Jan O'Sullivan (Limerick East, Labour)

I thank the Minister of State for her presentation on the Bill and the Department officials for the briefing we were given earlier in the week. We do not have any major issues with the substance of this legislation, but I have a number of questions and concerns regarding its results and the work carried out by the various agencies which are to be subsumed into the Department of Health and Children and HSE.

In particular, I ask the Minister of State to preserve the functions carried out by the agencies and ensure such functions are continued while not being in any way reduced from what they were under the specific agencies. I do not see anything specific in the legislation that would safeguard the work being done. Despite the fact that the employees are being transferred under the designation "unestablished positions" within the Civil Service, I do believe that gives any great assurance. Although the same individuals will be staying in their posts, it will be at the whim of the Minister and the HSE as to whether they will continue to work as they have done. Those individuals will not stay forever. We must safeguard this work into the future.

The Women's Health Council referred to by Deputy Reilly has spoken of safeguarding the knowledge or institutional memory built up by these organisations. That is a good way of putting it. They have obviously developed a high level of competency, expertise and interest in those areas. It is important this is not diluted in the new context. They would also have worked with civil society and with various organisations under the different headings, such as crisis pregnancy, older people, women's health, drugs issues etc. They have worked with different agencies and organisations and in some cases these bodies have even funded those agencies and organisations. It is very important that this voice and connectivity is retained. These are general concerns regarding the functions carried out by the various organisations and bodies that are being abolished and brought under the umbrella of the Department and HSE.

I do not have a problem with the principle of eliminating the significant number of organisations we have, not just under health but throughout our Departments and public bodies. If we can save money and bring about a co-ordination of effort while eliminating duplication, people on all sides of this House would be very happy to see such a process. A number of Bills like this were announced under various Departments but not many are being progressed. I do not know if the Minister of State will respond in general to this. We do not a major difficulty with the substance of the legislation.

Will there be a review or monitoring mechanism to ensure the work carried out by these agencies will continue? Will the issue be considered from time to time? Will the Bill save money? Even the briefings gave no great clarity on whether money is likely to be saved. I note the Minister of State indicated in her speech that, while there is a clear need to secure efficiencies from the rationalisation programme, the primary aim is to streamline service delivery and policy making in these areas, while efficiencies will be gained over time from economies of scale and the elimination of duplication in areas such as recruitment, procurement, payroll and ICT systems. There is no indication of where savings might be made.

We already have a significant number of people working within the Department of Health and Children and the number working there decreased by only a very small number when the HSE was set up. There are proposals for rationalisation within the HSE, in particular, and we strongly endorse such proposals, particularly in the middle management and other management grades. That was announced as an intention, but I do not know if it is to be progressed this year. There has been no information on that as yet.

In the current context, I am concerned about a slash-and-grab or panic approach within the HSE because of the amount of money it must save this year. It must save approximately €1 billion if one considers the various stages at which it has been told to save money, including the end of last year, early this year and the most recent amount of €72 million. It reported to the Minister this week on that issue but the Minister has not responded. There is a kind of desperate attempt by the executive to save money where it can, and unfortunately much of that will hurt patients and frontline services.

We already have evidence of the purloining of funds that were allocated for areas such as mental health, palliative care, disability and Traveller health. Money specifically set aside for development programmes in these areas was used to plug the HSE funding hole. I am concerned that the money for such important activities will get thrown into some vast effort to plug the hole in HSE finances. My questions about preserving functions and monitoring are asked in the context of the experiences we already have had, where money for certain areas has been used for other purposes in the HSE in particular. Will the Minister of State provide reassurance on that?

I wish to focus particularly on the Crisis Pregnancy Agency, which had very specific functions when it was set up. It has fulfilled those functions very well. It was set up as a direct response to a recommendation made by the all-party Oireachtas Committee on the Constitution and was to have a very singular focus on crisis pregnancy. It was given specific responsibility to develop a strategy to reduce the number of crisis pregnancies and to ensure that women faced with a crisis pregnancy are offered real and positive alternatives to abortion.

Official figures indicate that since the agency's establishment, the number of abortions carried out on Irish women has decreased by approximately 2,000. In anybody's language, this must be a success. I first became involved in politics in the early 1980s, when abortion was a major issue. We were all battered around the head for opposing the abortion referendum in the early 1980s and from time to time it has come up on the agenda again. The attacks on people who were trying to make reasonable arguments regarding family planning, etc., should never have been made. Regardless of one's point of view, however, the Crisis Pregnancy Agency clearly has been a success in the context of reducing the number of abortions in Ireland. As a result of its work, parenting is by far the most common outcome following a crisis pregnancy, adoption has decreased significantly — this is just a fact of life in this country and it is a matter we must address in the context of crisis pregnancy — and approximately 15% of women experiencing a crisis pregnancy choose to have an abortion.

The mandate of the agency was to reduce the number of crisis pregnancies, to reduce the number of women choosing abortion as an outcome of crisis pregnancy and to safeguard women's physical and mental health following termination of pregnancy. In statistical terms, there has been a decrease of 30% in the number of women who travel from Ireland to the UK to have abortions, a 20% decrease in the number and rate of births to teenagers and a 43% decrease in the number of teenagers travelling to the UK for abortions. In addition, the number of crisis pregnancy counselling services nationwide has more than doubled and free services are now provided at 50 locations.

The Crisis Pregnancy Agency has succeeded in bringing to the table services with opposing ideological viewpoints, keeping them there and encouraging them to work collaboratively on developing standards, resources and advertising. In that context, I am concerned that the work of the agency should continue. The agency had an extremely precise brief and it promoted public awareness and brought together those of opposing points of view in its efforts to reduce the number of abortions carried out on Irish women.

The Crisis Pregnancy Agency has stated that in sustaining and progressing the advances made to date, people must focus on a number of critical issues. These include: better access to and information on contraception and contraceptive devices, particularly for identified groups at risk of crisis pregnancy; improved standards and quality in respect of contraceptive services; measurable improvements in consistent contraceptive use; measurable improvements in knowledge among adolescents regarding relationships and sexuality; improved access to and delivery of crisis pregnancy counselling services and post-abortion medical and counselling services; recognised standards and regulations in respect of crisis pregnancy services; improved range of supports to making continuation of pregnancy more attractive; strengthened understanding of the contributory factors and solutions to crisis pregnancy, using research to promote evidence-based practice, communications initiatives and resource and policy development; tracking new emerging issues relating to abortion and crisis pregnancy; influence policy makers and key players on prevention of crisis pregnancy; reproductive decision-making and crisis pregnancy outcomes; continued positive engagement with service providers, particularly organisations which provide crisis pregnancy counselling where relationships are sensitive and require effective management; and effective management of the issue of crisis pregnancy in challenging economic circumstances.

I wish to ensure that the agency's good work in respect of reducing the number of women from Ireland who travel abroad to have abortions will continue. However, the Bill does not appear to contain any provisions in respect of maintaining the agency's functions, engaging in a review or ensuring that the funding relating to this issue will be ring-fenced and will not be used for other purposes.

Deputy Reilly referred at length to the concerns of the National Women's Council of Ireland, NWCI, regarding the Bill and the fact that the Women's Health Council is to be subsumed into the Department of Health and Children. I support the points he made in that regard. The Women's Health Council has played an important role in liaising with and obtaining feedback from women's groups, both directly and through the NWCI. It will be difficult for the council to fulfil this role when it is mainstreamed.

Deputy Reilly also referred to the fact that the Department of Health and Children has undertaken to establish a gender mainstreaming unit. It is important that such a unit should be set up. I am not concerned with singling out women's health — no more than I would single out men's health — I merely wish to ensure issues relating to women's health will be given the priority they require by the Department of Health and Children.

The National Council on Ageing and Older People is of particular concern to the Minister of State, Deputy Hoctor. It is important that the work of the council is maintained and that its voice should remain strong within the Department. I presume the council will come under the remit of the Minister of State when it becomes part of the Department. A number of concerns arise in respect of the elderly. Short, medium and long-term demographics indicate that the number of older people in society will increase dramatically. As a result, the demands placed on our health service will become greater. It will be important, therefore, to protect the rights and health of older people.

The recent debacle involving medical cards highlighted this issue. The medical card for those over 70 has given rise to better health outcomes among older people because when they were given their cards, they felt able to attend their GPs or to access primary health care — be it provided by home helps, public health nurses or therapists. A scientific study that was carried out indicated a measurable improvement in the health of these people. There is a concern that these individuals will not access primary health care to the extent they should and that, as a result, they will be obliged to access the more expensive acute care services.

Concerns have also arisen in respect of the fair deal legislation, particularly in the context that a resource cap will be put in place and that tight controls will apply in respect of the relevant budgets in the next couple of years. There is a real fear that people will not be able to access long-term private or public nursing home care as a result of the existence of the resource cap.

I spoke to a number of carers this morning regarding their concerns. The carers strategy has not been published. Reports emerged earlier in the week to the effect that the cuts that have been recommended to the Minister for Health and Children by the HSE may include reducing the number of home help hours available. I was informed by one carer that access to resource care — by means of which carers are able to take a break from their caring role — is becoming more difficult and that carers may be asked to make a financial contribution towards the provision of such care. I also spoke to carers who do not qualify for the carer's allowance as a result of the means test. One woman told me she cares for her adult son who has Down's Syndrome and who requires constant care. She is now a widow and because she saved her money over the years she does not qualify for the allowance.

These are the kind of stories older people are relating to us. Such people are concerned that as a result of resources becoming more scarce, the fact they no longer qualify automatically for medical cards and that carer's allowance is means tested and a variety of other reasons, they will come under pressure. Subsuming the National Council on Ageing and Older People into the Department of Health and Children may be a positive development because it may place the concerns of those to whom I refer at the centre of the decision-making process. However, people are concerned that this will not prove to be the case and that the Department's focus will lie in other areas. I wonder if the Minister of State is in a position to provide assurances in that regard.

The national cancer screening service speaks for itself. I do not have a concern about that because we knew this was coming and that it is part of the cancer strategy. I am not concerned about it being mainstreamed, although issues arise such as the fact that BreastCheck has not yet been fully rolled out throughout the country. It is not yet in my city. It is in the county but it is not in the city, nor is it in other areas of the west and the south.

On the other areas of the cancer strategy, we had hoped there would be funding to begin putting in place bowel cancer screening this year. So far that money has not been allocated, and I urge that it be allocated before the end of the year. I understand a report is to be made available before it is decided upon but it is vital that be rolled out. The cervical screening programme is progressing, which is welcome.

I do not have a difficulty with the issue of the drug treatment centre. It makes sense that should be part of the mainstream. The hepatitis C provision in the Bill is welcome. It is a practical proposal which is welcome.

I support what Deputy Reilly said about the issues that arise with Dr. Neary's patients.

A number of general issues arise under this legislation on which we can take the opportunity to comment. In the overall cuts atmosphere we are in, and I have already expressed my concern that the functions of these particular agencies should be preserved, we must find ways to make the entire system more logical in terms of the way money is spent and save wherever we can do so.

Before I discuss yesterday's announcement from the Minister, Deputy Harney, and the new group she is setting up I want to highlight ways in which we can save money. There is one area in particular that has been highlighted in the past few days, and I raised it previously by way of parliamentary question. It may be a relatively small area but it concerns something that annoys the public, namely, that patients cannot bring back the crutches, walking frame or wheelchair they got from the Health Service Executive when they no longer need them. They may have only used the crutches for a week to move around but when they bring them back they are told the hospital cannot take them back because if they are given to somebody else they might claim against the hospital if something happens to them, or some infection the patient had might be transferred to somebody else.

In the past it was possible to return such items, although people were given decrepit wheelchairs then, which is the negative aspect of it, but throughout the country perfectly reusable aids and appliances are not being taken back and reused. I urge that that practice be re-examined because it does not make sense. These items can be checked to ensure they work properly and I presume they can be decontaminated in some way to ensure infections are not passed on. I tabled a question on the matter and the answer I got was to the effect that these were the reasons they were not being reused but I have tabled another question to determine if that might be re-examined. The general public who deal with the public face of the HSE on issues to do with their loved ones find it illogical that they must hold on to a perfectly good walking frame that they know could be used by somebody else.

There are other areas where money can be saved. I support what the Minister said yesterday about the money following the patient. We have been saying that since 2002 when the Labour Party first put forward its proposals on a universal health insurance system. We wanted that system of collecting the money from the public through a universal health insurance system. The Minister said yesterday that her new group was not about gathering resources but allocating resources. However, it is important that we focus on how we take in the resources as well as on the way we allocate them, and I am disappointed the Minister is not examining in more detail the area of universal health insurance in particular because it is a fair system. It is a one tier system that eliminates the difference between public and private patients and takes from the public on the basis of their ability to pay. In other words, if someone is in the higher economic sector they pay their health insurance just as more than 50% of the population are doing at present. If they are in the lower area they get it free, as do people with medical cards. If they are in the middle, they pay a certain amount in accordance with their income.

As Deputy Reilly said, it is a very good group. I have no objection to the members of the group except that there is no patient representative on it. That is an important element that is missing. The members are excellent people but I am not aware of anyone who is representing the interests of patients. I ask that that important interest group be included in the group. There are people like Dr. Charles Normand, who has done very good research work, along with his colleagues. The Minister of State may know him because he is connected to the Adelaide Hospital Society, which has some interest in the Chair's constituency. It has done excellent work, specifically on the area of universal health insurance. Dr. Normand's contribution would be very valuable, as will that of the others.

It is vital that we do not simply dish out a budget to a hospital regardless of the work it is doing, and the HealthStat will help in that. I again acknowledge some actions within the health area because we have to measure the work being done and give the resources in accordance with that work.

I am concerned we are constantly being given these top down solutions. That is present in HealthStat where the specific measurements are all being done from the top. I frequently talk to people working on the front line of health, as I am sure the Minister of State does, and they constantly tell me of measures that could be taken in their hospital, community unit or whatever to save money and make things easier for the patient but it appears to be difficult for the people on the front line to get their voices heard in the type of proposals being made.

That is the contrast between what was done in Northern Ireland and what is being done here. The Department of Health, Social Services and Public Safety in Northern Ireland visited the hospitals, examined what they were doing, figured out better ways of doing things in co-ordination with the people working on the ground and came up with solutions that are working. In Britain, Mr. Robinson did something similar in that they went into hospitals.

There are hospitals here that already have very good systems. Kilkenny, which is often given as an example, has very good systems working particularly in co-ordination with the community care services, general practitioners and other people who deliver community care. I again acknowledge that some progress has been made in that regard because there will now be a realignment of community care and the acute hospital sector. The silos will be broken down, but they should never have been set up. That is part of the problem with all of this. The HSE was set up with all these separate units, a layer of management on the top and with most of the people already working in the various health boards cobbled together in what turned out to be a camel rather than a streamlined horse. That has turned out to be a system that does not work, and that must be acknowledged. It is being brought back again to bring community care and hospital care together but if it had been done right in the first place all of that could have been avoided. We could now have a streamlined, effective system. We could have got rid of the layers of management and deal with the downturn in the economy within the health services with a system that was geared to do that and respond in a positive way that would be good for patients. That is not what we got, however. Instead we have this system but according to the Minister this group will not report for another year when she will begin to figure out how to allocate resources in a way that the money follows the patient and that will encourage more treatment of patients and better use of resources. Another year will have passed by then and it will be more than five years after the setting up of the HSE. We have lost all that time and in the meantime the economy has collapsed and we do not have the money to do this in a way that can be effective and efficient.

I endorse everything Deputy Reilly said about the National Treatment Purchase Fund. It is madness to pay doctors to treat their patients on a Saturday and, after closing their beds and not providing them with theatres, to treat the same patients during the week in a public hospital. If we are to save money, the entire system must be re-examined, particularly in light of the consultants' contracts, because they are now obliged to spend more time in the public hospitals. There is a better way to do this, it is PD ideology and we must change it.

We should maintain the valuable functions being carried out by these agencies, putting in place timeframes so that we can see if they are being done effectively with the expected outcomes or if they have disappeared under this amorphous way of doing business which often happens in the HSE, where money is assigned for one purpose and used for another.

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