John Crown (Independent) | Oireachtas source

I will take a moment to compliment the Minister on the good work he is doing on the Protection of Life during Pregnancy Bill. It has not been an easy passage but the Minister has addressed it while others have neglected it. When the story of these times is told, people will recognise that he has taken a very wise and responsible course.

The hospital groups issue is being discussed today and there are two key elements. I am not an instinctive "save our local hospital" person and I have spoken for many years about the need to reform the Irish health system. The numbers may have changed slightly but as a general rule we had the highest number of hospitals and smallest number of hospital beds of any country in the OECD. That was a few years ago and the position may have changed slightly since. There was a clear and dramatic need for real and fundamental change in the number and configuration of our hospitals, with a particular need to concentrate resources.

We used to have absolute absurdities and even in our capital city, a hospital group had seven small hospitals - all allegedly university hospitals - with cardiology in one, endocrinology in another and some parts of surgery in one hospital and other parts elsewhere. As recently as a few years ago if a person had to have complicated treatment for primary bone cancer, care could be divided among four hospitals, which exemplifies the key need for a rationalisation of resources. I am 100% behind the Minister on the issue.

I am troubled by the bigger administrative picture emerging from this. The model of developing highly-centralised State-owned care in a trust system with a highly-developed cadre of managers is an extraordinarily accurate copy of exactly what happens in the UK National Health Service. The Minister should not take this as an unduly negative criticism but it should be thought through at this early stage of the reform process. It is not the right way to implement the process of money following the patient as money can only follow the patient where the patient goes. If, in a hospital trust system, all choice goes and a patient must go to one hospital, we may as well give the money to the hospital before the patient goes there on the basis of prospective budgeting. The purpose of money following the patient is so the patient can have a negotiable insurance instrument and can go to hospital A or B if he or she does not like the way hospital A is run or that fellow Crown. That is the way the process must be devised.

I am trying not to be pejorative but the copying of the British model to the extent of using the terminology of "trust" is not the way the go. It is easier to do it in places like Dublin where there can be a degree of choice between hospitals but we have seen the ultimate logic of the people being put in charge of this process. We have seen how they have acted in cancer care, and they have tried to take away that choice. Their model would be based on designing the system and deciding how many patients go through it, determining what they see as appropriate standards and auditing to see if those standards are met. Standards can be set high or low, which is the fundamental problem of the health quality movement, as it measures compliance rather than quality.

The Minister is aware that currently in the UK there is a major scandal brewing with regard to the spin-off in the Mid-Staffordshire hospital and health district, where systematic management issues have come to light in one NHS hospital, and as a result the Public Accounts Committee in the UK Parliament has called in the head of the NHS. There have also been calls for his resignation, as well as a focus on the notion of the gagging order culture. If there is a bureaucracy with a manager in charge, with the best will in the world, Acton's law will apply and power will corrupt. If there is no system of competition built in, there will inevitably be an emergence of a system of repression.

I agree with the Minister's comments on the extraordinarily high quality of our nurses and the general very high quality of our doctors. My concurrence with the diagnosis at that stage probably reaches a stone wall as I do not believe the next problem is that we need better managers. We should have the great doctors, nurses, physiotherapists and people who rise through the ranks of a profession put in positions of real leadership instead of being regarded as technicians. Currently, default leadership is provided by highly technically skilled managers who have no capacity for true leadership. We should follow such a model but I fear it will not happen here.

I may have to engage Mr. Bill O'Herlihy to get access to a high-powered ministerial team to make the following point. The Minister will come before the Seanad to deal with the health information Bill, which has within it the seeds of a real problem for clinical research in this country in the centralising, formalising and bureaucratising one of the few elements of the system that works relatively well in the hands of HIQA, the governance of ethical oversight for clinical trials.