Dáil debates
Tuesday, 11 March 2008
Leaders' Questions
3:00 pm
Enda Kenny (Mayo, Fine Gael)
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Last April, the Taoiseach told the House that we had a world class health service in respect of which the Government should be congratulated. Last week, we saw the carefully choreographed publication of three separate reports that gave an insight into the way the health service is run. While none was prepared by truly independent sources, their findings are quite damning of the way the health system responds to situations. This is at a time when the Minister for Health and Children states that it is not safe to go into any hospital.
What did the reports tell us about the health service and of what excellence for which we should be congratulated can we learn from them? Did they show a service that puts patients at the centre of the system? No, they did not. Did they show an organisation capable of dealing with a crisis? No, they did not. Did they show any cohesion between the Minister, Deputy Harney, and the HSE in responding to the crises and recorded incidents? No, they did not. When one strips away the words about systemic weaknesses, the reports show clearly an organisation that is bloated, over-centralised and disconnected from the patients it is supposed to serve. It is an organisation in which no one places his or her confidence. When one strips away those words, one finds a Minister who is detached from the reality of the health service in 2008 and far removed from what is occurring on the wards and in the accident and emergency units.
As the Taoiseach is taking his head out of the sand in respect of a number of other issues, has he read the report and, if so, is he still happy to say that we should be congratulated on the health service? If he is so convinced, will the Taoiseach use this opportunity to express his public confidence in the management capacity of the HSE to deliver results for the patients it is supposed to serve?
Bertie Ahern (Dublin Central, Fianna Fail)
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These reports pertain to the difficulties that have been discussed in the House in recent months. Obviously they are reports into serious problems that must be addressed. If Deputy Kenny is asking me whether I have confidence in the 130,000 people who are trying every day to deliver a health service for a population of 4.2 million in operating theatres and community health settings, who are trying to diagnose and implement treatments, to look after our old people and bring young people into this life and who are trying to serve us to the best of their ability, I consider them to be fine people. I am not in here to criticise any of these people. As for the reports published last week, such reports and examinations into the issues were conducted because problems arose. We are talking about the problems rather than the successes or the day to day work.
Last Wednesday, the Minister for Health and Children published two key reports relating to breast cancer reviews at Portlaoise Hospital. I refer to the Ann Doherty report into the HSE decisions to suspend breast radiology services, to carry out a clinical review of systematic breast radiology services and to place a consultant radiologist on administrative leave and to the John Fitzgerald report into management, governance and communication issues. Both reports contain many critical issues that have been reported on and which must be addressed. I am glad they are being addressed and will be addressed. No one is arguing about the need to address such issues. Two other reports, the Dr. Anne O'Doherty report and the John Bulfin report, also raised issues to be addressed.
However, both of the main reports published by the Minister are critical of aspects of the communication, co-operation and clarity of responsibilities that obtained. These are serious issues which must be dealt with and rectified. The reason for producing the reports was to highlight what went wrong and what must be put right. The Minister said at the Joint Committee on Health and Children last week that she considers the patient to be the absolute priority in events such as this and that everything must be about the patient. Clearly the greatest distress caused in this was to the nine women identified by Dr. Anne O'Doherty's review, who experienced a delay in the diagnosis of cancer. All involved must learn from the mistakes made and ensure the systematic weaknesses of governance, management and communications that were highlighted in this instance are addressed.
The Minister already has welcomed the recommendation from the HSE's board that the chief executive officer is to report to the April meeting on the implementation phase of this report. This is what is important at present. This will include the preparation and implementation of a new serious incident management protocol, which will be a clear process for managing all aspects of a response to any future serious incident similar to this one. In addition, the Minister has asked the board to deal with three other issues, namely, to adopt immediately an interim serious incident protocol, to designate one person immediately at national level to ensure that any future reviews are conducted to the required standard and to engage closely with the issue through its risk management committee until it is satisfied that serious untoward incidents of this nature are being managed to the required standards.
The Secretary General of the Department has been requested by the Minister, in consultation with the Chief Medical Officer, to review and strengthen the procedures within the Department to deal with clinical safety issues to make sure that clinical perspective is brought to all these stages. While many other issues were outlined, these are the main ones.
Enda Kenny (Mayo, Fine Gael)
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That is the prepared script and Members have heard it all before. The question I asked the Taoiseach was whether he is prepared to proclaim public confidence in the management capacity of the HSE to deliver results, for which they are paid, in respect of patients. He did not answer that question. He spoke of people who were under serious pressure, including front-line staff such as nurses and those working in wards and accident and emergency departments, who are under pressure on a daily basis as inadequate facilities prevent them from doing the job for which they are trained. However, I remind the Taoiseach that when Professor Brendan Drumm spoke to the Fine Gael parliamentary party in Portlaoise a number of years ago, his first point was that his organisation, which has more than 130,000 employees, had 2,500 employees on its payroll who did not know what was their job or where they fitted into the system but who would be paid for life. This is part of the administrative bureaucratic monster the Government and the Minister for Health and Children, who is absent, have created in Ireland.
Enda Kenny (Mayo, Fine Gael)
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This is the system that does not respond to the patient for whom it is paid to serve. This is the problem.
Tom Hayes (Tipperary South, Fine Gael)
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The Taoiseach should answer the question.
Enda Kenny (Mayo, Fine Gael)
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I refer to the evident mess in Portlaoise, in respect of which the three reports provide a damning indictment of the management capacity. It shows clearly that the bureaucratic monster set up by the Government is anonymous and responsible to no one. It answers to no one because no one is in charge of it. This is the reason the Taoiseach claims this is a systemic weakness. He should tell that to the patients who are waiting for 18 months or two years for check-ups. He should tell that to any of his Deputies, whose offices could be papered with letters from people whose loved ones and family have had experiences in which the HSE has not delivered in their interests. I again ask the Taoiseach whether he is prepared to express public confidence in the management capacity of this bloated, bureaucratic administrative monster that patently has failed as one of the twin pillars of the Minister for Health and Children, Deputy Mary Harney.
One does not need a PhD or to be a Harvard scientist to know what should be done with the HSE. I share the Taoiseach's view that clear, decisive and responsible decisions should be taken in this regard. I wish to suggest five proposals to the Taoiseach. First, the HSE must clearly put the patient at the centre of the system, which patently is not the case at present. Second, every employee must know his or her duties, responsibilities and remit. Third, decision-making in respect of services must be devolved to regional and local level to the greatest possible extent. Fourth, the bloated bureaucracy at HSE headquarters must be broken up. Fifth, accountability to the Oireachtas and to the elected Members of Dáil Éireann of all parties and none must be clear and must be dramatically improved. Were the Taoiseach to implement these five proposals, I would congratulate him.
Bertie Ahern (Dublin Central, Fianna Fail)
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I do not know whether Deputy Kenny really wants me to talk about the cancer service or about the reports but he has described——
Billy Timmins (Wicklow, Fine Gael)
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He did not answer the question the first time.
Bertie Ahern (Dublin Central, Fianna Fail)
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No, I will go through that.
John O'Donoghue (Kerry South, Ceann Comhairle)
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This is Leaders' Questions and the Taoiseach must be allowed to respond.
Bertie Ahern (Dublin Central, Fianna Fail)
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Your script was to allow me to say two words and then to interrupt.
P J Sheehan (Cork South West, Fine Gael)
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The Taoiseach has no answer.
Bertie Ahern (Dublin Central, Fianna Fail)
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We can deal with the reports of last week, which raises a question. If Deputy Kenny's view is that the HSE is an inefficient bureaucratic monster in which there is no delegation other than from the centre, which has been criticised, and in which there is no delegation to any of the regions, I cannot agree with him. The HSE has a designated manager in every region, through the National Hospitals Office, and in all the approximately 20 centres that have been set up. It has a line manager in these areas whose——
Tom Hayes (Tipperary South, Fine Gael)
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It has thousands of them.
Bertie Ahern (Dublin Central, Fianna Fail)
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It has a large number of managers.
Joan BurtonBertie Ahern (Dublin Central, Fianna Fail)
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However, there are designated people in the regions and there is a line management structure that perhaps——
James ReillyBertie Ahern (Dublin Central, Fianna Fail)
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——is a system that Deputy Kenny considers to be inferior to the health board system. In this House until January 2005——
Enda Kenny (Mayo, Fine Gael)
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I did not say that. I asked the Taoiseach a question.
Bertie Ahern (Dublin Central, Fianna Fail)
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I answered the question about the bureaucratic, out of touch health board systems that were totally unrelated to each other. For a long time, Deputy Kenny made a career of talking about PPARS——
Olivia Mitchell (Dublin South, Fine Gael)
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I would not mention that.
Bertie Ahern (Dublin Central, Fianna Fail)
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——which tried to bring together the diversity of thousands of grades on differing rates and conditions that grew over the years since 1971.
Paul Kehoe (Wexford, Fine Gael)
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Thanks to the Government shovelling money into it.
John O'Donoghue (Kerry South, Ceann Comhairle)
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Allow the Taoiseach to continue without interruption.
Bertie Ahern (Dublin Central, Fianna Fail)
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Following that, an attempt was made for the first time in 35 or 40 years to bring a new organisation into being with buy in from all the service's staff, from doctors to nurses and everybody else, and to progress the health reform report we have been implementing. Are there deficiencies in that service? Do problems and weaknesses exist in some areas?
Bertie Ahern (Dublin Central, Fianna Fail)
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Are great things and huge reforms happening through the work we are discussing today regarding Professor Tom Keane and cancer services? Is it not a fact that outstanding work is being done in cardiovascular treatment and that we have had significant successes? The answer to these questions is yes but my job, and that of the Minister, is to try to improve what is good, correct what is bad and learn from these issues in order to make improvements.
I am not here to berate people. If Deputy Kenny wants me to say that I think some staff are not working hard enough or others are too fat or too slim, that is not what it is about.
Bertie Ahern (Dublin Central, Fianna Fail)
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It is a matter of making the HSE, which is a large organisation, improve and maintain the health of the people of this country to the best of its ability and with resources of €16 billion and a large staff by international standards.
I hope some of the suggestions made by Deputy Kenny about patient focus are correct. I agree with designating to line managers. They are in the structure but are being paid for doing the job and perhaps they should be allowed to do even more. These are the issues we must address and we have not only to correct the inherent weaknesses in the locations identified by this report but must also ensure no other part of the organisation has the same weaknesses. We must correct the weaknesses that exist and try to remove bureaucracy and address some of the serious issues that have arisen. That is why the incident protocol and the other recommendations have been highlighted. Our job is to implement these as quickly as we can.
Eamon Gilmore (Dún Laoghaire, Labour)
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In his reply to Deputy Kenny, the Taoiseach stated that the Minister of Health and Children believes the women of Portlaoise are at the centre of this issue. She has a rather unusual way of showing that. Yesterday she circulated a motion to be debated in the House tomorrow which welcomes the report and praises her. However, it makes no mention of the women in Portlaoise, whether the nine who were misdiagnosed with cancer, the 101 who were called back for mammograms, the 143 who were called back for scans, nor does it mention the conclusions drawn in the reports. Ms Doherty's report stated that the rate of misdiagnosis in Portlaoise was six times higher than the best diagnostic centres. Mr. Fitzgerald's report stated: "The decision making process was fragmented, with insufficient clarity about decisions, who was making them, why they were being made, or when they were signed off" and went on to identify systemic weaknesses of governance, management and communication. Mr. Fitzgerald described a dysfunctional organisation. That is the organisation — the HSE — this Government established to run the health service. That is the organisation for which the Taoiseach and the Minister for Health and Children guillotined Dáil debate because they could not establish it quickly enough. It manifestly is not working.
The Taoiseach stated that issues have to be addressed, a review is to be conducted and the bureaucracy must be reduced. He has had 11 years to do that but we have ended up with a health service and a health organisation which are worse than what we previously had. Instead of speaking about reviews and issues to be addressed, I want to know what is going to be done. Let us start at the top. I agree with Deputy Kenny that we need a Health Service Executive which fulfils the five functions but we also need a Minister for Health and Children like Noel Browne, who had a passion and commitment to public health and saw curing and caring as a public service rather than viewing medicine as an opportunity for business.
These problems were brought to the attention of the then Minister, Deputy Martin, six years ago. Since the reports were published, what discussions has the Taoiseach had with that Minister or the current Minister, Deputy Harney, about them? Do these Ministers answer to him? Did he ask them to consider their positions? In most other countries, an appalling litany of mismanagement and bad leadership such as this would have only one response. What is the Government going to do about the HSE? It was reported this morning that the Government considered returning to some kind of regional structure but concluded, as it always does when faced with a difficult problem, that it would employ consultants. Is the HSE to be allowed continue in this dysfunctional manner, which according to Mr. Fitzgerald will inevitably lead to other people suffering the same fate as the women in Portlaoise?
Bertie Ahern (Dublin Central, Fianna Fail)
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The motion for tomorrow's debate reads "to ensure that patients' interests come first in the future management of all such reviews and serious adverse incidents", so patients' interests are included in the motion.
I have discussed the reports with my colleagues. We discussed them in the health committee when they were published last Wednesday and have since discussed them further and we have had meetings with the relevant Ministers on them. I will not rehearse all the details but Deputy Gilmore will be aware these reports concerned events which took place in 2003, prior to the establishment of the HSE. Rather than bundling that into it as if the issues did not arise in the former system, they did because the report went back to two years before the HSE was set up.
When one looks at the issues — I have not read every line but I have read large chunks of the four reports — Ann Doherty noted there were no multidisciplinary team meetings other than in oncology, consultant medical staff were not represented at the meeting which decided to suspend breast radiology services, confusion arose regarding roles and responsibilities in the hospital and gaps existed in decision making processes. John Fitzgerald noted a fundamental weakness in the management and governance of the review process because an authoritative co-ordination role was not established for the process as a whole, decision making was fragmented, communication was inconsistent and confusion in the status of the overall review process arose because too many individuals were involved. None of these issues makes good reading but they are probably happening in other areas.
This was not happening in the centralised management offices of the board of the HSE, as some comments implied. It was happening on the ground in the regions where decentralised services had been operating for many years despite the advice of a number of reports, including one several years ago by Professor Niall O'Higgins, that we should pull these together and create critical mass units. Let us be frank; nowhere has it been argued more than in this House over the years that we should keep a bit of the service everywhere and reject the many reports which advise that large units with a critical mass resulting from dealing with a sufficient number of cases are best. That is politically difficult, so we always try to keep a bit for everybody in the audience. We are beginning to learn that is the wrong thing to do.
It is fair to ask what we are doing about it. The implementation of the national cancer control programme is the Minister's major priority. We were lucky to get a person with the expertise of Tom Keane to take up the position. The recent decisions by the HSE in regard to the four managed cancer control networks and the eight cancer centres will be implemented on a managed and phased basis, hopefully by the end of this year, even though Professor Keane is committed to having it done by the end of 2009. There is the north-east one, centred on Beaumont and the Mater hospitals, the mid-Leinster one, centred on St. James's and St. Vincent's hospitals, the southern one, centred on the Cork University Hospital and Waterford Regional Hospital, and the western one, centred on University College Hospital Galway and Limerick Regional Hospital. The aim is to pull together the service that led to many of these issues and try to turn it into a world class service. That is what we are doing and what I support.
Charles Flanagan (Laois-Offaly, Fine Gael)
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Do the Taoiseach's Ministers support it?
Bertie Ahern (Dublin Central, Fianna Fail)
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I am not suggesting there are not problems or difficulties because that has been written and reported on. What I am interested in is moving quickly, with Professor Keane and those working with him, to having units of large enough size which are resourced and staffed to do this job better than the fragmented services did. This applies to many other services, although we do not like to listen to that point. If we consider some of the reform programmes, we can see that we must do this but, as Professor Keane said, it requires political will by everybody to achieve it.
We have put in the extra resources, staff and consultants this year to try to achieve this. It is fully recognised that there are geographical difficulties in dealing with these issues but we must have a managed control network so that we move away from the problems that were created in the first place. We also need to improve management services between the centre and the regions. Professor Drumm has given a commitment that he will deal with these issues at the April board meeting. I support that.
Eamon Gilmore (Dún Laoghaire, Labour)
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That is not a good enough answer after 11 years. What I understand the Taoiseach to conclude from the Portlaoise reports is that the problem was in Portlaoise and concerned the fact people there were not talking to each other, while the valiant efforts he and his Ministers were making to reform the health service were all resisted by people in this House and elsewhere. There is no mention, of course, of some of those behind him who were much to fore in this regard.
The Taoiseach is suffering from a bad dose of BSE — blame somebody else. That is his problem. For every problem with which he is confronted, he will find anybody to blame but Ministers in his Cabinet. The way he described Portlaoise — where people were not talking to each other, meeting or communicating — one would not bring a car to be serviced there if it was a garage he was describing.
After 11 years in office, this is the state of the health service he has presided over and which he is offering to the people. He is saying to the people that this is the service they are expected to accept. If they feel something is wrong with them and want to go for a test, they must go into institutions where people are not talking to each other, there is no communication, nobody knows what the other person is doing and nobody seems to be accountable to anybody else. That is not a functioning health service, it is a mess.
After 11 years, we need something more clear and definite from the Government than having it come to the House, shrugging this off and saying: "Well, we are going to make a fresh start." The Government has had ample opportunities to make a fresh start. It is no excuse to say that it was 2003, before the establishment of the HSE, as if somehow the Government is not responsible for what happened in 2003, when it had already been six or seven years in office and had already gone through two Ministers for Health and Children. The Taoiseach has presided over this monster, the HSE, which he created. This was his solution, which was going to solve the problem in the health service, but it has made it worse. All he can now do is plead that he wants to make a fresh start and spend another few million euros of taxpayers' money bringing in consultants to look at it again.
Bertie Ahern (Dublin Central, Fianna Fail)
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I wish to deal with two factual points. First, I was not giving my view on the reports; I was quoting from the reports. In what I said about Portlaoise, I did not give the Deputy one line of any view I had. I was giving a report on what Mr. John Fitzgerald said and Ms Ann Doherty did. When the Deputy reads the reports, he will see that is precisely what I am saying.
Richard Bruton (Dublin North Central, Fine Gael)
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It is time the Taoiseach took a position on one of these issues.
Bertie Ahern (Dublin Central, Fianna Fail)
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Second, I was speaking in defence of the HSE, not in my defence. These issues in the report are there from 2003. They are not to do with anything I said.
I do not accept Deputy Gilmore's position. This was a report into problems in Portlaoise. I have no doubt people in Portlaoise were doing their best but this is the judgment given in the reports that came out. It is not a question of blaming anybody. If the Deputy was listening to my reply, he would know it was a question of what we have been trying to do and what support we are giving to Professor Keane to make sure we improve the services.
This matter involved several hundred people. Some 22,000 people are diagnosed with cancer annually, predominantly older people, with 60% aged over 65 years. Approximately 96,000 inpatients and day-patients are discharged from hospital every year following a diagnosis of cancer, which is an increase of 75% in the success rate in the past ten years. More than 60,000 people were treated as day cases in 2006, an increase of 140% over 1997. There was additional revenue of €20 million in the Estimates for 2007. Patients in this country are benefiting from the development of a clinical trials network nationally. In the past few years the Health Research Board has invested a huge amount of resources, which includes major investment in the implementation of the cancer strategy.
Bertie Ahern (Dublin Central, Fianna Fail)
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It is wrong and irresponsible——
Ciarán Lynch (Cork South Central, Labour)
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Who is irresponsible?
Bertie Ahern (Dublin Central, Fianna Fail)
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In fact, we can forget about "irresponsible", it is simply wrong that the position is worse. The figures show — they are not just figures, they are people who are alive — the success and the dramatic improvement of oncology services in this country. It does not matter whether it was 1997, 1987 or 1967. The fact is our patients are being treated better, operations are more successful, diagnosis happens earlier and we are having considerable success.
Olwyn Enright (Laois-Offaly, Fine Gael)
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What about survival rates?
Bertie Ahern (Dublin Central, Fianna Fail)
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Those are the facts and what I want to do is to make it even better. If people want to take a report such as this one relating to difficulties in one aspect of the health service, or run around the place trying to find other areas where there is a difficulty, and simply use them to beat everybody who is trying to improve the service, I will not play that game.
Bertie Ahern (Dublin Central, Fianna Fail)
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I want to see the services in this country improved in the long term. That is what we all should be trying to do.
Emmet Stagg (Kildare North, Labour)
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It is every day, everywhere.
Eamon Gilmore (Dún Laoghaire, Labour)
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The Taoiseach is out of touch. He does not know what is going on.