Brendan Ryan (Labour)

I was taught in my days as a student in UCD that the job of management was clear: it was about planning, organising, staffing and controlling. It is the Government's job to manage the health service. Its members tell us, although I do not agree with them, that they have not controlled expenditure because they now admit, as the former Minister for Finance told us over and over again, that all the money went down a black hole. I do not share that view, but that is the Government's view, that it failed to control expenditure. It wasted money. That is what its members said. I could give them a reason for that. It is because they spent the money before they had a strategy. They had a lot of the money before they put together a strategy on how to spend it. That is not a great idea, but I do not believe they wasted the money.

There has been a significant increase in staff in the health services. That is one of the jobs of management. It called for more staff, but it was mostly management staff. Who are they listening to when every middle ranking manager suddenly discovers that he or she needs an assistant manager and then the assistant manager also needs a secretarial assistant? If one wants to find out why someone decided something one must meet the secretary to the assistant manager who tells one whether or not the assistant manager is available who, in turn, will talk to the secretary to the manager who will then tell one when the manager will be available. That is the experience of health care professionals. When they discover that a ward, which was open last week is now closed, their first question is, "Who decided that?" No one in a health board can say who made the decision.

The same will be true of the health service agency when it gets going, headless as it is at present. That is the job of management. No decision should be taken in the health service unless an identifiable person with management authority is clearly responsible for it. If they do not want to accept responsibility they should not be in the job and it is the job of the Government to deal with people who will not accept responsibility. Decisions are passed around from one to the other with no certainty as to who is responsible.

Centralising into a super-agency will change nothing because the personnel who will manage the health services, as distinct from the people who deliver it, will be the same people who are in charge now, except that they will be accountable to nobody. There will no longer be any local involvement. Extra staff do not help because failure to control means that staff are not where they should be.

The least said about organising and planning the better. How could anyone claim credit for planning who agreed the capital expenditure of €500 million to build new facilities and forgot that they would need to be staffed and equipped? Suddenly, there was a budgetary crisis because all these wonderful facilities were lying empty. That was management's failure.

We must not get away from the fundamental fact behind a distortion of which people hid for a long time. We are not spending enough money on our health services. The OECD figures show that we manage to include certain services in health expenditure and, to a great extent, spend money twice. When the Government talks about care of people with disabilities, it cites the chunk of the health budget which goes on such services. When it talks about health services it puts that chunk back into the health services. The truth is that, comparing like with like, we are close to the bottom of the OECD table and we are probably at the bottom of the table of comparatively rich countries. In deference to Senator Mansergh, I will not identify our position on the world table of richest countries. According to the famous report in The Economist we are the fourth richest, but other people see it differently.

We are among the lowest. The two indices of managing and funding the health service are both disastrous. There is no point in citing statistics about the extra numbers of this, that or the other. The measure is what the public get, and what they get is a mess. The fundamental cause of the mess is the lack of clear lines of accountability and responsibility and identifiable individuals who are responsible for budgets when those budgets are adequate.

What level of genius was required to figure that if the country is experiencing an economic boom and draws in vast numbers of former emigrants or new residents, the birth rate would rise? What level of planning and insight was needed for this conclusion? The problem is not confined to the Department of Health and Children. The Department of Education and Science is still on the trajectory of a declining birth rate in planning primary schools. We are subject to the tyranny of averages. In some parts of Ireland we have big schools which are empty, while in other parts of the country, villages with four times the population are served by schools which were designed and planned for the days when people were fleeing from those places in vast numbers.

The same issue arises with maternity services. I used to think we were doing extremely well in the area of infant mortality until I checked the figures this evening. In 1990, our infant mortality rate was 16th from the top of 29 OECD countries. In 2002, we were at the same level. Our infant mortality rates have progressed not a whit in 12 years of prosperity. We are still towards the bottom of the table. Our performance is not bad. By comparison with developing countries it is very good but it is not something about which to boast. To restrict funding to maternity services when infant mortality statistics do not show a spectacular success is close to scandalous.

If we are to have a health service of the quality our people deserve we need a fundamental change in the quality of management at every level in the health services because management has failed abysmally. Our doctors and nurses are among the best trained in the world but our management is letting them down. Good managers must be provided with spectacularly increased targeted resources to deal with the problems. Otherwise, we will end up with the same miasma of waste and incompetence which has held back the development of our health services.