Health Service Executive (Governance) Bill 2012: Second Stage

Question proposed: "That the Bill be now read a Second Time."

Minister for Health (Deputy James Reilly)

I welcome the opportunity to bring this Bill into the Seanad. It is an important Bill which, as the title, the Health Service Executive (Governance) Bill 2012, suggests, provides for a new governance structure for the HSE.

Senators will know that, in line with the programme for Government commitments, a series of legislative changes are planned to bring about radical reform of the health services which will see the introduction of universal health insurance. The programme for Government also envisages the HSE will eventually no longer exist as its functions move elsewhere under the health reform programme. This will take careful planning and sequencing, and further legislation. The Bill is intended, therefore, as a transitional measure, building on earlier changes to the composition of the board last year, and is designed to help prepare the health system for the changes ahead.

Under the Health Act 2004 which established the HSE, the HSE board is the governing body of the HSE. In 2011, I made changes to the composition of the board designed to facilitate greater co-ordination and integration between the senior management teams in my Department and the HSE. Since that time, the interim board has provided a basis on which to make early progress on the health reform agenda, facilitating a greater unity of purpose. However, when making changes to the board, I signalled that I would be bringing forward legislation to abolish the board structure and establish new governance arrangements for the HSE, pending its eventual dissolution. These changes are in the Bill now before the House.

The Bill abolishes the board structure of the HSE under the Health Act 2004 and provides for a directorate, headed by a director general, to be the new governing body in place of the board. This new structure is designed to help prepare the service delivery for the next phase of the health reform programme. The Bill's other purpose is to provide for further accountability arrangements for the HSE. In line with health reform policy, the Bill is intended to make the HSE more directly accountable to the Minister for Health, who in turn is accountable to the people through the Oireachtas. A number of technical amendments are also being made to the Health Act 2004 to take account of the replacement of the board structure by the directorate structure.

The HSE has legislative responsibility for the organisation and delivery of health services. Under the Bill, as the governing body, the directorate has authority to perform the HSE's functions. The directorate will consist of a director general and other directors. To offer flexibility and allow the size of the governing structure to adapt to changing circumstances, the Bill does not specify a fixed number of members for the directorate but instead provides for a maximum of seven and a minimum of three members, including the director general, who is automatically a member and chairperson of the directorate. The Bill provides that other members of the directorate must be HSE employees in the senior grade of national director. In support of the new directorate structure and to reflect a shift in focus to services, it is intended to recruit national directors in the areas of health and well-being, hospitals, primary care, mental health and social care. My intention is that the other directorate members will be drawn from these senior managers of services.

The HSE will continue to have operational responsibility for running the health service, but the Bill sets out parameters for the HSE. It provides that the directorate is accountable to the Minister for the performance of the HSE's functions and its own functions as the governing authority of the HSE. The process will be that the director general accounts on behalf of the directorate to the Minister through the Secretary General of the Department. In this way, the HSE will be required to account for its actions and decisions. The new provisions build on existing accountability arrangements under the Health Act 2004 which are being retained, for example, in relation to service plans, annual reports, codes of governance and the provision of information to the Minister.

The Bill also builds on accountability arrangements in the 2004 Act by allowing the Minister to issue directions to the HSE on the implementation of ministerial and Government policies and objectives relating to HSE functions where the Minister believes the HSE is not having sufficient regard to such objectives or policies in performing its functions. The Minister will also now be empowered to specify priorities for the HSE to which the HSE must have regard in preparing its service plan. The Minister may establish performance targets for the HSE in regard to these priorities. However, directions, priorities and targets may not be specified for individual patients or service users.

As is the case with the CEO, the Bill provides that the director general will be the Accounting Officer for the HSE. This is a temporary arrangement as my intention is to return the Vote to the Department of Health from 1 January 2014. At that point, the director general will no longer be the Accounting Officer. This will require further legislation to disestablish the HSE Vote and fund the HSE through the Vote of the Office of the Minister for Health. In the meantime, the Health Service Executive (Governance) Bill has new provisions for a statutory audit committee to advise the director general on financial matters relating to his or her functions and other related matters. This committee will report in writing to the director general and will provide a copy of that report to the Minister.

I will now deal with the details of the Bill. Part 1 has the standard provisions dealing with the Short Title of the Bill, commencement and definitions. It also provides for the repeal of those parts of the Health Act 2004 providing for the board and CEO structure.

Part 2, sections 4 to 22, contains provisions to amend the Health Act 2004 to reflect the new directorate structure and accountability arrangements. Some of the key elements are sections 5, 6, 7, 12, 14 and 17.

Section 5 amends section 10, on directions from Minister, of the Health Act 2004. Section 10 of the Health Act 2004 allows the Minister to give general written directions to the HSE in respect of the Act and to give specific directions on the submission by the HSE to the Minister of reports and information with regard to the performance of its functions. Section 10 is amended to provide also for ministerial directions on the implementation of ministerial and Government policies and objectives relating to HSE functions where the Minister believes the HSE is not having sufficient regard to such objectives or policies in performing its functions. As I stated earlier, directions may not be made with regard to individual patients or service users. Section 6 inserts two new sections into the Health Act 2004, namely, section 10A on setting of priorities by the Minister and section 10B on limitation as to exercise of power under sections 10 and 10A. Under section 10A, the Minister will be empowered to determine priorities to which the HSE must have regard in preparing its service plan and to establish performance targets for the HSE. Before specifying priorities or performance targets under this section, the Minister must have regard to best practice as respects the service, the subject of the priority or performance target, outcomes for patients and recipients of services likely to be affected by the priority or performance target which the Minister is considering specifying and the effect that specifying the priority or performance target concerned would be likely to have on other services provided by or on behalf of the executive. Again, priorities and targets will not apply to individual patients.

Section 7 inserts a new part in the 2004 Act to provide for the establishment of the new governing authority for the HSE, namely, the directorate. This new part will form sections 16A to 16M of the Health Act 2004. Section 16A provides that the directorate will consist of a director general and other persons referred to in the Bill as appointed directors. Section 16B sets out the detail regarding the term of office of an appointed director. The term of office for a member appointed to the directorate is three years and he or she may be re-appointed by the Minister for a second or subsequent term. As I outlined, appointed directors will be drawn from employees in the grade of national director in the HSE. An appointed director will cease to be a member of the directorate if they cease to be a national director in the HSE. Section 16C sets out the role of the directorate, which will have collective responsibility as the governing authority for the HSE and the authority to perform the HSE's functions. Subject to any directions of the Minister, the directorate may delegate HSE functions to the director general. This section also sets out the accountability arrangements to the Minister about which I spoke. Section 16D sets out eligibility for appointment and reasons for removal from office of persons appointed to the directorate. These are similar to the provisions in other legislation in respect of board appointments and removals. Section 16E provides for the appointment by the Minister of the director general. It is my intention, subject to the Bill being passed by the Oireachtas, to appoint Mr. Tony O'Brien, who is currently deputy chief executive officer of the executive, to be the first director general, as permitted by section 16E(4). Subsequent directors general will be appointed by the Minister following a recruitment process under the Public Service Management (Recruitment and Appointments) Act 2004. The appointment of the director general will be made on terms and conditions as determined by the Minister, with the consent of the Minister for Public Expenditure and Reform.

Section 16F sets out the eligibility requirements for appointment as director general, as well as circumstances in which the director general may be removed from office. Section 16G provides for the general functions and role of director general. These include managing and controlling the business of the HSE. In the operational aspects of his or her role, the director general is answerable to the directorate, as the governing authority of the HSE. On a day-to-day basis, national directors, even if appointed as members of the directorate, will be accountable to the director general for the performance of their functions as employees of the HSE. Section 16H sets out the arrangements for the delegation of functions by the director general. A key objective of the new HSE governance arrangements is to facilitate a system whereby authority to make operational decisions is delegated as closely as possible to the point of service delivery. Delegated functions may be subdelegated by the director general to HSE employees. This will be subject to any directions from the directorate. Section 16I provides for the attendance by the director general before Oireachtas committees. Other aspects of section 7 deal with procedural and related matters for the directorate.

I will now turn to section 12 which amends provisions in the 2004 Act in regard to service planning. Currently, the HSE prepares a service plan in line with certain requirements, adopts the plan and submits it to the Minister for approval. The Minister must either approve the service plan or issue a direction to amend the plan if requirements are not met. The 2004 Act is now amended to provide for the HSE to prepare a plan in line with current criteria, while also taking account of priorities determined and targets set by the Minister. While the Minister may direct the HSE to amend the plan if requirements are not met, the Minister may now also amend the plan, following consultation with the HSE. Section 14 provides for the 2004 Act to be amended in order that the Minister may direct the HSE to take specified measures with regard to the implementation of the plan. I have already spoken about section 17, which provides for the director general to be the Accounting Officer and sets out provisions for a new statutory audit committee. Other sections in Part 2 of the Bill deal with technical amendments to the Health Act 2004 consequential to the establishment of the directorate. Part 3 of the Bill has the standard provision for savers following on from the repeal of sections relating to the board and the chief executive officer.

I will conclude by stating the reform programme is about the patient. While this Bill is only one element of a legislative and administrative reform process aimed at ensuring a better health service for patients, it is an important one. Accountability and service delivery are fundamental tenets of the health reform programme. I believe this Bill, together with the new management arrangements, will help bring greater focus on service delivery and ensure more accountability during the time the HSE continues to exist. I also believe it will help to make sure the patient is at the centre of the service and the service is reminded continually of its obligation to serve the patient. The HSE is an experiment that has not worked. The Bill is doing what I promised to do when I stated last year that I would change the governance structure for the HSE. This is a step towards the overall reform of the health service that will see the eventual dissolution of the HSE as an entity and will facilitate the introduction of universal health insurance as included in the programme for Government. The new structures will improve patient care and will lead to sustainable performance improvement by the HSE. It will give better control of financial and clinical systems. It will lead to more integrated care and integrated governance, crucially with a clear line of accountability from the HSE to the Minister. As stated previously, it is an important step on the way to universal health insurance.

Senator Marc MacSharry

I welcome the Minister to the House. The Fianna Fáil Party will support this legislation but remains unconvinced about what it can contribute to the improvement of services and, in this context, I wish to make a few points. When I sat on the Government side of the House, I was highly critical of the establishment of the HSE in 2004. Moreover, even while on the Government side, Senator Cummins and others can confirm I thought it was wrong that such a large proportion of the State's budget and of taxpayers' money effectively would be under the control of a third-party organisation. In that context, I support the Minister's actions in bringing the budget back in, as is appropriate as it never should have left.

The origins of the HSE go back through quite a few Administrations. The initial idea may be traced as far back as the then Minister for Health, Barry Desmond. I agree that subcontracting the running of the health service to a third party organisation constitutes an abdication of the State's responsibilities in the interest of what was wrongly dressed up as this thought of political interference.

It is vital for public representatives to have the power to do work on behalf of the people. If they abuse that, there needs to be appropriate enforcement to deal with that. However, our automatic reaction should not be too subcontract the power and ensure we operate at arm's length. I would be critical of the Minister in some of his actions in that regard.

I look forward to more detail being provided on the legislation. I think of Titanic and ask myself if it were called Olympic would it have stayed afloat? If the captain were known as the skipper, if the engineer were known as the navigator or if the master at arms were simply known as the head of security, would the ship have stayed afloat? I doubt it would have. That is why I am concerned this legislation is just the relabeling of the existing structure, albeit with the potential to be under more control by the Minister, as should be the case. Will the same individuals go from being the head of a particular directorate as it is now, to having a different title? What are the service areas that each directorate will deal with specifically? What budget will be available for this transition? In an agency as large as the HSE as we know it, I hate to think of the cost of relabelling the doors where people's names are, just to name a very small and insignificant part of it.

I know it is envisaged that this legislation will have no impact on budgets, but I disagree. What budget has been earmarked for these changes? Will there be any job losses as a result of these changes? To what service areas will the new directorates apply? It seems we are cutting down to six or seven from 12. Will there be salary increases for the new heads of these directorates? Who is earmarked for them? Will there be a public procurement process to put these people in place? Will it simply be that the person who used to be called the skipper will now be called the captain resulting in the Minister now having full responsibility and being able to tell the individual to review particular area because the service plan does not include X or Y?

Is this legislation that was thrown together based on a promise made 17 months ago about how we would transform the health service? There is no plan or blueprint for how we will implement this and how it will change. All politics is local. The HSE, the Department of Health and the Government - past and present - would point to the national cancer control programme and the approach to cardiac care and cardiac categorisation as being highly successful. I ask myself what this new structure will do to undo the discrimination in an entire region, the north west. Statistically it can be pointed out that the people are looked after with 80% of them getting stents inserted within the two-hour best international practice period, and we have our specialist cancer centres of excellence. The approach seems to be that the 20% of the people living in the north west can either move closer or die as I have often said, including to previous Ministers.

In opposition the Minister was the foremost Member in the House at highlighting these discrepancies and inequalities in our health systems. When I was on the other side of the House some of my colleagues would not speak to me because I was so vociferous at saying similar things. Now that he is in government and in command why are those things not forthcoming? The people on the street do not care whether it is called Olympic or Titanic. They just want to know how the Minister will keep it afloat because the reality is that it is sinking and all we are seeing is a haphazard approach to management. I do not doubt the Minister's capabilities medically or in business. The previous Government was rightly criticised for poor communications but, by God, the communications of the Government and the Department of Health in recent months have been shambolic in the extreme. If I were captain of a football club and the vice-captain could not express confidence in me, that person would be gone. If a fellow manager in a club used language along the lines of stroke politics in describing something I did in carrying out my duties, that person would have to go or I would be gone. That is what the people are seeing.

What do people in the north west see? They see cuts to home help and discrimination in what are supposedly the successful clinical programmes, but that is down to where in the country one lives. Some months ago this House saw the breaking of the story about Creagh House. We were assured by a Minister that there would be no cut to the services and yet today, having been warned by me and many others, the unions have announced there is a problem and the Government needs to intervene. What is the legislation doing for them? The reality is that it is doing nothing for them.

We constantly hear the rhetoric that the cupboard was bare when the Government came into office and there was no money to implement the plans it wanted to implement. The Minister when in opposition met representatives of the troika as I did. When I participate in the Fianna Fáil delegation meeting the troika, I get to question it on what we can and cannot do. The Minister and his party colleagues, including the Minister for Finance, Deputy Noonan, did so when in opposition. However, they prepared a manifesto to buy the people by lying to them about what would be done in the north west, including the provision of centres of excellence and the retention of the accident and emergency unit in Roscommon. That is just my part of the country. Every parish has a story to tell and it was disgraceful and deeply cynical.

We are now passing legislation to change the name of the fleet. While we support it, I see nothing to give the people the confidence to which they are entitled in the management of our health service. However, the reality is that free GP care is nowhere to be seen. We have cost overruns of €500 million. Mr. Cathal Magee has resigned as head of the HSE having back in February told the Minister - based on freedom of information requests - that this would happen. The Minister's Cabinet colleagues are running for cover in the context of expressing confidence at one level and then half-heartedly doing so in the House. There is a Minister of State who openly flaunts her feelings and undermines his authority.

Where are sections 10 and 12 of the Bill in terms of the Minister's input into selecting primary care centres? I have no doubt that Swords and Balbriggan are as entitled to have those primary care centres as are Sligo town, Ballymote or other places in my area. However, we must have rules. Those on the outside looking in see poor management and a lack of management. Everybody knows the Minister needs to find savings and cuts will be required. However, all they see are a lack of communication and haphazard management - the headless chicken approach as I called it last week. If any good news is to be announced, the Minister and his senior colleagues are wheeled out to announce it while, if there is any semblance of bad news, Mr. Tony O'Brien is wheeled out to say the Minister had nothing to do with it. However, 18 months ago he claimed to be fully in control. Who is in control? Whether it is Titanic or Olympic, who is in charge and calling the shots? Is it the Minister on this, Mr. Tony O'Brien on that and the Minister of State, Deputy Shortall, on the other? In these difficult times people need to be able to say, "You know what? Reilly is a good one. He's a medical professional with business experience and in these difficult times he's in command." They are entitled not to see the vice-captain question him or a senior Minister saying that he is involved in stroke politics. While I know we will be in opposition for some time, in the interest of the country the Minister has my full support in giving himself a good shake, bucking up and giving the people the confidence they require in their health service. This legislation does not do much to give me that confidence at this point.

Senator Colm Burke

I welcome the Minister to the House and thank him for introducing this legislation. We need to consider where we are in health care and think about the very negative message given out on health care. We need to consider why we need reform and need to create efficiencies.

Currently, 27% of all Government spending is on health care. This means 27 cent of every euro paid in income tax goes towards health care services. The €13.588 billion provided for in this area in last year's budget was greater than the total amount collected in income tax. This means all other taxes collected were utilised to operate the remaining 14 Departments. There are huge inefficiencies in terms of health spend, in particular in the cost of drugs. In 2000, the cost of drugs in the health care sector was €576 million. By 2010, this had increased to more than €1.9 billion, which is a 230% increase, with little or no control during the intervening time over who or what was paid for drugs. In comparison with other countries, Ireland is one of the most expensive not alone in Europe, but in the world in terms of the cost of drugs. In terms of governance of the health sector, how did this happen and who is responsible for it? This Bill seeks to bring control of this sector back within the remit of the Department of Health.

The reform which took place in 2004 was supposed to bring about necessary changes. However, the cost overruns occurred after 2004 when the Health Service Executive was established. This will continue unless necessary reforms are put in place. The Brennan and Prospectus reports of 2003 recommended the establishment of one national entity to manage health services. Following the establishment of the HSE, the Minister frequently referred Deputies' parliamentary questions on health services for answer by the HSE, as a result of which a huge number of issues arose.

At the time of the 2003 report of the national task force on medical staffing there were 1,731 approved permanent consultants posts within the health boards. The task force predicted in that report that owing to the European working time directive there would be a need to appoint more consultants and that by August 2009 there would be in the region of 3,100 permanent consultants appointed. It was also stated that, by 2012, we would have 3,600 permanent consultants. Currently, there are 2,500 consultants in the system, which is 1,100 short of the target.

Last week Opposition spokespersons complained about waiting lists for appointments with senior consultants. However, these have occurred because policy, in terms of appointment of the planned number of consultants as set out in the 2003 report, was not implemented. The Opposition is not entitled to be critical of waiting lists given they are the result of the failure of the previous Administration to appoint the number of consultants promised. It is difficult now to address this issue owing to a tightening of budgetary provision.

This legislation puts in place a new structure of governance and seeks to provide for that promised in the programme for Government, namely, that money should follow the patient. This is just another step in that process. As outlined by the Minister, the legislation introduces a temporary transitional structure, which is but one of the steps needed to be taken in this area. While the Bill abolishes the board of the HSE, it does not change the legal status of the HSE. It also, as outlined in detail by the Minister, provides for accountability and establishment of the directorates.

Section 5 amends section 10 of the 2004 Act and allows the Minister to issue directions to the HSE on implementation of ministerial and Government policy. In other words, it gives back the power to the Minister to issue directions. Section 6 determines the priorities to which the HSE must have regard in preparing its service plan. The Bill also establishes performance targets for the HSE. It is important clear targets in this regard are set out. It is also important the terms of any plan and the targets set in each area are implemented.

Section 12 introduces changes to how the service plan is prepared and amends section 31 of the 2004 Act. The HSE must take into account the priorities and targets set by the Minister. It is important if we want to move forward with reform that the plan prepared each year takes into account the Government's long-term programme. The Minister has dealt with the various amendments to the 2004 Act that are required to be put in place.

A particular issue about which I am concerned - this relates to the task force report of 2003 in regard to reform of the health service - is front-line staff. In this regard I would like to outline to the Minister one issue which I believe needs to be tackled, namely, the appointment of locum consultants following the retirement of consultants. A number of instances in this regard have been brought to my attention. In one case, a consultant retired and an interview was held in November, following which the interview board agreed on the candidate to be appointed. As of today, the locum consultant remains in place and the selected candidate has not been informed of his or her selection for appointment. This is disappointing from the point of view that the HSE would incur no additional cost as a result of replacing a locum consultant with a permanent consultant. Perhaps the Minister would address this issue. We do not want a return to the situation whereby we are relying more on junior doctors. If the policy as I have just outlined continues, that is what will happen.

Another issue of concern is that of junior doctors. It is important I raise this matter with the Minister, as I have done consistently since becoming a Member of this House. One of the problems with which the Minister had to deal when he took up office approximately two years was the lack of planning in regard to the appointment of junior doctors. In April 2011, the Minister had to, on short notice, ensure recruitment of a huge number of junior doctors. In this regard, a number of people from India and Pakistan were recruited and given two year contracts. Those contracts will expire in June 2013. I want to ensure the necessary procedures are being put in place to ensure replacement of those doctors in June-July 2013. The planning for this needs to be in place now.

I am raising it because of a survey of final year medical graduates I carried out in April, May and June. Over 50% of those interviewed said they will not be working in Ireland after June 2013. Only 35% intended staying in the Irish hospital service in 2013. That is a concern and we must start planning for it because we are eight or nine months from 30 June.

The Bill brings the power back into the Department, while working with very good staff in the HSE. It is easy to criticise HSE staff but there are good and dedicated people in the HSE. It is important the cost of drugs is dealt with in a comprehensive manner. We are paying far in excess of what is required. It is one area where we can replace services.

We must work hard on the reconfiguration of services, which is being dealt with professionally in Cork. We used to have three or four hospitals doing a bit of everything at huge cost whereas reconfiguration assigns certain categories of treatment to certain hospitals so there is no duplication. It is a welcome development and the Minister has been very much involved in it. We need to do this throughout the country to ensure we are getting value for the money we put into hospitals and to provide the best possible level of care.

Despite media comment on the health care area, much progress has been made on outpatient care. The media will not cover the fact that the number of outpatient appointments has increased from 2 million to 3.5 million per year in the past ten years. The number of day case procedures has increased dramatically and there are more day case procedures now than ever before. This increase has taken place because of reform and reorganisation in health services. These changes can make the service more efficient but it is a question of how we manage it.

A HSE financial management issue raised recently concerns the small number of people dealing with financial management who have financial qualifications. The legislation refers to setting up an audit structure. That is very important. As financial management is about getting value for money, we need people with expertise. I am not convinced we have a sufficient number of people in the HSE to deal with financial management. I ask the Minister to give priority to this point over the coming 12 months. We need to get value for money but this requires people with the necessary financial qualifications to ensure we get the maximum out of every euro we spend in order that the patient is the beneficiary. The theme of the Minister is that the patient comes first and it is pertinent that the taxpayer also gets value for money. The level of cover for the patient should not be diminished. I look forward to working with the Minister in the implementation of the Bill.

Senator John Gilroy

I welcome this important legislation. No one could argue it is overdue. It offers hope that at last, and without prevarication, the Government is trying to get to grips with something often charitably described as a monolith. The Minister promised he would take this step and it demonstrates the determination of the Minister and the Government to have a working health service at last. Many local and national politicians have made a career out of criticising the HSE. Much of the criticism is well merited. It is remarkable that the previous Government, with such apparently innocuous legislation entitled the Health Act and acting out of the best motivation, managed to create something so unwieldy that we must take down the entire edifice after a mere eight years in existence. If it is remarkable, it is not particularly surprising when we reflect on the words of a former Minister for Health and Children who referred to the Department as Angola. It gives us a glimpse into the thinking that informed the decision to establish the HSE. The decision to create the HSE was driven as much by a desire to insulate the Government, which lacked political vision, from the inevitable criticism that would arise from an unreformed organisation as much as it was motivated to achieve reform. We have seen problem following problem and crisis following crisis in the HSE. The responses seem only to paper over the cracks without achieving real reform. It should not surprise us and we should not profess surprise.

The HSE was established on a premise guaranteeing that it could not succeed. In abolishing the old health boards and creating the HSE, all that was achieved was to lay down another layer of administration and management on top of a dysfunctional management structure. For good measure, we removed any trace of political accountability or transparency. We can cite a number of examples, such as the number of grade 8 administrators, a senior managerial post. The number of positions, which was in single figures under the old health board system, increased to 700 after the creation of the HSE. After the massive increase in managers, there was no discernible improvement in the delivery of health care. Matters became steadily worse until, despite spending up to 27% of the entire tax take, we have inherited a system that is not fit for purpose.

Although it is an interim measure, the Bill goes a long way to delivering on the health reform agenda set out in the programme for Government. Another example is the removal of local representation from the old health board system. This was heralded as a step into modern Ireland, where the fingerprints of local lobby groups could be found all over the map of the health service. It was a good idea and one that went some way to removing the overbearing nature of local interest at the expense of the national interest. However, like many things done by the previous Government, in making one reform and failing to replace it with the alternative, we fell into the double misfortune of having no political representation and no oversight.

When the HSE was established, one of its grand sounding platforms was the regional health service consultative forum, comprising local representatives, which met at quarterly intervals. Elected representatives had the opportunity to question officials on the operation of the service but without any input into policy decisions. This became a farce and remains so, but it served a useful political purpose to insulate the Government from any political fall-out that would inevitably arise from the unreformed service. I was a political representative on one of the fora and I was told in 2007 that, despite a projected €18 million overrun in September, no single person was accountable for the multi-billion euro budget.

Therefore, there was no financial officer available to appear before the board to explain how the circumstances could have arisen.

This is what the HSE and previous Government have bequeathed us. We have taken away political transparency at local level and added in, for good measure, a diminution of accountability at national level. With this, one could hardly be surprised to hear politicians of all parties, local and national, and service users complain that they cannot obtain even relatively insignificant information about the operation of services. We have even heard the Minister complain from time to time that the service is unbelievable.

It is very good that this Bill is appearing before us now. It strengthens the ability of the Minister to give policy directions to the HSE. We need to reflect for a moment on the ability of the Minister to give policy directions to the agency responsible for the highest expenditure, in excess of €13 billion in taxpayers' money. That the Minister has taken this on board demonstrates clearly what was wrong with policy-making measures of previous Administrations. It beggars belief that we must include such a provision at all. We must examine what the designers of the Health Act 2004 were thinking when they omitted to include such a critical provision in the legislation. That the Minister is taking upon himself direct accountability for the health service is a move that contradicts directly the policy initiatives of previous Governments, and it will be seen as politically courageous and demanding. It is a vital step in ensuring that the Government's policy decisions and commitments are properly implemented.

There will be criticism, of course. The health service problems will not be cured overnight and I suspect the Minister will fall in for much criticism during the period of transition. It is right to expect the Minister to be criticised if there are developments that are contrary to his plan.

Political generosity will be required from our political opponents. When I hear Senator MacSharry's mixed metaphors, I am not hopeful about gaining such support or even generosity. I will not labour the point-----

Senator Marc MacSharry

The previous Minister did not get it either.

Senator John Gilroy

-----suffice it to say that following eight years during which the delivery of health services was at best inconsistent and lacking integration, we cannot expect an instant panacea.

The reorganisation of the health service in line with the programme for Government, with the ultimate aim of providing universal health insurance, as outlined by the Labour Party as early as 2006, and perhaps a little before it, is ambitious and will require patience and forbearance. It is a plan that is long overdue and the Government has moved quickly such that the massively complex reorganisation of the HSE is well under way.

We look forward to working with the Minister in securing the badly needed change. This Bill is an important first step in delivering this change. We look forward to having a robust discussion on its separate and various provisions on Committee Stage. We look forward to working with the Minister on his ambitious plan to deliver real reform in the health service.

Senator John Crown

I was asked in public last week whether I would have voted to express confidence in the Minister last weekend had I had the opportunity to do so; I state unambiguously that I would have done so.

Senator Martin Conway

Well said.

Senator John Crown

The Minister inherited a very difficult job in very difficult circumstances. He set his face into the wind with the reform agenda, which will be difficult to implement. He has and continues to enjoy my confidence.

It is appropriate to point out at this stage that the Minister is the fifth, or possibly sixth, Minister under whom I have worked as a doctor in Ireland since 1996. Of the last four, the current Minister exhibits an extraordinary difference, namely, that his aggregate workplace experience, not just in health care, compares favourably with that of his three predecessors, whose aggregate workplace experience before becoming Members was four years. It was quite extraordinary in that two had worked for less than one academic year as teachers and one had worked for several years in a very reputable legal practice. That was the total life and work experience they brought to the job. We can see the difference in somebody who has not just worked in any workplace but in the health system. It brings understanding to the problems we face.

My one small concern is that the Minister may have been taken captive by the bureaucracy. I came back to Ireland in 1993 to work in a voluntary hospital that answered to the Eastern Health Board, which in turn answered to the Department of Health. After the first of many re-jigs, I worked for a voluntary hospital that answered to a regional health authority that answered to the Department of Health. Subsequently, I worked for a voluntary hospital that answered to the HSE and the Department of Health, and then for a HSE hospital that answered to the HSE itself, which was somehow quasi-independent from the Department of Health. More recently, the proposals are such that I will be working in a HSE hospital under a structure that is ultimately, I am thankful, to be prorogued and absorbed into another body.

Twenty years ago, I worked in a country that had the worst doctor-patient ratios and waiting lists of any country in western Europe. This is still certainly the case in respect of doctor–patient ratios. In the case of waiting lists, we are still close to the bottom. The most recent figures I saw, dating from two years ago, show we are still ranked way below the norm in terms of access to care.

Recent figures have shown that the waiting period for treatment has shortened, which is welcome, but the time taken to gain access to consultants to get the treatment has lengthened. I would love to know the aggregate waiting time from a GP decision that one needs hospital treatment to one's actually obtaining hospital treatment. I suspect it is not very different.

Twenty years ago, I came back to work in a system that was bureaucratised, centralised, undemocratic and corporatised. Regretfully, I still do. Some 20 years ago, new consultants could be appointed only by an entity called Comhairle na nOspidéal. In examining this organisation, one can only assume it was set up in the manner that dogcatchers were appointed in Tipperary after the Second World War to ensure there were no greenshirts or blueshirts being appointed in excessive numbers. The idea that the appointment of a radiologist in Macroom required the approval of a central committee somewhere in Dublin made no sense. The committee now has a different name and is called the HSE; it still makes no sense. As the senior Senator from Cork stated, there are still huge inconsistencies and illogical aspects associated with the appointment of consultants. I hope we can get this fixed.

When I first started speaking about health issues approximately ten years ago, I stated the central problems of the health service could be summed up in three broad silos. I have always believed the health service was of mediocre quality and I never bought into the hysteria suggesting we had a Third World health system. I worked in a Third World system and realise we have never had such a system here. We had a health system that was and sadly is still close to the bottom of the table of western OECD health systems in terms of access, specialist care, etc.

The system is characterised by extraordinary inefficiency. This is a product of our amazingly inefficient system of funding. We basically put in place structural incentives for hospital CEOs to close beds. When the money runs short towards the end of the year, they react by closing beds and operating theatres. This is why I am a little sceptical about the potential impact of some of the nuanced differences proposed for consultant working practices. As I said to my colleagues, they should accept everything they are asked to accept because they will not be doing any more work. The proposal will make no difference. If they sign up to do operations on Saturdays, there will be no theatre or nurses. The beds will be closed and the ambulance drivers will not bring the patients in. I said that if they are going to sign up to the agreement for the sake of industrial peace, they should do so, but that it will actually make no difference.

The third major issue with the health system, the third great pillar of dysfunction, is inequality. It is a case of the Paris Hilton health care system. Paris Hilton said that when she gets on an aeroplane, she wants to turn left and not right. This is the kind of system we have inherited, unfortunately. It is not of the Minister's making and it is one he intends to reform with the move towards universal and negotiable insurance. However, it is the system we have and it needs to be tackled.

There is a great scene in "Father Ted" in which Father Ted receives the Golden Cleric award and has the opportunity to be on the podium for a few minutes, where he vents his views, resulting in a form of group psychotherapy. Bearing this in mind, pardon me if I unburden myself of one or two anecdotes that I believe are illustrative of some of the dysfunctions.

When I came back in 1993, I discovered I was one of only four oncologists in the entire country, which was ludicrous. There was an unbelievable lack of access and patients were dying from treatable cancers. Women were having mastectomies because they could not gain access to radiotherapy for geographical reasons.

Women in County Donegal were more likely to have a mastectomy than women in south County Dublin because they were further away from radiotherapy centres. For approximately six months, I tried to go through the bureaucratic channels to highlight the fact that we needed a fundamental reinvestment in oncology services. I got nowhere, lost my temper and went public. For a year, I became something of a nuisance of a young man making public statements and pointing out grotesque deficiencies.

The reaction of the bureaucracy was not all that strange - it was probably internally consistent. In the first instance, we were called into a meeting. I will not name names, but a senior official at the Department of Health told us that the Minister of the time was unhappy to be reading accounts in newspapers about cancer service deficiencies and asked us to be quiet about them while he thought about what to do. That did not quite sit with me. I was then hauled in by my hospital and told that there had been a serious and credible threat to the effect that a proposed investment in the hospital would be withdrawn if it could not control me. I was told that, only for the fact that I had passed the one-year probationary period on the old consultants' common contract, I would certainly have been fired. It was not because I was an alcoholic or moral reprobate or doing anything illegal, but because I was not toeing the line or being quiet about deficiencies in the system.

I am not satisfied that the current provisions give any more protection than I would have had if I had not passed my one-year initial phase as a consultant. The central problem in our system is that it is undemocratic and bureaucratic. Until we have a truly democratised, liberalised and socially responsive health system with the elimination of most of the bureaucratic middle levels, we will continue to have these problems.

Early on, I heard the argument that I was only a clinician, what was a type of technician, that I did not know the situation and that the only people capable of acting in a self-disinterested fashion were health bureaucrats, civil servants and hospital administrators. Everyone but them had a vested interest. I became so tired of hearing this that I decided to enrol in a relatively arduous two-year MBA programme to study health policy and health management at the Smurfit school. It has been one of my best decisions. The first lesson we were taught on the first day was the difference between management and leadership. I fear that what we are seeing in the health system is layer upon layer of management and a failure of leadership.

The model that is best loved by the permanent government and the hospital administration class has a professional managerialist at the centre surrounded by a group of technicians who do technical jobs - the person who fixes the hospital boiler, the person who is in charge of the kitchen, the person who looks after the laundry, the person who does brain surgeries, the nurse and the radiologist. We need to move to a fundamentally different model. At the core of all of the world's great hospitals are clinical leaders - sometimes nursing rather than medical - who are surrounded by wonderful, technical managerial competence. The people in the latter group provide human resources, corporate governance, compliance, physical plant, etc. However, I do not see that model emerging in Ireland. Instead, a kind of tokenism is creeping into clinical involvement through the notion of clinical directors.

Thankfully, I have had the privilege of working in some of the finest hospitals in the world. The people who rose to their leadership positions did so because they were great leaders, not because they were acceptable to the bureaucrat who wanted to elevate a doctor to that position. Some doctors decide relatively early in their careers to become bureaucrats because they do not like practising medicine. They are scattered liberally across Ireland's health system. Disproportionately, the people who are allegedly the senior decision making doctors in our system are not the ones who have been forged in the fires of peer review or climbed the heights of quality, brilliance and achievement. Instead, they are felt to be the safest hands from the bureaucrats' point of view. This is what I fear is emerging in the development of the clinical directorship model.

My final points relate to what one might call guerilla health economics. Spending money on health care is no worse for an economy than is spending money on cars, white goods or holidays. Why is it that Bloomberg News or CNBC tells us that an increase in consumer spending on cars or holidays in February or an increase in house prices is good news whereas spending more money on health care is bad news? It is always bad to waste money. We need to understand that if we move to a model of reformed health care, we may end up spending more, but we will spend it more efficiently.

The next time the Minister meets any of the Germans, he should tell them, his friends and colleagues, that they can lecture us on how to run our economy and that Ireland will adopt their health system immediately. The synthesis that has emerged between the Minister's pre-election health policy and Labour's health policy is more correctly called the Deutsche model. Germany's model is the most successful of the large countries' health systems in terms of equity, equality and access. In summary, everybody is mandated to have occupation-based health insurance and society pays the premia of those who do not have it. This provides a freely negotiable insurance instrument. One may take it to any doctor or hospital one wishes. One may choose to attend a hospital run by the state, the Red Cross, a Catholic religious order or a university. One also picks one's doctor. Doctors deal with one directly and bill one's insurance. Such a system has risks. Doctors can overdo testing, in that there is a health economic concept called supplier-induced demand. However, there are ways to police that situation.

This is something like the system we have in our socialised health insurance model, namely, VHI, which is a community-rated form of slightly selective social insurance that is open to approximately 45% to 50% of the population.

The big bang that we need to reform the existing system is not that big. We have already gone half way with approximately one half of the population.

Acting Chairman (Senator Terry Leyden)

I do not want to interrupt the Senator, but his time has concluded. I must hand over to the Cathaoirleach.

Senator John Crown

I thank the Minister for his attention and wish him well in the rest of this work. If I have referred to deckchairs on Titanic, this has not been a speech on maritime safety. My remarks last week about a ten-month waiting list for abortions seemed to make people believe that I was actually discussing abortion.

Senator Deirdre Clune

The Cathaoirleach cannot ask me to follow that.

I welcome the opportunity to speak in support of the Bill. What it sets out to do is clear. The Minister called it a transitional measure that builds on changes he has already made to the composition of the HSE board. I wish him well as he prepares to move towards a system of universal health care, which is a central plank of the programme for Government. He will have my support in that work.

For many Senators, the Bill will focus our minds on the Health Act 2004, under which the State has been operating. Other Senators have outlined the situation that has since evolved. Oireachtas Members submit questions to the Minister only to be told that the matters involved are not for him, but for the HSE. I hope that those days will vanish with the passage of this legislation.

If money is being allocated from central resources to the provision of health services in hospitals and communities, it makes sense that Government policy be reflected in its expenditure. The Bill develops structures whereby the Minister will have an input into service plans and accountability measures will be introduced. The Minister will be in a position to issue directions to the HSE on the expenditure of funding and the provision of services. It is right that the HSE's priorities will be stated by the Minister.

I was concerned this week that services were not being provided for children who needed community speech and language therapy or occupational therapy. I contacted the Minister and the HSE, for which it is a matter, as funding has been provided. There must be an avenue whereby public representatives and members of the public can bring to the Minister's attention an issue where Government policy is not being reflected on the ground. This legislation would facilitate that.

I particularly welcome the proposed new structures and directorates. Primary care is extremely important and I know from working with people and their families how vital the service is. Senator Crown, who spoke before me, discussed the hospital issue. Primary care involves services in the community, including nurse specialists and public health nurses, that play a very important part in delivering primary care services. It also involves registered nurses, physiotherapists, and occupational and speech and language therapists. The primary care provisions have, to date, had an enormous impact on community services. They provide services locally and in the community, particularly for older people and people who may have children with learning disabilities. This ensures elderly people and the disabled can remain in their own house and community, and we all know the social and long-term economic benefits of that. This is an extremely important plank of Government policy, as it was with the previous Government, and it must be continued and expanded. I know the Minister is completely committed in that regard.

I will also mention the mental health directorate and the fact that this new section will oversee reform in this area. Money has been allocated in the provision of services, and A Vision for Change has been a long time in the making. There is a ten-year strategy that will facilitate a transfer from old psychiatric services to community-based services for those with mental health difficulties. It is a very important plank of the policy. The proposal to set up this directorate has been welcomed by interest groups, and it is particularly welcome that a director will now be responsible for driving forward change in this area and ensuring funding is spent where it is meant to be. It will guarantee that provisions will be available in the local community. With regard to social care, child and family services will also come under a directorate, and there will be clarity in how services will be provided within the HSE structure.

This is an important first step towards a system with universal health insurance and where the money will follow the patient. In such a system, services will be provided based on medical need rather than whether an individual has private health insurance. I wish the Minister well in his quest to get to that point, as I know this is an important first step for him.

Senator Thomas Byrne

I support the Bill, although it is more a case of letting it pass. The Minister has promised something good will come from it and we must wait and see. The Minister has given himself two Dáil terms to implement his health policy, which is longer than he gave the HSE to sort itself out.

Senator John Gilroy

That is one term shorter than the time it took for the Senator's party to destroy the country.

Senator Thomas Byrne

Many Members on the opposite side were members of defunct parties, including some in ministerial ranks. The Minister has argued that this is all the fault of the last Government; nevertheless, the people saying this and the staff representing the Minister are the same people who were in the last Government. It is a bit much to hear it repeatedly explained that it is the fault of the last Government as we are talking about the same staff. The only difference is the Minister is at the top, and it is annoying to hear his spokesperson make such comments.

The Minister has given himself more power with this legislation to direct the health service in any way he sees fit, which is a retrograde step. We will now see the politicisation of the health service.

Senator Martin Conway

There was politicisation of the HSE.

Senator Thomas Byrne

The politicisation of the health service led to ruin.

Senator John Gilroy

Fianna Fáil led us to ruin.

Senator Martin Conway

Politicisation without accountability.

An Cathaoirleach

Senator Byrne to continue, without interruption.

Senator Thomas Byrne

The director general of the HSE will be in the same position as the current chief executive in that he or she will be accountable to an Oireachtas committee. There is little change. This Bill is supposedly the first stage in the introduction of universal health insurance but we do not have much detail in that respect. The board of the HSE was abolished well over a year ago and nothing much has happened except that a gap has formed in accountability and direction. Officials on the ground do not know which way the Minister wishes them to go or how the political wind is blowing. There is a total lack of leadership and accountability, which is wrong, as the officials on the ground are taking the flak which the Minister is refusing to take.

The Minister is examining structures rather than people's health care. He is replacing a system with a very similar model but he will be able to say, in public relations terms, that we are making progress. The HSE has been in place for seven years and the Minister is giving himself longer to sort out these problems, and he will be able to say that the process was always going to take two Dáil terms. The Minister should have given the non-political public health service a bit more time, as there have been significant improvements in the past number of years, despite some faults.

Many of the Minister's promises remain unfulfilled. Fine Gael Deputies in my area are going around with leaflets boasting about the new GP card for long-term illness but nothing has happened in that regard. There were promises relating to a regional hospital before the last general election but nothing has happened in that regard either. Direct promises have been broken, and it is of great concern that power is being handed back to the Minister. I would personally oppose the Bill on that basis, as it is utterly wrong.

This has nothing to do with accountability. The Bill provides for the director general to be accountable, which will reduce the accountability of the Minister. Ministers were always good at taking credit while avoiding the bad news, and the current Minister, Deputy Reilly, is the same. There is not much change in that respect. He is putting in place many of the old health board structures that failed us when there was political interference leading, for example, to cancer services being kept in places when they should not have been. The national cancer strategy was rejected in the last Dáil, and a current Minister of State, Deputy Perry, disgracefully promised sick women that there would be a cancer service in Sligo. I do not know how people can sleep at night when they tell cancer patients-----

Senator John Gilroy

The Senator's party members resisted that strategy.

Senator Thomas Byrne

I speak for myself on this issue. I absolutely and wholeheartedly supported the national cancer strategy because cancer experts and the professor from Canada recommended it to us. I know not everybody, including Senator Crown, may have agreed but it was seen as the way forward. Fine Gael were unbelievably cynical in sinfully opposing that strategy, as it literally dealt with the lives of women, in particular. It was a terrible act.

Senator John Gilroy

The Senator's party members opposed it.

Senator Thomas Byrne

My party did not oppose it. I supported it.

Senator John Gilroy

Members of his party resigned over it.

Senator Thomas Byrne

I completely and utterly disagreed with them but they did not make a promise that they knew was false, like the Minister of State, Deputy Perry, and Fine Gael. The Fine Gael organisation indicated that services would be restored after the election. My colleagues resigned because they disagreed with the decision but they were also realistic in that they did not promise that a decision would be changed. There was a very specific promise made to ill people, which was a sick act.

I am opposed to more ministerial involvement and the private health care system proposed by the Minister. He recommended the case of the Netherlands but costs there have increased over the years.

Deputy James Reilly

It is an excellent system.

Senator Thomas Byrne

It is not the excellent system which the Minister purports. We should be cultivating and supporting the public health service, which is the best way to provide health care to the public. The biggest mistake made by Fianna Fáil and the Progressive Democrats with the Health Service Executive was giving it an awful name. Why is the National Health Service in Britain beloved?

It is a public health service which even the Tories would not dare to touch. It is beloved because there is a history there and a principle that everybody will be looked after regardless of his or her means, or lack of means. That is a principle we need to support. We need to gradually move way from the two-tier system, which has been in place under all Governments. I am not convinced in regard to private health insurance.

We cannot allow a Minister to make directions because there will be motions before the Dáil asking the Minister to direct the Health Service Executive or the director general to do different things which would not be the Minister's responsibility. However, the power would be there for the Minister to do so because it is a very general power and there is very little in the Bill as to the type of directions the Minister may make.

I can certainly see Members of Dáil Éireann tabling parliamentary questions asking that the Minister make directions in certain instances and I can see motions being put down on such directions. That is no way to run the health service. The health service should be run on the basis of medical need and medical priorities. I do not agree with the Minister interfering in that because Fine Gael has not shown it is able to manage health care and that it understood the health system before the election because if it did, it would not have made the rash promises it made around the country. In Roscommon the promise was completely broken, in Navan it was not kept and in Monaghan, it was completely broken. The Minister said in Monaghan that if he did not keep his promise, he would resign. That was a very dangerous promise to make and he has broken it but I would not ask him to resign over things like that.

A motion in the Dáil expressed confidence in the Minister and we must accept that but I appeal to him to work with the Minister of State, Deputy Shortall, on the primary health care centres. I want to see a primary health care centre built in Kells but I was very disappointed with the answer given last night by the Minister of State, Deputy Cannon, on the Minister's behalf. It was very vague on whether that health centre would be built. Negotiations were taking place with a preferred bidder who a number of years ago told the Department it could not afford to build it. I would like an update from the Minister on that because I will certainly do what I can to support that particular project, notwithstanding all the cynics out there. This Bill is an abomination and it is a pity my party is supporting it.

Senator Marie Moloney

I welcome the amendments to the Health Act 2004 through the Health Service Executive (Governance) Bill 2012. Any effort made to improve accountability and to make our health service more transparent is vital and this Bill will bring that about. The HSE can no longer hide in the long grass, not be accountable to the Minister and not give answers.

Senator Thomas Byrne

It is the only one giving answers; the Minister is not.

Senator Marie Moloney

We are dealing with people's lives and the use of taxpayers' money. At the end of the day, the buck stops with the Minister. Those opposite will hold the Minister to account for whatever happens in the HSE; therefore, it should be accountable to the Minister. I do not know how this accountability was taken away from the Minister in the first place and what people were thinking when they did that but we are trying to improve the situation. What worries me gravely is what Senator Crown said that people who are in the system and who are trying to highlight the deficiencies and inefficiencies in it are being muzzled. That is not good enough. He was one of those who was strong enough to stand up and speak about it. What about all the others who tried to do so but who were shot down and whose jobs were threatened if they spoke out about the system?

I had reason to attend a consultant in the past year and we spoke about the health service. He told me he was the only consultant in the hospital - I will not name the man or the hospital because he would be identifiable - with one registrar under him. He told me he took the job in that hospital because he thought he could make a difference. He said he worked hard but that he had not been able to make a difference because the system was pulling him down. Anything which can ensure accountability is most welcome.

Earlier we debated the Ombudsman (Amendment) Bill 2008, the Ombudsman's office and accountability. This is all about accountability. We must be accountable. Today Senator Barrett introduced a new word "agencification" in the House. That is exactly what we have been getting - agency after agency. We need to pare this back, throw open the curtain and have accountability.

I have been led to believe there are between seven and eight layers of management between the front line services and the Minister. Why do we need all those layers of management? Nobody is arguing that we do not need management. Every agency needs to be managed properly but do we need so many managers answering to each other? I do not believe that is good enough and we could do away with many of those layers.

For several years replies to parliamentary questions submitted to the Minister or representations made to him have stated that it is a matter for the HSE. I do not expect the Minister to have all the answers at his fingertips because no Minister could possibly have them. However, if the Minister asks the HSE to report back to him, it should do so and we should get the answer eventually. For 12 months, I have been trying to get an answer from the HSE. I wrote to the Minister who forwarded my letter on to the HSE. God only knows where it went because I have been chasing it from pillar to post but cannot find it. I wrote to the Minister last November and it is nearly October but I still do not have an answer to that issue. It is not good enough. We should be able to get answers.

The HSE has operational responsibility but with this responsibility, there seems to be no accountability. With the abolition of the board of the HSE and the introduction of the directorate headed by the director general, I hope a speedy transition is forthcoming so that we can progress with our health reform programmes for the betterment of the public. One gets sick of political parties arguing about whose fault it is. We should forget about that and work with what we have and for the betterment of the people. We tried the HSE and the boards of the HSE and they did not work. Let us change the system. If it is not working, let us fix it.

Senator Sean D. Barrett

I welcome the Minister. As I said the last time he was here, he occupies probably the most demanding post in Irish public life. Perhaps "disagencification" might be the word for this in that we are trying to get rid of agencies and restore ministerial responsibility which, as the previous speaker said, we were discussing with the Minister for Public Expenditure and Reform earlier.

Looking at the numbers employed in the health service, between 1980 and 2011, it went from 55,000 to 104,000. The rate of increase in the administration was to an index of 295 and the total staff was to an index of 187. We have a bureaucracy problem. With Senator Crown, I fear Sir Humphrey has had more of a say in this Bill than we would want him to have. That is where the expenditure has gone. In 1980, the number of non-doctors employed in the health service was 51,000 and it is now 96,000. We have to remove these layers.

I wonder if what we might call the "J Crown" model of hospitals, financially standing alone with their own management, preferably very little, and their own accountant, might not be a much better idea. I realise what is before us today is an interim measure to get rid of the layers of bureaucracy from the HSE but I put that forward for the Minister's thoughts when he is preparing for the next stage. When we are sick, we want to see a doctor and not the 15,500 bureaucrats who are employed in the system.

I was a member of the Brennan commission. Maurice Tempany was also a member. He was seriously concerned about the number of people with financial and accounting titles in the health services but with no qualifications, a point raised by Senator Burke. The Comptroller and Auditor General has also had that problem. It took some time to get the management letters from outside accountants commenting on what was going on. We really must be aware of all of that.

On page 67 of Health in Ireland: Key Trends 2011, one can see that the German health system - praise for which I am mindful of - spends 11.5% of gross national income and we spend 11.4%. Therefore, we are entitled to expect that kind of service and are duty bound to support the Minister in any measures he has to remedy that situation. The report also shows that our spend of €3,781 per capita is not that far short of Belgium, is bigger than Finland and Italy and about the same as France. Therefore, we are spending a lot of money and are entitled to ask why the service is not being delivered. The Minister deserves the support of the House for tackling issues related to very short working hours and restrictive practices in the health service under the Croke Park agreement and on his own initiative.

I am concerned about some sections, namely, section 16A(4), which states: "A person may not be appointed as an appointed director unless he or she is a person who is an employee of the Executive holding the grade of national director in the Executive." In the Brennan report, we were critical of that common recruitment pool. Why can other people not come in and help in this important task? Is that a restrictive practice? Like other Senators, I will see whether we will table amendments in respect of this. Section 16D concerns qualifications, which could help the Minister develop those points, but most of the qualifications are disqualifications as listed. One cannot be a Member of the Seanad or the European Parliament. What can one be to assist the Minister in this important task? Much the same is true of eligibility for appointment to the post of director general. We need to think outside the box in the same way as Senators Crown and Burke have spoken about. We have spoken about reform of governance and there has been reflection on why the Brennan report failed. In the other House, the Tanáiste said that no economies were achieved. One had a Health Service Executive into which every single person in the health boards was absorbed. That must be looked at because we have problems.

This debate must take place openly. I am concerned about section 16I(2), which states: "The Director General is not required to give an account before any Oireachtas Committee of any matter relating to the general administration of the Executive that is, or is likely to be, the subject of proceedings before a court or tribunal in the State." We know there is a sub judice rule but we now have the potential sub judice rule in order that they can refuse to participate in anything, which could happen in the future. This gets more draconian in section 16I(9) where it states that: "In carrying out his or her duties under this section, the Director General shall not question or express an opinion on the merits of any policy of the Government or a Minister of the Government or on the merits of the objectives of such a policy." We are all doing it but under that section, this person will be the only person in the country who does not engage in active debate with the Minister on these issues, much of it supporting him in the reforms he seeks to make.

Section 16J(1) states: "Notwithstanding his or her functions as an appointed director, an appointed director shall be accountable to the Director General for the performance of his or her functions as an employee of the Executive." Does that make for a board of people who all think the same way and demonstrate the herd instinct? We have had to investigate the problems caused by and deal with the consequences of this herd instinct in so many other areas of Irish life as we attempt to retrieve ourselves from the IMF and others. Section 16K(9) states: "A meeting of the Directorate shall not be quorate unless at least half of the persons who for the time being are members of the Directorate are in attendance at the meeting." That should be up around 90%. These people must attend board meetings and participate in these discussions. They have been let off far too lightly in section 16K(9). I became confirmed in my fears about the Sir Humphrey factor because under section 16M(8) the director will be called the director general, not the chief executive officer. I worry about people always looking for fancier titles. If they would just do the job, that would satisfy us much more.

In respect of the first step towards universal health insurance, I hope we will not continue the mistakes we have made in this area. We have lost in the Supreme Court, the European Court of Justice-----

An Cathaoirleach

The Senator has one minute left.

Senator Sean D. Barrett

I have had discussions with the Minister in the House on this issue and I am glad to conclude in the time limit. Milliman pointed out - I know the Minister sent it back into VHI - that people were being kept in hospital for 11.6 days when the average length of stay according to best practice was 3.7. We will end up with a hugely expensive system if we keep people in hospitals for an unnecessarily long time. Reforming our health service is a long road, as Senators Crown and Burke and others have said. This is a good first step. I think we will all table amendments in a helpful capacity when it comes to Committee Stage. We wish the Minister well but he has inherited a system that is highly inefficient, very expensive and, in many cases, not serving the patient.

Senator Martin Conway

I welcome the Minister to the House. He is a frequent visitor at this stage and enters into debate and discussion with us in a very healthy, open and useful manner.

I commend the last speaker for his contribution. He was very positive, as always, and I look forward to helpful amendments. It will be interesting to see what they are. I particularly commend Senator Crown for his contribution. It is very telling that he stated that had he the opportunity to provide a vote of confidence in the Minister, he would have happily done so. I believe Senator Crown has credibility in this area as a distinguished consultant who has specialised in the treatment of cancer over the years in this country. He knows the health system and what the Minister has inherited and is trying to do and is somewhat in unison with the Minister's vision.

This legislation is important when it comes to implementing that vision and I welcome and support it. For too long, the HSE was too much at arm's length from the Minister. When difficult decisions were being made and correct and incorrect decisions were being made, the previous Minister regularly stated that the HSE was effectively not accountable to the Minister for Health. In any political democracy I know, the line Minister takes ultimate responsibility for his or her Department and does not kick to touch. No disrespect to anybody but that is what happened for the past number of years. There was an awful lot of kicking to touch. What I would describe as an extremely right-wing philosophy saw the whole disaster that was co-location. That philosophy is what would often be regarded as the Boston-type philosophy. One often heard the phrase "Boston or Berlin". Based on what Senator Crown said earlier, I would be much more comfortable in the Berlin model. Most elements of Irish society would support that concept and did so in the last general election when the two coalition parties had broadly similar philosophies on health. They involved universal health insurance and a fair and accessible health system for all - effectively a public health system where no matter who one is as a citizen, what one's resources were and whether one had or did not have resources, one would have access to the same high quality health care.

Unfortunately, implementing that policy is not easy, especially when one is taking over the monster which was and, to a large extent, still is the health service. The Minister must effectively dismantle a health system that is not working and incrementally reassemble a working health system which has at its core the principle of patient care and safety, what is correct for patients and, most importantly, accessible, quality and safe health care. Trying to achieve that will not be easy. The Minister will make enemies because there are vested interests. When one is trying to manage vested interests and do the right thing, one will upset people. This Minister is not interested in the perception of change, rather he is interested in change.

Unfortunately, for too long in politics we have had too much of people spinning and trying to create a perception that change is afoot when in real terms no change is afoot. When dealing with the health service, perception is very dangerous because people's lives are at risk. Every citizen should be entitled to good quality health care. Unfortunately, for too many citizens that is not happening. The Minister is making a genuine effort and he has a vision. The legislation will enable him to penetrate that vision throughout the system by introducing the necessary changes.

Staff costs will have to be examined. While we are still within the terms of the Croke Park agreement it will be reviewed. Given that 70% of the budget goes on staff costs, it is difficult to implement change. However, genuine efforts to reduce costs are being made with the remaining 30%. There is an old saying, "Rome was not built in a day", but in this scenario change will take time. There was a mention of two terms of office. I would be delighted if I could say to citizens in my area and elsewhere that in ten years time we will have a high quality health service. The majority of people are buying into that.

I attended a HSE briefing at 8 a.m. on Friday last with Anne Doherty, chief executive of the HSE in the mid-west region which is considering the joining up of Ennis hospital, the Mid-Western Regional Hospital, Dooradoyle in Limerick, St. John's Hospital, Limerick and Nenagh hospital. The concept is that they should be looked at as one campus although there are four sites. The idea of creating specialist areas in various hospitals is the correct approach where risk assessment and quality care is assured. Therefore, when a patient from County Clare is referred by a general practitioner, it may be more appropriate for him or her to go to Nenagh hospital because that is where the particular specialty is located, or it may be more appropriate for a person from Nenagh to go to Ennis hospital. This is a small country with limited resources which is part of a troika programme. We have a responsibility to do things efficiently and in the best interest of citizens.

I believe in primary care and in keeping people in their homes for as long as possible. I subscribe to the notion of primary care centres. While I am not a medical expert, I am a reasonable observer of such things. If injuries can be treated at local level, without referral to accident and emergency departments, that is a more desirable prospect. I would like to think there will be advances in primary care in the lifetime of the Government and, by the end of the next term of Government, a blossoming of primary health care throughout the country.

A value for money audit was carried out on the provision of services for people with disabilities, whether personal assistant hours or a conglomerate of services, because money was being thrown at services and we were not getting value. Certain recommendations within the value for money audit show that a better service can be provided at a cheaper rate to those in need. Difficult decisions will have to be made. In terms of the body that nominated me for the Seanad, People with Disabilities in Ireland, 92% of its funding was going on office space and administration. It was inappropriate that it should receive €1 million of Government money when €920,000 was being spent on office space and administration. I had to support the decision because it was the right decision.

I call on all representatives of the Houses, in opposition and in government, to work together to ensure the people have a quality health system. Politics will have to be put aside. Unfortunately, party politics is necessary but, when it comes to the health service, there should be a national approach for the betterment of the people.

Senator Marc MacSharry

The Senator should tell that to the Minister of State, Deputy Shortall.

Senator David Cullinane

I welcome the Minister to the House. When I hear politicians say that we should put politics aside, it is always politicians in government. The reality is that, when the Minister for Health was in opposition, he was a robust spokesperson for health, rightly so. Our job is to hold the Government to account. We will work constructively with it if it makes the right decisions, but in many areas it is not making the right decisions.

Many previous speakers referred to Titanic. This is the centenary of the sinking of Titanic. It is apt for those Senators to raise that analogy in terms of where the health services and the Bill are at. We support the Bill only because it is an improvement, not because we believe it will deal fundamentally with the real problems in the health service. Essentially, this is rearranging the deckchairs on Titanic.

Public health services are struggling from day to day. Those who work in the health service are under extreme pressure. Hospitals are suffering and many are reeling from the latest round of cuts of €130 million and cuts to home care packages, in addition to the €750 million taken out of the health budget in 2012 and €1 billion in 2011. Fianna Fáil was also responsible for taking large amounts of money out of the health service and not properly reforming it. It, too, has to take responsibility for that.

Senator Darragh O'Brien

Sinn Féin put many people into the health services.

An Cathaoirleach

Senator Cullinane to continue, without interruption.

Senator David Cullinane

There is also the recruitment ban, restrictions on overtime and the hiring of agency staff, all of which are having a real impact on health services.

Senator Crown mentioned the deal with consultants. It may be a good deal but we will have to wait and see how it works. If there are fewer staff, fewer nurses, fewer doctors and less capacity in the surgical theatres, the deal will not amount to much. I come from the south east. This year, owing to cutbacks which the Government, the Minister for Health in particular, put in place, the regional hospital in the south east lost three of its surgical theatres, going from eight to five, 25 inpatient beds, six paediatric beds and front-line staff, all of which is having an impact on patient care. The Minister will have seen the reports of increased waiting times for outpatient activity and orthopaedic waiting times in Waterford Regional Hospital. He can shake his head but that is the reality. The clinical director at the hospital was on local radio this week confirming that is the case. In some areas waiting times have increased.

What we are trying to achieve is accountability in the health service. Pontius Pilate could not have arrived at a better system than the one in place. The major problem in the health service for far too long has been that no one takes responsibility, and that goes back to previous governments as well. How are we in a new era of responsibility when cuts of €130 million are announced, yet the Minister did not make those announcements, rather a senior civil servant? How is the buck stopping with the Minister and how is that taking responsibility for what is happening in the health service? It is not. The buck has to stop with the Minister and if there is to be accountability, he must take control. He made a big deal of saying he would take the reins of the Health Service Executive and he would take control, yet when the announcement of cuts of €130 million had to be made, he was nowhere to be seen. That is the reality. He was forced into a humiliating climbdown on the cuts to personal assistants for people with disabilities only because those unfortunate people camped outside Government Buildings to get the Minister to do what was right.

Mr. Cathal Magee resigned owing to problems in the health service and a lack of movement. There is no doubt the Bill provides for a slight improvement in services but it still creates a layer of bureaucracy. It is about management. Senator Crown is correct. What we want is a genuine health partnership.

What about the voice of patient groups? What about the voice of advocate groups? What about democratising the health service? That is something the Minister and his party spoke about when in opposition. They were critical of the previous Government, which abolished the health boards. What about local democracy and accountability? Why is it always bureaucrats and technocrats who are responsible for what is happening in the health service? What about people who represent real people such as people with disabilities? What about people who represent older people? What about local politicians who represent people who are elected? Surely they too should be part of how the health service is run.

The Minister's White Paper on universal health insurance is not going to be delivered as promised. It will be delayed, yet we still do not know how the scheme will be rolled out. I have heard a lot about the Boston, Berlin, Dutch and Deutsche models but I want one that is based on equality. We need a health model where a patient's treatment is based on need, and need alone, and not on their ability to pay. The system should be free at the point of delivery and funded through general taxation. That is what I want to see and it is the type of model that we should see.

The Government has shelved the scheme for free GP care to long-term illness patients. The measure has been placed on the backburner.

I wish to refer to an important issue raised by Mental Health Reform regarding the Bill. The organisation welcomes the Government's intention to improve the HSE's accountability through the Bill but it states: "[T]he current draft of the Bill does not ensure that a Director for Mental Health who has the competence to drive implementation of the Government’s mental health policy will be appointed." That important point needs to be taken on board.

I draw the Minister's attention to another important issue faced by patients and the people of the south east. I listened to the clinical director of Waterford Regional Hospital and I have listened to all of its consultants. They are concerned about a review of the hospital network in the region, the possible break-up of the clinical network in the south east and the potential for Waterford Regional Hospital to be networked with Cork. There is a fear that the region could lose services and that its regional hospital would be downgraded as a consequence. It is a real concern for the people in the region and I know that they have raised the matter with the Minister because they sent him their submission. They want to ensure that there are proper health services for people and that geography is not an issue when it comes to the type of treatment that one receives.

The Minister must do much better than this Bill if we are to deliver the type of public health service that the citizens of this country need. He must do better if we are to truly democratise the health service and ensure that patients and citizens get the treatment that they need as a right and is not based on their ability to pay or where they come from. The State has a responsibility to vindicate their right and deliver the best health services to the people of the State.

Senator Catherine Noone

Like other Senators, I support the Bill. It is a positive and necessary stepping stone that will bring us closer to the ultimate goal of the dissolution of the HSE. The Minister has intended to dissolve the HSE since we came to government.

The programme for Government clearly spelled out the intended future of the health service and the continued existence of the HSE was not part of it. The HSE is simply an organisation that has managers managing managers. A manager should at least have a budget and without one they should not be a manager. The situation that has prevailed to date is out of control. It was Senator Moloney who said that there are seven or eight layers of bureaucracy between the Minister and front line staff. That says it all.

The Bill provides for the abolition of the HSE board, which was established under the Health Act 2004, and for a new governing structure to fill its place. The board will be replaced by a directorate which will ensure further oversight and accountability for the HSE. The directorate structure is an interim measure intended to help put in place a more direct line of accountability between the HSE and the Minister. From a policy point of view, as well as every other point of view, the structure is welcome and necessary.

The HSE will face many significant challenges in the year ahead given the resources that are available and the dual constraints of both the national recovery plan and the Croke Park agreement. The health sector - like all other sectors - has experienced a reduction in financial resources over the past three consecutive years. During the period we have also seen a steady improvement in service and effectiveness which we hope will increase in the coming years.

The improvements are clear and must be acknowledged but there is more to come during this transitory period. I welcome the overhaul of the HSE's governance structure. The organisation has had eight years to prove its effectiveness but Senator Byrne has suggested that it should be allowed to continue for another few years to see if it could work. It is that type of Fianna Fáil logic that has led to the property sector going from boom to bust. There is an expression that "if it ain't broke then don't fix it" but I believe that if it is broken then one should fix it. In that respect it is good that we can control the health service and that sense will prevail.

With resources tighter than before we need to ensure that one hand talks to the other at all times and that the Minister has full, complete, accurate and timely information when making decisions that are crucial to the future of services both nationally and regionally. As the Minister has said, the new HSE directorate structure will allow us to redesign the system and to put the needs of the patient front and centre. The Bill will bring us closer to that happening and will allow us to take another crucial step in unwinding the years of damage. It will also make the health service more dynamic, agile, flexible, efficient, less expensive and more patient centred. I have belief in the Bill and the positive agenda that has been set regarding HSE reform. I commend the Minister and his officials on their work.

Senator Darragh O'Brien

I welcome the Minister. I have listened to the debate - particularly the last two contributors - and watched the television monitor earlier. Some of us on this side of the House have a degree of sympathy for the Minister. I talked to my health spokesperson and colleague, Senator MacSharry, and he too has had occasion to cross swords with the Minister of State, Deputy Shortall. I wish the Minister well with the mediation process. I would not take a bet on it but for his sake I hope that they can work things out.

Senator MacSharry has outlined my party's position on the Bill and we gave it a broad welcome. Without question the HSE, its structure and how it is governed needs to be changed and that is all fine, well and good. From my time in the last Dáil when the Minister was the Opposition spokesperson on health one was given the impression that the only problem with the health service was that he was not in charge. The same impression was given around the country when he promised many things to people in Monaghan and Roscommon. How are the plans for a new hospital in our area of the north east going?

The job of a Minister for Health is serious and I have acknowledged that before here. Recently, I watched the speech he gave in Monaghan where he gave an assurance that he would resign if it was seen that he did not keep his word. I ask him to watch his speech and to listen to what he and the Taoiseach told the people of Roscommon. More importantly the Minister should examine what was done. Does he have a clear conscious?

Last week we read that there are 340,000 outpatients on waiting lists. Successive governments have failed to deal with waiting lists. Before the Minister replies with the old mantra of what did or did not happen under the old regime I must state that advances were made, particularly in cancer services.

I consider the Minister to be a good constituency colleague. I have listened to him speak at various meetings where he talked about the importance of children. I agree that we must ensure that children and the most vulnerable in our society receive the services that they deserve. However, the aim must be explained to people in the context of managing a reduced budget and real choices must be outlined. The Minister should not leave it up to HSE officials to deliver serious announcements like those made three weeks ago. We do not have an unlimited pot of money and he should be upfront about telling people that. I acknowledge that he has a difficult job to do but we must give people choices because a lot of promises were made.

I have a question on governance. When will there be free GP care for long-term illnesses? I have written to the Minister and his office about various cases, particularly on behalf of people with diabetes and I would like to know how they are proceeding. I have heard a lot from the Minister for Transport, Tourism and Sport, Deputy Varadkar recently but I will not go into it. He has told me that he deems such free GP care to be unaffordable. The scheme formed an important plank of the proposals by the Minister for Health when he was Opposition spokesperson and I am interested to hear how the matter is proceeding.

I have a couple of serious matters that I wish to raise with the Minister on paediatrics and children. I raised the issue twice here and I wrote to him a couple of weeks ago.

I have yet to receive a response. I am sure it is in the Minister's office.

Senator John Gilroy

What does that have to do with the legislation before us?

Senator Darragh O'Brien

Is the Senator finished?

Senator John Gilroy

I am.

An Cathaoirleach

Senator O'Brien to continuie, without interruption.

Senator Darragh O'Brien

It is related to governance of the HSE. In fairness, the Minister is taking notes and I am sure he will do his best to answer the questions. If you are ever a Minister, which is highly unlikely-----

Senator John Gilroy

It is as unlikely as you being one.

Senator Darragh O'Brien

If you do not think it is important that matters relating to cystic fibrosis-----

An Cathaoirleach

Senator O'Brien must speak through the Chair.

Senator Darragh O'Brien

You might ask Senator Gilroy to control himself, although it is a difficult thing for him to do.

An Cathaoirleach

Senator O'Brien to continue, without interruption.

Senator Darragh O'Brien

This is very important. The Bill relates to the structure of the HSE and its various directorates. The question of the vacant paediatric cystic fibrosis post for physiotherapy in Temple Street Children's University Hospital, which looks after 94 children, is crucial. This Bill formally provides that the HSE is officially and under law required to report to the Minister, and I am asking the Minister to intervene in this matter. This post has been vacant for four weeks but it was flagged about six months ago that this retirement would take place. However, the human resources, HR, section in the HSE will not respond to the parents of these 94 children. The Minister, being a medical doctor, will understand the importance of physiotherapy for children with cystic fibrosis. I urge the Minister to check with the HSE as to when it will give its sanction to filling that post. I hope Senator Gilroy considers this an important enough issue to raise in the House.

With regard to our budgets and how the HSE manages its budget, we saw the figures last week which show that the overruns continue. We were given assurances by the Minister and the Government that front-line services would not be affected. However, I can offer an example from our constituency and north Leinster where there have been cuts to the HSE paramedic ambulance service in the north Leinster area and specifically in Swords and north County Dublin. Every Tuesday, between 7 a.m. and 7 p.m., there is no ambulance cover for 250,000 people. Last Tuesday they were covered by Loughlinstown hospital, but on the weekend before last there was no HSE ambulance on the Friday and Saturday nights in the north County Dublin area because the HSE would not cover sick leave and would not put in non-rostered staff. The Minister is aware of this issue. He campaigned in the previous election on the platform that Dublin North needs a Minister. Perhaps we did, but I believe we still do. I ask the Minister to deal with this issue as well. This is about governance of the HSE and examples of the front-line services which have been affected, such as the cystic fibrosis post in Temple Street Children's University Hospital and the north-east and north Leinster region having to wonder when it will have cardiac and advanced paramedic ambulances available to it.

Last week Loughlinstown hospital was covering Swords, but last weekend there was no ambulance in the north-east area. Why do the people of our area not deserve 24 hour, seven day per week advanced paramedic cover when other areas of the country do? This is about management and I wonder how this new structure of governance will make that change. The Minister might explain with regard to the different directorates being set up - I agree with the structure - how regularly they will report to him. How hands-on will the Minister be? When there are further cuts, will it be the case that the Minister will send out some poor official in the HSE to make the announcements for him? I believe there is an opportunity here for the Minister. It is not up to him to take my advice - I am sure he would not - but people realise that he has a difficult job and that the budget has diminished. However, if the Minister told people that he would keep his promise of protecting the front-line services, people would have more respect for his and the Department's approach. Consider the cut in home care hours and the welcome U-turn the Minister made regarding the personal assistants, which other Members have mentioned today. We must be much clearer about these matters.

If the Minister is to save €750 million next year, I believe a proper public debate must take place on how he will achieve that. On a personal level, I wish the Minister well in that endeavour. This is an area that is close to the Minister's heart and he has experience in it. However, many mistakes have been made over recent months in the management of the Department and the HSE. Is the Minister recommitting now to ensuring front-line services will not be affected? Is he recommitting to building a new hospital in the north east? Is he recommitting to ensuring the ambulance cover in the north Leinster area, lest I be accused of being parochial on this, will be reinstated? Will he give a commitment to ensuring the cystic fibrosis post in Temple Street Children's University Hospital is filled without further delay? I await with interest the Minister's responses to those questions.

Senator John Kelly

I will be as brief as possible. I welcome the Minister and support the Bill. However, like other Members, I will move swiftly along and raise a couple of issues with the Minister.

One of the issues relates to Government policy on co-sharing of services. I spoke to the Minister a number of months ago about the possible use of fire stations for the co-location of ambulances and ambulance personnel. The Minister and the Minister for the Environment, Community and Local Government, Deputy Phil Hogan, were supportive of the idea. Following that, a chief ambulance officer for the western region and a chief fire officer for my county agreed a policy document which would bring this about. However, the entire process was eventually frustrated by one official in the county council who said it simply cannot happen. Perhaps the Minister would get involved with the Minister, Deputy Hogan, and let these councils know that where these possible developments might take place, it is Government policy that they should. We talk about saving money and this is a way of doing that. There is no capital investment and only minor overheads.

The second issue I wish to raise is also about saving money. It relates to the home help service, which was mentioned by some Senators, and I have mentioned it to the Minister previously. I have carried out a costing of this proposal. I think the figure for the amount of money saved by taking 600,000 hours out of the home help service is approximately €8 million. I am not sure whether it is €6 million or €8 million. I have suggested previously that if we took on people who are unemployed and put them on community employment schemes - they are already receiving a social welfare payment - for the increase of €25 per week they would receive, we could provide the 600,000 hours that were removed from the service at a cost of €750,000. The 600,000 hours could be put back into the system for €750,000. Therefore, instead of saving €8 million, we could save €7.25 million if the Minister did things my way. I realise there are issues surrounding taking on community employment applicants and so forth, but they do this under the rural social scheme. It is important that this be considered. It is a way of delivering a quality service at the right price.

An issue arose today and I believe this is the second time I have dealt with such a situation. It relates to people who have poor circulation problems. The Minister will be familiar with this. When there are poor circulation problems there is always a possibility that the patient might have one or both legs amputated. The only machine available for dealing with this is the ArtAssist. I am sure the Minister has heard of it. It is available through the private sector but not in the public system. It is not available free. It is being made available, for example, in University College Hospital Galway, UCHG, to people who have serious circulation problems. I do not know what company has developed this machine but it charges for its use. The cost for a 90 day course of treatment using this machine is approximately €1,400, but people simply do not have the money to pay for it. They are medical card holders. A consultant in Galway has written an article about this.

He stated in his article that if this machine was made available for free to people who cannot afford to pay for it, they would save money through avoiding the need for amputations and follow-on care. Those are three ideas that would save money and improve the health service and I would appreciate the Minister's thoughts on them.

Minister for Health (Deputy James Reilly)

I am genuinely pleased to have been here today. The quality of the contributions has been excellent in the main and the debate has been stimulating and thought provoking and I am being genuine when I say that because some of the comments I have heard have re-energised me and made me glad that I have taken this job. When I conclude, I will do so in a forceful fashion.

A number of Senators have raised issues that have nothing to do with the Bill but they are important issues nonetheless and I will deal with them even though the Senators in question may have left the Chamber. In fairness they may have left because they did not think we would finish so quickly and I appreciate that.

Senator MacSharry asked if the same personnel would be involved and if there would be job losses. There will be job savings, although the Senator can call them job losses if he wishes. Will the same personnel be involved? Certainly not, we now have a new head of the HSE and a new person at the head of the Department of Health, with a new CEO of VHI. The Senator asked if there would be an increase in salaries. The previous incumbent in the HSE was on €320,000 per year plus a car allowance, the current incumbent is on €195,000 with no car allowance. The previous incumbent in the CEO position in VHI was on in excess of €400,000, the current incumbent is on €230,000 to €250,000. Not alone have we changed personnel, we have saved the taxpayer money.

The Senator said there is no plan but that is utterly untrue; there is a very clear plan. Time does not allow me today to go through the plan in its entirety but I will be happy to do so at another time. This Bill is an important step along the road.

The north-west region is an area of concern for me, particularly for 24 hour cardiac stenting. Today we are discussing the issue, and I will come to the hospital groups later, because I have been discussing those as well with Professor Higgins, who is carrying on his work as expeditiously as he can and he will come to me with a report later next month. I am glad to say, however, that I have been in contact with the Minister in the Northern Ireland Executive, Edwin Poots MLA, by phone on a number of occasions and that he issued a statement saying that rather than looking to Britain, which one report on cardiac surgery for paediatrics recommended, he wishes to have an all-island approach and that we should plan our services together with that in mind. I am happy to do that. I have also discussed with him the issues around air ambulance cover for the Border area and the issue of cardiac catheterisation. We will both tour the facilities along the Border in the near future so we can familiarise ourselves with the situation. Both Departments have been examining the issue, not just the big ticket issues like the hospitals but the small items such as ambulances crossing the Border, GPs accepting patients from either side of the Border and GPs having different rotations. If there is a man in Blacklion who is miles from his colleagues but close to people across the Border, why would he not be part of that cooperative or on-call service?

The Senator asked why changes are not coming but I challenge him and say they are coming, they are here already. Despite the fact €1.75 billion has gone out of the health service in the last two years, and another €700 million will go this year, with 6,000 fewer staff, and despite certain political parties saying there would be calamity and catastrophe at the end of February when people left, there was no such calamity. We not alone maintained a safe service, but we improved it. We have done so in a way that is measurable and verifiable. There are 22% fewer people on trolleys so far this year in comparison with last year, despite those challenges. The number is 13,450 people, a figure verified by the Irish Nurses and Midwives Organisation. There has been an 85% reduction in those waiting longer than one year for an in-patient procedure, a 63% reduction for those waiting longer than six months, and an 18% reduction for those waiting longer than three months. That is real, measurable and verifiable. There are 800 fewer children on waiting lists this year than at this point last year. I remind Senators there have not been any cuts to home helps or reduction in personal assistant hours.

I am happy to acknowledge when I make mistakes and I will make more because, as the adage goes, the man who made no mistakes made nothing. I had the 55 top managers of the HSE and Department of Health in a room in Dr. Steevens's Hospital two weeks ago and that was the first time it had happened since the HSE was formed. I said to them that I want to empower them to go out and try new things and when they try them and they work, I will laud them and if they do not work, I will support them in order that they can go out and try something new again. I will not castigate people or operate in an atmosphere of fear. I want people to be innovative and think outside the box, which is what Irish people are good at. I will return to that issue.

I am sorry to say it to Senator MacSharry but to have to listen to talk of cynicism from Fianna Fáil, I will not even comment on it.

Senator Marc MacSharry

Please.

Deputy James Reilly

The Senator asked when free GP care will be introduced. It will be introduced in this quarter, in this Dáil session, as promised. I accept it is a bit late, but I have explained before it is an extremely complex area. It is much more complex than I ever understood and the Attorney General is working with this to move from a system that is eligibility-based on means to a system that is based on disease entities. The work is nearly done and we hope to move on it shortly. We will introduce that legislation.

Senator Darragh O'Brien

Which areas will be in the Bill? The Minister said it will happen this quarter.

Senator Marc MacSharry

Swords and Balbriggan first no doubt.

Senator Darragh O'Brien

I was only looking for clarification.

Deputy James Reilly

I said it would be introduced in this Dáil session.

Senator Darragh O'Brien

Will it be available to people this quarter?

Deputy James Reilly

Is this a debate now? I will release the Ogden report in the next couple of weeks and the PA Consulting report and they will address many of the concerns expressed here by others, including Senator Barrett, and on this side by Senator Gilroy, on the lack of financial expertise in the system. It was asked who is in charge and I will make that clear. I am in charge and I will take responsibility for decisions I make that are good and for those that are bad.

There was a metaphorical discussion about changing the name of Titanic to Olympic and so on. The reality is that Titanic, like the HSE, did not have the necessary navigation systems on it.

Senator Darragh O'Brien

Or the right captain. Is that what the Minister is saying?

Deputy James Reilly

We did not even have headlights in the HSE, we could not see what was happening. Now we have the headlights, we have a much more sophisticated system.

I wish to refer to emergency departments. We were forever hearing the situation would be treated as a national emergency and everything would be done to correct the problems, with ten point plans in place but none of it worked, particularly at a time when the Government threw money at it. I will come back to the whole emphasis Fianna Fáil had on inputs - more doctors, more nurses, more money - with no focus on outcomes for patients.

Senator Darragh O'Brien

Not true.

Deputy James Reilly

What resulted from the investment?

Senator Darragh O'Brien

What about cancer care?

Acting Chairman (Senator Diarmuid Wilson)

Senator O'Brien already had an opportunity to contribute during the debate.

Deputy James Reilly

With the best will in the world, the Senator asked me questions and I will answer them but he has had his time and I ask him to please keep quiet.

Senator Darragh O'Brien

That is what the Chair is for.

Acting Chairman (Senator Diarmuid Wilson)

I thank the Minister for his assistance.

Deputy James Reilly

I thank the Chair and will be grateful for his protection.

Now we do not just measure the number of patients on trolleys at 8 a.m. with the INMO, we measure the number again at 2 p.m. and again at 8 p.m. in order that we can now predict a pattern and know at 8 p.m. the night before if we will be in trouble the next morning and can take corrective action. That is why, although many people had their hearts in their mouths when I said it, there will never be 569 people again on trolleys. I can never say that absolutely because there could be a catastrophe that might result in that but in the ordinary run of things that does not happen. Today there are 100 fewer people on trolleys than this time last year.

We now have put in place a system that can predict. For example, we have put in place a system for inpatient procedures whereby people are prioritised, once the urgent and cancer cases are looked after, on the basis of the duration of time they have been waiting. Moreover, in respect of outpatient figures, it is utterly disingenuous to state they have increased since last April. They were never counted before in this country and the figures never were available. Last April, we only had to hand half the figures and while we now have nearly all of them, they still are not complete. The current figure is 340,000, which ultimately may rise to 360,000.

However, I wish to assure Members about a matter that must be put into perspective. I have been told the outpatient services see approximately 200,000 people each month. If one is to believe some figures that have been given to me today to the effect that 3.5 million people were seen last year as outpatients, that monthly figure obviously is higher at 300,000 people. It is a problem that, when one first looks at it, is quite shocking. However, it can be addressed and the Government is determined to address it. I have stated in the past and repeat that I will put my neck on the block whereby my aim is that by the end of next year, 2013, no one will be waiting longer than a year for an outpatient appointment. Some 16,800 people have been waiting longer than four years for an outpatient appointment. This is an absolute disgrace and a cause of considerable concern to me.

Senator Colm Burke mentioned an instance of the non-appointment of a consultant. If he provides me with the details, I certainly will investigate it. The issue concerning non-consultant hospital doctor, NCHD, planning is ongoing. The Senator is dead right that many excellent people work in the HSE and I have always made that point. However, I always have complained about the lack of proper management, transparency, accountability and fairness. One must start at the beginning in that one must have transparency and one then can have accountability. When one has accountability, one may get fairness. Senator Burke mentioned the cost of drugs and this issue must be addressed. I am happy to state we are well advanced with our negotiations with the Irish Pharmaceutical Healthcare Association, IPHA, and hope to conclude them by the end of this week. I hate to say they will conclude because one never knows what could happen in negotiations. However, we are making good progress and I am quite confident that I will have good news on that deal in the short term. Another issue that arises with regard to the cost of drugs is drug reference pricing and the cost of generic drugs in this country. One need only go up the road to Newry, where one can buy some drugs generically at one tenth of the price we pay down here. Drug reference pricing will address this issue and as Members are aware the Health (Pricing and Supply of Medical Goods) Bill 2012 received support in this House just before the summer break, from where it will pass into the Dáil and become law very quickly. I already have mentioned how significant numbers in respect of financial expertise will be put into the system and I will have a definitive announcement in this regard in a couple of weeks time.

Senator Gilroy made the valid point that before the HSE was formed, there were approximately 13 grade eight staff in the system but by the time the Government came to power, there were more than 700 such posts. An explosion is not the word for it. I thank Senator Crown for his supportive comments. I can tell him I have no intention of being captured by the bureaucracy. I could not agree with him more regarding the employment of consultants by Comhairle na nOspidéal. I wish to devolve down to the managers of the hospital groups control over their budgets and control over recruitment of doctors and nurses. This must be their decision. There is very little point in giving them responsibility unless they are given authority and they know what they need by consulting on the ground where they are delivering care. I must refer to the example of Mr. Bill Maher in Galway. When he took over the hospital, had they not started to attack the waiting list, there would have been 9,901 people waiting for longer than one year for treatment. When I last spoke to him two weeks ago, that figure was down to 720 and he stated it would be 500 by last Thursday. This is a hell of an achievement and shows what can be done. However, Bill Maher did not do that on his own. He acknowledges he did this with the co-operation of the clinical directors, the nursing directors, the front line staff and everyone with a focus to put the patient first and to be fair.

Senator Crown spoke about the current funding system and I agree it is utterly bonkers and made that point in opposition. I refer to the idea that one gives a block budget to a hospital and that when the money is all gone, everything stops and the only people who suffer are the patients. Furthermore, there is a perverse incentive to leave lying on a bed a patient who has finished his or her acute phase of treatment because he or she only costs one grand a day, as opposed to taking in an acutely ill patient who could cost five grand a day. On a fixed budget, one simply does not do it. However, under a money-follows-the-patient system, one will do it because if there is no patient, one will not get paid. The new arrangements with consultants will mean they are available 24 hours a day, seven days a week, 365 days a year on five-day rosters, including night work. This means there will be a senior clinician in the hospital at all times. Senior clinicians are known to make more decisions more quickly with fewer tests. Consequently, this will save money and will put people through the system much more quickly. When I referred to the clinical programmes last year saving 70,000 days at a putative saving of €63 million, the point is not about the €63 million but about how more patients were treated more quickly and that is what it must be about, namely, the patient.

I do not want Senator Crown to preside over a system in which any man or woman working therein is afraid to speak out. However, neither will I preside over a system in which people can use their professional status to give a skewed version of what is happening to speak to their own vested interest. While I will encourage people to speak out, I will have others who would be prepared to speak against them from the same area of expertise. If they are telling the truth, the truth will be seen by the people but if they are telling a little yarn simply to further their own agenda, so be it as that will be found out too. I believe that to be fair and I hope Members agree. I want doctors to talk to doctors and nurses to talk to nurses. Senator Crown spoke of new management and clinical leaders and I believe that is of critical importance. It is hugely important to have clinical leaders with management responsibility and authority. As I stated previously, the success of the special delivery unit, SDU, is based on the fact that for the first time, those on the front line believe they are being listened to. Their ideas are assessed and if they look good, and make sense from a financial point of view, they are implemented and if they do not, they are not. In the case where there is a doubt about the idea, one should go back and revisit it. The Dutch model has been much talked about. I always have made clear that we take certain things from the Dutch model. However, we take ideas from Denmark on patient safety, from the United Kingdom on the trust model for hospital groups and from Northern Ireland the example of the SDU.

I take, in particular, the point Senator Crown made, also made by Senator Barrett, about doctors over-doctoring VHI. VHI now has new leadership in the form of a new chairman and a new chief executive officer with a remit to reduce costs and to bring in proper audit. I am sure all Members have heard anecdotal stories about people who were billed for procedures they had never had carried out or certainly were not aware they had carried out but for which the company would pay anyway. In addition, they have a remit for something that never was undertaken previously in VHI, namely, clinical audit. A cardiologist will ask the relevant cardiologist the reason he or she did something and if it was not necessary or clinically indicated, the company will not pay for it.

Seanad Éireann díospóireacht - Wednesday, 26 Sep 2012

Health Service Executive (Governance) Bill 2012: Second Stage

Seanad Éireann díospóireacht -
Wednesday, 26 Sep 2012