John Dennehy (Cork South Central, Fianna Fail)

This was one of the few areas where the client had an opportunity to seek accountability through the public representatives on those boards. The change was encouraged to save costs and the media supported disbanding the health boards. The money involved was a minor part of the health budget and the accountability provided outweighed the expenditure involved.

For many years we were told that if finance was available it would solve all the problems. This is not the case because the money now spent on health is a multiple of what was spent nine years ago. Those of us who served on the health boards never envisaged such investment. Severe cutbacks were made in the early and mid-1980s, due to the security threat to the State, and we had to compensate for this. However, few of us believed we could achieve the current level of spending so quickly.

Everyone — practitioner, patient, administrator or public representative — will agree that health service reform is essential. Certain practices, not just medical procedures, must change. The PPARS project, designed to set up a human resource management system was heavily criticised. One of the primary reasons for the difficulties encountered was that more than 1,000 agreements or special deals were made across eight health boards. This is one matter that must be reformed. It is incredible that the system was incapable of dealing with such complexity.

The Ceann Comhairle is aware of the most critical issue, the common contract for consultants. This agreement dates from the early 1970s and allows for a mixture of private and public practice. Some argue that it provides the public with access to some of the best consultants in the world. From my health board experience I believe we have a high standard of consultants in all disciplines. The initiator of the agreement told me that an old person with cataracts would have to go blind without this system that provided access to the best practitioners, even though one has to wait for the service. We must achieve the right balance.

It is difficult to quantify the breakdown between public and private practice. Some consultants are methodical in their work, others just want to get on with the job. The clerical and accounting aspects are not looked after. The original argument was that we could not afford full-time consultants in the public service and the best and brightest would leave for foreign positions. That argument does not stand up anymore and, although there may be reason for some degree of sharing, in the majority of specialties consultants should work full time in the private or public sector. The system can always be improved and, in some areas, the number of clients will not justify a full time appointment but this can be teased out over time.

The apparent closed shops within the health board care area must also be examined. Some five years ago members of the Joint Committee on Health and Children spent six months examining orthodontic services. Members were concerned at the cost to patients, double the price in Northern Ireland and much dearer than the same services abroad. They were also concerned at the disgraceful waiting lists involved. Consultants and trainers were brought before the committee but it made little progress. Unless we train more orthodontists we will be in the same situation in ten years' time. It seems this sector is a closed shop.

Accountability must also be on the reform agenda. Earlier speakers referred to the case of Dr. Michael Neary. One of the most damaging aspects of it was the failure of his peer group to deal with the matter correctly. It was a glaring argument against self-regulation by any organisation or profession. This case will be the catalyst for wide-ranging changes in the regulation of the medical profession and other professions. Everyone would argue for internal self-regulation if they could get away with it.

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