which that person can raise issues relating to dental services is at regional level.

It is in the nature of public representatives and local councillors to go to the top if they do not get satisfaction at area level. This means they will try to raise local concerns at regional level. The regional board which should be a small, tight, strategic body will be bogged down in operational matters with far too wide a brief. I appeal to the Minister to examine the manner in which the area boards and the regional authority are constituted. Rather than starting at regional level, he should start at area level and appoint representatives to the regional board.

I am pleased multiannual service plans will be provided by all agencies, including the area boards. This is a progressive development. It is also important that we ring-fence funding for services provided to people outside the eastern region in cases where specialities exist in eastern hospitals. The new eastern authority should not be landed with the expense of providing those services. It is important that this distinction is made.

I congratulate the task force on the work it has done. It has put an extraordinary amount of time and effort into developing these proposals and meeting staff at all levels and senior management. This has made the process smooth and workable. I have spoken to many members of the task force about my reservations. Most accepted my reservations and agreed it would have been better to start at area board level. However, the task force's brief precluded it from such considerations. In the interests of ensuring that these proposals work, that services in the eastern region are improved, more responsive to the consumer and more efficient, I appeal to the Minister to reconsider his approach and to put forward new proposals on Committee Stage.

Mr. Callely

The object of the Bill is to reform organisational structures in the health services in the Eastern Health Board region and to improve co-ordination and integration in the planning and delivery of those services. Improving co-ordination and integration is to be welcomed and is always in the best interests of those who avail of the services.

In his Second Stage speech, the Minister stated the need for radical structural reform in the health services. This has been recognised for some time in the eastern region. As Minister for Health in 1989, it was you, a Leas-Cheann Comhairle, who announced this proposal about the eastern regional health authority. That was a long time ago and much has changed since. At that time there were many groups working in the Eastern Health Board area, some with vested interests, providing a level of service to meet the needs in their sphere of interest. I congratulate the Eastern Health Board on the manner in which it recognised the need for change and entered into partnerships with other sectors who provide services in the region. There is now a common understanding of what is required concerning funding. Because this happened in the last decade, I am not sure whether the announcement made in 1989 still stands.

Much water has passed under the bridge since the initial move with regard to a new health authority for the eastern region. However, I acknowledge that society has changed dramatically since the Eastern Health Board was established in 1970. The population of the region has grown from under 1 million to in excess of 1.3 million. As a contemporary society, individual expectations have changed.

The challenges facing our health services are greater than ever – drug misuse, AIDS, HIV, family breakdown and homelessness. These are dramatic changes in the complexity of issues which must be addressed given the demise of the extended family support structure and the knock-on effect for the elderly, children and vulnerable people in our community.

The cost of providing health and personal social services to the people of Dublin, Kildare and Wicklow last year was £1.2 billion. A total of 27,000 people were employed in the delivery of services. The Eastern Health Board accounted for £6.8 million of the £1.2 billion total expenditure. This included the cost of running the GMS and the supplementary welfare allowance scheme. A total of £542 million went directly to the voluntary sector. The Eastern Health Board employs 9,000 people compared to the 18,000 people employed in the voluntary sector.

The Eastern Health Board and the voluntary sector are funded directly and independently by the Department of Health and Children. This dual funding makes it difficult to maximise health and social gain in the region. There has been concern for some time that the structures which served the region well in the 1970s and 1980s are inadequate and inappropriate to meet the enormous challenges of health and personal social services facing it in the first decades of the new millennium. It is appropriate that preparations are made to meet those challenges.

Various reports commissioned to examine the future needs of the region all recommended change. However, I am not sure whether I concur with all the recommendations. The task force drawn together to consider this matter comprised people with health board experience and representatives of the Department of Health and Children, the voluntary sector and private enterprise. The task force called for and received submissions from a wide range of interested parties and the members also brought their own experience and expertise to bear. I made a detailed submission as chairman of the Eastern Health Board in 1991. However, that is over eight years ago and I am not sure that I could stand over every item in the submission.

The Bill proposes a number of fundamental changes. The Eastern Health Board will be dissolved and replaced by the Eastern Regional Health Authority. This new authority will be responsible for strategic planning and negotiating funding for the region with the Department of Health and Children. The authority will be responsible for the commission of new services, but not the delivery of them. Services will be delivered by three new area health boards which will be established in the region. In addition, the voluntary sector, which traditionally has been funded directly by the Department of Health and Children, will now receive its funding along with the area health boards from the Eastern Regional Health Authority.

The boards will be known as the North Area Health Board, the South-Western Area Health Board and the East Coast Area Health Board. Undoubtedly, they will enjoy the benefits of a smaller geographical area and a correspondingly smaller population. Each board will be in a position to identify the needs and priorities in its area. This will enable the boards to plan services and allocate budgets accordingly. The decision making process should be brought closer to the people and as a result the boards should be in a position to respond to local needs.

Under the new arrangement, the service plans will be the key to creating a co-ordinated and integrated service between the area health boards and the voluntary sector. There will be contracts between the Eastern Regional Health Authority and the area health boards and the voluntary agencies. It will define the agreed level of services to be provided for a specific financial allocation. All these services will be rolled up into one overall regional service plan which the authority will submit to the Department of Health and Children. This will enable everybody to know who is providing particular services, what is expected of them and how much they must spend on a yearly basis.

I am not sure whether that is much different from what the Eastern Health Board did for 1998 and this year. It submitted its service plan and everybody knew what would be provided in terms of services and how much was required. Following the introduction of new accounting procedures in 1998, first charges will be imposed on any overruns in 1999.

The thrust of the proposed changes is to deliver a better quality service to the people of the region. It is to ensure that the money expended on the provision of services is spent in the most effective manner and that there is value for money. Undoubtedly, this is a good sound bite. The issue is whether it will work and if we know what ingredients are necessary to make it work. I am unsure, but I recognise that it is an opportunity to bring about the most significant reform of the health services in almost 25 years. It is a chance to empower staff with the ability to make a difference in the quality of service delivered. This challenge can ultimately deliver a better service and provide more rewarding jobs for all those involved in the delivery of services.

However, I have reservations. I am not convinced all this will happen as a result of the introduction of the Bill. The Minister used the example of a geriatric patient to illustrate the type of improvement he hopes the reorganisation will bring about. However, it does not require the Bill to effectively provide the service the Minister said the patient required. The same elderly lady referred by her general practitioner to an acute hospital may require step down convalescent care, domiciliary support and attendance at a day hospital. These services can be provided by the Eastern Health Board. However, there can be delays.

The acute hospital may not be in a position to accommodate the patient on referral due to blocked beds and discharge the patient due to lack of availability in the required step down convalescent care. It is a vicious circle. Another example is the case of a stroke victim. The hospital occupational therapist acknowledges the need for support appliances in the home. Although the patient is not meant to be discharged, she and many thousands like her are sent home while the support appliances are not in place. The patient must wait for the community care occupational therapist to call and inspect the physical structure of the home before the support appliances can be provided. This is extremely frustrating.

These cases involve elderly people in hospital who undergo the rigours of medical attention and rehabilitation. It is identified that a patient needs certain support appliances and the family is advised accordingly. The patient goes through an assessment in the hospital and his or her needs are identified prior to discharge. The bed is needed within a couple of days and the patient is discharged into the care of his or her family. However, no support appliances have been put in place. One asks why that is the case because the needs of the patient have been identified by the hospital's occupational therapist. However, the community care personnel must examine the physical structure of the home. The appliances cannot be put in place until the physical structure is examined. One can understand why this is necessary in certain circumstances. However, I am not sure that it should apply to a simple commode which would be of enormous benefit to the individual and to those who are caring for him or her and which should be in place before they are discharged. I disagree that a community occupational therapist should be involved and that there should be a wait of a considerable length before a commode can be put in place. In such cases the vicious circle goes for another little spin, and before the community occupational therapist arrives the person is back in hospital.

Since it was set up in the early 1970s the Eastern Health Board has covered the area comprising Dublin, Kildare and Wicklow where the population is growing and the demand for services is increasing. I pay tribute to my colleagues on the Eastern Health Board and to former board members, particularly the management team with whom I have worked closely. Former chief executive officers, Kieran Hickey and P. J. Fitzpatrick, were outstanding in their field. The current chief executive officer, Pat McLoughlin, has proved himself as a programme manager in a very difficult area, taking over the reins of the Eastern Health Board in an enthusiastic and determined style. I pay tribute also to his management team, Martin Gallagher, Maureen Wyndall, Séamus O'Brien, Bríd Clarke and Michael Walsh and the support staff and others employed in the Eastern Health Board. Perhaps only those of us who are involved at board level understand the commitment of those involved in the delivery of the Eastern Health Board's services.

In pursuit of its mission of health and social gain for all the people of the area, the board has placed considerable emphasis on prevention and support services and has been engaged in identifying and addressing barriers to the achievement of full health and well-being by individuals, their families and the local community. To achieve that, the Eastern Health Board has focused on generating a sense of ownership and responsibility for personal health and well-being among the community. The board has also worked hard to ensure that there is accessible treatment and care of the highest standard and at the most appropriate level available for all who need it. The board believes that clients and patients are entitled to receive an individual service delivered in an effective, efficient, courteous and user-friendly manner. The board has also developed constructive partnerships with voluntary agencies, local community groups and social partnerships, and these partnerships specifically target those most at risk of poverty and social exclusion.

One of my achievements as chairman of the Eastern Health Board, of which I am very proud, is the setting up of a customer services department at Dr. Steeven's Hospital which supports the needs of those it serves in a customer friendly way. It deals with over 100,000 telephone callers, via its freefone service, and 28,000 personal callers.

In the area of children's services, the Eastern Health Board's policy on child welfare and health involves an integrated approach which looks at all aspects affecting the well-being of the young. Its aim is to support families so that children can live with their families. This approach involves measures to support vulnerable families and to prevent family breakdown. These preventative and family support measures include the community mothers scheme for which I have tremendous admiration and which involves experienced mothers providing help and assistance to first-time mothers, neighbourhood youth projects for children of eight years and over who have dropped out of school and who need support and help to manage their lives in family resource centres which provide counselling for families.

In the area of mental handicap the Eastern Health Board and voluntary organisations in the field now provide residential services for approximately 2,500 people with learning disabilities. They also provide just over 7,000 day places. Major funding, both capital and revenue, is provided to the voluntary organisations for the development of residential and community facilities in line with the board's overall plan. Since the establishment of the Eastern Health Board, the board has reorganised its services for persons with a mental illness from an institutionalised to a community service.

In the area of drug services there are currently 3,565 drug misusers being treated in my area. Drug services and community services have a very wide and detailed programme. Since the 1970s there has been a shift away from the provision of centralised medical services in hospitals and ongoing development of health and social services in the community. The Eastern Health Board has opened a network of new state-of-the-art primary care centres around its region where public health nurses work across the community, particularly in relation to child health and the care of the elderly. The board provides public health and environmental health services in the area of food hygiene, food standards and edu cational support to all those involved. We also have a very active and lucrative property section which has proved to be of substantial benefit to the Eastern Health Board in maximising its assets and in the further development and provision of its services.

There is so much I could say about the Eastern Health Board and the good it has achieved. There is an old saying about whether it is necessary to fix something when it is not broken. I believe the Eastern Health Board is not broken. It has come on in leaps and bounds. It has created the partnerships about which I spoke that were not in place when this Bill was originally mooted.

The difficulties currently being experienced in the Tallaght Hospital baffle me. The planning of that hospital was a long time in the pipeline. I am disappointed given that that hospital was built at enormous expense to the taxpayer the hospital authorities came back, prior to its doors being opened, to request an extension to the accident and emergency department, despite the expert advice and opinion that was available from the Department. Here we have a Bill that was mooted in the late 1980s being introduced to deal with the 21st century. I ask the Minister to take on board the developments within the Eastern Health Board and model the new structures being proposed on the success of the Eastern Health Board to date.

Mr. Timmins

I wish to share my time with Deputy Frances Fitzgerald.

I welcome the opportunity to speak on this Bill. It is long overdue, and I hope it delivers a more efficient health service to the people of Dublin, Wicklow and Kildare. There has been a consensus for some time that the Eastern Health Board with the ever-increasing population it serves needs restructuring. In addition, the range of issues that the health board encounters has changed greatly in the past decade as our society opens up and addresses difficulties that have lain hidden in the dark corridors. Coupled with this movement to exposure, our increasing wealth has brought with it many of the problems that a less affluent society would not have to face. It is to be hoped that the new structures will be such that problems and tasks can be approached in a more efficient and economic manner and that the new organisation will give the lead to change in the other health board areas.

The new health authority will be responsible for some of the most deprived areas in the country and, contrary to a generally held perception, there are large tracts of poverty in the greater south-east area. It is interesting to note that if Wicklow, Carlow, Kilkenny and Wexford had been included in the Structural Funds application instead of Kerry and Clare, GDP as a percentage of EU average would have decreased from 73.3 per cent to 72 per cent. These counties are contiguous and I fail to comprehend how this indisputable fact squares with the claim that we have tried to maximise Ireland's receipts. In addition, this area covers a larger population. The concept of the affluent east should not blind us in terms of the many social needs that must be addressed in an area of rapid population growth. As society evolves, so should our laws and structures. The Bill is a welcome development in that it seeks to address the many areas outlined in the Minister's speech. It is a positive step to decentralise decision making, especially in the area of health where many people do not currently understand the funding and operation of the service.

It is necessary that the health service is viewed as such, not as a monolith whereby people feel that they have been lucky enough to receive treatment and are under a compliment. The most dedicated and caring members of our population work or assist in the provision of health care and their commitment never ceases to amaze me, yet the mental picture conjured up at the mention of the words "health service" is far from positive.

Many reasons may be put forward for this and we, as a profession, must take our share of the blame. It is an area where much political capital can be made as one can play on people's fears. The Minister adopted this approach in the past and now he is very often the recipient of the same medicine. We should move away from this approach and concentrate our energies on examining an area that receives much funding but about which a great deal of dissatisfaction is expressed. There are many groups central to the health service, among them consultants and the pharmaceutical industry. We routinely receive their periodicals and they outline strong cases. It is difficult to explain to a woman who experiences a certain level of constant pain that it will be a long time before she can have an operation. I am hopeful that a more efficient service will put an end to this.

The Minister stated that a new body will be charged with health promotion. This area has been neglected in the past and, indeed, this House and its associated work practices are not a great advertisement for a healthy lifestyle. The Minister also alluded to the imaginary elderly patient who moves through several strands of care and the hoped for positive experience of this patient will be one of the key criteria by which the service will be judged. I hope that this test holds firm. Deputy Callely believed this to be the case currently but I am not sure that he is correct.

The Bill brings about a major change in the funding arrangements for voluntary hospital and agencies in the eastern region. However, they will retain operational autonomy while being fully accountable for the public funds that they receive. Developing any new health structure can be difficult and this is epitomised by the Tallaght project. Hopefully, some pertinent lessons have been learned. Establishing a bond between the statutory and voluntary sectors that will benefit the patient is the task that awaits the new authority. Change and its management is always difficult. I wish the new authority well.

The Minister has not decided where the various administrative headquarters will be located, but I understand that Bray Urban District Council made a submission requesting the siting of the east coast authority in Bray. The Minister spoke about bringing the health service closer to the general public. Perhaps, when he decides on locations for these centres, he will establish them closer to people and give them the impression that the service is nearby. Patrick Kavanagh in his poem, Epic, wrote about a disturbance in Monaghan during the Second World War and a man “who owned that half a rood of rock, a no-man's land” . He compared it to Munich and was trying to equate the fact that the dispute in Monaghan was similar to that in central Europe.

The dental service for school children is causing concern in my constituency as there is a difficulty filling a vacancy for a dentist. I hope the Minister of State and his officials can address that.

Ms Fitzgerald

I welcome the opportunity to speak on the Bill which will establish the Eastern Regional Health Authority. I wish to be associated with Deputy Callely's remarks about the Eastern Health Board and the great strides that have been made in terms of providing services. More and more demands are made on our health boards and medical services. There are new and emerging needs and health board staff often deal with marginalised people. I have been particularly struck through recent contacts by people who are trying to establish drug clinics on behalf of the health board in my constituency. They are faced with great difficulties in attempting to do so but are making great efforts in terms of consultation in order to develop these services.

The Bill deals with the setting up of a new structure to deal with the huge population in the eastern health board region. Putting such a structure in place at administrative level raises many questions. The idea is that at the end of the day there will be a better delivery of services at local level, better local accountability and people will receive the medical and community services they need. However, making the move from an authority such as the Eastern Health Board to a new regional authority covering three different health board areas will be challenging and demanding. For example, organisations dealing with disabilities have attempted to amalgamate and set up new structures and it appears to be a procedure fraught with difficulty for staff. It is important that supports, including the necessary management training, are provided to staff. The authority will be challenging and enterprising but it will be demanding if it is to work effectively and fulfil the objectives outlined by the Minister when he presented the case for reform.

The difficulties of providing more specialist services which are not always easily available locally must be dealt with. We are moving towards more specialised centres, yet we are talking about more local access. There are inherent contradictions, which I have experienced in my constituency where three hospitals have closed over recent months because of the Tallaght project. On one hand, we need a project such as that in Tallaght because it has the size to provide a range of services while, on the other, we want to make sure that people have access to a range of services locally.

There has been a dramatic population increase in the inner city, yet medical services have been moved. There are no proper emergency services for children in the south inner city and families must travel too far. This must be dealt with by one of the new authorities when they are established. I call on the Minister to look again at the Meath Hospital, which currently provides some excellent local services. It is essential that the hospital is bought by one of the new authorities in the coming months so that the Minister will have the opportunity to provide the services needed in that area. For example, 18 per cent of children in Dublin 8 are under the age of 15, which is twice the EHB average. We must look at access to medical and emergency services for children in the area.

This area also has the largest number of elderly people in Ireland. If the new health authority is to provide local and effective services, these issues will have to be taken into account. It is also interesting at a time when we are trying to make services more accessible to consumers that my constituency, Dublin South-East, will come under two different health boards under the new arrangements. People on one side of the street will be under one health authority while those on the other side will liaise with a different one. The point to be made is the importance of information to consumers.

I would like to see more emphasis on consumers in the Bill and more mechanisms built into it for conducting research, for linking and forming partnerships with local communities and for liaising with voluntary organisations. While I welcome recent changes, the medical service has been incredibly slow in taking account of consumers' voices. An example would be my experience of working with the National Childbirth Trust. There have been changes in maternity hospitals over the past few years whereby these groups are now welcomed into hospitals and are provided with services and rooms where they can meet and talk with women about breast feeding and provide them with the information they need on maternity services. I would like to see some amendments to the Bill on Committee Stage to put greater onus on the authority to have more direct contact with consumers and also perhaps more representation on the board. It would be worthwhile and, if the provision of health services is to be seen as a partnership and if a partnership approach towards it is to be adopted, that would be an important aspect.

This is an exciting Bill in terms of the potential of the service agreements. Perhaps the Minister could give more information on those when he is responding, specifically how they will be prepared and monitored, how the Minister sees them working and how they will be evaluated. That would be helpful because it is a relatively new concept in the health services. It has been tried elsewhere but has led to difficulties. Perhaps the Minister could address that issue when he responds.

The task of the new Eastern Regional Health Authority is a wide one. It will have responsibility for planning, commissioning and overseeing all health and personal social services in Dublin, Kildare and Wicklow, including general hospital services and mental handicap provision. It will be responsible for the funding of those services in the region, for facilitating the integrated planning of those services and for ensuring there is better integration and co-ordination of service delivery. While the improvements made in these areas must be acknowledged, we still have a long way to go. The recent discussions on waiting lists, the need for more community care services and better services for carers all illustrate the huge gaps in services provided at local level.

The area in which the greatest gaps occur is the level of service provided to those caring in the home. One example is a young family with a seriously handicapped child. Looking in detail at the range of services provided to the parents, there is no doubt that services are weighted more towards residential care than towards providing sufficient supports at community level for parents to provide the care they want at home. They do not receive sufficient support when they care for physically or mentally handicapped children full-time in the home. That is an area which must be examined. It involves developing OT and home help services and providing physical aids.

There must be a database of the needs of the physically handicapped which does not exist at present. In delegating functions to the authority, the Minister should ensure the development of a database on the needs of the physically handicapped is a priority. I am not aware of one being in existence at present. We do not have the statistics and, without them, services cannot be improved or a proper service plan worked out. It is important the authority bases as much of its work on research. It has been underrated by the health service and we need to learn the lessons from research in providing the best services. Research has a great deal to teach us and we should focus on that.

I hope the authorities will have a strong role in the health promotion area, an area which lacks support. Considering the disturbing research published about young women and smoking, the huge pressure they experience from advertising, the focus of international companies on them and the health consequences for them, it can be seen that health promotion is an area to which funding should be given. It should also receive support in terms of individuals working in the area. Smoking is just one obvious example of many areas where a great deal more could be done. Sport is another area and, while it may seem far removed from what we are debating today, it has strong links in terms of promoting a healthy lifestyle.

The authority will have a wide range of functions. It will have to make arrangements with service providers, and this should involve monitoring and evaluation of services. There should be more consumer representatives on the board of the authority. I accept the point the Minister made in his speech that public representatives will be on the board, but the membership should be re-examined. I am not sure the nine voluntary representatives envisaged at present is adequate representation.

It is important consumer feedback on how the new services are operating is obtained quickly. It is also important before that is done that comprehensive information on the changes is provided to people. The public often feel removed from the service providers. A strong information campaign should be mounted so that people are aware of the new authorities, where they are working, the areas they cover and their responsibilities, and that there is plenty of scope for the public to have their input and to contact the authorities to submit their ideas and voice their concerns.

Community care services will need to receive much more support than they have in the past. One of the major challenges for the new authority is to develop further community services, especially for the vulnerable groups I have mentioned. The domiciliary care services clearly need to be built up more. I worked as a social worker in London 20 years ago and I remember the community care services available at the time for elderly people living on their own as being incredibly good. I do not believe we have yet reached that level here. We have a long way to go in terms of supporting elderly people who choose to live at home but who need strong support. Many people unnecessarily end up in hospital, long-term care or convalescent homes because they are still not given the supports they need.

I welcome the Bill, which is a first step on a long and possibly difficult journey. There are many aspects of the legislation which will need ongoing monitoring and evaluation.

Ms Hanafin

Ba mhaith liom fáilte a chur roimh an mBille agus go háirithe roimh an ath-struchtúrú atá á dhéanamh ar an mbord. In the 30 years since it was founded, the Eastern Health Board has outgrown itself. The population has increased by 41 per cent to a staggering 1.3 million and its budget is almost £1,000 per person at £1.2 billion. It is an opportune time to restructure the Eastern Health Board, which at this stage is up to six times larger than the other health boards. It has become difficult to offer the range of services for combating problems in the city and county of Dublin.

When the health board was set up, the problems of the elderly, children's health and public health promotion were the main issues, but there are now added problems of child and drug abuse and homelessness. There should be locally based structures to handle some of them. In the context of local government there are now three county councils for which a new management structure was needed. The management structure proposed in the Bill will ensure the involvement of local communities, councillors and voluntary organisations to ensure a good service is provided.

The new health authority will identify the needs of the eastern region as well as commission, oversee and evaluate services. I look forward to planning and co-ordination in each area health board. The involvement of voluntary hospitals is welcome. I understand this will be based on partnership. Their role and that of voluntary organisations should continue to be recognised. The Order of St. John of God provides services for the mentally handicapped. There is a need for greater co-operation and to ensure the bodies concerned are represented on the board in conjunction with the others mentioned.

The new structure should envisage locally based services in a number of areas. Breast cancer is of particular concern to me. About 1,500 new cases are diagnosed each year. About half of these will ultimately die. One in 12 will contract breast cancer, the most common malignancy among European women. An excellent service is provided in St. Vincent's Hospital where a complete service is offered each Friday. It should be replicated in each of the new area health boards. There should be a specialist breast clinic offering the services of a breast surgeon, a medical and radiation oncologist as well as clinical examinations, mammography, cytology and histology services. Every woman diagnosed with breast cancer should have access to a breast care nurse. Funding should be made available for the provision of these services.

The national breast cancer screening programme due to be introduced later this year is well planned. A total of 120,000 women between the ages of 50 and 64 are to be targeted for screening. The necessary follow-up services should be provided in each health board. Groups such as Europa Donna which was established recently are heightening awareness of breast cancer and pressing for the provision of locally based services.

The increase in drug abuse, particularly in Dublin city and county, and the role of the Eastern Health Board in providing drug centres is of concern. While health boards cannot win, I fault the Eastern Health Board for the lack of consultation with local communities. It was planned to provide three clinics in my constituency, one of which never got off the ground because local residents formed a chain across the road to block people entering. They also superglued the shutters. If the Eastern Health Board had sought to reach agreement and formulate a plan with local community leaders and local politicians, the problem could have been avoided. Where such centres are provided the board should comply with the agreement reached with the local community in terms of opening hours and the numbers attending.

Monitoring committees should continue to work with interested parties and where problems arise they should not be allowed to falter as happened in Dún Laoghaire. To avoid problems everybody should work together. It should be understood that clinics are provided for the good of the community. The fears of local communities need to be allayed and confidence built up.

The Eastern Health Board has issued a ten year action plan for the elderly. There are many nursing homes in my constituency. I am concerned that some of these are moving away from providing long-term care towards convalescent care. This obviates the need for round-the-clock nursing care. Fewer staff are required and there is a greater turnover. The area health boards should work with nursing home providers to ensure much needed places are provided. The necessary back-up facilities are not available in the community to allow the elderly remain in their homes.

I welcome the change in the eligibility criteria for medical cards for the elderly. This means they will now have more comfort in dealing with doctors and chemists.

One would regard Dún Laoghaire pier as a place where people go for a walk and to enjoy the sea. A sad sight is young homeless people sleeping on the pier. Those without a home in Dún Laoghaire are referred to hostels run by the health board in town. They are alien to people from Dún Laoghaire who do not know where they are going. They are not suitable for young mothers with children. Locally based hostels should be provided under the new structure.

Many of the homeless in my constituency are young mothers with children who must leave bed and breakfast establishments by 9 a.m. and not return before 6 p.m. There are no facilities available to prepare food for themselves and their children, not even a lunch box. Will the Minister consider funding a day centre for the homeless in Dún Laoghaire and in the other area health boards to ensure the health and safety of the people concerned?

There is another group for whom no one takes responsibility. They are not elderly but may be homeless because of psychiatric problems. The council does not want to deal with them because they have a psychiatric problem. The health boards do not deal with them because they are not old enough. The voluntary organisations do not want to deal with them because they have a myriad of other problems also.

I know of one particularly sad case of a young man who is sleeping in the park in Cabinteely. He has psychiatric problems and he now has developed drugs problems, but nobody will take responsibility for him. Following the break-up of the Eastern Health Board, I hope we can have a more locally focused service so that the various organisations will work together to ensure nobody falls through the net, we can provide a service, we can identify and respond to people's needs, and we can plan and co-ordinate for the good of each area. Dealing with 1.3 million people has become too unwieldy. It is beyond the power of the existing board. I hope the new structure will ensure that together we can work locally for the good of our community.

Mr. Durkan

I welcome the opportunity to speak on the Bill, which has been on the drawing board for some considerable time. In fact, it was mooted on several occasions in the distant past when I was a member of the Eastern Health Board. I am amazed it has taken so long to reach fruition.

I have my doubts about the beneficial impact of the proposal outlined in the Bill. I worry that a greater emphasis is being placed on the structure to be put in place to provide a service rather than identifying the need to provide an efficient, fast and direct service to the consumer. I am not sure that the proposal will not raise a refined form of bureaucracy in a specific geographic area, drawing on its past for its inspiration. We may have learned many beneficial lessons from the past, but the times have changed dramatically. The public expects a much more dramatic response than they were used to getting in the past.

After all these years it is amazing that there is an attempt to revert to the old Dublin, Kildare and Wicklow health authorities. The Eastern Health Board has given extremely good service to a large and varied population, including people living in a wide variety of terrain, over a period of time. The Eastern Health Board currently caters for approximately one third of the population. This requires the delivery of services in more rural areas, in terrain to which it is not as simple to deliver services as it is in a city or town. However, the board did reasonably well in that regard.

The problem I see arising in the future relates to how quickly and efficiently the health services, irrespective of their constituted form, respond to the public need. My one criticism of health services is that they appear to be run almost as a business. The problem is that one cannot run them as a business. It does not work that way simply because people do not become ill on cue. They become ill through no fault of their own and they require services in line with their illness at the time they become ill.

The health services, like the educational services, affect every family and person in the community at one time or another. In many cases, they affect people many times. Therefore, the constitution outlined in the Bill needs to look at how effective this will be in the more efficient delivery of the services to the consumer and recognise that the consumer is vulnerable. It is not as if the person is able to go to a particular location to order something and say that he or she will be back for it in a month. The service is required at a specific time but the consumer or patient may have to wait a great deal of time before delivery. Therein lies the big contradiction. This is the one area in which we cannot afford a delay in the delivery of service. While on the one hand great emphasis is placed on costs and the best return on investment, we should also recognise that the people to whom the services are being delivered have an urgent need. It is not something which can be postponed for a month, six weeks or a year.

I hope that the hospital services and the direct services to the public will be more readily available. I do not know that that will be the case because I have no reason to believe that the proposed structure will be any different from that which exists. It will not be the case until somebody somewhere decides to take the whole thing on board and asks, "If there are X number of people in need of a specific service at a given time, how fast can we deliver that service to them?"

Demographic trends change and the needs change. As the population grows older, the needs of a particular group in society change. Anybody who becomes ill is vulnerable and uneasy about the future. An elderly person is no exception but I want to emphasis that his or her sense of vulnerability is accentuated.

Strange things happen at present. For example, a specific group of people, who do not qualify for dental benefits through their social insurance contributions, are excluded from receiving benefits through the health boards because of the numbers which are coming on stream. This is totally illogical because it has no regard for the need of the patient. It only has regard for the logistics of the number of patients to be dealt with. That is grossly unfair. We should not automatically exclude a number of people, who could be women of child-bearing age, for example, who would be in need of dental treatment more urgently than many other people. Why should we go down that particular road? Will the Bill attempt to change that? It will not make a difference. It involves redrawing the map but I do not know if it will have a great impact on the delivery of the services. That is just one example.

Let us look at another example of where we need to look carefully to the future. As I said earlier, the changing times involve many threats as well as benefits. Take epidemics in schools and school medical examinations, for example, and the need for a sharp, efficient delivery of services there. I compliment the health boards and the Eastern Health Board, in particular, for its work in that area over many years since 1970. There is no harm in pondering for a moment on the various illnesses which affect children and the rapid way in which an infection can become established. Meningitis is a case in point. The causes of that illness are obviously as prevalent now as they were in the past. Attendant upon that is the concern of the patient or, in the case of menin gitis, the parents of the patient. The rapidity with which the services can identify the problem and respond to it is vital. Instant action must be taken and that involves making information available to parents, teachers and school authorities on the existence of an epidemic or the potential for an epidemic. There is a need to respond quickly and positively and to give clear information so that parents can have confidence in the services.

Part of the difficulty of being ill is the concern on the part of patients or their relatives as to whether they can have confidence in the system. If they do not have confidence in the system, fear takes over and loss of life can occur also. The attendant problem of anxiety and fear is something the patient can do without at that stage. Patients must have confidence in the ability of the services to deliver in a rapid and effective manner.

I want to refer briefly to areas such as special hospital services and the care of those with physical or sensory disabilities. Will the new structure be more effective and efficient? Will it address the issues raised by successive Governments and health boards over many years such as long-stay and respite care for the elderly and those with physical or sensory disabilities? Will it examine the fine print in detail in terms of the efficient delivery of services to the people in that category, who are very vulnerable? They depend on those around them to care for them.

We should examine the question of elderly people who rely on institutional care such as a private nursing home because there is a tendency on the part of health boards, having gone through the various assessment procedures, to determine if the person has a home they can sell or rent. Very often, because of the age of the person concerned, the house is in such a condition as to make it unsuitable for sale or rent. The health boards then tend to consider the possibility of the property being disposed of. That may be possible in some cases, depending on the bond that exists between the individual and the household, but what about people who are seriously ill or who require long-stay institutional care? They may find the only way they can afford the care they need is to sell the only possession they have remaining, their only tie with the past. It may adversely affect the health of such patients if they are confronted with the prospect of having to sell their homes. That is unfair and it should be possible to deal with the issue in another way. I know some health boards try to do that and alleviate such concern as much as possible, but this area must be carefully examined with a view to a sympathetic delivery of the services in so far as the needs of these people are concerned.

A previous speaker referred to the homeless, an issue about which those of us living in the suburbs of Dublin are also concerned. The homeless question covers a very wide spectrum now, particularly given the scarcity of rentable accommodation throughout the greater Dublin area. It is quite common for young women with one or two children seeking emergency accommodation to be sent to a hostel perhaps 20, 40 or 50 miles away. Three problems arise immediately. First, they are uneasy about travelling so far away; second, they have never been in that type of environment before; and, third, they are separated from their relatives and friends. It is not right to take people away from their local area where they have recourse to the support of friends and relatives, even if it is only psychological support.

I do not know if this legislation will change that. It should bring about a greater concentration on the services throughout its jurisdiction, but I not sure that will happen. I have not seen anything put forward so far that would indicate to me that that will be the case.

Notwithstanding all the lessons we have learned in the past, in general we have not responded to the health care and special housing needs of our population which should flow naturally from the demographic changes that have taken place. If we do not respond to them effectively it will result in a loss of confidence in the system and a potential danger to public health. I am not sure the package now emerging is more effective and capable of delivering better services than those which existed previously. I will say more about that later.

I referred earlier to the efficient delivery and cost effectiveness of the health services and that they appear to be run as a business. As the age structure of our population changes, greater emphasis is required in certain areas. We can give much lip service to the way we should address this question, but I wonder if we have done anything in this area. For example, can we deliver emergency hospital services to a wide area of Dublin? Does that population have ready access to that service comparable to that which existed 25 years ago? Deputies will remember all the hospitals we had in this area 25 years ago which are now closed. Everybody said that big was beautiful and that we would get better service in large hospitals delivering to a wide region. I am not sure that thinking was right or that method effective. I am not sure we delivered a more efficient service to the population in those years.

I hope this legislation will be of some benefit, not to the administrators but to the people to whom the service ought to be delivered. The key factor is the delivery of the service directly, quickly, sympathetically and efficiently to the people. If this is the core value of the health service we will have achieved something. In my years on health boards I have heard more reviews of every aspect of the health services than anyone in the House. I have seen many reports contradicted by subsequent reports and I now feel brave enough to put forward my own views.

Minister of State at the Department of Health and Children (Mr. Fahey)

I thank the Deputies for their contributions to the debate. The Minister, the Minister of State and I have listened carefully and I think there is agreement on all sides on the need for structural reform of the health services in the eastern region.

The task force recommendations form the fundamentals of the Bill. I wish to deal with a number of issues raised by Deputies. Concern has been expressed about the role of voluntary hospitals within the new arrangements. Some Deputies alluded to the fears that a culture might develop in which the authority would favour health board hospitals over voluntary hospitals in the matter of funding. The task force report states:

The authority must treat all service providers, statutory and voluntary, in exactly the same manner. There must never be a perception that one sector or another is receiving more favourable treatment. The structural arrangements must be such as to ensure that all providers operate on a level playing pitch.

That makes clear that the recommendations are designed to ensure that all service providers will be treated equally from the beginning.

The question of how the teaching responsibilities of major hospitals might be catered for under the new arrangements was raised. As proposed in the Bill, there will be a written agreement, to be renewed annually, between the authority and the hospitals which will specify the services provided by the hospital and the funds which will be made available for those services. In this context it will be possible to make the necessary arrangements for funding of such matters as teaching responsibilities.

The Bill makes it clear that the provisions in legislation which apply to health boards will also apply to the new authority. Therefore, the relationship between the new authority and the Department of Health and Children will be the same as exists between the Department and the health boards.

Deputy Shatter mentioned information systems. I agree that adequate information systems for the new authority are vital. The development and implementation of information systems in anticipation of the establishment of the authority is being commissioned and is being phased in over a five year period. The significant cost involved in this major investment would have arisen in any event because of the need to improve information systems in the Eastern Health Board region. It has to be said that in the context of the annual budget for the region's health and personal social services of over £1.2 billion, the cost anticipated as a result of the proposals in the Bill are very reasonable, particularly when the expected service improvements and efficiencies which will result from the establishment of the new authority are taken into account.

I thank all the Deputies who have participated in the debate.

Question put and agreed to.