Seanad Éireann díospóireacht -
Wednesday, 25 Jun 2003

Vol. 173 No. 13

Council Regulation on Procedures for amending the Sirene Manual: Referral to Joint Committee. - Health Service Reform: Statements (Resumed).

Mr. Feighan

I welcome the Minister back to the House. He has been one of the most efficient Ministers attending the House and I thank him for bringing these reports to the attention of the Seanad. The Minister mentioned the need for communications and, indeed, the reports could take a leaf out of the Minister's book because he has proved to be a good communicator in articulating health problems around the country. He mentioned that additional funding will be well spent. While I do not wish to go back over old ground, much of the money invested in the last few years was not well spent. That is what the Brennan report is about and I hope the Government, including the Minister for Finance, will not use it as a stick with which to beat the Minister by arguing that whatever money has not been well spent will be withheld in future. Current health problems certainly require much more investment.

There are three reports coming on stream, including the Brennan report on the organisation and funding of the health services. The latter report was commissioned to see where the health service can provide better value for money. The chairperson was Professor Niamh Brennan, professor of management in the department of accountancy in UCD, who is also academic director of the centre of corporate governance. Other members of the report team included Mr. Tommy Gorman of RTE, and the economist, Dr. Seán Barrett, so the Minister had a good team to work with.

The Prospectus report dealt with an audit of health service structures, including an assessment of the extent to which those structures and functions were capable of delivering the quality and fairness envisaged in the 2001 health strategy.

The third publication, the Hanly report, is ready but has not yet been made public, although these reports appear to have been made available to reporters over the last few weeks. The Hanly report deals with staffing needs in hospitals and the working group was chaired by a businessman, Mr. David Hanly. It comprised some 50 members, including Dr. Sheila Ryan, the chief executive officer of the Western Health Board.

Ms White

She is great.

Mr. Feighan

She is certainly an exceptional lady. Among the Minister's recommendation is the abolition of the health boards. Opinion is divided on whether these boards are a waste of money but some people say privately that they are very political. I imagine there will be strenuous opposition to their demise. A little over two months ago in this House, I said that while the health boards were a problem they were not the overall problem. The Minister, however, has the political will to take on the health boards and the consultants. It will be a dangerous road for the Minister to take because he may not get full backing from his own party. Like the dual mandate, however, it looks as if the health boards will go and the Minister has set out his stall in this regard. The abolition of the health boards does not represent a panacea for the health services and, unfortunately, it could be seen as a reduction of the input of local democracy. The health boards had some plus points.

Single issue Dáil candidates found fertile ground in the area of hospital action and they are the bane of the main Government party, Fianna Fáil. Such candidates were elected in Cavan-Monaghan, Wexford, Galway East and other constituencies. Those Independent Deputies are very effective and have brought a certain flavour to debates in the Lower House.

People accept, however, that local hospitals are not appropriate for many major medical procedures; they do not have multidisciplinary teams to perform the necessary number of procedures to ensure competence. I know of some people who had to go for operations in areas which lacked the competence of larger hospitals.

What acceptable compromise role can be arranged for Roscommon hospital, for example, in my own constituency? One of the key questions raised by the centralisation of hospital services is how long it will take patients, particularly those in rural areas, to get to hospital in an emergency. In such circumstances, ambulance services will have to be more efficient in order to gain public confidence. Every week, constituents tell me that they called for an ambulance which took an hour or 90 minutes to arrive. The Minister will continue to face such problems unless rural ambulance services can be improved.

A restructured ambulance service is needed so that the Minister's reforms can be implemented. The existing service needs more resources, including funding, and more ambulance centres are required also.

The N61 runs between the second largest town in County Roscommon and Roscommon hospital and has been included in the most recent national development plans. It is probably the worst road in the country. The ambulance service is experiencing many problems.

The annual health budget in 1997 was €3.7 billion, while in 2003 it is projected to be more than €9 billion. This significant increase has led to what is perceived as a poorer service. That is remarkable because every cent of taxpayers' money will be invested in the health service this year. The Government has commissioned three reports, two of which have been published with the third due shortly. It is puzzling that three reports were needed because there will be a considerable overlap, but, hopefully, there will be benefits in the not too distant future. Everybody, including the Government, accepts that the Administration will stand or fall on the improvement of the health service. Hopefully, the electorate will be wiser at the next election and will hold the Government to proper account for broken promises and failures.

The Brennan report highlights the absence of organisational responsibility for the management of the health service as a unified national system and notes that there are no incentives to manage costs effectively, with inadequate investment in information systems. This may surprise some people but, considering the performance of the service, perhaps not. The report is critical of aspects of the role of consultants in the service. That role and the parameters of the influence of consultants in the hospitals will not be easily or quickly grappled with because they are historic in nature. The Minister faces considerable opposition from consultants who will be key to making health reforms work.

The role of the consultant as a private and public practitioner in the hospital service is a web that nobody understands and significant reform is needed in this area. Professor Brennan said she was absolutely shocked by the common contract with consultants. An increased number of consultants is needed. Current estimates put the requirement at more than 1,000 posts. However, this will provide an opportunity to employ consultants on a proper and equitable basis. The role and influence of consultants is significant and it does not do much good to demonise such an important sector.

The key recommendations of the Brennan report are the establishment of an executive to manage the health service as a unitary national service, more appropriate financial control systems and substantial rationalisation of existing services. The report also recommends that all future consultant appointments should be on the basis of contracting them to work exclusively in the public sector, but this will not happen unless a serious move is made to sideline or take on consultants. Other recommendations include the reform of the medical card and general medical services schemes and publicly funded drug schemes.

The report identifies the key problems in the health service as a fragmentation of responsibilities, a lack of cost consciousness, insufficient evaluation and analysis of current expenditure as well as a lack of accountability, transparency and probity. Three broad themes in the report concern the patient, the taxpayer and the staff of the health service.

The Prospectus report recommends the abolition of the health boards, which has generated considerable interest. This is a flagship recommendation, as a result of which it is anticipated that everything will improve following the abolition of the health boards. I do not necessarily subscribe to that view. There will be a democratic input loss and, together with centralisation of administration rather than decentralisation, there will be a loss of local input.

The Minister recognises the tensions between local representation and national policy. The health boards will be replaced by a health service executive to manage, as a single national unit, three core areas within the health service executive. These will be a national hospitals office, a primary care and continuing care directorate and a national shared services centre. This is intimidating and there is broad criticism of the hierarchies of bureaucracy within the health service, to which these changes will add.

The report also recommends the establishment of four regional health offices within the health service executive to deliver regional and local services, which is confusing. The provision of appropriate local services is of primary concern to many people, especially public representatives in areas that are distant from the centres of excellence and service. This raises questions about equity.

I come from a rural county and we will have to look to large urban areas for services. While I accept the concept, people are shouting about decentralisation, but health services will be centralised. The national hospitals office will be established with priority for reform in the hospitals area and a health information and quality authority will also be established and support services modernised. The thrust of the report is to maximise public funding, which should be welcomed.

While the Hanly report has not been published, it has been leaked to newspapers and it contains a strategy to reduce the average weekly working hours of non-consultant hospital doctors to 48 by 2009 in order to comply with the EU working time directive. The practical implications of moving to a consultant-provided rather than a consultant-led service need to be analysed. However, it should mean that consultants will be immediately accessible for clinical decision-making and treatment through a renegotiated common contract. The current contract was not well negotiated. The report makes several recommendations on hospital structures including the provision of a single speciality hospital, a national hospital authority, training reorganisation, regional and national specialities.

However, overall, the reports are confusing and have been the subject of glossy production and hype. Not a single extra bed, nurse or medical card will be provided even though they were promised.

Ms O'Rourke

They will be.

Mr. Feighan

A few councillors can be sacked here and there, but that will not be the solution to the health crisis. Again, the health boards are the whipping boys. I would like to see real reform. Major efforts must revolve around the reform of the health service as it remains to be seen whether it is out of control. The process of analysis, about which I am concerned, is a growth industry, but it has not paid great dividends to date and one cannot feel greatly confident for the future. However, I will not dismiss efforts to reform out of hand. We can only hope that they will work and bring much needed respite to the thousands of consumers who should have, as a right, the primary requirement of decent health care in the advanced society in which we presume to live.

I wish the Minister well and I hope the reforms work. However, analyses, surveys, consultancy reports, policy reports and more restructuring are not needed.

Mr. Glynn

Cuirim fáilte roimh an Aire go dtí an Teach. I compliment the Minister who has been proactive in dealing with the ills in the health system.

When the health boards were established, the county councils and county borough councils had responsibility for the provision of health services, the county manager being the chief executive. There was quite an outcry at the fact that this would no longer be the case. It was felt that health boards would not fulfil the various functions of the local authorities. That was 33 years ago and since then the health boards have achieved much.

Time marches on, however. Nothing is cast in stone and no situation is so utopian that it cannot be improved. The health boards have achieved much. They can take much credit for the establishment of specialties. I am chairman of the Midland Health Board, of which I have been a member for almost 23 years. The board has set up a number of specialties which would not have been established in the region if there had not been a regional health board.

When the health boards were set up, they were lumbered with a number of unsuitable institutions, many of which are still unsuitable for their current use. Many of our psychiatric institutions were built almost 200 years ago. They were certainly not designed to serve as acute psychiatric treatment centres, their current use. There is no point in crying about their closure because they are not suitable. Many of the smaller hospitals, handed over to the health boards when set up in 1970-71, are not suitable and many are surplus to service requirements.

The Midland Health Board took the decision to rationalise hospital services in the mid-1980s. There was an outcry when we closed Longford County Hospital and discontinued maternity services in the Leader's own town of Athlone and in Tullamore. Time has proven that our decision was the right one. It is only in centres where there is a large throughput of cases that the provision of specialist services will be most efficient. This has been clinically proven by more eminent people than me.

The Minister has taken a radical approach to ensuring optimum benefit is garnered by the people of the country from what they pay for health services. The national health service reform programme will change the health service as we know it today. It will maximise the level and quality of our services and create a system that is accountable, effective, efficient and capable of responding to the needs of every patient throughout the Republic of Ireland. It includes measures which will impact on every element of the health system and draw on the conclusions and recommendations of the report of the Brennan commission on financial management and control systems in the health service and the Prospectus audit of structures and functions in the health system. We will soon have the Hanly report, which looks at the whole area of medical manpower etc.

My colleague across the floor asked the reason we have three reports. I say, "Why not?" They deal with three very important aspects of the health service. We do not want reports done by people who are jacks of all trades and masters of none. It is right that we have three reports because they deal with three specific elements of the health service. The Minister, in bringing forward the proposals, is taking account of what is stated in the reports.

As chairman of the Midland Health Board, I was one of the health board chairmen briefed last Tuesday evening by the Minister, for which I thank him and the Secretary General. It was most informative and helpful. I understand the Minister is coming to the Midland Health Board tomorrow morning to meet the members and staff of the board. He will be very welcome. With the Secretary General, he is expending huge resources of energy on the consultation process. This is very important.

The proposed measures include a major rationalisation of existing health service agencies. I said last Tuesday that it sometimes appeared that if someone had a pain in his or her big toe, an agency was sent up to deal with it. The situation had become ludicrous. This is an important aspect of the report. There was huge duplication and no one knew who was responsible for anything. There is to be consolidation and amalgamation of the 32 agencies, including the abolition of the health board system. Nothing is cast in stone and time marches on. The health service executive will be the first ever body charged with managing and delivering the health service as a single national authority.

Several opinions have been expressed about the delivery of health services. If something is being done, it is wrong and when it is not being done, it is also wrong. The Minister is doing the right thing. I urge him to press ahead, irrespective of what his critics say. I commend him for this.

The Minister proposes the immediate establishment of an interim national hospitals office to take early action in reforming the hospital sector. When a new service is coming on stream, it is essential that an implementation body be set up. The office will be one of three core parts of the health service executive, the others being the primary, community and continuing care directorate and the national shared services centre.

Some time ago Senator Norris and another Senator tabled a motion pertaining to the inappropriate occupancy of acute psychiatric beds in the Eastern Health Board region. They were so right. If this reform eliminates inappropriate bed occupancy, especially in the acute psychiatric services and accident emergency units, it will have done a good job. Our general hospitals have become general hostels and our psychiatric hospitals psychiatric hostels where people come in willy-nilly, disrupt the service in acute units, get bed and breakfast and head off the following morning, leaving a trail of disarray and a broken night's sleep for those who have serious psychiatric difficulties or other severe illnesses. If the Minister's proposals do anything to eliminate this problem, I will welcome them. They will do much more than this.

Housing aid for the elderly is a wonderful scheme which has done tremendous work. It is currently adminstered by the health boards. It should be taken over by the local authorities because it is more pertinent to the services provided by them. The health boards are health agencies, not housing agencies. Rent allowances should also be under the aegis of the local authorities. It is ludicrous that health board community welfare officers must spend long hours adjudicating on and paying rent allowances. That is not their job.

I ask the Minister to formulate legislation to deal with the abuse of accident and emergency services. To get drunk is a wilful act. No one gets a tundish and pours the drink down one's neck. If one gets drunk, arrives in an accident and emergency unit and causes disruption, there should be an appropriate mandatory charge and, in certain circumstances, a mandatory prison sentence. Doctors, nurses and health care assistants should not be subjected to the type of abuse to which they are currently being subjected by bowsies and whipsters and I do not apologise for making these remarks.

The Minister referred to the re-organisation of the Department of Health and Children to ensure improved policy development, oversight and evaluation of service delivery. This is a root and branch examination of every aspect of the health service, therefore, no one can say the Minister is just hitting the bottom. He is not. He is starting at the top and working down. He referred to the establishment of a health information quality authority to ensure that quality and effectiveness of care is promoted throughout the system. Quality control is a very important aspect of any service, so why should it not be the case in regard to the health service? Health care is what keeps our very existence intact. The Minister also referred to the devolution of responsibility for budgets to people in charge of delivering services.

The Minister is aware of my views on local authority members being represented on the health boards. I say this without apology to anyone. I believe some role should be devised for local authority members. They are a very important conduit both to relay representations and as policy-makers they take on board comments made by their constituents. I recognise that the health board system per se will not be in existence and obviously local authority members will not represent their constituents in that capacity in the future. However, some consultative role should be devised for them.

The devolution of responsibility to the people providing the services is very important because no one is better placed to manage resources than those who deliver the services. These people will have to cut their cloth according to measure and there is no point approaching Camillus Glynn or any other chairman or member of a health board asking them to get on to the Minister for more money. The Minister will get his budget from the Minister for Finance and he must manage it. When the chief executive officer and the board get the money, they must manage it, and when the people who deliver the health service get their budget, they must manage it. This will ensure that the optimum benefit is gleaned from that allocation, both in the context of quality of service and the value for money aspect.

There is the complex modernisation of supporting processes, such as service planning, management and reporting to improve planning and service deliveries. We have all been subject to consultancy services but we cannot have one in every town and village. We must accept the fact that there must be a centre of excellence. This is a little country measuring approximately 300 miles by 170 miles. In international terms, we must remember that we are no bigger than a cabbage garden. We have finite resources, not infinite resources.

The Government has poured unprecedented money into the health service. Spending has increased from €3.6 billion in 1997 to more than €9 billion this year. It is important to point out that the money has delivered significant increases in output. Almost one million people were treated in our acute hospitals in 2002, an increase of almost 25% compared to 1997. Why is this? It is very simple. Our population has increased and we have taken in many asylum seekers. There are also two more important aspects, that is, people are living longer and, consequently, they are drawing on the health services more than they were in the past because old bones can be cold and sore bones. There is also a greater inclination by people to avail of elective procedures than was the case 20 years ago.

There are 25,000 more people involved in providing health care. I disagree with my colleague opposite who referred to one extra nurse. The statistics show that the number of health service providers, doctors, consultants and nurses, has increased. In my health board area, the previous Minister for Health and Children, Deputy Cowen, set up a college of nursing. Two groups of general nurses have been trained. As chairman of the board, I was honoured to present the last group with their certificates. We have acquired at least ten community residences in the last year in the Westmeath catchment area for people with sensory and mental health disabilities. Some of these residences are already on stream and more are coming on stream. Psychiatric nurse training will commence for the first time in 21 years.

Mr. Feighan

Does a nurse ever retire?

Mr. Glynn

I am sorry that I have no bad news for the Senator. This is a reforming Minister and Government. I strongly support what the Minister is doing and all right-minded people would have to do the same. We must challenge what exists because nothing is a utopia. I believe in the fullness of time the actions taken by the Minister and the Government in relation to the health services will prove right.

Mr. Quinn

I welcome the Minister to the House and the opportunity to have this debate. I also welcome his opening statement that the sole objective of the health policy is to deliver access for all to high quality services.

Having listened to Senator Glynn, I realise that I do not know enough about the health services, systems and controls in Ireland. I am a big admirer of his efforts and success in the past. I hope he will excuse me if I do not talk with that knowledge but by trying to draw on the similar knowledge I have in regard to how business works.

I sought some advice by speaking to someone who has been involved in the health service for 30 years. She gave me a very good instance which was similar to my own business. She spoke about joining a small hospital in another part of Ireland, which was owned by the nuns. Because they owned the hospital they knew everything that went on. They watched every penny and also watched the patients and got to know them. She learned, as many of us do in business and in our first jobs, from being close to what is happening. She later moved to Dublin to a big hospital and she could not get over the difference that occurred whereby there was no ownership. Obviously the hospital was owned, or certainly the finances were owned by the State, but no one was keeping an eye on the pennies so that the pounds would look after themselves. There was not the same closeness to the customer in business terms and, therefore, to the patients.

My attention was drawn to this fact last year when visiting the home of someone who received very good health care the previous year. I noticed a pair of crutches in the house which the person said he would have to return. He had recovered from his illness a year earlier but no one asked for the crutches back. When he went back to the hospital to return the crutches which he no longer needed, the hospital said, "That is interesting. We lose hundreds of crutches each year." I gather the same applies in other instances in the big hospitals because of the impersonal attitude that develops as a result of size. I am concerned about size being the answer to everything, yet I know in the case of centres of excellence we must have size. We will, therefore, have to find some way of ensuring that those who run hospitals get much closer to clients or patients.

When I was chairman of a hospital some years ago, I made an effort to change the word "patient" to that of "customer" and I enjoyed doing so. However, it did not work very well. The consultants did not particularly care for the use of the word "customer". I was trying to impose a way of thinking on those who ran hospitals so that they would think of patients as customers. I also wanted them to think about the job we faced, as I believe was the case in that smaller hospital run by the nuns in the west. That to which I refer does not always happen with the authorities which run hospitals which become very large. It is this remoteness that concerns me. The danger of size is that the authorities that run hospitals often do so solely on the basis of financial concerns.

The audit of structures and functions in the health service and the Commission on Financial Management and Control Systems in the Health Service must clearly identify costs. What concerns me, because it is similar to what happens in business, is that one does not always get value for money. What has happened in recent years is we have invested huge extra sums of money into the health service and yet we have not managed to obtain value for money. However, it was not for the want of trying.

I was in this House when we passed the legislation which set up the smaller health authorities. I was pleased with that because we seemed to overcome the problem of remoteness to which I referred earlier because the health authorities would be more easily accessible for customers. What happened, as the Minister explained, is that a huge amount of the additional money invested in this area was put into administration rather than into catering for the needs of customers or patients. I approve of the Minister's effort to bring efficiency into the operation. Let us ensure that, in doing so, we, and those who will be responsible for making decisions, will not lose sight of the customers.

I do not like accountants. That statement is not correct because some of my best friends are accountants, but I become concerned when I read that the newly promoted chief executive of a company was formerly the financial controller. In such cases, one can see that the business, which was formerly run by looking after the customers, will now be run by an accountant, and one will see that organisation change. Businesses and hospitals must look after their finances, but if the person at the top is so concerned about controlling the costs and, therefore, looking after the customer or patient takes second place, we must find some way of imposing on and instilling in those at the top some way of getting close to the customer.

On one occasion I walked around a hospital with the chief executive and realised that he was so removed and remote from what was happening to patients that it seemed to be one of the few times he had actually been on the ward floor meeting them. I know from experience that a customer coming up and practically grabbing one by the lapels and stating that they hate the way one does things and asking why one does them has a much bigger impact than reading a report which states that X number of patients are concerned about something.

One way of addressing this problem in business is by holding focus groups and customer panels. I recall suggesting to one large organisation in which I was involved that we should have customer panels. The chief executive said it was a good idea and put customer panels in place, but the panels reported to a management consultant who produced more paperwork. It was very useful work, which produced good information, but it did not have anything like the impact of what I call "listening from the top". I refer here to finding some way in which the people at the top, in this case running a hospital, found a way to be closer to their customers or patients. One way to do that is to ensure that those who run the businesses or hospitals find time to be available on the floor. One way we do it in business is to have the manager's office on the floor so that he is available, contactable and approachable by the customers as well as everyone else.

My other concern about the size of the organisations, as we move to a system with fewer authorities, is the development of bureaucracy and how we avoid having so many committees, so many meetings and so much paperwork. I know it is good management practice, but the more systems, controls, processes and meetings that exist, the less time is spent on looking after patients.

One of the rules we established in my company many years ago was that we would never have meetings in a room with chairs and we held meetings standing up. We had meetings at 8 a.m. or earlier and no breakfast would be served until the meeting was over. It is a great control, a great system for stopping people from talking too much. In fact, on occasions it would not be a bad idea for this House, that we would have no seats here and we would have to stand. Perhaps we would not spend so much time on certain matters.

The Minister also touched on the issue of looking at value for money abroad. My daughter lives in Paris with her three children and she has often had to use the French system. I am so impressed at the efficiency of the French system that I investigated it to see if we could learn something from it. It seems to work very well. One of the reasons for this is that the money for the health system does not come from a central fund and it is ring-fenced. As far as I am aware, this money is paid in by each citizen. The Minister is probably well aware of this and I know it is a difficult issue for us to handle. However, it seems that if the money we invest in the health system is coming from the big purse of the Department of Finance, it is much more difficult to plan in advance.

I visited the Mater Misericordiae Hospital a few weeks ago and raised on the Adjournment my concerns about the closure of hospital beds. I realised at that stage that part of our problem is that the Minister is unable to disclose the budget of each hospital long in advance. The hospital authorities do not know their budget and are unable to draw up their budget in advance because we in Ireland do not use such a system. We use a system whereby the budget is allocated each year. The Minister does not have the ability to overcome that difficulty, but the Government and the Oireachtas will be able to help in that direction for the future.

We have pumped a great deal of money into the health service in recent years, but we have not obtained value for money. The Minister is aware of this and is now putting forward a plan, which I hope will work. It certainly has got his enthusiasm and I am enthusiastic about what he is attempting to achieve with it, but it will not be easy due to the constraints we are placing on the Minister and on the health system.

I also want to address the question of equity. When we, as a State, made a decision to provide a free health service to anybody over 70, irrespective of their means, it was admirable. It means, however, that some of that money, which now goes to the well off who can afford to pay for health care, could have been used for those who are in need of it.

When I talk about financial equity and need equity, I am talking about the same decision we made in regard to third level education. We made the decisions some years ago that we would provide free third level education. It was a great thing to do and perhaps we could afford it at that stage, but it does mean that when resources are finite, then we do not have that freedom to look after everybody in that same way. Let us, therefore, ensure that, in making such decisions, we are aware of the need equity as well as the financial equity.

One other aspect which concerns me is the power of the hospital consultants. I am not sure whether it is possible for a hospital consultant to have two masters and to work both for private and public patients. I heard the interview on the radio yesterday and I was stunned. I am not sure who the person was, but it was a good interview. It was about the consultants who admit spending only 20% of their time on public patients but who expect the State to pay 100% of their insurance costs. That is what I understood but the Minister is now challenging this. These are exactly the matters he should challenge. I fear that in the case of a consultant who looks after private and public patients, private patients usually get extra attention.

I am also surprised by the fact that all public patients seem to be given appointments with a consultant at the same time. If a consultant's clinic takes place between 2 p.m. and 4 p.m., all public patients arrive at 2 p.m. and wait. Private patients are given individual times for appointments. It seems difficult for some consultants to wear both private and public hats. I wish the Minister well in challenging this. We need to find ways to help him succeed.

The challenges facing the Minister are such that he will succeed but only if there is political recognition on the part of all of us in these Houses to get behind him. This should not be a party political wrangle. There will be some tough decisions. I hope that when we come to seek centres of excellence, as we are, we recognise that we cannot have a hospital in every town. This will be a difficult decision for many towns and counties to accept. We must sure we do not use this issue as a vote catcher by candidates who promise to keep hospitals in their local areas in return for votes.

I urge the Minister to show the enthusiasm he has shown in the past on this issue. He will succeed but will need the support of all of us.

Mr. Minihan

I join previous speakers in welcoming the Minister. In a debate during Private Members' time in this House last February the Progressive Democrats called on the Government to take early and decisive action to reform the management structures and financial accountability of the health service. I am delighted that the Minister has responded in such a positive way and congratulate him on the decisive action shown in the health service reform package announced last week by the Government.

This is the largest single reform package any Government has ever undertaken. It is only the start of a process of reform, a process designed to put patients first and at the centre of health care reform and investment. This is about patients before politicians, boards and structures. It is a decision which signals that the way we have always done things cannot be the way forward.

Everyone will be asked to accept change – politicians, public servants, doctors, pharmacists, administrators, etc. Everyone in the country wants change for the sake of patients. No one is exempt from change if we are to get the best possible services for patients and value for public money. We must all put patients first.

From now on, the debate about health will centre on reform. We are making the investment; we now need the reform. After an increase of more than €5 billion in current spending on health since 1997, no one can credibly argue that all would be right in health if all we did was to spend more. Even the Labour party now accepts this. The Government asked last week to be judged by reforms and results. There will be continued additional funding for health, so long as we keep the economy working well, with high levels of employment, more economic activity and growth. The biggest ever expansion of health care investment was put in place by the Fianna Fáil and Progressive Democrats coalition Government. Now, the biggest ever reform of health is under way, also led by the Fianna Fáil and Progressive Democrats coalition Government.

Unfortunately, political debates on health seem to concentrate on health boards. The Progressive Democrats' manifesto last year staed our management structures were not yet organised to deliver the best results for patients. We signalled that: "The health strategy provides for an early and clear report on health agencies and management structures", and concluded: "It is vital to all our people as well as all working in the health services to have health management structures that are tuned to delivering quality services and care for all".

The programme for Government made a commitment to produce a full analysis and rationalise our system. The Fianna Fáil and Progressive Democrats coalition parties stated:

We will seek the completion of the report on health agencies and management structures by the end of 2002 and will move forward on the principle of removing unnecessary overlap of functions and minimising delays in implementing service improvements.

That is the Prospectus report which, with the report of the Brennan commission, has set out a clear agenda of change in the management of the health service. The Government has accepted the need for the wide-ranging reforms recommended. It has decided there will be a single health service executive for the whole country, with its own board and chief executive. It will be accountable to the Minister for Health and Children. The chief executive will be an Accounting Officer and, therefore, answerable for the executive's budget to the Oireachtas.

With regard to democratic accountability, the health boards have been in place since the Health Act 1970. Now is the time for change. We should agree they are no longer appropriate for the governance, planning and delivery of health policy. This debate is not an attempt to blame health boards or question the integrity of their members. It would be unproductive in the current debate either to blame or exonerate any one group. We could go on forever analysing and decrying past mistakes and failures, sharing stories from our own experience and localities. It is the job of the Government to move forward, propose solutions and get on with implementing them.

Health board chief executives have welcomed the reforms, even if some health board members seem less willing to embrace change. In response to the points raised by Senator Feighan, we should have political accountability and democratic control over health services. We need national policies to work locally. Expenditure on health represents nearly one quarter of all current Government spending. With 166 Deputies and 60 Senators, I do not believe we also need 263 health board members to ensure political control. We have a small population of 3.9 million people and are already very well represented politically. When international analysts say local decision-making can help in public health care systems, they are envisaging local populations in the millions rather than the hundreds of thousands, as has been the case for some of our health boards.

The health service executive will not be remote from people and will have plenty of input from Oireachtas Members, consumer groups and the public. The creation of the new executive will allow a better focus on consistent service levels and budget management across hospitals, primary care and community health services. The creation of a national hospitals office as part of the executive will give a welcome national focus to hospital service planning and management. It is the only form of management and governance that can hope to address the issues that will be raised in the forthcoming Hanly report on medical staffing and hospitals.

The Government will also be reforming the terms and conditions under which hospital consultants work. The Brennan commission of 12 independently minded and public spirited individuals underlined the importance of the common contract for hospital consultants for achieving hospital services managed to achieve best value for taxpayers. They said: "The key question is, how can the health services contract with individual clinical Consultants make it possible to negotiate with them, in a systematic way, the resources they need for their practices without interfering in any way with their clinical independence in the treatment of patients?"

The reforms proposed address this question of involving consultants in management responsibilities. Hospital consultants are absolutely central to the effectiveness of health services. They set excellent standards of care and control who is seen, when they are seen and the resources used in treating them. The terms under which they are contracted by the State are also important to ensure we get equity and clarity in the public-private mix.

The whole point of the Brennan commission recommendations was to align incentives with desired public service outcomes. To do this, we need much better data and management of information on what many people do in health services, consultants included, as well as tighter contractual terms.

There have been many contentious points raised for and against consultants since the Government's announcements last week. Part of the reason there is such contention is that there is very little, if any, hard data on how consultants spend their time, for better or worse. This is part of the management vacuum. It would surely be better if we could debate and make policy on the basis of hard facts, not make deductions about how consultants respond to incentives implicit in their common contract. We do not know what consultants are doing. Many are doing superb work, well beyond what the common contract requires. Some are using the laxity of the contract to their advantage. How much time are they spending with public and private patients? We just do not know the answer.

A consultant contracting with the State is not, in essence, much different from a public servant, even if the consultant is technically self-employed. We require teachers to turn up for a certain number of days and hours. We do not allow them to delegate teaching to others, allowing them to give private grinds during school hours, even if many would not use that option. It is not anti-teacher to make this stipulation nor is it anti-consultant. There is a role for delegation but there is also a limit to it. It is simply common sense public management which, I believe many consultants will accept.

I was pleased to see Dr. Colm Quigley, president of the Irish Hospital Consultants Association, writing that consultants "are open to any set of proposals regarding amendments to the current contract". He said he had only one stipulation, that any new contract should be available to all consultants. We shall see what comes out of the negotiations with the Government. What is important is that a new contract should be negotiated and put in place as quickly as possible.

With regard to the cost of drugs, I will declare an interest because I own a pharmacy. The Government will also be implementing the Brennan commission recommendations on controlling drugs costs. We will be reforming the way we pay for drugs; where a generic drug is available, the Government will pay for it but not the high cost of branded drugs, just for the sake of having a brand. This is a sensible reform which has been proposed by my party colleague and Minister of State, Deputy Tim O'Malley, for which I congratulate him.

The cost of drugs is escalating internationally and there is an obvious public interest in tight cost management here. The OECD report stated:

The increase in public and private spending on pharmaceuticals has been one of the main drivers of rising health expenditure in many OECD countries in recent years, reflecting the introduction of new and more expensive drugs. Pharmaceutical spending rose by more than 70%, in real terms, between 1990 and 2001 in Australia, Canada, Finland, Ireland, Sweden and the United States. Pharmaceuticals now account for more than 10% of total health spending in nearly all OECD countries, and over 20% of health spending in France and Italy.

In Ireland, for example, the cost of the drugs payment scheme has doubled since it started. It cost €140 million in 2000 and is budgeted to cost €280 million in 2003.

The Brennan report puts the cost of pharmacy claims in the GMS at over €700 million in 2002. We cannot but try to control drugs costs. Pharmacists will have to recognise the public interest in controlling drugs and prescription costs. The Government will negotiate with them but if change is to affect everyone, pharmacists will have to be part of the equation.

There will be many others affected by the reform agenda such as civil servants, general practitioners, health board management and staff and local representatives. I do not underestimate the scale and scope of the agenda being undertaken by the Government. It is big but the public deserves nothing less. It expects the Government to govern and lead. Taxpayers are paying public servants generous increases under benchmarking and Sustaining Progress. With nearly 40% of the public service working in the health area, the quid pro quo must be visible in health service reform. Everyone involved in the health service has the opportunity to show that the investment in benchmarking and Sustaining Progress by society will pay off in better management, flexibility and responsiveness to public needs. That is where the challenge lies. If any one group asks to be exempt from change, nothing can work. If all work together to embrace change, everything can work.

Ms O'Meara

I welcome this debate. As the Leader pointed out, this House has been given the opportunity to be the first to debate these important reports which were published last week by the Department of Health and Children and the Government's announcement of a reform programme arising from them. We have already heard some interesting comments. I listened carefully to Senator Minihan, in particular. His pronouncements on the reform programme were delivered with even greater certainty than by the Minister, which leads me to suspect that I know from where the drive for this reform is coming. In that regard, it is interesting that the thrust appears to be value for money and how we spend it, not the priority of care of the patient or care being at the heart of the health system.

Mr. U. Burke

Hear, hear. A typical PD.

Mr. Minihan

It is a pity the Senator was not present to listen to the full speech. It was all about patients.

An Cathaoirleach

Senator O'Meara, without interruption.

Ms O'Meara

Senator Minihan will know that we all have monitors in our rooms and are well capable of listening to debates while we do other work.

Mr. U. Burke

He is obviously vulnerable.

Ms O'Meara

Thank you, a Chathaoirligh, for restoring order. I wish I had more than 15 minutes because I have a lot to say about these three reports, of which we are debating two. The Hanly report will be the third to be published. It will constitute a very important part of the analysis of the problems within the health service and the way forward in terms of a framework for reform and change. I do not think there is anyone who will argue that change is not needed nor is there anyone who will argue that the health service as currently constituted has been able or capable of responding and performing, particularly in recent years, at the level expected of it.

It is not surprising that the debate has focused on money because of the amount spent by the Government on health in recent times. There has been a failure by the service to deliver what we, as customers, to use Senator Quinn's phrase, would expect for the amount invested.

When one looks at public investment figures, one has to ask why there are such problems at Crumlin Children's Hospital. Why are children waiting for chemotherapy? Why are appointments being postponed and cancelled from time to time? Why are large Dublin hospitals closing wards and beds? Why has the problem of waiting lists not yet been resolved? Will the reform programme being outlined by the Government arising from these reports make changes? Will it ensure that the problems at Crumlin are solved? Will it ensure that the large Dublin hospitals do not close beds? Will it ensure that people are not left languishing on waiting lists and forced to use a programme such as the national treatment purchase fund? I know the Minister of State, Deputy Tim O'Malley, is in favour of the fund and pushes it quite often, but surely it is an indictment of our system that we need to send people abroad for procedures, given that we are investing such a large proportion of our national income on our health service.

I wish to discuss this issue in terms of the position at local level. Will this reform mean that the psychiatric unit at Nenagh General Hospital, which has been promised for 20 years, will be delivered? Has the prospect of such a unit now disappeared? Who can we ask about the matter? Who will tell us whether the psychiatric unit will be built and whether residential psychiatric beds will be made available in the county? Such beds are not available at present. How will this reform deliver change on the ground?

With regard to the proposed establishment of a health services executive agency, the major reforms proposed by the Government include the abolition of the health boards and their replacement with this agency and others. It seems that the executive will be a super-body which will, in effect, run the health service. I presume it will be given an annual or five-year budget by the Department. What will be the composition of the board? How will it function? The Government has published a general framework of reform, which is not specific. I presume we will have to wait for the legislation to be published before we will discover how the executive will work in practice. I will be interested to learn about the size of the board. Who will be on the board? Who will appoint the board? By what criteria will the board be appointed? For how long will the board stay in office? To whom will the board be accountable?

When it was announced that a national and centralised health services executive agency was to be established, with a brief to deliver on behalf of the Government, I thought of bodies such as the National Roads Authority, which is charged with developing the roads infrastructure. One would have to recall such examples, because hardly a week passes in the House without a Member speaking – not in positive terms – about the NRA. I will not speak at length about the authority, as I am merely citing it as an example of a board which has been established but which is not accountable to Members of the Oireachtas, as elected representatives of the people. It is remote from the people it serves. Senator Quinn made some valuable points in that regard.

What level of staff will be made available to the agency, which I presume will operate from a building in Dublin? What direct lines of communication, instruction and accountability will the agency have to its regional offices? Will such offices simply be offshoots of the agency? I presume it will tell the regional offices what to do and how to deliver. These are very important points. Most people want to know how the delivery of health services will work. If one can understand the labyrinthine structures, devices and habits of the health boards, one can understand how the health service works at present. The public is entitled to know how the new structure that is being devised will work. How will decisions be made?

We will need a further debate after the Hanly report has been published. I have encountered media reports and I have spoken to various people in the industry, for want of a better word, who are quite close to the Hanly deliberations. I am aware that it is possible that the new system will provide for large regional hospitals, such as Limerick Regional Hospital, which I hope will be designated as centres of excellence and which will receive the support and funding necessary to ensure they operate at that level.

I refer to the mid-west because the Minister of State and I are familiar with that region. There will also be satellite hospitals, such as St. John's Hospital in Limerick, Ennis General Hospital and Nenagh General Hospital. If the information available to me is accurate, the hospitals in Ennis and Nenagh will be downgraded from general acute hospitals to some sort of satellite hospitals. They may be day hospitals and it is possible that they will be driven by nurses. I do not know how the theatres currently in use at Nenagh General Hospital will be used under the new system. Will all consultants leave Nenagh and be relocated in Limerick? I suspect that they will. What will be the relationship between Nenagh and Limerick?

These questions will be asked throughout the country and I would like to receive answers. People want to know about the future of their local hospitals. I want to know about the future of Nenagh General Hospital, not for parish pump political reasons, as some media commentators and people not associated with the area might suggest, but because it is important that communities in Nenagh and in similar towns throughout the country are informed of the level of health services that will be available to them. Who will deliver the service? Of what will it consist? What form of relationship will exist between communities and local hospitals?

The connection of the people with the health service, through the political system and members of health boards, will disappear and will be replaced by the consumer panels the Minister has mentioned. I do not believe such panels will be sufficient because they are based on a weak model and will not be accountable. Will the consumer bodies have a statutory function? I presume there will be no such function, as I cannot envisage how it could be done. Whose responsibility will it be to decide who will serve on such panels? Will the members of panels be elected or nominated? If they are to be nominated, who will nominate them? Will people walking on the street be asked to participate? Will those who are well-known in the community be involved? I do not believe such a structure is sufficient.

A consumer body, of its nature, is simply a consultative body. The Minister, the regional office or the health services executive agency may or may not listen or take the panels' ideas on board. I imagine that Senator Quinn listens carefully to the opinions of the consumer panels in his stores, as his customer is king.

There is no sense that the patient, consumer or customer – one can use whatever phrase one wants – will come first under this framework of reform. The patient will not be at the heart of this reform programme because issues such as auditing, accounting, value for money and watching every penny will be priorities. I have examined the membership of the Brennan commission, which has produced a fine report and has done an excellent job so far, from a public information and public accountability point of view. It has given people details of how money is spent. I do not want anybody to say that the Labour Party does not consider this to be important, because it does, but spending money in a way that provides high quality health care for patients should be a priority.

Health service workers, such as nurses or doctors, are not represented on the Brennan commission. Many accountants are represented on the commission, but those working at the coal face are not. The names in the Prospectus report do not mean anything to me, but I understand it was commissioned by the Department of Finance.

Mr. T. O'Malley

No.

Ms O'Meara

It is the other way around. I presume that the Hanly report will balance that out to some extent.

The issue of democratic accountability is important in the context of the reform and the total abolition of the health boards. One only need only consider issues such as the blood scandal. Democratic accountability is extremely important, as is the way in which the system of accountability is structured. I look forward to the legislation in that regard and I urge the Minister to take that point on board. Whatever way it is devised, accountability must be built in to the structure of the reforms being proposed.

The Minister referred to an extended role for the Joint Committee on Health and Children. This is excellent, in theory, but it can only work if the committee is given the resources and the powers it will need to ensure accountability. Unless the committee operates on the same level as the Committee of Public Accounts, its function of democratic accountability cannot be fulfilled.

My final point relates to the role of consultants. I wish the Minister and the Department well in their battle with the consultants. I have no doubt that it will be a monumental battle. There will be blood on the floor before this is over. The Department is taking on one of the strongest vested interests in the country. The consultants are coming to the Department with a contract that the Department negotiated which, in effect, gives them everything. They are now being asked to give something back and, in any negotiations when one is taking something away from a group, they will strongly resist it.

It is important to note, however, that the wider context within which consultants previously operated is no longer the same. The consultant was always seen as the authority figure in a hospital and it is welcome that this will be brought to an end in the reform programme. In the same way as nurses, other doctors and workers in the health service, consultants are the servants of the people. I accept that we must pay people for their skills and level of education. We need their skills and expertise and we need to maintain what we currently get, namely, a high level of commitment from many consultants. We must, however, alter the current contract to make it fair and, to use the phrase employed by Senator Minihan, to get better value for money.

In regard to implementation, the Brennan report proposes an independent committee, but I gather from what the Minister said that he intends to do it in-house within the Department. Implementation will be the most important part of the process and its success depends on the manner in which this is done. The Minister needs to reconsider the position.

Ms O'Rourke

The health debate, as I proposed earlier, is being extended until 3 p.m. The sos will follow, after which we will resume with the Arts Bill. We tried to get the Minister of State, Deputy Roche, to come before the House, but he is standing in for the Minister in the Lower House this afternoon.

I welcome the Minister of State at the Department of Health and Children, Deputy Tim O'Malley. I acknowledge the presence of the Minister, Deputy Martin, earlier in the debate. I understand that the Minister of State, Deputy Callely, will be present between 2 p.m. and 3 p.m.

I congratulate the Minister, his colleagues and his team of civil servants on the production of these two fine reports. There is no doubt that the patient is at the core of both these reports as, I assume, they will be at the core of the Hanly report when we receive it.

I was particularly struck by something I read at the weekend in regard to health spending. How could anyone say that there should not be reform when the entire income tax take for 2003 will go towards gross health expenditure? In other words, if we receive €9 billion in income tax receipts, a corresponding amount will be spent on the health service. That is a huge factor to consider and such an approach is unsustainable. It would not be possible to just keep pouring money into health without seeing any benefit to patients. While we welcome their publication, these reports are long overdue.

There have been those who highlighted the fact that a number of accountants were on the teams that drew up the reports. What is wrong with accountants? They know how to count money.

The patient comes first in the reports, which seek to reorganise the structures of the health service in such a way that the patient will benefit. That makes sense and I have no doubt that we will all, ultimately, benefit from this. I acknowledge that it will be difficult. Problems are inevitable when one is trying to bring about the kind of monumental change that is envisaged here. Senator Glynn referred to the fact that the existing system has been in place for almost 33 years and, as Senator O'Meara said, there is bound to be blood on the carpet. There is no doubt that there will be blood all over Ireland as this change works its way through.

My advice to the Minister, Deputy Martin, the Department and the Government would be to adopt the Latin adage, carpe diem, seize the day. Reforms not quickly implemented lose their impetus. People will get tired of hearing about them. Once the momentum starts, it must be maintained. The proposal for nationwide seminars is a most effective way of meeting with all the interest groups. We must constantly inform the public as to what is happening to the health service and how the patient will benefit from what is being undertaken. That will be remarkable.

It was not surprising that the media focused on the proposed changes to the health boards. They were an easy target. I admire Senator Glynn's generosity in the manner in which he dealt with the matter from his perspective, as a chairman of a health board.

It was reported in the newspapers that it would be three years before health boards will be disbanded, which I think is far too long. There is a natural hiatus next year when the local elections are scheduled to take place. Who would want to be appointed to a health board which will soon become obsolete? I urge the Minister and his team to quickly put in place plans for the disbandment of health boards subsequent to next year's local elections.

The Minister did not say that it would take three years or more before health boards to be wound down, but that comment has been made. That is only one small aspect of a huge range of changes in the health service. The health boards must be commended for what they have done over the past 32 years. I never sat on a health board, nor did I wish to do so. I never sought it, asked for it nor got it. Throughout my political life, however, I observed the operation of health boards and what they have achieved. It may be forgotten that I previously served as Minister for Health. I was in the Department for almost three months, so I know quite a bit about health boards as I met them extensively during that period. It was a short but fruitful period and an enjoyable one.

The complexities of health care have developed apace. Technology has led to more precise ways being found to alleviate ills. Our ageing population places a different kind of demand on our health system. The structure of health boards sometimes led to people seeking things for their own area. That is not to discount the wonderful work they did, but there was an element of "look what we have here" involved. It is clear that one cannot have a centre of excellence in every village in Ireland. The Minister was right to point that out. We have to face up to that fact, as do the people of Athlone. Although Athlone is one of the biggest urban centres in Ireland, it does not have a hospital. However, we hope we are developing services in a much more community based way, which will be more beneficial to our patients, especially in relation to the involvement of consultants and so on.

The vista is huge but it cannot be endless. I commend the way the Minister and his team are proceeding. I also commend the authors of the two reports. Anybody would love to have Professor Brennan on his or her side in a difficult situation – she would certainly fight the fight on one's behalf.

I must warn, however, against the demonisation of consultants. There is no doubt that we need consultants in an ordered and structured system. Ultimately, we depend on their professionalism, hence my warning against the demonisation of them. Clearly, they will also have difficulties in adapting to change, as will every group now inherent in the health service. Each group will have to change and adapt but they should welcome this development. In the end, a country depends greatly on how it is perceived, in terms of treating its citizens in a proper manner with regard to health care.

One cannot possibly cover the subject fully within ten minutes. I commend this programme of reform. I am glad it has been published and that there is a great sense of urgency and momentum about it. This must be maintained because, otherwise, we will lose out. I am reminded of the Shakespearean line: "There is a tide in the affairs of men, which, taken at the flood, leads on to fortune". This must be taken at the flood and, if it is, it will have success. I wish it well. I know we will have many debates in this House when the three relevant pieces of legislation come through and as the programme develops and evolves. Let us take the tide at the flood and deal with it. This House has a strong record on health issues. I thank the Minister and his colleagues for attending here so often.

Senator Quinn said earlier – I am not sure whether the Cathaoirleach was present at the time – that Senators should come into the House without breakfast each morning and stand during the Order of Business. Will the Cathaoirleach arrange to have the chairs removed from the building in the morning?

Mr. U. Burke

I welcome the Minister of State, Deputy Tim O'Malley. I am glad the House has the opportunity of debating these reports. I agree with the Leader of the House, Senator O'Rourke, as to the urgency of implementing this programme. If implementation of the reports and reforms has to wait three years, they will have lost their initiative. We have had a rash of reports in connection with the health service, at local and national level. What has happened to the many expert reports during the years? They were embraced very readily and their contents regarded as gospel. However, after some time, the holes and cracks began to appear. I have no doubt the same will happen to these reports if they are not implemented quickly.

As Senator O'Rourke said, it is important that the Minister and the Department should tell the people what is happening and what progress is being made. The reality on the ground is that the people – patients and their families – have told the Minister and the Department what was lacking and how impossible it was to get access to services. That is what has led to the reports. Otherwise, people in the Department of Health and Children would have sat down, cushy in their present positions, and allowed the situation to drift on indefinitely. The response we have had today is due to people screaming for change and, in fairness, the work of the media in going into hospitals and highlighting the hardship cases, the reality.

I greatly welcome the Minister's opening statement that the sole objective of health policy is to deliver access to a high quality of service to all. With the greatest of respect to the two reports, we have to stand back and compare what we are about to put in place with what is in place at present. I agree wholeheartedly with the Minister's comment to which I have just referred. If I was confident that the Minister, the Minister of State and departmental officials had the capacity to deliver that single objective, everybody would be happy and there would be no need for further reports.

I am concerned, however, at the absence, in the reports, of any organisational responsibility for managing the health service as a unified national system. This makes one wonder as to what is actually happening. Is that statement in the report a clear indication there is no confidence in the Minister and the Department, which had the singular responsibility of delivering services in the past? As I see it, the finger is being pointed directly at the Minister and departmental officials on the basis that they had the responsibility and failed. That is true. Now, however, fingers are being pointed further down the line, suggesting that it is the health boards which have failed – that money has been dished out to them without response.

Let us look at the policies we have and the initiatives which have been taken. As a member of the Western Health Board, intermittently over many years, I remind the Minister of State that many policies developed at ground level were incorporated into departmental policy. That was a bottom-up approach, whereas we are now about to get a dose of top-down approach again. The roles have been reversed, with blame being directed at the health boards and their officials in a wrong and misguided manner. Fault cannot be apportioned just like that.

Those who say it is a bad idea to have politicians on health boards are entitled to their opinion. However, I shudder to think of what may happen in future in relation to local initiatives. How will they be recognised and monitored? Do we believe, for one moment, that personnel within the new executives will recognise what is good about the application of this new policy at ground level? The answer is no, because it will never get through the system – the network is in place but there is a gap. We are now going down a road which involves widening that gap and stifling progress on those aspects which were attractive and good. I do not, by any means, suggest that every aspect of the health board system was good. While it may be said that health board administration is top heavy, the reality is that many capable people work in the health boards and many of their good ideas have been put into practice, being incorporated into the Department's system. That will not happen in future, in the context of a top-down, stepped, tiered system from now on. If it works, I will be glad to acknowledge it but I cannot see it working in the future.

In one of his statements, the Minister said: "The Department of Health and Children will be restructured to ensure improved policy development and oversight". That is paralleled by what is happening in the Department of Education and Science, which involves farming out various sections of the Department. For example, the examinations section was moved out but it has not worked well. In a recent statement in this House the Minister used the very same clichés – that we will have a new Department of Education and Science whose sole responsibility in future will be – in exactly the same words –"policy development and oversight". Where is the responsibility in that regard? Has the Minister taken such a lambasting because of his failure, with his departmental officials, in the delivery of an accessible service to the people. Does he now propose to stand back and let somebody else take the flak because it is too much of a hot potato for him to handle? If any Minister, regardless of his or her ability, decides to drop the hot potato and run for shelter, we will have nothing to look forward to except more disaster and failure in the health services.

Let us look at what has happened with Department policy. The Department seems to respond to political pressure of one type or another. There are beautiful facilities, theatres and hospital wards lying idle because of the Department's failure properly to assess health needs. We are consolidating the same ideas today.

I know we have two reports, but a third one, which is the meat on the bone, is missing. We are talking about centres of excellence. If the Minister of State decided to visit the accident and emergency department of University College Hospital Galway, he would see confusion. The responsibility for that must lie with the general practitioners. The days when general practitioners were prepared to work and to deliver a health service are gone. Health issues are now referred to accident and emergency departments. The Minister must tackle that major problem.

I am sure Senator Kitt is aware of the situation in Portiuncula Hospital in Ballinasloe. I am sorry Senator Minihan has left the House because I wanted to tell him that when the Tánaiste visited Ballinasloe a short time ago on a sad and difficult occasion, she guaranteed that Portiuncula Hospital would be retained and that its services would be developed in the future. That is contrary to what we were told today and to what we are led to believe is in the Hanly report. Was it political expediency which prompted the Department to buy the Bon Secours Hospital in Tuam? There is now a chain on the gate of that hospital and it does not seem likely that basic services will be provided for the large hinterland around Tuam.

The Department has relinquished all its responsibilities in those areas and handed them over to the new executive. There is a failure to recognise the need on the ground. This report and the health strategy are aspirational. There will be hype about these reports for a while, but then they will disappear. I am afraid things will not change. I do not have the confidence in the Minister to say that things must be done because he has not shown any courage to date.

Mr. Kitt

I join my colleagues in welcoming the Minister of State to the House. I am delighted to take part in this important debate. I attended an interesting launch this morning by the Minister on the nursing home subvention scheme which was reviewed by Dr. Eamon O'Shea from the NUI in Galway. He was fair in his comments about the scheme. He said there were many ways it could be reformed, but he did not castigate it. I feel the same way when speaking about health boards and agencies which will now have to be abolished.

Dr. O'Shea mentioned the need for significant public investment in both rehabilitation and step down facilities for older people. That is relevant to what Senator Ulick Burke said. We are looking for a community nursing home in Tuam. We already have an excellent site and I hope the Minister will consider it. I know he is visiting Galway on Monday to meet the board and to discuss the reform package. I will be glad to talk to him and to raise questions with him.

Everyone is talking about health service reform. It is no wonder Senators are interested in the issue and I am glad we have an extra hour to discuss it. There is no point in people talking about a Third World health service or claiming that it will get worse. Health boards have done many good things. Any service which can deal with one million cases a year and which has increased the number of cases by 180,000 in only five years is not a Third World health service. Dr. Brennan put it well when she stated in the report's conclusion that there is scope to increase significantly the efficiency and productivity of the health system in Ireland, in effect, to provide better services to those who require health care and better value to the taxpayer for the substantial investment in health services. She likened it not to a black hole but to a colander which had many leakages.

I welcome what the Minister is trying to do. I do not agree with everything he has said, but I do not understand it all. It is not clear, for example, where the four regions or the local offices will be. I had hoped that the structure might be on a county basis. However, that does not appear to be the case. Perhaps it will be done on a community care basis. I recall in 1989 the local county health committees were abolished. They were advisory committees, but they were useful.

If one wanted to criticise the boards, one should have done so when they were set up. That was a different time and we have moved on since then. In 1997 when Deputy Martin was Minister for Education and Science he said the proposal to set up education boards would cost £50 million. He thought it better not to establish them and I agreed with him. It is like the tourist looking for directions in Kerry and being told by the Kerry man that if he were going where the tourist wanted to go, he would not start from that particular point. It is the same with the health boards. I pay tribute to the great work they have done over the years.

There is an issue about the lack of local representatives on the board. When the regions are established, it would be useful if we could find out what role local representatives could play. I welcome the fact there will be a role for Oireachtas Members. However, other people have been members of these boards for years.

Reference was made to a health and information authority. We have not always had good experiences of setting up new authorities. One cannot, for example, question Ministers about issues or raise issues in the Seanad. I think in particular of the National Roads Authority. The health boards have had many successful schemes and they have produced many new initiatives, such as the drug free cafes in Galway which we would like to see extended to smaller towns. The housing aid for the elderly scheme has been a tremendous success in the Western Health Board region. Approximately 1,200 projects were carried out last year, many of them through FÁS. I hope that scheme continues in the future.

A question was raised about wastage. Senator Quinn said that crutches and walking aids are not brought back to health centres. The Western Health Board has examined the issue of transport because it has a huge bill for taxis and ambulances. The health board has tried many ways to resolve this issue. I hope the new offices will continue to do that. Will families be able to help? Will appropriate public transport be provided? I hope all such issues will be considered.

Some of the Dublin hospitals have stated that they are not prepared to take people from outside the Eastern Health Board Authority region as priority cases. I was appalled at the outrageous statement that operations or procedures would not be carried out in Dublin for people outside the provincial area. In defence of the Western Health Board and our major hospitals such as University College Hospital, Galway, no hospital would refuse treatment to people who were not from Galway, Mayo or Roscommon. I am sure this is also true in Limerick. The chief executive officer of the health board and the hospital consultants have never refused treatment to anybody from outside those three counties. Dublin hospitals should never do this either because it is important that whatever treatments are not available outside Dublin should be available in Dublin for the most deserving patients.

The Brennan report referred to the question of times for appointments. I have come across cases in which large numbers of out-patients have been given the same time for appointments. There should be a better system: having more consultants working in the public area is important.

Merlin Park Regional Hospital is very old. When built, at a time when the scourge of TB was prevalent, it was decided to put units a long way from each other. People must make their way from out-patient consultant appointments to an X-ray area in a different part of the building. One wonders how people dealing with broken limbs manage this. It does not make sense. This is one problem which should be investigated by the new office.

Although I am usually supportive of the health boards, one problem I have found is in the area of disability, an important issue. The Minister is very kindly giving us extra money. Other Ministers have given money during the years. There seems to be an idea among the health boards that the money should be divided among counties not on the basis of need but of size. A little more is given to Galway because it is bigger than Mayo and Mayo gets a little more than Roscommon. That is totally wrong. Unfortunately, the same thing happens in relation to housing repairs for the elderly: the money is divided among counties with much political in-fighting. A county based structure would be better, although it would not be perfect. We would still have rows between Galway city and the rest of the county. I hope this issue will be dealt with by the new structures being put in place. We know the structures are lacking because the two reports mentioned this.

The Hanly report was also mentioned. This is a very important report for our region. I understood it considered three hospitals in the mid-west and three in Dublin. It has been leaked all over the place – it is a pity we do not have it here for discussion. How can it state many hospitals are to be closed on the basis of its consideration of just two regions? Portiuncula Hospital, Ballinasloe has been mentioned as one that will lose some of its services or status. This is wrong. The sooner the report is published and we can debate it the better because we are dealing with rumours and hearsay about the future of hospitals.

I thank the Leas-Cathaoirleach for allowing me to speak and thank the Minister for the debate he started. I also thank the Minister of State for all the work he has done, particularly in the area of disability. This has been a very useful debate and the Minister and his officials have done a very good job. They are already visiting health boards and coming to the west next week. It will be useful to see how the new system will work but we must consider its chances of succeeding. People say the same argument could be made for education – that it should be centralised – or agriculture but would it work? The health boards have done a lot of good work. Let us see how we will deal with the new structure.

Dr. Henry

I welcome the Minister of State. I found these two reports extremely interesting reading. I have been reading reports on the health service for quite a while now – I remember when the Fitzgerald report was issued because it resulted in my having to do a great deal of extra work. Professor George Fegan, for whom I worked at the time, was involved with the report and I remember the grave disappointment when it was not implemented, despite all the work that went into it. The Fianna Fáil Party was largely responsible for its non-implementation. So much time and money would have been saved if it had been implemented. An amazing amount of what is being criticised in the health service was actually foreshadowed in the report. It was an attempt to prevent waste in some areas.

The most important conclusion that can be drawn from both reports is that there is a dreadful information deficit in the Department of Health and Children. It will be very hard to move on unless something is done about this. Since Deputy Michael Noonan was Minister for Health and Children – about eight years ago – I have been asking for a population register in order that if we introduce a scheme, we will have some idea how many people will be involved and when they will be called for screening. When I asked for the population register to be established, Deputy Noonan was establishing BreastCheck. We then had no notion of how many women should be coming forward to be screened each year. Lists were being made up from the GMS and the VHI and people are still being left out now. The most obvious example of how important it is for us to set up a population register immediately is the medical card scheme for the over-70s, in which there were twice as many eligible to apply for a medical card than had been expected, at a huge and unexpected cost to the State. I hope a register is being set up and that this dreadful information deficit is being rectified because it is one of the most important things that needs to be done.

In both reports great emphasis is put on the fact that the health boards are to be abolished. It is right that we do this, because there are too many. Like other speakers, however, I am not only interested in denigrating the health boards. I had to leave the debate for about half an hour to go to Cherish, the organisation for single mothers, of which I am president, and give out certificates. Ever since Cherish was set up 30 years ago, we could not have managed without the support of the Eastern Health Board and subsequently the Eastern Regional Health Authority. I hope the sort of personal attention that can be given – and was given – to various problems by the health boards is not lost in this great new mechanism, because it has been very important. Cherish would not have managed without it. I went over to give out certificates to people who had done computer courses and so on and were now going into employment. Initiatives such as this need to be encouraged. I hope that with whatever mechanisms are put in place, we will be able to take account of what people are trying to do on the ground.

The Prospectus report deals with the amalgamation of various organisations. Sometimes I think I have sat on every medical organisation in the country but have now found out that there are a few on which I have not sat, such as the Poisons Commission. Some of the amalgamations seem very sensible but there are others about which I wonder. For example, the Pre-Hospital Emergency Care Council is to be combined with the National Social Work Qualifications Board. I cannot see anything these two have in common, particularly in view of the fact that the Pre-Hospital Emergency Care Council is actually getting to grips with pre-hospital care, which is improving enormously – paramedics are being trained to a much higher standard. I would have thought the council would have its hands full without taking on a lot of extra work to do with social work qualifications.

I wonder whether it is wise to amalgamate organisations just for the sake of saying there is a smaller number of them. It is perfectly sensible for the Poisons Commission to amalgamate with the Irish Medicines Board, particularly in view of the fact that it has apparently met three times in the last ten years. I would suggest that a rational look should be taken. Things should not be combined just for the sake of it and because it would look better to have a smaller number of organisations.

The situation with regard to the vested interests, the consultants, will be one of the most hotly debated topics in the entire report. Professor Brennan has been pretty harsh in her criticism of my colleagues. In one part of the report she says that there should be core times when a consultant must be available to patients in the public hospital and a formal act of monitoring work commitment in respect of public patients. Absolute categorical monitoring does not take place at the moment and if she wants to bring that in fair enough – it is not in the consultants' contract. Any time we tried to monitor each other, within the various hospitals in which I have worked, it was found that 90% of people were doing far more work than they were expected to do under their contract. Of course there was the 10% who were not doing it and we all ground our teeth about them and wondered how we could do anything because others had to carry their work. That happens in every organisation.

I am more concerned about the appallingly low morale within the health service, and particularly among the consultants and more senior nurses, than the fact that people have to be monitored. I am horrified at the hours some of my consultant colleagues work, starting at 7.30 a.m. and still there until 7 p.m. Of course there are situations where people are neglected. This can include private patients also.

A general practitioner colleague told me that his child was in hospital for five days, albeit not very ill, and not once did the consultant see the child. He did not bother doing anything about it because the child was well catered for by the registrars on duty. There will be incidences like that, so it is not just public patients who are left to one side. I do realise that, as in all professions, there are some people who do not pull their weight, but the vast majority are doing a great deal.

Much of the low morale is due to work not being done that was planned, particularly elective work. When an operation is cancelled it is terrible for the patient, but it is also terrible – particularly if it is a big operation – for the surgeon who has had to organise the entire day and arrange for a particular anaesthetist and maybe a radiologist. The waste of time involving all those people is shocking. In one of the Dublin hospitals at one stage they would phone me when there was an anaesthetist on duty but no surgeon available and vice versa. They gave up eventually as there was no point in phoning me. This type of issue is most unfortunate.

I would not concentrate too much on the public-private mix, because 50% of the population is involved in private medicine. I would not like to see the House getting bogged down on that issue.

The last thing I would mention is the drugs monitoring scheme and the use of generic drugs. I am particularly glad the Minister of State, Deputy Tim O'Malley, is here because he has a professional background as a pharmacist and we have talked about it outside this House. I have read the Forfás report on embedding the pharmo-chemical industry in Ireland and wondered if the health service was not contributing to it by the fact that the Government pays very high prices to pharmaceutical companies for drugs, which are much cheaper in other countries. The Government could do much in this regard. Of course we could buy generic drugs, although they would probably have to be branded generics. The Minister is aware, I am sure, that in Brazil, a very big producer of pharmaceutical drugs, 20 patients died recently from some sort of injectable radiological compound that was being made under totally unsuitable conditions. Six patients lost their sight owing to the effects of an eye gel which was being used in operations, probably for detached retina or something like that. We do have to be sure we have proper quality medicines.

It is important to remember that the medical profession's responsibility is to the patient, first and foremost. One cannot get away from that. It is ethically at the centre of what a doctor has to do. If doctors are being asked constantly to look at the accountancy side of things, naturally they get anxious. In neither report is the question of litigation addressed and it costs the health service in Ireland a fortune. There is four times more litigation in this country than in Britain. The awards given in the courts are four times higher than on the neighbouring island. I would like this to be addressed. I realise the Minister hopes to introduce enterprise liability on 1 July.

Officials in the Department of Health should talk to Deputy Jim Glennon who set up Medisec, a medical indemnity scheme for general practitioners. The fees for that were very small when they started, but after five years the amount of money general practitioners had to pay to be part of the scheme had to be doubled. This is one area that I am particularly sorry neither report has addressed. The Minister's Department pays a fortune for that, as he well knows.

Hospital rationalisation is essential. I have argued in this House that places such as Mullingar, Tullamore and Portarlington must get some centre of excellence for breast cancer. I am told that no woman from Mullingar or wherever will have to travel. This attitude must be overcome because we cannot have MRI scans at every crossroads.

I thank the Minister. I do hope something happens as a result of these reports. I have seen so many reports which have not led to action that I am just a bit pessimistic.

Mr. Fitzgerald

I welcome the Minister of State to the House. I also welcome this ambitious and challenging reform programme which he, with the Minister for Health and Children, Deputy Martin, and the Department have set before us.

It represents a huge challenge to address serious ongoing problems in the health service despite the phenomenal investment in recent years. Some commentators such as Colm Rapple have estimated that there was probably more investment in net additional terms in the health service than in all the other sectors put together. I am not sure he is correct, but it is a statistic he put forward two or three years ago in the media. Either way, the extent of the increased investment in the health service is quite spectacular. One quarter of entire public expenditure is accounted for by health – in excess of €9 billion, which is almost the entire income tax take. It is frightening that such quantities of money are invested in a service, which by its nature is extremely wide ranging and touches every community. It will also continue to expand, given the demographic changes that have taken place. The challenges facing the Minister and the Department will be correspondingly greater.

Looking into the future I am reminded of the words of the poet, Brendan Kenneally:

Though we live in a world that thinks of ending

that always seems about to give in

something that will not acknowledge conclusion

insists that we forever begin.

I am certain that apparently daunting challenges such the ones currently before the Minister and his colleagues never thwarted him. I have no doubt the words encapsulated in that little verse are similar to those that inspired him and his colleagues to embark on the challenging road ahead. There is a certain amount of pessimism as to the degree of commitment he is bringing to the task. I do not share this pessimism because I am aware of the commitment he shares with the Minister for Health and Children, Deputy Martin, to take on the challenge constantly to reform the health service. It should be a service, not about politics, which is deeply embedded in it through public representation, but about patient care and service to the community. In my recollection, however, there never has been an issue so politicised.

The Brennan and Prospectus reports contain recommendations for the future funding and structures of the health service. In addition, the forthcoming Hanly report will deal with interrelated issues which form an integral package for the successful delivery of a regionally-based, multidisciplinary, specialised health service at local level. According to the best placed sources, the Hanly report on medical staffing, which is to be presented to the Minister, but which has not yet been fully signed over by the parties involved, seems to be putting forward principles consistent with his thinking.

The report also appears to be in line with international evidence which demonstrates that clinical outcomes for patients are improved when they are treated by multidisciplinary specialist teams operating in units with high rates of activity and access to diagnostic and treatment facilities. We will have to face the fact that such a multidisciplinary service cannot be made available on every doorstep. As with the education sector, such specialised, widely available services cannot be provided in either the health sector.

Up to the 1980s, successive Governments sought to upgrade and modernise our second level education system. The Minister of State's relative, the late Donogh O'Malley, was one of the great inspirations who, as Minister for Education, brought secondary education into the modern era. It is a coincidence that the Minister of State, Deputy Tim O'Malley, is here because this is central to what I wanted to say. Donogh O'Malley was an inspiring figure who saw the true value of free second level education, which he provided in the 1960s.

From the 1950s onward, communities debated the need for secondary schools at every crossroads and street corner. The arguments were based on the premise that if primary education could be made generally available, why could the same not be done in respect of secondary education. That debate did not take account, however, of what was already happening in the primary sector, which was moving away from the national school structures that had already existed for the best part of a century. In addition, it failed to take account of the rapidly changing thinking on the need for a more rounded education, involving a wider choice of subjects, and the need for greater resources, including specialised teaching and improved facilities.

There was also a need to address inadequacies by providing specialised remedial services within the school system. The need for such changes was already apparent but had not been taken into account by those who were arguing, with the best interests of their communities at heart, for second level schooling on every doorstep. At that time, amalgamations were taking place at primary level in response to ever-growing demands, some of which were financial.

The same argument applies to the delivery of future health care services. The highest quality of care to meet an ever-increasing demand for a huge range of needs, can only be delivered at centres where the widest range of specialist expertise, including research and other facilities, is available together with the most up-to-date surgical technology. That, however, is where the parallel between health and education ends. Centres offering the widest choice and richest resources of educational expertise and facilities, can be accessed by a school transport system. Access to health care by remote communities will be challenged by conflicts between the pressures inherent in regional hospitals catering for ever-increasing patient numbers and the perceived urgent needs of distant local communities or, for that matter, individual patient concerns.

The continuation of existing community care facilities has been flagged, but, even if they are upgraded, I am convinced that such structures will not fill the gap by ensuring that there is a proper balance in meeting these potentially conflicting needs.

Accountability is required, both nationally and locally, but the reports point directly and significantly to a lack of accountability within the current system at national level, despite a huge commitment and investment by the Minister and his Ministers of State. If accountability is required nationally, then, equally, it is needed locally. At national level, the health executive and its three core pillars will have to be accountable to the Minister and, through him, to the Dáil and Seanad, as well as the Oireachtas Committee on Health and Children.

The structures will be a national watchdog for the implementation of this new, exciting and challenging, yet difficult, programme of renewal and modernisation in the health services. If the pillars were not considered to be essential as a conduit for accountability, I presume they would not have been sought through legislation. The Minister intends to introduce such legislation to make them accountable in that way. The corollary is that, both locally and nationally, a network of watchdogs will be required to ensure a fair balance between potentially conflicting needs. Sooner or later, I believe it will be sooner, local representatives, including councillors, will have to act as community watchdogs.

We have started down the road of separating national and local government representation by removing the dual mandate. I reluctantly supported that move because it was the right thing to do for the future. The evolving role of the national politician is seen as being distinctly separate to that of community representatives, although they are interrelated. A new and evolving role is envisaged for local councillors to represent local and community issues across all service sectors. It is both inconsistent and inconceivable, therefore, that local councillors would be left out of the frame in these new proposed structures.

With the abolition of health boards there is certainly a case for fewer councillors, but, equally, there is an indisputable case that the lacuna which will exist at community level can best be filled by locally elected public representatives. Any role these councillors may be given will clearly have to be compatible with and integrated into the new implementation structures. If the new structures need to be accountable nationally, they must surely be called upon to account for themselves locally.

Just as councillors should have a new local role and given that all other structures will be transformed, now is the most appropriate time to deal effectively and thoroughly with the role of consultants in our public health services and the practices that have developed from that role in recent years. From summaries I have read, I understand that the Brennan report points directly to the role of consultants and the best place to start is with their contracts.

Two years ago, as a humble Senator, I had the misfortune to cross consultants in the House and, as a result, I incurred their wrath and fury.

Mr. Norris

The Senator should not have an operation.

Mr. Fitzgerald

I merely wanted to talk about the bedside manner, but they took extreme umbrage at my remarks. What umbrage will they take now that the Minister, Deputy Martin, is intent on dealing with the issue of their contracts? It may prove to be a more formidable challenge than those he has previously tackled.

Mr. McCarthy

I wish to share time with Senator Norris.

An Leas-Chathaoirleach

Is that agreed? Agreed.

Mr. McCarthy

I welcome the fact that we have been given an opportunity to discuss these important reports. It is a sign of the way in which the House has evolved that it is the first Chamber in which they are being debated.

The Government parties have been in power for more than six years. For the majority of that time, there has been unprecedented economic activity. No Government had as much money at its disposal and there was never a more opportune time to reform the health service, as funding was available and public services were not strained. It was remiss of those parties not to engage in reform of this magnitude and a genuine opportunity was missed.

Proposals to reform the health service should focus on a decent standard of service, a high level of accessibility and equality for all. Those are the rocks on which a good health service should be founded. The national health strategy was launched two years ago amid massive inequality in the system. However, that is still the case in terms of caring for public and private patients. Waiting lists are as long as ever and the opportunity to reform the health service was not seized.

The health strategy is defunct, but it was doomed from the beginning because, two weeks prior to its launch, the Minister for Finance told the Minister for Health and Children that he would not allocate funding for it. The strategy was launched amid great pomp and ceremony. It was detailed and was consumed by the media and everybody with an active interest in the health service. However, the lack of funding spelt the strategy's death knell before it could be rolled out.

People availing of the health service are the most affected by cutbacks in public expenditure. For example, 25 surgical beds were closed recently in Our Lady's Hospital for Sick Children, Crumlin. The hospital had more beds when it opened in 1957 than is currently the case. The reports before the House have been termed in certain quarters as the most extensive reform programme of the health service in more than 30 years. However, the central deficiencies in the administration of our health system are not addressed as they should be in comparison to the technical aspects of how the system should be managed. That is the crux of the debate. For example, issues such as accessibility and quality of care are superseded by bureaucracy and administrative accountability. While those are necessary, the direction the health service takes needs to be prioritised.

The patient needs decisions to be taken about practical measures that can increase service and treatment available to him or her, not more analyses, so that he or she will not have to wait months and, in some cases, years to access absolutely necessary treatments. The reports are largely accountant-driven and there is nothing wrong with that. Details that affect costing must be examined and accountants are experts in this regard. However, we must be mindful that the patient must be at the core of reform of the health services and the administrative and technical details must come second to the patient at all times.

The administrative reform and the view of accountants about how the service should be run is useful in terms of identifying shortcomings, of which they are many. We should not denigrate the status of accountants, but we must remain cognisant of the fact that the patient should be at the centre of far-sighted reform of the health service.

In principle, the Labour Party does not oppose the establishment of a single authority to manage the acute hospital system, nor does it oppose the reduction in the number of health boards. Three more were set up over the past two years in the Dublin area, which highlights the administration issue. A number of people have been saying for a long time that health boards should be abolished, while others recognised the positive role they play. However, the abolition of health boards will mean the abolition of a core element of our democratic system.

As Senator Fitzgerald pointed out, councillors have made an important and valuable contribution to the development of the health service through their membership of health boards. That role should never be underestimated. For example, councillors in my county representing all parties have attended health board meetings and fought strenuously for projects to be delivered in the Cork-Kerry region. The proposed abolition of boards is causing anger and annoyance in many quarters but to make an omelette, one must break eggs. If one is to be far-sighted, proactive and positive in terms of reform of the health service, difficult and critical decisions must be made, particularly if patients benefit.

It would be dangerous if measures were taken to make the delivery of community health services less accessible to the people that they are intended to help. The performance of such services has been second to none and one only has to look at one's own area to see the role they have played. One should never look too lightly upon that important role, which is a principal element of democratic accountability within the health service.

Much attention has focused on the proposal to remove political representatives from health boards, but there is more to the reforms than that. Sometimes people focus too much on certain issues without examining the entire package. However, accountability must be maintained because, if it is not, the public will lose faith and projects will not be supported. The funding of the reforms is critical, given that the national health strategy was shelved because money was not available. If we are serious about implementing changes as radical as these, funding must be provided and the Minister should spell out from where it will be generated and how much will be allocated.

I visited the website of the Irish Medical Times to sample the professional commentary on these reports. Professor Brennan advises that the appointment of the first chief executive officer must be made through open competition and I would like the Minister to comment on that.

Mr. Norris

I am grateful to Senator McCarthy for giving me this opportunity because I had not intended to say anything. However, I am happy to be able to do so.

Deputies Martin and O'Malley are good and caring Ministers, but health is a poisoned chalice. It is one of the most difficult areas politically for any party to address. The problem is that more and more money is spent, but the customers are less and less satisfied. There is a series of reasons for that. New medical technology is available and ailments that were untreatable and incurable ten, 15 or 20 years ago can now be treated successfully. It is tantalising for someone with a painful or terminal ailment to know that treatment is available but that he or she cannot avail of it. It is the ultimate in tantalisation.

Services are much more expensive now. In my day, people went into a corner and died of an inward pain and that was it. They acknowledged that we are all perishable goods. Now people think that sickness is an insult visited upon them by Government and they expect to be cured. That will not happen because we are perishable goods and we will all croak at some stage. However, within the health service, things need to done and I am glad that there will be rationalisation. We have too many health boards and there are 58 agencies in the system, 30 of which will be abolished. I hope that this is done in a focused way and that there will not be abolition merely for the sake of cutting things out.

I welcome the opportunity to speak because I visited an elderly Hungarian relative in St. Vincent's Hospital yesterday. I have nothing but praise for the nursing staff there; they are absolutely wonderful. We are blessed with regard to the Irish and foreign nursing staff working in our hospitals. We will lose those wonderful nurses from the Philippines because of the technicality that we will not allow their spouses to come to this country and work. That needs to be addressed because we will be in real difficulty if we lose this element, to which we have become accustomed. It would not be any skin off our noses if we let them in and permitted them to work.

I looked at the ward where my relative was being wonderfully looked after. In an excellent hospital in Dublin, the ward of 30 people had one ancient bath, no shower and one lavatory. The bathroom was crowded with all kinds of other bits and pieces of medical paraphenalia. How they get the poor old people in and out I simply do not know. There were six people per division of the open ward. Some of them are dying and, while I was there, some were making involuntary noises. A radio was playing somewhere. The people were very ill, elderly and in considerable discomfort. Of the 30 people in this acute surgical ward, there were five for whom nothing more can be done but there is no place to send them. They are occupying five beds which are needed by acutely ill people in need of treatment. In a very gentle and nice way, this was explained to me by a member of the staff who is aggrieved on behalf of the patients and who is well motivated. I am not saying this in any partisan way.

I blithely accept this situation because the health service is so much better than it was in my day. There is a huge difference between the current position and that which obtained 30 years ago, when I was in my 20s. It is fantastic, but people's expectations are so much higher now. However, I was confronted with what I saw yesterday, with the smell and with the lack of shower and lavatory facilities. It would be good if the Minister and Ministers of State visited these wards. Perhaps they have done so. They should listen to the nurses and try to do something. I know that would be very much appreciated.

The Minister of State has my sympathy. The Department of Health and Children is the martyr's pitch. If I were in national politics as a party person, I would not touch it with a barge pole.

Why should we pay for the private part of consultants' insurance? Let them pay for it themselves while we pay for the public part. The Minister could make a few savings there and spend the money on installing extra showers and lavatories in a couple of wards in St. Vincent's Hospital.

Mr. Brady

I welcome the Minister of State. I congratulate him and the Minister for Health and Children on the publication of two excellent reports.

After 30 years, it is self-evident that the system of health service needs to change. Each year, €9.2 billion is spent on the service, which is the biggest public sector employer in the State. Nearly 1 million people were treated in acute hospitals last year and there were almost 60 million GP consultations, but problems still exist. Both reports conclude that there is scope for improvement in many areas, not least in the day-to-day management of the system and in the financial and accounting procedures of that management.

The system has served the country well in the past. The over 100,000 people employed in the health service have built up a huge reservoir of talent and expertise in a large number of areas. Both reports, and the Prospectus report in particular, acknowledge their commitment and dedication. They also point out that the workers, like their clients, deserve better. They deserve the opportunity to work in a system which is much better managed and controlled and which helps and supports them in offering the highest quality service to the public. However, both reports conclude that under the current structures this is not possible in many instances. As Senator Henry pointed out, morale in the system is very low. We must ask why this is the case.

The Brennan report is a comprehensive analysis of what is so wrong with the system. It points out that fundamental flaws in the structures of management and control are obvious. They are too fragmented and no one person or agency is accountable for performance. There is no accountability for value for expenditure and no financial management, risk management or performance management. There is no flow of information between different arms of the system and a distinct lack of data on the level of costs. This leads to a complete lack of forward planning. While recognising the unprecedented investment in the service, the Brennan report concludes that fundamental reform in how the system is organised and managed, along with changes in the financial management and control, is essential to any attempt to improve the service.

In my opinion, however, the mechanism suggested in the Brennan report is still too cumbersome. It would take us back to the multi-layered system where bodies report to other bodies which, in turn, report to the Department. The suggestion regarding the accountability of those people with responsibility for expenditure is to be welcomed. The targeting of resources for patients in the most cost-effective way and accountability for those resources is the only way to obtain value for money in the system. The report concludes that the arrangements that allow consultants to combine public and private commitments are unsatisfactory. This is one area of which most people will be aware and it has to be tackled. As Senator Norris pointed out, there is also the issue of medical insurance, which is costing the State €50 million per year.

Professor Brennan makes a valid suggestion in the area of information technology. In the medical world, almost daily advances in treatments, equipment, medicines and methods of diagnosis are commonplace but our current system of running hard to stay still has meant that, in some areas, we have fallen behind in research and development. Ireland has a worldwide reputation in some areas, such as, for example, cardiac surgery. As changes are made, we can lead the way in many more disciplines. The waiting list for cardiac treatment in St. James Hospital in 1997 was five years. It is now down to nine months and less in some cases where immediate treatment is required. In other areas, such as maternity and gynaecological services, we have an excellent service and one of the lowest newborn infant mortality rates in the world.

The Prospectus report states that we need "A health system that responds more effectively to the expectations of its stakeholders and achieves a much greater impact to the benefit of the consumer" and that we need to "build on the existing talents and knowledge of staff." I welcome the four major reforms proposed in the report, namely, a single health service executive, the delivery of value for money and management of ongoing change, simpler governance and greater level of accountability and a reduction in the number of agencies and the reports required from them. These proposals pose a huge challenge for service providers, legislators and consumers.

These changes will not and cannot take place overnight. There has to be parallel action on a number of fronts and the Prospectus report points out that an incremental response will only exacerbate existing problems. It concludes that the way we have done business in the past has resulted in the dilution of the effectiveness of reforms and of investment. It also suggests that a fundamental shift in thinking is required and that we should take a broader view of how we develop the system into the future. The report goes on to suggest that the proposed changes will require leadership which is strong, clear, firm and sustained.

That is exactly what the Minister is providing. The health service reform programme combines leadership with vision, takes the best of both reports, enhances the recommendations and gives us a pathway into the future which will ensure that all citizens, regardless of their circumstances, will be assured of a quality of access to a first class service. The restructured health service, as suggested in the programme, ensures accountability, greater efficiency and effectiveness in the delivery of the service. It also supports and encourages the many dedicated people working in the service and makes sure they have conditions which allow them to offer the highest quality service to the public. That is what this country deserves and has a right to. These reforms underpin that right. While no one is saying it will be easy or that it will happen overnight, the Minister is the person who can deliver it. I was pleased to hear him point out to the House that we need to face up to these issues.

A number of speakers pointed out various difficulties that arise as a result of these changes. However, as the Minister has said, we must face up to them. As a society, we must achieve a consensus. I congratulate the Minister on the programme he has undertaken of travelling around the country, coming face to face with the stakeholders, putting the proposals on the table and saying that this is the way we must go. I congratulate the Minister, the Minister of State and the staff on these proposals, which I believe are the way forward. I wish them well.

Mr. Finucane

I welcome my fellow Limerickman to the House, the Minister of State, Deputy Tim O'Malley. I want to deal with a specific local issue. I hope at the end of the discussion I will get a frank reply because I have also raised the issue on the Adjournment. This matter is very important to the community the Minister of State and I serve. It relates to the report of the expert review group on radiotherapy services, which has not yet been circulated. I understand the south eastern deputation got a frank response during the week. They were told by the Minister, Deputy Martin, that there would not be a radiotherapy unit in Waterford. I deduce from that response that a radiotherapy unit will not be provided for the Limerick area.

It has been stated that health boards, particularly public representatives, are often perceived to wear a parochial type hat. I make no apologies for being parochial on this issue. The Caiman-Hine expert review group stated that there was justification for two linear accelerators for radiotherapy services in an area with a population of 200,000 or 300,000 people. There is in excess of 300,000 people in the Mid Western Health Board area, therefore, there is justification for the service. A state-of-the-art area has been reserved for the oncology unit in the regional hospital but there is one vital ingredient missing, a radiotherapy facility. The statistics indicate that there is justification for this facility.

Given that the Government talks a lot about public-private partnerships, this was a classic example where the Mid Western Hospital Development Trust was prepared to put in the funding for the capital equipment and all that was required from the Department of Health and Children was to provide the finance for the people to be employed in that service. It is a retrograde step not to consider a radiotherapy unit for this area. I presume that by the end of the discussion today the Minister will at least be honest and say it is embodied within the report that there is to be no radiotherapy facility for the mid-west region. We can then be honest with the people in the region by telling them the facility will not be provided because it is not recognised that within the mid-western area the facility is required.

It is important to put this issue in context. We are discussing the Prospectus report and the Brennan report. The reports were commissioned by two Ministers with two separate objectives. The Minister for Health and Children is looking at the organisational aspect of the report and the Minister for Finance is looking at the financial constraints involved. It would be worthwhile studying the reports.

I would like to ask a pertinent question. The report states that 96,000 people are employed within the health board service throughout the country. It has also been pointed out by the Minister for Finance and other Ministers that there will be no job losses, therefore the 96,000 people will remain in place. If there was rationalisation within an industry, with a reduction in the number of plants from 11 to four plants, would there be job losses as such? How can one sustain all the management tiers if there is a reduction from 11 health boards to four regional health boards?

It is worth bearing in mind that between 1997 to 2002, during the period of this Administration, the number of employees in the health board sector increased by a massive 28,000, from 68,000 to 96,000. During debates on the health service, we are always reminded by the Taoiseach of the massive increase in funding in the health service, which has almost trebled over the five years. Much of that money went into funding extra jobs within the health service. There was a dramatic upsurge in the numbers of people recruited prior to the election.

The Minister should look at the administrative structures within the health boards to see whether consumers are getting value. I will give an example of a situation which probably exemplifies the frustrations of people. I recently met a person who suffered a stroke and has a specially adapted car. As she is going abroad on holiday and decided to take her children, she looked for an E1.11 form. She contacted the health board in Limerick and was told that they had the forms. When she asked for it to be put in an envelope and sent on to her, the person who answered the phone replied, "No, I can't because it is not my job. I will send an e-mail to the girl responsible so she can put it in the envelope and send it on to you." This person waited six weeks for the E1.11 form. If that is a classic example of an administrative layer doing a justifiable job, I would question it.

Has there been a major improvement in the health services over the period of five years? One need only point to recent opinion polls which showed that 92% of people were critical of the health system. It is time this was examined. Will we seriously engage in the discussion on reform of the structures or will people spin doctor and try to criticise consultants, perhaps unduly, in relation to the document? Will people try to criticise the councillors who serve on the health boards and who receive minimal expenses in relation to the overall health board budget? Let us stop this scapegoating. If we are serious about unravelling this issue, let us get on with it properly without scapegoating different sectors.

Much work needs to be done. It is worth bearing in mind that there are 58 agencies, at least 50% of which have emerged in the past ten years. It is very easy for the Government to set up an agency, commission or special committee and hide problems rather than face up to them. There is another essential component.

The other report for which the Government is waiting will cause ripples of discontent throughout the country. Whatever we may criticise about health boards, one aspect we understand is local involvement. If the Minister sets up four health boards with a different structure, will this give the same professional service in the areas we all represent? We will wait and see.

I hope the Minister will expedite this change as quickly as possible. He is being congratulated for consulting with people throughout the country. I would expect him to do that because he must sell this package. It will probably keep him in the news for a long time, just as it kept the Government in the news when it was announcing the health strategy prior to the election. It was to be the panacea for all the health problems. What has happened to that document? What has happened to the promises embodied within it? This is an effort to change the structure of the administration. However, it will not happen unless there is parallel development in relation to the expenditure required for the extra beds and teasing out the system in order to ensure that we do not have long waiting lists, or a queue waiting to join a queue to get on a waiting list. There are difficulties in relation to a whole range of surgical activities within the health board system.

There is no neuro-surgery unit in the mid-west region. People must wait to go to Cork and many of these people die before they get to Cork. These are the problems people on the ground have. They are not necessarily interested in the administrative structures within the system. They hope the Government will solve these problems, but they are equally concerned that people with cancer or people who need to avail of neuro-surgery should have the facilities available to them. This is a huge criticism of the current health service. Is it right for a person with a young family of five children to have to travel all the way from County Limerick to a radiotherapy facility in St. Luke's Hospital in Dublin for a five minute treatment?

I regard this as very serious. Perhaps the Minister of State, Deputy Callely, does not. It is not a matter for jesting. Those in Dublin have these facilities but we do not have them in the mid-west region. Rather than having to table a matter on the Adjournment to find out about an issue which is important for my area, I would hope to get an honest reply today stating that the radiotherapy facility will not be provided in the Limerick area so that I can go back and tell the people they must continue to travel to Dublin in the future for this much needed service.

Mr. Kenneally

In common with just about every other Member of this House, I welcome the debate on the health service against the background of the Brennan and Prospectus reports. Health is never far from the mind of a public representative and it is the one subject which comes up time and again when we speak to our constituents. This debate is timely, and perhaps even overdue, but I congratulate the Minister on having the courage to tackle the problem head on and initiate a process which we have not seen in this country for over 30 years.

We all are only too well aware that the health of the nation is costing us around €9 billion per annum. This is a staggering sum and if that is what is to be spent, then I am totally committed to it. However, I am convinced, from reading those reports, from my own observation and from what I have been told, that we are just not getting value for that kind of money. Logic alone tells us this is true. If anyone had told me back in 1997 that we would increase our spending on health by 125% in five years and add a staggering 25,000 extra personnel to the payroll in the health sector, I would have cheered and said that all our health problems were over. I would also have said it was a false election promise, which could not and would not be delivered on. I might have added that there would hardly be a Minister for Finance in existence who would sanction that kind of money, but I would have been wrong on all counts.

We must know at this stage that the allocation of extra resources and the recruitment of an endless stream of personnel will not in itself solve our problems. To ignore that would be to ignore logic itself. For that reason, I congratulate the Minister on firmly grasping this nettle at its very core.

We must all be aware that there are certain practices in our health service which are neither user-friendly or administratively acceptable. We also know that it will be very difficult to change those practices. We will be up against the habits of a lifetime, the perception of rights built up throughout a career and the possibility of interfering with fee structures or earnings which are both out of date and inappropriate to the climate and system in which we now operate. In short, we must eliminate bad practice and vested interests, maximise the resources available and examine every euro being spent to extract full value from it.

It is surprising the number of similarities there are between the two reports before us. I want to give two quotations which I find significant. The first, from Prospectus report, is as follows: "Our findings indicate that extensive reforms are required that go beyond the structures in the health system." The second, from the Brennan report, states: "In our view, many of the problems are fundamentally structural. They relate to how the system is organised and managed." It is quite obvious that a solution lies, not in throwing more money at the health service, but in better management.

We have tough decisions to make, so let us make them and move on. We all long for a time when we have a health service which serves the needs of all our citizens, when we will not see the necessity for people to knock on our doors to get a service which should be theirs of right. We are not achieving it under the present system, so let us do whatever is necessary, change what needs to be changed and get on with it. I fully realise that we will step on toes as we do that, but better to do so than to have people dying years before their time or having to spend lengthy periods on hospital trolleys while they wait for some necessary treatment. They are already contributing enough money to have the best; let us give it to them.

Let us look at the manner of achieving the correct balance between medical and administrative staff. For instance, in the accident and emergence department of one Dublin hospital there had been a manager to co-ordinate everything on a particular shift. This was necessary and maximised resources and was appropriate. When another person was added to that shift, it was an assistant manager, not someone who would increase the level of care available. This is symptomatic of what is happening in many areas of the health service.

Looking at the 25,000 jobs which were created led me to wonder where in the health service they had been provided. I got my answer on page 88 of the Brennan report, which states that management and administration staff increased by 26% over that period, while nursing staff increased by only 16% in the same period. This shows something is definitely wrong there.

There is a certain analogy with the old problem in the Irish soccer team where the "suits" were better looked after than the players producing the results. I know there has been a big increase in other support staff, but I would have thought that the front-line staff, the people who actually do the caring and curing, would have had first priority on any increased resources.

I am in full agreement with the close examination of the operation of the health boards as they have now been in place for 30 years. The Ireland in which they were set up was vastly different from the one with which they have to cope today and it is inevitable that changes and improvements could be made to better serve the people. They are only a minor part of the problem, but it is necessary to fully review their effectiveness.

I recall reading some time ago about the setting up of the boards. At that stage they were seen as being undemocratic, in that a majority on the body which would oversee the administration of the system would not now rest with the elected representatives. This was a fundamental change from the old boards of health and county councils. We now are told that the new boards will not be in any way representative of the elected members and that system seems even more undemocratic. When all is said and done, it is the elected representatives who are ultimately answerable and the only ones who go in front of the people regularly.

It is difficult to have faith in the present health boards when one looks at the recent proposal to extend the medical card system to all those over 70. It turned out that the numbers proposed were substantially incorrect, with many of the beneficiaries already dead. To use a non-medical phrase, the boards' finger is no longer on the pulse. A bigger scandal is in the drugs payment scheme, which since 1997 has gone up by 221%. This figure is ludicrous. While I agree wholeheartedly with the principle of both schemes, in regard to medicines we must make sure there is value for money.

There has to be greater use of generic drugs, which at present make up just over 4% of the total. That is unacceptable. There are unhealthy pressures from drugs companies which must be tackled and doctors must be encouraged to prescribe more generic drugs as an alternative.

It has puzzled me for some time how dentists and orthodontists can be employed totally within the public service giving service only within that framework, while other consultants can have both a public health role and a private practice. I have come across cases where consultants are manipulating the hours and services of registrars and house officers, sometimes moving them from hospital to hospital to look after their own private patients. This is totally unacceptable, but consultants appear to be uncontrollable at the moment. A new agreement requiring consultants to give a certain number of years exclusively in the treatment of patients in the public health service is long overdue and should be looked at as a matter of urgency.

No Member of the Oireachtas from Waterford or the south-east could contribute to a debate on health without referring to the problem of cancer care and the provision of radiotherapy services in our region, and specifically Waterford city, which is the accepted central location for it. In my time in politics, I have never seen such a concentrated, sustained or committed campaign as for the provision of this service in Waterford. I am convinced that no matter how long the debate goes on, or how long people must wait for this vital service to be provided in our area, we will see people on the streets and in the media looking for it, and I will be supporting them. This is long past the stage where it is a political debate, if indeed it ever was. I regret that the indicators coming from the Minister are all negative in respect of the provision of this vital service in Waterford and while I accept that no decision has yet been made, or at least been made public, I do not like the signals.

This is a service which will not cost the earth. We can see the parallels elsewhere and measure the cost from those. We are told that a relatively modest €20 million will solve the problem and give people this service which is their right. In the light of the enormous budget which I spoke about earlier, it is small change indeed.

This is not some pie in the sky request, or one that could be termed luxurious. People are suffering as a result of their enforced trips to Dublin and not having such an inexpensive service available locally is imposing unnecessary hardships on patients and their families.

I urge the Minister to take another long hard look at this matter, purely on practical and humanitarian grounds, and to give the south-east the service it deserves.

Mr. O'Toole

I welcome the Minister. Every time we have a debate on topics such as health or agriculture, it quickly deteriorates into a row between the various political parties on how they do their business, which does not help. Today's debate confirms my view that politicians and elected representatives have very little to offer the health service. That is not to say that they have nothing to offer, but they have no more to offer than ordinary members of the public. It is no argument to say that they represent the people. A populist approach will never run the health service properly. The more I hear political representatives of health boards arguing that they are the only people elected by the people, the more I take the view that they should have less of a role to play.

While there is a strong case for elected representatives to determine national strategy, they should not be required to take decisions on the basis of one small area of a health board from where their votes come. That is absolutely negative and is not what we are trying to do. The health boards should definitely be focused on the needs of the consumer. I make a clear distinction here between the needs and the wants of the consumer.

Everybody wants a hospital on every street corner and a full service general hospital within a taxi ride to their front door. Politicians are feeding such expectations. Every time there is a row on a health board, the politicians always take the populist view. People may say that it is easy for me to say this because I am not a member of a health board, but that is what I strongly believe. I am not saying there are not individual members of health boards who happen to be elected representatives and who may make huge contributions. However, they do not have to be elected representatives to make a contribution. Very often their sense of independence, integrity, clear judgment and focus might well be distorted and perverted by the fact that they have to represent people in a particular area. This should not be taken as any diminution of political representatives; people know my views on that. In this instance, however, it is not necessary.

I would like politicians to ask how many hospitals we need in the country. How many more times do we have to hear the argument as to whether the hospital should be in Cavan or Monaghan? It is a serious issue when a health board cannot make up its mind on one hospital. It is not that the board cannot decide; it will not do so because there is political fallout from making such a decision. It has nothing to do with the health needs of Cavan and Monaghan, but is rather a case of who will be closer to the hospital.

The same is true for all political parties. When I was first elected to the Seanad in 1987, I met the then former Labour Minister for Health, Barry Desmond, who was watching the row going on because the nasty Fianna Fáil Government decided to close Barrington's Hospital in Limerick. In the front row of those leading the march against its closure was the then leader of the party, the Progressive Democrats, which was going to impose cutbacks in every area, standing shoulder with the late Deputy, Jim Kemmy. Barry Desmond said that when he was Minister he had met a delegation from Limerick, which he had expected to make a huge plea to preserve Barrington's Hospital. However, he said he was wrong and that the delegation actually wanted a fourth hospital in Limerick. I believe that attitude still exists.

In addition to the lack of economies of scale through the health boards, there has been no uniformity of approach. There has been no sense of a central policy administered regionally. I have frequently sought to ascertain policies on issues that ran across different health board areas and discovered that they did not exist. Child abuse is a current topic. I carried out an assessment of the health boards approximately four years ago and I could not find any two health boards with the same approach to dealing with victims of child abuse. Some health boards had no policy at all. That cannot be an effective and efficient way to work.

I often compare this country with New Zealand, which is a post-colonial, ex-Westminster run country with a population of the same size, overshadowed by a huge neighbour – in our case, Great Britain and, in New Zealand's, Australia. It has the same issues, which in some cases are worse because it is a larger country geographically. New Zealand has taken some creative and attractive initiatives. To deal with the regional hospital issue, the authorities there designed a state-of-the-art mobile operating theatre, which can be moved between hospitals throughout the country. Via an airlock, this links in to a local regional hospital and allows a considerable number of operations to be carried out. Not everything can be done, including, for example, heart transplants. The consultants are brought from the main centres such as Christchurch and Auckland to perform the operations and the post-operative care can then be carried out in the regional hospital.

I do not know whether this plan will work. However we will know when we see it in operation. If it works patients will not spend days on hospital trolleys, we will not have mile-long queues and things will be dealt with in an efficient way. However we will not be able to judge by asking people whether they are getting a good service. I do not believe people will ever say that they are getting a good service and we need more objective ways of measuring its impact.

I agree with Senator Kenneally about investment since 1998. If I had been told then that the health budget would be increased by a factor of two and a half and increase the numbers working in the health service by an amount equal to our total number of civil servants, I would have thought all our problems would end. However, that has not been the case and it is irritating to hear a succession of Ministers and Government speakers say this; we all know it. They can either take credit for it or take the blame for not being able to make it work. However, it is not possible to have it both ways. It is not working and that may be because there is not enough money.

More investment is required in the health service. As President of the Irish Congress of Trades Unions, I believe that we cannot have Texas taxes and Scandinavian standards of care. This has not worked anywhere and we will need to bite that bullet at some stage. The junior partners in Government might not be jumping up and down with enthusiasm on that issue, but that is the direction we must take.

I do not know the answer to the questions posed about the consultants. I would be interested to hear the views of Senator Maurice Hayes on that because I know he has dealt with it, in some detail, in the North of Ireland. We must grasp the nettle of whether they should be confined to public work or should be allowed to also work with private patients. Professor Brennan makes one vital point above all others. If private people are using the public practice, they should pay for every penny of it, but that is not happening. The consultants have access to equipment bought by the taxpayer and this is not being paid for by private patients.

I recently spent three hours talking to a man who bought an MRI scanner about six years ago when there was a mile-long queue at every hospital looking for them and there were none available in hospitals in rural areas. Although I do not have time to outline them, I am sure the Minister would find extraordinary the difficulties encountered by that man in providing MRI scans at two thirds of the price it was costing hospitals. The machine was installed in a clinic attached to St. James's Hospital, right in the middle of the Minister's health board area. He was obstructed every step of the way and not by the politicians. It was the consultants who refused to read the scans, who refused to co-operate, who refused to refer people.

It was only a matter of time before large sporting organisations, large voluntary hospitals and hospitals down the country began to realise that they could send people to Dublin and get a quicker service at a given time rather than have people standing around all day in the waiting rooms of some of the hospitals in the Eastern Health Board area. These are issues that need to be examined.

I do not have time to deal with the related issue of restrictive practices as regards pharmacies. The shortage of therapists is interesting. There is no reason a shortage of therapists cannot be dealt with within three years but it means the provision of training places. Members of the European Community have a commitment to the mutual recognition of qualifications of certain professions. That should be extended to therapists. People who have trained and qualified in the United Kingdom are either acceptable here or else they should have a top-up. Failing those two options, we should provide more training places. We should take a stand on these issues.

There is a lot of work to be done in this area. I remind politicians on all sides that there is no political mileage in this issue. Whoever is in Government will have to deal with the same issue. I would love to see it being dealt with on an all-party basis. I agree with Members on this side of the House who have listed out the broken promises. There is no doubt that there were broken promises and I speak as a disinterested party.

Acting Chairman (Labhrás Ó Murchú)

Is the Minister of State prepared to spend an extra five minutes on this debate?

Mr. Callely

That is no problem at all.

Dr. M. Hayes

I am grateful to you, Acting Chairman, and to the Minister of State for that indulgence. With a degree of immodesty I suggest to the Minister of State that I spent several months of the year before last looking at the hospital system in Northern Ireland.

Mr. Callely

I would be happy to hear what the Senator has to say.

Dr. M. Hayes

I would rather he read this because he will not be able to take it all in today. If the Minister of State reads that report he will find that it deals with many of the issues that we have been concerned about, particularly the question of trying to square the circle between accessibility and excellence of treatment. I commend the Minister, Deputy Martin, and I urge him to put his hand to the plough and to stick to the task. It is time to go ahead and make the change.

The great tragedy is that the Fitzgerald report of 40 years ago was not implemented. If it had been, we might not now be dealing with many of these issues. The reports which have been put before the House deal with a range of issues but there is a danger that people believe managerial and administrative changes will be enough. At the end of the day, that may only be a rearrangement of the deckchairs on the Titanic. We must enable very gifted, dedicated and able people in the medical, nursing and allied professions to treat patients. That must be the outcome. From the amount of money that has been put in over the last number of years which has not been matched by outcomes, it is quite clear that there must be change. It is important that attitudes are changed, not the labels over people's chairs nor the titles they have.

Any service industry knows that the ones that succeed are customer-driven. They are cost effective and are capable of dealing with change and that must be the test. These are difficult, complex issues and difficult, complex sets of relationships. Overnight success and change cannot be expected. The person who has to make the difficult choice is the consultant sitting across the table from a patient. Where there is incessant demand and limited resources, there are difficult and tragic choices that have to be made. The object must be to engage the people who are making that commitment in the choice and in the discussion and that is the essence of the Brennan report. It is very important that it is handled sensitively.

I would not agree with all the Brennan report conclusions and say that a patient must be either private or public. I believe there is room for people to have the option of saying they will buy in so many sessions. I believe that private medicine should be practised in a private hospital, not in a public hospital. It should be a fully-fledged and insured hospital that does not then depend on the public hospital as the safety net to pick up the bits.

There is an over-concentration on the acute sector. The primary care sector is the key sector. That is where the resources and time should be invested. The shorthand should be how to keep people out of hospital when they do not need to be there.

It will be shown in the Hanly report that hospital systems must be dealt with. I believe it takes about 0.5 million people to support a full system. There are enormous developments such as telemedicine. The important area for investment is the diagnostic infrastructure so that people are given the results of tests quickly. That could be done at a great distance. I have a vision of the service as a series of systems with diagnostic-related groupings in which the main hospital becomes the acute ward, the intensive care ward, and as much of diagnosis and after care as possible is decentralised. If that is done and accompanied by a decent ambulance service, people will find that they have a better service locally and their overall health will be better.

The media and the health correspondents seem incapable of talking about a change without talking about downgrading. How is it downgrading to devote oneself to the care of elderly people? How is it downgrading to do something which is not actually the sexy end of acute medicine? What is required is a balance of services.

I was attracted by Senator Fitzgerald's notion. I too believe a local political input is needed, not at the executive end but in some consultative way. It could be that the district councils could be consumer councils for all the public services, particularly for the health service.

There is a suggestion in the report that consultants be made accountable. Of course people must be accountable but it is the manner in which it is expressed. These are very scarce commodities and very special people. If they do not get jobs in this country, the world is their oyster. Does talk of accountability mean they will be sacked or disciplined? That must be sensitively handled. I would rather see it done by involving ethics and other factors. There is a different calculus between the accountant and the manager and the consultant. We are thinking in terms of resources and they are thinking in terms of the care of patients. Somewhere, some place, a middle ground must be found.

I commend the report and the courage of the Minister who is taking it on. I say "God help you" to the Minister for State but I advise him to keep at it.

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

I thank the House on the number of speakers who have contributed to the debate. The purpose of the reforms that have been announced is to put patients first and we should not lose sight of that. We are putting patients and the public at the centre of our health policies. My colleagues in the Department of Health and Children and I are determined to deliver real improvements in the health services, particularly in primary and community care services. This matter has been touched on and I will go into greater detail in that regard.

Improvements will also be delivered in the hospitals system. We embarked on this process two years ago, when the reports were commissioned. We recognise the need for radical reform and we accept that many stakeholders and the general public will be involved in that reform. We are determined to press ahead with the reform as quickly as possible, to the benefit of the vast majority of the people. I am pleased and heartened by the positive comments I have heard in the House and I appreciate them greatly.

The urgency of proceeding with implementation does not need to be underlined. It is clearly accepted and acknowledged that it is important that we move forward with this process rapidly. A public consultation process with all the stakeholders is under way. Perhaps Members of this House can help to fast-track the implementation process. I would welcome their assistance in that regard.

Many Senators spoke about investment, both in terms of what has been achieved and what will be required. The level of investment in the health service will be in excess of €9.2 billion in 2003. Senator Kenneally referred to the fact that we spent just €3 billion on the health services five years ago. One can easily calculate that funding has increased threefold in a short number of years. The Minister, Deputy Martin, and I accept the clear need to match the level of investment with reform. We should continue to underline that there is no point in speaking of financial investment only, as we have to invest in the reform package too. I hope that reform will be accompanied by better accountability, better performance and much better management. Senators will agree that the people deserve nothing less from public representatives in terms of public services.

A number of speakers highlighted aspects of service or the proposed reforms in their own areas of interest or in their own constituencies. I have asked the House to assist in the radical reform package because reform is for everybody. Reform will only work if everybody supports and is involved in it and embraces the change that is required if we are to focus our attention on improving service for patients and the public.

I was interested to hear the remarks of Senator O'Toole, who followed two Senators who discussed parochial issues. I do not agree with all of the sentiments the Senator expressed about the role of public representatives on health boards. As somebody with quite a lengthy record on health boards, I have to say that excellent public representatives have made an extraordinarily positive contribution to delivering a service, and not necessarily on a parochial basis. I appreciate that certain public representatives are concerned about some of the structural changes. If we are all to sign into this reform, nobody can expect to be excused from the challenge of change. We should be big enough to participate in change in a proactive manner, if it is in the best interest of those we serve.

I will try to respond to some of the many other issues that were raised. The hospital services executive will be accountable through a board structure directly to the Minister. The chief executive officer of the hospital services executive, who will be the accounting officer, will report to the Committee of Public Accounts in the normal fashion and will publish ordinary public accounts.

A number of speakers suggested that the reform programme will somehow diminish primary care and community care services. The idea behind the reform package is to ensure the success of our health strategy document, Quality and Fairness – A Health System for You. The section of the document which refers to a new direction in primary and community care focuses solely on the importance of such care. The reform structure that has been proposed allows the primary care model to develop and grow. We need to recognise as a priority the need to strengthen the identified primary care support services and to identify the different management demands of sectors such as technology, organisation and delivery on the ground.

I draw the attention of the House to the fact that the Minister's contribution earlier today specifically addressed the issue of community and primary care. I sense that some doubts may remain, however, which I am happy to clarify rather than allowing misunderstanding to exist. I am happy to clarify any aspects of the Minister's comments. I wish to contradict some of the comments that were made by Senators. We wish to develop primary care and to put in place appropriate support structures. I encourage Senators to examine some of the 11 primary care pilot schemes that were undertaken nationally, spread throughout all regions. This new dimension, which involves working with the important keyholders to deliver health services on a community care basis, is working well. I understand from my knowledge of a number of the pilot schemes that they are going extremely well.

The development of the three pillars allows for primary care to grow and for existing community care structures to be strengthened. It will allow for more focus on the issues without having to compete with the constant over-emphasis on hospital services as the only part of the health system. We put undue pressure on this sector to deliver some aspects of community care services. Having said that, I acknowledge and recognise the great partnership between those who provide community care services and acute hospitals in the delivery of certain services. It would be wrong to extrapolate from what I have said that we are going to break up those partnerships. That will not be the case.

The accusation was made that this reform is based on a top-down approach. The philosophy underlying the health service executive is not to impose a top-down approach but, rather, to ensure that when good ideas have been developed, the lines going both up and down through the system would be clearer and the decision-to-action chain shorter.

This is not in any way, an attempt by me, the Minister, Deputy Martin, the other two Ministers of State at the Department or even the Department itself to stand back from the responsibility of good service delivery. Clarifying roles between the Department, the Ministers and the wider delivery system will allow us all to pay more attention to evaluating the impact of policy and investment in a much more focused way.

The health information and quality authority to which the Minister referred will provide the authoritative voice in regard to information, communications and health technology assessment and the development of a framework of quality standards in every aspect of the health system. A system-wide approach is sadly lacking at present.

Reference was made to the variation in service that is evident throughout the existing structures. This is why we want to ensure that we have a satisfactory system-wide approach, from Malin Head to Mizen Head, and that we will have equity of service to which everyone will have access.

It is difficult to respond to all the specific points that were made in the short time that is available. I hope that I can address most of them. If I fail to do so, however, I invite Senators to contact my office or that of the Minister to ensure that they get all the information they require.

A number of Senators raised the question of hospital services in connection with the Hanly report. I will not pre-empt what that report might contain. I am not in a position to do so, as many of the contributors to that report have not yet signed off on it, which is why it has not been published. Public representatives in the Lower House accused the Minister of deliberately withholding the Hanly report, which is nonsense. I am pleased to say that Senators have not made similar allegations. I hope that this House will have an opportunity to discuss that report when it becomes available.

Senator Maurice Hayes touched on the importance of the delivery of the service at proper facilities and by appropriately qualified personnel. I speak for all my colleagues in the Department when I say that we do not wish to see the downgrading, closure or reduction of any aspect of the health service. We will endeavour to continue to ensure enhancement of the service provision in whatever are deemed the most appropriate structures to ensure that the best practice is offered in centres of excellence.

Mr. Cummins

How many hospitals will be closed?

Mr. Callely

Will the Senator please stop talking such nonsense? He should have a wider and better understanding of—

Mr. Cummins

Let us wait and see.

Acting Chairman

There should be no interruptions while the Minister of State is concluding.

Mr. Callely

The Senator should read my lips. There will be no closures—

Mr. Cummins

We will await the report.

Mr. Callely

The Senator should look at what we have done with the service. There are Members present whose political parties had an opportunity to do some of what we have done in a relatively short period, but they failed to do so.

A number of speakers referred to primary care. Opposition parties when in Government had an opportunity to develop primary care facilities but did not do so. We have done it. We initiated a new direction in primary care. New supports have been put in place in regard to community structures. People harp on about the area of home help, but they do not refer to what we have done in other areas in terms of support structures.

I had the honour and privilege of launching a scheme recently which replaces a previous one where assistance was provided for a short period only, which may not have been of much use. We have moved on to a patient-centred system. That is the approach both at community and hospital level. We want to ensure that wherever the service is delivered it will be patient-centred and seamless. We aim to respond appropriately and adequately to patient need.

As Senator Maurice Hayes stated, there will be some tough and difficult decisions ahead. If, and when, we have to examine the appropriateness of a structure or a facility, I hope that all involved; stakeholders, public representatives, consumers and professionals will do so with a better understanding of the provision of our health service in its entirety.

There has been enough nonsensical talk about hospital closures. It is not my desire, nor is it that of the Minister or the other Ministers of State, to see the closure of any facilities. We would like to think that in the future our time in the Department will be seen as a period of great enhancement of service delivery and of the facilities that enable that provision of service in each community.

The Minister asked my colleagues and me to take note of the various matters that were raised with regard to the reform package. In the course of the next few days we will have a discussion on the suggestions and comments that were made in this House. One of the central issues in this regard is the role of the public representative and the possibility of there being a democratic deficit in the new structure. The Minister indicated that he will take on board the comments that were raised here today before he brings proposals back to Government on this issue.

I was heartened to hear from a number of Senators of the need to ensure proper planning and delivery of services. The response to patients needs is a central theme of the health strategy to which I referred earlier and is what this reform programme is all about.

In his concluding remarks, the Minister indicated his determination to move forward as quickly as possible with the implementation of the reform package. That is also my desire. We must commence the consultative process with the stakeholders as soon as possible. I encourage people who have contact with the stakeholders to participate in the consultative process so that we will be in a position to begin moving the process on by the autumn. The sooner we have a framework in place to mirror our requirements in the reform package, the sooner we will see the necessary improvement all of us wish to achieve with regard to service delivery.

I have covered, in a global sense, the various comments by Senators. If there are any specific queries on the reform package, I would welcome being informed of such matters now, rather than in the autumn, when I would hope we will be in a position to progress the requirements rapidly. Those who may prefer to work directly with the Department should feel free to contact the Secretary General who will be very helpful in responding to any points of clarification which may be required.

Ms O'Rourke

I thank the Minister and the official from his Department, who remained in the House throughout the debate. We had an excellent debate from all sides of the House. Unfortunately, all who wished to speak did not get an opportunity to do so – the Whip has a list of those who still wished to speak. However, there is nothing we can do in that regard at this time but I hope there will be a further opportunity to engage in such a debate in the future.

Sitting suspended at 3.25 p.m. and resumed at 5.30 p.m.