Health (Eastern Regional Health Authority) Bill, 1998: Second Stage.
Question proposed: "That the Bill be now read a Second Time."
Minister for Health and Children (Mr. Cowen): The objective of this Bill is to put in place an organisational structure which will deliver a more integrated, efficient and patient-friendly health service to the people of Dublin, Kildare and Wicklow. Several expert reports over the years have highlighted the need for radical organisational reform of the structures in the eastern region. The existing organisational structure is no longer suitable for the size of the region it serves and the scale and complexity of the issues with which it deals.
The population of the Eastern Health Board area has increased by about 40 per cent in the 30 years since the health board structure was put in place. It now stands at 1.3 million people, compared with other health boards which serve populations of between 200,000 and 500,000. The years since the board's establishment have also seen a marked increase in the range and extent of social problems in the region, such as drug abuse, child abuse and homelessness.
Acute hospital services have also come under pressure over the years, with ever-increasing demands for services. Despite our economic boom, high levels of deprivation persist in many parts of the eastern region and the population, as elsewhere, is gradually ageing. These issues will pose a formidable challenge to the health and personal social services in the eastern region over the coming years. Funding will always be an important issue, but simply throwing money at problems is not the full answer. We need to organise the services in a more efficient and effective way.
The 1994 health strategy emphasised the crucial need to define the strategic role of all the players in the provision of health care. It pointed out that to achieve the integrated and co-ordinated service fundamental to meeting effectively the requirements of all citizens, the roles of the Department of Health and Children, the health boards, the voluntary sector and specialist agencies had to be clearly defined. Since the publication of the strategy, the principles set out in it have underpinned the strategic developments which have taken place in the health sector. These include, for example, the accountability legislation in 1996, the establishment of the Health Services Employers Agency and the agreement with intellectual disability agencies regarding the transfer of responsibility for funding from the Department to the health boards. This legislation on the establishment of the eastern regional health authority is part of that process.
The core problems identified in the eastern region by successive expert reports are: the absence of a single authority with responsibility for planning the delivery and co-ordination of all services for the region; over-centralised decision making within the health board and the lack of an appropriate management structure at district level, and the need for better communication and co-operation between the voluntary sector and the health board.
This Bill is designed to tackle all these problems. It will establish an eastern regional health authority which will have overall responsibility for planning, commissioning and overseeing the delivery of an integrated, efficient and effective service. The main objective of the legislation, while providing for organisational change, is to place the patient as the focus of the collective activity of the health care delivery systems in the area. The organisational changes are designed to enable that objective to be met. They will enable the needs of the patient to be met in a continuous, integrated programme of services across all areas of care.
The authority will not be directly involved in the delivery of services. This will be the responsibility of the three area health boards which are also established under the terms of the Bill. The northern area health board, the south-western area health board and the east coast area health board will each have responsibility for the delivery within their own areas of the services currently provided by the Eastern Health Board. They will also plan and co-ordinate all services within their areas, in co-operation with the local voluntary service providers. The area health boards will enable the delivery of health and personal social services to be brought closer to the people. Decisions regarding the provision of local services will be made closer to the point of delivery and, through the involvement of local councillors on each area health board, more involvement by local communities in the planning and organisation of their health services will be possible.
This Bill also links the voluntary sector more closely into the overall structure of the services. To a much greater extent than elsewhere in the country, a significant proportion of the services in the eastern region are provided by voluntary hospitals and agencies. To date, these have been funded directly by the Department and have no formal links with the health board. The 1994 health strategy acknowledged that the direct funding of the voluntary providers by the Department impedes the proper co-ordination and development of services at local level. In particular, it has hampered the development of linkages between community and hospital services – linkages which are essential to the development of coherent, integrated responses to important health care issues such as care of the elderly.
The Bill addresses this situation by bringing about a major change in the funding arrangements for the voluntary hospitals and agencies in the eastern region. Under section 10 of the Bill, the authority and the major voluntary providers will negotiate service agreements which will formally link the voluntary sector into the overall services in the region for first time. The terms of the Bill ensure that the voluntary hospitals and agencies will retain their operational autonomy, while making them fully accountable for the public funds they receive.
As I have made clear on several occasions in the past, there is no intention on the part of the Department or the Government to take over the voluntary hospitals by way of this Bill or by any other means. The 1994 health strategy made it clear that the independent identity of the voluntary providers would be fully respected in the new structures. This Bill delivers on that promise.
I wish to make clear that there will be no change under the new arrangements in the status or operation of any voluntary provider, whether an acute hospital, an intellectual disability agency or other service provider. Their ownership will not change; their governing bodies, whether boards of management or trustees, will remain and will retain all their functions. There will be no change in the existing personnel and recruitment arrangements. Neither will the new arrangements interfere with the close co-operation between universities and their associated hospitals. What will change is that the voluntary providers will be funded in future by the new authority instead of by the Department of Health and Children.
The funding arrangements proposed in this Bill will ensure, in a more accurate and accountable way than is possible at present, that the £1.2 billion spent annually on the health services in the eastern region is providing the best possible value for money for the taxpayer. Under the terms of this Bill, all service provision within the eastern region, whether the service provider is a statutory body or a voluntary agency, will be on the basis of a written, legally binding service agreement between the authority and the service provider. Service agreements will facilitate better planning, budgeting and increased accountability at all levels of the services. They will ensure a degree of continuity and financial security for providers, while also ensuring that the use of public funds can be fully accounted for. In addition, the Bill requires the authority and each area health board to put systems, procedures and practices in place to monitor and evaluate all services provided on their behalf.
It is fair to say that the proposals in this Bill amount to the most significant reform of health service structures in this country since the establishment of the health boards in 1971. Any reform of this nature is not undertaken lightly, and Senators familiar with the health services will be aware that this particular reform has been in ges tation for some time. The Bill follows closely the recommendations of the task force on the eastern regional health authority, which reported to me in June 1997. The task force consulted widely with all the various interests involved. Meetings and discussions were held with many of the principal parties, including the members of the board and the management of the Eastern Health Board, the owners and management of voluntary hospitals, the voluntary agencies and organisations providing services to persons with an intellectual disability and some staff associations. Therefore, the proposals in the Bill have been formulated and developed taking into account fully the views expressed by those interests involved.
The implementation of the proposals in this Bill will present a formidable challenge to all involved and will take time, patience and perseverance. Much of the preliminary work has been done by the task force but much remains to be done. I hope the members of the new authority could be nominated and meeting informally by the autumn. Allowing time for the recruitment of the senior management and the putting in place of the new structures, I envisage that the new authority will be in a position to take over the functions of the Eastern Health Board on 1 March 2000.
Before turning to the detailed provisions of the Bill, I would like to refer briefly to Part V which is the proposal for a health boards executive. This will be an executive agency serving all the health boards. It is important to bear in mind that its establishment is an entirely separate matter from the establishment of the Eastern Regional Health Authority.
The chief executive officers of the eight health boards have been meeting regularly and co-operating on a voluntary basis for many years. Indeed, since 1996, they have been required by legislation to have regard to the need for co-operation and for the co-ordination of their activities. There is significant potential for further improvements in ensuring uniformity and consistency of treatment and standards across all health board areas. There is also great potential for achieving cost savings through increased co-operation and collaboration in areas such as procurement. At present, the chief executive officers of the health boards have no legal powers to act jointly as a group, or to employ staff or acquire office space to further their co-operative ventures. The establishment of the health boards executive will give them these powers and will put their current activities on a statutory basis so that they can continue and expand that co-operation.
I now wish to turn to the main provisions of the Bill. In Part I, which deals with preliminary matters, section 3 provides that the Minister shall by order appoint a day to be the establishment day for the purposes of the Act, that is, the day on which the authority and the area health boards will come into being.
Section 5 allows the Minister to amend the First and Second Schedules to the Bill. The First Schedule sets out the boundaries of the three area health boards. The Second Schedule is a list of the voluntary hospitals and agencies which are currently funded directly by my Department. The Minister is empowered to amend this Schedule, but he must consult with a voluntary body before deleting its name from the list. I will return to the significance of this provision later.
Part II of the Bill deals with the Eastern Regional Health Authority. Section 7 establishes the authority as a body corporate and defines its functional area, which will correspond to that of the existing Eastern Health Board. It provides that any reference in any enactment to a health board shall be interpreted as including a reference to the authority. This is a simple legal device which allows the authority to take on all the legal powers and duties of a health board. Elsewhere in the Bill, some of these powers are delegated to the area health boards.
Section 8 sets out the functions of the authority. These will consist of the existing functions of a health board and the new statutory functions of planning, arranging for and overseeing the provision of all health and personal social services in the region.
One of the key recommendations of the task force's report was that a clear division should be established in the new structures between the funding of the services and their delivery. Accordingly, the authority will not be involved itself in the direct provision of services. Instead, it is required to make arrangements for the provision of services with the three area health boards and the voluntary service providers. This section also requires the authority to co-ordinate the provision of services in its region, to put in place systems to monitor and evaluate the services provided, to provide details of its monitoring role in its annual report and to have regard to the advice tendered by each of the three area health boards.
The authority is also required, in section 8(2)(f), to have regard to the right of voluntary bodies providing services to manage their own affairs in accordance with their independent ethos and traditions. This provision has been included in the Bill in response to the concerns of the voluntary hospitals and agencies providing services for the mentally handicapped that the new structures might in some way cut across their status as independent institutions.
Section 9 requires the authority to delegate its reserved functions in relation to service delivery to the three area health boards. Reserved functions are those functions performed directly by the members of the board. Together with a similar provision in section 17 dealing with executive functions, this provision will ensure that responsibility for service delivery will rest at area level. However, where the authority decides that a certain function would be more efficiently performed in respect of the whole of the region by one area health board, this section allows it to delegate that function to one area health board.
Section 10 requires the Eastern Regional Health Authority to make arrangements, or service agreements as they are more commonly known, with service providers for the provision of services in its region. These arrangements will apply to the three area health boards as well as to the major voluntary services providers, that is, hospitals and intellectual disability agencies, which are currently funded directly by my Department.
The authority is required to make an arrangement with each area health board for the provision, within that board's area, of the services formerly provided by the Eastern Health Board. However, if it considers it appropriate to do so, the authority may terminate any part of a service agreement which it holds with an area health board and make an alternative arrangement with a voluntary body for the provision of the service concerned.
Every arrangement made under this section, whether with an area health board or a voluntary body, must consist of two parts: first, a long-term agreement of three to five years setting out the general principles by which both parties agree to abide and such other standards in relation to efficiency, effectiveness and quality as may be agreed between the parties. The second part will be an annual agreement specifying the services to be provided in respect of that year and the level of funding to be made available.
In section 10(5) the authority may delegate the making of arrangements to the area health boards, except in cases where the arrangement is with another area health board or with one of the voluntary bodies listed in the Second Schedule. Senators will recall that under section 5 the Minister cannot remove a name from the Second Schedule without consulting the voluntary body concerned. This provision, therefore, acts as a guarantee for the voluntary hospitals and agencies which are currently funded by my Department that they will be funded in future by the authority at central level, until and unless they decide that it is in their best interests to be funded by their local area health board.
Section 11 provides for membership of the authority. In this section, I have followed the recommendations of the Task Force on the Eastern Regional Health Authority which offered, in my opinion, a well thought out and logical solution to a potentially contentious issue. In this context, it is worth bearing in mind that the task force was constrained in its work by a number of parameters which were laid down for it by the previous Government, and accepted by this Government, including the requirement that public representatives would hold a majority on the authority.
This is a principle which I fully endorse because I do not want to see a democratic deficit develop in the governance of the Irish health services, a problem which has occurred in the health services elsewhere. However, we must all accept that once this rule of a majority of public representatives is applied, the scope for substantial numbers of other representatives on the authority is limited, unless we want a body of 100 members or more.
Of the authority's 55 members, 30 will be public representatives, nominated by the six local authorities in the functional area of the authority. The remainder of the membership will be made up as follows: 13 members of registered professions – doctors, nurses, dentists and pharmacists – elected by their peers in the same numbers and in the same manner as currently applies to the Eastern Health Board; nine representatives of the voluntary service providers, appointed by the Minister, and three ministerial nominees. Of the nine representatives of the voluntary service providers, this section provides that three will be nominated for appointment by persons or bodies which the Minister considers representative of the voluntary hospitals, three by bodies representative of the voluntary mental handicap agencies and three by other voluntary bodies.
I acknowledge that, for a governing body, the size of the authority as proposed in the Bill is large. The challenge for the members of the authority will be to adopt, from the outset, working practices and processes which will take account of its size and which will ensure that the overall task is broken down into sensible and manageable parts, enabling full use to be made of all the talents available among the membership. The mechanisms by which this might be achieved are being developed at present by the task force, so that concrete proposals in this regard can be put to the authority on its establishment.
Section 12 provides for the appointment by the authority of a regional chief executive, pursuant to a recommendation from the Local Appointments Commission. It gives the regional chief executive all the powers of a health board chief executive officer by providing that any reference in any enactment to the chief executive officer of a health board shall be interpreted as including a reference to the regional chief executive.
This section also provides that the Minister may appoint the first regional chief executive in advance of the establishment of the authority, for a period not exceeding three years. I am taking this power to myself in order to ensure that the planning and preparation for the new authority can get under way as soon as possible after the Bill has been enacted.
Section 13 provides that the regional chief executive can be required to attend before the Committee of Public Accounts to account for the expenditure of the authority and of the three area health boards.
Part III of the Bill establishes the three area health boards and defines their functions. Section 14 establishes the boards and provides that they will be known respectively as the northern, the south-western and the east coast area health boards. The boundaries of the three boards follow the recommendations of the Task Force on the Eastern Regional Health Authority, which spent some considerable time examining what might be the optimum division of the region and consulting with the various interests involved.
Section 15 sets out the functions of the area health boards. They are required to perform the functions delegated to them by the authority, to provide services within their functional areas in accordance with the arrangements made with the authority and to plan and co-ordinate the provision of all services in their areas, in co-operation with voluntary service providers.
This last function, the planning and co-ordination of services at area level, is perhaps the most vital of all the functions of the area health board. The need for substantial improvements in planning, co-ordination and integration of services in the Eastern region is widely recognised and was one of the key factors in bringing forward the proposals for new structures in this Bill. The role of the voluntary sector in this regard will be crucial.
Section 16 provides for membership of the area health boards. It provides that the membership will be specified by the Minister in regulations, subject to certain parameters as set out in this section. Members of area health boards will be appointed by the authority from within the authority's own membership.
At least one member from each of the categories on the authority – that is, public representatives, health professionals, voluntary sector and ministerial nominees – will be represented on each area health board. Registered professions which have only one representative on the central authority will have the right to attend and participate in the meetings of the area health boards of which they are not a member.
Public representatives will hold the majority on all area health boards and the public representatives appointed to each area health board will be from local electoral areas within that board's functional area.
Section 17 provides for the appointment by the authority, pursuant to a recommendation from the Local Appointments Commissioners, of three area chief executives and their assignment by the authority as to the three area health boards. The Minister may appoint the first incumbents prior to establishment day, pursuant to a recommend ation from the Local Appointments Commissioners. I would hope that these three posts could be filled very shortly after the enactment of this Bill, so that the new area chief executives could begin the preparatory work in their own areas in advance of the establishment day.
Section 18 provides for the keeping of accounts by the three area health boards. The accounts of the authority itself will be governed by existing legislation in relation to health boards. The section is an important expression of the stringent accountability which will characterise the work of the new authority.
Part IV of the Bill provides for the dissolution of the Eastern Health Board and the transfer of its staff and assets to the new authority. Section 19 provides for the dissolution of the Eastern Health Board on the establishment day and the transfer of its land, property, assets and liabilities to the authority. The authority may, in turn, transfer any land, property, assets or liabilities transferred to it under this section to an area health board. This section also provides for the drawing up of the final accounts of the Eastern Health Board and for the continuation of any legal proceedings, resolutions, court orders, notices, rules or regulations made by or involving the Eastern Health Board.
Section 20 provides that the staff of the Eastern Health Board will be transferred to the authority. Except where otherwise negotiated with a recognised trade union, staff transferred to the authority will be subject to terms and conditions not less favourable than those they currently enjoy. Staff transferred to the authority may be assigned by the regional chief executive to an area health board, and if so assigned, will be subject to the direction of the relevant area chief executive.
Staff interests will be fully consulted on all the implications of the transfer process. The task force, which has a mandate to manage and oversee the transition to the new structures, has made it clear that it will continue the consultation process which has been ongoing with staff interests since it began its task. It is also the task force's intention, on the enactment of this Bill, to launch an information campaign which will deal with the concerns of all Eastern Health Board staff regarding the implications of the changes for them and for their work. It is important to bear in mind that only a minority of the 9,000 staff employed by the Eastern Health Board will be affected in any substantial way by the proposed changes. The majority of the staff will continue to work at their present posts, but for a different employing authority. Of necessity, the level of consultation with staff interests to date has been fairly low key, as the Oireachtas has yet to give its approval to the proposals in this Bill. However, I expect that, once the Bill has been enacted, the consultation process will intensify significantly.
Part V, section 21, establishes a health boards executive. As I mentioned earlier, this will be an executive agency serving all of the health boards and its establishment is an entirely separate matter from the establishment of the authority.
The members of the health boards executive will be the chief executive officers of the health boards, including the regional chief executive, and the three area chief executives. It will be a corporate body, with the power to sue and be sued, to own land and other property and to employ staff. It will be financed by the health boards and will make an annual report of its activities to the Minister and to each health board.
Part VI of the Bill contains amendment to other Acts which, in the main, result from the provisions of the Bill.
In conclusion, I remind Senators that the primary objective of this important and far-reaching legislation is to put in place a structure which will enable the delivery of a more integrated, efficient and effective health service for the people who live in the eastern region. It is the result of a lengthy and inclusive consultation process which took into account the views and concern of all the interests involved. I am confident that these proposals represent the best way forward for the health services of Dublin, Kildare and Wicklow and, accordingly, I commend the Bill to the House
I welcome this Bill which puts in place an organisational structure that can respond to the needs of society as we approach the millennium. It takes account of the huge population of 1.3 million people in the expanded greater Dublin area compared with populations ranging from 200,000 to 500,000 in other health board areas. My fear is that the east coast area health board will be top heavy compared to the other health boards. I have a league table of funding, but I find it difficult to interpret. Funding from the Department of Health and Children to the Eastern Health Board is £426.15per capita as compared to the health board in my region which gets £626.42 per capita. The allocations to voluntary hospitals and other directly funded agencies are not included. I would like to have this matter clarified as I am not able to interpret the tables because the allocations to voluntary hospital and directly funded agencies are not included.
There has obviously been a huge population increase in the eastern region, but there has also been a population increase also in the Mid-Western Health Board area. A recent report, Health and Social Well-being in the Mid-West, shows the demographic trends and the areas of rising population. It is difficult to predict the exact nature of the rise in population in the Mid-Western Health Board area because it is related to inward migration, but it is clear there are more births. It is expected that the fastest rate of growth will be in the older population, particularly those aged over 85 years, which will have significant implications for service provision, particularly for the very elderly. Another statistic, which is quite frightening but not unusual, is that about a quarter of the elderly in the mid-west region live alone and that number is likely to increase as our population ages. I hope that the needs of other health board areas under these headings are examined and taken into account in task force reports. The Minister referred to a marked increase in the range and extent of social problems in the region such as drug abuse, child abuse and homelessness. He referred to the acute hospital services being under pressure and the aspect of ageing to which I referred. Poverty and health are intimately associated.
Deprivation and unemployment in the mid-west region are concentrated in urban Limerick. From 1989 to 1997 there was a 3.1 per cent increase in births in the mid-west. I am glad perinatal mortality is falling. It is closer to the national average. It should also be taken into account that the issues raised by the Minister are not peculiar to the eastern regional health authority area. I refer to the report, Health and Social Well-being in the Mid-West, which shows difficulties in relation to mental health in the Mid-Western Health Board area. Admissions for schizophrenia have risen to the national average. Depression is close to the national average and alcohol dependency is above the national average. The sad statistic is that the Mid-Western Health Board area has the highest proportion of mildly mentally handicapped children in the country. It is fourth overall among health boards. I am glad the suicide rates in the mid-west are below the national average, although they are still high.
Issues related to lifestyle have been raised many times and I would like to outline some statistics for the Minister. Approximately one third of students surveyed in the mid-west smoke and approximately 70 per cent – which is a huge figure – drink alcohol. More than 20 per cent of 13 year olds smoke and more that 40 per cent drink alcohol. That is a frightening statistic for people of that age. In addition, 30 per cent of students and almost 20 per cent of 13 year olds have taken drugs in some form. Continued consumption of tobacco and alcohol affects the health of the nation as a whole. They are threats to the health of much of our population.
Certain categories of people, particularly women, in the Mid-Western Health Board area have considerably poorer health than might be expected. I may have strayed off the point but it is important to put this in context. The problems facing this new authority are facing the Mid-Western Health Board to the same degree, albeit with a smaller population.
I cannot disagree with the Minister's objectives of focusing on strategic planning in response to identified and measured needs. This is not peculiar to health boards but is also part and parcel of the vocabulary of local government with the SMI. The commissioning of services from the statutory and voluntary sectors and overseeing and evaluating the services provided are worthy aims and I hope they are complied with.
I wish to refer to a point which the Minister made in the debate in the Dáil but not in this House, namely, the services to an elderly patient as a typical example of the type of improvement to be brought about under the new authority. Much as I would love this to be an objective, it will be difficult to bring about. It is not simply a matter of reorganisation; it is a matter of increased funding and resources. The Minister talked of an elderly patient under the care of her general practitioner who needs urgent geriatric care in a voluntary acute hospital. He hoped that if, on discharge from hospital, she requires convalescent care she could get it and that could be followed by time in a private nursing home. Finally, he said, she may be allowed home, with domiciliary support provided by the statutory services and attendance at a voluntary day hospital.
That is a marvellous objective but it may be more aspirational than practical given what happens in reality. The Minister has prioritised this and the last element of the service he outlined will be one of the key criteria by which the authority will be judged. Every person in the country would want that. It is very aspirational and I hope it will come about, not just for the elderly but as a prototype for other needs in a growing elderly population.
I am pleased with the accountability aspect, particularly the input of local councillors and local communities and the huge amount of money to be spent annually. The amount of £1.2 billion must be spent in an accountable context.
The Minister reiterated that he has no intention of taking over the voluntary hospitals and services, which is welcome. On representation, I would have hoped there would be more than one nurse with regard to professional representation – I would have liked three and I will return to this matter on Committee Stage. In the psychiatric area there should a representation of three nurses. The Bill states a member of an area health board may attend meetings of other area health boards, but may not vote. I hope in the calendar of meetings, opportunities would be provided for members to attend. This issue was referred to in the Dáil. I wonder how members will be available to attend so many meetings. I hope the arrangements will not be too bureaucratic.
I hope and presume that given the task force recommendations, union negotiations dealing with the transfer from the existing health boards to the authorities will be worked out very thoroughly.
I am concerned about child care services. Perhaps it is too much to expect the issue to be written into the Bill, but from my reading of the Bill I am not sure how child care will be dealt with. Will specific services be taken on and looked after by the authority or will there be a child care service within each area health board? I am also unsure about the co-ordination and continuity of assessment procedures.
With regard to the executive body, the Minister said the members would be the chief executive officers of the health boards, including the regional chief executive and the three area chief executives. I am not sure what its brief will be but I hope it will not be bureaucratic, it will be accountable and any decisions made by that body will be furnished to members of the area health boards so that people are aware of its actions. Will its remit be to consider issues on a national basis or will it co-ordinate specifically for the eastern region? Will it have an input with other chief executive officers, perhaps not on an executive level but on a consultative basis, on national issues such as breast cancer, cervical cancer and heart disease? Is it concerned with the health and well-being of the people of Ireland as a whole or is it an executive specifically for this region?
Are the executives of that board to be answerable to the regional executive? Will it be accountable to and report to the area health boards? I presume they will not be accountable simply to the regional executive, but that their ultimate objectives and focus will lie with the area health boards. I am not clear on this but I presume that is what the Minister means. This needs clarification. If the body is to deal with health issues in Ireland as a whole, it should liaise with the other health boards' chief executive officers. If it is to be focused only on the eastern region, which has a huge population, the expertise gleaned in exchange and interaction should not remain in that area. It should flow out to the other regions. Obviously the knowledge would benefit the others.
Those are my main concerns. While the Minister may create as many structures as he wishes to meet population demands, there are still problems with waiting lists and, to cite Limerick Regional Hospital as an example, magnificent buildings without the personnel and resources to utilise their infrastructure.
I looked for heart in the Minister's speech and a demonstration of care and feeling. I hope the structures will be such that the personnel involved will be satisfied with the new remit and will deliver something that is both aspirational and backed up by concrete resources, performance and accountability. This is especially important with regard to the care of the elderly. I look forward to further discussion on Committee Stage and I thank the Minister for his efforts.
I welcome this Bill and congratulate the Minister on the way he has taken problems by the scruff of the neck and attempted to solve them. He has done good work. The Bill is one of his most important measures. It has given the Eastern Health Board a more hands-on approach the health services.
When the board was established 21 years ago, the size of the population it covered was much smaller. Today there are over 1.5 million people in the Eastern Health Board area and its budget is £1.2 billion. This is spent on approximately 60 per cent of the people in the area as up to 40 per cent are members of various health insurance schemes. Given this level of expenditure, we must ask if we are getting best value for money. The Minister rightly said that throwing money at problems does not always solve them.
Under the new authority it is proposed that public representatives will comprise the majority of the memberships of the various boards. That is important because public representatives deal with people every day, listen to their complaints and are aware of what is happening.
There is a need to look at the community care area, something the Bill does not address. There is duplication between the responsibilities of local authorities and health boards with regard to housing. Health boards provide housing and essential repairs while the county councils and corporations provide housing and essential repairs grants. Often people apply to both bodies with the result that work is duplicated. In my 20 years as a member of the North-Western Health Board I have always maintained that housing should be a local authority issue. One body should be responsible. I ask the Minister and his officials to look at this matter and see if it is possible to eliminate the present anomaly.
The Minister has received much criticism about hospital services, including the use of trolleys for patient care. I am glad the Bill provides that the voluntary hospitals will retain their autonomy because, despite these criticisms, they provide a great service. Not long ago I was rushed by ambulance to the accident and emergency unit of the Mater Hospital. I was placed on a trolley for some time, but I received excellent service, care and attention. I pay tribute to the staff of the unit for the way they attended and worked.
My stay at the hospital was an education. Many people attended with self inflicted wounds. Despite the number of alcoholics and drug addicts who caused difficulties, the staff remained calm and provided them with a great service. A friend of mine from County Donegal had the same experience. He was released from the Mater Private Hospital early one day. He stayed in Dub lin overnight and developed a serious pain. The private hospital would not readmit him because he did not have a doctor's note. His wife sensibly arranged a taxi to bring him to the Mater Hospital accident and emergency unit. He praised the service he received.
I spent a couple of days in a public ward in the hospital because, although I was VHI member, there were no private beds. I did not indicate I was a Senator and I was delighted to be in a public ward because I saw the treatment and care patients received. Much of the criticism of the Minister and the health services came from visitors, but I did not hear any patients complain. I pay tribute to the Minister and to the hospitals throughout the country for the excellent services they provide.
The Eastern Health Board was becoming unmanageable because of its growing size. The Minister rightly complimented the task force established to review matters. It did great work, consulted widely and obtained the good will of all concerned. In consequence, this Bill has been well researched and well worked on. The proposal to have three area boards under a single authority will be a great advantage because there have been complaints for many years that the Department ran and dictated everything. This legislation gives the people involved the opportunity to make decisions on the kind of health services they want for their respective areas. They will not have to rely as much on the Department.
I am pleased that funding will be allocated to the proposed authority and that it will decide on allocations to the proposed new boards. The size of the Eastern Health Board area made it very difficult for the board to give the necessary attention to all aspects of its remit. All members of the three proposed area boards will be members of the proposed authority. It means there will be involvement at all levels, which allays my concern that they would be structured in the same way as health advisory bodies.
With a membership of 55, the proposed authority will be unwieldy. However, it covers a large area and its composition ensures it will provide a good service. I have no doubt that when the legislation is implemented and when the authority is established people in the area will received a greatly improved service.
Funding is always a major problem and the health board's budget is currently £1.2 billion. There will be accountability under the new system and it is good that the Bill provides for the chief executive officers to be summoned before the Committee of Public Accounts to account for any shortcomings, to explain how the money was spent and to make their case if they want more money. That is important.
It is good that voluntary organisations are encompassed in the new authority. We know they have done wonderful work for the health service, especially in the area of mental and physical handicap and care for the elderly. I am delighted they will be recognised fully for the work they have done by having a voice on the new authority so that they can play their part and put forward their views.
This is a very good Bill which will solve the problems of the Eastern Health Board. The people of the three counties involved can be assured of a good, hands-on service. They will know where their health board is located, they will be able to contact members more easily and will be more likely to know them because the new areas are smaller. It is a great hands-on approach. I welcome the Bill and wish it every success. I know it will be successful in terms of the provision of health care to the people of Dublin.
I welcome the opportunity to speak on the Bill and I welcome the Minister of State, Deputy Fahey, to the House. I found the Minister's speech interesting because it gave me an insight into the thinking behind the Bill and into his objectives.
Some years ago I spoke with a man born in 1903, who has since died, about the changes in the world in his lifetime. He said that when he was born in early 1903 the first airplane had not flown and it was not until the following year that radio was invented. We went on to talk about the changes which had taken place and what the next 100 years would be like. After we had talked about holidays on the moon and trips across the Atlantic for the afternoon, a woman present said the major change would be in health and medicine. All the figures show that in the next 100 years life expectancy could increase to 200 years. That may be mad, but the point she made was that the major change would be in medicine and health and we can already see signs of that.
That is why I welcome the Bill because it recognises that the structures needed in future will be different from those which prevailed in the past. While I would not go so far as to claim the new structure will solve all the problems involved in managing health services in the Eastern Health Board area, I welcome the effort made in that regard in drafting the Bill.
I will examine the Bill from the perspective of a manager by asking whether, if a manager examined it, he would deem what is proposed in the Bill good management practice. I will seek on Second Stage to find the areas of concern a practising manager would find by asking if it uses best management practice. Some concerns have already been touched upon by Senators Jackman and Farrell. Managing health services is not the same as managing a commercial business, but management issues are at the heart of achieving the aims of delivering good health care, not just in the immediate future but also for many years ahead, and achieving best value for money. That is a clear challenge when there are limited resources because there will never be enough resources.
Managing health services is a notoriously difficult challenge. I say that not just as a manager in a different area but also as someone who served on the board of a voluntary hospital and has been its chairman in recent years. Managing health services is difficult because one is dealing with matters of life and death at the extremes and matters of quality of life in everything one does. It is difficult because its services are provided by people who have professional skills in their specialist field but who usually have not been trained in the difficult task of management. It is also difficult because health services are notoriously expensive and becoming more so by the minute because of greater demand and the welcome advances in technology and science. Managing health services will always be like chasing a moving target with inadequate weapons; we will never be prepared for the advances taking place. However, we should not be pessimistic or fatalistic, rather it should spur us on to make the best possible efforts. That is why I was impressed by the Minister's words. He is clearly thinking this through from that point of view. In our case, we should be encouraged to find through legislation the best possible structure for providing health care into the next generation.
From a management perspective, the old Eastern Health Board was badly structured and that can be seen with the benefit of hindsight. There were two main drawbacks which I am pleased to see addressed in the legislation. First, a major part of the health care provision within the region was outside the remit of the health board and the board could not possibly take a strategic view of the entire field and make plans accordingly. Second, the size of the area meant a single board was too far away from the action, so to speak. A man applied to me for a job some years ago. He worked for a large American company and was managing director of its Irish branch. He said he wanted to change his job because he wanted to work for a company where he could talk to the boss. In the company for which he worked, he had seen the boss twice but had never met him. He wanted to get close to the action. That is clearly a problem with the size of the Eastern Health Board area and it is why I welcome some of the changes in the legislation in that regard. It is little wonder the Eastern Health Board did not have a good reputation. How could it given the bizarre structure it had?
The Bill brings the strategic aspects of health care provision in the region under a single regional authority while devolving the provision of health care to three new health boards which will be closer to the people they serve. I applaud the aims behind that approach. However, I am unsure if these clear distinctions will work as well in practice. We must avoid the creation of a multiplicity of levels of bureaucracy with matters being shuttled back and forth because the lines of demarcation are unclear. There are three main levels proposed – the Department, the regional authority and the local health board. This three tier structure will work if the respective roles of the three tiers are clearly defined and adhered to rigidly. This means a higher level should not do anything more properly done at a lower level. It must devolve responsibility.
Our experience in devolving power is not one of unqualified success. We have a record of setting up regional or local bodies and starving them of decision-making power. If that is done, intermediate levels of bureaucracy are only an expensive sham. It is almost 20 years since I was asked to become chairman of An Post. We took over a large organisation at the same time Mr. Michael Smurfit took over what was then An Bord Telecom. We argued strongly that, if two boards were to be set up, we had to be given the authority that went with them. The Government gave us the authority to do things which previously had not been delegated beyond the Minister. I was impressed that when the power was devolved to people who had been working in the organisation before the board was set up, they blossomed and grew and were able to do things they were not able to do in the old structure. Therefore, devolving responsibility can work, but only in the right circumstances. In that regard, I am impressed with the aims and objectives of the Bill. There is no point having intermediate levels if every decision has to go to the top to be resolved. We must try to avoid this scenario.
A few years ago I attended a conference where an American speaker told all the delegates to turn to the person sitting beside them and describe management to them in five words or less. After two minutes he asked us what we came up with and everyone said they came up with the words delegation, authority and responsibility. He said that those terms would not describe the term "management" to a Martian or someone who has never heard the word. Eventually we described management as getting results through other people. That is the objective of good management practice. In order to achieve this the Department of Health and Children will have to find a new way of working. It will have to learn to manage through the setting of broad principles, not through reserving all important decision-making for itself.
Experience might incline us to think that this will be a lesson that the Department, in common with other Departments, will find exceptionally difficult to learn. If this new system is to work there must be a clear delineation between the role of the local authority and the subsidiary health boards. If every decision has to be taken at regional level, then the local health board will be an expensive waste of time. For this reason I would like this Bill to emphasise the division of roles. The authority will focus on strategic planning for the overall region and each health boards will focus on actual provision within its own area. If this works it will be good.
I am unhappy with the structures we expect will deliver this outcome. The regional authority comprises 55 members. Senator Farrell referred to this number earlier. It does seems a rather unwieldy number of board members. It is a mind boggling amount of people in terms of getting anything done. The main reason this authority is so huge is the requirement that the majority of its members should be public representatives, that is, members of the relevant local authorities. Once people accept that principle we are into big number straight away. Each authority must consist of representatives from local authorities and political parties. Public representatives make up 30 members of the authority, and that is before we bring in anyone with an expert knowledge of health care.
Let me question the notion that public representatives have to be a majority on any Government body connected with health services. The Seanad is a dangerous forum in which to question this principle because at least 43 Senators are local representatives. Forgive me when I say that this is, in objective terms, a crazy idea. Almost every week we pass legislation setting up one new State body. Inevitably, as night follows day, when you burrow down into the small print of the Bill you will find a set of standard provisions that ban any Member of the Oireachtas or the European Parliament from being a member of the board of a State body. This is a rigid policy from which there have been – to the best of my knowledge – no exceptions.
I am familiar with area based partnerships. There were 12 pilot areas and then more later on. Their objective was to create a multi-dimensional approach at local level to the problem of solving long-term unemployment. I was a member of the Finglas area based partnership but when I was elected to this House I was immediately disqualified. Local area partnerships, which deal with employment issues, ban public representatives but the regional health authority wants 30 of its 55 members to come from local authorities. If there is a danger of a democratic deficit in one authority, surely it applies to the other as well.
I do not want Members to think I am naive about this issue. I know as well as anyone why these bodies have to be stuffed with public representatives. I am trying to show that this practice makes it extremely difficult – perhaps even impossible – for the body we are in the process of creating to do its work effectively. How can a chairman run an organisation that consists of 55 members? My heart bleeds for any chairman try ing to conduct a meeting of 55 members. I think it will be impossible. Inevitably, in a case like that, power is passed down to smaller groups who in turn have to deal with small aspects of the overall challenges. These smaller groups then submit their conclusions to the larger body for ratification. This is a bad method of doing things and it is not good management. The larger body either becomes a rubber-stamp for decisions that are made elsewhere or a place where the same arguments are repeated by people who are not members of the smaller groups. I would not be surprised to discover that Members have seen this happen. In a body consisting of 55 members it will happen. It is a recipe for doing nothing.
The real problem of an unwieldy body like this is that it lacks a common feeling of ownership of central strategic problems. No one bothers with the larger picture because most of their time is spent discussing small facets of it.
It is so difficult for a large unwieldy body to make decisions. For example, Britain and France were joint creators of the Concorde aircraft. It took them only two minutes to agree on a multi billion pound investment in the project but they spent four meetings trying to decide whether there would be an "e" at the end of the word, which was the difference between the English and the French version. In the heel of the hunt, while the small facets get plenty of attention, the overall picture does not get any attention. When this happens in a body that is primarily strategic in focus a structure is created that makes the realisation of its aims almost impossible.
These are some of the problems that are likely to arise from the unquestioning acceptance of the principle that a regional authority charged with developing health service strategy must consist mainly of public representatives. With all due respect to everyone concerned, and with all due recognition of practical realities, in management terms it is a nonsense. Let us move on because there are more managerial problems that could be avoided.
We are talking about setting up one regional authority with three area health boards. We are giving each body a full set of powers as if they were totally independent entities. Each of them will be employers and corporate bodies. Each of them will have the power to own property, enter into contracts, build bridges, etc. With regard to economics and efficiency, is all that duplication necessary? I think not. We have to remember that organisations take on a life of their own soon after they have been created. They develop the powerful instinct of self-preservation and ally that to a powerful urge to extend their empires. Everyone has seen that happen. It is natural for them to do so. The more self-sufficient they are, the more they are empowered to do this.
I became a Senator in 1993 and at that time we were dealing with the legislation setting up For fás, IDA and what was then known as Forbairt as three separate bodies. I was impressed by the elegant way in which this danger of duplication was avoided. Forfás was the central holding company that employed everyone and owned all the property. The other bodies used people on secondment from Forfás and leased property from Forfás. This was a novel idea which was voted through by Members. The conclusive proof that it was an excellent approach was that the ink had not dried on the legislation when the subsidiaries, IDA and Forbairt, set out to change it. They did so soon afterwards but that is another story.
While I am talking about the IDA, Forbairt and Forfás I am wondering if we could come up with a marketing name for them. When I hear the term "south west" I presume it refers to Kerry or some place like it. However, we are discussing Tallaght and the south west of the city.
We are creating a new layer of bureaucracy and it is our duty to ensure we do not create overlaps and duplication where they did not exist before. I am not sure that is being done in this case. From the point of view of good management and efficiency, I see no reason that the four bodies should each have a complete set of powers, as if there was no connection or relationship between them. For example, it would be simpler to have a single employer for the four entities. That would deliver economies of scale on matters such as payroll, it would avoid any difficulties arising from different personnel policies and, perhaps most importantly, facilitate the easy transfer of staff from one health board to another.
I agree heartily with the aims underlying the Bill and I wish the Minister well with it. I am aware that what we have before us represents the outcome of the deliberations of a task force established to produce a solution. I appreciate the efforts of the task force in this regard but that is not to say its proposals cannot be improved upon, which is what we are doing here. I urge that further consideration be given, even at this late stage, to the practical difficulties of realising the worthwhile aspirations of the Bill. I welcome the approach taken in the Bill and I hope we can improve its provisions.
Senator Quinn highlighted difficulties in terms of management and the delegation of powers which have haunted the Eastern Health Board. The board employs many excellent staff but problems have arisen from time to time because it either lacks or is overburdened by administration. I have never served as a member of the health board but I have dealt with it on many occasions in terms of submitting administrative and practical queries and making representations on behalf of individual constituents in respect of their problems or concerns. When the legislation is enacted I hope the new boards will be more accountable, identifiable and consumer friendly.
The Eastern Health Board is responsible for a large area and deals with the problems of a large cross-section of the community. The area I represent has an above average elderly population. People live longer because various diseases which were considered fatal 30 to 50 years ago are now curable. In addition, people can now have heart by-pass operations, transplants and receive more advanced forms of treatment for cancer, etc. and doctors have increased expertise in terms of limb replacement operations. As a result of people's longer lifespans, we must consider the question of nursing home care and the work done by those who care for elderly relatives in the home. I accept that this may not be related directly to the legislation but it is one of the issues we must address.
I wish to refer to the Loughlinstown and St. Michael's hospitals in south Dublin and the urgent need to invest additional funding in both institutions. A great deal of money has been invested in Tallaght, Beaumont and other hospitals and it is disturbing that St. Michael's private hospital is to close. It should be retained in some form, even as a facility for patients recovering after operations. At a time when waiting lists are so long, it is difficult to believe that a private hospital which has provided great health care services in the past – I cannot praise the nuns involved too highly – should be allowed to close. I hope that the land on which the hospital is situated will not be used for residential or commercial purposes but will be retained for medical use.
I support the legislation which will, I hope, improve the management mechanisms and the delegation of powers within the new board. From the chief executive to the people dealing directly with the public, I hope the staff of the board will feel themselves part of an organisation responsible for delivering a better health care service, which is, after all, much more important that commercial or financial services.
I thank Senators for their contributions. The Minister and I listened carefully and it is clear there is broad agreement on all sides regarding the need for structural reform in the health services in the eastern region.
The proposals in the Bill are the result of a long and detailed process of consultation and consideration. The Bill is based, to a large extent, on the recommendations of a task force on the eastern regional health authority. The task force made it its business to consult as widely as possible with the various parties with an interest in this issue and the level of consultation under taken will be clear to anyone who reads its impressive report.
Some of the details of the proposals in the Bill will not please everyone and I will deal with the more specific issues raised during the debate in a moment. However, no proposal of this nature can hope to please everyone. It is the Minister's view that the direction proposed in the Bill for the health services in the eastern region represents the best way forward and that it commands a sufficient degree of consensus among the various parties to enable its successful implementation in the coming months and years.
A number of Senators referred to the issue of child care. I accept that a difficult position obtains in the Eastern Health Board area in respect of child care. There is no question that too many children, particularly in Dublin, are being neglected or abused, mainly physically or emotionally but also sexually. We are not responding adequately to that problem. It is important to be honest about this issue and we require improved structures, management and resources. In the past two years I have striven to try to increase resources as much as possible but I am the first to admit that many social workers operate in extremely pressurised conditions in what is probably the most traumatic area of human experience. I will continue to press my colleagues in Government in respect of the need to increase resources in this specific area.
The organisation of child care services under the new arrangements was raised by Senator Jackman. The location of child care services will be a decision for the new authority. The intention is to devolve responsibility for services in the areas as far as possible to each of the three boards. The thrust of the legislation is to ensure the continuity of care from the Eastern Health Board. The Bill has been drafted in the office of the parliamentary draftsman and has been examined by legal experts in the Attorney General's office, who are satisfied that it deals adequately with all of the health board functions, including child care and adoption services.
I would agree with what Senator Quinn had to say about the changing world. He put it well when he spoke about a person who was born in 1903. It is remarkable to think that there were no flights or radios then and that there are still people in our midst who remember such a time. There has been a leap forward in the history of mankind in one century to the point where, as I read recently, the next step is to transport people from London to Australia in a matter of a few hours via outer space for part of the journey.
I agree that health care will be one of the most important challenges of the new century, especially with the great technological developments taking place and their associated significant costs. It will put a major strain on every economy, not least our own. I agree with Senator Quinn that it will be a challenge for the authority and the area boards to develop new methods of doing business which will respect the divisions in function between the strategic level and the delivery of services. I would accept that in the Dublin area and, indeed, all parts of the country the delivery of service leaves something to be desired. I am confident that the new tripartite structure will improve considerably the delivery of services. As the Senator said, the Department is aware of the need for the separation of the strategic level and service delivery. It is consciously developing and adapting its strategic role and it set out its aims in this regard in its statement of strategy.
I acknowledge that, for a governing body, the size of the authority proposed in the Bill is large. The challenge for the members of the authority will be to adopt from the outset working practices and processes which will take account of its size and which will ensure that the overall task is broken down into sensible and manageable parts, making full use of the talents available from its membership. The mechanisms by which this may be achieved are being developed by the task force so that concrete proposals in this regard can be put to the authority on its establishment.
I concur with what Senator Farrell had to say. He made practical suggestions. Perhaps more than any other, the need to concentrate more on the delivery of preventative services and early intervention must be the greatest challenge for the health services. In my area of responsibility, child welfare, unfortunately the public service has not got around to understanding the need for early intervention and for the expenditure of money in trying to prevent problems rather than to cure them. For instance, I have several juvenile justice initiatives in progress and it is clear that if we provided adequate money for the welfare of children and their families at an earlier stage, we would save a massive amount of money at a later stage trying to cure the problem.
I met a group of community gardaí in Dublin recently who made the point that they come across children with behavioural problems who are in trouble with the law at the age of 12. By then it is too late for the Garda to deal with some of those young people because they have become out of control. Their behavioural problems are so difficult and their family situations so dysfunctional that, unfortunately, it is too late. There is of course a way to prevent that arising. That is by putting in place proper family support structures, facilities and, in particular, direct assistance to those families which face the greatest adversity. I am glad to say that in the Dublin area we are doing that in a number of projects under my responsibility and, indeed, that of the Minister of State at the Department of Tourism, Sport and Recreation, Deputy Flood. It is being done for the first time on a synchronised inter-agency basis where the families themselves are being empow ered to seek help, not to feel stigmatised and to become part of their own project. Of course the communities in which they live are central to the development of this approach.
In the area of welfare, which is a critical part of health, one of the greatest challenges for the three new authorities will be to provide early intervention, especially in the black spot areas of Dublin to which, unfortunately, society has been prepared to turn its back. There are two particular estates in Dublin. We all know the deprived areas. We have been prepared to leave them behind. Society has been prepared to turn its back on the social cost of poverty. It is time we looked at the economic cost of poverty which is growing at a phenomenal rate. The number of children who need to be locked up is increasing at a phenomenal rate. Obviously the answer does not lie in locking them up. The answer must lie in intervening with them and their families and preventing their problems. I am confident that this new structure will add in a considerable way to a better management and strategic approach to that element of the health services.
I will not go into the other element with which the Minister dealt. I commend the legislation to the House. I have no doubt it will be a major step forward for health services in the eastern region.
Question put and agreed to.
When is it proposed to take Committee Stage?
Committee Stage ordered for Thursday, 27 May 1999.
