Derek McDowell (Labour)

I suspect I have more sympathy with the purpose of the Bill than most of colleagues who have spoken. There are genuine difficulties with local health boards and the way in which they have discharged their duties over the years. I do not lay the blame specifically or exclusively at the health boards' door because they have an impossible job. They have been asked to administer a system and be responsible for the local delivery of services when all the decisions that matter are taken by the Department of Health and Children.

There has been a growing tendency in recent years, partly for understandable reasons, for the Department to micro-manage, to the extent of deciding budgets on a local basis, not just specifically for health board hospitals but also for non-health board hospitals. It has become impossible, in the absence of an independent funding mechanism, for local health boards to make genuinely independent decisions which do anything other than reflect what the Department wants them to do. While they have not become redundant by an stretch of the imagination, they have been less than fully efficient in doing what they were set up to do.

The Bill does not abolish the health boards, it removes them without removing the sub-structure underpinning them. The decisions previously taken by elected members and members representing professionals will in effect be taken by the chief executive. The Minister will argue that this will only be the case for six or nine months or the time it takes to establish a national structure. This may well be the case but it strikes me that the decision to take this action now and follow it with further legislation at a later, unspecified date is typical of the way we do things here. It is like abolishing local authorities by effectively removing local councillors and leaving all power in the hands of managers, while leaving the whole local authority sub-structure in place. We are taking the easy option by removing the elected members and professional representatives and leaving everything else in place. By virtue of the action the Minister will succeed in taking today, an unsatisfactory system will become even more unsatisfactory.

While reading through a file on health in my office this morning, I noted the remarkable number of reports published on the health service, even in the past three or four years. The trio of recent reports was preceded by the value for money report by Deloitte & Touche, the bed capacity report and the medical personnel report.

The plethora of recent reports on the health service, many of which have much to recommend them, were drawn together before the previous election in the national health strategy published by the Minister for Health and Children, Deputy Martin. My party is on record as supporting a great deal of the national health strategy, including the planned reorganisation of structures. Since its publication, however, we have only had the easy bits. It is not too difficult to change the organisational structure, particularly when it involves abolishing rather than establishing bodies. It is difficult to deliver additional capacity or funding and specific strategies intended to deal with particular types of illness. The Department and Government have been peculiarly deficient in that regard.

In some ways the national health strategy document was a departure from what most civil servants would regard as common sense in so far as it has seven pages of specific dated targets, something civil servants prefer to avoid. Unfortunately, the document makes very sad reading. I was struck by Senator Jim Walsh's reference to the public private mix, which is specifically addressed in recommendations 89, 90 and 91 of the national health strategy. They refer, for example, to seeking greater equity for public patients in a revised contract for hospital consultants. We still await a revised contract. They also state that the rules governing access to public beds will be clarified. While this may have happened, I am not aware of it. They then refer to taking action to ensure that admission to public patients for elective treatments is managed in a particular manner. If anything, the problem identified in the strategy of private patients using designated public beds is getting worse, as we know from a report produced just a few months ago, yet nothing has been done to address it.

My point is simple. We have a great number of reports, many of them good, including one recommending that bed capacity be increased by 3,000 in the next seven years, but nothing is being done. The reality is that where political will was required and recommendations needed to be cleared with the Department of Finance, the Minister or Department have failed to do so, not because of any lack of political will on their part but because of a lack of will on the part of the Minister for Finance and Government as a whole. I see nothing to persuade me that this position has changed. As a result, we will end up in a typically Irish position in which we simply rejig the structures, while failing to do address all that underpins them, including in particular the need for greater capacity and investment.

I acknowledge there is a difficulty with local health boards, that health professionals see themselves as representing what are sometimes called vested interests and that at least some of our colleagues in the county councils have not taken their positions as seriously as they should. Having said that, there is an unquestionable need for a forum to be established to allow the views of patients to be represented at board level or addressed to the people who make the decisions about funding in the health service and the administration of the health boards.

I am not convinced that the regional fora to which the Minister refers will have this affect. We all know that health professionals, the people who deliver the service, and those involved in the executive side in deciding how a service will be delivered, will only listen to representatives of patients and local elected representatives if they must. This will require a structure to be established that would still allow a measure of decision making to be taken by elected representatives. As others have noted, if there is a better way to do this than having local councillors on such a body, I do not know what it is.

It is incumbent on the Minister when he refers to accountability, as he continues to do, to spell out in realistic terms how it can be delivered in a manner that makes sense. There is no sense in setting up a regional forum to meet quarterly, if people collect their expenses and express views which are discounted within minutes or hours of the meeting. We must have a forum with teeth to underpin the structure the Minister envisages. Nothing of that nature is in place.

I support the general thrust in the health strategy to reduce the number of agencies, approximately 57, involved in the health service as a whole. All of us accept there are too many and there is a need for not only a central policy making body, but also greater streamlining down the road. The Minister has suggested a reduction in the number to the low 30s or high 20s and that would be sensible. However, it must be ensured the baby is not thrown out with the bath water. The Minister should not rationalise for the sake of saving money. Given the way the Department of Finance has captured the health strategy and is dictating in financial terms the way in which it should be implemented, I am pessimistic because it will be implemented in a way that will ensure certain financial rather than health outcomes and that will be a tragedy.

The Minister has little time left in which to salvage the credibility of the health strategy. Significant promises made during the last general election campaign relating to the abolition of waiting lists by May 2004 and increasing the number of medical cards by 200,000 have been broken, but most of us knew that would happen. However, many other commitments which are to be met further down the line were made. A number of these, for example, setting up primary care teams, are even more important but they are running into the sand primarily because money is not being provided but also because the political will is faltering and a number of vested interests are busy obstructing the strategy. It is important that initiatives such as the setting up of primary care teams are driven not only by the Minister for Health and Children and his Department, but also by the entire Government and the Minister for Finance, in particular, who ultimately has a veto on such strategies, regardless of whether we like it.

Much of the strategy is good but there are plenty of reasons to be concerned regarding the process and pace of its delivery. It is in all our interests that the strategy should be delivered. Many of us will have canvassed over the past while. There is an increasing sense of desperation among people who depend on the health services. They do not believe the delivery of services can be improved and, unfortunately, that, in turn, has led to a belief that money spent on them is wasted. That is a profoundly wrong view. It is possible to examine the past seven years and beyond and point to successes in addressing issues concerning older people and people with disabilities and, for example, reducing the cardiac waiting lists. It is important that we in Opposition as well as members of the Government highlight where investment has paid off in terms of better services. However, unfortunately, the successes are being seriously compromised by a failure to deliver on so much more and by an insistence for political, cynical and opportunistic reasons on talking up promises, a number of which are not deliverable.

During the 2002 election campaign, following the publication of the Fianna Fáil manifesto which promised the abolition of waiting lists, I was asked whether the Labour Party would match it. We were in Opposition and we felt it would not be honest or serious to give people hope and set a target that was not achievable. The Government has played cynically and opportunistically on people's hopes and, by dashing them, it may have done serious damage in terms of the ability of future Governments to invest for the future and to achieve the political will and agreement of the electorate to do so. Health boards have problems and the legislation will not resolve them. However, a mechanism for local decision making is needed for the delivery of services.