Health Bill 2006: Second Stage.

Minister for Health and Children (Ms Harney)

I move: "That the Bill be now read a Second Time."

Dáil Éireann has been recalled one week ahead of schedule to begin the Second Stage of this critical Health Bill. This is a mark of the importance Members of the House and the Government give to legislation to set and enforce high standards of health care, particularly in residential settings.

This Bill represents a crucial element of the reform programme and is a new departure for the health services. For the first time, we are creating a body whose purpose will be to set quality standards and monitor enforcement of standards in an open and transparent way. Step by step, in the reform programme and legislation, we are leaving behind the old system which for too long included inconsistent standards across health boards, opaque and incomplete standards and even no standards. It gave us inconsistency of enforcement, some legal incapacity for enforcement of residential care standards and gaps in the scope of enforcement in these settings. We are also leaving behind the old system in which vital information in health was not comprehensively gathered and assessment of new technologies and drugs was not clearly and systematically made to serve the interests of patients and taxpayers alike.

The Bill establishes the Health Information and Quality Authority, HIQA, incorporating the office of the chief inspector of social services. This was a commitment in the Government's health strategy, Quality and Fairness. I assure the House that the preparatory work has been carried out by the interim HIQA in order that it will be ready to use its powers as soon as the legislation is enacted.

A fully independent inspectorate for all nursing homes for older people, both public and private, and centres for people with disabilities and children will soon be in place. The Health Information and Quality Authority has very strong powers. It will set national standards and the chief inspector will inspect residential facilities against these standards. Where necessary, the Bill provides for action to be taken quickly to protect service users. This includes provisions for the urgent closure of centres. There will no longer be any issue about the legal capacity to urgently shut down a failing nursing home or residential care centre.

Registration and inspection requirements will apply equally to Health Service Executive residential centres, centres operated by agencies funded by the HSE and private nursing homes, guaranteeing that the public, voluntary and private sectors providing residential services are required to meet the same standards of care. The chief inspector will also be responsible for overseeing standards in foster care for children, pre-school services and what is called in law the "boarding out" of older people where they reside in someone's home.

The social services inspectorate, SSI, has been operating on an administrative basis since 1999, conducting inspections into children's residential services run by the HSE under the statutory powers contained in section 69 of the Child Care Act 1991. Even within the confines of the existing legislative framework the inspectorate has played a major role in developing and enforcing high standards in child welfare and protection services. Commitments to provide for the SSI's establishment on a statutory basis were given in the health strategy and restated in the current social partnership agreement, Towards 2016, as were commitments to extend the inspectorate's remit to residential services for older people and people with disabilities. These commitments are being met in the Bill by the establishment within the HIQA of the office of the chief inspector of social services with specific statutory functions. This office holder will take on the SSI's current inspection work and register and inspect residential services for people with disabilities and older people, including private nursing homes.

It is essential that mechanisms and structures to audit this quality and an independent system for continuous performance review to ensure consistently high standards are in place. Alongside this Bill, I confirm that I am establishing a commission on patient safety and quality assurance to examine and make recommendations on a system of licensing for all public and private providers of health care. This will include public, private and voluntary hospitals. It is the direction we must take to give patients the greatest possible assurances of safe and quality care.

In brief, the functions of the authority will be to set standards on safety and quality for all services provided by the HSE and service providers on behalf of the HSE, and private nursing homes, with the exception of mental health services which are covered by the Mental Health Commission and the Inspector of Mental Health; monitor compliance with the standards it sets and advise the Minister and the HSE on the level of compliance; undertake investigations as to the safety, quality and standards of services where the Minister believes there is serious risk to the health or welfare of a person receiving services; carry out reviews to ensure best outcomes and value for money for the resources available to the HSE; operate accreditation programmes of health and personal social services in both the private and public health sectors; carry out assessments of health technologies, including drugs and medical devices; evaluate information available on services provided by the HSE and other service providers and the health and welfare of the population; identify information deficiencies and advise the HSE and the Minister accordingly; set standards, including governance arrangements, for the HSE and service providers in relation to information and data in their possession on health and personal social services and the health and welfare of the population and advise the Minister and the HSE on the level of compliance with the standards.

HIQA will now have a central role in health information development and the implementation of the recommendations set out in the national health information strategy.

As I said, the Bill provides for the establishment of the office of the chief inspector of social services. The chief inspector will be an employee of HIQA with independent statutory functions. These are to inspect and register residential centres, both public and private, for older people, people with disabilities, and children and inspect special care units for children; oversee the performance of the HSE of its functions under sections 39, 41 and 53 of the Child Care Act 1991 in respect of standards in fostering and pre-school services, and section 10 of the Health (Nursing Homes) Act 1990 in respect of boarding out of elderly people; act as an authorised person for the purposes of section 185 of the Children Act 2001 as amended by the Criminal Justice Act 2006; and act as an authorised person for the purposes of section 185 of the Children Act 2001, as amended by the Criminal Justice Act 2006. This means the chief inspector will inspect, at least once every 12 months, each children detention school under the administration of the Irish youth justice service of the Department of Justice, Equality and Law Reform.

The Bill sets out inspection and registration requirements for residential centres. A rigorous and robust inspection system is being set in place. Centres will be inspected against standards set by HIQA and regulations made by the Minister. The chief inspector will have extensive powers in carrying out inspections and may enter a centre, examine any records, take copies of documents and inspect and remove other relevant items. The chief inspector can also interview staff in private and interview residents.

Residential centres may not operate unless they have been registered by the chief inspector and it will be an offence to operate without registration. A centre must be in compliance with conditions of its registration. Registration details will be available to the public on the Internet.

The chief inspector can cancel a registration if the residential centre fails to meet standards. An urgent cancellation of registration can be sought by the chief inspector from the District Court if the chief inspector believes there is a risk to the life, or a serious risk to the health or welfare, of people resident in a centre.

I will now deal with the details of the Bill. Part 1, sections 1 to 5 inclusive, contains standard provisions dealing with Short Title, interpretation, commencement, establishment day and expenses.

Part 2, sections 6 to 11 inclusive, makes provision for the establishment of the Health Information and Quality Authority, details its functions, which I have already outlined, and contains provisions required for its operation and other matters. In line with arrangements for other statutory agencies responsible for setting standards and monitoring compliance, section 9 provides that standards set by HIQA must be approved by the Minister. Section 10 provides that the standards will be admissible as evidence in court proceedings.

Section 11 allows the HIQA to require information from the HSE and service providers. It should also be noted that under the regulations the Minister will be able to set out the procedures to be adopted by the authority in setting standards. This is to ensure the appropriate statutory bodies are consulted before standards are drawn up.

Part 3, sections 12 to 19 inclusive, provides for the establishment of the HIQA board and related matters. The board will have 12 members.

Part 4, sections 20 to 24 inclusive, covers standard provisions dealing with the appointment of the chief executive officer.

Part 5, sections 25 to 27 inclusive, contains standard provisions dealing with the recruitment of employees and advisers.

Part 6, sections 28 to 38 inclusive, deals with the accountability and funding of the authority. Section 28 allows the Minister to give HIQA general directions so ministerial policy will be clear. HIQA is required to prepare a five-year corporate plan under section 29. Sections 30 and 31 provide for grants to HIQA and submissions of a business plan. Under section 31, HIQA must draw up a code of governance which it must submit for the Minister's approval. Section 33 is a standard provision regarding the authority's accounts. Section 35 provides that HIQA may accept gifts under certain conditions. Section 36 obliges the authority to submit an annual report to the Minister. Section 37 allows the authority to assist other bodies which are carrying out functions similar or ancillary to its own. Under section 38, HIQA may charge for any services it provides except those it provides for the Government, HSE or public service providers. This will enable it to be in a position to charge for advice on safety and quality which might be requested by private service providers.

Part 7, heads 39 to 44, deals with the office of the chief inspector of social services. Section 39 establishes the office and section 40 sets out the functions of the chief inspector. These are the inspection and registration functions I outlined earlier. Section 41 provides for the attendance of the chief inspector before an Oireachtas committee to give a general account of the activities of the office of the inspector.

Section 42 provides for the appointment of assistant inspectors. I should mention at this stage that section 70 allows HIQA, at the request of the chief inspector, to also appoint qualified persons to assist the chief inspector and inspectors in regard to inspections of residential centres. Section 46 deals with the corporate and business plans for the office of the chief inspector and their inclusion in HIQA's corporate and business plans.

The HSE carries out inspections of voluntary children's residential centres and private nursing homes. The legislation provides that these will become a statutory function of the chief inspector. Section 44 provides that the Minister may require the HSE to carry out these inspections on behalf of the chief inspector. This is intended as a temporary arrangement to facilitate the continued inspection of these facilities pending a transfer of staff and resources to the authority. Inspections must be carried out in the manner specified by the chief inspector and in accordance with standards set by HIQA and regulations made by the Minister.

Part 8, sections 45 to 67, deals with the registration of residential centres for older people, including private nursing homes, people with disabilities and children in need of care and protection. These centres are known as designated centres in the Bill. Under section 45, a person shall not carry on or manage a designated centre unless the centre is registered and the person is the registered provider. A person is prohibited from managing a designated centre if the centre is not registered. Any person applying for registration or renewal of registration is prohibited from giving misleading or false information under section 46. Sections 47 and 48 deal with requirements in regard to applications for registration and the details to be included by the chief inspector on the registers he or she maintains. The registration of a designated centre is for three years.

Section 49 provides for the granting or refusing of applications for registration. The chief inspector will grant the application if satisfied that the registered provider and any other person involved in the management of the centre is a fit person and the centre complies with standards set by HIQA and regulations made by the Minister. If the chief inspector is not satisfied on these counts, the application will be refused. The chief inspector may attach conditions to registration.

Under section 50, the chief inspector can cancel a registration or vary a condition of registration, or impose new conditions in certain circumstances. These circumstances are where the registered provider or other person involved in the management of the centre is convicted of particular offences or is not a fit person or where the centre is not meeting its regulatory requirements. Registered providers may apply to the chief inspector to vary a condition of registration under section 51.

Sections 52 and 53 provide for notification by the chief inspector of proposed decisions and the right to respond. The chief inspector must give notification of proposed decisions to refuse or cancel registration, vary or attach conditions of registration or impose new conditions. Time is allowed for the making of written representations.

Section 54 provides that when the decision is made by the chief inspector, the person is informed in writing of the decision. Section 55 sets out certain requirements and prohibitions in regard to designated centres. Section 56 provides for the right of appeal, on the part of a registered provider or applicant, to a decision by the chief inspector to the District Court. Appeals must be brought within 28 days after receipt of a written notice from the chief inspector.

The Bill provides for the urgent cancellation or varying of conditions of registration where the chief inspector believes there is a serious risk to the health or welfare of residents. Sections 57, 58 and 59 set out the procedures and arrangements in this regard. The chief inspector must apply to the District Court for an order in regard to the registration and this application may be ex parte and without notice to the registered provider. An ex parte interim order may be granted by the court if it considers it necessary or expedient to make the order immediately in the best interests of the residents. The chief inspector may apply to the court for a final determination. Notice of this application must be given to the person who was the registered provider at the time of the ex parte application. The Bill provides for appeals of District Court decisions to the Circuit Court under section 60. The chief inspector must notify the HSE immediately when registration is cancelled and the executive must make alternative arrangements for residents.

Sections 64 to 66, inclusive, are technical provisions dealing with matters related to the closure of designated centres and the appointment of persons by law to take charge of a centre. Section 67 sets out the transitional arrangements for existing designated centres to allow them to operate pending registration for a period of not more than three years.

Part 9 deals with investigations by HIQA, inspections by it for the purposes of monitoring compliance with standards set and inspections of designated centres by the chief inspector of social services. Section 68 allows HIQA to appoint persons known as "authorised persons" to monitor compliance with standards set and to carry out investigations where the Minister believes there is a serious risk to the health or welfare of a person receiving services.

Section 71 gives authorised persons right of entry to premises owned or controlled by the HSE or service provider. An authorised person may inspect and take copies of relevant documents and inspect any other relevant item and remove it from the premises. All information required by the authorised person must be given, even if the records are held away from the premises in question. Authorised persons may interview staff in private. They may also interview service users, current or former, with their consent. The chief inspector, in respect of inspections of designated centres, has precisely the same powers as authorised persons.

A warrant may be obtained from the District Court if an authorised person or, as the case may be, the chief inspector is prevented from entering a premises or believes there is a likelihood of being prevented from entering a premises. In these circumstances, an authorised person or the chief inspector may be accompanied by a member of the Garda Síochána. It will be an offence to refuse, obstruct or give false or misleading information to an authorised person or the chief inspector. Provision is also made for entry to a private residence if necessary. This requires the consent of the occupier or a warrant from the District Court.

Section 69 provides that the HSE may appoint persons to examine designated centres in certain circumstances.

Part 10, sections 76 and 77, provides for the offences under the Bill and the proceedings for summary prosecutions. A person guilty of a summary offence is liable to a fine of up to €5,000 or a term of imprisonment of up to 12 months or both. A person guilty of an indictable offence is liable to a fine of up to €70,000 or a term of imprisonment of up to two years or both. Part 11, sections 78 to 82, inclusive, contains the standard provisions for board members, employees and advisers on standards of integrity, codes of conduct and prohibition against unauthorised disclosure of information and the standard disqualifications from board membership and employment.

Part 12, sections 83 to 94, inclusive, provides for the dissolution of the Irish Health Services Accreditation Board and the interim Health Information and Quality Authority and the transfer of their employees to HIQA. Part 13, sections 95 to 99, inclusive, provides for the general power to make regulations and specific powers to make regulations regarding registration arrangements and standards in designated centres. Regulations may also be made on the procedures to be followed by HIQA in setting standards under section 7. Part 14, sections 100 and 101, provides for consequential amendments to other Acts and the revoking of orders.

Schedule 1 sets out the Acts repealed and the orders revoked and Schedule 2 sets out the amendments to other Acts.

In line with guidelines on regulatory impact assessment, a public consultation process on the legislative proposals was undertaken last year. Over 70 submissions were received and the proposals to establish HIQA and the Office of the Chief Inspector of Social Services were generally welcomed. There has also been extensive discussion with the interim HIQA board and the social services inspectorate in respect of the Bill. The key features of the Bill reflect the outcome of those consultations and I am confident the Bill has been improved and strengthened as a result.

Before finishing, I will outline the substance of an amendment that I propose to table on Committee Stage. I am deeply conscious of the public concern and fears expressed in this House regarding the level of protection provided for health service employees who raise the safety and welfare of patients. In line with a commitment that I gave last year, I will introduce specific provisions in the Health Bill regarding the protected disclosure of information. Those provisions will support the existing statutory frameworks governing health professionals and those in the recently published Medical Practitioners Bill 2007.

This Health Bill is a central plank of the Government's reform programme for the health service. The establishment of HIQA and the Office of the Chief Inspector of Social Services will bring about a safer health and social services system that entrenches quality at all levels and in all settings. We are all learning from the past and leaving the past behind. This Bill will put in place an essential part of the 21st century health service in Ireland.

I commend the Bill to the House and look forward to hearing Deputies' views.

Dr. Twomey

I will table some technical amendments to the Bill on Committee Stage. Fine Gael, however, does not support the legislation because it does not meet the standards set out in our policies. The Government could have gone much further in this legislation but has clearly failed to do so. According to the Government, this Health Bill covers patient protection. It does not put the patient at the centre of health services, however, so how could we possibly support it? It is supposed to protect patients but it could have gone much further. The Government is verging on negligence in protecting patients. People have lost trust in the organisation the Minister established, the HSE, and they are quickly losing trust in her personally because she is failing on the core issue of patient safety.

If this Bill becomes law, patients will not be the focus of attention. After all the recent disastrous failures in Ireland's health service, such as the scandal at Leas Cross, the MRSA crisis, deficiencies in hospital hygiene and people left waiting on trolleys in accident and emergency departments, patient protection should be our number one priority, but that is clearly not the case in this legislation. The Government's maxim is to see what one can get away with, and that is becoming fatal when applied to the health service. The Minister for Health and Children should have attended the House bearing in mind people such as Mr. P. J. Walsh, who was clearly failed by the health system. Frances Sheridan, a nine year old girl, lost her life because of its failures. Mr. Peter McKenna, who was badly abused at Leas Cross, was also clearly failed by that system and by the Minister.

Recently there was the case of "Rosie", who had a hospital procedure cancelled on more than one occasion and has now been condemned to die of cancer by the failures of the Irish health care system. The coroner's report into the death of Mr. Valentine Ryan stated that he died from MRSA contracted through accessing hospital services. There were discussions about Mr. Henry Pollard, a man now probably forgotten by most Ministers, whose post mortem ascertained severe burns sustained from a radiator while in the care of a nursing home in County Kilkenny. That is what is happening in the health care system, which the Minister for Health and Children should correct and which the legislation should have addressed.

At Leas Cross, the HSE allowed old people to live in neglect and danger. That is where this legislation originated, but the Minister for Health and Children has clearly not lived up to her brief. Every day in accident and emergency departments, people are left waiting in Third World conditions. The Minister was supposed to deal with that but she has clearly not done so.

When patients leave such departments for the wards, their lives are continually threatened by the Government's failure to deal with hygiene, MRSA, clostridium difficile and all the bugs found in our hospitals each week. Nothing in this legislation deals with the MRSA scourge. It is strange that, as it has grown more prevalent in our health care system, other European countries have addressed the issue, in some cases quite successfully, while all we get is the same old bluster and by-lines to the effect that the Minister for Health and Children is truly interested in patient safety, when that is not the case. That is where the legislation fails.

It is clear that the Government lacks knowledge and clarity regarding what it wishes to achieve through this legislation and how it wishes to advance health services. It is clear that health is not its priority and that its only concern is staying in government. The legislation bears all the signs of having been rushed. It was inspired by a desire to establish a Health Information and Quality Authority, an office of the chief inspector of social services and a registration system for residential services for children in need of care and protection, people with a disability and older people. These are noble sentiments that remain until we read that the Bill contains exclusions and inclusions. Nursing homes and children are protected in specific cases. This is typical of how the Government produces legislation. It focuses on what is prominent in the media rather than what is needed in the health service.

There was a crisis concerning children, especially refugee children, who were trafficked into this country and escaped the protection of the HSE. The Minister is well aware that children went missing from a child care facility in Dublin. We have no idea where they have gone or what happened. Such an institution is not covered by this legislation. The legislation covers nursing homes and other specific institutions that have made media headlines rather than those to whom protection should be offered.

The entire mental health population will remain stigmatised because the Government sees fit to protect mental health patients under a different body. The Mental Health Commission is very good and I wish to apply the principles of the commission to the entire health service. We should not continue to marginalise and stigmatise mental health patients as though they are different from other patients in the health service. The Minister is institutionalising this separation in this Bill and I will refer to the consequences of this later.

Last week a commission on patient safety was established by the Minister because of the blatant omissions in this Bill. I commend the Minister on replicating Fine Gael's points in the policy document on a patient safety authority, published before Christmas, in most of the proposals for the commission. This is another example of the Government's laziness. The Minister may not have the will to alter the health care service but why did she not go further than stealing Fine Gael policy and implement it, as is needed? There is a growing sense that "Micheálitis" is continuing in the Department of Health and Children. Deputy Martin was the epitome of this affliction. He always had to have another report from another commission. The current Minister is acting in the same way on this important matter.

I am disappointed that certain lobby groups that represent patients are supporting this Bill. I call on patient advocacy groups, struggling to survive on donations, to stand up to the HSE and make their voices heard. They should not accept second best, such as this substandard legislation, for patient care.

Fine Gael published three policies before Christmas in the areas of mental health, controlling the accident and emergency crisis and establishing a patient safety authority. The media ignored the latter on the basis that it was not worthy of headlines on newspaper front pages or television news. Debating a patient safety authority in the Dáil will not grab the headlines either but the destruction and mayhem caused by the lack of a patient safety authority is headline news. Examples include the number of patients on trolleys, MRSA spiralling out of control and the appalling treatment of elderly people in Leas Cross. The Irish health care system needs this independent patient safety authority as proposed by Fine Gael and Labour in a joint policy document.

The World Health Organisation, WHO, has set up a commission under Sir Liam Donaldson, the chief medical officer of the NHS. The commission mentioned that the Opposition in Ireland has proposed a patient safety authority. The WHO is aware that the Opposition knows what is important in the health care service. What does the Government do but set up another commission? The Government is the laughing stock of the world, not just this country, because the issue could have been dealt with.

A number of issues have been left out of this legislation and the Minister is trying to wriggle away from them by talking about bringing forward whistleblowers' legislation next. Why has this not been put forward now?

Ms Harney

I will bring it forward.

Dr. Twomey

It should be brought forward now so we can see and discuss it, rather than the Minister telling us what she will do.

Mr. Stanton

An afterthought.

Dr. Twomey

There is no point in bringing in such legislation as an afterthought. The complete Bill should have been brought forward now.

I will point out the seriousness of where the Government has failed patient safety across its duration. The Neary controversy hit the headlines in 1998, when Dr. Michael Neary was suspended from practice in Our Lady of Lourdes Hospital. The Government's health strategy from 2001, the contents of which were in the Progressive Democrats and Fianna Fáil manifesto for the last general election, promised to prioritise patient safety issues.

The Leas Cross issue was topical in the Minister's Department from the first day of her role as Minister for Health and Children. Both the Minister and I came into our respective positions around the same time, yet the Minister has not dealt with it. I put forward the proposal of a patient safety authority, which I believe is very comprehensive. I know the Minister is taking on board the ideas we are talking about, but she needs to go a step further and implement a patient safety authority.

The Minister does not have to be a physician to deal with this, she merely has to have a commitment to deal with patient safety issues. The Minister does not have to be an expert on every issue. I am not an expert on everything, although I do my best to understand everything. I know what I want for the Irish health care service. I wish to protect patients in a way that is not limited to setting up commissions that will report in two years. We wish to set up, with our colleagues in Labour, a patient safety authority that will work for patients and have a clear commitment to protect them. I will analyse the Medical Practitioners Bill in the same way and will not be swayed by the Minister's nonsense. I wish to see action that will work for people.

This Bill will establish two bodies, HIQA and the social services inspectorate. HIQA will basically be an amalgamation of the interim HIQA and the Irish Health Service Accreditation Board. This is substandard legislation not because of what HIQA will do, but because the standards being brought forward have not been stipulated, which are very important. HIQA aims to provide patient protection but there is no protection for whistleblowers as of now, which is an issue. The likelihood of removing corruption and cover-ups from within the HSE will remain very low.

Nobody in Government has shown enthusiasm for proper whistleblowers' legislation from the time Deputy Rabbitte introduced a related Bill to the House. When the Government hits trouble with the public it brings forward legislation such as this and argues it will act on the matter. We will watch the issue closely.

The Minister's party has been painted as one which will clean up politics and improve Government, but it has not fulfilled its agenda. The Minister should demonstrate some enthusiasm and get the whistleblowers' legislation out as quickly as possible. Two student midwives having a discussion in a solicitor's office highlighted what was happening in Our Lady of Lourdes Hospital, which led to the publication of the Neary inquiry. Judge Harding Clark's recommendations on the entire health service were poorly implemented by the Minister.

The Minister receives her information directly. Most of the information sought by the Opposition must come by other means. The Minister and I both know problems still exist regarding matters which came to the fore in 1998. I wish to hear the Minister speak on them when she discusses the Medical Practitioners Bill. If she does not raise these issues at that time I will. She knows the type of matters I mean.

Other issues also demonstrate why whistleblowing is important. PPARS squandered €150 million of taxpayers' money before it was exposed in this House by Fine Gael as a total sham system. The Government and the HSE were content to pour millions into it until it was exposed.

We also had the despicable sham announcement of the new radiotherapy plan by the Minister in July 2005 which was exposed through leaks in the media. The Minister is playing politics. I am more concerned about the backing she received from the board of the HSE when HSE management and the National Development Finance Agency were concerned about the plan. The board of the HSE stated the documents in question were all historical documents which clearly was not the case. This is how we must receive information at present.

An Ceann Comhairle

I ask the Minister to withdraw the word "lie".

Ms Harney

I did not state the Deputy is lying. I stated the information he gave is not correct.

Dr. Twomey

Perhaps the Minister's advisers are afraid to tell her the truth.

We also had a situation whereby a HSE official asked doctors to stop writing letters to senior HSE managers so a paper trail would not exist. This was why the situation in Leas Cross was exposed and why we need patient safety authorities. We need such authorities because of the way the board of the HSE and ministerial advisers act and the way Fianna Fáil, because it has been in power for so long, uses the civil and public services as though it were an extension of the political party. Patient safety authorities are also needed because of the attitude of HSE officials that if letters are not written a problem will not exist.

This is the ethos we wish to change. We want the health service to work for people. The Health Information and Quality Authority, HIQA, makes no provision for patient advocacy. This means if patients want to complain about the HSE, health professionals or hold Ministers to account they run into brick walls. We must have an advocacy role within our health services because it is extremely difficult to follow the complexity of the bureaucratic system and we must help patients through it. We will change how the system works when patients can complain properly and give information to those who can change policy in a way which is understandable.

For these reasons, I will closely examine the Medical Practitioners Bill. Politicians and administrators are not the only ones who have a role to play in this; the medical profession also does. Either the Minister does not seem to grasp that concept or she is not willing to change the ethos of the health service. Advocacy is one of the best ways to start. The Minister should stop messing with another commission and implement our policy which contains a clear role for advocacy.

The main problem with the Bill is that it attempts to cover too wide a remit with far too many roles and functions. It makes hollow promises on patient protection. It also mentions evaluating IT projects and clinical cost effectiveness. The concept of clinical cost effectiveness can be quickly lost on people but it was not lost on the Minister. This is modelled on the British National Institute of Clinical Excellence which is extremely controversial. Under the remit of a patient safety organisation it becomes dysfunctional.

A national institute of clinical excellence may sound as though it does not do anything too distinct. Such an institute evaluates projects and drug costs. The case that caused considerable controversy in the UK related to a cancer treatment drug called herceptin. The institute said that some patients should be denied this treatment not because it was not working or that patients were at risk from it, but because it was not cost-effective. I find it very strange that the Minister would include an institution that denies treatment to patients in legislation that is also supposed to have a role in protecting patients. This, along with the setting of standards and the evaluation of IT projects, is giving rise to confusion as to exactly what HIQA is supposed to do in the coming years. The Minister has got it wrong and needs to step back. This needs to be separated because we are becoming very confused about the role of HIQA in the health care system.

I am worried about running out of time because I wish to cover a number of matters.

An Ceann Comhairle

The Deputy has nine and a half minutes remaining.

Dr. Twomey

Ms McManus

It would be good if the Minister was woman enough — being man enough would not be as good.

I welcome this debate. This is important legislation but it is also deeply disappointing. I wish to set the legislation in context. Thousands of patients are cared for properly and well each year in our health service but too many are not and they must be the focus of our attention today.

The story of a young mother called Rosie, as highlighted by Joe Duffy's "Liveline" radio show, is a stark and terrible lesson about the Government's failure to protect patients and provide them with quality care when they need it. Her life has been tragically foreshortened and her family traumatised to a heartbreaking degree, but the truth is she is not alone in her suffering.

In preparing for this speech today I looked at my own caseload, as one Deputy out of a total of 166. I suspect when it comes to complaints about the heath service none of us does anything more than touch the edges of the complaints that exist. I wish to give some examples of the cases I am dealing with in County Wicklow. A man in his early 60s spent this Christmas worrying about the five month delay he was experiencing as a public patient waiting for open heart surgery. He came to me as his local Deputy and, eventually, only because of the kindness of a secretary in a private hospital he has just been operated on following months of anxiety.

Today I was trying to help Pat, a patient with bone cancer. I am sorry to say it was without success. His pain is ferocious. He needs to be in St. Luke's Hospital. Yesterday he waited all day for the ambulance to take him but it never came. A nurse waited with him all day but to no avail. His admission to St. Luke's has been delayed by a further week. His suffering is now prolonged beyond endurance.

A few days ago I spoke to a mother whose beautiful 18 year old daughter died at home while they waited an hour for an ambulance. In their case the ambulance came but it was too late. Another lady called Ann has been waiting since 2004 for a bedroom for her disabled son under the disabled person's grant scheme. During the three year wait her own health has deteriorated to the point where she cannot manage the stairs. Her chances of getting a downstairs bedroom for herself are now being thwarted by the same county council that has already kept her waiting three years for a downstairs bedroom for her seriously disabled son.

In 2006 the Minister for Health and Children announced with great fanfare a repayment scheme to repay older people in residential care who were robbed by the State. We all welcomed that scheme. As is her wont, the Minister opted for the private sector to administer the scheme. She promised it would be faster, more efficient and more responsive, but the experience has not lived up to the promise. Last week I was honoured to present the President's cheque to a woman in Bray who had reached the great age of 100. Since she goes three days a week to play the slot machines on Bray seafront she can enjoy spending the money. However, this lady has been trying to extract her entitlement to repayment from KPMG and McCann Fitzgerald, the scheme administrators, since September 2006. We are now approaching February 2007. Not only can this lady not get the money she is owed, she cannot get any information about the payment date or why it is being delayed. This lady is in her 101st year. Time is not on her side. To whom can she turn for redress? Clearly this Bill that promised so much does not provide her with the justice she readily deserves. Yet many times when similar issues have been raised the establishment of HIQA had been proffered as a safeguard for patient safety and protection. These patients and others are being told to wait 18 months for a commission on patient safety to produce yet another report, in a health service that is weighed down with reports that have not been implemented. What will the commission do? It will tell us what we know already. It is not as if we do not know the problems.

The Bill to establish HIQA on a statutory footing is being debated. When I came to look at the Bill I posed a very simple question — a simple yardstick — as to its merits. Will it protect Rosie, Jerry, Ann or Pat into the future? The answer, regrettably, is no. This Bill does not provide the comprehensive and wide-ranging protection that patients need and deserve. In fact the Minister for Health and Children has implicitly acknowledged her failure on patient safety in establishing this new commission. She launched it last week ahead of the Bill being debated. If this Bill were up to the task it promised, there would be no need for a commission. The Minister's failure is defined by the gross deficiencies in this legislation and I regret that. I appreciate she has a hard job of work to do but this was legislation we knew was coming. The inspectorate in social services was integrated into it even though it meant a delay. This was the Bill that could have delivered on patient safety and yet again we are facing a failure and I regret that very much.

The Bill is essentially in two parts. It will establish a new independent inspection system for all nursing homes and care institutions and provide for a nursing home to be struck off the register if it fails to meet new care standards. It proposes a new agency, separate from the Health Service Executive, to independently inspect all public and private nursing homes and residential facilities. That is good news and I do not want to be churlish about this. It is a long time coming but it is being provided for.

More than 18 months have passed since the "Prime Time Investigates" exposé into Leas Cross nursing home. The controversy that arose out of that exposé led to legislation being demanded by an outraged public. The most disturbing conclusion in regard to the Leas Cross exposé was that it was clear there was systemic failure in the system rather than it being some kind of maverick institution that was an isolated case. In 2006 we witnessed some disturbing cases of neglect and malpractice in our health service and the exposure of poor practice. It was a year that saw reports into major scandals in health care provision — the Our Lady of Lourdes Hospital inquiry, Leas Cross and the death of Pat Joe Walsh.

February 2006 was dominated by the publication of Judge Maureen Harding Clark's report into obstetrician, Mr. Michael Neary. The report noted that Mr. Neary, or Dr. Neary as he was then, had carried out 129 peripartum hysterectomies at Our Lady of Lourdes Hospital in Drogheda between 1974 and 1998. Most obstetricians carry out less than ten of these procedures in their entire career. The report described this as "truly shocking" and highlighted the fact that no one shouted stop. A brave midwife and her companion did finally shout stop. Yet to this day that midwife is unwilling to identify herself. Instead of receiving accolades she chooses anonymity. What does that tell us?

I expected the Minister for Health and Children would provide the good robust protection of whistleblowers legislation as the Labour Party has done. We prepared the legislation and published it but the Government equivocated and we are still waiting for that provision to be made. There is praise for the unknown midwife but little or nothing has been done to ensure that others in the health service will feel brave and secure enough to come forward when malpractice or neglect occurs.

In September 2006 we saw the publication of the report into the death of Pat Joe Walsh. This man bled to death in October 2005 because he could not be transferred to another hospital for emergency surgery. The report describes some of the events on the morning he died as "surprising and barely credible". In November 2006 the report on Leas Cross was finally published. It was highly critical of the standards of care there and also criticised the role of the HSE and former Eastern Regional Health Authority in regard to the running of the home.

All of these reports — Our Lady of Lourdes Hospital inquiry report, the report on the death of Mr. Pat Joe Walsh, the report on the death of Mr. Peter McKenna, of the death of Roisin Ruddle and the Leas Cross report — are only some of the reports that examine the institutional abuse of elderly, frail people, the surgical mutilation of young women and the death of a middle-aged man who bled to death. These reports were about individuals who sought care from the health service and who suffered deeply as a result. There are others such as the patient who contracted MRSA and was not told and the family only discovered the fact when it appeared on the death certificate, the child with a broken arm left for 20 hours without water, and an older man left undiagnosed and in extreme discomfort and covered in his own faeces while in hospital. The complaints range from dirt in the toilets to the death of a child through medical misadventure. Data collected by the State Claims Agency show that 1,000 adverse incidents involving patient care occur in Irish hospitals every week. It is estimated that this figure is only 30% or 40% of the real figure.

The intended role of HIQA was to be the guardian angel of patients. When the Government set up the Health Service Executive, from day one the commitment and the understanding was that the balance would be provided by HIQA which would be the watchdog, the guardian angel, the body to protect patients. However, that never happened. The Health Service Executive was launched by a Minister for Health and Children who refused to prepare and plan for it properly. We are suffering all the problems as a result of that lack of foresight in planning. It was launched and allowed go free and the important balance of HIQA was never provided to protect patients. That has got to be seen as a grave political error and a failing when it comes to ensuring proper health care. Even now the Bill is not doing the business when it comes to providing the necessary powers to regulate services across the board, including the hospitals. The Minister said half the people die in hospital. She is absolutely right.

Ms Harney

Half the people who die, die in hospital.

Ms McManus

Yes, half the people who die, die in hospital. That, surely, is the point. We need to ensure there is regulation of hospitals because it is at a vulnerable time in our lives that we are likely to be in care in the acute hospital setting. Yet the Bill does not provide the important powers to end bad practice, to regulate the services and to encourage good practice because that is as important as ending bad practice. Instead we have got a commission, 18 months into the future, after the general election and lots of talk retracing ground that has already been retraced. An opportunity has been lost.

The Labour Party and the Fine Gael Party together produced a proposal and, frankly, I was disappointed the Government did not steal our clothes. It could have done so and we would have welcomed it, but instead we have a Bill that is not up to the task. Consider the reports that have been produced, particularly the Harding Clark report which put it succinctly: "any isolated institution which fails to have in place a process of outcome review by peers and benchmark comparators can produce similar scandals as those which occurred at Lourdes Hospital". That report showed clearly that systems had to change and that regulation was required. In addition, there should be registration of hospitals to ensure there are clear and comprehensive systems in place.

Professor O'Neill made the same point, that given the lack of structure, funding, standards and oversight, similar deficits in care to those at Leas Cross are very likely to be replicated to a greater or lesser extent in institutions throughout the long-term care system. It could be described as a seamless problem extending from acute hospitals to long-term care.

What lessons have been learnt? As far back as 1998 the HSE inspectors declared that Leas Cross should be denied official registration. There have been calls from experts for inspections of nursing homes to move away from the undue emphasis currently placed on examining the physical facilities and to focus more on quality of care. I am concerned about this because it is clear that despite the furore about, and concentration on, inspections there is insufficient expertise to consider fully the aspect of the care of the patient compared to the attention given to the physical environment of these homes. The environmental health officers tend to concentrate on their area of expertise as opposed to the clinical care of the elderly.

With regard to inquiries surrounding patient safety failure in our hospitals, the health report by Maev-Ann Wren and Dale Tussing noted that "the absence of a national licensing system for hospitals is a glaring deficiency in Ireland's health care system that exposes citizens to unacceptable risk". I do not have confidence this legislation will lessen that risk. It simply does not go far enough to give us such confidence. The Minister has missed the mark. She has failed to recognise, resource and empower agencies to protect patients. What she has done is provide a type of knee jerk reaction.

Leas Cross became the issue when it was all over the newspapers and featured on television. The people were outraged when they saw what was happening and demanded action. The Minister has now brought forward legislation that will, hopefully, deal with many of the concerns, although we will put forward a number of amendments in that regard. However, in terms of the tranche of care that is provided by other institutions and facilities, including in the community — I have in mind the unfortunate woman in County Wicklow, Ann, who has been so badly let down by the local authority and the HSE in her area — all the deficiencies cannot be addressed by this legislation because the means are not there to do so. We have not been given the means to ensure that patients who are suffering because of failures in the system will, first, be listened to and, second, will have their needs addressed.

The explanatory memorandum sets out the functions of the authority. The authority "may require the Health Service Executive or a service provider to provide it with any information or statistics the Authority needs in order to determine the level of compliance by the Executive or the service provider with the standards set by the Authority". That is an innocuous statement. The authority is to set the standards and the HSE and other service providers must provide the information to ensure that those standards are being met.

I wish the HIQA luck. Parliamentarians can get neither information nor statistics from the HSE. When I asked the Secretary General of the Department at a committee meeting if he was having difficulty getting information from the HSE, he said it was an unfair question. We cannot get information from the HSE, and there is supposedly a system in place to facilitate the flow of such information. I am still asking a simple question that arose from the Estimates. I will ask it now again, to give the Minister an idea of the frustration that exists and how HIQA will be trammelled when it tries to figure out what is going on.

In the Estimates the regions that are described for funding allocations are the old health board regions. There are four new HSE regions. When I ask the HSE to give me a breakdown of the population areas in terms of the old health board regions, it will not tell me. It continues to give me the figures for the four regions. It is simple statistical information and either it does not know the information, which is incredible given that the HSE is allocating the money, or it will not give me the information. What does that tell us? Will HIQA have to take the HSE to court to extract the information that should be publicly available?

As far back as 2004 the Composite Report recommended that HIQA should "have a role in ensuring that health professionals and the public have access to information that enables them to make informed decisions". That would be nice but the lack of transparency is worrying. The one thing that is clear about the health service is that where there is no transparency, the level of risk increases and the chance of scandals is far greater. We must have a system that is accountable. Regardless of what one thinks about the old health board system, there was some accountability in it. That has been ripped out in this reckless drive to centralise. It is extremely worrying and I cannot see how HIQA under this Bill will be in a better position than many others in trying to get information.

Health systems data which should be regularly published include health accounts, the national bed count, discharge and treatment patterns of public and private hospitals and earnings of health care professionals. There must be a new health accounting system within our health service. Debates concerning the proper level of health spending in Ireland have been confounded with debates concerning what the actual levels of health spending have been because Ireland has no national health accounting system. Figures commonly cited as representing Irish health care spending are widely known to include social spending. Reported current health expenditure is estimated to overstate actual health spending by more than 20%. At the same time, there are no regular and comparable data on private health care spending. A further confusion concerns inconsistent treatment of medical education. The education of a nurse appears in health expenditure, while the education of doctors appears as an education expenditure.

The other question I asked the HSE related to the number of beds currently in the system and where they are located. I still have not received an answer. It makes no sense that a body managing the health service releases so little information. Good decisions cannot be made unless there is evidence available on which to base them. At the core of many of the problems in the health service is lack of information. Any system or provision that will improve data collection and widen the evidence resource will be welcome. However, the spectre of PPARS will hover over all the commitments made in respect of spending money on computers.

The Minister is not helping in this regard when one considers her plans. There is a wilful determination on her part to privatise the health service. She is creating new and difficult dilemmas relating to patient safety. It is interesting to note the conclusions of Mr. Gerry Robinson with regard to the problems in the NHS. He could hardly be described as a socialist. He has come from the private sector and understands management in that sector. However, he made the point that there is better management within a health service where staff are directly employed in the NHS rather than employed by a myriad of private employers, to whom they are answerable.

This act of desperation does not provide patient care in an appropriate way or represent good value for money for the taxpayer. The Progressive Democrats talk about lower taxes. They are not ensuring the taxpayers get a good return for the taxes they hand over. This instance of co-locating private and public hospitals in a muddled and badly thought through way will raise issues of equity and bad value for money. This legislation represents a lost opportunity, and I regret that. I appreciate that the Minister has many problems to deal with.

Mr. Stagg

Most are of her own making.

Ms McManus

She does not have an easy job. The road map on patient safety was presented to the Government by my party and Fine Gael. We co-operated to pinpoint how we believe the important protections and safeguards can be put in place. This is a missed opportunity. I return to the cases in my casebook, in common with every other Deputy. Patients have suffered when they are sick and vulnerable, some when they are dying, and we cannot help them. All we can do is come here and ensure we produce the right legislation to meet the need. Regrettably the Government has again shown itself incompetent to provide protections and safeguards for patient safety that any person living in a modern, rich country is entitled to expect from the health service for which he or she has paid.

Caoimhghín Ó Caoláin

I propose to share time with Deputies Connolly, Catherine Murphy and Gormley. I have ten minutes, and I ask the Leas-Cheann Comhairle to indicate to me prior to the expiry of that time.

As the Government brings this Health Bill before the Dail, its health policy and its management of our health services is being exposed yet again as a shambles. As I mentioned to the Minister recently, the number of patients on trolleys and chairs in accident and emergency units reached 339 on one day already in 2007. When the task force report on accident and emergency was published last week, the Health Service Executive claimed a major improvement in accident and emergency but admitted it begins counting the waiting time for a patient in accident and emergency only from when a consultant decides to admit him or her as an inpatient. No account is taken of the time, often many hours, spent waiting to be seen by a consultant. The Government's cancer strategy is in disarray as exposed in the HSE report leaked last week. The Fianna Fáil-Progressive Democrats obsession with public private partnerships already mentioned here means that delivery of vital radiotherapy services is being delayed. The talks on a new consultants' contract are deadlocked and this is only January.

The Fianna Fáil-Progressive Democrats partnership has had nearly a decade to get health policy right and it has failed miserably. At the root of this is the Government's refusal to take a rights-based approach to health care. This Bill fails to vindicate health care rights. It is too little, too late. The Bill has been long promised and is long overdue. Action 63 of the Government's health strategy entitled Quality and Fairness — A Health System for You set a target date of 2003 for the establishment of the social services inspectorate on a statutory basis. This was to be in tandem with the establishment of the Health Information and Quality Authority. It took until 2005 for the Minister for Health and Children to establish an interim Health Information and Quality Authority. The Bill to establish the fully fledged authority and to put the social services inspectorate on a statutory footing is coming before us only now, in January 2007.

This legislation should not be enacted without another piece of equally long promised and long overdue parallel legislation. This is the promised Bill to provide "clear statutory provisions on entitlement to health and personal social services". This was the commitment given in the health strategy and the target date for publication of the Bill was 2002, five years ago. We still do not have that legislation and it is easy to see why. Such a Bill would raise many embarrassing questions for this Government about our grossly inequitable, two-tier, public-private health care system. If one sets out in law the entitlement of people resident in Ireland to health care, one must deal with the issue of health care rights and that is something this Government cannot face. It refused to enact rights-based disability legislation and it is refusing to enact rights-based health care legislation.

The interim Health Information and Quality Authority published its first newsletter in December 2005 and stated its purpose. It said it will "assure the delivery of world class health and personal social services". That is a very tall order indeed. To thousands of people who experience the reality of our health system today it must appear as a very sick joke.

A world class health service has been the repeated promise of this Government, but what have we got instead? We have got a two-class, two-tier health system that is inefficient because it is inequitable. I have already cited the health strategy, which has been effectively abandoned by this Government. In 2001 it stated that greater equity for public hospital patients would be achieved through a revised contract for consultants. The target date was the end of 2002. Here we are in 2007 and the talks on the contract have barely got past the starting post. To their shame, that section of consultants which runs the Irish Hospital Consultants Association is holding out in defence of what I regard as the indefensible, the so-called category two contract which allows consultants who are paid generously from public funds to provide care to public patients in public hospitals to also carry out private work for personal profit in a variety of settings, including private hospitals and clinics. To its shame, this Government and the HSE are preparing to make further concessions by allowing consultants working in public hospitals to spend more time treating private patients in those facilities.

All this comes as the Minister for Health and Children continues to pursue her scandalous scheme to privatise hospital services by providing land at public hospital sites to developers of private hospitals. This is on top of the massive tax breaks the developers will receive. The Government has no mandate for this privatisation plan and it should abandon it now.

The Health Information and Quality Authority is tasked in this Bill with setting standards on safety and quality in relation to services provided by the Health Service Executive and to monitor compliance with those standards. Will it apply different standards to the public and private systems? The reality today is that different standards do apply, and this Government and all its predecessors have perpetuated such a manifestly unjust system. How will this authority work if the two-tier system is maintained and is allowed to continue?

Anyone who doubts the injustice of the system and the fact that injustice in health care delivery costs lives should read the letter from the cancer patient in Kilkenny sent to RTE's "Liveline" on 9 January and widely publicised. This cancer patient has been told by her doctors that she has only a few short years to live. Her life could have been saved if she had access to a colonoscopy. She visited her GP in the summer of 2005 and was referred for the procedure, but she did not get that vital diagnostic procedure until 28 February 2006. It was found that she had bowel cancer and the cancer had spread to other organs.

On her 12th session of chemotherapy, the Kilkenny cancer patient spoke to the partner of another patient. She told her that her partner's GP had requested a colonoscopy and he was put on a waiting list. She then phoned the hospital and told them she had private health insurance and he got that colonoscopy within three days. The cancer had not spread and his life was saved. I wish to put on the record sections of what the Kilkenny lady had to say to the people of Ireland and to this Minister and this Government:

I then came home, flicked on the tv and got into bed. The first ad on the tv was from the government telling people that bowel cancer can kill, but not if caught in time. If Bertie Ahern or Mary Harney or Michael McDowell were within reach I would have killed them.

She concludes her letter:

Despite one and a half incomes we couldn't afford VHI or BUPA. But if we could we wouldn't have gotten it because we believed (and still do) that all people should get good care despite their incomes. We thought jumping queues was wrong.

Many people in this country agree wholeheartedly with the sentiments of that lady. I make no apology for placing what I regard as that eloquent indictment of this Government's health policy on the Dáil record today.

What will the Health Information and Quality Authority do for a patient like that? In a nutshell, inequity of access is the flaw in the system that is literally killing this woman. Apart from her experience of the Mater hospital, which she describes as "filthy and squalid", she does not complain of the treatment she received from the health services when she finally got treatment. However, the system failed at its most vital point, the point where it should have provided early, life-saving diagnosis.

This woman's experience is replicated by thousands up and down the country. Because the Health Information and Quality Authority will not be based firmly on legislation enshrining the right to equal access for all patients, it will have no remit to examine why this woman did not get immediate access to the early diagnosis that probably would have saved her life. We are not even clear if and how it will be able to examine individual cases.

I had other points to make but I will conclude. This Bill can be no substitute for comprehensive rights-based health care legislation. We in Sinn Féin base our approach to health on the principle that everyone has the right to timely and appropriate high quality health care that is available in sufficient quantity and accessible to all without discrimination. I commend that approach to this Minister and to this Government. It is never too late to row back from the perpetuation of the inequalities that she has presided over since she has taken over this Ministry and which she and her colleagues have presided over since 1997.

Mr. Connolly

I welcome the opportunity to speak on the Health Bill 2006. It is hoped that the theoretical establishment of the Health Information and Quality Authority and the placement of the social services inspectorate, which was established in 1999 on an ad hoc or temporary basis and is now being established on a statutory basis, can only result in the highest quality of standards and health care practices. For this reason I am pleased to welcome the Bill which may prove to be a landmark development for health services in Ireland. However, in the various functions and responsibilities which the Bill assigns to HIQA, I fail to see any reference to a dissemination of information to users and potential users of the service. It should be the case that a Bill dealing with information should provide for information to be disseminated to potential users.

The Health Information and Quality Authority would appear to be principally concerned with the evaluation provided by the HSE and by the social services inspectorate. It relies on its own internal information about nursing homes and standards of care. It is a transfer of information from one section to another and vital aspects of the information chain seem to be broken.

The proposed new appointment of a chief inspector of social services will gel quite smoothly with the functions and role of the social services inspectorate as an integral part of HIQA. The absence of the information provision is a grave omission from the Bill which provides for the establishment of HIQA, which will play a crucial role in the processing and provision of information.

It is right and proper that the operation of the social services inspectorate should be strengthened by the appointment of a chief inspector. Lines of communication with services and with the public should be developed and enhanced.

When I hear mention of communications and the HSE in the same sentence I sometimes wonder if the HSE knows what is meant by communications. There have been numerous examples, including the attempted establishment of a national children's hospital. It is evident that there has been a significant breakdown in communications between the three hospital groups. When two hospitals are not in agreement and the third hospital is naturally in agreement because it will receive the proposed children's hospital, this signifies a major difficulty with communications.

I was amazed to learn that the views of the paediatricians who provide these services on these sites were not taken into consideration by the group which was to decide on the site for the new national children's hospital. The same situation and similar upheaval is happening in Cavan-Monaghan, particularly in Monaghan General Hospital. The people on the medical board are expected to deliver the services although they do not agree with the proposed changes. Appearing before the Joint Committee on Health and Children, those who wrote the Teamwork report, which has been developed into a pilot project to be rolled out nationally, expressed dissatisfaction with the manner in which their report was being implemented. They stated that it did not make common sense and was not practical to remove services prior to the introduction of better, safer services. The Minister and Professor Brendan Drumm indicated that new services should be introduced. The Teamwork report stated that new grades of staff should be employed and placed in situ before changes were made. These are examples of my concerns about communications in the health service.

The Health Information and Quality Authority should provide publicly accessible information on health services on its website, as is the case in other countries. The website, Irishhealth.ie, performs this function on an informal basis. Members of the public would benefit greatly from collaboration between HIQA and Irishhealth.ie on the provision of health information.

Irishhealth.ie provides a service known as "Rate my Hospital", which is popular among members of the public who are able to read about or describe the type of services they will receive or have received. It also provides information on specialist discussion boards and facilitates members of the public to discuss and tease out controversial developments under way in the health service. In addition, it hosts discussions on new forms of treatment and so forth. HIQA should consider providing similar services for the public.

Ms C. Murphy

Christmas may be a distant memory but this special sitting has been called to discuss this important legislation. Reading the Bill one is struck by how exposed elderly and disabled patients have been in the health service, as manifested in a number of scandals in recent years. These elevated the importance of the Bill, which proposes to replace the informal, non-statutory arrangements currently in place. This indicates the reactive approach taken to many issues affecting the health service. One would expected the provisions of the legislation to have been introduced as matters of principle and to have formed the cornerstone of the health service.

The increasingly complicated arrangements operating in the health service are becoming difficult to fathom. If Deputies find them complex, members of the public will find them even more difficult to negotiate. While the Health Information and Quality Authority appears to be a stand-alone body, it is a sister organisation of the Health Service Executive.

I am under the impression that the HSE is little more than old health boards rebranded. As with Deputy McManus, I have noted that the replies it issues to parliamentary questions replicate those provided by the health boards.

I seek clarity on how HIQA will function. For example, the Bill allows for the transfer of HSE staff, with pension rights, to HIQA. However, HSE staff who monitor pre-schools or nursing homes may also deal with entirely different matters as part of their jobs. How will the ceiling on staff numbers be affected by these arrangements? Although it is denied that a recruitment embargo is in place, it is difficult to describe current policy as anything other than an embargo when staff numbers are not increasing in areas where more recruits are clearly needed. Will a separate funding mechanism be introduced for the new organisation? Will it have its own budget? What will be the staff complement and will it impact on the ceiling on staff numbers?

Is it necessary to provide that HIQA has a business plan, an annual report, a corporate plan and a code of governance? Is this not excessively cumbersome? The draft code of governance for the Health Service Executive announced last September has still not been finalised, yet the HSE has been in operation for several years. Timing is important. One would expect HIQA to establish principles or a code of governance before it commences its operations.

Accountability is a major issue in the health service and one of the briefs of the Opposition is to ensure it holds the Government to account. I am concerned that the provisions will have knock-on effects similar to the impact of nursing home charges on places such as the St. Raphael centre. Will the Minister examine this matter as it is causing undue concern for residents of many institutions?

Mr. Gormley

As someone who subscribes to a belief in less state interference and smaller bureaucracies, the Minister has managed to massively increase the amount of bureaucracy in the health service. As a result of the establishment of the Health Service Executive, bureaucracy in the health service has increased and the level of information available has reduced.

As regards health information, ostensibly the subject of this debate, Deputies receive less information in response to parliamentary questions than they received prior to the establishment of the HSE. The Minister may recall that during the Second and Committee Stage debates on the legislation establishing the HSE, I repeatedly stated it would lead to less accountability. My position has been vindicated and I could give countless examples of the problem. For instance, it is extraordinary that I have been waiting for two months for replies to parliamentary questions which I tabled on medical card entitlements and costings.

Having contacted staff in the parliamentary division of the Health Service Executive, all of whom have been co-operative and polite, I do not point a finger at particular HSE employees or officials in the Department but I must point a finger at the Minister because she bears ultimate responsibility. I hope she agrees that it is not acceptable that Members must wait for months for information. When we contact the parliamentary division of the HSE, we are referred to the Department. The mantra in the Minister's replies to parliamentary questions is that the matter raised by a Deputy has been referred to the Health Service Executive. Deputies who then contact the HSE with simple questions on issues such as hospital food do not receive replies and must spend considerable time trying to track down the relevant information. The bureaucracy becomes farcical when one is told by the Department that it must refer the matter to the HSE for a final time in order that it can be clarified. Does the Minister accept that this is terribly frustrating for Deputies, perhaps deliberately so? As I indicated in earlier debates, perhaps the reason for establishing the HSE was to have it act as the Minister's mudguard. Many people in the HSE are probably getting somewhat annoyed, if we consider the leak from the HSE concerning the cancer strategy. As far as they are concerned the cancer strategy is simply not deliverable on time. The Minister said subsequently that the information was historic and needed to be updated but that is not the impression given by the leaked memo. Looking at the facts, it seems the Minister's cancer strategy was not properly costed. According to the statistics, cancer rates will increase by 90% in 15 years. How can the Minister deal with that given the budget deficit attached to the cancer strategy? We are coming up to an election and the Minister wants to say it is deliverable, but clearly it is not.

Previous speakers have referred to the accident and emergency situation. I get the clear impression, mostly from anecdotal evidence but from fairly reliable sources also, that everything is now being done to ensure people are not on trolleys. This is not being done by increasing capacity, however, but by cancelling elective surgery. In addition, older people are inappropriately being pushed out of hospital into a step-down facility. They may then have to be re-admitted to hospital because they were prematurely discharged. Those are the sorts of stories I am hearing. Neither the Minister nor Professor Brendan Drumm are prepared to deal with the main issue, which is the capacity problem. They are quite prepared instead to allow the private sector to provide the solution by giving generous tax breaks but, thus far, that sector has not done so. In previous incarnations, people currently in the private health sector may have been beef barons or car salesmen. They are now looking to make a quick buck in the health sector. They are not from the caring professions. We ought to have learned from the experience of those who cared for older people in our community. We should see how the elderly were treated by people from the business sector who wanted to make money. They treated older people as a commodity. We can now see that health provision itself is being treated as a commodity. This ties in with the Minister's own neo-liberal PD philosophy, which treats practically everything in life as a commodity. Health cannot be treated in this way, however. The Minister ought to have learned from the failure of trying to introduce competition into the health insurance market. Even the Minister must admit that it has been a fiasco. Risk equalisation, which the Minister wanted to introduce, has not worked and was rejected by BUPA. How will we proceed with this matter? I did not hear any complaints about how the VHI operated as a stand alone company. It seemed that people could obtain insurance and gain access to a hospital at the time. Deputy Ó Caoláin stated previously that people purchase private health insurance because they want to skip hospital queues since our public health services have been allowed to run down.

It is disgraceful that a patient would have to use such a room and be treated in that fashion. What is happening in our hospitals? If that is the standard, is it any wonder we have high rates of MRSA in our hospitals? Many of the cleaning regimes are handed over to private contractors who are not doing the job properly. If the Minister has visited a hospital she will know what I am talking about; she will see the appalling standards for patients, including dust and filth. I will be more than happy to provide the Minister with all this information, including the photograph. I hope she will act upon it.

Mr. McGuinness

I am sure the Minister will be somewhat relieved that the discussion has come back to this side of the House. The debate so far has centred on a number of negative aspects of the HSE and of this legislation, but I commend the Minister for bringing the Bill before the House. As I have done publicly on many occasions, I also commend her for taking on the position of Minister for Health and Children. She has approached the role proactively with a willingness to take on the challenge required to turn around a health service that, without a shadow of doubt, is ailing. It requires increased and ongoing funding. As far as her job is concerned, the Minister is determined to try to change the culture, structure, direction and focus of an old administrative system for health. At the same time, she is trying to improve front-line services and make available the necessary capital funding throughout the country to ensure buildings can house the increased number of services. In addition to ensuring the necessary expertise is available, the patient must be central to everything that is done by way of legislative change in the health sector.

While I am sure we will not find common ground on all health service areas, there are some where the Opposition could engage with the Minister to ensure a Tallaght-type strategy. As long as there are political divisions over health, there will always be a risk that it will be more difficult for the policies of the Minister, the Government or the HSE to succeed. It becomes even more difficult to change the existing culture when political differences are factored into the overall changes that are required. I encourage the Opposition not just to roll out the different cases, as I could do from this side of the House. We all have our case load and understand what is going wrong within the HSE and the Department of Health and Children. However, to stand up to speak without having a tangible, workable solution to some of the issues embedded in the system that need to be changed is a clear indication the Opposition is without a policy. I do not deny changes are needed but I believe we have a Minister who will ensure the finance is made available and who has the ability to apply that finance through the HSE to ensure real delivery for the patient at the end of the line.

There has been a change with regard to how the health services are administered from the time of the old health boards to the new HSE. Some Members of the House — we have heard them already — will harp back to the days of the old health board system and suggest it was almost better than the current HSE system, although it has not been in place long enough to allow it to develop to the extent it should. The old health board system simply did not work. The members of the boards did not fix the system or come up with imaginative policies at regional level to change the speed of delivery in the context of services to the patient. They failed and that is why we had the debate about the changes that were necessary, which led to the establishment of the HSE.

It is an easy way out for the Opposition to point the finger at every turn and claim the Minister is at fault. The example given earlier by Deputy Twomey was that the Bill does not tackle MRSA. It will take more than legislation to tackle the issue of MRSA or of providing an efficient health service. It is not achieved that easily. To make it sound simple is to miss the point of assessing the HSE under Professor Brendan Drumm and contributing to its success.

This is not to suggest there is no need for an ongoing debate and ongoing change, and perhaps some of the decisions taken by the HSE were wrong or fell short of the mark in some way. However, in this debate the HSE is seen as being on one side with the Department and the role of the Minister on the other. One can define the role of the Minister as one who oversees the health service and as the person with whom the buck stops. One can point the finger at every turn but that would be wrong because, below the Minister, there is a very well paid group of managers in the HSE's management system. If there has been an error or bad judgment, it is their judgment and professionalism which should be called into question. This is not to defend the Minister or leave her position to one side. It is about identifying where the system went wrong, identifying responsibility and making a manager who is well paid admit he or she made a mistake, as Dr. Gary Courtney and St. Luke's Hospital, Kilkenny, did in regard to Rosie's case, which was a positive development.

Like Opposition speakers who referred to Rosie, I too feel sorry for her and would like to have seen her case turn out otherwise, as would all of us. What should we do? I do not blame the Minister. I examine the system and ask what happened and how we can improve it. The improvement in that system has been identified by Dr. Courtney and a project is currently under construction on the St. Luke's Hospital campus. I accept that more needs to be done and that finance is needed for the project that is being undertaken to improve that aspect of the service.

The HSE is inefficient in delivering funding to hospitals such as St. Luke's. It is paying lip service when it suggests it will reward excellence. Rewarding excellence means putting one's money where one's mouth is. It means directing funding specifically to a hospital that is innovative in its approach to the various complex health care problems and openly supporting those who support change within the HSE. If we do not do this, the group of staff who are not rewarded will not be encouraged to introduce change, ensure it is patient focused and cost effective, and deliver either an old service in a new way or a new service in new surroundings. That is what the HSE needs to do in this regard.

Holding up St. Luke's Hospital in Kilkenny as a model that works efficiently, and as one that should be rewarded, is not good enough unless the required funding is invested in the hospital. A current project at the hospital, which aims to correct a particular problem, will cost €500,000. If I was to ask anything of the Minister, it is that this money be found and immediately directed to that problem, thereby providing the infrastructure to deliver the service and remove a problem within a hospital that is functioning properly.

The question of communication with the HSE is a major issue in the House. During the debate on the HSE and its structure, I raised this issue in the context of many other Bills that have passed through the House. Members of the House seem to believe that placing an organisation an arm's length away will in some way ensure it will not become contaminated by the political system.

Notice taken that 20 Members were not present; House counted and 20 Members being present,

Mr. McGuinness

I would like to deal with the provision of information by the HSE, specifically with regard to responses to parliamentary questions. Other speakers have also raised the issue. The information provided in responses is almost misinformation or no information. This area needs to be revisited. Money has been spent on setting up the particular unit to provide information.

Parliamentary questions asked in the House generally relate to a specific issue such as the case of a particular patient, the lack of a service, the issue of a medical card and other normal issues commonly brought to the attention of every Deputy in their clinics. We want information provided in this area for patients who are already within the system. I cannot understand how having gone through the parliamentary question system and put staff in the House to the bother of going through the process of placing the question, there is little or no information in the reply or we are told to tell patients to return to their general practitioner if their health deteriorates. It is unacceptable that an organisation as large and well funded as the HSE should take this course of action in response to a Deputy acting on behalf of a constituent or hospital or seeking funding for some project.

The HSE is affected negatively by the old culture of the health boards where there was a cloak of secrecy around what was going on. It needs to understand that the public wants to know what is going on and wants to be able to get information, whether from a website or by way of parliamentary question. As parliamentarians, we should be able to scrutinise the activities of the HSE. This is done in part by the Committee of Public Accounts, PAC, but there is not sufficient in-depth examination in the context of the direction taken by the HSE or the policy being implemented. The HSE must be more accountable to the House in order to be more transparent and to regain credibility in the eyes of the public.

The HSE route is the correct one to take, but I am concerned about the executive's management structure. Before being interrupted by Deputy Stagg, I was making the point that like local government, there are not enough administrative professionals in the HSE to ensure the correct systems are in place and that they deliver information efficiently and assist consultants and patients to ensure more transparency. The PAC gains that transparency when it examines the accounts, but these accounts are only figures after the event. In the context of our work, we need information provided as the story unfolds.

I can give many examples of occasions when I had to intervene for patients, for example for patients waiting for a bed. On occasion a patient waiting for a long time gets a letter in the post to say an appointment has been secured, but for 2008 or 2009. What good is that? I believe this occurs because of bad administration. Another recent example of bad administration occurred when a patient travelled from Kilkenny to Waterford Regional Hospital to have a cataract removed and was brought to have his knee X-rayed. A further example is that of a patient who was called to Waterford Regional Hospital for 8 a.m., but was turned away because they could not see him and was asked to come the following Thursday at 8 a.m. He did, but he had still not been examined by 4 p.m. He left because there was nobody to tell him whether he should stay or go.

Should we point the finger at the Minister in this regard or should we admit that such incidents illustrate a serious lapse in terms of administration?

Mr. Perry

It has to do with accountability.

Mr. McGuinness

No. Deputy Perry knows from his involvement in business that it is the system that is wrong. Would people blame Deputy Perry because their packet of butter was gone off? No, they would blame the creamery. The Deputy might be asked to contact the creamery, but somebody else is accountable.

I listened to Deputy Twomey's arguments and to the examples he mentioned. To blame the Minister for MRSA is misleading and demonstrates that Fine Gael has no real policy to deal with the issue. Fine Gael did not take the opportunity to tell us its policy in this regard but diverted attention from the issue by blaming the Minister. This omission by Fine Gael is unforgivable in an Opposition and will not be forgiven when we go to the country in the coming election.

The parliamentary affairs division system of the HSE needs revision in the context of transparency and of our work as messengers for the public. We need direct access to real information from the HSE and it must be accountable on a regular basis. I know it is accountable to the House, but we want real accountability in the context of both the Committee of Public Accounts and the Joint Committee on Health and Children. I hope we will have direct access to the new commission and HIQA by way of parliamentary question and that they will come before the relevant House committees regularly to explain their situation. We do not need a focus group when parliamentarians who represent the people can become involved and help to improve the system.

I commend the Minister on the amendment she intends bringing forward on the section of the Bill relating to whistleblowers. Instead of a charter that allows every person with a chip on his or her shoulder to come forward, make a statement and point the finger, we need protection for the people working within the system who are willing to come forward with a positive contribution on how to improve it. These people need protection. In the old health board system I saw it happen far too often that when complaints were made about patients' funds, the shutters came down and it was difficult to get replies to any questions.

It is equally difficult to get replies from the HSE, but its staff, who are anxious to protect their position and integrity, inform us that there are serious difficulties with regard to the administration of accounts. This is not good enough. I asked in the Committee of Public Accounts whether an audit had been completed on the transfer from the old to the new system, but the question could not be answered. Therefore, whistleblowers who are constructive and positive on what needs correction in the system must be protected. I have seen it happen that when such people come forward with the best intentions, they are identified by the system. Then, over the course of time they end up by retiring early, or getting sick and leaving the system. Such people, with patients and the health system at heart, are a loss to the system when they end up leaving as a result of having made a complaint. Again, I commend the Minister on the amendment. It should apply in most Departments and in local government where there is a need for solid protection of whistleblowers so they will not lose their jobs or be sidelined in terms of promotion. They must be dealt with in a constructive and positive manner.

The Bill deals with how the inspectorate will engage with nursing homes or with those in care. I have taken a good look at this sector. Leas Cross has left people with a bad opinion on the issue of care of the elderly. However, we must acknowledge that within both the public and private sector those at the coalface provide an excellent service. They give excellent service in the care of the elderly and must be supported. I hope that the inspectorate will go across the sector ensuring that those who break the rules, laws and regulations are brought to justice, being fined heavily, suspended or put out of business. The response must be heavy-handed since children and the elderly are extremely vulnerable. In that regard, those on boards or providing oversight for such institutions or people in care should be professionals or have an interest beyond politics.

As part of what the Minister for Health and Children attempts regarding the HSE and legislation, she should strive towards ever less bureaucracy in the system, removing red tape and continuing to put the patient first. By doing so, she will keep a constant focus on the patient in a legislative context. The old system did not work and the new one will function, but there must be some correction to the heavy, bureaucratic approach that it now adopts.

Mr. Naughten

I wish to share time with Deputies Enright and Perry.

I welcome the opportunity to speak on the Bill. Everyone in the country knows what went on in Leas Cross, which was an appalling situation indicative of the great weaknesses in the current system. However, on the other hand there are many good nursing homes at present. We must ensure a high standard in public and private nursing homes throughout the country.

Last Monday's Irish Independent stated that one in five nursing homes failed to administer drugs properly. Two points made in that report were that patients’ prescription forms were not being signed by GPs and that drugs were being prescribed over the telephone rather than in writing. I recently came across a situation where an elderly resident of a nursing home, the holder of a medical card, was charged by her GP when he called to visit. That should not happen and provision is made in the nursing home payments scheme that an elderly person should not be charged for such a service. That may be part of the current weakness in nursing homes.

Another big difficulty is that where problems are reported to the existing inspectorate in the HSE, it can sometimes be extremely slow to respond. Certain things stand out in the Bill, for example, an amendment is to be made to the Health Act 2004 to require the HSE to have regard to the new standards set by HIQA when performing its functions. However, the condition is applied that it should happen only where practicable. Second, and more important, it should be subject to the available resources. There is not much point in our setting standards for the HSE and others to follow when it is subject to the available resources. That makes a farce of the legislation when it comes to setting standards.

The Bill also excludes acute hospitals and mental health services, which is a great disappointment. The Minister speaks of the need for quality and safety, something that we all welcome. However, let us reflect on Deputy Twomey's comments on MRSA. The current situation is that elderly people are afraid to enter hospital for basic procedures owing to the risk of contracting it. That is unacceptable. The Bill should cover all hospital services and medical institutions rather than only part of the problem. The Bill sets standards, but they vary by area regarding services, safety, quality, statistical data and information. There must be much more clarity on those issues.

The Government has stated consistently that its priority is to keep people out of nursing homes in the first place so that they can retain their dignity and independence at home. The sad reality is that it is no more than lip service because the elderly are not being provided with such support in their own homes. Let us consider questions that I have tabled here on numerous occasions regarding physiotherapy, occupational therapy, OT, and home help resources. Very little is being said in response to the current backlog, which highlights where the system is falling down.

Older people are being forced into nursing homes because basic health care services are not being provided for them in their communities. The Government has singularly failed to provide the necessary investment to support the elderly in the community. Through the HSE, it has blocked the appointment of staff critical to services at that level. A comprehensive service must be provided for the elderly in the community regarding accommodation, specific services such as OT or physiotherapy, public health nurses and proper support for carers. The cost per annum of supporting a carer in the community is approximately one tenth of paying for a person in a public nursing home and that must be addressed once and for all.

In tandem, we must consider step-down facilities and rehabilitation beds for the elderly. An elderly person in my constituency required physiotherapy for 20 minutes a day in the rehabilitation unit of the Sacred Heart Hospital. That person was told that the only way to get it was to spend 24 hours in a hospital bed at the unit. Despite living only a mile from the hospital, the patient could not be provided with the service at home, being required instead to take up a hospital bed. That is where the system currently falls down.

We have no facility for Alzheimer's or dementia patients in County Roscommon. We are to have one by 2010, but it is already over-subscribed. Yet there are facilities available in Carrick-on-Shannon, County Leitrim, and Ballinasloe, County Galway, to which people who live within a few miles of them in County Roscommon are denied access. It is clear that there are still boundaries when it comes to health services.

There is also the death tax that the Minister is considering introducing, a 15% clawback on property. The Government claims that it is introducing the scheme because many elderly people are currently forced to sell their homes. However, it was the Government that forced through the 5% calculation regarding means before Christmas. Under the new scheme, it is only those patients who are defined as highly dependent who will enjoy access.

What is really sickening about this legislation is that elderly people will now have to pay a death tax, yet there is no clarity regarding how often inspections will take place. It is purely at the discretion of the chief inspector of social services when and how often they occur. Elderly people are paying a premium but not getting a service.

Ms Enright

I too welcome the opportunity to speak on this legislation. I wish to stick as far as possible to the Bill itself, but before continuing further I will say a few words on MRSA. No one suggests that it will be simple to fight it, but it cannot be ignored.

I will relate an experience that I had when visiting a patient in a hospital on the south side of Dublin the week before last. When I entered, there were yellow and orange neon signs absolutely everywhere to the effect that one should not enter and that only urgent family visits should be undertaken owing to the risk of MRSA. People all around me were walking in and out of the hospital and they were clearly visitors rather than patients. I went to the reception desk and asked whether it was all right for me to visit the patient in light of the signs. I was told that it was up to me. I asked whether I should visit the gentleman in question but was again told that it was up to me. Eventually I asked whether the signs were there for my benefit or that of the patients in the hospital, and all I got in reply was a shrug of the shoulders.

There either was or was not an MRSA outbreak in the hospital at the time. If there was one, we should quite clearly not have been allowed in. It cannot be left up to individual members of the public whether to enter; we either can or we cannot do so. The hospital should have such basic matters under its control, with extremely clear rules in that regard. I support Deputy Twomey in his views on the proposals contained in the Bill, which do not adequately deal with the issue.

The legislation is late and is a lethargic response to what can only be described as criminal abuse of the elderly in our community. Leas Cross was disgusting and I am sure the Minister for Health and Children feels the same way. We have seen and heard appalling stories about a few nursing homes, representing a degradation of these elderly people's human rights. We hope that nursing homes such as Leas Cross are a tiny minority but we do not know for certain that is the case. We rely on anecdotal information and people must base their opinion on nursing homes with which they have had dealings. We need far more information on operations and standards.

Perhaps the Minister has not accessed the inspection reports on the HSE website recently. I seek an explanation why there are no inspection reports for the two private nursing homes in County Laois. Only three reports have been published for nursing homes in County Offaly. I have read all three closely but they do not refer to care received in the nursing home. The report focusses on the physical state of the building. Although that is important because accidents can happen if the building is not in good condition, the crucial matter is the level of care received. On the last page of all three reports, after the inspectors have signed off, it is stated that no medical officer was available to assist with the reports. The three reports on nursing homes in Offaly were based on physical state of the buildings. Families can see if a light bulb is missing but it is more difficult to determine the standard of care being received.

I am disappointed that the legislation does not outline the standards to be applied. Will regular, unannounced inspections be compulsory? People should be able to evaluate nursing homes before they or a family member enter the home. Owners of nursing homes should have nothing to fear. If the home is properly run, its name should be up in lights. The standard of care is the most important issue.

A study by Dr. Shaun T. O'Keeffe and Dr. Jean Murphy was carried out on the frequency and appropriateness of prescribing anti-psychotic drugs to older people in long stay institutions. The study found inappropriate prescribing in more than 50% of cases. The patients exhibited behaviour common in those who suffer from dementia, including wandering, anxiety, shouting, spitting, restlessness, fidgeting and nervousness but they were given anti-psychotic drugs. This was a more common occurrence in private institutions than public institutions. The study also found that those residing in public institutions had a greater level of specialist care. In the United States the Omnibus Budget Reconciliation Act 1987 deals with such matter. Ireland has no such legislation. Before it was enacted in the United States the levels of inappropriate prescribing were similar to those in Ireland at present and have improved since then. The study does not recommend that the legislation be enacted in Ireland but that guidelines be introduced. It also suggests better education for medical and nursing staff about prescribing and improved access to specialised geriatric services. This is particularly important in private institutions.

I am disappointed there is no advocacy role given to patients under this Bill. Patients are among the most vulnerable people in society and are entitled to a voice. If patients attempt to make a complaint they face a daunting process that is not designed to meet their needs. Everyone else in the system can rely on an employer, insurance or a union to provide support. The patient is the only one without a voice.

The Bill does not address home help and home care packages. The vast majority providing this service are inadequately, if at all, supervised and are not vetted to ensure they are suitable. These people provide a service to elderly, vulnerable people, most of whom are home alone at the time.

The HSE must play a role in providing community care facilities. My home town is an example of an extremely good facility but the HSE is slow to provide more. In 1997 a 20-bed extension was approved for Riada House in Tullamore. A block has not yet been laid ten years later but already a greater number of beds is needed. At meetings with the HSE I have asked what will happen to the old Tullamore General Hospital when the new facility is built. It would be ideal to provide step down facilities at the old location. I fear more offices will be put there, which is not acceptable.

Mr. Perry

This document is similar to other policy documents. It is long overdue and neglects many of society's most vulnerable people. While the introduction of an inspectorate for nursing homes is long overdue, a Bill to deal with the protection of all vulnerable people is needed. It is a scandal that public health nurses working with vulnerable elderly people in the community are not told about patients with MRSA when they are discharged. This leads to the spread of MRSA. Hospitals are only concerned with discharging these patients. Hospitals seek to control an outbreak of MRSA and then get the patient out. Such is the incompetence within the hospital structure at present.

This Bill does not recognise or protect patients registered with the Mental Health Commission or those residing in acute hospitals. The Leas Cross case highlighted the mistreatment of the elderly and it is positive that the Bill recognises this. Irish people suffering from mental health disease are cruelly neglected by the State. The standards of psychiatric care are appalling. I am pleased the Minister of State at the Department of Health and Children, Deputy Tim O'Malley, is present. A facility for Sligo has been discussed for the past 20 years but it has not been delivered.

The constituency of Sligo-Leitrim suffers from government neglect. This is particularly obvious in the provision of breast cancer screening. It is a damning indictment of the Government that it has done so little to introduce early cancer detection. The leader of the Minister of State's party has told us the country is awash with money. We cannot spend it quickly enough. A national steering committee was set up ten years ago to examine this matter but women in the north-west still have no access to screening for breast cancer. This service is only available to half the women in the target 50-64 age group. It will be several months before women across the north-west have access to screening for breast cancer, ten years after the steering committee was set up and seven years after the service was offered to women on the east coast. Some 650 women die of breast cancer in Ireland each year and 2,300 more are diagnosed with the disease. This figure is forecast to rise to 4,700 by 2020. In 95% of cases early detection can lead to full recovery but women in the west are denied the right to screening. Early detection makes the treatment process much less of an ordeal for the patient. Doctors state that women in the west are more likely to have to have full mastectomies because the disease is discovered later. A report on women and cancer in 2006 by the National Cancer Registry contained deeply worrying statistics on the north west. The report highlighted the urgent need for Government action on the national roll-out of BreastCheck and the national cervical cancer screening programme.

The Government is dragging its feet on an issue that is costing women's lives. It has let women in the north west down very badly. The former Minister for Health and Children, Deputy Martin, announced on 3 March 2003 that breast cancer screening would be in place in the north west within 20 or 30 months, meaning that such screening would have been in operation in Sligo-Leitrim by September 2005 at the latest. Some 16 months later women in my constituency are still waiting. The latest communication from the Minister for Health and Children is that she is committed to ensuring BreastCheck services are rolled out to the remaining regions in the country as quickly as possible. That has been stated time and again.

The Minister, Deputy Harney, stated on 5 December that she is pleased screening will take place in spring 2007 and I have no doubt this will again be announced before the election. While I would like to be confident that women in the west will have access to breast screening in the coming months, the Government's record does not offer much hope.

A 2006 report indicated that cancer is the second most common cause of death for women in Ireland, with the death rate being higher than any other western European country. Fine Gael has repeatedly called for the Government to stop dragging its feet at the expense of women's lives and immediately roll out nationwide screening.

Women in Northern Ireland will next year celebrate 15 years of breast cancer screening, with a reduction of one fifth in the rate of death from the disease. By that time, hundreds of women in the Republic of Ireland will have lost their battle with breast cancer and hundreds more will have endured devastating radical surgery. By the time we get screening in the north west, women on the east coast will have been screened for at least seven years.

The Government must also set out its plans for radiotherapy and cancer treatment in the north west. Previously we were told there would be provision for radiotherapy services by 2011, but we urgently need clarification on the Minister's exact plans. As the issue stands, 2011 is four years away. We have been let down badly when one considers the amount of money involved in the national development plan announced yesterday. For some millions of euro, a BreastCheck service in the north west could be provided. I am appealing to the Minister because we are fed up of promises and we need the service.

Mr. T. Dempsey

I wish to share time with Deputy Glennon.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. T. Dempsey

Déanaim comhghairdeachas leis an Aire Sláinte agus Leanaí agus na hAirí Stáit as ucht an Bille seo a chur os ár gcomhair. Roghnaíodh mar Theachta Dála mé ceithre bliana ó shin. Gach uile lá ó shin, léighim trácht sna nuachtáin agus cloisim daoine ag gearán ar an raidió agus teilifís. Go minic, bíonn cúis cheart acu gearán a dhéanamh faoi chúrsaí leighis sa tír. Tharla rudaí uafásacha go minic sa tír seo. Déanaim comhghairdeachas leis na hAirí éagsúla agus an HSE toisc go raibh siad cróga go leor dul i gcoinne na rudaí seo agus céimeanna a ghlacadh ionas go mbeidís ábalta na deacrachtaí a scrúdú agus a bheith cinnte nach dtarlódh a leithéid arís.

From the time of my election a few years ago, somebody has often made a statement on the radio nó sa páipeír or on television about the awful events in places such as Leas Cross. I congratulate the Minister, Deputy Harney, and the Ministers of State, including Deputy Tim O'Malley, who is in the House tonight, for being brave enough to put before us a scheme which will guarantee to the ordinary person that there will be no repeat of such disasters.

The components of the name Health Information and Quality Authority are resonant of what has been wrong. There is nothing more important than the health of the individual in a nation. There is no guarantee more necessary in a democracy than equality of health care. Deputy Enright mentioned standards of information and I agree with her points in that it is very important that rigid standards are put before us.

It is also imperative that quality, which has sadly been lacking, will be addressed through this new authority. I would go so far as to suggest a league table. Such a table would be abhorrent in education but not in the health sphere as people should know the standards available before registering in a nursing home.

The vulnerable sectors of society are referred to specifically in the Bill. The quality and standards which this Bill will implement have been commonplace in industry and for Deputies. Every four or five years, Deputies go before the public, are scrutinised and their performances are judged in the most critically analytical manner. It is time the standards applying to industry are applied to public and private services in the provision of health care.

I note the Bill will implement an independent inspectorate for public and private services, which is very important. For too long inspectorates and their inspectors have not been independent. Although I use the education system as an example, rather than criticising it, inspectors there usually come from a pool of teachers. The Garda is inspected by peers. The saying in Latin is "Quis custodiet ipsos custodes?” or “who will guard the guards?” The guardians of this new approach, implementable through HIQA, will be independent and I commend the Ministers involved and the HSE on this independence.

The power of enforcement is also needed. I am delighted HIQA can close a nursing home or section of a hospital if it does not meet justifiable and acceptable standards. In the past, the legal process required to do this rendered it is impossible to achieve closure.

Registration requirements are also important. I believe that anybody could have opened a private nursing home until now, although I am not completely sure about that. Standards were very limp if they existed. This board will in future oversee registration and I am confident there will be serious scrutiny of those who wish to provide care for our most vulnerable sector.

It will be a single national agency and if no other benefit flows from the HSE, this will be one. There could be no single independent inspectorate under the various health boards but under the HSE, we can have a unified approach. The standards maintained in Wexford will be similar to those in Limerick, Galway etc. It is very important to have a single authority scrutinising these issues.

Enforcement is important and there should be no compunction in closing those facilities that do not deserve to remain open. I was interviewed this morning on South East Radio about the national development plan, particularly with regard to education. I was delighted to note that it is hoped to bring 50,000 people out of the poverty trap through second chance education. The Christian Brothers did this for me and many others when they provided education at no cost to the taxpayer and little cost to the consumer.

Listening to various Deputies discussing MRSA, I am reminded that nuns in the past voluntarily rendered a service to the public that ensured cleanliness unequalled anywhere else in Europe. Those days of voluntary service, within or without the various churches, are gone and voluntary effort is no longer available at the scale it was when the Christian Brothers worked in education and nuns worked in hospitals.

It is therefore important that this board will have representatives of the consumer. I believe Lord Denning described the ordinary man as the man on the Clapham omnibus, and this man often suffers in the hospitals. If one has enough money, it is sometimes possible to get a service that is otherwise unavailable. There will be equality of service. The gaps in the scope of enforcement that have existed for too long and allowed too many unscrupulous people to escape ordinary moral standards are being closed by this Bill.

I am glad the Minister has mentioned the standards in the care of children in pre-school and foster care as well as old people being cared for in types of boarding houses. These people will also be protected through HIQA.

I will refer to the Minister's speech in which she briefly mentioned the functions of the authority. I will not go through all of them because her speech contains too many and I prefer to speak off the cuff rather than read.

The first functions mentioned are to "set standards on safety and quality for all services provided by the HSE and service providers on behalf of the HSE, and private nursing homes, with the exception of mental health services which are covered by the Mental Health Commission and the Inspector of Mental Health" and "monitor compliance with the standards it sets and advise the Minister and the HSE on the level of compliance".

It is hoped inspections will take place unannounced and someone will drop in and see what is happening on that day. The ultimate mistake in the past was to announce inspections. If one knows an inspector is coming, it is easy to prepare. I hope HIQA will send people without notice.

The functions also include to "undertake investigations as to the safety, quality and standards of services where the Minister believes there is serious risk to the health or welfare of a person receiving services". I hope a need for such an investigation will not arise. From my reading of the Bill, if HIQA operates with the vigour the Minister intends, we will not have investigations because the standards of registration will automatically ensure we do not have rogue traders.

Another function will be to "carry out reviews to ensure best outcomes and value for money for the resources available to the HSE". During my interview this morning, I was asked what was in the national development plan for the current health budget. I stated that in 2005 approximately €4 billion was taken in income tax from ordinary taxpayers and €13 billion, more than three times the total income tax take, was spent on health services. To me, that is enough. It is now time we saw value for money. I hope the inspectorate will also scrutinise HSE resources. We have had too many failures in the past.

The next function mentioned is to "operate accreditation programmes of health and personal social services in both the private and public health sectors" and "carry out assessments of health technologies, including drugs and medical devices". It has always amazed me that one can buy a ventolin inhaler in Spain for approximately 20% of what it costs in Ireland. From my association with sport, I know many athletes who must take ventolin. It is one of the drugs banned by the new authority and one can only take it with the authority of a doctor.

Having been in Lanzarote with the Wexford hurling team and seeing the number of young men entering shops to buy inhalers, I recommend to the Minister of State at the Department of Health and Children, Deputy Tim O'Malley, that the cost of drugs be taken into the remit of HIQA. It is a scandal that although we are in a common market we do not have a common price for drugs. Not only do we not have a common price but the price in Ireland is extortionate when compared with the countries with which we trade on a daily basis.

The authority will also "evaluate information available on services provided by the HSE and other service providers and the health and welfare of the population". I congratulate the Minister and the Ministers of State for their courage in seeking standards which have been commonplace in industry for many years.

Mr. Glennon

Listening to my colleague, Deputy Tony Dempsey, I cannot help but remark on the confluence of opinion between us right down to the issue of sportsmen and ventolin inhalers. I do not know whether it is because this is the first day back and we are looking at a different future to most Members of the House. One of the key pieces of equipment in the gearbags of a remarkably high proportion of young men playing physical sport is a ventolin inhaler. I suggest the figure is in excess of 30% which is remarkable when one considers the pressure on one's breathing which high-level sport automatically brings with it.

While I do not wish to play politics with this issue, it is most unfortunate Deputy Crawford's colleagues in a putative coalition are absent from the Chamber, particularly given that within the past hour they saw fit to enter the Chamber and call a quorum. For such important legislation as this not even to have a token presence in the Chamber says something. I will not draw further conclusions from it.

Regarding the Bill, a particular paragraph from the speech by the Minister for Health and Children is worthy of repetition.

Step by step, in the reform programme and legislation, we are leaving behind the old system which for too long included inconsistent standards across health boards, opaque and incomplete standards and even no standards. It gave us inconsistency of enforcement, some legal incapacity for enforcement of residential care standards and gaps in the scope of enforcement in these settings.

Some would also state it left opportunity for no enforcement whatever. The paragraph continues:

We are also leaving behind the old system in which vital information in health was not comprehensively gathered and assessment of new technologies and drugs was not clearly and systematically made to serve the interests of patients and taxpayers alike.

This paragraph accurately sums up the sheer magnitude of the task facing not only the Minister but particularly Professor Drumm and the staff of the HSE. It is a mammoth task which by no means will be easily achieved. However, it must be achieved not for any political reason but for quality of life and the confidence of people in the body politic.

My colleague, Deputy Tony Dempsey, referred to inspections and not only do I wish to endorse what he stated but I also want to add my opinion. For a long number of years, this country has had a culture of what I call "Irish inspections". The Revenue Commissioners have come out of a lengthy process of modernisation, updating and depersonalising while at the same time retaining a high professional standard. They are now a model for the type of inspection culture we should have.

Currently, we are in the throes of the early stages of a similar change in attitude to drink-driving. Specific traffic corps, usually from another Garda district, are brought in to deal with inspections. That is as it should be. This Bill is mainly about inspections and for inspections to be what they claim to be and to serve the purpose they must, the culture of "Irish inspections" must be eradicated from the system.

This Bill provides us with an opportunity to take another step along the road and eradicate the defects in inspections in the health service. It will take a strong man or woman at the top and a strong management team to do it. However, it must be done not only to achieve the end result in the health service in particular but also because of its place in the overall culture of inspection in Ireland.

This culture has probably generated an imbalance in politically correct attitudes in an attempt to eradicate the culture which has been in place for so long. It is interesting that we are discussing a poor culture of inspection and political correction. There must be an imbalance if we are to rectify the deficits in the system. I wish the very best to the Minister and chief executive of the HSE in their efforts to address this task.

Another issue I wish to address is whistleblowing. I will quote very briefly from the Minister's speech. In the final paragraph, she stated:

In line with a commitment that I gave last year, I will introduce specific provisions in the Health Bill regarding the protected disclosure of information. Those provisions will support the existing statutory frameworks governing health professionals and those in the recently published Medical Practitioners Bill 2007.

I do not doubt that it is very important that we facilitate whistleblowing. In a previous life, I dealt on a daily basis with the Medical Council and am also aware of excessive facility being afforded to whistleblowers because there are professional reputations on the line in every instance of whistleblowing. I look forward to the Minister producing balanced legislation in this regard and wholeheartedly welcome her statement to the effect that there will be a lay majority on the new Medical Council under the proposals in that legislation, which is yet to be put before the House. I have called for that in this House in the past and am delighted to hear that it is coming and the nettle is being grasped. I do not see that the medical profession has anything to fear. Deputy Tony Dempsey referred to an old Latin phrase which I cannot remember but which translates as "who guards the guards?", or in other words, "who polices the police?". It is time that self-regulation in this country is seen for what it is, namely, a behemoth of times past for which there is no place in a modern democracy if we are to have public confidence in the political process. Objective deliberation in respect of the policing of all the various professions is a fundamental necessity.

In conclusion, I refer to a particular issue of relevance to my constituency. The importance of this issue can be drawn from the fact that Leas Cross is literally across the road from my constituency. It was originally part of the constituency that elected me but is no longer located there. However, a significant number of its patients were from my constituency. Beaumont Hospital, which has many problems, is the principal hospital for my area. The north Dublin GP co-operative, which was the last such co-operative for out-of-hours coverage to be introduced in the country, covers my area.

This area is not one that has experienced all the positives of our health service by any stretch of the imagination. The major negative it has suffered from has been the affair at Our Lady of Lourdes Hospital, which is the other hospital in my catchment area. Again, I take no pleasure from renewing my call in respect of this issue, but I want to ensure I avail of the opportunity available to me today. The plight of the victims of Michael Neary and what took place at that inquiry deserve to be highlighted again.

This is the ninth new year through which the victims of Micheal Neary have lived since the scandal first broke. We are all aware of the horrible suffering they have endured. They have dealt with this suffering in a most professional and rational way and their courage and contribution to medicine in this country has been praised by the president of the Medical Council, Dr. John Hillery. They have shown remarkable patience and strength during those nine years. Unfortunately, we are at a stage where if there is no immediate action, the State will again fail these women and their families.

An Leas-Cheann Comhairle

Deputy Glennon must conclude.

Mr. Glennon

I will conclude by stating that of the victims of Michael Neary, two lost full-term healthy babies due to negligence at birth. A small number of other women underwent unnecessary and profoundly damaging gynaecological procedures in the unit. The exact number will not be known until all medical reports are available, but the number will not exceed 20. In total, approximately 200 women suffered damage, a word I use deliberately, at the unit. These women ask for and deserve nothing less than closure and acknowledgement. Justice can never be given to them to compensate for what they have lost, but I urge the Minister of State, Deputy Tim O'Malley, to convey to the Minister my view that this issue should be dealt with and a redress scheme put in place at the earliest opportunity so that these unfortunate victims, for such they are, receive closure and acknowledgement in the same fair and even-handed manner in which they have approached their difficulties.

Mr. Crawford

I wish to share time with Deputies Connaughton and Deenihan. I cannot help but start where Deputy Glennon finished and give total support to the women to whom he referred, which has been evident across parties. I represent Cavan-Monaghan in which a number of patients who were dealt with in such a dreadful way by Mr. Neary live. There is complete recognition of the facts. Although there were questions afterwards about how the matter was initially dealt with by the medical services, there is no question about the results. I add my voice to those urging the Minister of State, Deputy Tim O'Malley, to ensure that the Minister deals with this issue as a matter of urgency because it is something we can all do without. Whatever little help can be given to these women in their desperation should be given.

The issue of Leas Cross is a sad saga. The majority of nursing homes in this country have a tremendous record. I think of St Mary's Hospital in Castleblaney and the tremendous service it provides to all the people who go through its doors. I also think of the Sacred Heart Home for the Elderly in Clones and many others. However, this does not mean we should turn a blind eye to what has happened in those nursing homes that have been exposed.

It is vital that this Bill is not just passed by this House but is properly financed and that the inspectorate does the job it is supposed to do. We are very good at passing legislation. I cannot help but remember the Bills which went through this House in 1989 regarding meat and bone meal. If they had been acted on then, we would certainly not have experienced the BSE crisis six years later. It is vital that this Bill's provisions are properly financed.

But for a proposal introduced in this House by our party leader, Deputy Kenny, and supported by Deputies Twomey and O'Dowd, we would not have this Bill and in that context, I welcome it. However, without proper funding, the Bill will not work. I appreciate the Bill gives the inspectorate the power to close nursing homes if it finds anything wrong with them and that there will be proper fines, but any inspection must be an on the spot inspection. Not long ago, I remember Department officials in another field telling us they were going to conduct an inspection three months later during the first week of a particular month. If somebody knows that something is going to happen, it cannot be called an inspection. It is purely a visit. When one has visitors coming around, one normally puts out the best china and has the parlour ready.

There must also be inspections of other health services. I spent a few days in Monaghan General Hospital during the Christmas recess and was most impressed by its level of cleanliness. It reminded me of the old days, as referred to by Deputy Tony Dempsey, when hospitals were run by nuns and other groups that had proper structures in place to ensure cleanliness. If that were still the case, MRSA and other problems of that nature would not have gained such a foothold. It is almost sickening to visit a home where an elderly parent has died due to contracting MRSA when in hospital for a minor operation.

Although the Government has made many promises about extra help for the elderly, it is not yet in place. Home help services employ agency staff rather than those who want to be employed. People who require ten hours of home help a week receive two hours. I referred previously in the House to one of the worst cases I came across which related to an individual in Carrickmacross in south Monaghan. A person from there had spent two months in the National Rehabilitation Hospital in Dún Laoghaire. The individual concerned was sent home last August or September with the promise of physiotherapy services etc., but to date has received no treatment. Physiotherapists were available but none was provided to treat this person. None of the newly qualified physiotherapists who graduated from college this year was employed. That is a serious situation. In this case the individual was in their 40s. An 18 year old in the same town also failed to receive treatment following an operation with the result that the operation was a dead loss because nothing was done subsequently to follow up on it.

I am not sure how much time is left.

An Leas-Cheann Comhairle

If the time is being divided equally the Deputy's time is up.

Mr. Crawford

Subvention is still a major problem. The new rules were introduced before the Dáil went into recess last year. When I spoke to people in the subvention office yesterday it became apparent they did not know of the new rules yet, although all cases were supposed to be brought up to date by 31 January 2007. That is totally unacceptable. It is the wrong way to treat the elderly.

Mr. Connaughton

Will the Leas-Cheann Comhairle tell me when 14 minutes of my time has elapsed?

Like most Members, I welcome the Bill but I cannot understand why it was not introduced long before now. It has been sought for the past couple of years.

Mr. Sherlock

The system is long in need of reform.

Mr. Connaughton

I assume we would not be here today were it not for what happened in Leas Cross and in other places. I cannot understand why the Government dragged its heels for so long on this matter. It had to be dragged in here screaming. I have heard all sides of the argument, including from the Minister for Health and Children, but none of it made any sense. This legislation should have been enacted a couple of years ago. Many people will welcome the protection provided by the Bill. It was within the remit of the Government to introduce this measure but nothing was done. I accept it is not the fault personally of the Minister of State, Deputy Tim O'Malley, as I assume he would have wished to introduce it earlier. There is no indication of why the Government dragged its feet on this issue.

The setting up of the inspectorate would not have involved major difficulties. The Government's aim should be to extend protection to the most vulnerable in society. The legislation should provide the best possible protection for the elderly when they are committed to care. There is nothing very complicated in that. I am still bewildered as to why the legislation was not introduced before now.

I hope the legislation will provide what people want. There is no more vulnerable place than to be than lying on one's back in a bed other than one's own. Given his job, the Minister of State is no doubt familiar with this but most people can understand the difficulties attached to being aged over 70 or 80 with a disability and having to depend hand and foot on somebody else who is not a relation for help. No matter what gloss one puts on it, none of us would like to be in that vulnerable position.

I concur with my colleagues' views on the inspectorate. I do not object to a stock-taking audit of nursing homes where nursing home owners are warned in advance. The people of east Galway who elected me and people from everywhere else want a "flying column" approach that would allow the inspectorate to strike at any time of day or night, Saturday or Sunday, Christmas Day or any other day. That approach should be expected from the new inspectorate. The fear of an unannounced visit would ensure any organisation would keep on its toes.

My experience is similar to Deputy Crawford's, in that nursing homes I know are perfectly run. I have not heard a single complaint about them. However, I accept there are bad apples in the barrel and the number will increase if people think they can get away with it. It is vital for the legislation to incorporate a strict code allowing the inspectorate to strike at any time without warning. I assume that is the direction the Government will take but given the length of time it took the Government to introduce this provision I would not be surprised by anything.

The Minister announced an increase of €100 per week in the subvention. I concur with what Deputy Crawford said. I have been told the rules of the scheme have not been made known. When the Minister announced the increase it was to come into operation from 1 January 2007. It should be up and running. The sting in the tail is that 15% could be retained under certain conditions where the family home would have to be sold. That was a tentative proposal which was unlikely to be implemented legislatively until after the general election. How cynical can we be?

There would be no better way to split families, cause infighting and put the fear of God in the elderly than to introduce such a scheme. I am totally against such a concept. I received two telephone calls today from families whose elderly relatives wanted to know before they went into a nursing home whether there was any danger that the family home which they hoped to pass on to a son or daughter would become subject to the 15% rule. If that is happening before the legislation is introduced, can one imagine the trouble that will arise after its introduction. In fairness to the Progressive Democrats and Fianna Fáil, there was no danger it would be introduced until well after the election, one way or the other. What cynicism is this? I hope the elderly will see through it. There is no doubt the Government has managed to frighten them.

Mr. Deenihan

I welcome the opportunity to speak on the Bill and this very vulnerable sector of society. Unfortunately the benchmark for success as seen by the Government and a large number of commentators is how the economy is progressing. The economy should be seen as an important part of society as it provides the necessary resources to enable the most vulnerable and those who need support to get it. Those who look on the economy in isolation have tunnel vision of how a society should be run.

We politicians are elected to represent the entire society, not just a particular sector. That is why the Bill is important although we in the Fine Gael Party do not agree with all aspects of it and consider it should be more comprehensive. I understand that our spokesperson, Deputy Twomey, will table amendments to improve the Bill. Nevertheless, it is important for the type of protection it will afford to three vulnerable sectors of society, children in residential services who are in need of care and protection, people with disabilities and older people.

I understand there are approximately 21,000 patients in public and private nursing homes. According to Government figures the number will increase to 44,000 by 2036 and to 61,000 by 2056. That is a conservative estimate. From my experience, people are living longer because, generally speaking, when they go into nursing homes they get better care and more services are provided for them. Due to isolation and given that families are not as committed as in the past to looking after their elderly relatives, more elderly people will go into nursing homes. There is no doubt this will result in a greater imposition on the budget to provide services for them.

In general, our nursing homes are in good condition and have good hygiene standards and a major effort is made to keep patients and their environment clean. Unfortunately, there have been exceptions where nobody seems to have bothered. That nobody monitored or supervised what was happening means there are a number of bad examples. Hopefully the Bill will provide the protection people need.

When replying will the Minister indicate whether standards will include accommodation, qualifications, numbers of employees and screening of employees, their background and so on. Employees who work with vulnerable people must be of the highest calibre and have an impeccable record and must be of sound character. Recently we discussed an advocacy Bill for people with disabilities. Will part of the remit of the chief inspector of social services be to provide advocacy services for patients and, if so, is that provided for in the Bill?

There are respite centres for children with disabilities. Are such centres provided for in the Bill? Given that it is important for a parent who has a child with special needs to get rest at the weekend, the child is placed in a respite centre operated by the HSE or by other organisations. Is that provided for in the Bill?

On the issue of care of the elderly, the home care package is weak; I am aware of this from recent experience. If we were to depend on the home care package to keep people at home they could not stay at home unless other services were provided. While it has been said that a good home care package exists, that is not the case. The back-up services for people who come out of hospital following a stroke or a serious operation are not as extensive as they might be. Unless a family member is present or unless the family pays somebody to be present, the home care package as it exists is not adequate to provide the type of support needed by older people recovering from illness and who may never fully recover to allow them stay at home as is their wish.

There is a certain therapeutic aspect for an old person to live in his or her own home. It helps them to recover and remain positive. In many cases when people are institutionalised they give up hope and just wait until their life ends whereas when they stay at home they are far more positive.

I welcome the Bill. It provides us with the opportunity to debate the issue of care in nursing homes. Perhaps the Minister will indicate if the three issues I have raised are provided for in the Bill?

Mr. Ardagh

I wish to share time with Deputy Carey.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Mr. Ardagh

I am delighted to have the opportunity to contribute to the Health Bill 2006 which provides for the establishment of the Health Information and Quality Authority and the Office of the Chief Inspector of Social Services. The area that concerns me is the form of governance that will apply. I hope to be convinced that, as a result of this, there will be separation of responsibility and that the bodies responsible for these important areas will be accountable in a proper governance way to the Minister and to the board of the HSE.

It is not good enough that the Office of the Chief Inspector of Social Services should report to HIQA. Similarly, it is not good enough that HIQA should just report to executives within the HSE. What is being done by these bodies is so important that there must be a degree of independence for the executives that they can, if they see something that needs to be changed, report that to the board of the HSE directly in some way without fear of offending an executive of the HSE. If the Health Information and Quality Authority is to set the standards of quality and safety in many areas, it should not be constrained. It should ensure that those standards of quality and safety are world class. The head or chief executive of HIQA should on occasion, whether it be quarterly or twice yearly, report to the board of the HSE without the executives of the HSE being present.

The HSE, effectively, would have responsibility for HIQA. Normally, on an administrative basis, the chief executive of the HSE would have that responsibility. However, we must ensure that the authority is not in any way prevented from ensuring that the highest professional standards that apply throughout the world also apply in this country. The Office of the Chief Inspector of Social Services is under HIQA and will assess whether these standards are being applied and adopted. It might be better if that body was separate from HIQA, although still reporting in the same way to the HSE. It could have the same governance with regard to reporting to the board as I have suggested for HIQA.

There are times when the Office of Chief Inspector of Social Services might see instances where the standards are being applied but where it is obvious that those standards could be improved. The inspectors must be in a position, without offending anybody in HIQA, to recommend that standards be improved, whether it be in nursing homes, the provision of occupational therapy or chiropody services or other home care services. They should be able to report, without fear, directly to the board of the HSE or a committee of that board on a quarterly or semi-annual basis, just as an internal audit committee within the HSE probably reports to another committee of the HSE board without the presence of the chief executive or other higher executives of the HSE.

This already happens in State organisations. The National Pensions Reserve Fund Commission and the National Treasury Management Agency work together and Dr. Michael Somers is still the chief executive. The two bodies work hand in glove very effectively. A more independent HIQA and chief inspector of social services should be considered so there would be a separation of responsibility and greater independence. It would result in a greater degree of double check within the system. One body would be able to balance the other body and improve the service rather than have it in a position where it would just carry on in a certain fashion because that is the way it was done last year.

There are many other things I could say about the board but as this is a health matter and I am a representative for the Dublin South-Central constituency where Our Lady's Hospital for Sick Children is located, this is an opportunity for me to state that I fully support the national children's hospital being located on the site of the Mater hospital. It should be proceeded with. Any further delay will be to the detriment of the many children who need the world class tertiary services that can best be provided by a single hospital in a single location.

However, the team in the Crumlin hospital have spent much time exploring the design of a world class tertiary facility in that location and, as a result, has developed a valuable body of work and a good knowledge base. It would be an awful pity if that is not used and developed with the other methods being applied. There is a stand-off at present and this is not the time for it. Hopefully, wiser counsel will prevail.

The question of location should be put to bed at this point. I cannot understand how access can be a problem. Consider Dundrum Shopping Centre where ten times, if not 100 times, the number of cars enter and exit on a regular basis. It means there are three entrances to the car park but it is not beyond the imagination of the designers to have at least two entrances to the multi-storey car park at the Mater hospital. That should not be a problem.

The knowledge available from the Crumlin team should be recognised, brought on board and used with the knowledge provided by the Temple Street hospital and Tallaght hospital personnel. The new hospital should be put in place as soon as possible.

Mr. Carey

I appreciate the opportunity to comment on the Bill. I compliment the Minister on her courageous programme of reform, which has not always received the support of everybody in this House or across the country. This legislation is part of that reform programme. What the Government is doing in this and other areas will stand the test of time.

I commend the Minister on her steadfastness on the new tertiary paediatric hospital on the Mater Misericordiae Hospital site. Although some might say I do this because I live on the north side of the city, it has little to do with that. I want to debunk a number of issues that have arisen from time to time. Deputy Ardagh mentioned the question of access. A great deal of our time on the north side of the city is spent discussing with the Railway Procurement Agency the alignment of metro north and the type of stations there will be. It escapes some people that Mountjoy Prison will be gone to a site on the outskirts of Dublin long before the hospital is built. It might not be perfect, but it is the site that has been chosen for it. That will free much space for expansion and redevelopment of that part of the city. The specialties in Temple Street, the Mater, Beaumont, St. James's and Tallaght hospitals will complement each other.

I support the thrust of this Bill. As other speakers have said, there is a culture here of avoiding inspections if we can get away with it. I come from a profession where, at my level, we were regularly inspected. As time went on pressure mounted to ensure we were warned of inspections well in advance. I cannot say I complained overly about that. As Deputy Crawford said, sometimes the best china is brought out and a lick of paint might be applied to smarten up a place that might not otherwise look its best. I see the same arising in farm inspections. There must sometimes be unannounced inspections. We have examples of best and worst practice in supervision, inspection, monitoring and the implementation of legislation. One of the best examples I know is the Office of the Director of Corporate Enforcement because it is built on robust legislation and has independence and resources. We need to ensure this Bill has the same strength. If what happens in this city is any guide, the planning enforcement legislation is almost a laughing stock. It is not strong enough to force offenders to comply, penalties are inadequate and resources are not granted to it.

Even when the most rigorous measures are in place some people will always find ways to avoid complying. For example, the Police Ombudsman for Northern Ireland, Mrs. Nuala O'Loan did not get complete co-operation from all of those she was trying to question for her recent report. Let us hope the Garda Inspectorate does not fall into the same trap of becoming part of the system. The proposed inspectorate we are discussing here must be at arm's length from the HSE and maybe the House will tease that out on Committee Stage. A degree of independence and distance is important. In education, with which I am reasonably familiar, we have the National Qualifications Authority of Ireland, which, in the short period of time it has been there, is respected. It monitors the quality of courses, the environment in which courses are delivered and, to a certain extent, teaching. A good example of an organisation with teeth is the Food Safety Authority of Ireland. Sometimes authority is built around the personality of the chief executive or the chairman of the board, but the FSAI is built on good legislation. I do not know which Government was in power when it was established, but whoever was responsible for it deserves credit as it is robust.

This proposal to establish the HIQA is important and good. Its role needs to be sharpened and defined further. The roles it is designated to carry out are clear and wide ranging, and my only reservation, as articulated by Deputy Ardagh, is its governance, reporting role and independent functioning. There is a danger that an overarching body such as the HSE can squeeze uncomfortable parts of its operations if HIQA becomes a thorn in its side. We have seen bodies that were originally established as independent being emasculated, being subsumed into Departments and their powers and effectiveness being reduced further.

The public health system stands rigorous examination by any authority or inspectorate. Over Christmas I visited a number of public hospitals such as Blanchardstown Hospital and St. Mary's Hospital in the Phoenix Park, and smaller operations such as Seanchara in my constituency, where there was a warm, welcoming atmosphere. As Deputy Burton knows, St. Mary's will never win prizes for architecture but it will win prizes for quality of care. Although it is not right to say this, people are almost killing each other to get into it and that is a testimony to the staff who work there and the quality of provision there. On the other hand we have seen private nursing homes where the quality of care is less than satisfactory. I am also a great believer in day care centres. The HSE has recently opened two such centres in my constituency, Nether Cross and Odin's Wood. Before Christmas, a time when people may not feel at their best, I was impressed by the quality of care, the delivery of services and the happiness of the people there.

The office of the chief inspector of social services has operated on an administrative basis since the late 1990s. There are convincing arguments for setting the HIQA and the inspectorate of social services apart from each other. There is potential for confusion and the organisations working at cross purposes. I am not certain the functions of the social service inspectorate in monitoring the delivery of foster care, the quality of provision in pre-school centres, crèches and detention centres, of which there is one in my constituency, under the Criminal Justice Act 2006, and the monitoring of standards, care, staffing and resources can sit easily with the functions of the HIQA. I am open to persuasion and the thinking may be that one may complement the other. There is at best the possibility of duplication of inspections, registrations and monitoring of standards. At worst there is the possibility of deliberate confusion between the roles of the two authorities. It needs to be clarified whether they will be separate sub-committees of a HSE executive or just administrative units with some joint reporting role. The Minister in her reply may be able to satisfy some of our concerns.

Like Deputy Glennon I welcome the commitment to the provision regarding whistleblowers from within the health service as this is necessary in light of experience. The Bill has the potential to be effective legislation but its functions and operations need to be teased out.

Mr. Sherlock

I wish to share time with Deputy Burton.

I have listened to the other speakers during the past half an hour. It is pure sickening to listen to what is being said on this issue.

With regard to the care of the elderly, the issue of referring patients to private nursing homes arises on a daily basis. It is the practice in general hospitals to give families of patients application forms for nursing homes and they are advised they will receive a subvention. I refer to a case in Mallow General Hospital. An 86 year old lady, dependent on her pension, whose family could not afford to pay for a private nursing home, was told she had no choice but to accept the private nursing home and that the subvention would be paid immediately. A total of 500 people in the Cork-Kerry area are waiting for enhanced subvention. Is this the correct kind of treatment for our elderly people when in excess of 500 people are waiting for enhanced subvention?

In one case in the north Cork area, an application was made in November for a person who is severely disabled and the basic subvention has still not been paid. What authority has a HSE employee in a public hospital to direct a person to a private nursing home? They order people to go to private nursing homes. The payment of subvention is the big issue. No extra beds are provided in public hospitals and no provision has been made by way of contracting out arrangements between the HSE and private institutions. This matter needs to be fully investigated in the interests of our elderly. The services can be provided directly by the HSE in one of its hospitals, in another publicly funded hospital or by way of contracting out arrangements between the HSE and a private institution. The current legislation does not provide for this. If the Government wishes to provide for our elderly people, why does it not contract with the private nursing homes and pay the amount required?

The management of the general hospital system was referred to in a "Prime Time" programme last night. In 1989, Mr. Justice Gannon in the High Court granted that a proposal to discontinue acute services at Mallow General Hospital was void. It is a designated general hospital linked to the Cork University Hospital which takes all the share of the allocation. Mallow General Hospital should be treated like any other general hospital. The number of beds should be increased as they were reduced in the mid-1980s from 103 to 80.

I reject the decision of Comhairle na nOspidéal and adopted by the Government to reduce accident and emergency facilities at the hospital. This matter has been debated many times. Mallow General Hospital currently services more than 100,000 people and it is estimated this is set to increase substantially. The town is a designated hub town and a growth area under the national development plan. It has been established by the GPs in the region that the downgrading or removal of the 24-hour accident and emergency service at Mallow General Hospital would leave some patients two hours from acute care. Mallow General Hospital is a valued facility in its local community and catchment area. Patients benefit from visits from relatives and friends. Tertiary hospital care is very important in the health care system although it treats a very small proportion of the population compared with those treated in primary care services. The hospital staff in Mallow General Hospital are to be congratulated on the hospital winning the national hygiene awards in 2005, with an increased score from 88% to 91% in the section for national acute hospitals. The management team at Cork University Hospital is also responsible for the management of Mallow General Hospital and it is natural that priority is given to the university hospital rather than to Mallow. Ninety per cent of people requiring hospitalisation can be treated in the general hospital system. I do not wish to say anything against Cork University Hospital but the daily cost is twice that of Mallow General Hospital. There has been no progress in the matter of the day procedure unit at Mallow General Hospital. It is surprising that capital funding was referred back to the Department in 2005 by the HSE and not utilised to make provision for this unit.

It appears the response of the Government and the HSE is to encourage people as much as possible to pursue private health care. A new private hospital will be built in the Cork University Hospital area. I refer to the traffic situation in Cork and the amount of money being spent on the car park. It makes little financial sense to transfer patients by ambulance from Mallow to Cork to treat them in Cork University Hospital, when one considers that the estimated daily cost per patient in Cork in 2005 was €848 as against €574 in Mallow. The appointment of a consultant radiologist at Mallow General Hospital has been delayed since 2001. I ask the Minister of State to inform the House of the current position. The installation of a CT scanner is worthwhile.

There are significant issues to be addressed regarding the care of elderly people and the position of smaller general hospitals.

Ms Burton

I was interested in the comments of Deputy Carey, whose constituency borders mine, on the selection of the Mater Hospital site for the new national children's hospital. It is ironic that the Government was able to spend tens of millions of euro on hundreds of acres of prime farmland at Thornton Hall for a new prison but could not acquire a site for a maternity or children's hospital. Perhaps it should consider investing similar amounts in our children and on prisons. I do not know if any member of this Government, which is characterised by a lack of joined up thinking, ever considered that Thornton Hall, with its access to the M50, might be worthy of consideration as a site for the provision of children's and maternity services.

Yesterday the Government, in the style of the Soviet republics of old, launched a great leap forward with its next six-year national development plan. People find it hard to comprehend expenditure of €184 billion because such large numbers tend to swim around in one's head. In Stalinist Russia the authorities showed pictures of comely maidens on tractors and wheat fields before harvesting to help people understand progress.

A sum of €2 million may be a drop in the ocean to the Government but it is a great deal of money to ordinary people. Since the Government parties took power ten years ago my local hospital, Connolly Hospital in Blanchardstown, has been promised an MRI scanner and other high level radiological equipment. The total cost would be less than €2 million, with an MRI scanner probably costing less than €1 million. Connolly Hospital serves the population of Blanchardstown and surrounding areas, extending as far as Finglas, Dunboyne and other parts of County Meath, but is the only major Dublin teaching hospital without an MRI scanner and up-to-date radiological services.

Unfortunately, west Dublin experiences high levels of crime and violence. With peace thankfully taking hold in the North, Connolly Hospital has replaced the Royal Victoria Hospital and other hospitals as the national hospital specialising in gunshot wounds. If a person requires a scan for either trauma or orthopaedic purposes, to cite only two examples, he or she must travel by ambulance to Beaumont Hospital or the Mater Hospital, both of which are roughly five miles away. However, because the routes of both journeys take in some of the most horrendous traffic conditions in Dublin city and region — in both cases the ambulance must cross the M50 roundabout — the return journey times would probably be roughly two hours in low traffic volumes and four hours in high traffic volumes.

The legislation provides for the introduction of inspection services. Where is the economic justification for denying the fifth largest teaching hospital in the country a basic, functioning MRI radiology scanning system, particularly given that it specialises in trauma owing to the large number of patients admitted with gunshot wounds as a result of the gang wars we are enduring under this Government? What is €184 billion when, over a ten-year period, the Government cannot find €2 million?

Some time ago, the Minister for Communications, Marine and Natural Resources, Deputy Noel Dempsey, stated that the €155 million spent on the PPARS system was a drop in the ocean which would not be noticed. People in Blanchardstown notice that only €2 million of the money wasted on the system could have bought an MRI scanner for their hospital. The national development plan promises much. It can only be broken down into meaningful component parts when one asks why hard-working people who pay taxes to the State at the 42% rate cannot secure basic facilities in a leading teaching hospital in Dublin.

Why is Connolly Hospital being left out in the cold? The upgrade of vital radiological equipment was confidently promised eight or nine years ago when phase one of the reconstruction of the hospital was promised by the Government. Despite the money having been allocated and put in the kitty by the rainbow Government, the Fianna Fáil-Progressive Democrats coalition has not found its feet on this matter. The only reason I can find for the failure to fulfil the promise to provide the equipment as part of phase 2 of the new hospital is the Minister's recent directive that a private hospital be constructed on the grounds of Blanchardstown public hospital. It seems essential improvements for public patients will be long-fingered indefinitely whereas the private hospital initiative is under active consideration.

Irrespective of whether a private hospital is built in Blanchardstown, a matter on which I have given my view, the public hospital requires radiology equipment immediately. It is unbelievable that one of our largest new towns, with a population in excess of that of Waterford or Limerick, should be left without essential modern equipment such as an MRI scanner. Why should Connolly Hospital be left behind?

While I welcome the establishment of an independent inspectorate, it is important to recall that the Leas Cross scandal occurred at a time when the prototype inspectorate was in place. What is the connection between the rush by beef barons and others to become nursing home owners and the long-term provision of care for those who may be frail and require full-time nursing home care in their later years? The answer lies in the availability of tax breaks. Those who build private nursing homes benefit from highly lucrative tax breaks without being required to commit to providing long-term care. The initial round of tax breaks for nursing homes required a commitment of only seven years. After long debates the Minister for Finance, Deputy Cowen, finally conceded my point and extended the period to approximately 15 years.

The accounts of Leas Cross show the company made a pre-tax profit of €619,000 on a turnover of slightly more than €4 million in 2005. Bearing in mind the likelihood that little or no tax will have been liable on this sum due to tax breaks, the figures constitute a return of roughly 16%. This is an extraordinarily high rate of return on a long-term investment such as that required to operate a care facility. These figures alone should have raised questions.

I will refer briefly to the good and bad points of inspectorates. The Inspector of Prisons and Places of Detention, Mr. Justice Kinlen, is in charge of inspecting the prison regime. The poor man produces report after report but the Minister for Justice, Equality and Law Reform, Deputy McDowell, and senior officials in his Department raise two fingers to them. The reason is that while Mr. Justice Kinlen is a fiercely independent rapporteur on conditions in prisons, his position lacks independence. His position is not comparable with that of Nuala O'Loan. Although he can speak without fear or favour, he is not listened to by the powers that be in the Department.

We want an independent, fearless and balanced inspectorate. We do not want a rush to judgment; we want a structured and measured inspectorate that will be fearless and independent in carrying out its job. We want a representative inspectorate that will not look after the primary interests of people getting tax breaks, but the interests of little people.

An Ceann Comhairle

The Deputy's time has concluded.

Ms Burton

We do not want an inspectorate that will be bogged down in paperwork, with social workers afraid to do anything apart from filling in forms while they phone their lawyers about how their positions should be protected, rather than the children, the elderly or disabled people they are supposed to be looking after. We know what works and what does not. It will be challenging for the Minister to show us that this inspectorate will genuinely replicate somebody like Nuala O'Loan in the North of Ireland, rather than a little whimpering organisation that will be the HSE's lap-dog.

I fully support the decision to provide this hospital and I commend the Government for proceeding with its construction. Unfortunately, that fundamental point has been overlooked in all the hysteria surrounding the location of the hospital. It appears unseemly and is at times unsightly to witness the decisive battles in which some people are engaging over the hospital's location. No site will satisfy everybody. Since we live in the real world rather than an ideal one, no location will satisfy every box in any selection process. Many suggestions have been made about the location. Unfortunately, however, in many cases, depending on the arguments being made it is easy to trace the origin of the suggestion. It is no secret that long and difficult discussions have been going on over the location of such a paediatric hospital for many years. Eminent consultants have apparently engaged in localised turf wars to protect their own hospitals. While locally this may be understandable, in the greater scheme of things it can be disastrous. For the sake of sick children, and not just those in Dublin, I plead with the paediatric consultants and nurses in all three Dublin children's hospitals to bury their differences, embrace change and support the building of a new super-hospital as soon as possible. We have had enough in-fighting, so let us move on.

The new national children's hospital will provide care at tertiary level. We will still need many paediatric beds in Dublin to provide secondary care. These beds can be provided in existing adult hospitals — for example, in Tallaght Hospital or on other sites. Let us be clear, however, that the country needs a single tertiary hospital. The HSE commissioned experts to choose the location of this hospital. They chose the Mater site, so let us build on it now.

The paediatric unit at Sligo General Hospital has been providing care of the highest quality to sick children for many years. I pay tribute to the doctors, nurses and all other staff who have made the reputation of the paediatric unit in Sligo what it is. This is all the more remarkable when one considers the cramped, out-of-date facilities that patients and staff have had to endure for years. There have been many promises over the years that the paediatric department would get an up-to-date modern facility. There have been many false dawns. Staff and patients have watched in dismay while other sections and departments within Sligo General Hospital have been extended, renovated or newly built. I know that the staff have no problem with other developments and improvements in the hospital, but at this stage they want a department that will allow them to provide the requisite level of care to their patients. As long ago as when Fine Gael was last in Government, the paediatric staff were promised a new facility but nothing has happened. There is a deep sense of frustration, if not downright anger, that the paediatric unit in Sligo General Hospital is not getting what is needed to provide the right level of care in 2007. The staff do not want any more promises, they deserve a modern paediatric unit. I ask the Minister of State to intercede with the HSE so that this much needed and long overdue facility can be provided as soon as possible.

Mr. J. Brady

I welcome the opportunity to speak on this new Health Bill. As we all know, the Bill is a fundamental part of the health reform programme begun by the former Minister for Health and Children, Deputy Martin, in 2003 and continued by his successor, Deputy Harney, since she took over the Department in 2004. Coming from the north-east, a Cheann Comhairle, you and I know the problems that have existed in that region over the years. We all welcome the commitment from the HSE that a new regional hospital will be built in that area. I compliment colleagues in my town, including the members of Kells Town Council and in particular Councillor Brian Reilly. The council has made land available if the health area executive needs it to build a hospital there. If not in Kells, I hope it will be built in Navan or elsewhere in County Meath. It would be a suitable location for a regional hospital. When the announcement is made, I hope County Meath will be the location.

The programme currently being undertaken includes the most extensive reform of the health system in more than 30 years. The programme's priority focuses on improved patient care, better value for taxpayers' money and improved health care management. The development of a world class public health service is a core objective for everyone in this House. We want to expand quality and access, which we will achieve through greater investment and system reform. No-one can claim there has not been investment in our health services in the past ten years. As a share of national income, non-capital public expenditure on health has increased from 5.8% of GNP in 1997 to 7.6%. We are matching this with reform. The HSE has been established under the reform programme. It is up and running and while it is facing many challenges, I am confident of its success.

A key policy aim of the health reform programme is to deliver high quality services based on evidence-supported best practice. The Health Information and Quality Authority, which this Bill establishes, is central to advancing this aim. The mandate of HIQA is to ensure that world class, quality standards are applied in Ireland's health and personal social services across the public, private and voluntary sectors; to monitor and inspect against these standards; to provide information in regard to the services; and to undertake health technology assessments. HIQA will play a crucial role in promoting delivery of the highest quality and most efficient health services to people in every part of the country. It will provide the common thread of efficiency, quality and effectiveness for the health sector, to help inform and assist decision-making at all levels — national, local and individual0

It is the job of HIQA to ensure that best practice is rapidly, effectively and consistently advanced nationwide, while acting as a resource for planners, health care professionals, patients and their carers to help them make decisions about treatment and health care. HIQA will provide a stamp of assurance for the public and taxpayers that the highest possible standards of safety and best systems are adopted by and embedded within the sector, and that value for money in the delivery of health and personal social services is guaranteed.

Much of the focus on this Bill arises from the fact HIQA will incorporate a new and independent inspectorate and registration authority for residential services. In other words, the Bill provides the means by which we will get tough on setting standards and tough on enforcing standards. Make no mistake, an independent organisation with real power is being created. With this Bill, we are placing the Social Services Inspectorate, SSI, on a statutory basis and providing for its expansion to inspect and register residential services for people with disabilities and older people.

The SSI was established in 1999 on an administrative basis to inspect the social services. The priority at that time was the inspection of children's residential centres run by the HSE and, more recently, the inspection of foster care services. Inspections are conducted against the National Standards for Children's Residential Centres of 2001, the National Standards for Special Care Units of 2002 and the National Standards for Foster Care of 2003, which were produced by the Department of Health and Children. These were the first nationally agreed standards in this area.

The SSI publishes its inspection reports, which include findings and recommendations under standards for best practice. In 2005 the first full round of inspections of all statutory children's residential centres in the country was completed. The SSI uses unique insights gained through inspection to support developments that improve quality in the sectors in which it operates. Annual reports provide an overview of findings in the sector, prioritise areas for improvement and offer a national summary of service provision.

The SSI will now be established as an office within HIQA. It will continue its work in respect of child welfare and protection services. This replaces and strengthens current inspection and registration arrangements. For the first time, there will be a fully independent inspectorate for all nursing homes, public and private, as well as for centres for people with disabilities and children. There will also be clearer procedures to close a centre if its continued operation poses a risk to the health or welfare of residents, including an explicit procedure for an immediate or urgent closure of a centre.

The purpose must be to make sure that the standards set are applied consistently and on a national basis, and that, where necessary, action can be taken quickly and effectively to protect service users. In monitoring standards, HIQA will have strong powers, including the power to enter and inspect premises, access documents and interview staff. HIQA will review and inspect to ensure services are being provided and to investigate serious concerns in health or social services. It will evaluate and provide information to staff and the public in regard to how well services are performing, which will inform the planning of future services. The authority will also assess new and existing drugs and equipment to ensure they impact positively on the quality of life for patients and represent value for money.

Mr. Callanan

I welcome this necessary Bill, which will leave behind poor standards of inspection in the HSE regional areas and create better standards in all our nursing homes, private and public, so never again will we see old people ill-treated, as happened in Leas Cross. Our elderly are entitled to be looked after in a proper and caring environment. I welcome that under the Bill there will be a fully independent inspectorate for all nursing homes for older people, as well as centres for people with disabilities and children.

The Health Information and Quality Authority has very strong powers. It will set national standards and a chief inspector will inspect residential facilities against these standards. Where necessary, the Bill provides for action to be taken quickly to protect service users. This includes provision for urgent closure of centres. There will no longer be an issue with regard to legal capacity to urgently shut down a failing nursing home or residential care unit.

It is fair to note that many private nursing homes have high standards and provide a very good service for their patients in a kind and friendly way. I compliment the Minister, Deputy Harney, for the increase in the amount of subvention from the standard rate of €190 to €300 per week. As she is aware, the amount of subvention paid in the west was grossly unfair when compared to the rest of the country.

I compliment the nurses and care staff in St. Brendan's hospital for the elderly in Loughrea for the great care they provide. I look forward to the building of a new unit there as soon as possible. A new unit for the elderly is also sanctioned for St. Brigid's psychiatric hospital and will be built shortly. This community welfare home is necessary to cater for the Ballinasloe catchment area and the elderly from St. Brigid's hospital.

I welcome the commitment of the Minister to the home care packages. I am a strong supporter of home care for the elderly. Every elderly person should have the choice to be cared for in his or her own home for as long as possible. It is where every person would like to spend his or her final years, although this is not always possible. The introduction of home care packages, increased home help and the easier access to carer's allowance will allow more elderly people to remain in their homes.

Another piece of the home care jigsaw needs support, namely, services provided by the social services, which provide meals on wheels to the elderly and bus them to their local social services day centres, where they can avail of many services and socialise with other elderly people during a game of cards, bingo or other entertainment. This service is important for these people and provides a break to their carers. Respite care is also an important aspect of home care programmes as it provides short breaks for carers.

I cannot let this opportunity pass without complimenting Portiuncula Hospital, Ballinasloe for the great care provided there. I hope it will not be too long before a new accident and emergency unit is provided because the current space is inadequate. I welcome the Bill and look forward to an excellent service for the elderly and for children, a service that will be well monitored and that will ensure nobody abuses the system.

Mr. Sargent

Tá áthas orm an deis seo a fháil. Ba mhaith liom mo chuid ama a roinnt leis na Teachtaí Crowe agus Finian McGrath.

Tá sé thar am go bhfuil an Bille seo againn agus go bhfuil muid ag plé leis an gceist tábhachtach seo. The Health Information Quality Authority is urgently needed. It is ironic that in many residential and nursing homes and in many homes for people with intellectual disability, their kitchens are better scrutinised in terms of health and regulations than the welfare of the residents. We need to put this right urgently. The previous speaker mentioned that 95% of our elderly live at home. Notwithstanding this, we are very concerned about the 5% of our elderly who do not as they need to be protected and to be provided with the best facilities in nursing homes.

As a result of the situation in Leas Cross, my area has become something of a litmus test in this regard. This test should continue to apply given that the situation did not just concern Leas Cross but also the HSE, the issue of responsibility and the matter of other nursing homes cherry-picking the easiest patients. Leas Cross ended up having to deal with many issues for which it was not adequately prepared and there should have been a wider evaluation in that regard. There were problems in Leas Cross and they seem to be the focus of attention while other areas have not been highlighted. We need to look at the broader issues.

The issue of the MRSA virus is an indictment of our system and an indication of some of the deeper problems in our residential institutions and hospitals. The problem indicates there has been a rush to cut corners through such policies as outsourcing cleaning and that the principle of profit before people has been allowed to take hold. This problem has caught up with us now and we can no longer look at the bottom of the balance sheet with regard to issues like cleaning. Cleaning must be done properly and people must be held accountable for how it is done.

I have read that the national development plan will put money into health and plans to provide value for money. However, it seems to miss the point in this regard. If hospitals are dirty and doctors and staff do not observe the highest hygiene standards, heads must roll. Whatever other problems the system may have, it is indefensible that bad hygiene can be accepted. Have heads rolled on account of this, not just the heads of the cleaning contractors who have not done the job properly — perhaps they are not paid enough to do it properly — but also the heads of those who employ them, who can see that standards are not adequate? People must be accountable for standards. Hopefully, the Bill will go some way towards addressing this issue and ensure standards are maintained as they should be.

Mr. Crowe

The Minister for Health and Children, Deputy Harney, talked tough in her statement when she published the Bill last month. She said we were getting tough on standards and on enforcing standards and that an independent organisation with teeth was being created.

As someone who meets every week people who have experienced the unfairness and the lack of proper resources in our health services, I find this kind of hype from the Minister hard to stomach. Fianna Fáil and the Progressive Democrats have been in Government for the past nine and a half years and have had almost a decade to comprehensively reform the health service and ensure that people receive the health care they need. Instead, three Ministers for Health and Children in succession have presided over a system that has failed the people.

This is not a criticism of the great work being done within the system by health care workers who have to provide care in the context of a fundamentally flawed system that fails to give all patients equal access on the basis of need. In April 2006, the latest date for which figures are available, a quarter of patients waiting for surgical procedures in the State had been waiting for more than a year and more than one third had been waiting for between six and 12 months. These patients are predominantly public patients. Those who can afford private health care have fast-track access to surgery. We have two waiting lists, public and private, which is an obscenity. Under our system, the lives of some patients are valued more highly than others. Wealth buys health here. Otherwise, patients are left on a waiting list or on a chair or trolley in accident and emergency units. The Bill will not change any of this. The Health Information and Quality Authority can set standards and monitor implementation, but it cannot challenge the two-tier system that gives better access to services to people in the private health care sector. This is not rights-based legislation.

None of these issues was addressed by the Minister in her opening speech. She concentrated almost totally on the part of the Bill dealing with the chief inspector of social services and on the role of the office in regulating residential services, including nursing homes. However, the Health Information and Quality Authority is tasked in the Bill with setting standards and monitoring compliance with standards for all services provided by the Health Service Executive or on its behalf. How this will be done is unclear.

The Leas Cross scandal exposed how many vulnerable older people suffered as a result of not implementing existing legislation and because of the lack of stronger and tougher legislation. Unfortunately, the latest nursing home inspection reports, published by the HSE, show that the Leas Cross scandal was not an isolated incident. They contain a litany of failures that put the health and safety of residents of nursing homes in danger. These include staff being aggressive with patients and compelling them to take medication; a night nurse left alone with responsibility for 41 patients, most of whom were classified as maximum dependency; used incontinence pads left in open bins; a reception area used to treat a maximum dependency patient; a lone nurse caring for 46 patients overnight; inadequate and improper use of prescriptions and medicines; and dirty and badly maintained premises. The reports also give and account of some homes' front doors being left wide open and report concerns with regard to patients' access to clean water.

The HSE should have published 430 reports on nursing homes by end-December 2006, but only 230 have been published so far. We must wait anxiously to discover to what other horrors some of our older citizens are subjected. Will the Bill address these problems? I doubt it because it is not rights-based legislation and it is unclear how the inspectorate and the authority will relate to individual patients. How will the authority relate to acute hospital and primary care services? Many people justifiably suspect that what is being set up in the Bill is another layer of bureaucracy. It was highlighted recently that the HSE has 3,000 administrative staff, yet it pays millions to outside consultancy firms to advise it on its finances. This is farcical.

Some speakers have mentioned that the Government's cancer strategy is in disarray. It is a mess brought about by neglect and mismanagement on the part of successive Governments and Ministers. The same can be said with regard to the debacle of the proposed national children's hospital. On that issue there has been a total lack of clarity and proper planning, and repeated delays in providing the care and facilities that children so desperately need. Tallaght Hospital incorporates a children's hospital now in limbo. We do not know what services will be left in Tallaght or what will happen with Crumlin. There is a lack of satellite services, but we do not know which will remain. What are parents to do regarding their children? We currently have three accident and emergency departments in Dublin but do not know where they will go in future.

Sinn Féin takes a rights-based approach to health. We believe fundamentally that health care is a right and also that social and economic equality, and therefore the elimination of poverty, the achievement of full employment on fair terms and equal access to essential public services, is a necessary precondition for the vindication of equal rights in the area. This Bill is not in the same ball park regarding health care rights, and that is simply not good enough.

Mr. F. McGrath

I welcome the opportunity to speak on the Health Bill 2006.

This important debate allows us all to make constructive proposals on the running of the health service. Before going into the detail of the legislation, if we wish to sort out the health service once and for all, we must invest. We also need reform and, above all, more beds in hospitals. Anyone who proposes the opposite of such a strategy of investment and reform is not being honest with the electorate. We have the money and resources to look after our elderly, disabled and sick citizens, and it is up to the Government to act on that wish and use resources to assist them. That must be at the core of this debate. Let us end the waffle and invest in change and reform. We must look after the sick and elderly and, above all, the disabled.

It saddens me to hear hospital representatives and politicians fighting over a children's hospital. It is time to end the squabbling and get on with the new hospital. I support the independent and sensible proposal to locate the new children's hospital on the Mater site. The research has been conducted, and I strongly support it. When one considers the details and facts, one sees the real situation. The McKinsey report studied international best practice in tertiary and secondary hospital-based paediatric services and its strategic implications for Ireland. McKinsey was not commissioned to recommend a site for the new hospital, and therefore paediatricians consulted during its preparation were not asked for their views on any site. Those are the facts.

The McKinsey report published in February 2006 stated that Ireland, because of its population size, could support only one paediatric hospital. It was highlighted that the greater the volume of patients and procedures, the better the outcomes would be. Examples were given of where fragmented services had been brought together, with improved survival rates as a result. In other words, that was good practice and in children's interests.

To ensure a critical mass of patients and activity, McKinsey recommended that the hospital be located close to an adult teaching hospital, provide secondary paediatric services for greater Dublin, and be part of a national and city-wide integrated service. McKinsey said the adult teaching hospital should have an appropriate level of specialties. Of the 17 paediatric services across the world that McKinsey examined, 15 were co-located with an adult teaching hospital. Three existing children's hospitals accepted the findings of the McKinsey report. That is the reality, and the Minister for Health and Children and those directly involved should get on and build a hospital on the Mater Hospital site in the interests of sick children.

When one considers the legislation before us, one sees that the Bill provides for the establishment of a Health Information and Quality Authority and an office of the chief inspector of social services, also establishing a registration and inspection system for residential services for children in need of care and protection, people with disabilities, and older people. The core principles therein are extremely positive, and we must ensure that those bodies that implement them have teeth. We have a responsibility to inspect providers and ensure that children in care, those with disabilities, and older people receive a quality service. This debate is about service standards and the quality of service, and the legislation attempts to do something about that.

It always amazes me when I see staff from the HSE go into a public house, in a bike shed behind which one or two people are smoking, and close it down, since it does not comply with regulations. At the same time elderly people are on trolleys or in institutions, and the inspectorate and HSE are nowhere to be seen. Why is swift action not taken regarding such people? Our elderly citizens must be supported and looked after.

Section 6 provides for the establishment of the authority to perform the functions assigned to it under the Bill as a body corporate that may sue and be sued in its corporate name and acquire, hold and dispose of land or an interest in land or any other property. It also provides for the authority to have a corporate seal. Section 7 sets out the authority's functions, providing that it set standards on safety and quality regarding services provided by the HSE and in accordance with the Health Acts, except for services under the Mental Health Acts 1945 to 2001, which are the responsibility of the Mental Health Commission, the Child Care Acts 1991 to 2001, and the Children Act 2001.

We are talking about and insisting on standards for people. It is unacceptable that a constituent should have been waiting in Beaumont Hospital for the last six months for a public nursing home place. That man, in his 80s, is waiting and there is no movement on the issue. I raise those questions because of their importance. As the Minister of State, Deputy Tim O'Malley, is in the Chamber, I also highlight the importance of our developing services for psychiatric patients, particularly mental health services. We must do something in that regard and improve services. Today 60 psychiatrists said that resources and services were not being put in place. The Minister has challenged them on that, but they should get on with the job and act. The money and resources are there, and those people need our support.

Since we are on health, I was astounded and outraged to view a recent communication from the Health Service Executive to the Irish Pharmaceutical Union, the IPU, stating it could not negotiate fees or remuneration with the union for pharmacists operating State schemes, as that would contravene the terms of the Competition Act 2002 regarding price-fixing. That came from the same HSE that quite literally fixed prices with drug-manufacturers last year. I say that regarding the pharmacy sector, about which the Minister of State will know a great deal, given his background.

Pharmacies are a vibrant part of the country's primary care infrastructure. They have always been unique in their ability to deliver on their brief on time and on budget, with scarcely a whisper of patient discontent. They provide an accessible service over long hours and with excellent value for money for the State, often being at risk of robbery and physical violence by virtue of the type of product stocked. Other sectors are beset by constant and seemingly insoluble problems: waiting lists, accident and emergency departments, nursing home scandals, overspends on computers that do not work, MRSA and so on. All the while the professional, responsible management of medicine and drugs in the community has continued without fuss, waiting lists, or public and private case distinctions.

Some 400,000 people visit Irish pharmacies every day. A recent survey found that 95% of people trusted and valued the advice and care of pharmacists, with 71% stating that they availed of pharmacy services every month. Pharmacies are an essential first port of call to keep people out of accident and emergency departments. I raise that to lend my strong support to the IPU in its simple and sensible demands, which are the way forward. Negotiations should commence between the IPU and the HSE on the payment of fair fees for the provision of dispensing services to 75% of subscription-holders in the country. Provisions must urgently be put in place to ensure the continuity of drug supplies during implementation of the drugs cost reduction measures to ensure patient welfare is maintained and that pharmacists are fairly compensated for the changes thrust upon them. Third, appropriate and realistic remuneration must be agreed as a matter of urgency for the continued operation of the methadone scheme to take account of the costs and risks associated with its operation by community pharmacists, whose work I commend. Many have taken risks in that regard. I raise those issues because they are part of any sensible health strategy. If a group of people within the health services are providing an excellent service we should support them.

Section 39 establishes the office of chief inspector of social services and outlines the remuneration, appointment and grounds for dismissal of the chief inspector. It is important that credible people with integrity, who will put care of the elderly at the top of the agenda, are involved in this office. We have many examples of quality public service and now we need such people in this section of the health services to ensure the elderly, disabled people and children are given maximum protection and professional care.

Mr. Dennehy

The Dáil has been recalled one week early, devoting itself to this matter today and tomorrow. Some Opposition spokespersons complained about these arrangements, stating that it was a waste of time. I disagree because we will not discuss anything more important than health care reform and administration. My constituency colleague, Deputy Martin, began reform of the health service and it has been a top priority for the Government since then. It was always likely to be a long and difficult process, immersed as we were in the old methods, practices and thinking.

I was not happy that reform began with disbanding the former health boards which were a public forum.

Mr. Durkan

Deputy Dennehy is right about that.

Mr. Dennehy

This was one of the few areas where the client had an opportunity to seek accountability through the public representatives on those boards. The change was encouraged to save costs and the media supported disbanding the health boards. The money involved was a minor part of the health budget and the accountability provided outweighed the expenditure involved.

For many years we were told that if finance was available it would solve all the problems. This is not the case because the money now spent on health is a multiple of what was spent nine years ago. Those of us who served on the health boards never envisaged such investment. Severe cutbacks were made in the early and mid-1980s, due to the security threat to the State, and we had to compensate for this. However, few of us believed we could achieve the current level of spending so quickly.

Everyone — practitioner, patient, administrator or public representative — will agree that health service reform is essential. Certain practices, not just medical procedures, must change. The PPARS project, designed to set up a human resource management system was heavily criticised. One of the primary reasons for the difficulties encountered was that more than 1,000 agreements or special deals were made across eight health boards. This is one matter that must be reformed. It is incredible that the system was incapable of dealing with such complexity.

The Ceann Comhairle is aware of the most critical issue, the common contract for consultants. This agreement dates from the early 1970s and allows for a mixture of private and public practice. Some argue that it provides the public with access to some of the best consultants in the world. From my health board experience I believe we have a high standard of consultants in all disciplines. The initiator of the agreement told me that an old person with cataracts would have to go blind without this system that provided access to the best practitioners, even though one has to wait for the service. We must achieve the right balance.

It is difficult to quantify the breakdown between public and private practice. Some consultants are methodical in their work, others just want to get on with the job. The clerical and accounting aspects are not looked after. The original argument was that we could not afford full-time consultants in the public service and the best and brightest would leave for foreign positions. That argument does not stand up anymore and, although there may be reason for some degree of sharing, in the majority of specialties consultants should work full time in the private or public sector. The system can always be improved and, in some areas, the number of clients will not justify a full time appointment but this can be teased out over time.

The apparent closed shops within the health board care area must also be examined. Some five years ago members of the Joint Committee on Health and Children spent six months examining orthodontic services. Members were concerned at the cost to patients, double the price in Northern Ireland and much dearer than the same services abroad. They were also concerned at the disgraceful waiting lists involved. Consultants and trainers were brought before the committee but it made little progress. Unless we train more orthodontists we will be in the same situation in ten years' time. It seems this sector is a closed shop.

Accountability must also be on the reform agenda. Earlier speakers referred to the case of Dr. Michael Neary. One of the most damaging aspects of it was the failure of his peer group to deal with the matter correctly. It was a glaring argument against self-regulation by any organisation or profession. This case will be the catalyst for wide-ranging changes in the regulation of the medical profession and other professions. Everyone would argue for internal self-regulation if they could get away with it.

Debate adjourned.

The Dáil adjourned at 7.30 p.m. until 10.30 a.m. on Thursday, 25 January 2007.

Dáil Éireann díospóireacht - Wednesday, 24 Jan 2007

Health Bill 2006: Second Stage.

Dáil Éireann díospóireacht -
Wednesday, 24 Jan 2007