Seanad debates

Wednesday, 10 October 2018

Health Service Executive (Governance) Bill 2018: Second Stage

 

Question proposed: "That the Bill be now read a Second Time."

10:30 am

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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I want to begin today by sending my deepest sympathies to the family of Emma Mhic Mhathúna and especially to her children. Ar dheis Dé go raibh a h-anam dílis. Emma was a woman who strongly advocated for a better health service and shone such a bright light on why that is required in areas such as oversight, governance and accountability that clearly need so much improvement. We think of Emma today, her family and community and we all pledge to build a better health service in her memory.

I am pleased to have the opportunity to introduce the Health Service Executive (Governance) Bill 2018 to the Seanad. It is important to say that this legislation is directly relevant to Dr. Gabriel Scally's scoping inquiry report and our overall response to his recommendations, which we are determined to implement in full. The focus of the Government now is on working to try to eradicate cervical cancer and ensure we have a screening and vaccination programme worthy of women like Emma.

The Bill before us is an important step on a long journey of reform, as committed to by the Government in A Programme for a Partnership Government, and the delivery of a world-class health and social care service for Ireland as envisaged in the Sláintecare report of the Oireachtas Committee on the Future of Healthcare. With a budget of €17 billion, as of yesterday, and a significant workforce, the HSE is our largest State agency and one of our most important. It has a range of functions under legislation and provides essential services across the health and social care spectrum to citizens in every city, town and village in the country. It plays a vital role in each of our lives, often when we are at our most vulnerable or in times of crisis. Therefore, it is essential that we ensure good governance, accountability and transparency across all layers of the HSE. This Bill, as introduced to Senators here today, plays an essential role in the reform process by providing for independent board oversight of the HSE.

The Health Service Executive (Governance) Act 2013 established the directorate governance system. This system was of its time and allowed for intensive co-ordination between senior management teams in the Department of Health and the HSE. However, by its very nature and design, and by intent, it was always envisaged as an interim measure. Therefore, the core objectives of this Bill are to establish an independent board governance structure for the HSE and to dismantle the current directorate governance system. This board will be the governing body of the HSE and will be accountable to me as Minister for the performance of its functions. All board members must maintain high standards of integrity and probity and develop clear expectations concerning culture, values and behaviours and ensure personal and corporate compliance with any relevant legislation. The new governance structure will set the tone for the culture of the organisation and how the HSE must operate in the future. Therefore, it is essential that the implementation of this new structure is based on some key fundamental principles.

The first is independence. A board as the governing body supports transparency and accountability of actions in order that people can have confidence in the decision-making and management processes in the HSE. The board must ensure that it challenges the management, and itself, to demonstrate value achieved for the very significant public funds provided to health and instill an organisational culture of continuous improvement.

The second is inclusiveness. The board will act in the collective good at all times, ensuring that all stakeholders' perspectives are taken into account, be they patients, the taxpayer and staff. The HSE must welcome and take on board differences of opinion, while ultimately taking decisions based on the public good.

The third is compassion. I think none of us here today was not moved by recent events, or do not have our own personal experiences, perhaps good or bad, which have highlighted the need for compassion to underpin all layers of the health service and everything that happens with it. That only strengthens my resolve to ensure the HSE core values of care, including compassion, are embedded throughout our services and evident every day for every patient. As we establish a new board we must make very clear that independence, inclusiveness and compassion must underpin all of the board's work.

I expect the board to introduce and operate effective board governance processes, to play a central role in the direction, leadership and corporate and clinical governance of the HSE, to foster a positive relationship with the CEO of the HSE and the HSE executive team in order to facilitate the conduct of good governance, and challenge and support them to deliver priorities and improvements while holding them to account in doing so. I also expect the board to support and challenge the CEO and the HSE executive team in establishing an effective performance management and accountability system in the HSE, to promote a culture of accountability, and ensure that the HSE demonstrates value achieved for the very significant public funds provided. I further expect the board to develop constructive relationships, including with the Minister for Health, the Department of Health and the Government, and to drive and oversee a significant programme of reform in a challenging environment.

The board will have a membership of highly-skilled people with strong competencies across key areas. I think it is important to have a competency-based board, which will provide the leadership to guide, challenge and support the CEO and the HSE executive team to deliver major organisational transformation and reconfiguration within the health service.Members of the board will be expected to have experience and expertise in one or more of the following areas: corporate governance, patient advocacy, clinical governance, quality assurance and patient safety, strategic planning and change management, strategic human resource management, and public communications.

Last month, after a demanding Public Appointments Service, PAS, process, I was pleased to announce that Mr. Ciarán Devane is the chair-designate of the new HSE board. I am delighted with the outcome of this appointment process and the range of skills, experience and leadership that Ciarán will bring to this role. I cannot underline more strenuously the importance I place on this role as a key enabler of change and transformation in our services. I will work closely with the new chair-designate in this regard, and I have high expectations of what we can deliver together for the citizens of this country.

The PAS process for the other board members has now begun, and I look forward to the outcome of this process and appointing the full board. With the Seanad's and the Dáil's support, I hope to be able to do this before the end of the year in order that this new governance structure in our health service can take office at the beginning of 2019.

I would also like to make clear on the record of this House that I have accepted in full Dr. Scally's recommendations that there should be at least two patient advocates on the new board of the HSE. I commit today to fulfilling that recommendation in order that we can embed the voice of the patient at the most senior level of the HSE.

I wish to bring the Seanad through the main provisions of this Bill. Part 1 contains a number of standard provisions, including the Short Title and collective citation of the Bill. It also provides for the repeal of Part 3A of the Health Act 2004, which instituted the directorate governance structure.

Part 2 allows for the required changes in the Act to reflect the structural changes proposed in the Bill, which in essence are the establishment of an independent board and the appointment of a chief executive officer, CEO, of the HSE, and the values, principles and conditions which underpin this structure. Section 7 proposes to insert a new Part 3B, sections 16N to 16U, inclusive, in the 2004 Act to contain provisions for the membership and role of the new HSE board. Section 16N(1) provides for a board of management for the HSE comprising a chairperson, a deputy chairperson and seven ordinary members, all of whom will be appointed by the Minister for Health.

The appointments and functions of the CEO of the HSE are covered by the insertion of a new Part 4A, sections 21A to 21G, inclusive, in the 2004 Act. As Senators will be aware, we are in the process of recruiting a new director general for the HSE. The successful applicant, under this legislation, will become the new CEO of this important national State body and will be a pivotal appointment in improving the management, performance and quality of our health and social care services. The legislation also sets the accountability structure between the CEO and Oireachtas committees. Under the new section 21E, the CEO of the HSE is required to attend Oireachtas committees to give an account of the general administration of the HSE. The requirement for the CEO to appear before the Committee of Public Accounts is covered in the amendments in section 17. Sections 9 to 29, inclusive provide for other amendments to the 2004 Act, mainly consequential to the new board and CEO structure, and to take account of the move to a board and CEO structure from the directorate governance structure.

Part 3 comprises sections 30 to 34, inclusive, which amend references to the director general in primary and secondary legislation.

The establishment of an independent board and the appointment of a CEO are crucial components of a strengthened governance framework and new leadership for our health service. We must now look further and more deeply at how this new leadership can transform the accountability, culture and performance management of the HSE at all levels. Dialogue is ongoing between my Department and the HSE in this regard, and I am anxious for this work to continue in parallel with the passage of this Bill through the Houses. I will ensure that any amendments required as a result of this dialogue will be brought before the Houses as early as possible in the process.

The Sláintecare committee and the Sláintecare report concluded that an independent board for the HSE needs to be put in place. Therefore, this Bill meets a key recommendation of the Sláintecare report and constitutes one part of a broader package of measures that are intended to strengthen and improve governance, leadership and accountability within the health service. The revised governance architecture proposed in this Bill, however, is not an end in itself but rather a means to an end. The end that we all strive for is the real transformation of our health service to deliver, to the best of our ability, timely, effective and safe health services for the people. We are moving towards this with the implementation of Sláintecare. An executive director has been appointed, a programme office has been established, a new Sláintecare advisory group chaired by Dr. Tom Keane, who did amazing work on reforming our cancer services, is in place, and a detailed action plan will be published at the end of this year setting out the priorities for 2019.

As Senators will have seen in the budget yesterday, a huge priority has been attached to delivering on Sláintecare in the coming year. The establishment of the HSE board is only part of a broader package of recommendations in the Sláintecare report to revise our health structures. The geographic alignment of the community healthcare organisations, CHOs, and the hospital groups is also significant. This will allow for the creation of regional integrated care organisations which will provide for integrated care. I do not think that anyone in this House, regardless of his or her political persuasion, thinks the current construct of the HSE is fit for purpose. The way the HSE was designed is inappropriate. It is too large, too bureaucratic and needs to be reformed, which is not just my view but also the view of the former director general of the HSE, Mr. Tony O'Brien, who referred to the HSE as an "amorphous blob". The HSE needs to be reformed. It is too big in its current guise.

What we want to do under the Sláintecare report is devolve more to the regions, remove layers of bureaucracy, and create regional integrated structures where the community structure and the hospital structure are not at odds but rather form one structure delivering the full continuum of care for our patients. What we are doing today with the HSE's board structure is putting a better governance structure in place for what will ultimately be a leaner, more efficient national centre, which will still be called the Health Service Executive.

I look forward to moving ahead with these reforms as quickly as possible. As the Senators know, a public consultation on the geographic alignment of hospital groups and CHOs has been completed, and I intend to make a number of announcements on that by the end of this year. I recognise that the publication of this Bill and its passage through the Houses of the Oireachtas is only the beginning of the journey that we have all signed up to as part of Sláintecare. It is a significant milestone, however, which is crucial to moving from talking about transformational change in our health services to delivering this goal.

I commend this Bill to the House. With the assistance of Senators and Deputies, I hope we see its speedy passage in order that we can put this new structure in place.

Photo of Keith SwanickKeith Swanick (Fianna Fail)
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I welcome the Minister. Fianna Fáil supports this Bill, which restores the HSE board. The 2012 decision to abolish the board was a clear mistake which was contrary to good corporate governance. The establishment of a board was also recommended in the Sláintecare report, which pointed out that good leadership and governance are critical functions of any health system.

The committee strongly stated there is a requirement for clearer clinical and managerial accountability and governance throughout the whole system. This includes clarity at all levels, from the Minister of Health and his Department to the HSE and all health providers. Sláintecare proposes that the HSE be reformed into a more strategic national centre with an independent board and fewer directorates. Recognising the international evidence on the negative impact of system re-organisation or merger, Sláintecare recommends that structural change should be as simple as possible, with only what is needed to meet the requirements of integrated care. An explicit recommendation of Sláíntecare is that an independent board and chair should be appointed to the HSE at the earliest opportunity by the Minister following a selection process through the PAS. Board membership should reflect the skills required to provide oversight and governance to the largest public service in the State. The chair of the health service board will be accountable to the Minister, and the health service director general will be accountable to the board.

I would like to echo some of the sentiments of various commentators following the budget yesterday that the implementation of Sláintecare lacked a certain urgency. I was disappointed the funding for the Sláintecare reform programme was not specifically identified in yesterday's budget, but I take on board the Minister's comments at last week's Committee on Health that progress will be made in the coming weeks, which I welcome. The recent Scally report on the CervicalCheck screening, which we discussed this morning at the health committee, noted how changes to the overall governance of the HSE itself had a significant impact on the CervicalCheck service. The report states: "It is difficult to see who, under this configuration, was representing the patient and the public interest." That is a fundamental, impactful statement.

I hope the implementation of this Bill will not only deal with the recommendations of the Sláintecare report but also address the anomalies set out in the Scally inquiry. One of the most important recommendations that I heard from the Scally inquiry was the establishment of the national screening committee to advise on any new programmes that may be required and, probably more importantly, to advise on any modifications of existing programmes. I welcome the establishment of that committee, and we support this Bill.

Photo of Victor BoyhanVictor Boyhan (Independent)
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I welcome the Minister for Health and acknowledge his simple but comprehensive and clearly laid out report. As we know, the Oireachtas Committee on the Future of Healthcare concluded that we needed an independent board for the HSE and this also ties in with Sláintecare. I welcome this positive legislation. The Library and Research Service has produced a comprehensive digest, which I recommend it to all Members as it sets out the position very clearly. It also places great emphasis on transparency, accountability, integrity, the participation of stakeholders in the broadest sense and also policy capacity. These are the key issues that the Minister has already outlined.

In 2011, the soon to be Minister, Senator James Reilly, stated that under his watch the existing "monster of the HSE" would be abolished. At the end of April 2011, the then Minister stated that the HSE board and its sub-committees were established by his predecessor to "put distance between the minister and their responsibilities." He added that he would shorten "that chain of command with this new change". This, he said, would be "for the betterment of the patients". Senator Reilly is not here today and I fully understand if he is on other business. He made these remarks following the voluntary resignation of the board of the HSE, a decision which was largely driven by his rhetoric. The board was replaced by an interim board. It was not until the Health Service Executive (Governance) Act 2013 commenced on 25 July 2013 that the Minister formally abolished the board of the HSE. Speaking in the Seanad in September 2012, the then Minister stated the purpose of the Bill was "to make the HSE more directly accountable to the Minister for Health, who in turn is accountable to the people through the Oireachtas". Seven years after the forced resignation of the HSE board and five years after it was legally abandoned, we are re-establishing the board. That is an important point to make. I have no problem with people doing U-turns. The reality is that the main element in the current Administration has been in power for the past seven years.

One of the consequences of the reckless governance structures in our health service for the past seven years was made plain in the recent report by Dr. Gabriel Scally. It states:

In 2013, legislation changed the nature of the governance of the HSE entirely, replacing the Board structure with a Directorate consisting of a Director General and no fewer than two, and no more than eight, Directors all of whom were HSE staff. The Director General and Directors were all effectively appointed to the Directorate by the Minister for Health. It is recognised that this was a step along the intended path of abolition of the HSE.

The following is important. The report continues:

The net effect was to remove external, independent input into the running of the HSE at its highest level... This change from the accepted good practice of having independent Board members in an oversight role, and involved in a committee structure beneath the Board, was a major move away from the established norms of good governance of public bodies. It is difficult to see who, under this configuration, was representing the patient and public interest.

I could go on but there is no point in doing so.

As we are here today, I want to express my deepest sympathies to the family of Emma Mhic Mhathúna. It is poignant and appropriate that her cortege, according to her wishes, should pass some Government Buildings and proceed to Áras an Uachtaráin. Ms Mhic Mhathúna made a courageous decision. Her death is only one of many and, sadly, in the weeks and months ahead, we will speak in the House about a number of other people who are due to pass away.

I commend the Minister on what he is trying to do. It makes sense to have new governance for the HSE. I am particularly impressed with the importance placed on the qualifications and expertise of members of the new board. I hope it will not be a political board but one based on merit, capacity and ability.

I repeatedly raise issues in the House and I do not intend to rehash them here today. I hope we will meet he Minister soon. We receive political feedback through parliamentary questions and in responses to Commencement matters in which we are told the issues we have raised are matters for the HSE. When we raise them with the Minister, we are told he cannot do anything about them. I accept that he has a lot of work to do in his extensive brief and has many responsibilities on his shoulders. His task is not easy. The sooner this legislation is enacted and the sooner we have an independent board that has the confidence of the people and, more important, the confidence of its users as well as the practitioners and clinicians involved in the delivery of a broad range of health services, the better. I wish the Minister well.

Photo of Colm BurkeColm Burke (Fine Gael)
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I welcome the Minister. The legislation is a welcome development. I disagreed with the abolition of the board some years ago because I believed it was not the best way forward. I am delighted that the board will be re-established.

I served on the board of the Port of Cork for ten years and found it to be a great experience. The board was comprised of people from various backgrounds and my background was in local government and the law. Likewise, when setting up a board like this one it is important to draw in people with expertise in management and good governance. It is extremely important that the structure of the board is properly established. I congratulate the Minister on choosing the person he has appointed chair of the board. He has made a very good appointment as the person has considerable experience.

The need for a board was highlighted when the Minister announced that €17 billion will be allocated to health in 2019. It is important that this large budget is managed appropriately and that we get good value in the management of that money so that we can deliver services.

One of the concerns that I have had over the past three to four years is about recruitment within the HSE. The number of people employed in the HSE has increased from 99,000 at the end of 2014 to more than 111,000 now. This means more than 12,000 people have been recruited to work in the HSE since December 2014. This exceeds the entire workforce of the Irish Army. A large number of people have been taken on and it is not clear that a strategy was set out to prioritise the areas where we need to employ people. One of the things a board can do is set out a clear strategy for priority areas and ensure value for money is achieved when delivering a service, thus ensuring that the maximum number of people benefit from the service that is being delivered.

This morning, at a meeting of the Oireachtas Joint Committee on Health, a colleague raised the important issue of ensuring patient advocates on boards are adequately remunerated for their time and efforts. Patient advocates normally have other commitments. It is important, therefore, to ensure they are adequately remunerated on boards or sub-committees they serve on. That is one of the issues raised at the committee meeting this morning.

Dr. Scally appeared before the Joint Committee on Health this morning. The implementation of reports is an important issue. It is great that Dr. Scally, supported by the Minister, is committed to remain here to implement his recommendations. One of the reports that was referred to this morning was the Madden report, which was published in July 2008. Some of its recommendations have still not been implemented. While it is fine to produce reports, and we have produced a large number of reports on the health service in recent years, the issue is the need to have a clear structure in place to implement their recommendations.It is important that the new board of directors of the HSE is clear on how to move forward in the context of reports that have already been produced. Rather than undertaking new reports, the focus must be on implementing the recommendations contained in existing reports.

I have raised on numerous occasions my concern about the moving of the deck chairs within the HSE, whereby people in particular positions move on to other positions within a very short period. I am concerned about the lack of continuity in the rolling out of particular services. Recently, for example, 12 people in the HSE were to meet to deal with a decision relating to an individual but that meeting was cancelled because one of those involved had moved on to another job. The issue to which I refer has been going around the houses within the HSE for 18 months but, as yet, no decision has been made in respect of it. The culture that has developed within the HSE during the past 15 to 20 years is such that people are afraid to make decisions because of the possible consequences of doing so. We need to change that culture. We all make decisions and sometimes we regret those decisions but that does not mean that we should be hung, drawn and quartered, which seems to be why people are afraid to make decisions. I have seen issues within the HSE starting off at one level of management but going through three or four different stages before a final decision is reached, which delays the entire process. This can relate to decisions on purchasing new equipment, undertaking refurbishment work, opening additional beds and so on. People always complain about a lack of accountability but my biggest concern regarding the HSE is its failure to make decisions in a timely manner. I hope that a new board will be able to generate a new culture in that regard.

The other issue of concern relates to appointments within the HSE. I am still a little concerned about the internal appointment processes in the HSE. I have issues with the way posts are advertised internally and the way in which interviews are conducted. It is not clear that the people in the HSE who are conducting interviews have adequate training. There are extremely good people in the HSE working in the administrative, medical, nursing, caring, cleaning and catering areas. We must work with them to reassure them that their work is appreciated. There is a lot of negativity surrounding the HSE which some people are taking very personally. Morale within the hospital system is low and that is something which must be improved.

We must also work on the issue of staff numbers in certain areas and, for example, on the ratio of nurses to patients versus care assistants to patients. Nurses who are highly skilled and highly trained are often doing work that care assistants could easily undertake. Furthermore, nurses could do a lot of the work that junior doctors are currently required to undertake. We need to look at that area more closely as it may be possible to deliver a better service while also appreciating the work that people are doing.

Photo of Maire DevineMaire Devine (Sinn Fein)
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I welcome the Minister. Last year, the Government decided to reintroduce a board to oversee the operations of the HSE. I commend Senator Boyhan on quoting the Scally report, which makes clear and common sense. Its recommendations are not couched in political speak to confound us all, leaving us guessing the words and what they mean. The Government's decision followed a number of high-profile scandals within the health service, which were mainly due to failures within the HSE at corporate level.

The new board will be a slimmed down, nine-person version of the former HSE board. Six years ago, the Fine Gael-led Government removed the then ten-person version of the board. Sinn Féin opposed the legislation which sought to dissolve the board not because we thought the board was working well but because the legislation bestowed too much additional power on the Minister and did not give the Dáil additional powers of scrutiny or make the Minister further answerable to the Dáil. It is welcome, therefore, that the Government has seen fit to reverse the decision of six years ago. There was talk that the board would include a patient advocate, which is something Sinn Féin is determined to achieve in the wake of the Cervical Check scandal. Our determination predates this scandal, however. Senators know that I am passionate about this issue, as evidenced by the motion I tabled during the previous session in respect of parent advocates on the steering committee for children with complex needs. I welcome the fact that there will be a minimum of two patient advocates on the board but I am interested to know how they will be selected. How will that process work? I am pleased that patient advocates will no longer be sidelined, ignored or considered a nuisance.

The Government claims that the new board will restore public confidence in the HSE through a series of actions to strengthen the management, governance and accountability of the organisation. These are grand claims but they are the same as those made when the board was dissolved. Only greater oversight and proper accountability of the board by the Minister of the day will ensure better governance, accountability and delivery of our health services. It is a pity that we did not have that view six years ago. Instead, the Minister of the day decided to remove what can be seen as the checks and balances of good governance that applied to the HSE. We welcome the reintroduction of the HSE board because it is standard practice for public bodies to have an independent board which operates at arm's length from Government and provides independent oversight, particularly in the context of the spending of public money and accountability to the taxpayer. It was a sad state of affairs for the former Minister to do away with the necessary and important checks and balances.

When the HSE board was dissolved in 2012, there was an opportunity to progressively reform the organisation in order to achieve the highest level of corporate governance. This was not done and amendments to strengthen the legislation at the time were not facilitated. We did not support the dissolution legislation for that reason. Indeed, we have the same concerns regarding the Bill before the House. We would like to see provisions strengthened to make the Minister for Health and the new board more accountable to the Dáil. The board must also be able to robustly hold the Minister to account and the Oireachtas must be able to hold the chairman of the board to account. The re-establishment of the board cannot give the Minister the opportunity to hide behind or push aside the HSE when it suits.

The HSE has been described as a growing monster. Most Members of the Oireachtas, including the Minister, get so frustrated with the lack of answers from the HSE and with its use of political speak that clarifies nothing. One often feels that one is banging one's head off a brick wall. In many cases, one only gets a response ten months after submitting a query.

The must be public competition when it comes to membership of the board. There must be patient advocates on the board. The board in its entirety must be committed to the full implementation of the Sláintecare report. Sinn Féin welcomes the key fundamental principles, as outlined by the Minister, of independence, inclusiveness and compassion. Many in the HSE are experiencing compassion fatigue. Indeed, I attended an event on mental health earlier today in Dublin 12 and the constant message from the workshop discussions was around compassion and the lack thereof.

We will be submitting amendments on Committee Stage and I look forward to working with the Minister to strengthen the Bill. I wish the new HSE board well and ask its members to ensure that all decisions are guided by the three fundamental principles of independence, inclusiveness and compassion.

Photo of Anthony LawlorAnthony Lawlor (Fine Gael)
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I welcome the Minister to the House following his tough negotiations with the Minister for Finance to secure extra funding for the HSE, in particular in light of the fact that it required €700 million for this year. It is a sizeable sum of money. I hope it does not all go on administration. The money should be for patients rather than administration. As part of his role, the Minister is determined that should be the case and that money should follow patients.

I have a couple of queries about the HSE board. I am always nervous about the independence of boards and, in particular, their ability to question an executive. We have had too many boards around the country. I hark back to one of the major causes of the financial crash which was the boards of banks consisting of wine-guzzling, cheese-chaffing individuals who did not take their roles seriously. It was a very important role, however. Sadly, the boards acted not for their shareholders, the ordinary citizens who bought shares, but for the bankers themselves. They followed like little sheep the lead ram, namely, the chief executive of the bank, through the gap.

Photo of Maire DevineMaire Devine (Sinn Fein)
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Was the champagne and caviar for them?

Photo of Anthony LawlorAnthony Lawlor (Fine Gael)
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I will not go any further. The role of a board is to provide oversight. It is to ensure the functions of the board and the executive are carried out. It is the same as the role local authority members fulfil around the country. They are like board directors. I would like to see the Minister legislate for who he wants as members. He mentioned patient advocates. That should be put in writing. It might be a view the current Minister has, but a subsequent Minister might decide it is unnecessary. We are going through the Judicial Appointments Commission Bill now and the Minister for Justice and Equality has practically no say in who he can appoint to the commission because it is written and defined in the legislation. Another key issue is the Minister's role in relation to sub-committees, which are equally important. The audit committee is extremely important as it has to be sure about where money is allocated. Health funding will exceed €17 billion this year and that money should be spent on patients.

I ask the Minister about regional boards, which also play an important role. What connection will they have and how will they feed into the main board? Perhaps a main board member should sit on a regional board to ensure there is a direct line of communication from board to board rather than having the executive passing to regional boards hearsay as to what was said at a board meeting. That is important. Accountability is extremely important. While there is accountability to the Minister, board members should come before the health committee, not with the chief executive who sometimes prods and leads board members, but as the board itself, namely, in the persons of the chairman and a couple of members. Perhaps we can do something on that.

I will get a little parochial now. The Minister got a great deal of money yesterday and I would love to see some of it go to home care packages in my area. There are many people in hospital today who would be moved to their homes if home care packages were allocated. There are up to 700 people in my local CHO 7 waiting for packages. I ask for something to be done on that. I would like this money spent on home care, where it goes to the patient, rather than on the hiring of more staff. Senator Colm Burke referred to the taking on of 12,000 staff and noted that it might stun us if the percentage of those who were administrators was released.

This is a sound and robust Bill. If the matters I raise could be included, it would be even stronger. I thank the Minister and wish him the best of luck going forward with this.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I thank the Senator. He was never shy in coming forward. Well done.

Photo of Jerry ButtimerJerry Buttimer (Fine Gael)
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I welcome the Minister and commend him on the budgetary achievement yesterday. To be fair, it is a significant health budget. If I am honest, notwithstanding the good work of the Minister, and Ministers of State, Deputies Jim Daly and Catherine Byrne, I have never been as disillusioned about the governance of our health system. I say that as a former chairman of the health committee and as someone who sat on the HSE's southern health forum. I am disillusioned for a number of reasons. We have no accountability. The only person who is accountable is the Minister or another politician. Senator Lawlor referred to accountability and regional boards. A silo mentality is operating in our health system and, from what I can see now, there is precious little coming together. We can have all the talk we want of Sláintecare and reform, which is badly needed, but unless the patient is at the heart of our health system, we might as well take the Bill and put it up against the Sunbeam wall in Cork.

The Minister's intentions are noble and correct. We talk about good governance and accountability and to be fair to the Library and Research Service, it has produced a wonderful document for the Houses for this debate. However, I am disillusioned because I would like to know who will be accountable in the executive. We talk about transparency, accountability, participation and integrity but where are they? We have gone full circle in the wrong direction regarding the role of politicians in health. I have become a firm advocate now, having changed my mind on this, of the old health boards and the eight regions where we had politicians sitting with clinicians and other interest groups at a public forum. We should forget these meetings in Kilmainham and have public meetings with full disclosure to facilitate full openness. We are accountable as politicians. We can get voted in or out. The Minister can attend the Dáil or the health committee and be questioned. I hope we go back to that, although I know the Minister will not do so.

I welcome the fact that we are dismantling the current system. I am a firm advocate of the hospital group model and of money following the patient. I admire Senator Colm Burke's tenacity in putting down questions around recruitment and the filling of vacant positions. We are lucky to have a Minister who is committed to implementing a new model. I hate to use the word "reform" because we have had so many reports on it that it is old news. The Minister's legacy in the Department will be for people who want a health system which meets their need for access to treatment, acute hospital beds, timely outpatient appointments and emergency departments in which they do not have to wait an inordinate amount of time to be seen. Some of this is not about reform but about better management of resources. We have all been in emergency departments where people have had to wait not because of the queue but because of the process. I commend the nurses, doctors and other front-line staff in our hospitals because they do Trojan work. I was in a hospital last Sunday and saw the work they were doing.

We must go back to reality. I know the Minister wants to go so I will finish on this. I sat on the health forum when I was a member of Cork City Council.It was the greatest waste of time ever because there was no accountability or ability to get answers. It was a farce. The executive was laughing at us. We had to submit a question in advance and then we would get a written answer but - God help us - we could not go in and ask about A, B or C. I am not giving out to the Minister, and I hope he knows that, but in response to parliamentary questions, we are told the matter raised is one for the HSE and the Department cannot answer it or else we are taken from here to the Red Cow roundabout and back.

Photo of Maire DevineMaire Devine (Sinn Fein)
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It is farcical.

Photo of Jerry ButtimerJerry Buttimer (Fine Gael)
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Yes, it is. I support-----

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I love this meeting of minds.

Photo of Jerry ButtimerJerry Buttimer (Fine Gael)
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The Leas-Chathaoirleach is a businessman. We have €17 billion in funding for the Department of Health. For the second year in a row, the Department has received its highest allocation ever. What will happen? I will conclude on this matter because it is important. Senator Lawlor referred to respite care and home helps. If we want a health system that delivers for people, it has to be about the people who need it and not the suits. I have become seriously disillusioned with the suits because there is no accountability. I would love if the Minister appointed politicians to his board so that they can go in and get answers because this needs to be done publicly, not in a room with no coverage of proceedings.

I wish the Minister well. He has done a good job thus far. I hope he gets the support he requires to deliver gargantuan change. Senator James Reilly initiated it after the failures of his predecessors, Deputy Micheál Martin and Mary Harney. I wish he had been Minister when money was available. This Minister has a another opportunity and I know he will deliver. I am sorry for being cross, but this is an important issue.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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I think the Minister and I understood that the Senator was not cross with us.

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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I thank Senators for their contributions. There were many similarities in the themes being raised, many of which I can relate to and support. I will try to respond to a couple of them. The very issue Senator Buttimer outlined in raising the challenges public representatives feel - this is not about public representatives - on behalf of citizens is one of the reasons we need to reform the health service. I, too, chaired a regional health forum before I was a Member of the Oireachtas. I do not mean to be in any way disrespectful to the councillors up and down the country who go to these forums and do fine work, but they do not have enough powers or teeth to get the answers they want on behalf of their constituents. We will set up regional entities which will have boards. I will consider how public representatives can have an input and play a role in that regard.

I do not mean to be disrespectful to any colleagues here or in the other House, but it is bizarre that, in a national parliament, the Minister for Health can be before an Oireachtas committee or in the Dáil or Seanad answering questions on very local issues. I do not mean that rudely or disrespectfully. I am happy to answer questions all day long and I know the reason Members find they have to raise these issues in the Houses is that they often cannot get an answer at a local or regional level. When such issues have to be raised here it is a sign that something somewhere else in the chain is not working well. We have a chance now, as we develop these new structures, to get the governance right at a national level. We need a national entity. While we can do a great deal in the regions, we would not have delivered a national cancer strategy, a national maternity strategy or many other things if we did not have a national entity. A national health service is needed, but we also need to be able to devolve more functions, as appropriate, to the regions in what is a relatively small country. For this reason, we intend setting up integrated regional entities in order that the silos can be broken down and we can avoid a scenario whereby community health has a budget and management structure in one location, the hospital group has a budget and management structure in another and the two never meet.

The good news is that this is not just my view but one to which every political party and grouping in both Houses of the Oireachtas has signed up through the Sláintecare plan. Sláintecare is a ten-year plan, which we will not be able to implement overnight. That is not what we need to do in health. What we need to do is to keep working away at a vision regardless of who the Minister is or who is in government because we have all signed up to the same policy direction in a bipartisan fashion.

Yesterday was a very important day for Sláintecare because we now have more than €200 million to start making the plan a reality. We have a €20 million integration fund and, on the capital side, €6.6 billion of health capital funding will be directed towards Sláintecare over the next ten years. We reduced prescription charges and the threshold for the drug payments scheme and we provided for more people to access free GP care, all of which were Sláintecare recommendations. Today - probably as I speak - representatives of a doctors' organisation are in my Department seeking to recommence talks on a GP contract in order that we can make general practice sustainable, something which I know is very close and dear to Senator Keith Swanick's heart and which he raises and advocates for in this House.

We have the policy and resources but we need to have the proper structures, as all of the Senators have said, to make sure that those resources and policies get to where we all want them to get to. We want staff on the front line and patients - citizens - using our health service. It is clear to me that the distance, as Senator Colm Burke eloquently alluded to, between the decision-making process and the citizen is often far too big. We need to look at how we can address that.

I will now answer a couple of specific questions. In respect of how people are selected for the board, we will use the Public Appointments Service. I issued a statement today noting that this process is under way. We also selected the chair-designate of the board through that process. The chair-designate is available to go before the Oireachtas Joint Committee on Health. I am sure he would welcome that. I would welcome the chance for the Oireachtas Joint Committee on Health to meet him as well. Senator Lawlor made a number of interesting points on how we could improve the legislation, as did Senator Devine and others.

Photo of Maire DevineMaire Devine (Sinn Fein)
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Is the chair-designate a him or a her? Has a definitive decision been made on who will assume that role?

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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Ciarán Devane is the chair-designate so it is a him. Senator Lawlor made a number of suggestions about how we can improve the legislation. I particularly like his idea of making sure there are always patient advocates. He also asked whether that provision should be strengthened or if it should feature in legislation. I will reflect on that before Committee Stage. I will also reflect on a number of the Senator's other suggestions in respect of how the board will interact with the Oireachtas Joint Committee on Health, the regional board structures and sub-committees.

On the issue of home care packages, I expect we will be in a position to increase the number of home care packages again in 2019 and, I hope, through the winter period. I am aware of the issue the Senator has brought to my attention regarding demand exceeding supply in community healthcare organisation, CHO, 7. I am also well aware that there is a national issue in this respect and I hope we can make some progress as a result of the extra funding we have received both for the winter and for 2019. The Minister of State, Deputy Jim Daly, is working hard on trying to develop a statutory home care scheme. This is the big prize which we all work for. Every single one of us will say we want people to be able to grow old with care and dignity in their own homes and communities, yet the only statutory scheme today is the fair deal scheme, which is a scheme to send people to nursing homes. Home care is an ad hocnon-statutory scheme that varies between counties and constituencies. I will support the Minister of State very much in this regard. If we can get to the point where we have a statutory scheme in the coming years, that will be a game-changer in terms of the provision of healthcare.

To return to the legislation, this Bill is a very important step, albeit only a step, in putting in place the appropriate governance structures for the HSE to deliver and oversee the implementation of Sláintecare and the creation of a world class health service. It is also an important step in telling all of the people of Ireland, particularly women, that we are acting upon Dr. Scally's recommendations. One of his key recommendations related to governance, oversight and accountability. We need a competency-based board to achieve this. That is why I am very pleased to commend the Bill to the House.

Question put and agreed to.

Photo of Paul CoghlanPaul Coghlan (Fine Gael)
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When is it proposed to take Committee Stage?

Photo of Colm BurkeColm Burke (Fine Gael)
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Next Tuesday.

Committee Stage ordered for Tuesday, 16 October 2018.

Sitting suspended at 1.40 p.m. and resumed at 2.30 p.m.