Séamus Healy (Tipperary South, Independent)

For many years, and particularly in recent years, politicians of almost all persuasions and commentators in the media have claimed that a huge problem in the health service derives from over-manning of management and administrative posts. Nothing could be further from the truth. It has been independently demonstrated that this is not a problem and that focusing the debate on this issue is a diversion from tackling the real problems in the health service.

Only 6% of health service staff are in administrative or management roles which do not directly affect and serve patients, doctors, nurses or other health professionals. Approximately one in 20 health service workers is directly administrative. The Brennan report has confirmed this situation. It states that ten out of every 11 additional employees in this category recruited since 1997 are engaged in duties of direct service to patients and to the public. The report went on to state:

There has been ongoing comment during the course of our deliberations that the majority of increased employment in the health sector has been taken up by administrators, that is, that administrative staff rather than those providing a direct patient service have consumed the additional resources allocated. We have not found evidence to support this perception.

The writers of the report did not find evidence to support that perception because it is not a fact.

A reduction in administrative and clerical staffing would mean doctors, nurses and health professionals spending their time typing, filing and preparing budgets, PAYE returns and payrolls. These roles are not appropriate to professionals of that kind. Any attempt significantly to reduce clerical and administrative staffing would be seriously detrimental to the delivery of health services.

The basis of the Health Bill and of the Hanly report is that centralisation is good in itself and will be beneficial for the health services. That argument cannot be sustained and is fundamentally flawed. There has been a serious lack of consultation relating to the Bill and to the new structures proposed in it. Those people who do admirable and trojan work in the health services have been consulted considerably less than they should have been.

Existing health boards are to be abolished before adequate new structures are put in place. If the Bill is enacted we will have a health service executive in five weeks' time, but many issues will not have been clarified. How will jobs be protected, what will the new staff structures be, how will roles of responsibility be allocated and where will staff be located? These and many other questions have not been answered. If this is how the Health Service Executive means to go on, we can look forward to a health service in even more difficulty and in even more of a shambles than at present.

The Bill leaves a huge democratic deficit in the health services. It removes elected public representatives who were doing an excellent job on health boards and who carried the views and concerns of patients and constituents to those bodies. I worry that we will have a body such as the National Roads Authority. Deputies will have no right to ask parliamentary questions regarding the executive. We will be told by the Ceann Comhairle's office that the issue raised is a matter for the Health Service Executive and that the Minister has no day-to-day responsibility in the matter. The Health Service Executive will not be accountable to the Dáil.

The Bill does nothing to address the serious problems in the health service. One of these is our two-tier health system. A wealthy person can have access to health services at the drop of a hat while those in lower or middle income groups without access to health insurance must wait for months and years. Recently, a constituent of mine, who had a medical card, was told he would be waiting eight months for an out-patient appointment and another 18 months before a necessary orthopaedic procedure would be carried out. The gentleman and his family got sufficient money together and he became a private patient. He had an appointment within the week and had the procedure carried out the following week. This example gives an indication of the inequality and unfairness of the health service. There is a geographical, two-tier health system depending on where one lives. For instance, in the south-east there is no BreastCheck or radiotherapy service. The situation is similar in Limerick, Sligo and other locations. It is a form of health apartheid.

The Hanly report is part and parcel of the new approach to health services, which includes the legislative proposals before us. When it comes to hospital services, we are told centralisation is everything. Unfortunately, however, the Hanly report is based on a number of serious fallacies, the first of which is that centralisation will improve quality and safety. That is not correct. The second fallacy is that smaller hospitals have lower standards, which is also incorrect. The third fallacy is that smaller hospitals are inefficient, which is not true either.

I worked as a hospital manager for 21 years in the South Eastern Health Board area and I know that some of our smaller hospitals are more effective, efficient and have higher standards than many regional and tertiary hospitals. Smaller hospitals are supposed to have poorer training for NCHDs and it is claimed that larger centralised hospitals would provide a better quality of access, but nothing could be further from the truth. If the Hanly report's recommendations are implemented, we will witness a downgrading of general hospitals such as my local one in south Tipperary and others in Nenagh, Ennis and elsewhere. In addition, only elective surgical and medical day procedures will be catered for, while there will be no on-site, overnight medical presence and no accident and emergency services. We will have nurse-led minor injury units, which I had the unfortunate experience of seeing in Clonmel in the 1970s and early 1980s. We had to close the unit down because it was ineffective; it was not staffed by medical personnel and could not provide a proper level of service despite excellent work by the nursing staff involved. Such units simply do not work. I am concerned for the future operation of obstetric maternity and paediatric units in general hospitals if the Hanly report is implemented as outlined.

Part 8 deals with public representation and user participation but there is no obligation on the new health service executive to take into account anything that comes from the various fora to be established under the provisions of the Bill. For example, according to the terms of the Bill, the national health consultative forum may "advise the Minister on matters relating to health". In addition, a regional health forum may "make such representations to the executive as it considers appropriate . . . ", but there is no obligation on the Health Service Executive to take into account the views of public representatives or users.

Part 9 deals with complaints but an independent complaints procedure is required, not one that is operated by any body established under this legislation. Those who have legitimate complaints about the health service should have access to an independent complaints procedure, rather than to someone who is part of the system. The perception would be that such a person would not have the same feeling for dealing with genuine individual complaints about the various health services provided.

A redress board should be established to deal with complaints deemed to be well-founded. People who have gone through the health service and have come out at the other end with serious disability or trauma should be able to seek redress.

The idea behind the Hanly report and other reports published is to centralise the health system, including hospital services. I am satisfied, however, that centralisation is not always a good thing. In fact, as many health services as possible should be provided at local level, thus ensuring wider public access to them.

Many of the Hanly report's recommendations are based on a seriously flawed understanding of the services currently available in local general hospitals compared to regional hospitals. It is not true to say that big is best. We should not go down that road. I will oppose the legislation when it comes to a vote.

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