Brian Lenihan Jnr (Dublin West, Fianna Fail)

The Prospectus report recommended very far-reaching changes in our health structures. In a House in great part elected by local representatives it is understandable that concerns have been expressed on all sides at the prospect of eliminating the local councillor as a key feature in securing accountability in the health system. Senator Mansergh highlighted this concern and I reply to him by asking him to consider the historical position regarding the organisation of our health services.

We started with the poor law unions in the 1830s and the original health services were organised on a poor law union basis — a sub-county unit — and certain elementary services were introduced through that structure. We then moved to a county-based system at the foundation of the State with the services centralised on a county basis. In 1970, the then Minister for Health, Mr. Erskine Childers, introduced the current health board system we all know and love so well as it was found that the county was inadequate as a unit. While I am not making judgments about the Hanly report or any other issues, the county as a unit was not sufficient. Prior to the 1970 Act, many local authorities had already formed joint county boards to administer particular hospitals and health services. As the county was seen simply as being too small a unit, we adopted a regional approach in 1970.

There have been significant social changes in the 34 years since. Communications, medical technology and the nature and character of our social services have changed a great deal. It is understandable to adopt a unified approach to the administration of the health system in a state with a population of only 3.7 million. There are many single health authorities in other parts of the world which cater to populations well in excess of 3.7 million and there is a solid intellectual case to be made against fragmenting the organisation and delivery of services across eight health boards. People in public life will be well aware of obvious examples of problems in this regard. Whether medical card guidelines can be waived and a special or exceptional case made rests ultimately with the discretion of the chief executive officer of a health board. Is it right from the point of view of the citizen that his or her entitlement to a medical card should be dependent in exceptional cases on the discretion of an executive officer who may follow a different set of criteria to those followed by his or her seven peers? Clearly, it is not and the public does not understand why this practice obtains.

It is clear that there has been a revolution in hospital management and practices with significant increases in the costs borne by the Exchequer to provide services. That is as it should be. If one considers hospital services in their totality, it is clear that there is a significant degree of interdependence. To maintain that a health board area has a self-sufficient hospital service is to state the unreal given modern medicine as it obtains in Ireland today.

I do not make judgments on the Hanly report as that is a debate for another day. Senator Leyden expressed his views on the report very clearly and I do not want to go down that road now. This Bill is not about the Hanly report, it is about how we organise the health service.

Almost every Senator said there must be a real and proper role for local authority members in the context of the delivery of health services. I agree with them. It must be remembered that health service funding is borne by the Exchequer and he who pays the piper must be allowed to call the tune. There must be some form of central direction in a system where the funding is being provided from the Oireachtas. However, the size and complexity of the system, the vast numbers of staff deployed and the significant range of health and social services provided make it essential to ensure that local authority members continue to have a real contribution to make to the assessment of delivery. The Minister subscribes to this point of view. Senator White outlined how he was brought around to it in the course of her contribution. Continuing input from local authority members is one way of ensuring accountability in the system in a very important way.

I hope Senators will forgive me for not responding to every contribution in turn. I have replied in a general sense to the points which have been made. It is important to note the issues raised about complaints and an ombudsman. The statutory framework for complaints will provide for an appeals system. If a complainant is not satisfied, he or she will have a right to appeal to an ombudsman. This system is part of the provisions the Minister envisages. I join Senator Ó Murchú in paying tribute to those who served on health boards and did a great deal of public service down the years. The issue is to refashion the system through the measures we are considering today.

Senator Paddy Burke expressed concern about the increased powers of health board management. Under this temporary legislation, health boards will be accountable to the Minister. There is real accountability. Senator Ulick Burke expressed the view that the Bill represented a retrograde step and ran contrary to the need for greater decentralisation. We have decentralisation. The Hanly report will not be used as a threat to local hospitals. Local hospitals and community care facilities are decentralised organisations as they stand. However, given the large amount of public money being spent, we must ensure overall accountability and transparency in the health area. That is what the public is telling us and what we are learning from examining the sector. It is the basis of the Minister's reform proposals.

I take the strong message of today's debate that Senators are anxious that local authority members should continue to have a real input in the analysis and questioning of the delivery of health and social services at local level.