I move amendment No. 1:
To delete all words after "That" and substitute the following:
"Dáil Éireann declines to give a second reading to the Bill in view of:
(a) the inadequate time given to members of the Dáil to consider the terms of the Bill;
(b) the fact that the position of Chief Executive of the Health Service Executive has yet to be filled;
(c) the threatened industrial action by 15,000 members of the trade union IMPACT, arising from concerns about jobs and working conditions;
(d) the confusion and uncertainty that remains about Government plans for reform of the health services.".
This Bill is a major legal instrument that will result in a new configuration of administration of our health service. It is an important Bill worthy of full public scrutiny. It is clear the Minister for Health and Children believes otherwise. By forcing through a rushed debate without any period for reflection or consultation, she is trampling on every safeguard that a reasonable person, regardless of their political outlook, expects of a Parliament worthy of the name. By her actions the Minister for Health and Children is treating this House with disdain and the people we represent with contempt.
This Government has had 18 months since it announced its plan to abolish health boards and establish a Health Service Executive. During that time we have seen no detailed proposals of the legislation envisaged. No heads of the Bill have been published and no briefings on the Bill have been held for Members of this House. The arbitrary date of 1 January was set as the start-up date for the new HSE and due democratic process has been sacrificed at the altar of expediency as a result.
There is, at the very least, a convention in this House, which I understood the Minister supported, that a Bill, particularly a major Bill of this type, should be published two weeks — at a minimum — before it is debated on Second Stage so that time and attention can be given to the changes contained in it. That procedure has been flouted by the Minister. Debate on the Bill was due to begin tomorrow, although it was published only last Friday evening. However, even that ludicrously tight timeframe was not tight enough for the Minister and the debate is now shoved back into today's Order of Business. I am not interested in any statement of regret from her about this decision. What is needed is a full and comprehensive explanation as to why the Government is so intent and determined to stampede this important Bill through the House just 96 hours after publication and 36 hours after Members received their copy of it. It may be a record but, if it is, it is a despicable record. A new low has been reached by a Government that has lost the run of itself. The Minister should tell us the reasons for her hurry and tell us what is so important or pressing that democratic accountability must suffer at her hand. The Minister built her reputation on telling it as it is so let us hear it from her now.
Maybe we should not be surprised — this high-speed hijack of democracy is only the latest twist in a comedy of errors that has characterised the Government's approach to health care reform since it was announced in June 2003 — but we should begin to worry. The comedy of errors has every likelihood of becoming a catalogue of disasters. Back in the heady days of the health strategy launch in 2002 we were promised health care reform. However, by June 2003 we discovered what was on offer was administrative reform only.
The big challenges facing a true health care reformer were ignored then and continue to this day to be ignored. The Government has no policy to tackle the inherent inequality in our health service. The system of apartheid between the treatment of private and public patients is intact. There is no policy to shift care towards the most appropriate level, to move, that is, towards primary and community care so that fewer patients end up in hospital. The Cabinet decision on generic drug description has disappeared off the map, the 3,000 beds did not materialise, the hospital waiting lists did not disappear and the 200,000 medical cards were taken away. Yet, those who suffered are expected to be grateful for a cheap, yellow pack substitute.
We have a new Minister but we still have the same old spin. On RTE's "This Week" programme last Sunday the Minister for Health and Children spoke to the Irish people and told them a cock and bull story. She told them that the level of medical card coverage is now at its highest level since 1995 as a consequence of the provision in this year's Estimates, which is simply untrue. The claims made by the Minister are unfounded and she knows well that a medical card provides for a whole range of benefits other than the visit to the doctor, and to claim that a free general practitioner card is a medical card is gross dishonesty.
The Minister talks, as her predecessor did, about a patient-centred health service, and she again referred to it in this debate. To have the patient at the centre of the service is a wonderful idea but it does not match reality despite the best efforts of professionals caring for patients. It is worth noting that in this major Bill, which covers 68 pages, there is only one mention of the word "patient". We may have been promised a patient-centred health service, but instead all we got was an announcement from the Government of its intention to abolish health boards and to establish the Health Service Executive. This is hardly a health care reform programme. Nor it is correct to maintain, as the Minister repeated in her contribution, that the changes announced followed recommendations made in the Brennan and Prospectus reports. This was the spin but the truth is different. The truth is that Professor Brennan's report specifically recommended the retention of health boards, in the Minister's words, "to safeguard the need for local democratic representation". Her only caveat concerned the size and number of health boards, which should be reviewed, a point on which I support her. All that is left in the Bill of her recommendation is sham local representation.
Even within the narrow confines of administrative reform there is a shortfall between what was promised and what we received. The Government's health care programme states:
A key policy aim of the health strategy is to deliver high quality services that are based on evidence-supported best practice. In order for the reformed health service to base planning and policy-making on world-class standards, it is essential to ensure that high quality information is available to the system. The Health Information and Quality Authority will be established to achieve this aim.
The Government is merrily pursuing its course of establishing the HSE on 1 January next without this essential reform being published. There is no sign of the Health Information and Quality Authority or the Bill to establish it. Information and quality should be central to the new structures which are to come into being. Without this piece of the jigsaw in place, the proposal to set up the HSE is seriously defective and even risky.
It is 18 months since the Government set in train an interim HSE to deal with transition issues and to enable a smooth transfer to the new structures. Instead, there has been a lack of consultation and certainty at all levels over that period as new structures and systems affecting around 120,000 people are being mooted and developed. The Minister for Finance stated publicly that there would be no forced redundancies and the Government stated there would be no voluntary redundancies. Meanwhile, however, health boards have been abolished and will no longer function as an entity in the new structures. It is difficult to envisage how this circle can be squared, particularly as a whole new layer of administration is being created by the interim HSE.
Today I received the most extraordinary answer to a parliamentary question in regard to senior management posts which might have been filled by health boards. I discovered that a circular went out from the Department of Health and Children last March advising health boards that they were not to appoint to new posts without permission because of the changes in the structures, which sounds reasonable on the part of the Minister and the Department. However, it turns out that since March last 22 senior management posts have been filled. That does not make sense. These senior management posts have been filled at a time when the employers making the appointments are in effect out of a job in the sense that the health boards are defunct. These 22 posts mean that a remarkable number of senior managers have come into the system at a time when we should expect, if anything, movement in the opposite direction.
The Minister should tell us how many staff will be left in the Department of Health and Children when these structures go through, which might provide a picture of what is happening within the service. It would be useful also if the Minister would tell the House how many staff currently employed in particular positions will no longer be employed in those positions given this change across the health board structure. I presume she knows the answer.
IMPACT is a trade union with an honourable record of embracing change and is not one of the trade unions which has tried to block development. However, even that trade union has been driven through frustration to the point of holding a strike ballot and directing its members not to attend briefing meetings. The vote was endorsed by a massive margin of 7:1, whereupon Mr. Kevin Kelly, chairman of the HSE, went on radio and stated it was all due to a misunderstanding. A misunderstanding, if that is the problem, should not arise if the people driving change are doing their jobs properly. However, the IMPACT spokesperson, who was also interviewed on radio, made it clear that this is about more. He spoke about a breakdown in trust, delays, breaches of agreements and an AIB culture intruding into the health service. This is serious from a trade union that has welcomed health care reform and helped to deliver it in the past. We will have to wait and see if this is to be another first for the Minister. Will she be responsible for the birth of a new statutory body that on opening its eyes for the first time will confront the possibility of a strike by the workers for whom it is responsible?
We move on to the matter of the new chief executive officer or, to be more accurate, his failure to show.
Professor Aidan Halligan was to be the Bonnie Prince Charlie of our day, coming over the waves to liberate us. He was such a catch that he was offered the highest salary rate ever for an Irish public servant, who could afford to get home in time for his tea every day by helicopter if he needed to, and whose coming was announced officially by the Minister, again with a virtual fanfare of trumpets. First he was to come next April. Then he was convinced to come by the end of next January. Deliverance, we were to understand, was at hand for the Irish health service.
Alack and alas, like the Young Pretender the professor never did come over the sea. It turned out he had not signed any contract nor signed off on his existing job. He is perfectly entitled not to do so, but I would love to hear what he has to say about all this. The failure to appoint a CEO further undermines confidence in the Minister responsible. Professor Halligan's withdrawal leaves a disturbing lacuna. There is little reassurance to be drawn from the temporary appointment of Mr. Kevin Kelly in that position.
We have no proper debate or scrutiny of legislation, no information and quality authority, no partnership, no streamlined system of change, no CEO and no need for the headlong rush to meet the 1 January deadline. That is why we in the Labour Party are tabling this amendment.
With regard to the appointments to the HSE board itself, appointments which as Deputy Twomey pointed out are still unknown, the Bill quite rightly specifies that no member of the Oireachtas or European Parliament should be appointed. However, there is no statutory bar on other inappropriate appointments other than the obvious ones related to criminal records and the like. This board will have sole responsibility for the management of our health service. It will meet in secret. It will be very different from the current management system which is essentially the responsibility of the Minister and is managed by the Civil Service. Whatever about the shortcomings in the current system, there was little if any possibility of a conflict of interest. In the new environment, where private individuals rather than civil servants will be managing the health service, that will no longer be the case.
We hear a lot about vested interests in the health service. In this new structure there is even greater likelihood of influence from vested interests such as the pharmaceutical industry, for example. A person from that industry is currently on the interim board, and I note that solely as an obvious example.
A code of conduct is provided for in this Bill for those appointed to the board but it is for guidance only and looks like a very poor protection against powerful interests that have much to gain by having a foothold in a body managing the entire Irish health service. The reference to gender balance is so weak as to be meaningless. We do not know who these members will be but we know they will meet in secret. The media will not have the access it has hitherto had to health board meetings and the public will not have access either.
In section 20 of the Bill, the CEO is defined as the accounting officer. That is a significant change. I find it unacceptable that the Minister for Health is going to bring in amendments as yet unseen to her own Bill on this particular section. If they are simply technical amendments as she claims, what is the delay in publishing them?
Section 32 of the Bill requires the executive to prepare and adopt a service plan specifying the services to be provided within the financial limits for the year. The Minister has extensive powers and can amend the plan and issue directions as to its form and manner of preparation. However, there is no requirement on the Minister to publish the draft service plan or give any ministerial directions, nor is there any requirement in this Bill to publish the service plan even in its final form.
I have grave concerns with the proposal that the Oireachtas Committee on Health and Children will have the oversight role. That is unrealistic and my experience so far has not been encouraging. The only time that Mr. Kelly addressed the committee was in his early days, when he clearly did not have much experience, but he referred repeatedly to the road-map being the composite plan towards which everyone was working. As a member of the committee I looked for a copy of that composite plan. I did not get it for weeks and I had to badger everyone, including the then Minister, the Taoiseach and others before I got it. That is not a very encouraging experience if we are talking of an Oireachtas committee which is very busy and which has to concentrate on many aspects of the health service, playing such a central role.
Part 8 outlines a series of bodies that have the potential to be expensive and time-wasting talk shops. A national consultative forum "may be convened" from time to time — big deal. The county councillors are to be pacified by regional health forums with no power, but of course with expenses, and if that is not enough we will have local panels which will be circumscribed even in the matters they can discuss.
The biggest failing of the health board structure was the lack of direct accountability. Members of health authorities should have been and could still be directly elected by the people, not channelled through county councils. Had that decision to have direct elections been taken and had Professor Brennan's advice been heeded, we would have a dynamic and responsive structure, unlike this plethora of bodies that will be all mouth and no teeth. I am dissatisfied because the nature of this Bill is to offer much promise but then let us down. It is very disappointing in what it does.
Do the proposals for a complaints procedure satisfy the need for a clear and independent assessment of complaints? The appointment of complaints officers will be made internally both at executive level and at service provider level. Inevitably that will not protect the independence of any response to a complaint. I would have thought that the experience of the Garda Complaints Board and its utter failure to deal with complaints from the public should be a warning to the framers of this legislation. I would prefer to see the proposal for a health ombudsman who would play an effective and focused watchdog role which would benefit the service as well as the user and would be a much healthier, cleaner way to deal with complaints. A complaints procedure was promised for a long time even before this Bill was mooted but what has been produced in the Bill is a deep disappointment.
The voluntary hospitals are not mentioned in the Bill. I wonder what discussions have been held with them, or with the Department or the HSE with regard to their future relationship within the health service.
Will the Minister define personal social services? The Minister may need to seek legal advice on that issue. Part 2 of the Disability Bill defines "health service" as meaning a service, including a personal social service, provided by or on behalf of a health board. "Personal social service" is undefined in that Bill and in any other statute. If one looks up Oasis, Comhairle's information on the public services website, one is cross-referred to "community care services", a term that has no statutory definition either. According to the website, public health services provided in the community in Ireland are sometimes referred to as community care services. They are generally provided by the health boards or by voluntary organisations in conjunction with or on behalf of the health boards. Entitlement to community care services is not as clear-cut as entitlement to hospital services. There is also wide variation in the level of services available in different parts of the country. In general, medical cardholders are entitled to community care services free of charge, though not of course the "yellow pack" unfortunates. Others may also be entitled but it is not always possible actually to get the services.
Community care services can include the public health nursing service, home help service, physiotherapy, occupational therapy, chiropody service, day care, respite care service and so on. The rules about which community care services must be provided differ in accordance with the different services. In some cases, health boards are obliged to provide services, while in others the health board has discretion about whether to make the service available.
The website goes on to deal, in turn, with public health nurses, care assistants, home helps, physiotherapy, occupational therapy, chiropody, technical aids, respite care, day centres, meal services, transport, social workers, speech therapists and dieticians. I can find a statutory basis for the provision by health boards of some of these services — for example, for home nursing, home help, employment training and technical aids for disabled adults. However, other services do not seem to fit within the statutory framework but, admittedly, the framework is piecemeal and I may have overlooked something.
In regard to social workers, the position seems to be that on the abolition of public assistance provided by local authorities and the introduction of supplementary welfare in the 1970s, the remaining public assistance officers were transferred to health boards but the health boards, in general, and these transferred officers, in particular, apart from dispensing supplementary welfare, were not given any specific social welfare brief. It would be odd if there were no statutory basis for the employment of social workers or the provision of services by them outside the context of child care and the Child Care Act, but perhaps the Minister might find out and advise us in her reply.
Are physiotherapy, occupational therapy and chiropody sought to be justified as being outpatient services under the 1970 Health Act which includes institutional services other than inpatient services provided at, or by persons, attached to a hospital or home and institutional services provided at a laboratory, clinic, health centre or similar premises? Where does respite care fit in? Is it deemed to be a form of home help for which there is statutory authority? Is a health board justified in providing or funding a day centre which provides activities such as recreation, sport or leisure facilities outside a strict employment training context? Where do technical aids for disabled children fit in? Neither seems to fall under section 68 of the Health Act 1970. It may be that the Disability Bill not only deals with the provision of an indeterminate range of undefined services, variously described as community care or personal social services, but that in regard to some of them at least, there is no statutory basis for their provision in the first place.
The matter is confused rather than clarified by the Health Bill 2004. This Bill proposes to define health and personal social services for the first time. It is clear that it is simply to be a compendious term which encompasses everything existing health boards already do. The term is defined in section 2 as meaning services provided in accordance with the scheduled Acts. The Schedule lists every Act that contains a reference to a service provided by a health board. For example, health board functions under the Marriages Act 1844 and the State Lands (Workhouses) Act 1930 and 1962 are health and personal social personal services. A person with a disability will be entitled to an assessment as to whether health board services under the Rats and Mice Destruction Act 1919 are required to meet the needs occasioned by his or her disability but not, apparently, whether he or she needs a speech therapist. That may seem like a technical point but it is an apposite one since we have been dealing with systems and structures with which we have become familiar and which have provided services at community level. However, I raise the question whether they all have a statutory basis. Does that issue need to be addressed in this Bill?
The concentration has been on changes in administration to the point of obsession. Essentially, the problem lies in the hospital sector and I would prefer if a new national hospitals authority had been established and if the health boards had been directly elected and streamlined, that is, fewer in number, larger in geographic area, and maintained not to deal with hospitals but with community services such as primary care and so on for which they have built up a responsibility. That separation would have made a lot of difference but with a lot less disturbance and cost.
Obviously, there are always concerns about bureaucracy and streamlining to make sure there is not unnecessary bureaucracy but I do not see this Bill resolving that issue. I remember discussing proposals to create four health boards in the Dublin region and making the point that everyone acknowledged that the old Eastern Health Board was a monster but that there was a real risk that we are going to create four monsters instead of one. There is a real risk here in that this Bill is being rushed through to the point where nobody has stopped to reflect and to ensure things which could be done better will be done better. There is a real risk we will end up with a board that is unaccountable and untouchable, other than by way of its connection with the Minister, that there will not be proper oversight and that it will not be open in the way modern society and the protection of patients demand.
