Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance) | Oireachtas source

I apologise, as I do not know how to turn off mobile telephones. Mine is dysfunctional as well.

Re-organising the structure is a positive move if, as the Bill suggests, that re-organisation is a transition towards a better structure that is more responsive to the needs of the service's users, for example, patients, delivers services better and ends the unacceptable scenario of some politicians asking about the executive's dysfunctional nature and being told it is an operational matter for the HSE while other politicians take no responsibility for what goes wrong in the health service.

The aspirations are good, as is the rhetoric. However, the rhetoric was also good when the HSE was being established in 2004. The digest supplies a telling quote from the then Minister for Health and Children, Ms Mary Harney. Her rhetoric was electrifying. One would really have believed we were on the brink of a wonderful revolution in the way health services were being delivered. She stated, "This is an historic piece of legislation." How often have we heard that? She continued:

It provides for the most comprehensive reorganisation of our health services since 1970 which is long overdue and vital. It is a once-in-a-generation event. It is our generation’s chance to put patients first in the design of the management of health services. It is our chance to put in place modern, effective management to make the best use of these tremendous resources we are applying to health and to get clear value and clear results for that money.

To be honest, there is not much difference between the 2004 rhetoric and the rhetoric now. The main question is whether the new re-organisation of the dysfunctional health service into what it needs to be - modern, efficient and a provider of the services that people desperately need - will transpire in reality. I am sure Ms Harney sounded convincing when she made that speech, but the reality did not match.

I will put my cards on the table. The Minister is trying to square a circle that cannot be squared. It comes down to resources. I am not claiming there are not structural issues of management, mismanagement and organisation, elements on which the Government places much emphasis. Historically, Fine Gael has put a great deal of emphasis on them. The Government's main assertion is that we need better management, but this argument does not stack up for me. I am not saying we do not need better management, but focusing on it is to gloss over the fundamental problem, that being, from where does bureaucracy come. Does it just arise because we do not devise the right structures?

I am sure the HSE's current structures probably sounded reasonably convincing following the rhetoric of Ms Harney's speech. I am sure there were many arguments about how health boards were not terribly functional, were somewhat corrupted by political influence and cronyism, etc. Directorates based on particular areas of service provision or care also sound like a good idea. However, is this element the problem? I do not know whether the word "Directorates" is a reference to the French revolution and Robespierre, but it sounds good and revolutionary. I put it to the Minister that the HSE's structure is not the main problem, although it may be a problem and probably could be redesigned.

Someone whose name one probably cannot mention in polite company without being laughed at by certain sides of this House, but who I will simply call a revolutionary from the turn of the century, explained that bureaucracy and corruption developed because of shortages. He used the example of a bread shop. If the shop is packed with enough bread for everyone who enters the shop, there will be no queue and people can get the bread as they need it. However, if there is a shortage, a queue forms and people start jostling with one another over who will be at the front. Once a queue develops, it becomes necessary to have someone to keep it in order. That person often seems to use an arbitrary and coercive power to keep in line the people who are queuing for bread that they desperately need. As the person whose job it is to order the queue has power over people's access to scarce resources, he or she is vulnerable to corruption even if he or she does not start as a corrupt person. This allegory of how bureaucracy and corruption develop is at the heart of the problems with the health service.

I do not know how one can resolve the problem of great layers of bureaucracy that are dysfunctional and where there is mismanagement of the health service when the problem is that we do not have the resources. We are cutting the elements in the health service that work. We are cutting the number of nurses. Everyone says the nurses are wonderful. The front-line staff are wonderful but what have we done to the number of front-line staff but slashed them. We are cutting the one part of the system that works, and we are demoralising such staff with pay cuts. Even if they were wonderful up until now they certainly do not feel wonderful anymore. One wonders how long their goodwill can last under the hammer of the cuts. Front-line staff are the one part of the health service that work. Ambulance drivers and others are withdrawing their goodwill for the same reasons. They say they are working their backs off trying to provide the service and everybody acknowledges that they do it well but what do they get for it? They have their wages cut. They get attacked and are asked to work longer and harder for less. One could ask how that can work. I put it to the Minister that it cannot.

Perhaps the lack of detail on the directorates and what will follow what the Minister describes as the transition provided for in the legislation tells its own story in that regard. It may be a dawning awareness of that fact. As I understand it, it is Government policy that we are in transition towards a model of universal health insurance. We need to know what the model will look like. I am not sure whether the Dutch model, about which the Minister initially spoke a lot, is still the model we are following. The evidence is piling up in the Netherlands that what the Dutch model produces is ever-higher health insurance costs. More and more of the resources that go into the health service there are being taken up with the bureaucracy of the private health insurance system. The most dramatic and developed example of such a system is the United States, which is the ultimate example of where universal health insurance as delivered by private health insurance companies is the main model, in contrast to, for example, the national health service model in Britain that was set up at the end of the Second World War where everyone gets free health care and it is paid for out of general taxation. What is happening in this country seems to be a transition towards that failed model in the United States and the failing model, in so far as it has been developed, in the Netherlands where the public are becoming increasingly angered and outraged over the increased costs.

The facts about the American model are shocking. They spend more on health than any other country but 40% of it is wasted on administration. The reason that is the case is to do with money, because companies are billing people. There is a massive administration for billing people. That is what it is about. The money is not going into the front-line services. That is not its primary purpose. It exits to make money so one has a huge bureaucracy whose job it is to capture the money instead of financing health care through revenue and a system of taxation that already exists and which is progressive and can capture the funding necessary for public services without creating a new privatised bureaucracy whose main job is to make money and who will push up insurance premiums as it needs. I ask the question in that context because there is so little detail in the Bill. Is the main concrete proposal in the Bill the separation of service provision from procurement? Is that what is going on, that the Bill is setting up the system for the move towards privatisation where services will be purchased by the private health insurance companies and provision will come from the public system? I suspect that is the case. I urge the Minister not to go in that direction because it is a failed model. The alternative is more in the direction of the British health service model.

I see it as a positive step that the Minister is seeking to take more personal responsibility for what goes on in the health service, but there is a need for checks and balances at local level. I agree with Deputy Penrose’s point about the former health boards. It was a localised form of governance of health services. It would be necessary to reform them. The boards should not be as they were, made up of cronies but of patient representatives, health professional and other stakeholders such as representatives of the workforce and perhaps elected representatives to represent the wider public to see how policy translates at the other end. My concern is that we are preparing for the outsourcing of much of the health service to private insurance companies and the directorates, which will possibly compete for resources among themselves, will still represent a top-down structure.

I stress the importance of localised oversight and management of health services. I wish to bring to the Minister’s attention what on the face of it the evidence suggests is an absolutely shocking example of the mismanagement of HSE funds in the home help sector. I am reluctant to go into too much detail because the charges that are made are serious against home help companies in the Fingal and Wicklow areas. There is substantial evidence, and allegations have been put forward by employees in both areas, of rampant misappropriation of HSE funds. Significant amounts of funding were invested by the HSE in home help services in Wicklow and Fingal. The allegations suggest the misappropriation of hundreds of thousands, perhaps millions of euro in funding. One company was getting €250,000 a month from the HSE. Allegations have been made of company credit cards being used to finance holidays and to buy cars. There was no oversight of the expenditure of funds. No regard was taken of proper regulation and how the service was being run although it was dealing with vulnerable people. Rules were flouted and people who blew the whistle were sacked, among other actions. I will not go into much more detail in that regard. Snippets of information appeared in the newspapers before Christmas but some of the people directly involved have told me they met a brick wall in trying to get proper investigations into these matters which they describe as rampant corruption and misappropriation of scarce resources supposed to be directed towards a vulnerable sector of society from the public purse via the HSE but where the HSE did not provide proper oversight in the matter.

It is not clear to me at all, from what the Minister is proposing in this Bill and from the lack of detail about where this is going, that the new structures will deal with this problem. We need a level of local oversight to determine what is happening with moneys that are being allocated centrally. What is being done with the funds? Are the local units delivering health services to vulnerable citizens being managed properly? Are the resources actually going to patients, staff and so on? That is a role that any reformed health board system operating at a local level and made up of stakeholders would be far better at performing.

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