Health Service Executive (Governance) Bill 2012: Committee Stage
Section 1 agreed to.
NEW SECTION
I move amendment No. 1:
In page 3, before section 2, to insert the following new section:
"2.—The Health Service Executive shall cease to exist on 1 January 2014.".
The Minister and I have had many interesting debates, including debates before he became Minister for Health and I became a Member of this House. The great Fintan O'Toole chaired one debate we had in TCD. It is a great pleasure to welcome him and wish him well in the task because, as I said the last day, it is probably the most demanding job in Irish public life.
The Minister said the last day that he envisages the demise of the Health Service Executive, radical reform and the introduction of universal health insurance. I share the Minister's goals but would it not be better to put a sunset date on the Health Service Executive, which we are agreed should go? As approximately half the population has commercial health insurance and more than one third has a medical card, could we speed up the introduction of full coverage for people for health insurance? I hope that health insurance involves competition because the Milliman report showed that protecting one monopolist as health insurer was not a sensible policy. There are many issues like extended average length of stay, the lack of scrutiny of claims and so on. I know the Minister has sent Milliman back into VHI to see how efficiencies can be gained. I think they will also be gained by having a choice of insurance providers.
The Minister and I would probably be in agreement that it is an expensive health service, as the Department of Health's own data shows. We spend 11.4% of gross national income on health while Finland spends 8.9%, Sweden 9.8%, Switzerland in 11%, Denmark 11.3% and Norway 9.6%. Colleagues, like Senator Crown, might disagree with the UK system but it is getting a universal health service for 9.6%. Even Germany, which was mentioned the last day, is a couple of percentage points ahead of us. We have a very expensive health service which must deliver and that is why I support the Minister in his reforms. I realise that attempts to reform the health service have been seriously damaging to the political careers of very many Ministers for Health. I certainly feel a duty that if the Minister is trying to reform the system, he deserves my support.
One of its faults is that it is excessively bureaucratic. The number of clerical and administrative staff in 2011 was more than 16,000 while in 1980, it was 5,400. The total staff in the health service between 1980 and 2011 went up by 87%. That is against a 195% increase in clerical and administrative posts, that is, 2.24 times.
I support the Minister in his reforms. My amendment is purely a suggestion and I will not push it. It should be accepted that we implement the reforms the Minister wishes faster. That is the purpose of the amendment. I think it is called a "sunset date" in US legislation. Alfred Kahn, in the context of the Civil Aeronautics Board, said that if one leaves bureaucracies around, one gets function creep and they will invent other things to do. Is it not better to tell them it is all over on a certain date? It might not necessarily be the date I have put in the amendment.
Unfortunately, I do not agree with the amendment. The discretion has to be left with the Minister in this matter because we are talking about a major change in abolishing the HSE and setting up the new structure. The discretion has to be left with the Minister in regard to putting it in place.
I refer to the negativity about the health care sector. It is interesting to look at the key indicators in regard to health care over the past ten years and I give credit where it is due, including to the previous administration. The media focuses very much on the negatives in the health care sector but the argument I keep putting to people is in regard to maternity care. The number of babies born has gone up from 55,000 to 74,000 per annum. We have one of the lowest perinatal mortality rates in Europe, and long may that continue. Likewise, outpatient attendance has increased from over 2 million per year. The Minister disagreed with me the last day and he had a lower figure but I checked my figures. In 2011, more than 3.5 million people attended outpatient departments. That works out at approximately 37,000 attending Irish hospitals each working day, excluding Saturdays, Sundays and public holidays. That is a huge number.
There are many positives and the EU survey on health care attitudes in Ireland showed that Ireland has the highest percentage of its population in the EU reporting to have good or very good health.
That is an indication of the service that is being provided. There are difficulties in certain areas and there is a need to be far more efficient in respect of the services provided, particularly in trying to eliminate waiting lists. However, that will take time and we must continue working on it. We must bring about the changes needed where deficiencies have been identified in the service. The Minister has done much in the past 18 months. In fairness to the previous Minister and previous Administrations, much good work was done. The major issue was the escalation of costs during that period. Perhaps more should have been done to ensure checks in the system, in particular, where the cost of drugs within the health care sector increased from €576 million to €1.9 billion. That should not have happened and needs to be addressed. While I agree in principle with Senator Barrett about a timeline, the discretion must be left with the Minister and it is accommodated in section 1.
I appreciate Senator Barrett's support and share his sentiment. I want to expedite the changes as quickly as possible but the abolition of the HSE, as an entity, will take careful planning, consultation and complex further legislation. It would be premature, therefore, to include a date for the abolition of the HSE in the Bill. The Bill is intended, as a transitional measure, to help prepare the health system for the changes ahead. I hope the Senator will understand that and not push this to a vote.
I agree with what Senator Colm Burke has said that the ratings which were published by the Minister show that we seem to think we are healthy but we have problems with the health service. I have made a proposition to the Minister and as I have heard his reply I withdraw the amendment and look forward to seeing it appear, under the Minister's name, in due course.
Amendment, by leave, withdrawn.
Section 2 agreed to.
Sections 3 and 4 agreed to.
SECTION 5
Amendments Nos. 2 and 3 are related and may be discussed together, by agreement. Is that agreed? Agreed.
I move amendment No. 2:
In page 4, to delete lines 24 to 27.
I welcome the Minister to the House. My colleague, Senator Marc MacSharry, spokesperson on health, will give the Fianna Fáil position on the Bill as a whole and propose a range of amendments to improve it. I want to speak to my amendments which seek to ensure greater accountability within the health service for mental health, in particular, and I have proposed a number of amendments from that perspective.
The amendments as a whole are designed to ensure the Bill puts in place the leadership and accountability structures needed to ensure implementation of A Vision for Change and delivers real improvements in mental health services. I do not need to tell the Minister that mental health problems have huge social and economic costs. The social costs are immeasurable on families when people go through mental health problems unsupported. Even at a time of limited resources and priorities within the health service, we cannot turn a blind eye to the fact that there is a huge cost for individuals, employers and the State as a whole.
Unfortunately, we do not have a good history of prioritising mental health services. They have long been the poor relation of the health service as a whole. In 2010, just 5.3% of health spending went on mental health compared with 12% in England, 18% in Scotland and 20% or more in other EU member states. It is clear we are starting from a low base and much progress has been made in recent years, as acknowledged by the previous speaker, but we have a long way to go. The particular weaknesses have been highlighted by groups such as Mental Health Reform, that our approach to mental health focuses purely on a medical model, that there is limited access to supports other than medication, an over-reliance on inpatient services, inconsistent support across the country and there are large gaps in geographic areas for particular groups, such as children and adolescents. A Vision for Change set out the roadmap to improve the position and has widespread support from a broad coalition of groups who want it implemented.
The reason I have tabled the amendments is that A Vision for Change has not moved on and is not where we had hoped it would be at this point. There have been consistent and widespread concerns about the HSE's lack of accountability for delivering on A Vision for Change. That has been attributed by Mental Health Reform, in its constituent groups, in large part to the absence of empowered leadership within the HSE and gaps in structures of accountability that lead to a lack of planning and a lack of separate reporting on mental health services. The Bill presents an opportunity to put in place the structures in A Vision for Change which called for the establishment of a national mental health services directorate and that it would be one of the main drivers of implementation of the policy. It is not clear from the Bill that will be achieved on the current wording. It is not specific about who the directors will be. There are other flaws that I will point out later.
I welcome the fact that the section strengthens the Minister's control over the HSE's activities and provides that written directions can be given by the Minister to the HSE "concerning the implementation of any policy or objective of the Minister or the Government which relates to a function of the Executive, where the Minister is of the opinion that the Executive is not having sufficient regard to such policy or objective in the performance of its functions." That appears to be an improvement on the current position. However, I am concerned, as is Mental Health Reform, about the limitation that the Minister can only give a direction on policy implementation where he or she is of the opinion that the Executive is not having sufficient regard to that objective in its performance. It indicates that the Minister must wait until there is a failure before he or she can give a directive. We propose an amendment that provides that the Minister shall be empowered to give a direction on policy implementation at any time, without limitation, not waiting for a problem but ensuring that clear directives are given in the first place.
Amendment No. 3 is designed to increase public accountability of the mental health services and the role of the HSE in that respect. The section, as drafted, increases the HSE's accountability to the Minister for implementation compared with the present position, by saying that the HSE should report to the Minister on its compliance with any ministerial direction. Clearly that is positive. We are proposing that to ensure greater public accountability, any such report by the HSE, concerning its compliance with ministerial directives, should be published.
In recent days we have witnessed instances of concerns about lack of accountability and an unwillingness on the part of HSE officials to answer questions at parliamentary committees in order that there could be greater public scrutiny, more of which is needed in the current context. The amendment seeks to ensure there is nothing to hide and that the HSE should be happy to publish reports on compliance and making clear what it have been asked to do by the Minister and whether it is performing its function.
They are two simple amendments, the purpose of which is to improve accountability and transparency,
I understand the concern underlying amendment No. 2, that the Minister will not be able to act fast enough or that he or she may have to wait until the HSE has failed to take account of policy before he or she can issue a direction under section 10(1)(c). The provision, as drafted, would not result in this scenario. Section 10(1)(c) balances the Minister's responsibility for policy with the HSE's responsibility for operational matters. The HSE has responsibility under the Health Act 2004 for the provision of health and personal social services. However, the HSE also has a statutory obligation to have regard to ministerial and Government policies and objectives when performing its functions. The HSE, similar to any statutory agency, is expected to fulfil its statutory functions. Section 10(1)(c) should not, therefore, need to be used often but is intended as an additional power for the Minister to use when it is needed.
The new ministerial power should also be seen in the context of the proposed new accountability arrangement for the HSE whereby the HSE is accountable to the Minister for the performance of its functions. That means it will have to explain its decisions and actions to the Minister. This will help in ensuring that the Minister can act in an effective and timely way in regard to issuing a direction under section 10(1)(c). It should help to avert a situation where section 10(1)(c) needs to be used.
If the Senator withdraws the amendment, and rather than put it to a vote, I will seek further Parliamentary Counsel advice on the matter. I do not believe that it will be necessary but I will come back to the matter on Report Stage.
With regard to amendment No. 2, I am concerned that there could be too many reports on compliance regarding a single direction and their publication could lead to confusion. An overall picture of service matters would be available from performance reports against the service plan and from the HSE's annual report. There is already a legal requirement for the HSE to publish its service plan and annual report. Therefore, I do not propose to accept these amendments.
I welcome the commitment given by Minister that on withdrawal of my amendment he will seek further advice on it. I appreciate that he probably needs to take a timeout with his officials and to think it through with a cool head. I can resubmit my amendment on Report Stage. The deletion still gives the Minister the discretion that he needs because it leaves him with the overall powers. I have used a good wording and I appreciate that the Minister has committed to examine the matter. We can revisit the issue on Report Stage, if necessary.
Amendment, by leave, withdrawn.
I move amendment No. 3:
In page 4, paragraph (c), between lines 36 and 37, to insert the following:
“(8) The Director General shall publish any reports presented by the Executive to the Minister concerning its compliance with a Ministerial Direction.”.
Amendment put and declared lost.
Section 5 agreed to.
SECTION 6
Amendment No. 4 has been tabled by Senators Power, MacSharry and other Fianna Fáil Senators. Amendments Nos. 4 and 21 to 24, inclusive, are related and may be discussed together by agreement.
I move amendment No. 4:
In page 4, lines 41 and 42, to delete all words from and including “priorities” in line 41 down to and including “service” in line 42 and substitute the following:
“priorities in accordance with which the Executive shall prepare its service”.
The intention behind section 6 is to strengthen the accountability of the HSE to its service delivery. It provides for the HSE to "have regard" to priorities set by the Minister in its annual service plan and could enable the Minister to set a priority to provide the kind of community-based mental health care services that we need. Undoubtedly, it is a step in the right direction to provide that the Minister can indicate his priorities and expect the HSE to "have regard" to them. I am concerned that the phraseology of "have regard" is too weak. Hence, we tabled an amendment to strengthen the provision by saying that the annual service plan must be prepared "in accordance with" the priorities set by the Minister. Thus, we have inserted an automatic requirement that the priorities set by the Minister are adhered to.
Again, the amendment stems from the point of view that mental health services have traditionally been the poor relation in the health service. When the HSE operates throughout the year there is panic as to whether there is enough money for services such as accident and emergency and other services. Often mental health services are the first in line to have funding cut. It is important that the Minister takes responsibility for saying that mental health services should be given priority. The measure should evolve into an automatic requirement being placed on the HSE to act "in accordance with" that priority. It would ensure that money is safely ring-fenced for mental health services. It is not simply that the HSE must "have regard" to it which appears to be quite weak language.
I will respond to each of the amendments separately. I appreciate that the Senators are motivated by a concern to ensure that provisions are sufficiently robust to ensure that the HSE abides by priorities set by the Minister.
In regard to amendment No. 4, the Bill provides that the Minister may specify priorities to which the HSE must have regard in its service plan. The HSE must take heed of these priorities when preparing its service plan. Moreover, the Minister may direct the HSE to amend its service plan if the plan does not have sufficient regard to priorities and performance targets. I think that provision is sufficient to cover concerns.
In regard to amendment No. 21, I understand that the issue is whether particular terms in section 12 are strong enough to ensure that the HSE follows the Minister's directions. Section 12 amended section 31 of the Health Act 2004 which deals with how the HSE prepares and submits its service plan for the Minister's approval. Directions under section 31(3) relate to the form and manner in which the service plan is prepared.
Under section 31(4) a service plan must be prepared in a formal manner that is consistent with any direction under section 31(3). This seems appropriate wording and, therefore, I do not intend to accept amendments Nos. 4 and 21.
The purpose of amendment No. 24 is to delete the reference to policies in section 31(9)(d). The subsection provides that the Minister may, after consulting with the Minister for Children and Youth Affairs, direct the HSE to amend a draft service plan if, among other gaps, it "does not accord with the policies and objectives" of the two Ministers or the Government. A deletion of the term "policies" would mean that the subsection would then refer to "objectives" rather than "policies or objectives." Both terms are useful and I am also conscious of the term "policy or objective of the Minister or the Government", a term used consistently elsewhere in the Health Act 2004 and in this Bill. Therefore, I do not propose to accept the amendment.
I shall deal with amendments Nos. 22 and 23. I would like the opportunity to give further consideration to the amendments tabled by the Senators and, subject to legal advice, I may table related amendments on the service plan on Report Stage.
With regard to section 12, and subject to legal advice, I may table technical amendments to clarify the information given in the service plan about the number of employees.
I explained the rationale behind amendment No. 4 in my opening address. We are discussing the amendments together and the Minister gave his position on amendments Nos. 4 and 21 to 24, inclusive. All of the amendments are structured in the same way. They are about changing terminology and using stronger wording. Amendment No. 21 wishes to substitute the words "is consistent with" with "complies with."
I appreciate the Minister's undertaking that he will consider amendments Nos. 22 and 23 and we can discuss those on Committee Stage. I hope that when he reflects upon them that he will see the wisdom behind them. They are based on a critique of the Bill that was sent to me - as I am sure that it was to many other Members - by the mental health reform group. I am sure the same critique was also sent to the Minister and the Government. The amendments are based on the views of groups that have an intimate understanding of current issues and want them improved. I hope that when the Minister considers the amendments he will see they have merit. We can discuss the issue again on Report Stage and I withdraw amendments Nos. 22 and 23.
I wish to make a general comment on the amendments as Senator Power has already dealt with them.
I am concerned that some of the terminology used - and with respect to the officials - ensures that Sir Humphrey has control. When a Government policy and priorities exists then the State agency responsible has a statutory duty to comply with them, not merely to resemble the policy or priorities.
Terms like "consistent with" are very loose and when the Minister was in opposition he would have said such terms would give the Minister of the day plausible deniability. From the Minister's perspective such terms grant him a safeguard and an ability to blame the officials if something does not go to plan. My view - and our view - is that the Government of the day should set policies that are in line with the demands and needs of the people in terms of services. The relevant organisation must carry those out to the letter, not to the extent that the person of the day may feel that it is consistent with, resemble, or be to the fullest extent possible but they must "comply with" them. Particularly in the context of an organisation whose budget, under the new regime, will come from the Minister, it will have to be responsible for spending one of the largest portions of the tax take. In that context, whether it is Minister Reilly or another Minister from whatever party, now or in the future, there needs to be absolute control and input in order to stand over spending.
We do not want a future Committee of Public Accounts or Oireachtas Joint Committee on Health and Children to have an argument over whether a particular action was "consistent with" the policy or priorities of the Minister of the day as opposed to "complies with". I do not feel there is a level of plenipotentiary status that officials within a State agency should have which could supersede the Minister of the day or the policy or priorities he or she might have set.
Regarding amendment No. 4, the service plan is designed to take account of a number of matters and must include information on various issues. For example, it must indicate the type and volume of health and social services to be provided by the HSE during the period to which the plan relates. The proposed amendment could have unintended consequences with its emphasis on ministerial priorities given section 31 as a whole.
Regarding amendment No. 21, this is a direction on the form of the service plan and is a separate issue from a direction under section 10 which may relate to policy implementation. The current wording is clear. With regard to directions on policy implementation, the service plan must be consistent with any directions issued by the Minister under section 10. The Minister may direct the HSE to amend the draft service plan if it is not consistent with any directions issued under section 10.
Question: "That the words proposed to be deleted stand" put and declared carried.
Amendment declared lost.
Section 6 agreed to.
SECTION 7
Government amendment No. 5:
In page 6, line 18, to delete “ “PART 2A” and substitute the following:
“ “PART 3A”.
This is a technical drafting amendment to clarify that the new Part inserted in the Health Act 2004 in regard to the directorate is to be called Part 3A and not Part 2A. The numbering of the sections contained in this new part starts at 16A in order to follow section 16 of the Health Act 2004.
Amendment agreed to.
Amendments Nos. 6 to 8, inclusive, 10 and 20 are related. Amendment No. 9 is an alternative to amendment No. 8. Amendments Nos. 6 to 10, inclusive, and 20 may be discussed together by agreement. Is that agreed? Agreed.
Government amendment No. 6:
In page 6, line 30, to delete “Subject to subsection (3)” and substitute
“Subject to section 16K(10)”.
These are drafting amendments. Section 16A(3) states: "The Directorate may perform its functions notwithstanding a vacancy in the membership of the Directorate." Amendment No. 7 proposes to delete this subsection because section 16K(10), subject to amendment No. 20 captures the objective of providing that the directorate may continue perform its functions in the event of a vacancy even in the office of the director general or in the office of an appointed director. Amendment No. 20 would delete “act” and substitute “perform its functions” in section 16K(10).
Amendments Nos. 6, 8 and 10 are consequential technical amendments. I ask Members to accept amendments Nos. 6 to 8, inclusive, 10 and 20. I also wish to indicate that, subject to legal advice, I may table an amendment to clarify the provisions and arrangements for the director general or an appointed director who is absent for an extended period.
Amendment agreed to.
Government amendment No. 7:
In page 6, to delete lines 34 to 36.
Amendment agreed to.
Government amendment No. 8:
In page 6, line 37, to delete “(4) A person” and substitute “(3) A person”.
Amendment agreed to.
As amendment No. 8 has been agreed, amendment No. 9 cannot be moved.
Amendment No. 8 substituted “(3) A person” for “(4) A person” and the Minister is seeking legal advice. As I am not sure my amendment contradicts what the Minister has said, I seek to indulge the patience of the House. I sought to delete the section stating: "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." I am trying to facilitate the Minister in his reforms. Does this tie his hands unnecessarily? There could be a person who had experience as a private hospital manager, a health insurance company manager or, as the Minister mentioned earlier, somebody from Scandinavia. I put forward these thoughts. I know the Minister is seeking legal advice on the matter, but that was what I had in mind. In performing this important task the Minister's hands should not be tied. That is the spirit in which I offered amendment No. 9.
I appreciate the Senator's help and the sentiments.
It is redundant at this stage anyway.
The Chair has already ruled.
Amendment No. 9 not moved.
Government amendment No. 10:
In page 6, line 41, to delete “(5) An appointed” and substitute “(4) An appointed”.
Amendment agreed to.
Amendments Nos. 11 and 12 are related and may be discussed together by agreement. Is that agreed? Agreed.
I move amendment No. 11:
In page 6, between lines 45 and 46, to insert the following:
“(6) The post of Director for Mental Health shall be a publicly advertised position, subject to strict criteria.”.
The amendment has two purposes. The first is to ensure that one of the directors appointed will be a director for mental health. The second is to address, in the context of the mental health post, the issue Senator Barrett has just raised. It is bizarre that the Bill specifies that only individuals who are currently national directors in the HSE can be appointed as directors. There is a significant risk that the best person for the job might not be appointed for that reason. I do not know anything about the individuals serving as national directors or anything about their performance. However, it is bizarre to tie the Minister's hands in that way. The trend in public sector management in recent years has been to ensure there is external competition, particularly for top posts so that we can get the best person for the job.
Senator Barrett referred to somebody who might have delivered health service change elsewhere. In particular it would be crazy to exclude someone, who has experience of mental health services, from interviewing for the job. I do not understand the intention behind such restrictions in the Bill and I ask the Minister to reconsider. If the best person for the job is somebody who is currently serving as a national director, so be it. However, the Minister's hands should not be tied in that fashion. We need to ensure there is a proper competition so that people can have faith that the person appointed holds the expertise and experience required. This is one of the most important amendments we have tabled and I ask Members on the other side of the House to reflect on the wisdom of tying the Minister's hands and not having a proper open competition for key leadership posts in turning around the health service in general and in particular in the area of mental health, which needs leadership more than most areas in the health sector. It needs somebody with a passion for mental health and the ability to deliver real change.
Senator Power makes a compelling argument for her amendment. I would like to explore the issue further and perhaps the Minister might elaborate on it. I believe there is considerable merit in the proposal. While it might be somewhat premature to include it in this transitionary Bill, I ask the Minister to elaborate on it.
We will press the amendment to a vote. On Second Stage, I asked whether the Titanic, if it had been called the Olympic, would have stayed afloat. As Senator Power has said, while nobody is specifically saying that any of the current directors of the HSE are not capable, qualified or the best people for their various jobs, whether in mental health or in the other directorates, the reality is that we cannot stand over a process that effectively legislates to establish a new agency - a better structure - with the same people at the helm.
There will be no public confidence in the system. This is a charade if we are merely, to use the phrase used on Second Stage, "moving the deckchairs around the Titanic" or changing the name. Do we still want Captain E.J. Smith to steer the boat, expecting that his time it will skip around the iceberg? The reality is that the Minister will need to be able to stand over this process and to be exceptionally confident that "X" is the correct person to be the director of mental health services and so on. The process must be open and allow applications from other people.
The Minister stated there will be no expense incurred in putting in place this legislation. It is hoped that in order to avoid expense, a decision was made to have no recruitment process, which if not managed correctly can cost a significant amount of money, with everyone sliding into the various jobs, as was done in respect of Mr. O'Brien, CEO of the HSE. I do not think this gives rise to public confidence. I am not suggesting the people concerned would not sail through the recruitment process. However, it is in the public interest that the process is robust and transparent in terms of the appointment of people with the required experience and qualifications. This, in turn, will ensure the people appointed are assured of the people being behind them. This will not be the case in this regard. Regardless of how qualified those appointed are, confidence in them will be undermined by this process.
I agree that this matter should be looked at again. Senator Power has put forward a strong case on the issue. This relates to an issue previously highlighted by me, namely, financial management of the HSE. When we looked at this area we found that many people involved in financial management of the HSE did not have the financial management qualifications required. I am not suggesting that the person to be appointed does not have the relevant experience or qualifications. However, this proposal provides the Minister with an option that might not exist under the Bill as drafted. It is a proposal worthy of consideration.
I have a clear recollection of the reason this provision was included in the Bill, which is the following. This is a temporary arrangement. An open competition would have involved procurement issues and so on, which process could go on for six months. This is a temporary arrangement to carry us on to the next phase when the HSE is abolished in toto and we move to an integrated care agency. It does not preclude people from outside the current health family from involvement. They can apply for another role in the HSE and be appointed directors from that family.
I agree with the sentiment of what Senators' are saying. If we were legislating for an ongoing situation as opposed to a temporary structure, I agree there would be a need for open competition. Given the life of this agency will not be for more than three years, possibly less than this, the decision was made to expedite the process in a real way to allow reforms to be progressed quickly. We can come back to this on Report Stage if Senators wish, prior to which I will seek some legal advice on it. I am sure Senators will agree on the need for quick progression of the reforms and change in terms of how we do business. We also want to ensure accountability, transparency and that the patient is at the centre of everything we do. That is the rationale behind this, without going into the legal niceties in terms of the notes I have with me on this issue.
We are not happy with this provision. I do not believe the Minister is happy with it either. How long is a piece of string? Will it be in place for one, two, three or four years? We are all aware of the scenario that arose yesterday, with €329 million becoming €374 million in a month. People need confidence in this process. What is happening is that a new entity is being established with no change in personnel. Express parts of the legislation state that the only way one can qualify for the position is to have already held the position under the previous regime which did not work.
We will reflect on this between now and Report Stage. I ask that the Minister do likewise. I believe this is not in the public interest.
Amendment, by leave, withdrawn.
I move amendment No. 12:
In page 7, after line 46, to insert the following:
“16D.—The Director for Mental Health shall be responsible for planning, budgeting for and reporting on the implementation of mental health policy. His delegated functions shall include but are not limited to producing a multi-annual plan to implement the Government’s mental health policy; consulting with patients, their families and significant others and other stakeholders in relation to a mental health services reform implementation plan; producing annual service plans, approving mental health service area budgets, reporting regularly against performance indicators agreed with the Minister for Health and ensuring equity of resources between Mental Health Catchment Areas.”.
This is the most important of our series of amendments in that it seeks to ensure the appointment of a director of mental health and sets out the functions of such person. It is important these are set out in the Bill. The Bill as drafted refers to the appointment of between four and seven directors but does not state what will be their functions or responsibilities. We strongly believe there is a need for a director of mental health. A key recommendation of A Vision for Change is that a mental health directorate be established. This must happen. I do not understand the reason the Minister would not be willing to accept an amendment to the effect that there will be a director for mental health unless he is confident one will not be established. In legislating for such an appointment, it is important to set out the functions of that person. As such, the amendment specifies that the director for mental health would be responsible for producing a multi-annual plan to implement the Government's mental health policy, consulting with users of mental health services, their families, significant others and other stakeholders in relation to a mental health reform implementation plan.
Senator Gilroy has been going around the country consulting with people. We held a joint meeting two weeks ago to hear the views of the public in terms of their experience and that of their families in the area of mental health services. I was struck by the gap between what some of the service providers believe is happening and the experiences of people who have been through those services. It is important that the director would be specifically tasked with ensuring there is ongoing consultation with the users of mental health services and that this feeds into policy being subjected to external scrutiny. It should not be the case that families in difficulty are treated as customers subjected to an overall plan. There is a need to really listen to people and to allow change on the basis of proper feedback.
The other functions set out in the amendment include the need for annual service plans for the mental health sector and a specific budget for mental health services, which is key given the raiding this year of the mental health budget to support other areas of the health service. It is important there are performance indicators agreed with the Minister in this regard and that information in terms of the plan, where it is at, the budget in place and how it is being spent, outcomes for patients and so on are publicly available. It is also crucially important to ensure equity of resources between mental health catchment areas, which is a real problem now.
We strongly believe it is crucial this Bill follows through on A Vision for Change and ensures there will be a person specifically tasked within the directorate with provision of leadership for the mental health sector and that the statutory functions and responsibilities of this person are clearly set out in the Bill so as to ensure real implementation. That is what we need. We have a plan for the health services. There is broad agreement on the fact that A Vision for Change is a good plan. However, what we do not have is implementation. I am not convinced there will ever be real implementation unless a person with leadership responsibility is appointed and there is a clear reporting structure on each of the issues outlined. I hope that the Minister can accept the amendment.
There is nothing in this amendment that I could not support. It is a worthy proposal. However, it may be premature given we are in a transitionary period. While I support all that has been said by Senator Power, it is not relevant at this time.
The comments made on A Vision for Change are quite right. I remember some years ago I was involved in a literature review of various mental health policies at international level. A Vision for Change was certainly the best we could find at the time. I agree with Senator Power that we need a driver behind it because it will not be delivered without one. We are not speaking about establishing a new agency but reforming the existing one. Everybody would rather see the change expedited rather than prolonged and I hope we will get through this transitional period as quickly as possible and go through the procurement and interview processes required to find somebody for the role of mental health director for A Vision for Change.
To comment briefly on Senator MacSharry's fondness for nautical metaphors, I remind the House that the iceberg which sank the Titanic melted, as did one which sunk our economy which was called Fianna Fáil.
That will really help the sick people of Ireland.
As I outlined previously, the Bill provides that members of the directorate be drawn from HSE employees holding the grade of national director but does not specify individual national director posts. In tandem with the proposed new governance structures, new administrative structures will be put in place in the HSE to reflect the need for greater operational management focused on the delivery of key services and greater transparency of funding, service delivery and accountability. The planned director posts include a director of mental health. However, this is separate from the Bill. When performing their functions as members of the directorate, members will act collectively as part of the governing body of the HSE. This is distinct from their individual responsibilities as senior employees holding the grade of national director.
Given the overall structure of the Bill and its purpose, which is to abolish the board of the HSE and not abolish the HSE itself, I hope Senators will appreciate it would not be possible to accept these amendments and provide the level of specificity suggested with regard to a particular service area, notwithstanding the importance of this area. I do not propose to accept the amendments but I have listened carefully to what Senator Power has stated and I agree with her sentiments on the importance of mental health. We will have a director of mental health who will have control over his or her budget. The idea of these directorates is that the directors will have clear line of sight over their budgets and what happened previously will not happen again, whereby budgets and moneys were moved from one area to another after being voted for a specific purpose by the Houses of the Oireachtas.
Amendment put:
The Committee divided: Tá, 19; Níl, 29.
Tá
- Barrett, Sean D.
- Byrne, Thomas.
- Crown, John.
- Daly, Mark.
- Leyden, Terry.
- MacSharry, Marc.
- Mooney, Paschal.
- Mullen, Rónán.
- Norris, David.
- O'Donnell, Marie-Louise.
- O'Donovan, Denis.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- Power, Averil.
- Reilly, Kathryn.
- Walsh, Jim.
- White, Mary M.
- Wilson, Diarmuid.
- Zappone, Katherine.
Níl
- Bacik, Ivana.
- Bradford, Paul.
- Brennan, Terry.
- Burke, Colm.
- Clune, Deirdre.
- Coghlan, Paul.
- Comiskey, Michael.
- Conway, Martin.
- Cummins, Maurice.
- D'Arcy, Jim.
- D'Arcy, Michael.
- Gilroy, John.
- Harte, Jimmy.
- Hayden, Aideen.
- Heffernan, James.
- Henry, Imelda.
- Higgins, Lorraine.
- Keane, Cáit.
- Kelly, John.
- Landy, Denis.
- Moloney, Marie.
- Moran, Mary.
- Mulcahy, Tony.
- Mullins, Michael.
- Noone, Catherine.
- O'Keeffe, Susan.
- O'Neill, Pat.
- Sheahan, Tom.
- Whelan, John.
Tellers: Tá, Senators Marc MacSharry and Diarmuid Wilson; Níl, Senators Paul Coghlan and Aideen Hayden.
Amendment declared lost.
Amendments Nos. 13 and 14 are related and may be discussed together by agreement. Is that agreed? Agreed.
I move amendment No. 13:
In page 9, line 25, to delete "Subject to subsection (4),".
This is similar to the earlier scenario where we are saying that the recruitment of a director general and directors would be subject to the Public Service Management (Recruitment and Appointments) Act 2004 without being subject to subsection (4) and relates to the fact that people would automatically have to have been in the existing organisation before they can become directors of the new organisation.
The question of confidence in the process arises again. Given the difficulties that have arisen in the health service, it is a question of integrity and ensuring the peace of mind of the director. While I am sure the candidate's qualifications and experience will be such that he will sail through the process, the public has an entitlement that must borne in mind.
I will be happy to listen to the Minister's response. While we intend to withdraw the amendment, I ask the Minister to reflect on the matter between now and Report Stage. We must return to this on Report Stage in the interest of the public. Neither the public interest nor that of the Minister will be served if we put this provision into law temporarily. This also applies to the provision the Minister said he would reflect on between now and Report Stage. With respect to the Parliamentary Counsel people can credibly and justifiably say the legislation is a charade and means nothing.
Those Senators who wish to engage in conversation should do so outside the Chamber.
With this provision, the programme for Government is once again torn to pieces. The amendment my colleague seeks to make merely seeks to implement what is in the programme for Government. The Senator is asking that "subject to subsection (4)" be deleted. The subsection means a public competition does not have to take place in respect of the job. Where is the new politics and open government? Where is the programme for Government to which the Government solemnly committed before the people? Where is the change that people expected? The programme for Government stated all appointments above principal officer level should be subject to open competition. This Bill makes an utter mockery of that.
How does the public know it is getting the best possible person for the position? Quite simply, it does not. All it knows is that the Minister appointed a person of his own volition and that nobody else was involved in making the decision. This is wrong. The Government promised to change this process but has failed to do so. That is exactly what is driving the public mad. It expected new politics and new methods of public administration. It is not getting them in this Bill, particularly in this section.
We were doing well until Senator Byrne arrived.
Am I supposed to agree with everything?
The point we are making is the same as the one we made on amendments Nos. 11 and 12. The transitional nature of the Bill requires that we move fast. Senator MacSharry's amendment does nothing to expedite the change we all desire. The legislation is transitional, and the legislation for the establishment of a new board and to bring about the reform we all desire is coming down the road. Senator Power mentioned a period of three years, but this is not a target so much as the deadline. I am confident that the Government can deliver the necessary change well within that period. Stating the Government has broken pledges in the programme for Government is irrelevant to this Bill. I am sure the Minister will have a few words to say in this regard also.
I could easily start by saying we all know what drives the public mad. What has driven it mad is our financial sovereignty being handed over to a troika due to the actions of the previous Government. Let us call a spade a spade.
A number of issues arise. This Bill is an interim measure on the way to the abolition of the HSE. I refer to an interim structure at the top of the HSE to replace the board. It is to give a clear line of sight.
I wonder how many takers one would get for an interim position that certainly will not last any longer than three years and particularly for the salary in question, given that the previous incumbent was on €320,000 per annum plus a car allowance of €25,000. The director-general designate is on €195,000. This represents a considerable saving for the taxpayer.
We are very fortunate to have someone of the calibre of the gentleman concerned agreeing to take the post. I have absolute confidence in him, the Secretary General of the Department of Health and the new leadership of the VHI. These represent the three legs of the stool that comprise our health service. It is terribly important that all three interact in a meaningful, coherent way to address the cost base of the service, which is clearly too high. This was not addressed heretofore but it is now being addressed. As the House knows, new arrangements were agreed at the LRC talks by consultants and these will have a major benefit.
Section 16E provides for the appointment of the director general. Under subsection (4), the first director general is appointed by the Minister. This is not something that has not happened before. Subsequent directors general will be appointed by the Minister following a recruitment process under the Public Service Management (Recruitment and Appointments) Act 2004. There are legislative precedents providing that the first person appointed to a new office be appointed as envisaged under subsection (4). The use of this provision is the most practical way to advance the new directorate's arrangements. I do not, therefore, intend to accept the amendments.
It is important at a time of change that there be some sense of direction and that people have some certainty about who is in charge. Having the director designate in position to walk into the job achieves this comprehensively. The people in the HSE now know where the new leadership lies and they are rowing in behind it. I welcome that.
The view expressed by the Minister that nobody can be found to run the health service for €195,000 per year for three years is beyond belief, ludicrous and untrue. The Minister has not even tried to engage in a public appointments process. In one case in which there was a public appointments process, the candidate ultimately selected was unable to take up the position. In this case, however, the Minister has not even tried. He just appointed somebody whom he knows. I am sure the person in question is well respected – I have no doubt about that – but that is not the point. The Government parties committed in the programme for Government to a new type of politics, with the consequence that positions such as the one in question would be open to competitive tender. There may well be other talented people who would be better for the job. However, we do not know because the competition has not taken place. The Minister has ridden roughshod over the programme for Government. He promised new politics but failed to deliver. The Minister can huff and puff all he likes-----
The Minister signed up for a programme for Government but this legislation goes directly against its provisions. I do not understand how the Labour Party, which is so concerned about the programme for Government, and Fine Gael can let this occur and laugh it off. The public is not laughing it off.
The Minister talked about blame and suggested what the public is angry about. The public is angry with a number of different parties. We can start debating those issues if the Minister wants. I will be more than happy to do so because some brickbats that are thrown by Fine Gael towards us would have me suggest that some people should look in the mirror.
Let us stick to the amendment.
We had an opportunity on Second Stage to get stuck in politically. There is a private Members' debate later in which I am sure none of us will be holding back, but I do not want any of us to lose sight of the fact that nobody is saying the current appointee is not suitable for the job in the context of this legislation. I may have points to make in this regard during the Private Members' debate later, but that is a different matter.
The public needs to have confidence in the process. We cannot have confidence in a process that sets up a new organisation with existing staff. While I have used Titanic metaphors, this is a question of people having confidence and those inside the organisation having peace of mind from knowing that they have come through a robust process unaided. How long will a person be in that position? When it ceases to be temporary, will he or she be required to go through a recruitment process or will another exception be included in the legislation in respect of the first director general and directors? The latter instance would be wrong. It is an insult to people to state that someone will struggle along on €195,000. For those who are lucky enough to have a job, the average industrial wage is low.
I will give an advance taster of this evening's Private Members' business. The previous Administration in its wisdom did not make me the Minister for Health and Children. I am not responsible for that policy. This is a new day.
The Senator supported the policies.
As the distinguished former Minister and Leader, Mrs. Mary O'Rourke, often and clearly stated, that was then and this is now. I was not in government. I made no policy. When I make a point on legislation or issues, it is credible, as it is being made by someone who has been elected in a new time and on the current Minister's watch. Regardless of how badly the game may have been played at different times or on different pitches over the years, there is little point in examining last season's matches to assess today's game.
I will not push the amendment to a vote, but we will vote all day on Report Stage unless the Fianna Fáil group can exit this Chamber knowing that, although the same people may be on the board, they will be selected via a process in which the people can have confidence, one that proves there was no one better to do the job in these difficult times. We owe it to people to ensure this happens, given the fact that a deficit of €45 million is being clocked up each month.
I would like an opportunity to respond to some of the Senators' comments. In fairness to Senator Byrne, he was not present for the early part of the debate. Perhaps he did not hear the arguments.
I was attending the finance committee.
I do not know where the Minister was. He could not be found by the media for a number of days.
Please, could we avoid personalising this debate?
The Minister personalised it in respect of me. I was attending the Oireachtas finance committee.
No. I merely pointed out that the Senator was not present to hear the argument.
There was an implication.
I stated, "In fairness to", but the Senator is so scratchy and itchy, he just wants to row no matter what.
I am trying to point out that this is not a new organisation, but a reorganisation of the top of the existing organisation. This is not the abolition of the HSE, but of the board of the HSE. I am sure Senator MacSharry will agree that I did not claim that anyone would struggle on €195,000 per year. I clarified that it was a saving to the taxpayer. I also pointed out-----
The Minister stated that we would be lucky to find someone for that money.
No, I stated that we were lucky to have someone so good. One might not be able to find many people who are prepared to enter into a three-year contract. The time may be even less, depending on the rate of progress with the interim care agency, which is planned to replace the HSE.
Amendment, by leave, withdrawn.
Amendment No. 14 not moved.
I move amendment No. 15:
In page 10, line 26, after "opinion," to insert the following:
"such opinion being corroborated by independent written medical advice,".
Speaking from a legal point of view, the section is correctly drafted and the amendment could cause legal problems. If a person refused to appear for the medical assessment, which he or she would be entitled to do, the Minister's hands could be tied. The Minister has made adequate provision, as the Bill states: "in the Minister’s opinion, the person has become incapable through ill-health." No Minister will let someone go without adequate evidence. If a person was let go because the Minister's opinion was that he or she had a medical complaint, the courts would find in favour of the party who was forced to retire unless the Minister produced copper-fastened evidence. The amendment would cause major complications and tie the Minister into producing medical evidence. Without that evidence, the Minister would not be able to take necessary action. I will not support the amendment.
Implicit in the section is what the amendment proposes. The amendment touches on being tautological.
I accept what Senator MacSharry is trying to do in terms of the perception of safeguarding the employee, but there are many examples in legislation of removing someone from office when, in the opinion of the body or person responsible for the matter, the officeholder has become incapable through ill health of effectively performing his or her duty. The Bill's provision is based on these examples and I fail to see the need to go further than is usual. As Senator Burke pointed out, the amendment could have unforeseen consequences. The Bill's provision is a standard legislative measure throughout Departments and I do not propose to accept the amendment.
Amendment, by leave, withdrawn.
Amendments Nos. 16 and 17 are related and may be discussed together. Is that agreed? Agreed.
Government amendment No. 16:
In page 12, to delete lines 9 to 15 and substitute the following:
"(b) where and to the extent specified in a delegation made under paragraph (a), authorise the subdelegation of any or all of the functions delegated under paragraph (a) to or by other employees of the Executive.".
These are technical drafting amendments on the subdelegation of functions within the HSE and I ask Senators to accept them.
Amendment agreed to.
Amendment agreed to.
Government amendment No. 17:
In page 12, to delete lines 31 to 34 and substitute the following:
"(a) vary any delegation or subdelegation of a function made under this section, including by modifying the geographical area to which the delegation or subdelegation relates,".
Amendments Nos. 18 and 19 are related and may be discussed together. Is that agreed? Agreed.
I move amendment No. 18:
In page 13, line 17, to delete ", or is likely to be".
This amendment is to delete ", or is likely to be" from the line "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". I tabled my amendment long before yesterday's events at the Committee of Public Accounts. I appreciate the sub judice rule, but I know of no other "likely to be" sub judice provision. The Bill's provision could allow people not to answer questions, something that seemed to annoy many of our colleagues yesterday. Is there anything in law that allows one to refuse to answer a question because it is likely to be sub judice? Is there a burden of proof on the person using that defence at an Oireachtas committee or can he or she just shrug his or her shoulders, claim the issue might arise again and not answer? The spirit of the amendment is to solve a serious problem. We do not want to give people easy reasons to avoid answering questions at Oireachtas committees.
That deals with the first amendment.
Amendment No. 19 seeks to delete: "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 in a democracy and are in a position where we have had to be rescued by the IMF. Silencing people, including this director general, is not appropriate. I welcome the discussion we are having this afternoon. Let us all have the ideas. No one is so precious as to be able to claim he or she is precluded by law from discussing 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". It is draconian in a democracy. If we had all the answers, we would not be in the position in which we find ourselves of trying to solve them with all the reforms we are carrying out. I welcome everyone's views and I hope the Members of the House would consider deleting that subsection along with what I regard as an extreme version of the sub judice defence mentioned in amendment No. 18.
We certainly agree with amendment No 18. It appears Sir Humphrey inserted this provision. It is the out clause for the committee that the lads attending the Committee of Public Accounts yesterday might have liked to have had, but unfortunately it does not and should not exist in law, as far as I can see. Who knows what might come before a court or be the subject of a legal issue.
However, I do not agree with amendment No. 19. I would like the director general to be very robust in the context of the Minister's office in challenging policy which he or she might disagree with or felt was not in the best interest. However, I do not believe he or she should voice opposition to a particular policy in the public domain if heading up the agency to carry out the directions of the Government of the day. One would hope and expect that voicing disagreement often happens in the confines of the Minister's private office, but not elsewhere.
Amendment No. 18 is worth exploring more and I would be anxious to hear the Minister's comments. Surprisingly, I agree with Senator MacSharry's comments on amendment No. 19.
It is rather remarkable in that regard. It would be a recipe for chaos for the director general to be publicly at odds with the policy of his or her own Department. I would like to hear something more about amendment No. 18.
I acknowledge that this section copies section 21 of the Health Act 2004, as I understand it. However, I do not agree with the provision and I am not sure it has been invoked up to now. I would hope that it would not be invoked under any circumstances because I believe an Oireachtas committee can make its own determination as to what is or is not sub judice. This option for the director general should not be included. It would be reforming if this were removed in its entirety to allow the director general to be answerable to the Oireachtas. I would hope the procedure of going to the High Court would not be invoked. It has not been up to now under the old Act and this is very similar to that provision. There is merit to Senator Barrett's point on the sub judice rule, which has not been noticed up to now. Credit is due to the Senator for spotting it and his amendment should be supported.
I would go further and oppose the entire section which is not good and should be changed. It should not be left the way it is for the sake of it. As we saw yesterday, there certainly was disagreement between Members and officials as to what could and could not be discussed. The Member was not looking for the officials to go into policy. Although they responded that they were precluded from talking about policy, I do not believe they were being questioned about policy but about the operation of the health budget.
I disagree with the Senator on Government policy. It is not the function of public servants to advocate policy one way or another when it has not already been decided. It is a matter for Ministers and for Oireachtas Members and I would be happy for that to continue. That would place an intolerable burden on public servants who are supposed to be and are neutral. They would not want that burden. The Minister and the Government should be accountable for policy and not public servants.
The provision relating to amendment No. 18 is: "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." This is found in much other legislation, as it would be important not to interfere with the integrity of any future court proceedings as well as to protect the integrity of any current court proceedings. The phrase "is likely to" is designed to narrow matters down in the context of possible future proceedings. The new section 16I(6), as inserted by the Bill, provides for an application to the High Court by the director general or the committee to determine whether the director general is required to give an account to the Oireachtas committee. This is widespread throughout Departments and State agencies.
On amendment No. 19, the subsection concerned is located in a general section dealing with the attendance of the director general before Oireachtas committees. It is in that context that the subsection is enacted. Senators will notice that subsection (9) begins with the words: "In carrying out his or her duties under this section". It is not an attempt to prohibit or censor the director general in any way but to delineate the position of the director general when he or she appears before an Oireachtas committee.
If one were to accept the amendment and delete the provision, as proposed by Senator Barrett, an Oireachtas committee would be free to ask the director general about matters of policy and his or her agreement or disagreement with it, and he or she would be obliged to answer. Matters of policy are properly the domain of Ministers and the Government, as other Senators have pointed out. It would not be appropriate for a representative of the HSE to comment on policy matters. To ask a director general such a question would compromise his or her ability to properly serve the elected Government of the day and would also compromise the ability of the Government to have a working relationship with the director general, who has a pivotal role under this legislation in the planning and execution of policy in regard to health matters. This type of provision is standard in legislation setting up State bodies.
Therefore, I cannot accept these amendments. I agree with the Senators who have pointed to the chaos that would result if public servants had to decide on whether they agreed with policies and argue with the Government of the day which is elected by the people to implement its policies.
I thank the Senators for their views on these amendments. It is a pity that the occurrence of "or is likely to be" is widespread in legislation. We are facing a problem when so much public administration has failed. It gives a defence against answering questions and a considerable amount is wrong. While I do not have a background in the health service, in the area of economics, during the period we got into trouble, where on earth were highly paid people in the Central Bank, the Department of Finance, and the accountancy and other regulatory bodies who were supposed to be regulating banks? The Government is introducing whistleblower legislation, but we must assist them so that bodies that have failed cannot use opt-out clauses to stop discussing policy. We have spent four years trying to find out what on earth the aforementioned bodies were doing in the damage they did for the economy, which also has implications for the health service. I would hope we would move towards more answering of questions and less closed public administration. The current system is not serving the country.
It could be said that the public face of Government was easily solved because we had an election, following which one of the Government parties, which had been in power for the best part of 80 years, was reduced from 78 to 20 seats.
There is concern that the permanent Government remains, is largely exempt from the consequences of failed advice and bad policies, continues to opt-out on the basis of freedom of information defences, does not write anything down lest a journalist might discover it and so on. We need a new culture of administration and not only in the area of health.
I accept what the Minister said. However, our public administration has failed people. The political element of failure has been dealt with by the public. We now need to reform the way in which we do our public business. I will withdraw the amendment based on what the Minister had to say. However, I believe we have a wider cultural problem in Irish public service, to which I have tried to draw attention in my amendments.
I would like to comment on the amendments before they are withdrawn. We have been told that this is a striking blow for more accountability, openness and transparency in the health service. However, what we are getting in terms of the section under discussion is the same legislative provisions as heretofore in terms of accountability and the delegation of functions down the chain away from the Minister and director general. That is the sum total of the change, which does not say much for this legislation. One wonders why bother to introduce it.
In regard to devolution of powers, this has been the cornerstone of this Government's policy. We want local people to have the say over their services. This is the reason for the establishment of hospital groups. We will shortly be publishing a document on hospital groups and on small hospital frameworks. I cite the situation in Galway following the appointment last January of Mr. Bill Maher to run Galway University Hospital, Merlin Park Hospital and Roscommon and Portiuncula hospitals. Mr. Maher has ensured a substantial increase in footfall at Roscommon Hospital, with the addition of new facilities and services, including plastic surgery and ruhematology services. There is also a commitment to build a new colonoscopy unit there. Furthermore, when Mr. Maher took over there were 9,901 people who, had they not been treated by September, would have been waiting a year or longer for treatment. The current figure in this regard is zero. Also, when Mr. Meagher took over the number of people on trolleys was between 40 and 50 per day. That average figure in this regard is now seven.
There is more work to be done. However, devolving power locally gives people autonomy over their budgets. I want to see them given autonomy over their recruitment and procurement, albeit done with a mind to central information so that we get the best deal. That is what delegation is all about. I have seen this work already in the example given. There are other examples also.
I thank Senator Barrett for his contribution and his clear sentiment towards expediting the reforms we are all so keen to see come about. I thank him also for withdrawing his amendments.
I am delighted to hear the good news story outlined by the Minister. However, this was done under the Health Act 2004, which begs the question as to what is the purpose of this legislation.
Further reform and more powers are needed. Much more can be achieved with further devolution to local management in respect of their hospitals.
Amendment, by leave, withdrawn.
Amendment No. 19 not moved.
Amendment No. 20 has been already discussed with amendment No. 6.
Government amendment No. 20:
In page 15, line 39, to delete “act” and substitute “perform its functions”.
Section 7, as amended, agreed to.
Sections 8 to 11, inclusive, agreed to.
Amendment agreed to.
SECTION 12
I move amendment No. 21:
In page 18, line 42, to delete "is consistent with" and substitute "complies with".
Question, "That the words proposed to be deleted stand", put and declared carried.
Amendment declared lost.
Amendments Nos. 22 and 23 not moved.
I move amendment No. 24:
In page 20, line 22, to delete "policies and".
Perhaps the Minister will consider a small adjustment for Report Stage. It is proposed to delete where it does not accord with "policies and" objectives of the Minister. We should discuss "policies". One would appreciate that everybody involved has the objective of extending healthiness, life spans and so on. Some people might believe this is best done at GP level and others believe it might best be done at hospital level. We can differ. We can discuss "policies" without disputing the Minister's objectives, which is exactly what we are doing this afternoon. We share the Minister's objectives. I do not foresee any difficulty where people have different ways of achieving those objectives. In contrast to what I was describing earlier about economists who sat around in public employment when this country got into trouble, debate goes on all the time and is most refreshing, stimulating and wonderful. Let us not rule anything out because in such a context we would be discussing policy.
If somebody disputes the Minister's objectives, he is right to oppose. However, I do not believe the issue of people having different policies towards his objectives should be a major deal in this legislation. That is the spirit in which I proposed this amendment.
While I allowed the Senator some latitude in terms of speaking to this amendment, it has already been discussed with an earlier group of amendments. I will allow a brief comment from the Minister if he wishes.
We have already discussed the matter.
Section 12 agreed to.
Amendment, by leave, withdrawn.
Sections 13 to 16, inclusive, agreed to.
SECTION 17
I move amendment No. 25:
In page 22, lines 42 to 44, to delete all words from and including ", in" in line 42 down to and including "to" in line 44 and in page 23 to delete lines 1 and 2 and substitute "have professional qualifications in auditing.".
This relates to a consideration expressed earlier by Senator Burke. He is probably better equipped to deal with this matter than I. The amendment proposes that those who are engaged in auditing should have professional qualifications. We are seeking to assist the Minister in terms of the new role of the audit committees. The Minister may be able to reassure us that this is already the situation or is what he has in mind.
The section as drafted provides for the appointment of not fewer than four people who have the relevant skills and experience to perform the functions of the audit committee established under the Bill. These functions include advising the Director General on financial matters relating to his or her functions, risk management and other related matters. I understand the Senator’s purpose and logic in bringing forward this amendment. However, in view of the committees overall functions, I am anxious not to limit the criteria for membership and consider that the particular qualifications set out in the Senator’s proposed amendment are encompassed in the current wording which refers to relevant skills and experience. I, therefore, do not propose to accept the amendment.
In regard to section 17 which provides for the audit committee, I would, however, like to indicate that I may be bringing some technical amendments on Report Stage to clarify a reference to risk management and some other arrangements in relation to the committee.
I thank the Minister and look forward to hearing what he has to say on these matters on Report Stage. It is important this onerous task, in a sector wherein there was a tradition of auditing not being done by professional people, is undertaken by those with the best skills.
In other fields, such as banking, the accounts were not very reliable either and those people had professional qualifications. As it has been a problem in the health service which has drawn the attention of the Comptroller and Auditor General on many occasions, I will support the Minister in whatever measures he has in mind. The very large health budget should be properly audited and perhaps we can examine this again on Report Stage.
Amendment, by leave, withdrawn.
Section 17 agreed to.
Sections 18 to 22, inclusive, agreed to.
NEW SECTION
I move amendment No. 26:
In page 27, before section 23, but in Part 2, to insert the following new section:
"23.—Any officer/employee of the Executive shall be tax resident in Ireland for the duration of his or her employment with/by the Executive.".
This amendment has been tabled to highlight an issue about which the Taoiseach expressed concern in the Dáil. Deputy Micheál Martin raised the issue of external consultancies providing legitimate tax avoidance for special advisers to the Minister for Health. Two UK companies are involved but I will not name them as they are doing something which is utterly lawful and allowed. They provide consultancy services to the Minister for what is effectively the role of a special adviser. An individual person has been chosen by the Minister to give him advice. We have always had issues with special advisers, as did the Government when we were in government and we appointed them.
In this case the special advisers have been based abroad and have established consultancy companies or provide advice through such companies abroad. This gives them a legitimate tax benefit. Deputy Martin raised this with the Taoiseach who stated he would speak to the Minister about the issue. Deputy Martin stated it will add to cynicism and scepticism among the public if this means of procurement and utilisation of consultancies by the Minister and his advisers is allowed to continue. The practice is unlawful in Ireland and special advisers based here would not be allowed to do it under tax law. It is a retrograde step.
I may well withdraw the amendment and return to it on Report Stage. I accept the amendment may not have the exact effect I intend because some of these advisers are not employees of the HSE but employees of the Minister or the Government. However, it is an issue worth highlighting because of the tax saving in the order of €250,000, an amount which would have a significant effect on the budget of many hospitals. It would pay for a number of home helps or nurses. The issue should be addressed. In the Dáil, the Taoiseach replied to Deputy Martin that he would raise the matter with members of the Government, that he did not believe it was acceptable to have consultants involved in work if it had the effect described, that he would certainly raise the issue with the Minister and that he would revert to the Deputy. I am now raising the issue with the Minister to see whether any improvement in the situation has been made.
I call Senator Burke but I do not expect him to answer the questions asked by Senator Byrne. The Minister will speak afterwards.
I have a difficulty with the definition of "officer/employee". The amendment would not apply to someone who was contracted. I do not believe the amendment would be in compliance with EU regulations on the freedom of movement of workers. Locum consultants work in hospitals from time to time because no one else is available. Even if they work in Ireland for only a month and are not normally resident here, they must pay the full amount of tax which is deducted at source. For the past two years if a medical consultant employs someone to carry out locum work, the Revenue Commissioners insist the medical consultants who subcontract such work must deduct and pay the tax while it is up to the person who does the locum work to claim back the money. I understand the point being made by Senator Byrne but perhaps the issue should be examined with regard to tax rather than health care.
These individuals are not advisers to me; they are advisers and consultants to the special delivery unit. In the broader sense, employees of the HSE are subject to the same taxation arrangements as other employees working in Ireland. As Senator Burke stated, taxation arrangements are not appropriate to the Bill and therefore I will not accept the amendment.
The special delivery unit is not an outside body. It is a fundamental part of the Department which the Minister established. The individuals who have benefited from these legal arrangements were selected by the Minister and he has publicly praised them for their expertise. Along with Mr. O'Brien, he stated the State is lucky to have their expertise. The Minister did not employ their companies but quite legitimately they used companies in foreign jurisdictions to reduce their tax liability, a practice which I understand would not be allowed if they were resident in this country. This is the point I am trying to make.
Neither the Minister nor Senator Burke has dealt with the serious issues which have been raised by Fianna Fáil and at least considered by the Taoiseach as something worthy of raising with the Minister and the Minister for Finance. We should put a stop to it. The €250,000 could go a long way in certain services. It would not be a panacea for the entire health service. However, it adds to public scepticism and cynicism. On the day we have seen what I believe is the longest list on record of patients waiting on trolleys in Our Lady of Lourdes Hospital, people do not have much confidence in the special delivery unit and neither do I.
This raises a major point which we do need to address, namely, the tax avoidance industry. As Senator Burke stated, it may be more appropriate to finance legislation, but the Minister for Social Protection, Deputy Joan Burton, was particularly keen on targeting this when she was in opposition. A major scandal emerged in the UK where the head of the student grants agency had such an arrangement and was engaging in what is called tax avoidance, which deprives the Exchequer of large amounts of money. It is distinguished by an entire body of tax lawyers and accountants from tax evasion, which is criminal. At all times the Government should be against these tax avoidance schemes.
The Carter commission in Canada argued for the simple rule that a dollar is a dollar is a dollar and if it has purchasing power it should be taxable, regardless of the source. It is also an issue in the United States in that one of the presidential candidates because of his sources of income probably pays approximately 13% income tax, which is much lower than the average worker in the health service.
The amendment is sounding a caution. The Leader wants to discuss these issues in a pre-budget debate, but tax avoidance schemes such as this got away scot-free in last year's budget while special needs assistants and others doing important work did not. It is very important that the issue is raised now and perhaps the Minister will bring it to the attention of his Cabinet colleagues.
This is an illegal tax avoidance scheme in this country but legal in Britain and this is the issue I am trying to highlight. I am happy to withdraw the amendment, reformulate it to address some of the concerns raised and re-introduce it on Report Stage.
Does the Minister wish to comment?
Normally I receive on my phone information on the highest numbers of people on trolleys every day but I do not have them today. Yesterday 45 people were on trolleys in Our Lady of Lourdes Hospital. In the past the number has reached above 50 so to say it is the highest is not accurate.
In January last year we had 569 people on trolleys throughout the country and today the number is approximately 230. Last year it was 330 so it is now 100 fewer. Let us examine what the special delivery unit has achieved along with the clinical programmes and the front-line staff. It is fair to say the unit had a very good conversation with those working in the hospital alluded to by Senator Byrne. It asked what they felt needed to be done and introduced a range of initiatives involving home help, home care and teams to give intravenous antibiotics at home. More long-term and acute beds were opened and they undertook to conduct a capacity study, which showed a capacity issue had arisen so more beds were opened as a consequence.
None the less, there is no question that this hospital remains a problem, and there is a need for support for the management there because not alone has it the worst record with regard to patients on trolleys, it also has one of the highest rates of absenteeism. Let us look at what it has achieved because we do not say it often enough. There has been an 85% reduction in the number of people waiting a year or longer for an inpatient procedure. There has been a 63% reduction in the number of people waiting nine months or longer for an inpatient procedure. There has been an 18% reduction in those waiting three months or longer. They are real measurable improvements and signs of progress that have come about because of a focus by the special delivery unit, SDU, in conjunction with the clinical programmes and the front line which is doing sterling work. There has also been a 22% reduction in total in the number of people on trolleys. That equates to more than 13,400 people who do not have to endure being on trolleys.
We should bear in mind that it was only a year ago in January that 569 people were on trolleys despite billions being spent on the health service. We are not looking at inputs all the time anymore. We are looking at outcomes for patients as measured by those who have to wait three months, nine months or a year, or those who have to wait on trolleys or have to be re-admitted. We are looking at outcomes for patients in terms of the stroke programme, which is now saving one life per week and avoiding three other people having to go into long-term care. They are Irish citizens, our people, our friends and people in our communities. They are real. That is what the SDU has been able to achieve in conjunction with the clinical programmes.
I will mention some of the things that have been done. For the first time in this country, there is now an accurate figure for outpatient waiting times. There is an attempt to say they doubled from April to last month when in fact only half the hospitals had been counted in April. Nearly all of them have been counted and there are only about two more to go. We reckon the full figure will be 360,000. That seems like an insurmountable figure but it is not if one thinks that more than 200,000 people are treated every month in outpatient departments. We are not afraid to have clarity around these matters, identify the problems and address them in conjunction with those in the service. We will do that. We had a very good debate in the House a couple of weeks back in respect of this.
In respect of this issue, the SDU has had a remarkable effect on our health service, has brought the focus back to where it should be - on the patient - and, for the first time, has enabled the front line to do the work it wants to do and grow the self-belief again that it can handle this challenge and do what we all want to see done. This is to have a health service that is equitable and accessible for everyone, not just those who can afford to go privately.
I will withdraw the amendment. I will bring it back on the tax issue, which is a serious one. I raised the trolley issue and the Minister came back with an answer. If I am not correct with regard to that figure, I will take it back because the figure was not from the Irish Nurses and Midwives Organisation. It was given to me today by a person concerned with that area. I accept that this is not the figure on the INMO website. Obviously, it is an ongoing issue. I will withdraw the amendment but bring it back on Report Stage.
Amendment, by leave, withdrawn.
Section 23 agreed to.
Title agreed to.
Bill reported with amendments.
When is it proposed to take Report Stage?
Report Stage ordered for Tuesday, 16 October 2012.
