Dáil Éireann díospóireacht -
Thursday, 9 Dec 2004

Vol. 595 No. 1

Health Bill 2004: Report and Final Stages.

Dr. Twomey

I move amendment No. 1:

In page 10, line 15, after "formed" to insert "by a registered medical practitioner".

Before I speak to my amendment, I welcome the Tánaiste to the House. We spent ten hours debating the Bill on Committee Stage, during which we called no divisions. The Tánaiste agreed to consider most of our amendments and to come back to us on Report Stage. Having read the Report Stage amendments last night it is very difficult to know whether she has incorporated our amendments and if so where they are in the legislation. Unfortunately this will probably slow down this afternoon's proceedings.

We received representations from a number of voluntary, patient and professional organisations. They have had no opportunity to give us their input on the Report Stage amendments. After Committee Stage the Irish Hospital Consultants Association stated that its disciplinary procedures did not appear to be covered by the HSE. While I am not sure whether that is true, we have had no opportunity to review the Report Stage amendments. Next week we might find that a number of provisions have been omitted from the legislation and we will have no opportunity to discuss them.

I am concerned about the issue of transparency in this legislation. During the afternoon I hope the Minister will indicate where my amendments have been included and I am sure the same applies to Deputy McManus and the other Deputies who speak on the health portfolio. I am concerned about how patients will be treated individually. None of my amendments seems to have been adopted in the section on complaints. No changes have been made as to how individuals may complain in that section. I am also concerned about the 100,000 HSE employees. The chief executive officer will have huge powers under section 19 and again none of my amendments seems to have been adopted.

Acting Chairman (Mr. Glennon)

Amendment No. 1 is before the House and Members should speak to it. This should not become a Second Stage debate.

Dr. Twomey

It is not a Second Stage debate. The problem is that we have no clear idea as to whether our amendments have been taken on board. The Report Stage amendments were given to me last night and it is very difficult for me to know where my proposals are contained in them. We sought the postponement of this debate as we have had insufficient time to read the amendments. We must make that point clear before starting Report Stage. While I know I am supposed to talk about amendment No. 1, the way we are going about this is disgraceful. It is quite possible that the amendments that affect the Deputies will not even be reached this afternoon. We spent ten hours on Committee Stage without divisions so that we could have a smooth passage for the legislation. I have no idea——

Acting Chairman

Amendment No. 1 relates to a single definition and I ask the Deputy to confine his comments to it.

Mr. Gormley

On a point of order, taking up a point made by Deputy Twomey, it would be helpful for the Tánaiste to explain where she has addressed our concerns in her amendments. We have had last minute phone calls telling us the amendments were in our cubbyholes and we have not had the opportunity to scrutinise them in the detail required. To save time in the House I ask the Tánaiste to outline where our concerns have been incorporated into her amendments. She should outline where the issue of accountability has been addressed as she promised on Committee Stage.

Acting Chairman

Standing Orders do not allow for this, except in the course of orderly debate on individual amendments. I ask the Deputy to adhere to that requirement.

Mr. Gormley

With respect, I am suggesting that with the permission of the Acting Chairman the Tánaiste make a very brief statement, which would be very helpful, as I am sure most Members would agree.

Tánaiste and Minister for Health and Children (Ms Harney)

It might be helpful for me to intervene at this point. Many of the issues raised by Deputies on Committee Stage concerned the accountability of the Health Service Executive. I have tabled amendments that will oblige the Minister to lay before the House a copy of any directives given; oblige the Minister to publish the names of persons appointed to the board in Iris Oifigiúil; enable the Oireachtas Joint Committee on Health and Children to summon the chairperson or in his absence the chief executive or senior management of the executive; oblige the Minister to lay copies of service plans and amended plans before the Houses of the Oireachtas; oblige the executive to publish service plans; and enable the Minister to make regulations governing the executive’s dealings with Members of the Oireachtas.

The accountability matters are covered in amendments Nos. 8, 9, 20, 40, 42 to 46, inclusive, and 130. Superannuation issues are addressed in amendments Nos. 55 and 56. Consequential amendments affecting the service plan are dealt with in amendments Nos. 75 and 76.

I have taken on board many of the suggestions made and will also be making regulations on matters where regulations are more appropriate than detailed legislation. It is not possible to write into legislation the detail of how the executive should deal with queries from Members of the Oireachtas etc. As that is a logistical issue, it will be addressed by way of regulation, as will many other issues. Any regulations made would clearly need to be laid before the Houses of the Oireachtas etc. Suffice it to say that many of the issues concerning strengthening accountability have been addressed in the amendments I have tabled today.

I have also tabled a number of technical amendments to address issues raised. I flagged these at the end of Committee Stage last week.

Amendment, by leave, withdrawn.

Caoimhghín Ó Caoláin

I move amendment No. 2:

In page 10, line 33, after "by" to insert "or on behalf of".

We recognise that health and personal social services are provided not only by the bodies named in Schedule 1 and defined in section 56, but also in practice by other bodies and groups, either contracted by or on behalf of one of the stated bodies, which are the health boards and the Eastern Regional Health Authority. In practice we are well aware that many services come under the broad definition of health and personal social services and those that fall clearly under Schedule 1, which is the outline of all the Acts that come under the definition of health and personal social services. This section of the Bill states:

''health and personal social services'' means services that immediately before the establishment day were provided under the Acts referred to in Schedule 1 by a specified body as defined in section 56.

I have referred to that. It is important that we recognise that other bodies act on behalf of the list of those that appear in Schedule 1. I urge the Tánaiste to accept that this is a better presentation of the intent of this section and that by changing it to "by or on behalf of", we will ensure it is fully inclusive and encompasses and incorporates all the various health and personal social services available directly from the board or presented on its behalf or on behalf of any of the other named bodies in Schedule 1.

Ms Harney

The Acts in Schedule 1 permit the health boards to make arrangements with service providers for the provision of services on their behalf. As the executive is required to continue to provide the services provided by health boards under the Acts specified in Schedule 1 prior to establishment day, this is sufficient to require the executive to provide these services.

Caoimhghín Ó Caoláin

This is a useful proposition that is clearer because of the addition of the words "or on behalf of" following "by". Each of the raft of different bodies — the health boards, the Eastern Regional Health Authority, the area health boards, the hospital bodies administrative bureau, the Health Boards Executive, the General Medical Service payments board, the Health Services Employers Agency and the interim health service executive — in their respective responsibilities have either engaged, contracted out or embraced the services being provided by independent bodies that are an essential element of the overall delivery of health care and personal social service needs in this State, particularly in the community and voluntary sector.

The wording as presented is specific, stating "by a specified body as defined". Many of the services to which I refer are not directly provided by those bodies created by the Acts listed in Schedule 1. This is a useful and wise amendment that clearly indicates that it is the service that is the priority, not the body or institution, which is vital in this instance. I commend the amendment to the Minister and ask her to re-evaluate the position she has articulated and to accede to the proposal.

Ms Harney

The executive is required to have regard to services provided by others. In sections 38 and 39, we deal with future arrangements to be covered. Section 38 makes it clear that the executive may, subject to available resources, enter into terms and conditions, as it considers appropriate, for an arrangement with the person for the provision of a health or personal social service. These sections make explicit provision for the basis on which the executive may enter arrangements with service providers. Any arrangements or contracts with health boards continue within the executive on establishment day so there is no question of current arrangements ceasing and there being a vacuum. There will be continuity in any contracts or arrangements health boards have entered into with service providers.

Amendment put and declared lost.

Ms McManus

I move amendment No. 3:

In page 12, between lines 19 and 20, to insert the following:

"7.—Subject to the provisions of this Act and the resources available to the Executive, the primary function of the Executive is to take such steps as are open to it to ensure that each person in the State is facilitated in availing of an individual entitlement to such health services and personal social services as are appropriate to meet the needs of that person.".

This amendment was resubmitted because it is central to the Bill. The Bill does not contain a mission statement for the health services executive. Without this amendment we are simply talking about bureaucratic change and administrative juggling without a statement of the purpose for which all this change has been brought about.

The Tánaiste on Committee Stage rejected this amendment because she misinterpreted the intent, seeing it as being about unlimited rights for the patient or public to access services. That is disingenuous of her. It is clear from the way the amendment is framed that it allows for the inevitable limitations of resources. We all understand health care is about rationing and setting priorities, but if there is administrative change that has no goal other than the mushy aspirations that both the Tánaiste and the interim chief executive officer have expressed, it is not worth a hill of beans.

If, however, there is a commitment made by way of this amendment to make clear what we are doing, it would be reassuring and would introduce logic to the Bill. Otherwise, the Bill is simply about bureaucracy and may even add to it. The purpose of all this must be spelt out. It is a reasonable amendment and I am astonished that the Minister for Health and Children has misinterpreted it. I hope she accepts this amendment, even at this late stage, and that the matter is treated with the seriousness and clarity with which it is being presented.

Ms Harney

I accept that the Bill is about providing a rights-based approach, subject to resources. I equally said on Committee Stage that this legislation is about a new administrative and management system for the delivery of health care. Separate legislation will deal with eligibility. That will be introduced shortly so I am not in a position to accept the amendment.

Ms McManus

It is a sad day if the Minister for Health and Children thinks eligibility is about promoting the rights of patients and the public. Eligibility is as much if not more about defining who cannot access services as who can. It is about setting limits. This is about a project to improve patient care, access and excellence across the board. Eligibility is a different matter. The Minister never speaks about eligibility when she speaks about improved patient care. If she spoke about eligibility in the context of the establishment of the Health Service Executive, people would be mystified. We are not talking about eligibility or who qualifies for what, who qualifies for a medical card, yellow pack or otherwise, or who must pay the increased charges that are mushrooming daily. We are talking about the end project. I regret that the Minister for Health and Children appears to be unable to get her head around the idea that it is not good enough to mouth aspirations or give out the clichés such as patient-centred focus or patient-centred service without including them in the Bill. If it is to be a patient-centred change, we must say that. The word "patient" appeared once in the original Bill.

At this stage I am so befuddled I have no idea how the Bill will end up given all the changes. It is like a serial in a women's magazine. Each month there is a new version and a new chapter. It is the same old formula but it keeps coming back in a different guise. In this instance we need to know its purpose and objective and what people can refer to when they ask what this is all about, as they do in increasing numbers, especially those working in the health service. It deals with confusion but it also sets out a goal.

Amendment put and declared lost.

Acting Chairman

Amendment No. 4 is out of order.

Caoimhghín Ó Caoláin

May I say a few brief words? The Ceann Comhairle has allowed me do so in the past as I appear to be a frequent victim of this ruling that the amendment involves a potential charge on the Revenue. If that is the interpretation that is put on amendment No. 4, the only way it can proceed is if the Tánaiste will adopt it as her own and that it would form part of the Government's amendments. As an Opposition Deputy I am not in a position to effect an amendment that would potentially deliver a charge on the Revenue. I tabled this amendment because I believe it is essential that the new Health Service Executive should be guided by certain basic principles.

Acting Chairman

In the absence of a response from the Tánaiste I have to rule the Deputy out of order.

Caoimhghín Ó Caoláin

I can say with honesty that in the past the Ceann Comhairle has afforded me an opportunity to point out my disagreement and disappointment at the ruling because this amendment is essential. It is about equity in the delivery of health services. It is about every citizen having the right to health care commensurate with his or her needs and not as is the current position where those with wealth can buy health care while many are on long queues and left out in the cold.

Acting Chairman

The point has been made.

Caoimhghín Ó Caoláin

I do not mean to be argumentative. I appeal to the Tánaiste and Minister for Health and Children as the proposition is for guiding principles and it is important. I hope she will consider the amendment worthy of her support. It goes to the kernel of what the Bill should be about, that is, delivering equitable as well as efficient health care. The current system in this jurisdiction does not measure up, as we know only too well and as is reported daily on the floor of the House.

Acting Chairman

Amendment No. 4 is out of order.

Ms Harney

I said in response to Deputy McManus that the issue of eligibility and entitlement will be dealt with by way of separate legislation. This is about putting in place a new unified administrative management system in which there would be greater uniformity and efficiency, all of which is being done not to create a better management module but a better system for patients.

Amendment No. 4 not moved.

Acting Chairman

Amendments Nos. 6 and 7 are alternatives to amendment No. 5.

Ms Harney

I move amendment No. 5:

In page 12, lines 37 and 38, to delete "training of its employees and the employees of service providers, and" and substitute the following:

"training of——

(i) students training to be registered medical practitioners, nurses or other health professionals, and

(ii) its employees and the employees of service providers,

and".

I have tabled this amendment on foot of what Deputies Twomey and McManus said on Committee Stage about the training of medical and nursing students and, as appropriate, other heath care professionals. The amendment ensures that the current arrangement, whereby students in the health profession have an opportunity to work in appropriate settings to obtain the necessary work experience, is given legal standing. I commend the amendment to the House.

Ms McManus

I am happy to withdraw my amendment in view of the Minister's amendment.

Dr. Twomey

As promised on Committee Stage, we endeavour to move as quickly as possible to ensure that as many amendments as possible are dealt with. I am happy to withdraw my amendment to enable a longer discussion on more important sections.

Amendment agreed to.

Amendments Nos. 6 and 7 not moved.

Acting Chairman

Amendments Nos. 8 and 9 are cognate and may be discussed together.

Ms Harney

I move amendment No. 8:

In page 12, lines 39 and 40, to delete "or Dáil Committee on Health and Children".

The amendments arise from consideration by the Attorney General's Office of two amendments tabled by Deputy Twomey on Committee Stage which incorporate a requirement in section 7(4)(c) on the Health Service Executive to provide advice in respect of its functions that may be requested by the Committee on Health and Children. That is in addition to the requirement in section 7(4)(c) on the Health Service Executive to provide advice in respect of its functions that may be requested by the Minister.

Deputy Twomey's amendments were accepted subject to consultation with the Attorney General's Office. That office has indicated that problems arise with this approach in relation to the doctrine of the separation of powers which is an important feature of our form of constitutional democracy. As the Health Service Executive is required to provide advice about its functions to the Minister, because the Minister is the person who has political responsibility for the executive to the Houses of the Oireachtas, the line of accountability to the Oireachtas is through the Minister. It would conflict with this to have a Health Service Executive providing advice about its functions to the Oireachtas as well. The Oireachtas committees have the power to call the Minister or the chief executive to appear before them to discuss relevant issues. In addition, the chief executive officer in his or her role as Accounting Officer will be required to appear before the Committee of Public Accounts.

Mr. Gormley

I asked the Acting Chairman on a point of order to ask the Tánaiste to outline areas where we will have more accountability and she listed amendments Nos. 8 and 9. How can she say the House will have more accountability under these amendments? We will have less accountability because the reference to the Joint Committee on Health and Children, of which we are members, is being deleted. It makes a mockery of the way we are processing the legislation because the Bill, as initiated, did not contain this provision. Deputy Twomey suggested the amendment which was accepted on Committee Stage. It is now in the Bill, as amended, and it is being deleted again on Report Stage, apparently on the advice of the Attorney General.

The question I put repeatedly on Committee Stage — and other members joined with me in asking this question — is where is the accountability. How will the members of the Joint Committee on Health and Children be involved? Apparently we have the right but, as I said on Committee Stage, the Joint Committee on Health and Children has a majority of Government Deputies and, therefore, we are cut out of the equation. What the Government always wants is more secrecy and less accountability and we have been cut out of the picture. I am afraid the two amendments the Tánaiste said at the beginning of the debate will result in more accountability, will lead to less accountability. I do not know how she can make any other argument.

Dr. Twomey

I hope our consideration of these amendments this afternoon will not be like Lanigan's ball, with the Tánaiste stepping in and the Attorney General stepping out again. We need to develop some cohesion in the health services. The Tánaiste could have proposed an amendment to provide that "the Minister will endeavour" to inform the Joint Committee on Health and Children. That would have been a poor substitute for the Members of the House, however. The Tánaiste is aware that members of the joint committee have tried since last February to get the Minister for Health and Children to appear before it. Due to time pressures, the Tánaiste and her predecessor as Minister for Health and Children, Deputy Martin, were not in a position to give the committee an account of what the Department of Health and Children is doing. If Ministers do not appear before the committee under the existing legislation, is there any hope that they will do so after this Bill has been passed?

If the new CEO of the HSE does not want to make himself available to the Joint Committee on Health and Children, he can use the excuses we have been hearing for the past 11 months. I have asked for a small concession, which I do not even consider to be watertight. It would give some semblance of accountability to what is happening with the HSE. It was clearly stated on Committee Stage that 363 people — county councillors, professional representatives and ministerial appointees — were accountable for taxpayers' money. The Tánaiste may argue that their powers were reduced in 1996, but they were still responsible to the public in that way.

Public representatives are particularly keen to ensure that accountability is retained because the public will punish them if taxpayers feel that their money is being thrown away. I proposed my amendment on Committee Stage because the Dáil is the only remaining place where one finds accountability for the health services. The Tánaiste should have made some allowance for that, perhaps by providing that "the Minister will endeavour" to inform the committee, rather than dismissing it out of hand.

Caoimhghín Ó Caoláin

I was incredulous when I saw that these amendments had been proposed because I thought that attempts would be made to strengthen further this Bill, which suffers from a deficit of democracy and accountability, and all that will emanate from it. Amendment No. 11 in my name seeks to extend the executive's remit to the Oireachtas and its joint committees. The amendments before the House, however, propose to delete references in section 7(4)(c) to the “Dáil Committee on Health and Children”. All Members acknowledge that the system that was in place since 1977 was flawed, but at least it contained a semblance of democratic accountability. Many elected public representatives actively participated in the system over many years because they had a role on the health boards, but they will no longer be able to do so. Those who suggest that the consultative health forums are providing anything other than powerless talking shops are codding themselves. Nobody else is fooled by it.

It is essential that every measure necessary is taken to widen access to, and accountability for, the delivery of health care. The Joint Committee on Health and Children is central to that work. If we are to achieve the confidence of the wider public, including the service users of the State health care system, we have to demonstrate a clear commitment to democratic accountability. Amendments Nos. 8 and 9, which seek to delete references to the "Dáil Committee on Health and Children", will contribute to a further erosion of confidence in the system that will be introduced in the new year. The amendments are detrimental to the type of health care delivery to which people aspire. I appeal to the Tánaiste to withdraw her two amendments, in the spirit of better accountability to the House and within the House, to ensure that there is some degree of public confidence in what is being promised.

Dr. Cowley

I am disappointed by amendments Nos. 8 and 9 because I had great hopes that good amendments would be introduced to assuage the real fears of Deputies, who represent our constituents as part of the democratic process, and to address the democratic deficit that will develop under the proposed new system. All Deputies agree there is a need for reform. I hoped, on the basis of the Tánaiste's promises, that she would table some good amendments on Report Stage to try to take out of our misery Deputies who have great fears about what the Bill will do or will not do for public accountability. The Tánaiste has claimed that her amendments will address the democratic deficit, but I think they will do the opposite. I cannot see how they will make the system more accountable. I ask her to withdraw the amendments because they certainly do not address the problems I have mentioned.

Ms McManus

The manner in which the Bill is being processed is evidence of a deep contempt for the work of the Oireachtas. An amendment tabled by Deputy Twomey, which related to accountability to the Joint Committee on Health and Children, was accepted on Committee Stage, but it is now proposed to remove it from the legislation on Report Stage. The Tánaiste has argued that she has received legal advice suggesting that the two functions have to be kept separate. She has also said that the CEO will be required to attend meetings of the committee, on request. She has not referred, however, to her weaselling amendment No. 52, which we may not reach. It provides that the CEO will be able to delegate responsibility for attendance at a committee meeting. The amendment, which proposes to insert a new section 21(10), states:

With the permission of the chairperson of the Oireachtas Committee making the request under subsection (1), either—

(a) the chairperson of the Board, or

(b) an employee of the Executive nominated by the chief executive officer,

may attend before the Committee in place of the chief executive officer

It should be considered that the chairperson of the committee is 99% likely to be a Government appointee.

Mr. Gormley

Yes.

Ms McManus

He or she will come from the Government side of the House. The Tánaiste, who has said that she is committed to accountability, will make the executive less accountable if amendment No. 52 is accepted. Rather than the CEO appearing before the committee, some flunkey or functionary will be given the job of attending a meeting of the committee to give its members any old stuff to keep them befuddled. It is inevitable, when one considers the way in which these institutions typically evolve, that the person who will be given the job of looking after the Oireachtas committee will be asked to percolate as little information as possible to parliamentarians, who are seen as a nuisance. The CEO will be making decisions and doing whatever he or she has to do and wants to do without scrutiny. That is not accountability. The Tánaiste's contemptuous approach involves trying to fool the House into thinking that the amendments she is introducing will increase accountability. While some of the amendments will increase accountability, the balance of her amendments involve a shift in the opposite direction.

Ms Harney

I accepted certain amendments on Committee Stage in good faith, subject to legal advice. I, like every other member of the Government, am obliged to accept the advice of the legal adviser to the Government, who is the constitutional officer of the Government with responsibility for this area. I am doing so in this case because of the separation of powers.

The CEO, if summoned before an Oireachtas committee, is required to attend except where the provisions of section 52 apply. It was asked on Committee Stage what would happen if the CEO were not available. The CEO will be obliged to attend, not only once per year but as many times as the committee wishes him or her to do so. It is unfair to suggest that any old flunky can go in his or her stead.

Ms McManus

That is what it says.

Ms Harney

It does not say that.

Ms McManus

It does.

Ms Harney

It does not. It refers to a representative of the HSE, who must either be the chairperson of the board or an employee of the executive nominated by the CEO. The CEO will not nominate any old flunkey to come before an Oireachtas committee.

Ms McManus

How will we know? We do not even have a CEO.

Dr. Twomey

We do not know the members of the board.

Ms Harney

We do not have flunkeys working in the health service.

Ms McManus

We know neither the members of the board nor the CEO.

Ms Harney

We have problems in the health service but there is an extraordinary number of committed people.

I have made it clear that it is my intention to attend a meeting of the committee once per term. I intended to do so a few weeks ago but unfortunately I had a very bad flu.

Ms McManus

What about this morning?

Ms Harney

I outlined why it did not happen. It is my intention to attend a meeting of the Oireachtas Committee on Health and Children at least once per term and I will not hesitate to honour that commitment.

Mr. Gormley

I thank the Minister.

Ms Harney

Deputy Gormley should realise it is a joke to suggest there was accountability in the health boards.

Mr. Gormley

The Minister should be addressing Deputy Ó Caoláin.

Caoimhghín Ó Caoláin

We had democratic representation on the health boards, which was very important.

Acting Chairman

Is amendment No. 8 agreed?

Caoimhghín Ó Caoláin

One should not dismiss the input, over many years, of elected representatives in the health boards.

Ms Harney

Power was taken off them.

Caoimhghín Ó Caoláin

Many of them played a very important and excellent role.

Ms Harney

I agree.

Amendment put and declared carried.

Ms Harney

I move amendment No. 9:

In page 12, line 41, to delete "or Dáil Committee on Health and Children".

Amendment put and declared carried.

Acting Chairman

Amendments Nos. 10, 15, 64, 74, 92 and 100 are related and may be discussed together.

Caoimhghín Ó Caoláin

I move amendment No. 10:

In page 13, line 5, after "provide'" to insert "and the need to co-operate and co-ordinate with such bodies,".

Subsection (5)(a) of section 7 reads:

(5) In performing its functions, the Executive shall have regard to—

(a) services provided by voluntary and other bodies that are similar or ancillary to the services the Executive is authorised to provide,

Amendment No. 10 seeks to insert "the need to co-operate and co-ordinate with such bodies" after "provide" at the end of the subsection. That is an eminently sensible approach to the work of the executive. Co-operation and co-ordination with voluntary and other bodies will be essential to the effective, efficient delivery of health services.

I referred in the discussion on amendment No. 2, to the work of bodies external to the main authorities in the current health care delivery system. It is very important that we recognise the value of the input of the voluntary and community sector in the health services, which input will obviously perpetuate itself in the future. The sector should be regarded as an integral part of the overall health system and should be valued therefor. It should not only be respected but should also be regarded as an equal partner in the areas in which it operates.

On the basis of my family's knowledge and experience over the years and because I have a brother with Down's syndrome, I can attest without hesitation to the value of the voluntary and community sector. Throughout our growing years, it was the voluntary sector that covered the need for my brother's care on so many occasions. That reliance on the sector in terms of respite continues. That is the reality for many families throughout the State. If we were to have depended only on the services provided by the State and successive Governments, we would have noted that there would have been no supports at all. I pay tribute to the voluntary and community sector and note all the areas that it has addressed and continues to address. Its input is essential and it represents an integral part of the overall health and personal social services area.

I agree with the Disability Federation of Ireland that this Bill does not live up to the commitment in the White Paper on the relationships between the State and the community and voluntary sector. One must recognise that the White Paper promised more than mere consultation. It committed the Government to the participation and active involvement of the sector in both decision making and policy formulation processes. We must afford due recognition to the sector and not leave this to a whim. We cannot proceed with a health Bill that completely ignores the input and valued contribution of the voluntary and community sector over decades. It is not enough to say the executive "shall have regard to" the sector. Big deal. When one considers all the families that have depended on the services provided by these bodies and organisations and the real hope and support they have given over the years, one will realise that having regard for them is not good enough.

It is essential that the executive and all those who sail on her in the years ahead know exactly what this House requires of them and that it is not left to their whim and discretion to recognise the voluntary sector. It should be clearly stated in legislation that there is a need to "co-operate and co-ordinate with such bodies". The expertise of such bodies and their undoubted commitment in their particular areas of address require more than regard. They should be embraced fully and be understood to be such within the health services. It is essential that amendment No. 10 be considered in that spirit.

Let me speak to amendment No. 15, in both my name and that of Deputy Twomey. I know the Deputy will have further words thereon. I understand the Disability Federation of Ireland presented us with the wording of the amendment. It states:

In page 13, between lines 26 and 27, to insert the following:

"(9) In the performance of its functions the Executive shall co-operate and co-ordinate with the voluntary sector where it is involved in activities similar or ancillary to the remit of the Executive.".

This amendment is giving further expression to the arguments I have presented on amendment No. 10 and is therefore grouped with other amendments that reflect a similar spirit. If the amendment is accepted — I urge the Minister to accept it — this Bill will acknowledge the key role and valuable contribution of the community and voluntary sector and recognise it as an equal health partner. That is the spirit in which we should go forward. The role of the community and voluntary sector must be enshrined in this legislation and amendments Nos. 10 and 15 are designed to accommodate that.

Statutory recognition, which we hope to achieve, for the community and voluntary health and personal social services sector will greatly strengthen the Health Service Executive and will be seen to have done so. This is a sizeable and formidable sector that commands great respect and regard throughout the State. It is imperative that the wording of the Bill reflect that and not in an aspirational tone on the lines of "must have regard for". We must enshrine it in the legislation, give it due regard and recognition and show the community and voluntary sector that it, and the State, are going forward in partnership to ensure the best quality of health and personal social services delivery that people can expect and enjoy. I commend amendments Nos. 10 and 15 to the Minister and support the other associated amendments in this grouping.

Dr. Twomey

The six amendments I and Deputy Ó Caoláin moved were discussed on Committee Stage. We acknowledged during that debate with the Minister that not all voluntary and community groups provide services as outlined in the legislation. Advocating on behalf of the patients they represent is just as important. The Minister could argue that five of these amendments do not fit in with the legislation but we hoped that she might take on board the spirit of these amendments when she was reformulating the legislation to bring it back to the House on Report Stage.

It is regrettable that no concession has been made, considering the great work done by the groups to which the amendments refer. Deputy Ó Caoláin referred to the Disability Federation of Ireland which helped us formulate one of the amendments but many other groups are represented here and some will not have the opportunity to make representations to Members before the legislation goes through. The Minister said on Committee Stage that she would examine ways to give some clear indication of how this legislation might recognise these organisations.

All too often, as we have seen over the past seven years in Dáil Éireann, many disability and voluntary groups were ignored and underfunded. For the first time ever in a budget, the disability sector received significant funding, not as much as it expected but it is a significant amount. Maybe in the spirit of the Government's change of attitude it should have done something to which it could point. Maybe there is and we have misunderstood the Minister. Unfortunately, we did not have enough time to read through the legislation to see if the amendments had been taken on board to any degree and if there was anything we could show these groups to indicate that the Government takes their concerns seriously and is listening to them in a more than patronising way.

Perhaps the Minister can indicate whether she will summarily dismiss the amendments or if she has taken some changes on board.

Ms Lynch

I support Deputies Ó Caoláin and Twomey. These amendments go to the heart of accountability. This year's budget is the first I have seen that did anything close to what should have been done in past years for the disability sector, but most services for people with disability are provided through a voluntary sector. In order to get the best possible value from it there should be co-ordination and co-operation because the sector cannot be separated and isolated. If these people vanished in the morning the health boards would have to do the job anyway. Surely under this legislation it is necessary to have nationally based co-ordination and co-operation.

The amendments are very sensible. Not alone do they bring voluntary organisations or service providers into the mainstream but they ensure accountability which the disability organisations want, in other words, a sum of money is not simply thrown at particular groups which have no service plan or end goal. The Minister should look seriously at this to see what can be done to bring these people under the umbrella of the health service.

Dr. Cowley

I support these amendments because as one who comes from the community and voluntary sector it is obvious there is no way the State could do the work of that sector. Many people, of whom carers are only one example, work and do not count the cost but do it out of love or whatever. In any service there must be co-ordination and co-operation. If this is not for the people who is it for? It is to serve the person. The health strategy puts the patient at the centre of the equation. The voluntary and co-operative sector represents the patient. If it does not have a meaningful input into the HSE I fear for the executive. These are very rational amendments which should be accepted.

Ms Harney

We had a good discussion on these matters on Committee Stage. I am a great fan of the voluntary and independent sector. I believe in a minimalist role for the State in all our lives, including health care. All but two of the hospitals in this city are voluntary, private, independent organisations. The voluntary sector has an important role in the delivery of health services. The Bill imposes several requirements on the Health Service Executive. It must have regard to what the voluntary and independent sector does. Under section 7(1), object and functions, it must ensure that it uses its resources in the "most beneficial, effective and efficient manner to improve, promote and protect the health and welfare of the public" and in section 7(5)(e) it must “secure the most beneficial, effective and efficient use of those resources”. It must have regard to things done by ancillary, voluntary or independent groups but it must also ensure that it uses its resources efficiently and effectively and achieves the best possible arrangement.

Reference was made to the disability sector and Members welcomed what happened in this budget. In the 1996-97 budget €1 million was given to the disability sector. We have come a very long way since the middle of the 1990s on disability and a host of other voluntary sectors, including education, health care and the welfare system generally, and that trend will continue. There is no question of the HSE not engaging with service plan arrangements, including contracting the voluntary independent sector to provide services. That is how things will be. However, we clearly cannot place them in a legal straitjacket. They must co-ordinate and co-operate with that group, but they need not do so with other professional groups. We must mandate them to do it in an efficient and effective manner. Not every voluntary or independent group or every private operator provides efficiency and effectiveness, and that may not be the most beneficial way of providing resources. Many of the private sector facilities emerging are independent, not-for-profit organisations. Simply because someone decides to provide a service, we cannot oblige the HSE to require it if there is a better, more efficient and effective way of doing it.

The voluntary sector in health care is very large and will continue to be so, whether in delivering hospital services or regarding issues such as meals on wheels or care of the elderly. Whatever it might be, the situation will continue as at present. Nothing changes as a result of this legislation. On the contrary, the powers are enhanced because the executive must have regard based on efficiency, effectiveness and what is beneficial from a resource point of view. Everyone wants the best possible services provided for patients and service users, whether in the voluntary, State or private independent sector. We must take whatever is best for patients and users and provide services accordingly.

Unfortunately, I cannot accept the amendment tabled. Section 39 of the legislation provides for a situation where the HSE continues to fund a wide range of voluntary bodies that currently provide services or new organisations that may emerge and will provide services.

Caoimhghín Ó Caoláin

The Minister must accept that there is scant acknowledgement and only limited recognition of the role of the voluntary and community sector in the legislation as presented. Given the specific and, in most cases, heroic contribution that sector makes to the health and personal social service needs of communities, the legislation falls far short of what is required. No one is arguing that it has a definitive role in determining policy but we are arguing for its right to an input into policy formulation. Consultation is very important, with co-operation on the subsequent outworkings and delivery of that policy and there must be co-ordination or the whole thing will not work. I, therefore, see nothing in amendments Nos. 10 or 15 that runs contrary to the protective position the Minister seems to be taking regarding the executive.

The legislation, to all intents and purposes, limits the community and voluntary sector to service provision. In any area in which it is referred to, it is seen as something on which one may depend, a crutch to save the State accepting responsibility, as Deputy Lynch said. If it were not there, the onus would surely fall on the Minister's shoulders and those of her Cabinet colleagues. However, it exists and is doing trojan work. It has earned the respect and regard of the entire population. There is no family untouched by the wonderful work of people in the voluntary and community sector in health and personal social services provision, and we all have our own experience of that. Over all those years of committed service, it has earned the right — I emphasise the right — to have a role and input in policy formulation. It should not be at the whim of the executive simply to "have regard to" it, the language used here.

I know that there are time constraints on my second contribution and I appeal to the Minister to examine the wording, which in no way locks the executive, the Minister or her colleagues into an untenable policy position on the health services — far from it. It affords the Minister the opportunity properly to appraise all initiatives and proposals, and the people to do so are those at the coalface of delivering those services. They are the experts in a great deal of what we depend on as a people today. I have no hesitation in saying that I appeal to the Minister emotionally to consider this. I have great respect and regard for those who have given a lifetime of service in this area and whose expertise and warmth in their respective fields and disciplines is truly remarkable and deserving of all our praise. I once again commend the amendments to the Minister.

Dr. Twomey

We are focusing on voluntary and community groups. We have mentioned the disability sector several times in the course of the debate and it is an interesting one on which to concentrate. We seek some legislative role for the voluntary sector that the Government might recognise. The Minister can point out how much money was put into the disability sector eight or nine years ago. However, it had to wait seven years for the present Government to put significant funding into it.

During the Budget Statement, the Minister for Finance, Deputy Cowen, said that the disability sector had been neglected for so long because of persistent lobbying by the primary care and acute hospital sector in recent years. That is insulting both to the families and the disability groups who have been working extremely hard for the past seven years to convince the Government that their situation was dire and that they needed the extra funding that took seven years to come their way.

That is why those groups are pushing for some role in legislation. Otherwise they will always be at the whim of a Government watching the way the wind is blowing and how it is seen by the electorate before it can make a decision on who gets funding in what sector. In some respects, when this legislation goes through, even the role of the Minister for Health and Children might be in doubt, perhaps being little more than that of a Minister of State at the Department of Finance. It is important that we take on board the issues we have discussed and give them legislative effect. Otherwise, in another five or six years, depending on who is in government, those groups might find themselves back out in the cold again.

Ms Lynch

It appears from reading the entire Bill and all the amendments that the Health Service Executive will be very much removed from anyone's control apart from that of the Minister, whoever that may be, as Deputy Twomey said. On the other hand, the Health Service Executive will be hands-off, having no role regarding a very large sector providing services. In many ways it is protected on both sides. It has no accountability before elected members and it has no responsibility towards a sector that is doing a great deal of work. I am not certain this Bill is about the provision of health services for the citizen as much as about protecting the executive from any type of intrusion. The Minister should seriously examine these and other similar amendments when we reach them. If the executive is about providing essential health services, it must be not only be accountable but held responsible. These amendments are part and parcel of ensuring that.

Dr. Cowley

We hear a great deal of talk about partnership and there are the social partners and so on. These amendments present an opportunity to work in partnership with people who provide health services on a day-to-day basis. The Minister is aware of the problem that arose in the past when groups did not get the support they deserved. These amendments present an opportunity for the executive to act in an inclusive way by working in partnership with these people. It is all fine and well to have regard for a person, but one can have such regard and then go one's own way. We have regard to many people, but that can be all it amounts to. In the spirit of partnership, it is logical that there should be a proper partnership arrangement and these amendments present an opportunity for the executive to operate in partnership with the voluntary and the community sector.

Ms Harney

There is no point in trying to convince me about this because I am a huge fan of the voluntary, independent sector. Many of the causes of the more marginalised in our society would not have been taken up if it were not for voluntary bodies over the years, many of which involved members of different religious communities. There is no doubt about that. I referred to the fact that of all the hospitals in this city, of which there are many, all but two of them are voluntary hospitals. That is the reality of the health environment and that will not change. The disability sector is one such group in the voluntary sector and there are many more.

The Health Service Executive is required, when providing services, legally to have regard to anything that is done by the voluntary sector or the independent sector. Provision is made in section 39 for grant aiding those voluntary bodies. From the debate emerging one would imagine we planned to privatise the health service. Deputy Lynch referred to the executive being an independent body and not accountable to anybody. Deputy Twomey seems to think that the Minister responsible for it will be a Minister of State attached to the Department of Finance. I will not go into the arguments about that as I am aware Members have strong views on this.

For the past 30 years we have had the worst case scenario. We have had, effectively, 11 health boards with 11 chief executive officers with responsibility in their functional area for the delivery of health care. However, overall accountability for this area rests with the Secretary General of the Department of Health and Children. It did not rest, as some would suggest, with the local representatives who were members of the health boards. That is not a clear line of responsibility and does not deliver clarity or accountability.

In terms of the provision of a uniform service throughout the country, many Deputies often complain that in one health board area one can get X by way of a service while in another health board area the service is somewhat different. In a country with a population of four million, I am not certain that level of service is satisfactory. A unified system with clear lines of accountability to the Oireachtas, which is the ultimate accountability in our democracy, is the preferred situation.

The executive will have to provide services on the most efficient, effective and beneficial basis bearing in mind available resources and so on. That is a strong mandate not only to the voluntary sector but to all those private operators or whoever with whom the executive will engage for the provision of services to patients.

Unfortunately, I am not in a position to accept this amendment. Government policy is strong on consultation with the voluntary sector. The concept of social partnership, which is fundamental to our system of Government, involves the social partners, which includes the voluntary sector, one of the pillars in the social partnership process. It involves that sector in consultation on a range of issues other than pay-related issues. Whether it is development in education or health care, the consultative forum we have in place on many of the changes under way in the health care system involves all the stakeholders, including many of the representatives of the voluntary sector and many of the professional bodies, employee organisations and so on.

Equally, in regard to advisory panels and other aspects of the legislation, section 43 requires the executive to provide for the participation of voluntary groups and advisory panels. If any deficiencies emerge when this body is up and running, there are many ways, including by way of ministerial direction or regulation, by which we can require the executive to do particular things. However, when we are setting up a new unified management administrative system for the delivery of health care to our population of four million, we must make sure we have strong powers from an accountability perspective, in respect of which I disagree with some of what was said earlier.

Equally, we must have flexibility to deal with new situations as they arise and not put too many mandatory requirements on a body that must administer in a system that is changing every year. Complexity in health care, in terms of the technology and the availability of new products in the pharmaceutical and medical devices area, is changing health care rapidly in terms of the procedures available to patients and many other actions that can be taken. We are moving, I hope, towards a situation where more technology will be used in the development of health care. With all those changes, we want to ensure that we have a strong, regulatory framework in the form of the executive, but equally that it has the flexibility to engage with bodies to provide services on its behalf for patients in the best possible, most efficient and beneficial way that can be done.

Caoimhghín Ó Caoláin

I suppose the Tánaiste was speaking tongue in cheek when she said that for a moment she thought we were of the view that she was going to privatise the health service. That is probably the view some us have. Is it not the case that a spokesperson for her party, as recently as in the past fortnight, indicated that she will address some of the deficiencies in the overall health service configuration in terms of the delivery of health services through further privatisation measures? That statement was made by a Progressive Democrats spokesperson, of which I am sure the Tánaiste is aware.

Ms Harney

The Deputy is confusing private sector operators with privatisation. They are different things.

Caoimhghín Ó Caoláin

I am not confusing anything. I am saying what I understand to be the case. That is the Tánaiste's broad disposition.

Ms Harney

Does the Deputy know anyone who would buy a service that requires €11 billion a year of taxpayers' money?

Caoimhghín Ó Caoláin

Yes I do, the people. We own it; we do not have to buy it.

Ms Harney

Does the Deputy know anyone who would buy it?

Caoimhghín Ó Caoláin

We do not have to buy it. It is not like the telephone system. We own it.

Ms Harney

The Deputy is confusing different things.

Ms Lynch

We are buying it, as such.

Caoimhghín Ó Caoláin

Yes. At the end of the day, it is ours.

Ms Harney

Does the Deputy know of any private operator who would buy it and run it?

Caoimhghín Ó Caoláin

We should protect it and be proud of it. We do not always have to look to see if there is a buyer and who is offering the biggest buck.

Ms Harney

The Deputy does not understand the difference between private initiatives and privatisation.

Caoimhghín Ó Caoláin

I can be open to ideas that will find a mean position to secure the best return for people, but I have a fundamental different view from that of the Tánaiste on addressing of such matters. On that, we will have to disagree and accept that we will not bridge that gap today or any other day I can think of.

I want to reiterate briefly that this is one of the most important elements of the Bill and is no less important than the democratic accountability deficit which we addressed and will address further in the next set of amendments. In terms of the Tánaiste's response where she will make it mandatory on the executive to do A, B and C, we are not seeking to lock it into unworkable positions. We are making it a requirement of the executive to co-operate and to co-ordinate. This executive could not succeed if it did not get the co-operation and co-ordination of the voluntary and community sector in the first place. It is a two-way street. We cannot say to people, to the organisations and religious bodies, to whom the Minister has referred, that we want their co-operation but that we, in turn, are not prepared to give them any substantive role in the development of policy. That is critical because they have the expertise and can make the greatest input. We are denying ourselves because, despite the Minister's assurance that this Bill mandates that it must have regard to the need for co-operation with other public authorities, the executive will in practice fail to have due regard to that need, and certainly not in the spirit of co-operation and co-ordination with the voluntary and community sector which is such an integral factor in the delivery of health and personal and social services in this State. This is a major deficiency and the Government's failure to address it leaves me no choice but to challenge on this amendment.

Amendment put.

The Dáil divided: Tá, 47; Níl, 66

Tá

• Allen, Bernard.
• Boyle, Dan.
• Breen, James.
• Broughan, Thomas P.
• Bruton, Richard.
• Burton, Joan.
• Connolly, Paudge.
• Costello, Joe.
• Cowley, Jerry.
• Deasy, John.
• Deenihan, Jimmy.
• Durkan, Bernard J.
• English, Damien.
• Enright, Olwyn.
• Ferris, Martin.
• Gogarty, Paul.
• Gormley, John.
• Gregory, Tony.
• Hayes, Tom.
• Healy, Seamus.
• Howlin, Brendan.
• Kehoe, Paul.
• Lynch, Kathleen.
• McGinley, Dinny.
• McGrath, Finian.
• McGrath, Paul.
• McHugh, Paddy.
• Mitchell, Olivia.
• Morgan, Arthur.
• Murphy, Gerard.
• Neville, Dan.
• Ó Caoláin, Caoimhghín.
• Ó Snodaigh, Aengus.
• O’Dowd, Fergus.
• O’Shea, Brian.
• O’Sullivan, Jan.
• Pattison, Seamus.
• Penrose, Willie.
• Quinn, Ruairí.
• Ring, Michael.
• Ryan, Eamon.
• Sargent, Trevor.
• Sherlock, Joe.
• Stanton, David.
• Twomey, Liam.
• Upton, Mary.
• Wall, Jack.

Níl

• Ahern, Dermot.
• Ahern, Michael.
• Ahern, Noel.
• Andrews, Barry.
• Ardagh, Seán.
• Brady, Johnny.
• Brady, Martin.
• Brennan, Seamus.
• Browne, John.
• Callanan, Joe.
• Carey, Pat.
• Carty, John.
• Cassidy, Donie.
• Cowen, Brian.
• Cregan, John.
• Curran, John.
• de Valera, Síle.
• Dempsey, Tony.
• Dennehy, John.
• Devins, Jimmy.
• Ellis, John.
• Finneran, Michael.
• Fitzpatrick, Dermot.
• Fleming, Seán.
• Fox, Mildred.
• Glennon, Jim.
• Grealish, Noel.
• Harney, Mary.
• Haughey, Seán.
• Hoctor, Máire.
• Jacob, Joe.
• Keaveney, Cecilia.
• Kelleher, Billy.
• Kelly, Peter.
• Killeen, Tony.
• Kirk, Seamus.
• Kitt, Tom.
• Lenihan, Brian.
• McDowell, Michael.
• McEllistrim, Thomas.
• McGuinness, John.
• Moloney, John.
• Moynihan, Donal.
• Moynihan, Michael.
• Mulcahy, Michael.
• Ó Cuív, Éamon.
• Ó Fearghaíl, Seán.
• O’Connor, Charlie.
• O’Dea, Willie.
• O’Donnell, Liz.
• O’Donovan, Denis.
• O’Flynn, Noel.
• O’Keeffe, Batt.
• O’Keeffe, Ned.
• O’Malley, Fiona.
• Parlon, Tom.
• Power, Peter.
• Power, Seán.
• Roche, Dick.
• Smith, Brendan.
• Smith, Michael.
• Wallace, Dan.
• Wallace, Mary.
• Walsh, Joe.
• Wilkinson, Ollie.
• Woods, Michael.

Tellers: Tá, Deputies Ó Snodaigh and Kehoe; Níl, Deputies Kitt and Kelleher.

Amendment declared lost.

An Ceann Comhairle

Amendments Nos. 11, 14, 18, 46, 48, 49, 52 and 130 are related and may be taken together, by agreement. Is that agreed? Agreed.

Caoimhghín Ó Caoláin

I move amendment No. 11:

In page 13, line 11, after "Government" to insert "or resolutions or reports adopted by the Oireachtas or by any of its Joint Committees".

The amendment seeks that section 7(5)(c) would read: “the policies and objectives of the Government or any Minister of the Government or resolutions or reports adopted by the Oireachtas or by any of its Joint Committees to the extent that those policies and objectives may affect or relate to the functions of the Executive”. It is important that it is not only Government which would have a direct input in determining the overall shape of health and personal social services policy development and implementation. It is imperative the Oireachtas and all its elected Members have the opportunity to have this input, which is what the amendment seeks to achieve in the context of the Houses of Oireachtas and the joint committees.

In this instance, I am running contrary to amendments Nos. 8 and 9 which the Tánaiste earlier mooted in regard to the deletion of the phrase "or Dáil Committee on Health and Children". My amendment would require the Executive to take account not only of Government policies but also of the views of the Oireachtas as a whole, which includes its committees. This is imperative.

With regard to some earlier amendments, it was stated there is a democratic deficit in the Bill. The Tánaiste stated that the role of elected representatives on the health boards was deficient at best. While I agree, they at least had access and opportunity and in many cases played an important role in the defence of health services on boards throughout the State. For all its faults, that role for the elected representative is now gone and the consultative health forums are no more than powerless talking shops. Therefore, there is nothing to compensate for the loss, deficient though the system was, nor does anything in the legislation allow for a direct input by the democratically accountable elected representatives in the State and, importantly, the Members of the Houses of the Oireachtas and its respective committees.

It is, therefore, essential that democratic accountability is provided for as far as possible and the role of Oireachtas Members should be written into the Bill, not just the role of the members of the Government of the day. The Bill states: "the policies and objectives of the Government" but allows no recognised role or input to the wider make-up of the Houses. As matters stand, invariably, if not in all cases, the Government position will be reflected because of its in-built majority. However, by adding the words "or resolutions or reports adopted by the Oireachtas or by any of its Joint Committees", we are at least affording all Members an opportunity to have an input and, I hope, to play a constructive role in debating and determining the shape of health and personal social services policy into the future. I commend amendment No. 11 and the associated amendments Nos. 14, 18, 46, 48, 49, 52 and 130. I hope the Minister will accept amendment No. 11.

Dr. Twomey

These amendments relate to accountability in respect of Members of the Oireachtas. There is a number of reasons we would like to know about matters. To go back to the previous amendment on disability groups, they will expect 1,000 front-line staff to be employed next year, as announced in the budget. These amendments are the only way we have of finding out whether the Government is fulfilling the commitments it made in the budget last week. The Minister discussed the State's role in health services provision and said she would like to see the State removed as much as possible from it. Unfortunately, that will not happen as quickly as she might think. We would still like information on what the State does in the provision of health services.

The Minister's own baby is the national treatment purchase fund. It has been a very good service for the 17,000 people who have benefited from it. However, I am not aware if a cost benefit analysis has been done on it to see how competitive it is. For a number of years, the waiting list initiative was run concurrently by the health boards. I do not know if a comparison was made between the two initiatives.

When Deputies, journalists and others try to get information on the health services to make comparisons, to get figures to see if the health services are being run efficiently and if value is being achieved for the €11 billion of taxpayers' money and to do a cost benefit analysis on Ministers' pet projects, we need to get full information and we should not be fobbed off with answers telling us to speak to the chief executive officer of the Health Service Executive.

We should keep a copy of the amendments we have tried to make today because in two or three years time many of the Government backbenchers who have not taken too much heed of the debate today might be the very ones looking for such amendments if they are no longer in Government. That is the reason we take this issue so seriously. This reduces the accountability of Members of the Houses of the Oireachtas to the people they represent. There is a large number of issues about which I could talk, including whether this money is being spent efficiently on behalf of taxpayers and whether people are getting the service they expect.

This morning the Minister acknowledged there was a difficulty in regard to medical card patients paying charges in nursing homes. It will be interesting to see if anyone with a medical card paying charges to a nursing home will be reimbursed under the legislation. The Ombudsman published a report on this issue two years ago. When this type of information comes into the public domain, it makes us all more accountable to the people who elected us. We should watch out that we do not try to reduce that accountability too much.

Amendment No. 130 states that confidential information has the same meaning as in section 26(3). The next part states "a dealing" in relation to any Member of either House of the Oireachtas means any dealing with any Member in his or her capacity as a Member. What does that tie into? It looks as if it fell out of space and landed in that spot. I do not understand how that improves my accountability to my constituents in regard to the health services if I am looking for information. Perhaps the Minister might explain that. When she spoke about it on Committee Stage, she spoke of a paramilitary sector in the HSE.

Ms Harney

Parliamentary, not paramilitary.

Dr. Twomey

Hopefully, although there might be both.

Ms Harney

I did not expect that from the Deputy.

Dr. Twomey

The Minister might explain that a bit more. It does not go as far as the Minister seemed to indicate when she discussed it on Committee Stage. We were not too happy about what the Minister said on Committee Stage but this is even less enlightening and I am sure other Members might have more questions on it when she explains it.

Dr. Cowley

I wish to refer to my amendment No. 18 which provides for cognisance to be taken of any recommendations made by the Joint Oireachtas Committee on Health and Children and amendment No. 48 which states "shall come before the Joint Oireachtas Committee on Health and Children to discuss any matters raised by the committee on a quarterly basis at the very least, on days to be arranged with the committee". The Health Service Executive should have some way of communicating with the people and the Joint Oireachtas Committee on Health and Children is one way to do that since its members are elected and have a special interest in health.

Amendment No. 48 proposes that the chief executive officer appear before the committee on a quarterly basis, which is not too much to ask. On Committee Stage, the Minister said that if the committee is asleep, it will never call the chief executive officer. It is a question of the committee deciding to do just that. As I said on Committee Stage, the non-appearance of Ministers for Health and Children at the committee was very educational. I know the Minister is full of good intentions, and they say the road to hell is paved with good intentions. We all have good intentions but unless there is an obligation, it is hard to do everything one intends to do. The Tánaiste is a very busy person but as Minister for Health and Children, she is three times as busy and she has much to do. We know that because already the Minister has been unable to attend the committee, which I understand. The same happened with the previous Minister, Deputy Martin. There must be a requirement to attend. There must be a certain standard. I do not believe that minimum standard is in place to allow any semblance of democracy.

It is obvious this has gone full circle. On my first day in the Dáil, I called for the abolition of the health boards. However, we have thrown out the baby with the bath water and it is time to bring back the baby and have some semblance of democracy. These amendments go some way towards that. The Minister is taking all this upon herself. Responsibility for the whole health service radiates up to the Minister for Health and Children through the chief executive who is in the very precarious position of getting his head chopped off by the Minister and the Government. However, that is the chief executive's problem and I believe Professor Halligan did not accept the job because he did not want to get his head chopped off.

Mr. F. McGrath

He got a better offer.

Dr. Cowley

The Minister would be doing herself a favour if she accepted these amendments because she would be sharing the responsibility and she would be fulfilling that democratic need in a more meaningful way if the chief executive officer was allowed to appear before the Oireachtas Joint Committee on Health and Children four times per year at a minimum.

We have gone full circle from over representation. I agree with the Minister that there were big problems and that is the reason I was anxious that order be put on the situation. There were 11 health boards each competing with each other and with 11 different software systems or, in some cases, none at all. There was no co-ordination.

We will have great difficulty getting the chief executive officer to appear before the Oireachtas Joint Committee on Health and Children. According to section 21, when the chief executive officer appears before the committee, he must give an account of the general administration of the executive but we must be able to raise matters which are relevant and pertinent and which mean something to the people we represent.

The Tánaiste said she would return with amendments concerning the issue of accountability with regard to the Oireachtas committee and the parliamentary affairs division of the Health Service Executive. She stated: "I hope members of the committee will be happy when they see them." I am not happy with the amendments, however. I had hoped that she would have done better than this. She should at least accept these amendments. I said this morning that I was disappointed and I was hoping against hope that some of the amendments would be accepted. Let us face it, health boards are being abolished and the chief executive officers will no longer be answerable to them. Elected Members, such as ourselves, are here because of our interest in health matters and a desire to represent our constituents. The Bill would get ten out of ten for accountability and an A-grade for auditing but it fails when it comes to representing people, which is what it should be about. I have to give the legislation a failure mark in that respect.

We are talking about giving elected representatives an opportunity to have a real input into the health system. I agree there is absolutely no co-ordination between the Department of Health and Children and the health boards. We have seen so many bad policies and regrettable decisions. For example, we ended up having a BreastCheck service for half the country, which was decided upon in 2000. It will be 2007 or 2008, however, before the service is extended to the other half of the country, even though radio advertisements for BreastCheck are being broadcast all the time. It drives everybody bonkers in the west when they hear the advertisements advising women to avail of the BreastCheck service.

Ms Lynch

In the south too.

Dr. Cowley

Yes, indeed, in the south as well.

Mr. F. McGrath

Up Cork.

Dr. Cowley

There has been a total lack of co-ordination in the decision-making process. While the Bill envisages major reform, it has thrown the baby out with the bath water. It is time, therefore, to recover the baby. I ask the Tánaiste to re-examine these amendments.

Mr. Neville

I support the amendments and reiterate my concern about the legislation's lack of accountability. While views have been expressed about over-accountability in the old system, it provided public representatives with an opportunity to present cases and raise issues at health board level. In that way they could publicly obtain a response from the executive. That possibility has now been removed. In fairness to the Tánaiste, she said on Committee Stage that she was concerned about this matter. She also said that the issue of accountability through representation would be addressed by the new executive. While we can take her remarks at face value, I would like to hear how this will operate in practice.

I envisage a situation in future where we will be refused information from the Health Service Executive that will feel it is all-powerful and that its work is not accountable to individual politicians, parties or even the Dáil. The executive will only be accountable according to the provisions of the Bill. We need to be in a position to quote the views of the Minister as regards people's aspirations and representations being heard at every level, including local level. Once accessibility, including the freedom to express views, concerns and complaints, is removed, public confidence in the health service will diminish. Regardless of the difficulties involved, including waiting lists and accident and emergency problems, there is a connection between the public and the health service in hospitals and community care centres. Will that connection be removed over time by failure to respond to public concerns about health services? If so, it would be a serious development because the Health Service Executive would be seen as inert, unconcerned and unresponsive to public needs. We must have a health system in which people's humblest concerns can be expressed and responded to.

Some people may say that waiting five hours on a trolley is of no concern because others have to wait for 20 or 30 hours. For a person whose survival is at stake, however, that five-hour period would be of extreme concern to them and their family. We should be in a position to express such concerns on behalf of patients but will the new system allow for that? To be fair, there is a certain level of response at present, depending on the attitude of the chief executive, deputy chief executive or hospital manager concerned. I accept there is a lack of consistency in such responses but at least people's names are known and information can be obtained immediately.

People need to know what is happening in the health service and understanding attitudes are required. If someone is waiting on a trolley in distress for five hours and his or her family is concerned, the hospital may have another side to the story. When the hospital's viewpoint is expressed to a patient and his or her family, while it does not remove the health problem, it provides them with a better understanding of the difficulties experienced within the hospital. This will now be removed as a result of this legislation. On Committee Stage, the Tánaiste said it would not be removed, but I see no evidence of that.

Currently, if I make inquiries concerning the future development of national primary or secondary roads in my constituency, I receive only vague information. We are told the Government has a policy on this, that or the other, but my constituents want to know when something is happening. I cannot obtain the relevant details, however, because the National Roads Authority takes its policy from the Minister and the rest of us can wait. I rarely contact the NRA because there is no point in doing so. Prior to the establishment of the NRA, councillors could obtain such information from their local authority. In 99% of cases the county manager or the executive responsible would be only too happy to communicate as much information as possible. We seem to be going in the opposite direction with this Bill. The Tánaiste has heard these concerns but it is only right to reiterate them on Report Stage.

What is the position regarding the availability of Ministers and the Health Service Executive to appear before the Joint Committee on Health and Children? Last March, the committee sought a meeting with the Minister for Health and Children. We were supposed to see him before the summer recess and again in October, but did not. In the meantime, a new Minister was appointed and we were supposed to see her this morning but we could not do so. The Minister said she had to take the Health Bill in the House, which is fair enough, but she has a team of advisers. While we have no advisers, I was prepared to be at the meeting with Deputies Twomey, Cowley and McManus. At this rate, we will probably meet the Minister on the anniversary of our request for a meeting, which is only two months away.

I want to know how concerns and complaints about administrative issues will be dealt with under the terms of the Bill. I asked a question on Committee Stage about raising concerns regarding clinical decisions, but such a process is not envisaged in the legislation. If a patient is concerned about a clinician or a clinical decision, it cannot be raised under the provisions of the legislation.

The Minister is familiar with a report that I obtained and discussed in the House, in which an independent body expressed significant concerns about clinical decisions in regard to a patient in a psychiatric unit. The patient's family had already expressed serious concerns, which were borne out by the report. One issue highlighted in the report was the failure of a clinician to read a report indicating that the patient was suicidal and in need of constant care. The report also heavily criticised the situation whereby the admitting psychiatrist, who was responsible for making decisions about the treatment of this adult patient, had only three months' experience in child psychiatry. The report also observed that the nursing staff in the hospital failed to read the patient's notes on admittance. These are only some of the issues highlighted in the report. There were ten in total and I could point to 100 more because of my contacts in this area.

Can these types of issues be raised by a concerned family in a similar situation under the provisions of this Bill? Unfortunately, we will probably not have time to discuss the relevant provisions today. It is inadequate for the Minister to say that there is a professional body, such as the Medical Council, to which patients can address their concerns. A distressed person, such as one who has lost a family member through suicide, cannot be asked to go through a complicated and remote procedure to access a body representing the medical profession. An ordinary person with a grievance wants to communicate his or her difficulty to a local public representative, community advice centre, GP or some other local person whom they trust and who can access the relevant information. In most such cases, I can obtain a response from the relevant director of services, deputy chief executive officer, hospital manager or another relevant authority. The response is generally immediate or may take two or three weeks if an issue must be investigated.

This system provides some level of satisfactory explanation. However, it seems that inquiries regarding the decisions of clinicians cannot be made under the new complaints system in which the Tánaiste has expressed such confidence and which she compared on Committee Stage to the service given by the Department of Social and Family Affairs. Such a system does offer a level of service and we will be pleased if all queries and concerns regarding the operation of hospitals, community care and all other health service provisions within our area can be addressed. However, if members of the public see that their local Deputies or other significant persons have no role in communicating their concerns and obtaining speedy and detailed responses, a situation will develop whereby people will lose confidence and understanding and become frustrated with the health service. They will conclude that it is pointless to complain and that they must suffer in silence. It is in such circumstances that grievances fester.

Mr. F. McGrath

I support Deputy Ó Caoláin's amendment No. 11 and Deputy Cowley's amendment No. 18. If one takes an objective view of the amendments that are put forward, and can conclude that they give some teeth and balance to the Bill, it is essential to support them.

I support reform and change in the health service and the urgent need for investment. As I said last week in the House, I support the overall ethos of the Bill and voted accordingly. In this context, I urge the Tánaiste to open her mind to constructive ideas in this matter. We all learn from the different angles and views expressed in the House. The views of Oireachtas Members are essential because we are elected by the people. There is great respect in this House for democratic values and any Minister for Health and Children and any Government must respect that.

There is great experience in the House in the area of health and disability. There are Deputies who are GPs, health care workers or the parents of children with disabilities. All Members are citizens who have had some experience of the health service and have constructive and positive ideas to put forward. The Dáil represents a great cross-section of society. The Tánaiste should listen to the views expressed in the tabling of amendments. The Government listened in regard to the disability issue, as evidenced in the budget with its provision for a major investment in respite and day care services for persons with intellectual disabilities. I commend and thank those directly involved in the brave decision to take action in this area rather than choosing a popular issue or spreading the money elsewhere. These types of decisions are important. However, I would like to see the role of the Oireachtas written into the legislation as provided for in amendment No. 11. Such a provision will serve to strengthen the Bill.

We need a system of effective measurement. In addition, it is important to have quality management procedures in place in the health system, which are effective in delivering services to patients. That is the bottom line in this debate. We can talk about legislation and amendments but the bottom line must be the welfare of patients. I commend all those who are doing an excellent job in the health services and urge the Tánaiste to work with them in implementing the major reform and radical changes envisaged in this Bill.

I have welcomed the plans for vital investment in respite and day care services for persons with disabilities. However, if some €900 million is to be spent on both services and infrastructure projects, it is important that this allocation is monitored. We must look at the area of the management and utilisation of resources. Funding must not be wasted and must be seen to be delivering services effectively. It is unacceptable that adults with intellectual disabilities, such as people in their 40s and 50s with Down's syndrome whose parents are in their 80s, should be on residential waiting lists. I am glad we are waking up to the reality and that this situation will end soon.

It is vital that we have an effective system for monitoring and measuring the expenditure of resources in the health service. A strong input from Oireachtas Members is essential. In this context, I strongly support amendments Nos. 11 and 18. Deputy Cowley, who has tabled the latter amendment, is an Independent Member with a significant interest in the health area. He also has direct experience of this issue. Deputy Cowley should be commended for his work in the Dáil in the past two and a half years on issues such as this. Amendment No. 18 should be considered seriously. I welcome and support amendments Nos. 11 and 18.

Ms Harney

I share many of the concerns expressed by Deputies on the issue of accountability and so on. That is why I have sought to bring forward amendments on foot of the debate on Committee Stage. Unfortunately, we have not reached those amendments yet.

Deputy Twomey raised queries on amendment No. 130, which is to insert the new section 79. He asked what the term "dealing in relation to a Member of either House of the Oireachtas" means. It means that a Member of the Oireachtas cannot inquire about anyone in his or her constituency. Members may make representations on behalf of people who have asked them, as elected public representatives, to do so. Being a Member of the Oireachtas does not entitle us to all information. Queries which relate to individuals must be made in a representative capacity. Regulations will clarify this matter further and provide for the issue of breaches of confidentiality. Confidentiality may not be an issue where a constituent asks a Member to represent him or her.

The executive will be responsible for the delivery of health care to a large number of people. It will not be exclusively responsible. There will be other agencies. Reference has been made to the national treatment purchase fund, under which almost 22,000 patients have been treated since its establishment.

Mr. Neville

No psychiatric patients have been treated.

Ms Harney

That is true. If there are waiting list issues I would like to hear about them from the Deputy.

In its initial phase, the national treatment purchase fund has dealt with surgical procedures. The budget for the fund has been increased by 50% for next year. I am looking forward to having discussions in the next two weeks with the chairperson and chief executive of the national treatment purchase fund regarding how those additional resources should be used. Many patients and others have raised the question of long out-patient waiting lists in some specialties. We need to examine ways of extending the remit of the fund, without taking away the focus of why it was established in the first place.

Dr. Cowley

Children have been waiting years for treatment.

Ms Harney

The waiting time is six months, not years.

Dr. Cowley

It is six months once a patient is on the list, but patients wait years to get on the list.

An Ceann Comhairle

Deputy Cowley, you will have an opportunity to make a contribution.

Ms Harney

I will make announcements shortly regarding waiting lists and so on. The position is very unsatisfactory in relation to that matter.

The national treatment purchase fund was established by Government, almost as a universal insurer, to deal with the longest waiters, some of whom had been waiting years for essential treatment. Generally, it is working well although some issues need to be resolved. Most people would acknowledge that.

The Health Service Executive cannot be required to take policy direction from an Oireachtas committee. The Minister and the Department will remain responsible for policy under the new system. The HSE will be responsible for the delivery and implementation of policy and for management and administrative arrangements. Its relationship to the Department will be very much like that between the national health service and the Department of Health in the United Kingdom. The Minister is accountable for policy. Of course, Ministers take into account the views of Oireachtas committees across a range of areas, not only in health care, and that will remain the position. However, an administrative management body cannot be accountable to the Oireachtas for how and where it spends its money, to the Minister with regard to its overall responsibility and to an Oireachtas committee for policy. That would not be in the interest of the agency, the Oireachtas or anyone else. I want to have a clear focus on what is the role of the HSE. The Minister of the day can give it directions and seek policy advice from it because it will have an enormous resource of expertise. However, policy will remain a function of the Department of Health and Children, not of an agency of this kind, which will be an administrative management system for the health services.

Deputy McGrath spoke about people suffering from disabilities and their parents, children, brothers and sisters. Many Deputies have that experience in our families. Many people bring to this process not only legislative or official advice but their personal experience. Very often, such personal experience can affect appropriate change more than can official responses. We should all be flexible in these matters.

The complaints procedure was referred to by Deputy Neville. It will apply to anything which does not involve a clinical judgment. The examples cited by Deputy Neville relate to administrative issues. When someone does not read something, that is an administrative error. Such matters would be the subject of the complaints procedure. An inspector will deal with the area of psychiatric illness. I understand that complaints can be brought to the attention of the inspector. I see Deputy Neville is nodding. I acknowledge that he has more expertise in this area than I do. With the exception of clinical judgment, which is and must remain the responsibility of the clinician, other matters which fall under the remit of the Ombudsman for Children or the general Ombudsman can be complained about. I hope they will be corrected in a local environment to the satisfaction of the vast majority of complainants.

In its annual report, the executive will be required to give details of the nature of all complaints so that we will have an idea of the kind of complaints being made and how complainants have been satisfied. In this way we will ensure that whatever has been brought to light will not happen again or that the circumstances in which it happened will be minimised. Unfortunately, I am not in a position to accept these amendments.

Deputy Twomey's amendments would mean the HSE could not engage in any project without consulting or informing the Joint Committee on Health and Children. That would place an unnecessary burden on the executive. Accountability provisions are provided for in many of the amendments I have brought forward and further accountability issues will be dealt with by way of regulations. This is a more satisfactory way to deal with some of the detail we discussed on Committee Stage.

Caoimhghín Ó Caoláin

Amendment No. 11 deals with the same subsection as the previous set of amendments and amendment No. 10, and relates to the voluntary and community sector. Regrettably, the Minister rejected those amendments. In this instance, I am trying to ensure that the executive takes full cognisance of the views of the Houses of the Oireachtas and their joint committees. Not only is that a very reasonable pursuit but a laudable one.

The section states that in performing its functions the executive shall have regard to the policies and objectives of the Government or any Minister of the Government. My amendment seeks to add the words "or resolutions or reports adopted by the Oireachtas or by any of its joint committees" which would be relevant to the work of the executive. Given the configuration of the House and the make-up of its committees, once adopted it is most likely that this proposal would have the imprimatur of Government in any event. However, the amendment would allow for cases in these Houses and their committees where resolutions and reports are adopted in which we all have the opportunity to participate. Government, on the other hand, operates outside this House and at a different level. The amendment would ensure that the democratically elected and accountable representatives of our people would have an input and that the executive would have regard to that input. I will conclude with this point. I believe that——

An Ceann Comhairle

I would prefer the Deputy to conclude after two minutes. If Deputies take more time than they are entitled to, not everybody will be able to contribute.

Caoimhghín Ó Caoláin

I ask the Tánaiste to give due regard to this request.

Mr. Neville

I thank the Tánaiste for her reply. Obviously, the interpretation of "clinical" is key. This term has been interpreted differently based on contacts I have had with health boards. While in certain circumstances a clinical decision has been seen as one of the clinician, the Tánaiste has now interpreted this as not being so. It is the decision of the clinician to identify the condition the person has and the treatment that should be carried out in those circumstances. If I am interpreting the Tánaiste correctly perhaps as much 80% of the clinician's work might be of an administrative nature. I give an example that I come across all too regularly. Families are often extremely concerned about a suicidal relative in a psychiatric hospital who is to be discharged and often make complaints. Is the discharge of such a patient a clinical or an administrative decision?

Dr. Cowley

The Tánaiste spoke about waiting lists. The national treatment purchase scheme was a very good idea. However, some would say it was a vote of no confidence in the system that rather than investing in the system we would arrange for people to go to a private facility or abroad to have a procedure carried out. It fails to address the 100,000 people waiting to get on to a list.

Section 10 states:

10.—(1) The Minister may issue general written directions to the Executive—

(a) for any purpose relating to this Act or any other enactment, and

(b) concerning any matter or thing referred to in this Act as specified or to be specified, or as determined or to be determined, by the Minister.

Amendment No 18 seeks to insert the following:

"(c) any recommendations made by the Joint Oireachtas Committee on Health and Children.”

If the Tánaiste cannot issue a directive after a meeting between the Oireachtas Joint Committee on Health and Children and the chief executive of the new board, what is the point of having such a committee? I have been a member of the Oireachtas Joint Committee on Health and Children for the past two years and we have received deputations from many parties talking about some very important issues, including post-polio, rheumatology and helicopter emergency medical services.

Mr. Neville

Orthodontics.

Dr. Cowley

If the Tánaiste cannot even write a general direction after deliberations by the chief executive of this new body, I am very worried about the executive.

Ms Harney

While I could envisage a committee taking a decision on a matter, it does not necessarily mean that the Minister of the day will adopt it as policy. Under our system policy is decided by the Government. It must clearly be endorsed if not voted on by this House. Clearly if the House has no confidence in the policy it will no longer remain as the policy. That is quite separate from requiring a Minister to take a direction on foot of a recommendation from a committee. It is generally the case that when dealing with a matter related to a constituency or a region, Deputies of every hue, including Government Deputies, will have a particular view. When the number of Members of the House is factored in, no decisions could be taken. It is the duty of Government to make choices, subject to it having the confidence of this House. I am not in a position to accept Deputy Cowley's amendment.

In response to Deputy Neville's question, the Ombudsman has interpreted very widely issues concerning clinical judgment. Obviously it excludes what we would all broadly or normally regard as clinical judgment, the doctor's judgment of what is required. The administration surrounding that is clearly a separate issue and would fall under the remit of the complaints procedure in the legislation. I am advised that the discharge policy of psychiatric patients is the specific remit of the inspector of mental health services. If somebody wants to make a complaint about a psychiatrist who determines that a patient is fit to go home, that complaint should be dealt with by the competent authority, which is the inspector of mental health services. It is not possible to have an administrative complaints procedure to deal with such issues.

Caoimhghín Ó Caoláin

The Tánaiste's response and her defence of rejecting the amendments do not stand up to scrutiny. She referred to the possibility that an Oireachtas committee, for example the Oireachtas Joint Committee on Health and Children, might pass a resolution or adopt a report, which could run contrary to Government policy. We are not making it mandatory on the executive. We are trying to enshrine in the legislation that the executive should have regard to recommendations by the Oireachtas Joint Committee on Health and Children, which is not requesting too much. It is a very sane and sensible proposition. The executive should, of course, have regard to any resolution or reports adopted by the Oireachtas Joint Committee on Health and Children and any report or resolution adopted by the Houses of the Oireachtas, just as Government should have regard to these matters. I reject the Tánaiste's rejection of the arguments for this worthwhile amendment, which will result in a deficient wording in the Bill.

Amendment put and declared lost.

An Ceann Comhairle

Amendments Nos. 12, 16, 17, 19, 31 and 53 are related and may be discussed together by agreement.

Caoimhghín Ó Caoláin

I move amendment No 12:

In page 13, between lines 17 and 18, to insert the following:

"(f) the need for openness, accountability and transparency in the performance of its functions and, to that end, shall, when requested, provide all information necessary to the Minister to enable him or her to furnish a complete reply to a Parliamentary Question.”.

I will not speak at length on this amendment. It is essential that the executive be required to assist in every way in the answering of parliamentary questions. There is real concern across a whole range of opinion in this Hose that the establishment of this executive will lead to a further erosion of democratic accountability. These views are also held on the Government side of the House. While they will not say so inside the House, they have said so outside the House. Ultimately the Tánaiste is the Minister responsible for all matters pertaining to health and children. It is important, therefore, that we ensure it is clearly understood that the Minister's accountability to this House is reflected in the wording of the legislation. The Minister of the day must be answerable to the Dáil for health policy and the overarching management and delivery of health services and personal social services. Many times I have watched in great frustration the Minister's predecessors wash their hands when matters have come before them in the House. They said it was a matter for the health board or for this, that or the other. Will we now get the response that it is a matter for the executive? There will be no democratic accountability and our role in here will be absolutely undermined and frustrated in the key areas of health and children. If that is the case, it is outrageous.

The only way we can ensure there is parliamentary accountability is to insert this amendment into the legislation so it is patently clear to the executive that it has a responsibility to ensure that all parliamentary questions placed by Members of this House to the Minister are answered fully with all relevant detail. That is essential, otherwise the executive will become another quango, as have so many other offspring of the political system, with ministerial appointees but with no accountability to elected representatives here or people outside.

I hope the Tánaiste will recognise the importance of this amendment that guarantees accountability and that when we place parliamentary questions we have not only the right to expect full disclosure but that it is clearly understood by the executive that we get proper, detailed, informed replies. Otherwise, our role as representatives of our communities and constituencies will be undermined.

Dr. Twomey

The guillotining of this Bill is disgraceful. There are 151 amendments. Part 9 of the legislation dealing with patient complaints will not be reached because the amendments relating to it start at No. 100 and we will only deal with 30 amendments.

Some of the amendments relate to accountability to the Oireachtas Committee on Health and Children. This is a flawed approach because the committees have a Government majority and they can block or railroad change of it suits the Government. I experienced this in June in the Committee on Finance and the Public Service, when Government Deputies called a vote and blocked a discussion on our having a two week discussion of decentralisation a month after the local elections. We have also seen changes being railroaded. One of the first things I saw happen on the Committee on Finance and the Public Service was amendment of the Freedom of Information Act to reduce the accountability of the Government.

These amendments, however, are different. They deal with parliamentary questions and how they are answered by the CEO and the board of the Health Service Executive, local authorities, statutory bodies and anyone who has a connection with the executive. To have these taken on board is important. The last time we discussed these amendments the Minister said regulations would follow but we have no idea what those regulations will be even though we will vote on this Bill in 15 minutes. The Minister should have taken these amendments on board and refused to guillotine this legislation because there is so much important debate still to take place. We have no idea what regulations the Minister will bring forward. I will only be able to discuss ten of my 50 amendments. Other Members will be equally disgusted that having done such hard work on preparing their amendments and having facilitated the Tánaiste on Committee Stage by calling no votes, she has come back on Report Stage without recognising our good faith and delivering legislation we could all support. We cannot support it because we still do not know what is happening.

Ms Lynch

A new amendment from the Minister for Health and Children was given to me at 4 p.m., 15 minutes ago. It is only a technical amendment but that is typical of what has happened with this legislation. Deputy Twomey is right, there was a great deal of goodwill towards the Bill and its handling because the Tánaiste was new in the post. Goodwill was extended and it is unfortunate the Tánaiste has not extended the same degree of courtesy to the Opposition.

Most of us who have local experience of health boards are dismayed that the sections dealing with them are further on in the Bill. The health services will not be accountable at local level. No matter what anyone thinks of politicians, we are elected by the people and the voice of the people is the voice of God in a democracy. We are chosen to question but we have no mechanism for extracting the information necessary to ensure accountability. If there is nothing to hide why will the Tánaiste not accept the amendment? That concerns me.

Why is this Bill being amended so extensively, even by the Government? The list of amendments is frightening. The Bill was rushed and technicalities such as the use of "he", "she", "are", "may" and "shall" must be amended. The Minister should withdraw this Bill and take six months to consider her plans.

We must be careful about welcoming the treatment purchase scheme. I agree with Deputy Cowley, it is an excellent scheme to address extensive waiting lists in particular specialities, but it is not the way the health service should go. We should build our own health service. It is an indictment that we must send people abroad to avail of services that other countries have put in place for their citizens. This may be the way the Tánaiste intends to privatise the entire service, by sending everyone abroad.

If this Bill is not hiding anything, we should debate it fully. We are talking about issues of accountability.

Mr. F. McGrath

I support amendment No. 12 because it is positive and constructive and adds to the Bill. There are Members on the other side who want this amendment. I spend a good deal of time speaking with backbenchers and they are supportive of this amendment. Sadly, I cannot see them supporting it because of the Whip's position.

The overall thrust of the amendment is about reform, change and improving services. I emphasise the issue of reform and accountability. It is essential when dealing with the issue of services that there is strong accountability. Given that some €30 million has been spent on reports in recent years I accept it is time to move on and allow the Minister get on with the job and deliver the services. At the same time our patients and citizens are demanding change and efficiency in the services. It is not acceptable, under any circumstance, that there are still patients on trolleys. This issue should be resolved by January or February because what we are talking about is the provision of approximately 300 beds. I urge the Minister to move rapidly. Everybody was open and flexible at the beginning of her term of office but it is time to move on and start delivering. I set a target date of January-February for the delivery of those beds for the frontline services and particularly the accident and emergency services.

Has the Minister looked at examples of good practice in accident and emergency services in other countries? Countries such as Sweden have experience in the area of medial community care. For example, Cuba has an excellent medical service despite being a poor country and has much to offer and has many new ideas. We should not be afraid to look at constructive ideas from around the world because of certain political baggage.

Amendment No. 12 deals with the question of openness, accountability and transparency which is an important part of the issue. I mentioned earlier the whole question of services for people with disabilities. I welcome John Dolan from the Disability Federation of Ireland who is in the Visitors Gallery.

Amendment No. 15 is relevant given that it deals with the voluntary and community sector. I avail of this opportunity to commend the disability groups which worked hard before the budget, lobbying Deputies and Ministers and which organised an effective campaign. I commend and thank them for their work because they had a major influence on Government policy. It is important to commend such groups as well as parents' groups as people were prepared to listen to them. Many of their ideas are coming to fruition.

While amendment No. 12 may be about old-fashioned public service, a civil servant or a public servant working in the interests of the national good and the common good, sadly it is missing in today's society. I urge support for the amendment.

Mr. Sherlock

I am a former member of the Southern Health Board. As the Tánaiste and officials will be aware the function of that board was to provide a service plan. When that plan was provided and submitted to the Department, the officials approved it and the amount spent in that health board was what was contained in the service plan. Where is the service plan now? Will 11 people sitting in their posh offices in Dublin know what is going on in any part of Cork or Kerry? They will not. There is no representation. The Minister speaks about local committees. The health advisory committees were abolished in the mid-1990s although they were effective. As Deputy Lynch has said the Bill should be withdrawn as it is bad legislation.

Mr. Gormley

This legislation is disgraceful. The promises made to introduce greater accountability on Report Stage have not been delivered on. I simply do not see them. If anything the Bill will encourage a culture of secrecy in the health service. I expect, a Cheann Comhairle, to receive many letters from you ruling questions out of order when I will be told the question does not apply but is a matter for the Health Service Executive. If we are lucky the chief executive officer will come before a Dáil committee, or some minion or other. I know the Tánaiste does not like these people to be referred to in those terms but I wanted and had tabled amendments, to make it mandatory for the chief executive officer to come before the Joint Committee on Health and Children on at least two occasions annually. It is not mandatory but is at the discretion of Dáil committees which, unfortunately, are controlled for the most part by the Government. We do not have the transparency that is required or the accountability but an erosion of democracy.

We are told the patient will benefit. The patient cannot benefit from that type of secrecy and lack of accountability. We will see if it delivers on the accident and emergency crisis, the bed shortages and the real crisis at the heart of the health system.

In regard to this legislation the Minister intends to say she did her best and she can hide behind the Health Service Executive when services are not delivered. The problems at the heart of the health service go back to some basic issues. One can speak about organisation and the health boards have been much maligned and criticised, but even Niamh Brennan did not ask for their abolition. There was some form of democratic representation but that pillar is gone.

I regret the honeymoon is over. This is retrograde legislation. It is a sad day for democracy and this House. In years to come people will ask what the Government was thinking about when it rushed this Bill through. It is clear the Tánaiste wished to rush it through and to guillotine it because she does not believe in the same democratic values in which we on side believe.

Dr. Cowley

It is regrettable we will not have an opportunity to debate the amendments that others and I have tabled relating to the complaints procedure and disclosure which would be in the interests of patient care. I am disappointed given that we had been promised so much. When we ask a question we are told it is a matter for the health board. The Tánaiste assured us there will be openness and transparency since she will be answering those questions. Like other Members, I am afraid that when we ask questions the response will be similar to those concerning the NRA, when we are told issues are not the responsibility of the Minister but of the NRA and that the Minister cannot interfere. I sincerely hope that will not be the case. In reply to the same question on Committee Stage, the Tánaiste said the Ceann Comhairle would rule on whether a question was in order. I hope the Ceann Comhairle will ensure that we can get all our questions answered.

Mr. Gormley

We will rely on the Ceann Comhairle.

Dr. Cowley

We are operating on a wing and a prayer at this stage. I am sorry that a guillotine is being imposed and that democracy has been thrown out the door.

An Ceann Comhairle

As it is now 4.30 p.m., I am required to put the following question in accordance with an order of the Dáil of this day: "That the amendments set down by the Tánaiste and Minister for Health and Children and not disposed of are hereby made to the Bill, Fourth Stage is hereby completed and the Bill is hereby passed."

Question put.

The Dáil divided: Tá, 68; Níl, 50.

Tá

• Ahern, Michael.
• Ahern, Noel.
• Andrews, Barry.
• Ardagh, Seán.
• Brady, Johnny.
• Brady, Martin.
• Brennan, Séamus.
• Browne, John.
• Callanan, Joe.
• Carey, Pat.
• Carty, John.
• Cassidy, Donie.
• Cowen, Brian.
• Cregan, John.
• Curran, John.
• de Valera, Síle.
• Dempsey, Noel.
• Dempsey, Tony.
• Dennehy, John.
• Devins, Jimmy.
• Ellis, John.
• Finneran, Michael.
• Fitzpatrick, Dermot.
• Fleming, Seán.
• Glennon, Jim.
• Grealish, Noel.
• Harney, Mary.
• Haughey, Seán.
• Hoctor, Máire.
• Jacob, Joe.
• Keaveney, Cecilia.
• Kelleher, Billy.
• Kelly, Peter.
• Killeen, Tony.
• Kirk, Séamus.
• Kitt, Tom.
• Lenihan, Brian.
• McDowell, Michael.
• McEllistrim, Thomas.
• McGrath, Finian.
• McGuinness, John.
• Martin, Micheál.
• Moloney, John.
• Moynihan, Donal.
• Moynihan, Michael.
• Mulcahy, Michael.
• Ó Cuív, Éamon.
• Ó Fearghaíl, Seán.
• O’Connor, Charlie.
• O’Dea, Willie.
• O’Donnell, Liz.
• O’Donovan, Denis.
• O’Flynn, Noel.
• O’Keeffe, Batt.
• O’Keeffe, Ned.
• O’Malley, Fiona.
• O’Malley, Tim.
• Parlon, Tom.
• Power, Peter.
• Power, Seán.
• Roche, Dick.
• Smith, Brendan.
• Smith, Michael.
• Wallace, Dan.
• Wallace, Mary.
• Walsh, Joe.
• Wilkinson, Ollie.
• Woods, Michael.

Níl

• Allen, Bernard.
• Boyle, Dan.
• Broughan, Thomas P.
• Burton, Joan.
• Connolly, Paudge.
• Costello, Joe.
• Cowley, Jerry.
• Crawford, Seymour.
• Crowe, Seán.
• Cuffe, Ciarán.
• Deenihan, Jimmy.
• Durkan, Bernard J.
• English, Damien.
• Enright, Olwyn.
• Ferris, Martin.
• Gilmore, Eamon.
• Gormley, John.
• Gregory, Tony.
• Healy, Séamus.
• Higgins, Joe.
• Higgins, Michael D.
• Hogan, Phil.
• Howlin, Brendan.
• Kehoe, Paul.
• Kenny, Enda.
• Lynch, Kathleen.
• McGrath, Paul.
• McHugh, Paddy.
• McManus, Liz.
• Mitchell, Olivia.
• Morgan, Arthur.
• Moynihan-Cronin, Breeda.
• Ó Caoláin, Caoimhghín.
• Ó Snodaigh, Aengus.
• O’Shea, Brian.
• O’Sullivan, Jan.
• Pattison, Séamus.
• Penrose, Willie.
• Quinn, Ruairí.
• Rabbitte, Pat.
• Ryan, Eamon.
• Ryan, Seán.
• Sargent, Trevor.
• Sherlock, Joe.
• Shortall, Róisín.
• Stagg, Emmet.
• Stanton, David.
• Twomey, Liam.
• Upton, Mary.
• Wall, Jack.

Tellers: Tá, Deputies Kitt and Kelleher; Níl, Deputies Kehoe and Stagg.

Question declared carried.