Brendan Ryan (Labour)

I hate occasions such as this. These are not circumstances in which it is appropriate to beat the Government over the head. A man died and there is a need for a certain amount of restraint. I know that if anyone in Government could wave a magic wand, this type of incident would not happen. Therefore, if I use strong language, it is not because I believe people care less than I do about this situation. What troubles me every time something like this happens is the fact that there is no sign of a learning process taking place. There is no sign that we are advancing because we continue to have tragedies like this one in areas of public service provision.

As an engineering student I did a small amount of management studies as part of my course. I was taught that the function of management is to plan, organise, staff and control. That is standard business studies teaching. It is extraordinary that we do not know what, precisely, were the rules under which Monaghan General Hospital was working. I do not want to point the finger. There has been a tendency in some quarters to point the finger at the people who were working in the hospital, but they are not the managers of the health service in the north eastern region. They are the people who work on the ground and it is not their responsibility to plan for the service. It is also not their responsibility to organise and staff the service, nor to control how the service operates. That is the function of management.

The fundamental flaw in our health service is the absence of a clear and transparent line of management authority. Ideally Senator Wilson or Senator O'Brien, for example, should be able to say that the person who knows precisely what is supposed to happen is X. This is not the case in reality. Let us suppose there was a fatal accident in a pharmaceutical plant in Cork and the Health and Safety Authority arrived on the scene to be told by the management that it was conducting an independent inquiry and would be able to tell the authority in eight weeks time precisely why a person was killed. In such a scenario, the HSA would have the management in court the following day. I do not understand why we cannot find out the precise operating instructions for the staff of Monaghan General Hospital who are there after 5 p.m.

People are now talking about exceptions, emergencies and so forth but we do not know how the hospital staff operate. Nor do we know the precise instructions given to the staff in Cavan General Hospital. The services are either being run on an ad hoc basis or they are being managed. Many senior public officials have told me that the gap in salaries between the top and bottom levels in the public service has expanded dramatically in the last 20 years because of the major increase in responsibility taken on by managers.

However, when we have a problem like this one, management goes missing — although in this instance, Professor Drumm was an honourable exception to that norm. In this instance, the managers have gone missing because there is an eight week inquiry taking place and, therefore, they cannot comment on the matter. Why should it take eight weeks to find out why a fundamental systems failure happened? If one wants to include a plan to ensure that such a failure never happens again, then perhaps eight weeks is a reasonable length of time. We want to know on whose authority it was decided that Mr. Walsh could not be transferred to another hospital. Whose rules were in operation, what precisely did those rules say and are they written down? If so, they should be published now. If there are unwritten rules, let us hear them now.

In eight weeks time we will receive a report which, I am willing to bet, will identify a systems failure. I have heard of so many systems failures in Ireland in recent times. Another part of the report will contain a statement from the HSE asserting that the problems are all in the past and that it has devised new procedures to guarantee that such a systems failure will never happen again. Another likely finding in the report is that no senior member of management in the HSE is accountable or culpable in this case. Perhaps no one is culpable and such things can happen. However, if a gap in planning for service provision is identified, then it follows that somebody who was paid to manage the service allowed that gap to open up. As has happened in similar situations, it will probably be the nurses, doctors or some junior official who will be blamed for not doing what they were supposed to do or for exceeding their authority. It will emerge that such people were supposed to know what to do but that the service provision was not planned properly.

If we are to have a proper health service in this country we must get to a point where those who are called managers actually manage the service, where they are not merely administrators. Managers should not be people who simply transmit orders from above to those below or transmit information from below to those above them. Managers must take responsibility and if they do not, they should not be in managerial roles. That is the fundamental point and we do not need an eminent medical professional from Belfast to examine our management system. In fact, he is possibly not the best person to examine the management system, but it is with that system that the fundamental problem appears to lie.

If one decides that a particular hospital cannot provide certain services between 5 p.m. and 9 a.m., then one is duty bound to plan for what happens if an emergency arises during those hours. One must go through all the eventualities, deal with all the possibilities and have a procedure which is tested and works. It cannot always be the case that some kind of tragedy is necessary for health service management to realise there is a fault in its planning or management. It cannot be changed by tragedy, which is awful. It is a bit like saying that the safety of the chemical industry would only be examined after someone is killed. The fundamental way the best parts of our industries work is by pre-emptive planning to avoid anything going wrong.

Related to this are some of the comments of the chief executive of the HSE. I refer to it as the HSE, because I presume when he speaks, he speaks for the HSE. The presumption is that big hospitals are better, which is the basic argument of the Hanly report. The statistical evidence used in the Hanly report has been challenged and demonstrated to be dubious. First, there is not a convincing study of the statistical evidence which could convince any objective person that, in 80% of cases, a small number of big hospitals produce no improved outcomes. Second, while I do not claim to be an authority on it, what happened this week in the north-eastern region did not happen under the old regime. No matter what anyone said about the inadequacies of the service, the inadequacies of the training or the inadequacies of the cover, what happened this week did not happen under the old regime. It is, therefore, the responsibility of the advocates of the new regime to explain how their regime is better, instead of asking people to trust them because they know what they are doing.

Fundamentally, after an incident such as this, the issue for most people is trusting the HSE and believing its management is really in charge. What sort of system is it whereby a manager must be telephoned at 3 a.m. to persuade a hospital to take a patient? I admire the manager for taking responsibility and directing this be done. However, the real job of a manager is to organise matters in such a way that people will not have to telephone him to get something done that he or she believes should be done and has the authority to make happen. Managers do not need to be on the premises 24 hours a day. They should put together systems that work. One must have enormous sympathy for Mr. Walsh and his family who suffered, not just because of his death, but because of the way he died, which was awful.

For once in this country, we must identify lines of authority, lines of responsibility and lines of accountability based on real managers who are now paid managers' salaries, operating as managers and not as administrators, passing around other people's responsibilities. This is the fundamental issue that arises here and all over the health service.