Brian Cowen (Laois-Offaly, Fianna Fail)

In fairness, I do not think that was the intent. Customer service and customer delivery are part of the management of delivery. There are three aspects to these operational review programmes. These include the level of strategy in these Departments, how they are delivering and the situation for customers and people who use the service. Of course citizens use the service. No one is trying to say otherwise. This is the terminology used in the organisational review. It is not meant to devalue the importance of the service or the people who use it. The reviews then evaluate how Departments are measuring performance, the feedback from stakeholders and from people who use the service and what is the input into policy and strategy that derives from that.

As a management tool, a review is a good and objective exercise. For it to be rigorous, robust and thorough, one would expect that there would be recommendations and that weaknesses and strengths would be identified. It is like a SWOT exercise to identify strengths, weaknesses, opportunities and threats and to make sure an organisation responds to needs and to its strategy remit.

Where resources are limited issues will arise and critical service pressures will emerge. The programme is intended to get best practice across the system. Service pressures may emerge in some areas which are not replicated elsewhere because there are different ways of dealing with these things. In many respects it is down to management, personnel, the involvement of stakeholders and the team approach that can be adopted. It is only fair to say that we are engaged in a huge change management programme regarding the delivery of health services, moving from a regional structure that was with us since the mid-1970s to one that is now based on a programme involving a national hospitals office. This has been good and a means by which centres of excellence could be provided rather than looking at the need for resources regionally.

We have seen what has happened in regard to the cancer care programme, which is a very good example of the sort of change management programme required. These management programmes never meet with universal approval but outcomes for patients are far more likely to be better because of the changes than they would be under the status quo. Sometimes defending the status quo can get people involved in loyalties to institutions rather than seeing the bigger picture of what is in the best interest of patients. It is also about trying to localise as many services as possible and reconfiguring how we deliver them in a way that will, in many cases, increase service levels in many localities while developing centres of excellence in other areas. That is how the hospital system is being reformed. People have strong views on these matters. I have outlined the overall thrust of developments. Certainly, the status quo was not sustainable, nor was it providing the sorts of outcomes we would like to see. There was certainly no uniformity of outcome, as one can see from various statistics.

It is important that this exercise be about ensuring that, departmentally, the strategic plan of the health services is implemented by the bodies and agencies whose functions are on the operational side of the equation. Despite the constant portrayal to the contrary, the existence of problems does not mean progress is not being made. One can identify many areas in which objective progress is being made. I am glad to say the experience of the health service of the vast majority of people has been good. Members will note this themselves if they are prepared to admit it. People confirm my point and have been very happy with the way their relatives, or others, have been catered for or cared for. There are circumstances in which this may not be the case but, if one considers the overall level of activity, one will note that the thrust of the policy and the objective of the ongoing effort are to achieve uniformity across the service in every respect and on every occasion. Against the background of limited resources, that is a continuing challenge. The Croke Park agreement is a once-off opportunity to transform circumstances in a way that could provide us with a sustainable and practical future for stakeholders and citizens who use the service. That is my honest opinion.

Clarifying the roles of the Department vis-À-vis the agencies continues to comprise an area in respect of which further work is needed. We are in the process of implementing a change management programme and when we come out the far side - it will not happen overnight but over a period - the basic thrust of and philosophy behind the changes will prove to have been correct and will best guarantee accessibility. We have changes in respect of long-term care and care for the elderly, in respect of which there is now much more equity and a far better statutory basis for the equitable provision of such care than would have been the case in the past when various care systems grew almost organically and regionally depending on what resources were available and what practices were in place in various regional organisations.

There have been many improvements but, as I would expect, particularly in a Department such as the Department of Health and Children in respect of the delivery of health services, there are areas for further improvement.

There are significant areas where matters must improve further and in respect of which we must ensure that the strategy is implemented in the best possible way. The redeployment provisions in the Croke Park agreement are fundamental to ensuring that we can allocate resources into communities, where appropriate, and that there is efficient use of the hospital system.

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