John Crown (Independent)

I give the Minister, Deputy Reilly, a particularly warm welcome. It is critically important to understand that he has a set of credentials that distinguish him from his three most immediate predecessors. I will not personalise this other than to say that the aggregate work experience, in any part of the workforce, of the Minister's three predecessors in this portfolio was four years. I do not refer to their experience of working in the health service — I refer to their total experience in the workforce as a whole. Although I am totally in favour of the concept of civilian control of all technical aspects of health care, it is a very positive development to have a Minister who understands the problems in the health service at first hand — he does not need to have them filtered by the opinions of the professional bureaucracy — and has a clear set of plans to address them.

I will use several matrimonial analogies during my brief speech. The first of them is to remind the Minister that we are on our honeymoon. I wish him all the best. He will hear little harsh criticism from me during the first year after his ascent into office. I think he needs a full year to get all the ducks in a row. I will strongly support him as he tries to address the various problems. If I sense during our honeymoon that the Minister has been taken captive by the Civil Service, I will be available to ride to his rescue. He might find the odd criticism being addressed along those lines.

I will make an historical point before I ask some questions. I have made it in this House previously. Much has been said about the advances made in cancer care in recent years. Those advances were made by Deputy Noonan. He was the first Minister for Health to announce publicly — he did so on his first day in this portfolio — that this country's cancer services were a shambles. The speech he made was inspired by one I had made and published in a previous circumstance. He made a number of very telling points that needed to be made. He set the wheels rolling for the reform of cancer services.

The first of my questions relates to the reported management deficiencies in the HSE. They led to the Minister's decision to appoint private management consultants to oversee the functions of Merlin Park, Portiuncula, Roscommon and Ennis hospitals, and to run the day-to-day operations of the university hospitals in Galway and Limerick. I have a specific question and a more general one. Is the Minister at liberty to go into some of the details concerning some of the specific management deficiencies he found which needed this rather radical surgical intervention?

My second question brings me to an issue which I believe and hope will be a theme of the Minister's tenure, that is, the difference between management and leadership. Those of us who have studied for MBAs have come out of them with varying degrees of enthusiasm for what we learned. One lesson that stuck with me when I did the health care MBA was that there was a real difference between management and leadership. Historically, we have had zero leadership in our health service. It has been top heavy with management but has been heavily deficient in leadership. The difference is, as they say, that leaders do things right while managers do the right things. Leaders make policy while managers implement policy. Much of what passes for leadership in the health system has, in fact, been a cult of high-end managerialism. I refer specifically to the issue of clinical directorates. I believe that we have constructed no leadership positions for doctors within our health service. We have constructed a series of management positions for doctors where they may have authority over who does what outpatients' slot or who has access to which operating theatre, but no doctor in Ireland can hire or fire another doctor. This is wrong. It is not the way that the best health systems, hospitals or academic institutions in the world work.

The most classic example was given by the former director of the national cancer control programme who famously said, when he refused to meet local representatives who were discussing the deployment of cancer services, that he was not there to make policy but to implement it. That is fair enough but we do need people who can lead and develop policy, people who have some inspiration and vision to do this.

Setting up a new bureaucracy — the special delivery unit — is not the answer to waiting lists in the health system. The Minister speaks eloquently of the new systems that will identify those areas where there are waiting lists, but I can tell him where they are: it is in Ireland. We have a six year waiting list for obesity surgery. We have up to two year waiting lists for some elective specialist appointments in different geographical areas. These problems are not of the Minister's creation but they all have one core item. There is a grotesque deficiency of the specialists who are needed to provide those services and a grotesque deficiency of the facilities they need to do them. There is no contractual reason for this; it is simple arithmetic.

We have heard that we are below the OECD average. I would like to tell my esteemed colleague, however, that we are not below the OECD average, we are at the bottom of the OECD average for all these medical ratios. The only thing which makes it look better is that we have such an inflated number of junior doctors which are counted in those.

With great respect to the Minister, it is widely felt that the reforms that were introduced in Northern Ireland were not durable in their outcome. There was a short-term bump in the efficiency of certain aspects of the system, which is also grotesquely under-resourced. I am sure the Minister understands that the only thing which saves the reputation of staffing levels in our health service is that the second worst in the OECD are our near neighbours and the only country with which we share a land frontier, Her Majesty's United Kingdom. The UK has the second worst provision for the number of specialists per head of population of any major health system. We need to set our bar higher than to say that if the British have done it in Northern Ireland, then we can do it here.

I have a few quick technical questions for the Minister. I will not read the entire text for my colleagues although we can make it available. I have asked the Minister to clarify the future plans for the redeployment of paediatric diabetic services. This is in response to multiple overtures which I have received from concerned professionals who believe that the care and future health of young diabetics in Ireland is being compromised because we do not have this.

My next point relates to a matter on which the Minister could make his name internationally. The former Minister, Deputy Micheál Martin, did a very good job in introducing the original smoking ban which was a policy-changing event which made world headlines. We should go one further by picking a date sometime ten to 12 years from now and say it will be illegal to import, manufacture, sell or distribute tobacco products. If we invented tobacco tomorrow it would be illegal. The only reason we tolerate it now is because of the existence of a large number of addicts who are fed by very well-off pushers in the tobacco industry. There is no ethical obligation on us to sustain self-destructive addictive behaviours for the benefit of drug pushers. That, distilled to its core, is what the current discourse on tobacco is all about. I urge the Minister to pick a date and agitate with our European partners to do the same. Make it 2025, or whatever deadline, to make Europe tobacco free.

I ask the Minister sometime during his tenure to get colleagues in the Department of Education and Skills to pay attention to the notion that we have a profound abnormality in the way we structure our medical schools. We have six medical schools for a population of 4.5 million, which is approximately twice the European average and three times the North American average. I believe it is the highest average in the world with the possible exception of some small Caribbean islands whose economy basically revolves around one or two medical schools.

On the flip side, none of these schools has anything remotely approaching the faculty levels which we would find in international medical schools. Although I am having trouble getting the numbers, on aggregate, Ireland has approximately 100 to 120 full-time consultant level positions to staff the six medical schools. The Harvard medical school has 1,500. This is a health education system which is cobbled together on the basis of voluntarism. The system is not immune to the criticism of being extremely self-interested and one which I believe outside agencies will need to examine.

I have one last technical question. Why is the Department of Health's administration budget expanding by 16%, with a 92% increase in travel and subsistence, at a time when the numbers of officials are supposed to be decreasing?

I wish the Minister the best in reforming the health system. It is a fantastic challenge and I will do everything I can to support him in it, but I ask him to try to set the goal of reforming it in the lifetime of this Oireachtas. The plan to introduce universal social insurance mixed with private health insurance is not the Dutch model, but is really the German model. A mixture of public and private insurance is being proposed. I am sorry if I am being vulgar, and I have made this analogy before, but stating that this will not be introduced until after another election is like promising a young bride that one will be faithful to her after the first five years of marriage. We need to make it a policy that we will do it within this Oireachtas and will reform the health system while the current Minister has control over it. He will have my 100% support at every stage along the line in trying to implement that level of reform.