John Crown (Independent) | Oireachtas source

I thank the Minister of State for his thoughtful and considered reply to my amendments. I understand the broad thrust of his not wishing to bind the hands of negotiators with legislation when circumstances can change. The negotiator in this case, however, is the HSE, an organisation of which there is a general feeling there needs to be enhanced political scrutiny. That is all we are trying to do here, to make sure that not only do we have civilian control of the military but we have political control of the civilian infrastructure as well. It is not inappropriate to set out broad guidelines about what the HSE can and cannot do within its contract. The HSE has a conflict of interest, not only does it run the general practice but also the hospital and other services. In fact, it runs a breathtaking array of services. It is quite staggering to see the breadth and scope of the services for which it is responsible.
In attempting to deal with high profile budget problems in some parts of the service, such as the hospital service, it is all too easy for it to push work aside onto other parts of the service. That is one of the things that I and my GP colleagues fear in terms of the carte blanche approach to what it can put in the contract. In effect, it can be prescriptive about services, tests and treatments which can and cannot be provided and it can ask GPs to perform services which it could be argued could be best performed in some other part of the public health service by public health nurses etc. That was the genesis of those particular objections.
I will press for a vote on the amendment on the gagging order. I feel strongly about that. The point needs to be made because it does not apply just in general practice or the health service. The country has suffered on multiple fronts because of a lack of whistleblower protection. We are told there will be enhanced whistleblower protection. In the first draft of the first contract offered to the GPs it was being suggested that somehow the essential nature of whistleblower protection would be undermined. It has to be enshrined in every Bill governing any part of our public service, that this can never happen. This is as good a starting point as any.
On a more general point concerning the Minister of State's questions about the management, the managers and the officials in the HSE and the Department of Health, I do not hold them individually responsible for the problems in the health service although I think they have collective responsibility.

As the largest vested interest group in the health service, HSE managers stand to lose most from true health service reform, as a result of which they would cede virtually all of their power.

The key problem is profound and relates to the culture of management and leadership. People in officialdom and politics used to tell me to be quiet about health policy because I knew nothing about it. In the memorable words of one senior civil servant in the Department of Health, I was just a technician and the civil servants were the people who knew how the health service should be run. To prove the individual in question wrong, I signed up to do a health care MBA to which I gave two of my precious middle years. I found this an extremely interesting and informative activity. The first lesson we learned in the first lecture on the first day of the first semester was the difference between management and leadership. The key problem we have is that we do not have much leadership in the health service. For example, there is a lack of an appropriate cohort or adequate number of full-time academic doctors providing intellectual powerhouse medical schools, rather than mere "degreemails", as is unfortunately the case at present. We have far too many medical schools per head of population. Many of them are also small and understaffed, with approximately one tenth of the number of full-time consultant level people employed in them as one would find in equivalent institutions abroad.

One whole side of what should be the leadership part of the equation of Irish medicine and health care is missing. In our hospital structures every single consultant is co-equal with every other consultant and there is no question of an individual being the leader of a department, exercising autonomy and trying to hire and fire or bring in people. We simply do not do this.

I do not mean my remarks to sound pejorative but the specialists in human resources, physical plant and procurement should deal with human resources, physical plant and procurement, respectively. Instead, however, the people who are in a leadership situation, the technical managers, default into leadership roles. This is the reason we have most of our current problems.

The people who run and provide the intellectual inspiration for a law firm are the lawyers, not some group of professional managerialists who regard the lawyers as technicians who merely interpret the law. That is the core problem. We need to develop a cadre of leaders in nursing, medicine and the ancillary areas who will lead the service and tap into the expertise of managers, while having their activities subject to appropriate civilian control. That is not the current position. The reason so much flak is rained down on those who manage the health service is that they are doing the wrong job. The core problem is that they are doing a job they are not trained to do.

I will press the amendment because it is a very important issue of principle. We will dispose of the others when they come before us.