Brendan Howlin (Wexford, Labour)
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I will call on the Deputies who tabled questions to the Minister for Health and Children in the order in which they submitted their questions to my office.

Jan O'Sullivan (Limerick East, Labour)
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Question : To ask the Minister for Health and Children the proposed changes to the management structures of the Health Service Executive, whether she has approved the proposed changes, whether legislative authority is required for the proposed changes, and whether she will make a statement on the matter.

James Reilly (Dublin North, Fine Gael)
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Question : To ask the Minister for Health and Children whether the reports in today's newspapers on the Health Service Executive are factual and, if so, whether she can give details of the full plan and a timescale for implementation, whether she can confirm if there are any cost implications and, if so, whether they will necessitate a Supplementary Estimate.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I do not want to talk specifically about the report but will talk about the plans, if that is in order.

I am delighted to have the opportunity to answer these questions. I confirm there are management changes taking place in the Health Service Executive. Work has been proceeding on these changes since the middle of last year. The CEO of the HSE recruited consultants to help him and the board of the executive to devise an appropriate organisational structure for the executive. Considerable work preceded the passage of the legislation to establish a unified service in 2004. Some called for its establishment as long ago as 1980. The legislation does not need to be changed as it provides flexibility to the CEO, which is appropriate, to delegate functions and organise the management structure as he or she sees fit. This must obviously be with the authority of the board of the HSE.

I have been in discussions with the HSE for quite some time. As we know, the higher review group on public pay drew attention last year to the need to have greater clarity regarding the management roles in the HSE. More recently, the Fitzgerald report drew attention to the systemic weaknesses in governance and management in regard to the events in Portlaoise. Following this, on 4 March, I wrote to the chairman of the HSE asking him whether the deficiencies identified in Portlaoise had wider application. In that context, the HSE is proposing it will continue with nine national directors but will consolidate, into one pillar, the National Hospitals Office and primary, community and continuing care. It believes it is appropriate when providing an integrated service to patients to merge the two pillars into one, not just at the top but right down the line. I support this.

Merging the pillars will mean that, at hospital level, there will not be confusion over whether a home care package comes from the hospital budget or another budget. The merger of the pillars will allow for a more effective response to the needs of patients. The population health directorate will be entering a new planning unit which will have different care managers. This will be headed by a director of planning, who will effectively be the person responsible for setting standards, making strategic plans and overseeing the implementation of change. The communications functions will be at directorial level. These are the changes taking place.

The HSE will continue to have nine national directors. It is simply a question of reorganising what they do, and particularly of elevating the post of director of communications to directorate level. All the directors will report to the CEO of the organisation and will carry out the responsibilities delegated by the CEO. There will be no increase in head count. Rather, when the new management structure is in place, as will occur over the coming months, the contrary will be the case.

At local level we want to consult stakeholders, particularly employees, on local arrangements and this will take some time. The intention is to recruit the directors at national level very quickly.

Recently, a new head of human resources started with the HSE. I had written to the HSE asking it to fill these posts because many posts at national level are held by people in an acting capacity, rather than by people who have been appointed to the positions. Clearly, that is unsatisfactory for an organisation that now is more than three years old. Consequently, I am delighted to note that a new head of human resources started recently with the HSE and he will be charged with overseeing the implementation of the new approach.

Essentially, what is happening in this regard is that many of the decisions that currently require approval at central level are being devolved to a more local level in respect of service delivery. One of the deficiencies identified in the Portlaoise report was that some people were managers for delivery of service, while also being involved in many strategic and national initiatives, such as negotiating with consultants or whatever. Clearly, those who have the responsibility to manage the delivery of services cannot focus completely on such delivery if they also are involved in national issues. The new organisational changes that are being made will bring an end to this, which is appropriate.

Many people have called for greater clarity and accountability. Many human resources gurus and management consultants have stated and advised — one telephoned me in this regard today — that to be able to devolve appropriately, one must centralise. One must know one's organisation and its capability. The HSE was not simply a merger of ten health boards and the Regional Health Authority. It also involved the merger within it of more than 50 different organisations. Clearly, before one even contemplates something like a redundancy plan, one must know what one's resources are, what resources one requires and what such resources should do. Notwithstanding the calls for redundancy programmes, the idea of a redundancy programme could not be entertained until clear organisational structure and lines of accountability were in place. As I noted earlier, this is a forerunner to giving consideration to what redundancy programme might be put in place, obviously on a voluntary basis.

Many of the changes that now are taking place have been called for in this House. More recently, the Labour Party outlined in a six-point plan proposals on how the Health Service Executive could function more appropriately. Some of these developments must be music to the ears of those in IMPACT and other trade unions who believed the decision making and day-to-day delivery of services to be over-centralised.

Finally, this change will involve an increase in neither budget nor headcount and will involve no change to legislation. Clearly, however, as Minister for Health and Children, notwithstanding the operational nature of the HSE's remit, it also is my responsibility to ensure that appropriate management and governance exists within the HSE. This is the reason the Department of Health and Children and I have been involved in detailed discussions over the past 12 months pertaining to the changes that now will be put into effect and which were communicated to the worker representatives through the unions this morning.

Jan O'Sullivan (Limerick East, Labour)
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Does this constitute an admission that the centralised structure, which was the Minister's big idea a couple of years ago, has failed? This is how it appears to me. While I appreciate the Minister's reference to the Labour Party's proposals, I am unsure whether her proposals closely resemble them. On the one hand, the Minister spoke of not being more centralised while, on the other, I understand that everyone will report to nine national directors at central level. The Minister should clarify this point because I now am more confused about what is being proposed than I was after reading this morning's edition of The Irish Times.

Are regional structures proposed? The article that appeared in The Irish Times today suggested that such regional structures were proposed. The Minister has made no mention of regional structures and were such structures not proposed, I would welcome it because the Labour Party seeks the devolution of decision making down as close as possible to the patient's level. If the Minister states she agrees with the Labour Party proposal, its Members are on her side in that regard.

I wish to question the Minister in respect of a number of issues. First, how is one supposed to believe this? On the introduction of the HSE, Members were told there would be fewer layers of management and more staff on the front line. However, the complete opposite happened. Will more than 600 managers still be at grade eight and above? Before the establishment of the HSE, one could count such managers on two hands. The Minister stated there would not be an increase in staff. However, where will such staff be located and will new people be brought in? The Minister mentioned a couple of new posts and mentioned various directorates as new posts. Can the Minister explain to Members what exactly will happen in respect of staff? Does she intend to thin out the existing top management levels?

In addition, the Minister stated that, essentially, she would make decision making more streamlined between community and hospital care. Can she explain exactly how she proposes to so do? Will this take place at local level or does the Minister continue to refer to an entity that is led from the top, is centrally controlled and in which those who wish to make a decision in their patients' interests are obliged to go to the top?

As I noted at the outset, I am considerably more confused now than I was after reading the newspaper this morning because the Minister now appears to be stating there will not be regional structures. I seek clarity on whether there will be such structures. As for the implementation of this initiative, has consultation taken place? What is going on and to whom is the Minister talking? Has the measure been costed and has the Minister done her homework in respect of how it is to be implemented from the perspective of personnel and so on?

It appears that what has been proposed is a good deal more confusing than the existing structures. Having read the Fitzgerald report on Portlaoise, it noted, for example, that when meetings were held on what to do, although five different kinds of managers attended such meetings, not a single clinician did so. The meetings were attended by network managers, safety managers, hospital managers and all sorts of managers. How will the Minister's proposals address the need to have clear decision-making processes at the level of the patient and which do not constitute a continuation of the mess that is the HSE at present, in which no one who tries to make decisions that are close to the patient has the power to so do but is obliged to refer them up the line?

Mary Harney (Dublin Mid West, Progressive Democrats)
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First, regional structures exist at present. On the hospital side there are eight network managers and on the community and primary care side, four regional structures are in place. Implementation units probably are what are being envisaged under these proposals, whereby the two will be together. For example, in the case of a long-stay patient in a hospital, the responsibility for funding either a home care package or a long-stay place rests not with the hospital, but with the primary and continuing community care division. This leads to many service deficiencies and we want it to be integrated as close to the patient as possible in order that someone on the ground can make that decision and that such a decision will not be inhibited because it affects someone else's budget.

Jan O'Sullivan (Limerick East, Labour)
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That is in the Labour Party's proposals.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Yes.

Jan O'Sullivan (Limerick East, Labour)
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So far so good.

Mary Harney (Dublin Mid West, Progressive Democrats)
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As for the new directorates, I wish to make clear that the people at the top, including the chief executive officer, are responsible for strategy, standards and configuration of services, such as, for example, the cancer plan. Professor Keane is implementing the cancer plan and this is a national role. Clearly, however, he has people at local level who are responsible for implementing it in Cork, Galway, Dublin or wherever. I wish to distinguish between service delivery, that is, the implementation of the strategy, and the people who are responsible at the top. In this regard, there will be a new post of clinical affairs director. I believe it is extremely important to have a clinician at national level with responsibility for risk assessment, protocols and the kind of issues that have emerged in recent years. The public has much greater confidence in a clinical response than in one from someone who does not have a clinical background. In fairness, Professor Drumm identified this deficiency approximately one year ago. He has put this in place at local level, including the Deputy's own area, where she is familiar with Professor Lyons who has responsibility for the implementation of the changes there. I believe this will work well.

The communications job is being elevated to director level because, as the Fitzgerald report highlighted and Members are aware, the HSE faces a major communications challenge to communicate what it is doing and to inspire confidence in the wonderful new things that are happening. I have stated in other fora that the HSE is somewhat like German unification. While it was known the principle was right, it takes one a long time to put together all the pieces. The current cancer plan, which is based on eight centres, would not have been developed had the health boards continued in existence because a number of areas will not have a designated centre. Similarly, we would not have consistency and uniformity in the way nursing home standards are being implemented. We would not have the current focus on where services are provided if the local hospital, as the Taoiseach said here the night he was elected, was the centre of the medical universe. We know high quality service cannot be provided at local level. None of that is possible without a unified organisation and I remain convinced it is the right way to go. As the Deputy is aware, other countries are going down the unified organisation route but that is not inconsistent with ensuring that for the day-to-day delivery of service, responsibility rests as close as possible to where services are provided.

The Deputy asked me about front-line staff on which I have given the statistics previously. It is wrong to say there has been an increase in administration staff at the expense of frontline staff but it is true that under the old health board regime there were many people in managerial roles with various titles and when a single organisation came together, both as a result of that and through IR issues that arose in connection with it, there was greater clarity on that aspect. I look forward to a reduction in the number of people in management positions but a precursor to that must be to have clear lines of accountability and responsibility before we go down a redundancy route. The purpose is to reduce the layers of bureaucracy.

On the Portlaoise issue, which the Deputy mentioned, one of the criticisms was that the person responsible for the hospital was also involved in a great deal of national activity and clearly one cannot do the two. That is why it is important that some people are concerned with the national focus. In some countries some people are involved with the reform and others get on with the delivery of the services on a day-to-day basis. That is what is happening here and it makes a great deal of sense.

James Reilly (Dublin North, Fine Gael)
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I thank the Minister for coming into the House to take this Private Notice Question on a rather miserable July day.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I am not responsible for that. I hope the Deputy is not blaming me for it.

Jan O'Sullivan (Limerick East, Labour)
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Climate change.

James Reilly (Dublin North, Fine Gael)
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No, but the Minister's Government is responsible for the misery patients suffer under the Health Service Executive and that we must suffer in terms of the finances of the country.

Like Deputy O'Sullivan, I am no clearer now on the position and I want to ask the Minister a specific question. It is reported in The Irish Times that there will be four or possibly eight new regional management structures. Is the Minister telling the House there will be new management structures regionally or there will not because it is not clear from what she has said? It said also that the existing services would be broken up and existing management structures streamlined. If that is not true, I would like the Minister to clearly indicate that.

The Minister mentioned redundancies, something we have all looked for, but it is clear that should have been done before the HSE was formed. The Minister coming into the House and talking about more changes in anticipation of redundancies down the road is a recurring theme because whether it is cancer services she referred to or other services, removing existing services today on a promise of something wonderful to come tomorrow is wrong. We now have another plan that promises to deliver something further down the line. The Minister's promises have not been well kept. She promised there would not be any health cuts, but there were, and she promised they would not hurt patients, but they did.

Some time ago I asked the four questions I felt had to be answerable by management in the HSE. They were not answerable in either the Fitzgerald report or the Doherty report. Can the Minister give us a guarantee as a result of this measure that in the future management will be able to say who made the decision, why it was made, what it cost and, most important, how it impacted on patient care because none of this matters a whit if that is not the net result?

Furthermore, anybody in the HSE should be able to say what is their job, who they report to and who reports to them. If, as a result of these changes, the Minister can say those questions can be answered she will have done a good day's work but, unfortunately, I do not believe from what the Minster has said that that will be the case.

Another recurring theme of the Government is that the Minister intends to promote the communications director to that of national director. If that director was to control internal communication, which is a major deficit within the HSE, that might be something we could applaud the Minister for, but I have a sneaking suspicion, having listened to her outline all the wonderful work going on in the HSE that must be communicated to the wider public, that we are back to another Transport 21 situation where €15 million was spent on explaining to people why Transport 21 is not being delivered while telling them about all the great measures that will be taken.

The same is being done with the HSE. It seems to be a case of more money spent with very little gain for the patient. That is the major issue. How will patients benefit from this measure? Rather than the philosophical, patient centred wonderful words we heard from the Minister, we should see some action because we have seen no action that has resulted in true improvements for patients.

The Minister has told us in the past, as has the chief executive of the HSE, that services have improved, the figures are much better etc., yet independent figures taken from the Irish Association for Emergency Medicine show that in Beaumont Hospital the figures for the number of people lying on trolleys for over 12 hours waiting for a bed in April of last year were in the region of 380. Last April the figure was 904. It is the same in Galway. The figure was 185 in April last year while this year in April the figure was 444. That is one of the regions that will be a centre of excellence for cancer services, which are being delivered to an excellent standard currently in Mayo and Sligo, but the Minister wants to remove them and locate them in Galway where there is no adequate parking, there is a €4.6 million ICU suite that cannot be used because there is no staff and in April or May they were already €4.6 million over their budget. I do not know what the figure is now. There are all the signs of overcrowding, with the accident and emergency figures and MRSA.

I believe the Minister has taken notes of the main question but I want to ask one other question.

Brendan Howlin (Wexford, Labour)
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I will call the Deputy again.

James Reilly (Dublin North, Fine Gael)
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Will the Minister confirm that there was no increasing cost as a result of all these grade 8 appointments because I am sure that was the case?

Mary Harney (Dublin Mid West, Progressive Democrats)
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To repeat again, I remain a strong fan of a unified service. I will give the figures for the cancer plan because it is so important. Our outcomes in Ireland — 18th out of 23 countries in Europe — are very bad. It is important that we put in place the appropriate services for cancer patients, but that did not happen. We saw what happened in the midlands when there was a piece of the action for every hospital in the region and we could not get multidisciplinary expert care.

James Reilly (Dublin North, Fine Gael)
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When they were not properly resourced.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Deputy Reilly is a doctor and he knows that with breast cancer, 150 new patients a year are needed to warrant the kind of skill, training and throughput to deliver quality services.

James Reilly (Dublin North, Fine Gael)
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Each centre, not each individual——

Mary Harney (Dublin Mid West, Progressive Democrats)
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Deputy Reilly will always go on about the measures that do not work. Every vested interest in the health system that has a whinge seems to be able to get it aired on the floor of the House but the reality is that accident and emergency services have improved greatly since the establishment of the HSE, and the Deputy knows that.

James Reilly (Dublin North, Fine Gael)
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It has not. I refute that.

Mary Harney (Dublin Mid West, Progressive Democrats)
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The idea that before an organisation is established we can start deciding who to make redundant——

James Reilly (Dublin North, Fine Gael)
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Any merger would do that.

Mary Harney (Dublin Mid West, Progressive Democrats)
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We cannot do that. I have no expertise in this area but I have spoken to quite a few people in other sectors who have and they all say that we need to centralise before we devolve and know what we have in place. For Professor Drumm or the board of the HSE to decide before the organisation was put together who they would get rid of would not have made sense. Some people, like CEOs, went because we abolished their jobs by law——

Dan Neville (Limerick West, Fine Gael)
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We reappointed them.

Mary Harney (Dublin Mid West, Progressive Democrats)
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The organisation has to be put into effect before deciding the management structure that is required, the individuals or whatever. The idea is to have fewer layers of bureaucracy.

The Deputy asked me about regional structures. We have regional structures currently. We have eight network managers for hospitals and four such persons for community continuing care. In the first instance they will be brought together because it does not make sense to have them separate. We want to have consultation with stakeholders and the HSE should have consultation. It is the employer, either directly or indirectly, of 130,000 people. It wants to and should have consultation with stakeholders, community groups and others. What the shape of those operational units will be — whether there will be six or eight — is not yet determined. It is around that ballpark figure on which they are having discussions. The first measure taken today was that the structure agreed by the board and supported by me, my Department and the Government was put forward to the IMPACT union and other unions today. That is the first step because, obviously, it affects many people who work in the organisation.

I was asked about a voluntary redundancy programme. I remain committed to a redundancy programme, once we know what we want to do by way of numbers and what is required to do the job. In particular, we do not want to lose——

James Reilly (Dublin North, Fine Gael)
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Mañana.

Mary Harney (Dublin Mid West, Progressive Democrats)
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It is not. This State does not have a good history of redundancy programmes. Sometimes the best people go and then they come back as consultants. We want to ensure before a redundancy programme is devised that we put this organisational structure in place.

On communications, even Deputy Reilly's own organisation, Fine Gael, has a director of communications, who is an excellent person. Surely an organisation that spends a budget of €16 billion is entitled to have a director of communications at a reasonable level. I do not think anybody would begrudge that. It is important for internal communications and for external communications.

All of the directors report to the CEO. Professor Drumm remains the CEO for the organisation. He is given significant powers in the legislation that established the organisation to delegate etc. He remains responsible and people report to him.

Brendan Howlin (Wexford, Labour)
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There are four minutes left and three Deputies indicating. I will try to accommodate them. I call Deputy Finian McGrath.

Finian McGrath (Dublin North Central, Independent)
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I welcome the Minister's response on the managerial issues within the HSE. They were constructive and positive solutions.

Brendan Howlin (Wexford, Labour)
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A brief question.

Finian McGrath (Dublin North Central, Independent)
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I have three short questions. First, will the improvement in the management structures planned in the regional areas improve delivery of services for persons with disability?

My second question relates to the communications challenge. The Minister accepted there is a negative image of sections of HSE services. How do we improve that?

My third question relates to the redundancies. The sum of €30 million would appear to be a high cost. How does one prevent top quality staff leaving the senior management and medical sections of the HSE?

Brendan Howlin (Wexford, Labour)
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I will take Deputy Barrett's question as well.

Seán Barrett (Dún Laoghaire, Fine Gael)
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Is the Minister aware that it seems to be official policy that an elderly person who is seeking accommodation in long-stay nursing home facilities is being told officially in a letter I received yesterday that one of the ways of doing so is to remain in a bed in a public hospital until a place in a public nursing home facility becomes available? In other words, we are now being told that one brings somebody through accident and emergency into a hospital to remain in a bed until a place becomes available.

Brendan Howlin (Wexford, Labour)
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It is an important issue but perhaps it would be more suited to an Adjournment debate.

Seán Barrett (Dún Laoghaire, Fine Gael)
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Is this official policy, which I received by way of letter yesterday?

Mary Harney (Dublin Mid West, Progressive Democrats)
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If I could start with Deputy Barrett, I would be horrified to think that it was an official letter. I would like to see the letter, if he would share it with me.

Seán Barrett (Dún Laoghaire, Fine Gael)
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It is a letter.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Of course it is not the policy. The policy is to allocate long-stay beds to those who need them most. In fact, the policy is very much to keep people out of long-term care and to encourage people to stay at home with home-care packages and clinical support. From a zero base five years ago, we now have 11,000 such persons being supported at home. That is what older people want. If the Deputy would share the letter with me, I would like to pursue it.

In reply to Deputy Finian McGrath, the HSE is an enabler of providing services. It is not the panacea, or anything like it, nor could any organisation be. The purpose in having a unified organisation, and the reason so many people advocated it — all the parties in this House supported it although they had issues about the speed at which we implemented the legislation — and former Deputy Ivan Yates, in 1998, recommended it was because they believed it was a more appropriate way of providing better services. I believe it will provide better services. In particular, it will allow decisions around services to be made locally. At present, if one wants to make simple decisions, he or she must go into Professor Drumm's office.

That brings me to the issue of redundancy. With appropriate management structures right down the line, one will provide incentives to people to remain in an organisation where their talents are used appropriately, where they have got responsibility and where they can make key decisions. Nobody would want to stay in an organisation where they felt they had no real role except passing issues up the line, and that will be important.

It is too early to speak of redundancies. Clearly, there will be capacity to reduce the number of people who work for the Health Service Executive, not just in the corporate HSE headquarters where there are approximately 3,800 but in the health service generally. We must ensure, before we even embark on that, that we encourage the right people to stay. That is a human resource job. Other organisations can do it successfully and I believe we can too.

Brendan Howlin (Wexford, Labour)
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That concludes the time allocated for Private Notice Questions.