James Reilly (Dublin North, Fine Gael)
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I appreciate the intervention.

Senator Byrne referred to the same staff being in place but I already have made clear the staff has changed considerably. Many have made the point that the board of the HSE was abolished last year. However, it was not abolished - its membership changed - but this governance Bill will abolish the board.

As for talking about two terms to implement the reform, I believe that for the first time both parties in government had the political courage to state before an election that it would take two terms to carry this out and that they could not promise what they could not deliver. However, the Government will deliver it within two terms. Someone also mentioned the Dutch system, how the costs have risen and how the entire system is unaffordable. I happened to be in contact with the Dutch permanent secretary fairly recently at an informal meeting in Cyprus and he explained how the costs of course have risen because they have begun to cover dental care. Senator Moloney spoke about the muzzling of health workers and I have covered that point. It is not something with which I agree. Senator Barrett referred to the increase in the number of non-doctors in the health system from 56,000 to 96,000.

We also need to include among those non-doctors nurses, health care assistants, physiotherapists, occupational therapists and others. This brings me to a key principle in which I believe, which is treating the patient at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. I do not want consultants seeing patients whom GPs should be seeing and I do not want GPs treating patients whom their practice nurses or physiotherapists should be treating. I do not want nurses looking after patients whom the health care assistants should be looking after. Why is it that one of our major hospitals has nine nurses to one health care assistant and another hospital other similar size has three nurses per health care assistant? Through the HSE and SDU we will transpose uniformity across the system and where we find excellence of care or really efficient methodologies being used that are safe, we spread them across the system.

I often quote the example of the physiotherapists who, when screening orthopaedic referrals, found that 50% of the patients did not need to see the surgeon at all. Some of it might be because they could treat them and some of it could be because it was the only way the GP could get the patient the physiotherapy service. The same thing is happening in psychiatry with counselling services. There is considerable dysfunctionality in how our systems are organised.

A colleague of mine recently turned up at an outpatients department along with 35 other patients at 9 a.m. I find that a disgrace. That is a system that is self-serving and shows disdain for citizens and patients. There is no reason for that - it must stop and it will stop. I have asked Mr. Tony O'Brien to ensure it stops and people are given appointments. I accept we need to allow for those patients who do not arrive. Large numbers of people are not arriving and that could be a factor. If they have had to wait for a year they may have got sorted out somewhere else. There are simple things we can do and will do such as sending text messages 48 hours beforehand and asking them to reply indicating whether they are coming. We will also send a text message again on the morning of the appointment reminding them to come. Equally if those people do not reply by text, the next time they seek the appointment it will cost ¤10 or ¤20.

I wish to refer to the money being spent. Many of the things I said when in opposition have been quoted, but here is something else I said frequently when in opposition. I said we should not put another bob into the black hole that is the HSE until I find were the leak is and we are getting there. Like most things I have found out that it is like a bloody colander - pardon the language.

Diarmuid Wilson (Fianna Fail)
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The Chair did not hear that.

James Reilly (Dublin North, Fine Gael)
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The Senator raised an issue about section 16 and the national directors. I have reservations about that and I would be happy to take amendments on Committee Stage. The rationale is as follows. The jobs for national directors can be advertised and then they become eligible to go on the directorate. As this is a temporary arrangement we made a decision to limit it to the wider health family as opposed to outside. We do not want a long process of tendering, appointments and all the rest of it. If the Senator is worried about section 16 we can review that on Committee Stage. It concerns the issue of the director general not giving evidence to the committee on an issue that is being dealt with by the courts. Perhaps the Attorney General has a view on that matter and I will need to revert to the Senator. However, I remind him that it is a temporary measure.

Senator Darragh O'Brien mentioned VHI. The clinical audit is one thing and there is the other audit. We will also now do a deal with VHI and I have informed it of this. I believe it should be doing this on the private side but public patients should not be charged per day any more but per procedure. If the hospital is efficient the procedure will be done efficiently and the patient will be in and out quickly. If it is inefficient then the hospital will lose money. That is the only fair way to do it.

Senator Conway spoke about vested interests. As we challenge and change the status quo the noise will grow to a deafening din - it is getting a bit loud already. We are not afraid of that. We said we would change things and we will do so. As I said on a radio programme, we were elected by the people to do it. They did not say they would like us for the way we did it or that they would like us for having done it, but we will do it.

The value for money audit was mentioned. I have said we are focused on outcomes for patients and not inputs, which formed the main focus of the previous Government. We can measure hospital outcomes in many ways, but we still do not have the measures of outcomes in primary care we need.

Senator Cullinane spoke about rearranging the deckchairs on Titanic - I have dealt with that issue. I have spoken to his obsession with inputs rather than outputs. I have spoken about the consultant talks at the LRC. I thank the consultants' leadership for bringing this to a ballot of their membership. They are leaders in the health service and where they lead others will follow. Senator Crown mentioned nurses and said that there would not be anybody in the theatre to support the consultants - there will be. Nurses are already well used to working different shifts as are others. We will get the efficiency and care citizens need in a much better way. I believe consultants will also have much better job satisfaction.

I am not sure of the accuracy of whether there is an increase in the waiting list for outpatient appointments in Waterford Regional Hospital. The Senator spoke about the announcement of ¤130 million by civil servants - they were not civil servants, but public servants. I appeared on the radio and television the following day to reassure the people that they would not lose their service. Just as increasing inputs does not necessarily improve outcomes, reducing them does not necessarily mean a cut in outcomes for patients. From what the Senator has said I know he agrees with the model of care we are proposing and universal health insurance. If there are real concerns in Waterford Regional Hospital about the new hospital groups we will review it and consult further. The Senator concluded his speech by saying it was not a bad idea but I must do better. I have not heard any better idea from him.

David Cullinane (Sinn Fein)
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I mentioned community health partnerships. The Minister was not listening.

Diarmuid Wilson (Fianna Fail)
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The Minister to continue, without interruption, please.

James Reilly (Dublin North, Fine Gael)
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I agree that we need to flatten the pyramid of management and devolve more authority to the local level to which I have alluded. I want more power locally the people who do the job locally.

Senator Darragh O'Brien talked about the OPD figures. I spoke about this issue in his absence. He is back now. He asked when GP care would be provided. I have covered that issue. It was suggested that it might not be affordable but I believe it is and it will be delivered. The physiotherapy issue in Temple Street Hospital, while nothing to do with the Bill, is important. No moratorium will be applied to critical such posts. That will not happen. I am informed that patients who need it are being given physiotherapy.

Darragh O'Brien (Fianna Fail)
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Not in Temple Street Hospital.

James Reilly (Dublin North, Fine Gael)
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However, I agree with the Senator that we need a permanent physiotherapist in situ there. I will need to check the situation regarding ambulance cover.

John Gilroy (Labour)
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Perhaps Senator O'Brien can drop into the Minister's clinic on Saturday.

Diarmuid Wilson (Fianna Fail)
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No interruptions, please. The Minister has limited time.

James Reilly (Dublin North, Fine Gael)
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I am nearly finished. I am very grateful to Senators for their forbearance.

Senator Kelly made a number of excellent suggestions. It is eminently sensible to share facilities to give services in areas, particularly where the populations are small. We would need to examine the suggestion regarding community employment schemes. While it is a great suggestion, there are issues that would require negotiation. I will certainly inquire about ArtAssist for peripheral vascular disease.

I thank all the Senators who contributed. We have had a very good debate and I am looking forward to further debate during the remaining Stages of the Bill in the Seanad. I am more determined and committed than ever to introduce these changes and to fix the health service. However, I am more convinced than ever because of the new leadership that is emerging at the top of the HSE, in the Department and hospitals. I am sure Senators join me in thanking them and those who work on the front line for the excellence of the work they do.