Billy Kelleher (Cork North Central, Fianna Fail)

I welcome the opportunity to discuss the Health Bill. It gives Deputies an opportunity to broaden the debate on the health service. At the outset, we must acknowledge a few simple facts. We have spent large sums of money in this area, more than €10 billion this year. The health budget has been doubled in seven years. The number of people working in the health service has been increased from 67,000 in 1997 to more than 100,000 in 2004, which is welcome. We must also acknowledge that while we have an excellent health system, it is not as satisfactory as we would like. We would like it to be better than it is. However, it is wrong to dismiss the wonderful work done on a daily basis by all those involved in the health service.

For too long we had a health industry as opposed to a health service — Deputy Mitchell referred to this. The important aspect was to ensure that salaries, wage increases and so on were factored into the equation and what was left was divided up to ensure patient care. We must examine the issue from the other side. First, what do patients require and when that is established, we should work backwards to ensure the staff are available to provide patients with a service.

I have advocated for a long time that the health boards in their present structure are not functioning and delivering the required service. The number of health boards in place for a population of less than four million did not allow for efficiencies and economies of scale within the health service. The fragmentation of tendering procedures, purchase of equipment and so on was expensive and inefficient. I hope the new Health Service Executive will achieve large-scale efficiency and economies of scale.

There are significant opportunities available to us. There has been massive capital investment in hospitals, including new accident and emergency units, operating theatres etc. In the area of surgical procedures, hospitals should operate 24 hours a day. I cannot understand why specialised equipment must wind down at 3.30 p.m. or 4 p.m. Hospital procedures, particularly surgical procedures, should be carried out on a 24-hour basis, five to seven days a week. It is not acceptable to have expensive specialised equipment lying idle at certain times. When it is established, the Health Service Executive should examine this matter.

On the centralisation of procedures and treatment, for too long services have been too fragmented. Some services were scattered throughout the country and more specialised services operated on a regional basis. I do not think people will object to travelling a certain distance for guaranteed specialised treatment. We cannot have specialised units in each hospital and community throughout the country. Politicians have a leading role to play in this regard. We must accept that on occasion difficult decisions must be made in the interests of the greater good. Because there were so many political agendas within the health boards, they were unable to make difficult decisions. Very often people said it undermined democracy. This is not about democracy, it is about providing health care for patients who need it.

I welcome the overall thrust of the Bill. I advocated the abolition of the health boards, because they were inefficient and unable to cater for and cope with changes in medical practices and the demands of new technologies and advances in treatments.

It is simplistic for people to pick figures out of the sky with regard to waiting lists. Many new procedures have come on stream in the last number of years. A new advance in medicine means a new waiting list. People who were previously unable to avail of treatment automatically go on a waiting list. It is disingenuous for people to use waiting lists as a barometer of the efficiencies of a hospital or health system. If one did that the logical conclusion would be not to provide a service in the first place. In that way, there would be no waiting lists.

The problem with accident and emergency services must be addressed with a positive and imaginative approach. Until recently, one went to a GP with various ailments or injuries. The GP examined the ailment, analysed whether it was serious and wrote a letter of referral to an accident and emergency unit for an x-ray or further check-ups. This system of referral has caused huge problems and delays. The new Health Service Executive should set up community health centres with specialised facilities where GPs work co-operatively. Why must everybody go to accident and emergency for an x-ray? Technology exists for x-ray units to be situated in health centres outside of hospitals. In this way, one would go to the local GP, perhaps with a broken arm after falling off a bike. The GP would make a judgment by x-raying the arm and deciding whether it was broken or sprained or whatever. Such a measure must be taken.

Doctors can make the call 99% of the time. However, they cannot be 100% definite. For that 1% they must make a referral. It is wholly unacceptable and inefficient to go to one's doctor and then sit in a car or on a bus on the way to accident and emergency. If one goes to an accident or emergency unit on any day of the week, as I have, there are people there who went to the doctor with a pain in their chest and were referred on. Doctors cannot make a 100% definite call. We should be imaginative in setting up health centres where GPs practise co-operatively. Specialised facilities would be available for them to make a definite call. Doctors have referred people to accident and emergency units for treatment of an ingrown toenail. GPs are capable of treating it themselves, and a mechanism should exist to allow them to do so.

The new Health Service Executive must be imaginative. It should be allowed tax incentives or financial inducement or assistance if necessary. Capital expenditure could be invested in specialised equipment, and tax reliefs could be used to set up these centres. We have a wonderful centre in Glanmire, headed by Dr. Tadhg Rafferty, who is also involved in setting up Southdoc which is a positive service. It would be of huge benefit to the community and would stop referrals if the centre in Glanmire was able to purchase specialised equipment.

We often speak of the health industry. However, the previous Minister was worried about the health of the population, and the new Minister has appointed a Minister of State with special responsibility for obesity. This issue must have a single focus. The Health Service Executive will do its own thing, the Department of Health and Children will promote health within communities and society, the Department of Arts, Sport and Tourism will promote sport as a healthy option, and the Department of Education and Science will encourage health within schools. There should be a single focus between all Departments in encouraging people to partake in healthy lifestyles.

There are anti-smoking, anti-obesity and anti-drinking campaigns. However, they have not been significantly effective. The smoking ban was effective in that it cut down consumption of tobacco, which is a positive development. The effect of that reduction will be seen in future years. However, there are statistics relating to obesity in young people and an increase in alcohol consumption. These problems will have a negative impact in terms of pressure on health services in future years. Whatever the Health Service Executive does with regard to the provision of services which tackle such issues, it must manage and bring forward any scheme in conjunction with Departments, and must be singularly focused on healthy, preventative measures as opposed to providing services thereafter.

With regard to the issue of an ageing population and care of the elderly, alarm bells ring when one looks at the demographics after 2025. Provisions have been made with regard to pensions. We must examine the matter seriously and start planning in the next few years. People are not able to cater for older relatives because of pressures such as double income families, the cost of child care, changing society and expectations etc. We must be imaginative in terms of how we cater for the elderly. Currently, the system is haphazard. There is respite care, whereby people go into a nursing home for a few months. They then go home, and then go back into respite care at the nursing home and so on. Proper facilities should be in place whereby an elderly person can be in a nursing home and also access proper medical care. We are not at the stage we would like to be. If we are not at that stage now, one can imagine what will happen as the population ages drastically in 20 years. We must plan well in advance for the provision of such services. It takes a long time to build facilities in terms of planning problems and providing capital costs. It is a bubble that could burst.

The carer's allowance exists for people who are able to give up work and care for elderly relatives at home. However, are these people properly supported? They are willing to make sacrifices to care for an elderly person. They are also saving the State a huge cost and doing it a service. Any person who does the State a service should be rewarded in some manner. We should look at how we support carers in the home. The disabled person's grant is one issue. It beggars belief that people wait months and months for an occupational therapist to inspect a house and the person applying for the disabled person's grant. Any person involved in the medical services in that person's area would be able to do this. An occupational therapist is not required to say a stair lift is needed because an elderly person is 83 years old and cannot climb the stairs. That is well beyond what is required to draw downfunding.

The disabled persons grant should be streamlined because its administration is quite confusing. However, the matter regarding occupational therapists should be considered immediately. I know of cases in which people waited six or eight months for an inspection to be carried out. When an inspection is over, a case can move quite rapidly, but to have the inspection carried out is often the hardest part. If we are serious about encouraging families to keep their loved ones at home, there must be a financial incentive. While the carer's allowance is in place, we must be imaginative and more must be done.

In a conversation in a pub or at a football match, consultants are often blamed for every ill, which is wrong. Consultants work, have contracts with health boards and the Department of Health and Children and provide the services. The buck stops at the top desk, which is normally that of a consultant. We must move to a situation where we appoint contract consultants to work in the public patient area only. For too long, consultants have had the trump card in negotiations because they are specialists in their area and can dictate the pace.

I do not understand why a consultant in one health board area can carry out four procedures per day while a consultant in another area can carry out seven. We must ask whether consultants are the cause of the difficulties or whether they are not given the support to work in the public patient area. However, they would fall over each other to treat private patients. This must be investigated. If we are imaginative in using facilities such as hospital theatre facilities and having consultants contracting for public patients only, we could make progress in removing from the system patients waiting for various treatments.

The accountability of the Health Service Executive to the Oireachtas was referred to. Accountability must stop with this Parliament. We live in a representative democracy and have an obligation to ensure that public representatives can highlight issues of concern to their constituents or to the taxpayers funding the services. Section 21 of the Bill refers to the attendance of the chief executive officer of the HSE before an Oireachtas committee. While I do not know how effective the section will be in guaranteeing accountability to Parliament, it provides a level of comfort. However, a Deputy should be able to come to the House, put a parliamentary question to the Minister and receive a response to address the concerns of a constituent or a group which had approached the Deputy with some concern.

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