Bernard Durkan (Kildare North, Fine Gael) | Oireachtas source

I am glad to have an opportunity to speak on this very important subject. I must confess that I do not possess any expertise on any subject, least of all this particular subject. However, I have spent on nigh on 20 years as a member of a very large health board. I heard all the arguments before, and you heard them as well, a Cheann Chomhairle. Every Member of this House has heard the expert opinion on all sides, each deemed to be the ultimate in expertise, each having found out eventually to be wrong, and that is the sad part about it. The situation in which we found ourselves was how to deliver a comprehensive, effective, modern, reliable and safe health service in a situation where we have 10% fewer staff and 10% less money. I have not heard anybody from that side of the House suggest how that was going to be done. In actual fact, every single contribution, with the exception of Deputy Mathews, did not suggest the spending of more money, which is unusual coming from the Opposition side of the House, but is not unique.

The challenge is how to deliver the services. I would be very concerned that we are reaching a situation whereby we are rummaging around looking for the right answer, and we have to find it whether we like it or not. I remember many years ago when were compared to Calderdale in Greater Manchester, which has a population similar to this country and where it was deemed that a single health structure was the ideal way to deliver the services. I did not believe that at the time because there is no comparison between the length and breadth of this jurisdiction and an area that somebody can walk across in a couple of hours. Therefore, the two areas are not comparable at all.

We need to have a system that is accessible. We need to have a system that does not have people on waiting lists interminably. I disagree entirely with Deputy Shortall. There have been huge improvements in waiting times for particular services. In the past people were waiting for up to four years for a hip replacement, and nobody seemed to understand that the patient was suffering extreme pain during the course of that waiting period. Very few people realise this, except the patient. I remember dealing a few years ago with a patient who was waiting for a hip replacement. I am sure it was a great consolation to the unfortunate patient to be told "You are on a list, we will eventually get to you." However, when something else comes in of an emergency nature in the meantime, that list is lengthened considerably and the wait goes on.

In the old days of the health board system, the three key areas were the delivery of the general medical services, the delivery of the mental health services and the delivery of community care. There were programme managers who were responsible, whether we liked it or not, to the public representatives who were elected by the public. We had access to that. The health board system was set up in 1970, and critics at the time said that the old county health board system was better. We inherited that system from the previous administrators in this State. Maybe there were good aspects to it and maybe there were not.

During that period, I saw some things in various hospitals throughout the country, including mental hospitals, that were embarrassing, to say the least. If anybody suggests to me that system was better, he should realise it was not.

What happened next was that we tried to adjust, change and modernise. A great deal of work was done on this. The problem was that every time we did such work, it was presumed we could do better than before by changing the system. The challenge now is essentially a management one. It is a question of determining how we manage the system we have to deliver the required services to the population, with its various demographic characteristics, efficiently, effectively, reliably and safely. It is a management challenge. Everybody has his own view but the fact of the matter is that somebody must deliver the change.

When the HSE was established I remember asking Professor Brendan Drumm whether he believed the HSE concept, that of a single structure to develop the health services nationally, was the ideal one. I remember his reply well: "I don't know". He does now, as does everybody else. He had to wait and see. Professor Drumm genuinely did not know the outcome. I was totally opposed to the proposal at the time because I felt it could not work based on the little bit of knowledge I had. I had no expertise at all but believed it simply would not work.

When the good people who are now absent from this Chamber decided to change the system, they introduced the HSE to replace the health boards. Previously the number of health boards had increased from eight to nine, and then to 11, and then reduced to eight, each time incurring administration costs. Eventually, it was decided to have a single structure. We then heard how difficult that would be to achieve. The number of staff increased by approximately 60,000 over a couple of years during the boom, when the Celtic tiger was roaming the land looking for prey.

What really happened was that the HSE began to show creaks in its structure straightaway. Delivery could not be possible under that kind of structure. There are managers within the health service who are criticised regularly - they are in our respective areas - but who are well capable of running the system. They know how it needs to work. They know how to proceed and could do so effectively, efficiently and cost-effectively, which is important at present. Generally, they comprise people from the old system who taught those in the new system. They need some kind of support and for somebody to tell them they can do what is desired and what the structure will be.

The proposal to dissolve the HSE is the correct one. The HSE was not accountable and it was independent. It was roaming around itself and it was a satellite of the Department of Health. Any new system would be better than that. I would like to see a system involving restructuring of the old health boards but with fewer boards and a single board of administration accountable to this House.

I remember sitting on the other side of the House only to have been told daily that the Minister could not answer question I asked. I was told he had no responsibility to the House. We believed this system would be cost-effective and that it would result in the better running of the health services. Had we gone mad? Did we lose our reason? It could not be done. If there is no accountability, it is not possible.

We have now amassed the knowledge required to try to deliver the service desired. We need a modern hospital structure. Community care is very important. Deputy Maureen O'Sullivan made a very interesting intervention on prevention. Deputy Peter Mathews referred to statistics that should be available, and I agree with him. Some of us have pursued this for many years with regard to autism and various health conditions that appear to be more prevalent in Ireland than in other jurisdictions. Modern health research is now such that it should be possible to come up with some kinds of answers in order to plan ahead with knowledge of the costs that might arise.

The main point concerning the delivery of health services is that they are demand driven. One cannot postpone maternity services, for example. They must be made available within a certain cycle, and they are; it is as simple as that. National maternity hospitals are all under pressure because we have an increasing population. Those who referred to 2035, which is regarded as the black spot in terms of our ageing population based on the view that we will all be elderly at the same time, should note we are better placed than most other European countries in terms of the age profile of our population.

With regard to insurance, is it better to have a single organisation through which the health services can be delivered? Is it better to have a two-tier system involving private insurance or a public system? If there is duplication, there are obviously higher costs. There are those who have private health insurance, including me and most Members in this House, and we have had it for years. During my time in public life, I have tried to ensure people in the public health sector got services in the way they should when required, and that they were not put on a waiting list interminably.

I do not regard it as particularly wrong to have universal health insurance at present. It is a way of providing for the kind of demand everybody knows about. To a certain extent, it is an increasing demand, but it is varying. There is a necessity to recognise that if we are to provide a health service to a large number of people, we must have a safety net that will facilitate co-ordination.

Deputy Róisín Shortall made some remarks about two systems competing. For me, the jury is out on the concept of competition as a means of delivering services. It is debatable. One can gain and lose from competition because, as we all know, it works in both directions. It certainly worked in the banking sector, but not to the benefit of the country or its economy or people.

I acknowledge primary care is very important. However, I am not so certain it is the most cost-effective or efficient type of care. The jury is still out on that. The reason I say this is based on the care requirements of patients heavily dependent on nursing care for 24 hours per day, as opposed to elderly persons who can be cared for in the home. What is the best way to deliver the service of the highest quality to 100 patients who are 100% dependent on those around them? I have no doubt but that the best and most cost-effective and safe way from the patients' point of view is to have them housed in a central area, be it sheltered accommodation or otherwise, where they can be cared for. The medical services need to be readily available to such patients. How else can it happen?

The thrust for many years has been towards closing down the public nursing homes. Several public nursing homes throughout the country have been affected. The finger is pointed at such nursing homes regularly on the grounds that they cost more than the private nursing homes. They cost more only because they deal with the heaviest nursing requirements in the system; it is as simple as that. In the course of any evaluation of the system, I encourage those concerned to take that into account. If the heavily dependent 100 patients were dispersed throughout the country and had to be attended to by doctors, nurses and consultants daily, I would hate to think of the cost. All of us in public life know well the costs that are incurred if one must travel regularly. There are travel costs involved that seriously skew the system.

I cannot understand why some elements of the Opposition can see nothing positive about anything, ever. It gets tiresome after a while that they can think of nothing. They can criticise but not one of them came forward with a single positive or constructive view as to how the system could be improved, with the exception of the poor unfortunate man over there. With all those years and all the experience those on the other side of the House have of running the health services down, surely they could have come up with some little modicum of help, support and vision for the Government at this time.

I am glad the Minister of State, Deputy White, is in the House. He and the Minister, Deputy Reilly, have been given a very difficult job to do. I do not think the public outside this House fully understand that, or that they understand that to deliver the kind of service that is required, given the expectations of the people at present, requires a Herculean effort on the part of those charged with the delivery of the service to be able to do it all.

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