Wednesday, 7 November 2018
Children's Health Bill 2018 [Seanad]: Report and Final Stages
I move amendment No. 1:
In page 6, line 9, after “section 5” to insert “, known as the Kathleen Lynn National Children’s Hospital”.
This amendment is close to my heart. I first wrote to a Minister for Health in 2013, or perhaps it was even before that, when Senator Reilly was in charge of the health portfolio. I subsequently wrote to his successor, now Taoiseach, Deputy Varadkar. I also wrote to the current Minister, Deputy Harris. The reason I wrote to the Ministers for Health is that they are ones overseeing the development in St. James's Hospital, in what was the South Dublin Union, of a new children’s hospital. I always felt that in naming the hospital it would be appropriate for us to pay homage to those who were the front runners in children's health in this country. We know of the earlier attempt to name it when with some fanfare the name Phoenix hospital was chosen. That debacle came to an abrupt end when the Phoenix Children's Hospital in the United States reminded those who could not do a Google search that it existed and that it would possibly sue if the name was used.
That brings me back to the letters I wrote asking for Kathleen Lynn who was a pioneer in every sense in the medical field for children to be remembered by naming a hospital after her. We should remember that it was she who in 1919 set up the first children's hospital in this city, Saint Ultan's Children's Hospital. Would it not be appropriate, almost 100 years later, to name the new, far-reaching state-of-the-art hospital after someone who in her time showed such vision? Kathleen Lynn was from County Mayo. She attended the Catholic University Medical School on Cecilia Street and graduated in 1899. She was a pioneer because at that stage few women qualified as nurses or doctors. She qualified as a doctor. She also attended the Royal College of Surgeons in Ireland. She set up in private practice where she was living at the time on Belgrave Road in Rathmines. She was a pioneer and also a radical in many other fields. She was a leading member of the Irish Citizen Army.
Originally I wrote my request prior to the centenary of the 1916 Rising. In 2016 I said it would be appropriate to remember Kathleen Lynn because of her role as the only female commandant during the 1916 Rising. She came to that position having been second in command of the Irish Citizen Army garrison that took over City Hall and the Rates Office. The first in command, Sean Connolly, who had been an actor in the Abbey Theatre, was shot dead on the roof and Kathleen Lynn became the commandant, a fact that is forgotten. Ms Markievicz is always regarded as the female volunteer who had the highest status during the 1916 Rising, but, in fact, she was in second in command.
Kathleen Lynn has left a legacy beyond politics in the city where she was both a Deputy and a councillor. She stood for election in the Rathmines area. If nothing else, she should be remembered for her work in the health service and setting up Saint Ultan's Children's Hospital. I am not the only who is making the case for her. Sometimes people say it is simply because she was a Sinn Féin woman for a certain period, but that is not the reason I have come to believe Kathleen Lynn should be remembered. It is also because of her pioneering nature. During the years I have talked to historians and others who have views on the naming of buildings and the like. I know that I am supported in the demand that the hospital be named after her by the likes of Diarmaid Ferriter, Dr. Mary McAuliffe and Martin Mansergh, with whom I had a long discussion. He believed it was appropriate that the hospital would be named after her. Diarmaid Ferriter wrote an article in October last year after the debacle surrounding the name Phoenix for the hospital. He quoted others, including Professor Mary Morgan, president of the Royal College of Physicians of Ireland, who supported the idea that the hospital should be named after Dr. Lynn. The idea was also promoted by the ophthalmologist Tim Horgan. There are others also. In his article Diarmaid Ferriter outlined starkly how, in the midst of the revolution in Ireland in the first two decades of the 20th century, Kathleen Lynn had established Saint Ultan's Children's Hospital on Charelmont Street in 1919 with her confident, Madeleine Ffrench-Mullen. It was to provide medical and educational facilities for impoverished infants and their mothers. That underlines the seriousness with which the women had taken the point made in 1917 about tacking social problems. Diarmaid Ferriter outlined earlier in the article what was happening at the time. Dr. Dorothy Stopford Price also worked in the hospital. She was the first doctor to introduce the Bacillus Calmette–Guérin vaccine. That illustrates the pioneering nature of the hospital.
I am trying to encourage the Government to accept the amendment in recognition of the work done and the woman who led it and stood by it. Kathleen Lynn's legacy is significant, not only in terms of the work done by the hospital or her revolutionary involvement but also in terms of her medical and social work for Irish children because she battled the sectarianism and prejudice that faced women and the poor in this city.
I do not propose to accept amendments Nos. 1 and 2. The legal name of the new body in the Bill is Children's Health Ireland. The broad name reflects the objectives and functions of the new body which are broader than simply those of a hospital. As the Minister mentioned during the debate on Second Stage, it is considered that it may be useful for the new body to have an operational or brand name. Several names have been suggested for the new body, including that of Kathleen Lynn, a former Member of the House and co-founder of Saint Ultan's Children's Hospital. I agree with the Deputy that Dr. Lynn's work during her lifetime, including on behalf of impoverished women and ill babies in Ireland, was exceptional. The Department is engaging with the children's hospital group on arrangements for the new process to agree a name that will be endorsed by the Government. That process has yet to begin. It is expected to acknowledge the work undertaken in the previous naming process and the valuable input of staff, patients, service users and the Youth Advisory Council. The names suggested include that of Kathleen Lynn which will be considered as part of the process. The new operational name will be endorsed by the Government before it is announced. Accordingly, I do not intend to accept amendment No. 1.
The objects of the new body are set out clearly in the Bill. They include improving, promoting and protecting the health and well-being of children. The objective of the Bill is to create a new body that will be responsible for the governance and management of Ireland's national paediatric centre. It will also be expected to have a leadership role in the implementation of the model of care for children. The new children's hospital will include a 20-bed acute child and adolescent mental health inpatient unit. As Deputies are probably aware, the body needs to be a formally approved service provider under the Mental Health Act to provide such services. The provider of mental health services in the new hospital will be the child and adolescent mental health services of the HSE, rather than the new body. Since the provision of the mental health services located in the new children's hospital will remain with the HSE and the new body will not seek to be formally approved for this purpose under the Mental Health Act, it would not be appropriate or correct to reference mental health as a function of the new body. However, in providing services for which the new body will have responsibility it will be mindful of children's mental health needs. It is worth repeating that among the functions of the new body is the function to provide for patient safety, equality of patients and care in the hospital. Accordingly, I do not intend to accept amendment No. 2.
I wish to address Deputy Ó Snodaigh's final remarks about Kathleen Lynn. I acknowledge that a Kathleen Lynn medal has been awarded to people who undertake exceptional service on behalf of children. It is a major acknowledgement of a lady who, as the Deputy said, was at the forefront in dealing with children, especially in paediatric services.
I welcome the opportunity to speak to the two amendments. To respond to the Minister of State on amendment No. 2, I find it difficult to understand the reason for not including the term "mental health" in the Bill given that mental health is as important as physical health and that this relates to the children's hospital. I support the amendment.
I agree with the Minister of State on amendment No. 1, which proposes to name the hospital the Kathleen Lynn National Children’s Hospital. We have to give the new body or board some authority or control when it takes over the hospital and it should be a matter for it to decide on the name. It is not for the Oireachtas to assume that responsibility. We should stick to what is in the Bill and be supportive of the new body or board when it is set up. I acknowledge that Dr. Kathleen Lynn did much good work and it is appropriate that Deputy Ó Snodaigh would want to name the hospital after her. However, that is not a matter for this House to decide but a decision for the board or body to take.
I had intended to speak to amendment No. 2 in my first contribution. It would be illogical in this day and age not to mention mental health. The proposal in the amendment does not give rise to an extra cost or present a major difficulty. There is an acknowledgement that mental health falls under health in general. However, given the scale of the issues involved and the fact that, as the Minister of State outlined, some of the provisions of the Bill deal with mental health, surely mental health should be mentioned in its own right. We are much more enlightened now than we were in the past and that enlightenment allows us to call things as they are. Including a specific reference to mental health, as proposed in amendment No. 2, is not an onerous ask and should be done.
On amendment No. 1, it is a pity that this has not been done at this stage. I first asked about the establishment of a national children's development board or similar in 2011 or 2012 because it was provided for in the programme for Government in 2011. I have asked about the development board three times per year ever since because it was supposed to have been set up. It would have dealt with the question of the name of the new hospital before a sod was turned on the site. I was told it would be in place before a sod was turned but the sods have been turned and there is a hole in the ground. The Minister of State knows that because she lives close to the site and probably sees the effects of it every day. The decision on the Phoenix hospital name was announced last October. We were told then that we would have a naming system, but it has not started a year later. For this reason, my party does not have faith in the decision to wait because this or that might happen. I am pressing amendment No. 1 which specifically provides that the hospital be named after one of the most pioneering women in Irish medical history.
I replied already. The HSE's child and adolescent mental health services, CAMHS, will be responsible for the provision of mental health services. While the new children’s hospital will include a 20-bed acute CAMHS inpatient unit, the provider of the service will be the CAMHS service of the HSE, rather than the new body. It is for this reason that the term "mental health" is not included.
I am pressing the amendment. It is a pity that we are left with the national paediatric development hospital or whatever title we want to give it today as an operational or brand name. The hospital is being built and will probably open in two years. We are all waiting with bated breath. The plan was welcome and it will be a beautiful hospital, but it does not have a name. The name we are proposing is appropriate, including because the site featured in the 1916 Rising. The South Dublin Union was held by the volunteers, so St. James's Hospital has that history as well.
If we associate the new children's hospital with a pioneering medic, nobody will give out. If the amendment is defeated tonight, I will have no problem encouraging all of those I mentioned earlier and others who have contacted me in recent weeks and over the years to liaise with whatever consultative mechanism is set up to try to come up with a name. It is often a bad approach to agree everything by committee because we will end up not delivering for everyone. In this case, the State has the power. It is providing the money and it can make the decision. It should, therefore, call it rather than delaying this issue unduly as has been the case thus far.
Richard Boyd Barrett, John Brady, Tommy Broughan, Pat Buckley, Michael Collins, Ruth Coppinger, Seán Crowe, David Cullinane, Pearse Doherty, Dessie Ellis, Martin Ferris, Peter Fitzpatrick, Kathleen Funchion, Danny Healy-Rae, Michael Healy-Rae, Séamus Healy, Alan Kelly, Martin Kenny, Mattie McGrath, Denise Mitchell, Imelda Munster, Catherine Murphy, Paul Murphy, Aengus Ó Snodaigh, Jonathan O'Brien, Louise O'Reilly, Maureen O'Sullivan, Thomas Pringle, Maurice Quinlivan, Brendan Ryan, Seán Sherlock, Bríd Smith, Peadar Tóibín.
Bobby Aylward, Maria Bailey, Seán Barrett, John Brassil, Pat Breen, James Browne, Richard Bruton, Peter Burke, Catherine Byrne, Jackie Cahill, Seán Canney, Ciarán Cannon, Joe Carey, Pat Casey, Niall Collins, Marcella Corcoran Kennedy, Simon Coveney, Michael Creed, John Curran, Michael D'Arcy, Jim Daly, John Deasy, Pat Deering, Regina Doherty, Stephen Donnelly, Paschal Donohoe, Bernard Durkan, Damien English, Alan Farrell, Frances Fitzgerald, Charles Flanagan, Brendan Griffin, John Halligan, Simon Harris, Michael Harty, Seán Haughey, Billy Kelleher, Seán Kyne, John Lahart, James Lawless, Charlie McConalogue, Michael McGrath, John McGuinness, Joe McHugh, Tony McLoughlin, Josepha Madigan, Mary Mitchell O'Connor, Aindrias Moynihan, Michael Moynihan, Margaret Murphy O'Mahony, Eugene Murphy, Denis Naughten, Hildegarde Naughton, Tom Neville, Michael Noonan, Kate O'Connell, Patrick O'Donovan, Fergus O'Dowd, Kevin O'Keeffe, Fiona O'Loughlin, Frank O'Rourke, John Paul Phelan, Anne Rabbitte, Michael Ring, Noel Rock, Eamon Scanlon, Brendan Smith, Niamh Smyth, David Stanton.
I move amendment No. 3:
In page 8, to delete lines 24 to 26.
The reason I have included amendment No. 3 is that I believe this subsection is questionable in some way. It exemplifies what is often called "mission creep", that is, a gradual shift in objectives which often results in unplanned changes in the longer term. I do not see why Children's Health Ireland would need to acquire, hold or dispose of shares or other interests in a company or to become a member of a company. The hospital and the board have a mission, that is, to provide paediatric healthcare for children across the State. I do not see why the board of a children's hospital would need to become a member of a company. Under other sections, for example, section 8, the board will have scope to establish subsidiaries, etc. It may also have room to take part in the formation of a company. It is curious, in the context of this amendment, why Children's Health Ireland would need to have the ability to become a member of a company, which would not be appropriate. There is more to this than meets the eye.
On amendment No. 4, I understand the need for a provision to borrow for capital purposes against the income and assets of the hospital. It is a provision which is used by many universities across the State. However, I do not see why a hospital would need to borrow for current purposes, given that the State should be funding it to deliver in line with demand. Hospitals run by the State should be funded for the provision of services from the Exchequer. If the word is left in the Bill, it will allows this or any other Government to underfund the hospital in the future and instruct it to borrow money to provide paediatric healthcare services. It is strange. The inclusion of the word allows for exploitation in borrowing for such purposes. It is something of which we should be wary.
I do not propose to accept amendments Nos. 3 and 4. The new body must have an arrangement with multiple universities, academic institutions and research bodies owing to its national remit in the education of healthcare professionals in paediatrics and engagement in paediatric research. The formal arrangements between the universities and the new body will require some corporate identity to be decided. While it is not yet clear, it is considered prudent to allow the new body to become a member of a company, subject, of course, as one can see, to the consent of the Minister. The provision also keeps options open for the type of structure that may be required for a body to carry out philanthropy for Children's Health Ireland.
On amendment No. 4, the provision which allows the new body to borrow for current, as well as capital, purposes is considered useful, but, as one can see from the Bill, it is strictly controlled. The ability of service providers to avail of strategic investment opportunities in the public interest, within legal control limits, must be seen as a progressive step in managing hospital facilities into the future. I understand there may be a concern that the retention of this provision will allow this and other Governments to underfund the hospital and exploit the provision by instructing the new body to borrow money for the purposes of providing healthcare services. Let me reassure the Deputy that the new body will be funded by the State as a section 38 agency, as the three children's hospitals currently are, through a service level agreement reached with the HSE. The primary driver for a service provider to borrow is better value in services provided for patients in a cost effective and timely manner. The provision will allow the board to respond to strategic opportunities or needs as they arise. Borrowing for current purposes could be considered in situations where the hospital did not have sufficient internal funding resources in the short term to develop a service but was able to demonstrate longer term viability and an ability to repay.
The ability to borrow within controls creates that opportunity.
Circumstances in which the new children’s hospital would make a case to borrow money, or engage in activities that had an element of borrowing, could also arise in regard to leasing or the licensing of commercial areas, the leasing of equipment or investing in a strategic service initiative. This could include expanding operational capacity in a service that has hospital income generating potential such as attracting international patients to avail of cutting edge high technology services or specialist paediatric expertise and experience that will be available in the new hospital. There is also the need to consider possible scenarios where the new body could require the potential to borrow to invest in extending existing services further to provide cross-jurisdictional services, for example, for children from Northern Ireland, which could generate hospital income to repay initial borrowings. As part of an accountability framework, all such scenarios would be subject to the approval of a business case demonstrating a return on investment, with the potential to repay borrowings and generate hospital income.
The Bill allows for proper and fully accountable governance and management within the framework of national policy. It is acknowledged that since the new body will be largely funded by the State, its borrowings would form part of the overall public debt of the State, as assessed by the European Union and other bodies and that the State must exercise control before such liabilities are undertaken. The Bill, therefore, includes a provision for borrowing, subject to the approval of the HSE and the Minister, as well as the approval of the Minister for Finance and Public Expenditure and Reform. It is, therefore, considered appropriate to provide for the potential to borrow in the Bill. Accordingly, I do not intend to accept amendments Nos. 3 and 4.
That is a pity. I believed the Minister of State might think about the amendments again, in particular amendment No. 4, which deals with borrowing. I cannot and should not be able to foresee a situation where a children's hospital would be required to borrow to meet its day-to-day expenditure. It would be a sad day for Ireland if that were to be the case. However, we can all see the basket case that is the funding of hospitals, given that every year they are left short of what is required to meet capital expenditure. For example, in recent years the Minister for Finance has had to come into the House with a supplementary budget. This is due to incompetence in drawing up the exact figure required. We would not see this happen in the future if the children's hospital was told that it would not be given a supplementary budget and that it would have to borrow for three or six months until the time of the next budget. If that were to happen, we would have to work out how to give it money for that year and the following year at the same time, or else ask it to tighten its spending. That is what it is being asked to do. The amendment we have put forward suggests we leave out the reference to borrowing for current expenditure purposes.
Amendment No. 3 deals with a strange issue. The Minister of State has admitted that it is being inserted to keep options open, which is not a good enough reply. I raised the question of when we would see Children's Health Ireland having the ability to become a company and use a corporate identity. It is a hospital with a hospital board, of which we need to be aware. As I said, it is to provide paediatric healthcare services, not to be a corporate entity.
I move amendment No. 6:
In page 15, line 31, to delete “or a local authority”.
Amendments Nos. 6 to 8, inclusive, were tied to amendment No. 5, in the name of Deputy Louise O'Reilly, which has been ruled out of order in a bizarre manner, although we will not go into it. The intention of the four amendments was to try to ensure representatives of workers, patients and Dublin City Council would be on the board in some form or other. We have seen this happen during the years. For example, there are Dublin City Council representatives on the board of Our Lady's Children's Hospital in Crumlin, something which has served the hospital and patients well. As I was never a member of Dublin City Council, I do not say that because I was a part of it.
Perhaps it might have been better to stick with the old health boards and tweak them a little, as there might not be as much chaos as there is. Sometimes the more local board members are, the better their understanding. It can also bring some expertise. A representative of workers could be a representative of the ICTU, for example. In many hospitals we find that by the time an issue enters the public domain, it is usually getting very close to a strike. However, if issues were raised early enough at board level by workers' representatives, problems might not arise because those who would take wrong decisions would not take them because they would be afraid the issues would be raised at board level. That is why workers' representatives should be on a board. They could answer about what was going on with staff or how changes in management decisions were affecting the running of the hospital. The most practical solutions in a hospital often come from staff, in particular front-line staff and from the ground up. It is about trying to get them to board level in order that the staff would be listened to and have their concerns acted on as early as possible, rather than having them fester.
The idea of a patient advocate is a no-brainer, but as I said, that amendment was ruled out of order and the other three are tied to it. I will still pursue them because there is logic behind them, but they are consequential on amendment No. 5.
I do not propose to accept amendments Nos. 6 to 8, inclusive. This is a common legislative provision that provides that a person may not be appointed to the board or remain on it if he or she is or becomes a Member of the Oireachtas, the European Parliament or a local authority. The reason for it is to keep the work of the new body apolitical. As I stated, the Bill provides that the board is competency-based. I am sure we can all agree that that is what is required for a body of this nature and national importance.
Best practice should dictate whether a person should be considered for board membership. There should be no perception that the person could be biased or influenced in the independent decisions to be made by the board owing to a particular political affiliation. Accordingly, I do not propose to accept amendments Nos. 6 to 8, inclusive.
I understand the logic behind what the Minister of State has said. It was never intended to be in the gift of one party or another to be able to appoint a person to a board. The appointments could be made by way of a lottery of those in a council who were interested who could serve for a single term only and so on. It does not have to be political. Local authority members are not paid at the rate at which they should be. They are not Deputies or Senators who can influence legislation; they are ordinary citizens who often have a huge wealth of expertise and knowledge. Despite the fact that their jobs are not full-time, they are being excluded from potentially playing a vital or beneficial role on a children's hospital board, which is strange. I can understand the logic behind excluding Deputies and MEPs and I am not arguing that they be considered, but we should not be ruling out people just because they work part-time as councillors. Some of them work full-time, but they are not paid for it. There could be a retired paediatric doctor who is also a councillor whose expertise would be vital and he or she could be asked to choose between being a councillor representing his or her local community and city and taking up membership of the board. I do not think we should be turning down expertise in the form of, say, the best manager of a company in the world on the basis that he or she is an elected representative. In this case, it is wrong to refuse such expertise.
I understand where Deputy Ó Snodaigh is coming from on this issue. In Galway the health forum provides an opportunity for public representatives, advocacy groups and other persons to participate. It allows everybody to contribute. I note the Minister of State's point that in the future, when the next children's hospital has been established, she will review and engage on the issue in the context of best practice throughout the country. I agree with Deputy Ó Snodaigh that local councillors should not be ruled out because they have a wealth of knowledge about what is going on. I will give an example of what works really well in Galway which has nothing to do with the health service. I refer to the joint policing committees, JPCs. This format could work well in the case of the hospital. The JPCs are made up of councillors and representatives of a wide variety of community groups, all of whom participate in a positive and collaborative way. In the case of the hospital, the members of the board would advocate for staff and the provision of services in working with the Department. That could be a positive result. At this point it might be too prescriptive in writing the future in terms of who can and cannot be considered, but I would not like to see us take the route of ruling out councillors or people with relevant expertise. I cite the JPCs and the health forum as good examples in that regard.
I move amendment No. 9:
In page 18, line 9, after "Children's Health Ireland" to insert "and its subsidiaries".
These amendments seek to ensure subsidiaries of Children's Health Ireland will be subject to the oversight of the Committee of Public Accounts and the Comptroller and Auditor General. All too often, there is little or no public accountability by subsidiaries of State companies or organisations. I am sure all Members are aware of situations where a chief executive officer or other representative of a State company or organisation has told the Committee of Public Accounts that he or she cannot answer questions about a subsidiary as neither of the bodies has oversight of or responsibility for that subsidiary. The amendments are practical and sensible. They seek to ensure transparency into the future in the spending of public moneys. I hope they would also add to public trust in the project.
The amendments relate to the appearance of the chief executive officer, CEO, before the Committee of Public Accounts. The purpose for which the CEO appears before it is to enable the committee to examine and report to Dáil Éireann on the annual financial statements and reports of the Comptroller and Auditor General on Children’s Health Ireland. Children’s Health Ireland will be preparing financial statements that will follow the standard rules and be audited by the Comptroller and Auditor General. Section 9 of Financial Reporting Standard 102 deals with the requirement to prepare consolidated financial statements. Under the section, the new body will be required to present a financial statement for itself and any of its subsidiaries on a consolidated basis. This means that the CEO is already required to give evidence on the economy and efficiency of a subsidiary of the new body in the use of its resources and the systems, procedures and practices employed by a subsidiary of the new body for the purpose of evaluating the effectiveness of its operations. It would, therefore, be unnecessary to reference this separately. Accordingly, I do not intend to accept amendments Nos. 9 and 10.
It is a pity the Minister of State is not accepting the amendments, particularly in the light of how subsidiaries and organisations that have received State funding, albeit not always directly but through a State agency, have in the past avoided accounting in full for how funding was spent. I accept that the intention is that all of the companies are to be audited under the standard rules, but during the years, at the Committee of Public Accounts in particular, not only in this term but in every other term also, these standards have not been achieved in some organisations, while in others they have only been achieved somewhat. Some companies are very willing and able to account for very last cent they spend. Allowing companies involved in medical spending or spending any public funds to be one step removed does not add to the intention that all State companies and their subsidiaries will be open to scrutiny, if required by the Comptroller and Auditor General, in particular, but also by the Houses of the Oireachtas which passes the Votes to meet the expenses of these organisations via the HSE, Children's Health Ireland or some other mechanism.