Maureen O'Sullivan (Dublin Central, Independent) | Oireachtas source

When I was thinking about the health service, I tried to work out what word would best summarise it and I came up with "fraught". This is a service that has a massive budget yet it still has significant problems. It seems to totter from one crisis to another. I receive a considerable number of calls every day to do with health matters. This is not to take from the excellent care and service that health service staff provide to those who do get into the system. I am thinking particularly of the areas of cancer, heart, post- and neonatal care, and gerontology, all at a time when health service staff salaries are being cut and staff are not being replaced. Workloads are increasing and budgets are being reduced.

I can remember the old health boards, which came from the belief local authorities, which had been overseeing most health services, were not suited to the task owing to the much wider trends in health care development and increasing costs. As the health boards had elected representatives and representatives from the health care professions, they had a democratic element, as Deputy Healy mentioned. Then the view emerged that the health boards had to go and the HSE was born to manage the services as a single national entity. Now we are on the move again.

Health care is the largest spending programme after social protection, accounting for 27% of total Government expenditure. In 2011 the cost was over €13 billion, with 37% spent on hospitals and 34% on community services. When one takes that into account, with our relatively small population, it is incredible that we do not have a state-of-the-art health system with easy access for those in need of services, regardless of their personal circumstances and ability to pay. I was struck by one statistic in the 2011 annual report and financial statements that over 75% of the population availed of services through 425 primary care teams.

This seems to suggest ours is a very unhealthy population. Without being too simplistic about it, we are not paying enough attention to prevention measures. I will give two examples. We know the medical and health issues associated with obesity, two being diabetes and heart problems, yet when a suggestion was made that there be a tax on sugar which might have gone some way towards addressing the problem, we took it no further. We know all about the health problems associated with addiction, particularly alcoholism, yet when there was mention of and support for minimum pricing of alcohol, with related advertising mesures, it went no further.

I refer to an article in the health supplement of The Irish Timesyesterday which confirms what we already know, namely, the effect of poverty and unemployment on health. The article quotes Professor Kennedy who spoke on the Irish Cancer Society's strategy statement, 2013 to 2017 - Towards a Future Without Cancer. The point is made that people living in disadvantaged communities have a far greater risk of having cancer and dying young because they are twice as likely to smoke, eat too much poor quality food and be physically unfit. Professor Kennedy mentions particular cancers that are much more common in areas of high unemployment and deprivation. These health inequalities have been evident for far too long, as confirmed by one report after another, and in different parts of the world. The point is made that social injustice is killing people on a grand scale. People living in areas of high unemployment and deprivation engage in unhealthy behaviours because of the feelings of powerlessness they experience, exacerbated by the lack of educational attainment. These massive inequalities are not being addressed and the problem continues.

There has been much criticism of the HSE, some of which is justified, some not. The criticism which is justified relates to the general lack of integration and cohesion across the organisation, insufficient openness and transparency and the specifics of the relationship with the Departments of Health and Children and Youth Affairs. We are now moving to a transitional structure, with another to follow in two years time. Is anybody convinced, however, that this will address the health needs of the nation? The programme for Government contains a grand plan for a health reform programme to bring about a universal, single-tier health service based on universal health insurance. It would be great to think the Bill would contribute to this. There are serious issues, some of which relate to recent decisions, that could be aided by the Bill and give more authority to the Minister. However, we know what happened in the case of the primary care centres. One area I represent, Summerhill in the north inner city, one of the most disadvantaged areas in Ireland, is still waiting for a primary care centre, although there is a move in the right direction. If transparency is an issue, is giving more oversight powers to the Minister and the Government the answer? I remember what Mr. Cathal Magee stated to the health committee, namely, that the financial system environment in the HSE was not fit for purpose. Another statement was made to the Committee of Public Accounts concerning a financial deficit of €500 million at the end of last year. It is good that the Bill provides for an audit committee and sets out various functions, including reporting.

I refer to the position of director general. The Bill provides for the putting in place of between two and six directors. Media reports have considered seven directorates - primary care, mental health, hospitals, social care, child and family services, health and well-being and corporate services. However, the Bill does not provide details on the administrative structure and how the particular service areas will be assigned among the directorate. I make a special plea for a directorate for addiction services. During the years we went from having no one in government having responsibility for this area to on a number of occasions having a full Minister, then no one, followed by a Minister of State on a number of occasions but only with it forming part of a much wider brief. We need a directorate with responsibility for this area because addiction encompasses so many aspects. The Technical Group introduced a Private Members' Bill last October. We asked the Minister to prioritise addiction services as a health rather than a criminal issue. It is positive that the issue of drug addiction comes within the responsibility of the Department of Health, but then one looks at the wide range of addictions and the associated mental, physical and emotional problems and illnesses, including suicide, homelessness, imprisonment, sexual violence and rape, as well as the socio-economic aspects. If I take the first six directorates, primary care, mental health, hospitals, social care, child and family services, health and well-being, addiction is related and relevant to each of them. The importance of addiction services will be further disjointed if they are covered by six bodies. There is a need for us to take this issue on board and address it.

I turn to the area of mental health and there is no doubting the need for a directorate. It is welcome that this job was advertised earlier this month. I presume that the position of mental health director will be prioritised if the Minister opts to have only two. The Bill should state as much. There are questions to be asked. What will be the relationship between the new director of mental health and the regional directors? It appears these have not been mentioned before but are now being mentioned in the booklet which outlines the job description of director of mental health. There are also questions about budgetary control. The new director is crucial in this regard. It is recognised by everybody, especially those working in mental health services, that this function is needed to implement mental health policy.

In July 2012 the Technical Group made a submission on the Bill to the Minister. The first point we made was on the need for a strong framework for the sustained improvement of mental health services, with increased transparency and accountability in mental health service expenditure. We know what to do and have known this for a long time; it is all more or less contained in A Vision for Change, particularly the need to shift the balance of care from long-stay to community services.

To date, there has been poor accountability in the case of the budget. In 2008 almost half of the €51.2 million in government funding intended to support implementation of A Vision for Change was diverted to meet deficits in other areas. The 2009 report highlighted the absence of timely and detailed data and information. There was no real assessment of progress in capital investment or current expenditure. The 2010 report showed gaps which prevented financial accountabilty for the allocation of funding to support delivery of recommendations made in A Vision for Change. One reason is that the HSE does not track expenditure by care group, including mental health services. As a consequence, the HSE cannot state accurately how much is spent on mental health services. The 2011 report found that there was no system of performance indicators in place to enable monitoring of progress on the policy. That report, from Trinity College Dublin, stated establishing a national mental health service directorate was urgently needed, a body that would have the authority to control both existing and new resources. In budget 2012 €35 million was not spent, while in budget 2013 there is an additional €35 million. It is like Lannigan's Ball - one steps in and out with this figure of €35 million. Some 477 new posts were included for mental health services, as well as the 414 promised in 2012. Of this figure of 414, 58 had taken up positions by 31 December. In 2006 the programme under A Vision for Change estimated the need for an approximate 1,800 new professionals to implement reforms in mental health service provision. There is a caveat in the 2013 service plan, namely, that actions will be carried out "subject to affordability", which, of course, rings alarm bells.

I support the mental health reform coalition which identified two urgently needed measures to ensure accountability for delivering policy, one being the appointment of an empowered competent director of mental health with a statutory duty to implement A Vision for Change. The functions of that director should be outlined in the Bill, as well as the provision that he or she consult users of mental health services, their families and other stakeholders.

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