Tuesday, 14 May 1996
Dáil Éireann Debate
Mr. Browne: (Carlow-Kilkenny): Ba chóir go mbeadh córas sláinte éifeachtúl againn i gcónaí, mar bíonn daoine tinne ag brath air go mór; ag brath ar leapacha bheith ar fáil sna hospidéil, gur féidir leo coinne a dhéanamh le dochtúirí. Mar sin, cosnaíonn sé seo a lán airgid chun an tseirbhís seo a dhéanamh  éifeachtúil. Tá súil agam go bhfuil an córas atá againne amhlaidh agus go gcuirfidh na hathruithe seo feabhas air.
The three main objectives of this Bill are to improve financial accountability and expenditure control procedures in health boards; to clarify the respective roles of the members of health boards and their chief executive officer and to begin the process of removing the Department of Health from detailed involvement in operational matters. We are spending £2.4 billion each year on health services.
Section 2 provides that health boards must have regard to certain matters in carrying out their functions. They relate to securing the most beneficial, effective and efficient use of resources, cooperating and co-ordinating their activities with other health boards, local authorities and public bodies and giving due consideration to the policies and objectives of Ministers and the Government. Given that this section must be included in the Bill, is it the case that those matters were not considered in the past?
A total of £2.4 billion will be spent on health, of which £1.3 billion will be allocated to health boards. I was concerned that in the past consideration was not devoted to the efficient use of resources and to ensuring adequate co-operation and co-ordination among health boards, but I hope this section enshrines in the Bill what was the practice in the past. The allocation of £1.3 billion, for health boards works out at almost £4 million a day. That is a considerable amount of money and there must be co-operation across all sections of health provision, whether among hospitals or health boards, to ensure it is spent efficiently.
Irrespective of how many improvements are made, an unusual approach to dealing with hospital waiting lists, particularly for patients awaiting heart operations, appears to have been adopted. Cardiac surgery is traumatic for the patients and their families. Patients on a waiting list for a hip operation can survive even though they may have pain, but the life of patients  awaiting heart surgery may be in danger.
I know of a person who was involved in an accident which necessitated surgery while he was on a waiting list for a heart operation. That person had to have the heart operation first. People on a waiting list for surgery find it difficult to understand why there is such a delay. Most heart operations are performed on an emergency basis. People collapse, are rushed to hospital and have a heart operation, thereby displacing the next person on the waiting list. I feel sorry for a person next on a waiting list whose operation is cancelled because of an emergency. We are all aware of people who have had emergency surgery and some of us have had personal experience of it. We are grateful that an excellent surgeon is available to perform emergency heart surgery when required. The skills of the surgeons who save so many lives and give people lucky enough to have a heart operation a better form of life are appreciated.
Health boards, which spend almost £4 million a day, play an important role in administering health services and it is vital that they put the best arrangements possible in place. I question whether in the past hospitals were located with the interests of the patients in mind. I am mindful of the south east region. I do not understand how Waterford hospital, situated on the coast, is regarded as central to serve the south eastern coastal region. Only seagulls with broken wings can fly in from its west side and they will not visit the hospital. Hospitals should be located centrally.
One of my county council colleagues pointed out yesterday that a patient from Hacketstown on the Wicklow border must travel to Waterford to attend a hospital and the people of Waterford would be nearer to Fishguard than Hacketstown. There is also the added problem of the need to travel a road that is not in the best state of repair. In this regard the condition of the bridge in Waterford could also be improved. The future location of hospitals should be given serious consideration. I appreciate  that a decision made in the past will not be changed but dragging people from one end of a region to the other does not represent good planning and some planning in the past was bad.
There should be a certain amount of decentralisation of health services. Patients from north Carlow should be able to avail of health services in Carlow rather than being transported, even while recovering from an operation, to the other end of the health board region. It would be better if medical specialists saw 20 patients at a venue, such as the district hospital in Carlow, than to ask those 20 patients to travel to Waterford to attend the hospital. I accept the South Eastern Health Board is reviewing the position and I hope they will make such a recommendation.
Health boards administer many areas of health service. I have particular interest in facilities for the mentally handicapped. I am thankful that I do not have any personal experience of mental handicap, but I am involved in a group, Delta, which operates a training centre for adults with a mental handicap. The health boards do great work in this area and I do not wish to criticise the South Eastern Health Board in this regard as it has given financial assistance to our group but I find it difficult to accept that it is considered sufficient for health boards to provide 80 per cent of the cost involved. People with a mental handicap need special care. School, youth and adult facilities for the mentally handicapped should receive 100 per cent funding. I appreciate that talking in terms of facilities receiving 100 per cent funding seems extreme, but in the case of ordinary schools the parish and parishioners provide all the necessary funds. Parents of children who have a mental handicap, and their friends, are worn out fund raising to provide necessary facilities. Instead of attending talks designed to assist parents help their children with a mental handicap, they must attend fund raising meetings organising the selling of tickets and so on. The parents and friends of people with a mental  handicap should be relieved of the awful burden of non-stop fund raising.
When an extension was added to the training centre in Carlow a few years ago, the parents and friends of the children collected £36,000 which involved a great deal of hard work. Those parents and friends also look after St. Laserian's Special School and Teach Sonais, a house which provides overnight accommodation. There are many demands on the funds raised by parents. It is becoming increasingly difficult for them and their friends to encourage people to take up official positions and they cannot be blamed for that. It is difficult in any walk of life to raise funds, but parents with a child with a mental handicap have much more to worry about. They should not have to attend fund raising meetings, run cabarets, sponsored walks or sell tickets they should be able to attend meetings designed to assist them to help their children.
The Department should consider transferring funds to meet the needs of such children. People with a mental handicap deserve the best facilities available and the provision of them should not mean any trouble for the parents. I include elderly people who represent an increasing proportion of the population. We must provide first class facilities for those people who kept the State going, worked for miserable wages in many cases, did not have the benefit of electricity when they were growing up and suffered many hardships. The least we can do is provide proper facilities for them in their old age. Many hospitals provide excellent services for the elderly. This represents a major change from the time people talked about the “county home” which in many cases represented the final straw. This is still the case in many instances: one can change the name of a hospital and modernise it, yet some people still think of it as the county home. In the past some old buildings were not up to standard but in fairness the nursing profession provided excellent care for the elderly. Health boards must continue to ensure  that beds are available for elderly people and those suffering from, for example, Alzheimer's disease.
Section 15 requires a health board to publish an annual report on the performance of its functions during the preceding year. Deputy O'Malley said that in some cases reports had not been published for three or four years and this amendment will ensure that action is taken as soon as possible to deal with a problem which arose in the previous year. Section 20 deals with nursing homes. Most nursing homes provide excellent facilities but we always hear about those which are not up to standard. Such homes should not be tolerated and section 20 will ensure that people cannot cash in, so to speak, on the fact that elderly people have to be admitted to nursing homes. No mercy should be shown to nursing homes which do not meet the required standard. In saying that, I admit that most nursing homes provide excellent facilities. While people must have adequate financial means to be admitted to private nursing homes at least they ensure that people can end their days in peace.
I welcome section 21 which provides that the Minister may extend the term of office of An Bord Altranais pending the enactment of a Bill to revise the Nurses Act, 1985. I hope An Bord Altranais will prosper and that the present dispute with the nurses will be resolved. It is of little use referring to the vocation of nurses when they believe they deserve more money. The Minister has gone a long way towards meeting the demands by providing £40 million and I hope a solution can be found to this difficult problem. We do not want nurses to go on strike as it would not be good for patients or the nursing profession.
I welcome the Bill which I hope will improve the workings of health boards and their members who are being given responsibility for the allocation of funding. I was a member of a health board for a few years before I became a Deputy and I know how easy it is to  criticise the chief executive officer for not doing certain things. However, it is not easy to cut back on the funding for one section and give it to another. I hope that the members of health boards will spend these vast sums of money wisely so that we have a better health service.
Mr. Morley: I welcome the opportunity to contribute to this debate. I also welcome the Bill which represents the first review of the legislation governing health boards since their establishment in 1970. This important legislation deals with the structure and procedures for delivering the health services to the public and its aims and objectives are timely and laudable. It proposes to strengthen financial accountability and the expenditure control mechanisms for the various boards, to define more clearly the prospective roles of board members and chief executive officers and to give greater authority and responsibility to the board for everyday operational matters.
While the Minister will correctly continue to have overall responsibility and be accountable to the Oireachtas for all health services, the Department of Health will not be involved in the detailed management of individual services within a board's remit. For example, a board will be free to dispose of land or to grant-aid voluntary bodies in its area within broad guidelines laid down by the Minister and the Department without having to seek approval of the Minister in each case. This is a desirable development. Deputy Browne referred to section 20 and I agree with the sentiments expressed by him on this matter. I am pleased that this section makes it an offence to run a nursing home which is not registered under the Health (Nursing Homes) Act, 1990.
These provisions should strengthen the structure of health boards and make them more efficient in delivering health services to the public. However, the Bill does not address many of the defects in the services. They need to be addressed urgently and I trust the Minister will  give consideration to some of them in the context of the legislation. I am not sure if they were dealt with in the strategy document Shaping a Healthier Future and as a member of the Western Health Board I wish to refer to some of them.
The first defect which affects all boards is the long waiting list for various procedures, the second is the closure of wards which has resulted in overcrowding in hospitals and the third is the early discharge of patients. The waiting lists in all health board areas are too long and a patient who has to wait too long for a service is effectively being denied it. There should be a more reasonable relationship between the length of time a public health patient has to wait for a particular service and the time within which it can be provided for a private patient. Some years ago the Minister of the day allocated extra funding to reduce waiting lists and the Minister has continued this practice. While this has led to some improvement there were still 28,000 people on the waiting lists last year.
Cutbacks and stringent budgetary control, necessary and desirable as they may be from a financial point of view, have had the effect during the years of having wards closed with resultant overcrowding of available space and overstreching of personnel and services within hospitals. We have all heard stories of patients left for hours on trolleys before being attended to properly and convalescing patients discharged into far from satisfactory home conditions. There is a need for much more funding for such services as home helps.
In this context I appeal to the Minister to consult his colleague, the Minister for Social Welfare, with a view to easing the conditions for the carer's allowance. There should be no means test for this allowance. Taking on the responsibility for caring for an elderly or sick person is a serious and onerous task and, if the allowance has to be graded, the grading should be based on  the degree of care required by the patient. A patient cared for at home for as long a period as possible means a financial saving to the Department and the State.
I appeal to the Minister to take some initiative to develop and strengthen the community care programme in every health board area. I am familiar with the programme in the Western Health Board area which has suffered most because of the cutbacks and budgetary pruning over the years. There is a level of demand and standard of service below which one cannot go in hospital programmes. People who are acutely ill have to be admitted to hospital and given treatment appropriate to their illness, but there is no such yardstick in the area of community care, apart from ensuring that people have access to a doctor and chemist.
For this reason the community care programme has had to bear the brunt of financial pruning with the result that many of the services intended to be developed have not been provided or provided on a hit and miss basis. Strengthening the programme makes economic as well as health sense. A properly developed community care programme would mean fewer admissions to hospitals, shorter stays, better after care in the community and less chance of suffering a relapse which would necessitate rehospitalisation at further cost to the Department and the taxpayer.
I draw the Minister's attention to what appears to be a serious unevenness in the services provided by health boards. This manifests itself in many ways. For instance, the length of time one has to wait for various procedures and the level of service provided, such as home helps and public health nurses, vary from board to board. Even medical cards, so essential to the less well off, appear to be more easily attainable in some board areas than in others. This is a vital matter, especially when one considers that a medical card is not alone a  passport to free medical care and hospitalisation, but to school transport and other fringe benefits.
An effort should be made to ensure that the range and standard of services are identical in all board areas. This can only be done by ensuring that there is an equitable distribution of departmental funding taking into account the unique and special circumstances pertaining in each board area. This does not appear to have been done in the case of the Western Health Board. Little account, if any, has been taken of the fact that it caters for the highest percentage of dependent persons in any health board area, that people have to travel long distances to avail of and provide services and that a large number of people have to travel outside the area, principally to Dublin, to avail of services not available within the board's hospitals.
I wish to refer briefly to the current nurses' dispute and wish the Minister well in his efforts to resolve it. It will be tragic if these dedicated people have to resort to industrial action. They are in the front line in delivering vital services to patients in their most vulnerable physical and mental state. Very often, the quality of these services is determined by the diligence, care and dedication of the nurses on duty and is seen to be so by the patients themselves. How often have we heard patients on their discharge from hospital after a serious illness comment on the quality of care provided by and attention received from this dedicated band of health workers who have given sterling service during the years and are entitled to be appropriately rewarded without having to take to the streets?
As a member of the Western Health Board, I wish to refer briefly to the Kelly Fitzgerald case mentioned in this debate and widely in the media and, in particular, the decision of the board not to publish the report of the inquiry which the board itself set up although satisfied at the time that its services had done all that was possible in the case. The report of the inquiry was discussed  by the board on 11 March. In my opinion the facts supported its earlier view that its services had done all that was possible, but as well as the facts there were many opinions, based on hearsay and with the benefit of hindsight.
The board sought legal opinion which strongly advised against publication. It was not reluctant to publish the report, but there was a strong view that it was neither fair nor fairly compiled. There was no list of people who gave evidence and no details of their evidence. The staff of the board who had co-operated fully and willingly in the inquiry were not given any opportunity to see a transcript of the evidence they had given. The report did not give enough weight to the circumstances under which they were operating at the time without adequate resources or take into account the limitations of the law under which they did not have the right of entry to the family home, to insist on access to the children or require that they undergo particular treatment. All this and more led the board to conclude that the report should not be published, although it did decide that the recommendations should be published.
Since the publication of the report there has been a disgraceful scape-goating of the board and its staff although any objective reading of the facts and the report and, in particular, the response of the board would lead one to conclude that the board acted honourably and with accountability in this case. The bringing into effect of the 1991 Child Care Act and the large increase in staff and other resources since then gives some idea of the circumstances under which the board was operating at the time. I hope, now that the media and other commentators have had their pound of flesh, we can get on with the job of providing better support services for families in trouble, due to environmental factors or other inadequancies, and making the task easier for child care agencies such as the Western Health Board. I welcome the Bill and urge the Minister to rectify the  deficiencies in the services which the boards have to deliver and which I, in this brief contribution, have tried to highlight.
Mr. Nealon: This is a significant, important and, as Deputy Morley said, non-contentious Bill which will have a major influence on the quality of our health services in the years ahead. It sets down new planning management and accountability provisions which will change the way the health boards conduct their business. It presents a challenge to all in the health sector to work within a planning framework linked to specific resources and clear objectives. It brings accountability much more to the fore in planning and reporting terms. It is about achieving efficiency.
The North-Western Health Board by any standards, is one of the most efficient boards in the country. It has not always been rewarded for that. When budgets were tight in the late 1980s and funding was allocated on the basis of previous costings, that board was penalised for its efficiencies whereas inefficient boards which ran up big overdrafts had them wiped out.
The basic principle governing the conduct of health affairs of health policy and overall control of expenditure but should not be involved in the detailed management of health services. Greater responsibility should be devolved to health boards and other executive agencies. The role of all key parties, including the members of boards and their management, must be clearly identified and greater autonomy must be balanced by increased accountability.
The amount provided in the Health Estimate for this year is £2.4 billion. In the last five years the level of non-capital expenditure on health increased by 7 per cent in real terms. This Bill provides for improved financial accountability for these vast sums of money and expenditure control procedures in health boards. It clarifies the respective roles of members of health boards and chief executive officers and begins the process of removing the Department of  Health from detailed involvement in operational matters.
The first objective is to strengthen the financial accountability arrangements in health boards. The Bill provides that the boards will operate in an environment of service planning, with strict financial control and accountability. It reflects the Government's strategic management initiative, with emphasis on making the public service more responsive, accountable and open. The public expects a more open and accountable system of health administration. Health boards will be required to prepare and adopt an annual report on the performance of their functions in the preceding year. That will help the taxpayers to judge whether they are getting the best possible value for the money they contribute to the public finances. Services will have to be even more responsive to people's needs and more information will have to be made available on the actions and decisions taken on their behalf.
Another objective of the Bill is to clarify the respective roles and responsibilities of members of health boards and chief executive officers. One of the key problems identified by the Commission on Health Funding in the present structure is that it confuses political and executive functions, to the detriment of both. The exercise we are involved in here could be called subsidiarity, a decentralisation of authority, devolving from central control decisions that are best taken at local level where they are implemented. The Bill is very important in that respect.
The North-Western Health Board has the reputation, and deservedly so, of being a very efficient board. I hope in allocating the budget in future years due account will be taken of the special circumstances in that area, such as the ageing population which is scattered over a huge geographic area where some places are inaccessible, with many people qualifying for medical cards, not because it is easier to get medical cards in that area  but because people's circumstances dictate it. In regard to means testing for medical cards and other facilities, that there is a variety of means tests creates a major problem. The Minister, together with the other Ministers involved, particularly the Minister for Social Welfare, should seek to have a common means test to cover all areas. Because of the importance of the medical card to many people it is essential that the criteria are wholly appropriate.
I hope this Bill leads to the provision of a greater number of regional services, thereby bringing to an end the practice where patients have to travel to Dublin from all parts of the country for services. I accept because of the nature of the service we are talking about, there will always be centres of excellence such as in the child care area and other specialities, and patients will have to attend those centres for treatment. I have no objection to that, but with improved hospitals and consultants living in regional health board areas there is no reason many of the services should not be provided in the regions, putting an end to the mass movement of people to major centres, which has been a feature of our health services in the past.
Regardless of whether authority for our health service is vested in the Minister or in regional areas, one of the main objectives must be to get rid of waiting lists, a very unfavourable feature of our health services down the years. All of us have heard examples of people who have to wait four, five or six years for hip replacement operations. That is not acceptable, particularly for elderly people. I would like to see waiting lists eliminated. I am aware that will not happen, but it should be the objective of a good and caring health service. I hope that giving greater authority to health boards will spur them on to eliminate waiting lists.
As Deputy Morley mentioned, there should be greater concentration on home care. The carer's allowance should be made more readily available by providing sufficient finances and removing the outrageous restrictions  that apply to it. The net result would be a saving of money. I welcome this Bill which deals with a service we all hope will be delivered in the most efficient manner possible. As a result of its passage we will see major advances in that area.
Mr. Foley: I welcome the opportunity to contribute to this important Bill which, in the Minister's words, aims to modernise the planning and management systems in the health boards. It sets down new planning, management and accountability provisions which will change the way health boards conduct their business. The local government audit services was responsible for the audited accounts of health boards for years up to and including 1993 and the Comptroller and Auditor General was responsible thereafter. The report of the Comptroller and Auditor General on the audit of the 1994 accounts of health sector bodies and health boards points out that up to 1993 local government audited reports were relied upon for assurance that moneys had been properly used and controlled by the health boards.
A number of issues were raised by the local government auditor's reports down the years which were common to four or more of the boards. They include: (a) the formal sanction of the Minister for Health under section 31 of the Health Act, 1970, had not been received in respect of net expenditure by boards in excess of approved allocations for the four years 1990-93; (b) there are a number of unresolved disputes between boards and local authorities involving material sums due on foot of services rendered; (c) the effectiveness of the systems in operation for the collection of hospital charges leaves much to be desired and (d) the eight health boards, as part of a value for money initiative, formed a national purchasing committee which undertook to invite and examine tenders for the supply of certain products and to obtain and agree the best possible price in  relation to a decision taken by the committee.
A High Court action was taken against the board by an aggrieved supplier for an alleged breach of European Union directives and the Competition Act, 1991. Following lengthy negotiations the action was settled out of court for a sum of £225,000 including costs. The cost of this settlement, with the board's own legal costs of £133,000, was divided between the eight health boards. This was a very costly exercise.
Other issues that came to light were that financial reviews in relation to disabled person's maintenance allowance and other allowances were grossly in arrears with many reviews of cases dating back to 1994 not yet carried out. Staff shortages were the explanation for the huge backlog. The failure to carry out reviews in a timely and efficient manner increases the risk to allowances, benefits and medical cards enjoyed by claimants who no longer qualify for the relevant scheme. The possible consequential loss to all concerned cannot be quantified.
I welcome the Minister's statement that one of the first objects of the Bill is to strengthen the financial accountability and arrangements in health boards. The Government is determined that the health boards will in future operate for the betterment of service planning and in alliance with strict financial control and accountability.
I wish to refer to a recent report of the Comptroller and Auditor General with regard to fixed assets of health boards. The Department of Health accounting standards stipulate that all land, buildings, vehicles and equipment should be accounted for in the balance sheets of a health board. The boards are directed to use the insurance value of buildings as the basis for determination of the amount to be included in the balance sheet taking into account factors such as age and condition. Only two of the eight health boards have included values for all fixed assets in their  accounts while one health board has not accounted for its fixed assets.
The valuations used for buildings in the accounts have been computed in all cases. For instance, one board has shown a value of £41 million for buildings where the insurance valuation amounted to £235 million at 31 December 1994. Another board has shown the valuation of buildings as being half the insurance value for accounts purposes. Moreover, the valuation for vehicles and equipment has not been properly stated in the accounts of six of the eight health boards. Further action is needed to ensure that all fixed assets are correctly recorded in the accounts of the boards.
The Comptroller and Auditor General also referred to stock control in hospitals. Stock control is an important element of the management of hospitals. In the course of audits of health boards and other hospitals it was noted that there was a general absence of proper control of pharmacy stocks. Apart from the financial implications of such poor control, the potential misuse of misappropriated medicines or drugs must also be taken into account. The Comptroller and Auditor General has drawn the attention of the relevant authorities to this area of stock control weakness.
Another aspect of the Bill is to clarify the respective roles and responsibilities of the members of health boards and their chief executive officers. One of the key problems identified by the commission on health funding in relation to the present structure is that it confuses political and executive functions to the detriment of both.
I take this opportunity to congratulate our health care personnel. They are excellently trained and their tremendous dedication, in many cases working under difficult circumstances, has made a major contribution to maintaining a very high standard in our hospitals. One can have a certain pride and satisfaction regarding the overall quality of our health services but a number of warning signs indicate that there is no room for  complacency in terms of the service. One must be concerned at the high cost of newly developed drugs for the treatment of conditions such as cancer, chronic illness and infectious diseases.
The current population projection indicates that over the next 20 years the number of elderly people in our society is likely to increase substantially. This trend towards increased life expectancy will, however, place a further major strain on our health care services, particularly within the acute hospital section.
The more efficient our health boards become, the more they will benefit our health care system. The time is now opportune to re-establish the local health committees on a county basis, although it is stated in the Bill that will not be acceptable. They were of tremendous benefit and it is agreed that the health boards structure helps to devolve power from the centre to the regions in terms of determining the organisation of health care throughout the country.
I welcome the general trend towards increased accountability which is the basic purpose of the Bill. However, in an area of such great importance we must take urgent steps to improve the scope and detail of information and research available on the performance of our health services. For example, data from the hospital patient inquiry system has tremendous potential to provide anyone involved in health care policy with detailed information on the performance of acute care. To date, however, this source of information does not seem to be fully exploited. I expect there is a similar position in relation to many other elements of our health care system.
At a time when a wide range of factors are combining to create ever increasing demands for resources in the health care sector we must take every possible step to ensure that audit and quality control become an accepted part of the delivery of health care services. We simply do not have an option in this regard if we wish to maintain and improve the quality of our health care system.
 Ensuring the efficiency and effectiveness of our health care services is a matter of concern to every family. Sooner or later almost every individual has to receive medical care either from the family doctor or from hospital based services. In general we have much to be proud of in our medical services. As public representatives we frequently receive complaints about undue delay in providing services such as hip replacements and various other surgical procedures. There is no doubt that such backlogs are the cause of much distress and pain for people dependent on the State for medical treatment. It is most important that renewed efforts are made to eliminate such problems in our health care services.
Another matter of concern is the weekly hospital clinic and I refer in particular to Tralee General Hospital. Each week medical card holders are notified to attend clinics at approximately 9 a.m. but some of them are still there at 6 o'clock in the evening. I appeal to the Minister to do something about these waiting lists. Patient appointments should be staggered to avoid undue waiting. That would be most appreciated.
In regard to the provisions of the Bill, section 2 requires that health boards, in carrying out their functions, should secure the most beneficial, effective and efficient use of resources and co-ordinate their activities with other health boards, local authorities and public bodies. Sections 3 and 4 clarify the respective roles of the members of health boards and their chief executive officers. That is to be welcomed.
Provision is made for certain specified functions to be known as reserve functions to be carried out directly by the members of the health boards. These include the adoption, supervision and amendment of service plans, the appointment and removal of the chief executive officer, the purchase and disposal of land, the borrowing of money and decisions to discontinue the powers of maintenance of any premises. The chief executive officer will assist the  board, as appropriate, in these matters but the board will have the final say in the performance of these functions.
Any function not reserved to the members will be, subject to some minor exceptions, a function of the chief executive officer and the staff of the board. The chief executive officer will be advised to provide the board with any information it might require in relation to such functions but will otherwise be autonomous in performing them. The effect of these changes will be to bring the management system in the health boards into line with the arrangements that have worked well in the local government system for many years. I welcome the Health (Amendment) Bill, 1996.
Mr. Crawford: I welcome the Health (Amendment) Bill, 1996. The purpose of the Bill is to strengthen the arrangements which govern the financial accountability of health boards. That is extremely important because, in the not too distant past, certain health boards simply refused to remain within their budgets which resulted in the creation of huge deficits. I acknowledge that the previous Government utilised the amnesty moneys to rectify that problem to some extent but we must guard against it in the future and this Bill has a major role to play in that regard.
The Bill spells out a number of things we must take seriously. Health boards have a responsibility to work within their budgets, to ensure proper accountability and good value for money. There is also a need for the chief executive and staff to ensure they co-operate with the health board and work within the structures. One must not forget the Minister and successive Ministers have a responsibility here. There is no point in Ministers deciding that certain functions should be carried out by the health boards and the chief executive if sufficient moneys are not provided. In this context, I question some Members of the Opposition when they call for extra services to be provided and on the other  hand call for major cuts in taxation. We need a clear indication from parties, especially the Progressive Democrats, as to whether they agree with this Bill and support it. We need to ensure that whatever Minister is in office provides long-term funding to the health services. This Bill will have implications for the boards and the chief executives if proper funding is not available to carry out the work they are asked to do.
The fact that there is £2.4 billion in the health budget means that the Minister and the Government as a whole must ensure there is proper accountability and that proper use is made of that money. As the Minister stated, the health boards get £1.34 million so there is a need for control, management and openness and accountability in regard to those funds. A member of the Opposition said the other night that Ministers should get out of their offices and visit the health boards and see where the real problems are. The Minister for Health and the Minister of State, Deputy O'Shea, made their presence felt in my constituency of Cavan-Monaghan. They met and worked with the health boards as far as possible. They were received courteously by all members of the health board. The North-Eastern Health Board works closely with certain committee groups — I am sure Deputy Leonard will refer to this later — and is making good use of the funds available.
I pay tribute to the chief executive Mr. Donal O'Shea and his deputy, Mr. McLoughlin, who are trying to work with all the different groups involved in an effort to ensure people are aware of what is happening and what is being done. Deputy McCormack said that the Eastern Health Board got £5 million from the tax amnesty to bail it out. The Eastern Health Board had lived within its budget and did not have to be bailed out by anybody. There were many things which should have been done and could have been done if it had been as reckless as some of the other boards. In fairness the then Minister, Deputy Howlin, recognised that and gave £5 million towards many different projects which  have proved beneficial. Both he and the present Minister, Deputy Noonan, have provided funding for much needed improvements in the whole region, especially in Cavan-Monaghan. It is vital for the well-being of the people that the service is provided as near as possible to their homes.
To that end a health care centre in St. Davnet's complex, in Monaghan town, is nearing completion, a tremendous step forward. A training and community care centre will be established in the town centre which will bring the services into the main street. Carrickmacross will have a new hostel for the handicapped in the not too distant future. In Ballybay the credit union and the health board applied for planning permission to restructure the whole service in that area. In St. Mary's Hospital, Castle-blayney, some wards are being closed down. Funds have been made available, a unit for older patients suffering from Alzheimer's is now open and the day centre is almost finished. These are the types of facilities which health boards, with the aid of funds from the Minister, can provide.
Much discussion has taken place down through the years about the difficulties at Monaghan General Hospital. Only the other day I was approached once again by scaremongers who tried to suggest the hospital is in danger. I pay tribute to the board and the chief executive for bringing the Cavan-Monaghan hospital under the one hospital group. Seven new consultants have been appointed there and more will be made available if and when they are needed. A new dialysis unit and a new scan unit, with the help of sizeable funds raised by community groups, has been provided in Cavan and a new scope unit in Monaghan. All these facilities make and bring health care nearer the homes of the people. As Deputy Nealon said in his contribution, regional treatment is essential. The new dental units which have been provided are important. The need to introduce new treatment centres is one matter but the provision of funds to run them is very important.
 For example, in regard to dental treatment, numerous people come to our clinics seeking new dentures and ordinary dental treatment but have no idea when they will get them. We now have a clear statement from the Minister that the matter is being rectified and that treatment will be available. Following this statement I ask the Minister to ensure that staff is available in each health board area. As soon as announcements are made concerning these facilities the people want to see them in operation.
The North-Eastern Health Board has a good record in its care of the handicapped, as set out in our programme for Government. Extra funds have been made available for this purpose. We are fortunate in the Cavan-Monaghan region that we have a special unit in Cootehill for schooling and care of the handicapped. These special people need our care. We also have a unit in St. Davnet's complex. More social housing will have to be provided, especially in County Monaghan, to provide more accommodation for the elderly. We have a poor record in that area with the exception of one house for the handicapped outside Monaghan at Tierneal and Camphill community. I look forward to the involvement of the Department of the Environment together with the Department of Health in this issue.
Care of the aged has been mentioned. This is an extremely worrying matter for health boards and for the Minister for Health and the Department of Finance. With an ageing population we need more and better accommodation not only in homes but at home, if possible. The longer we can keep people in their own homes, with proper care, the better.
When I first came into this House little or no home help care was available —the carers' allowance existed in name only. There are still problems with it but successive Ministers have made a genuine effort to improve the position. Families can now earn £150 without having it taken into account. This is a major improvement but there is still a  great deal of red tape to be removed. The best place to care for the elderly is in their homes. It is better to pay a carer to give a hand in the home, rather than pay him or her the dole. We must consider more ingenious ways to tackle this matter, so that those who are prepared to look after their elderly relatives at home get all the help they can.
When patients go into hospitals for emergency treatment they have to fill forms and answer questions. It would help health boards if the new charge scheme for the Dublin area was extended. Form filling and red tape takes up the precious time of nurses and clerical staff. The Cavan-Monaghan area has one of the best nursing staffs anywhere. We should do anything we can do to take the pressure off health services whether through negotiations or reducing red tape to save time.
Health care is of major importance to everyone. It crosses national and county borders and this is where the benefit of regional treatment is seen. If we can prevent families having to travel to Dublin or further afield we are doing a good job. The health boards and the Minister should provide funds to ensure treatment is available at regional level. I am glad the current Minister has been involved in discussions and negotiations with our colleagues across the Border to ensure their health services can be utilised by people in the Border region— they will be more accessible if peace continues. This will make the best treatment available and and keep the waiting lists as short as possible for those requiring hip operations, heart surgery, etc.
I welcome the Bill and hope it can be used to strengthen the health boards. Under the legislation responsibility lies not just with the boards and their chief executives but with the Minister and the Department to provide the funding to maintain the health service.
Mr. Leonard: This is an important Bill which deals with efficiency and value for money but like most of the legislation and pronouncements we deal with, it is  full of aspirations. There is a continuing increase in demand on the health services under practically every heading. We speak time and again about living within inflation but it is not happening in the health boards—the demand is astronomical.
I have been a member of a health board for almost as long as I have been in this House, which is nearly a quarter of a century. The three main objectives of the Bill are first, to improve the financial accountability and expenditure procedures in the health boards; second to clarify the respective roles of members of the health boards and their chief executive officers; and third, to begin the process of removing the Department of Health from detailed involvement in operational matters. I welcome all those aspirations. On clarifying functions, members can contribute greatly to the process along with their chief executive officers and they will take up this challenge.
Health boards are doing good work. I am a member of the North-Eastern Health Board and we remain quite far behind. The councils provided health services until the Health Act, 1970 but the Department has seemingly continued funding on a pro rata basis, rather than making a close examination of requirements. It did not take into account areas which needed more.
My health board has devoted much time and discussion in the last few years to advanced planning, with the theme being value for money. There has been an amazing change in facilities in the geriatric, orthopaedic and child care areas and in general hospitals, etc. Undoubtedly there have been improvements, many of which are due to drawing up the plans in advance. Treatment within the regions was mentioned and we have laid great emphasis on that. The time has come for health boards to build up as many specialities as possible within their regions. They will not be able to provide heart operations overnight; however, the NEHB is providing dialysis and ENT in conjunction with  Omagh hospital — they treat our outpatients and consultants come to us. This is to be welcomed from a cross-Border perspective and it has been effective. Before this dialysis patients had to leave for Dublin at 4 a.m. while other patients were picked up along the way. For the 12 months this has been in operation it has worked well and the demand is far in excess of what we are capable of providing, not alone in the four counties which from the health board area but also for patients from adjoining counties who wish to benefit from these specialities.
The first funding for the waiting list initiatives was provided by my party. In the orthopaedic field it has been a terrific success — previously we were continually in touch with the orthopaedic hospital in Navan about people who were in severe pain. The waiting time for operations is not as long now. However, there is still great difficulty with cataract operations. It is annoying to meet people in their seventies or younger, who may be retired or cannot work, who are unable to watch television or read a newspaper. Many people have to wait years for cataract operations. I hope the Department addresses this problem. As I said earlier, arrangements were made for patients from the Cavan-Monaghan area to go to Omagh Hospital for ear, nose and throat services but, unfortunately, the list for cataract operations in the North is as long, if not longer, than here.
Funding under the peace and reconciliation initiative should be used to the best advantage. There is no better bridge building exercise than the development of cross-Border services. I hope the proposals for joint day care facilities materialise and that people can avail of some services in the North and others in the South. This would greatly reduce transport costs and bring people, North and South, closer together. When day care facilities were initiated, people were not inclined to travel to avail of them but that is no longer the case. They are now eager to avail of those worthwhile services.
 The system should be geared towards caring for our elderly in the home, not in institutions. A person is paid a mere £1.40 an hour for providing a home help service. While health boards have endeavoured to provide training for home helps, the meagre wages are not an incentive to anyone to avail of it.
County enterprise boards could provide funding for private nursing homes. Two applications for £50,000 were submitted to my local board for building nursing homes. There is a need for nursing homes in the area and approximately 24 jobs would be created. Many people from the area are being cared for in nursing homes in, for example, Benburb, Dungannon and Fivemiletown in Northern Ireland. However, even though the county enterprise board would like to provide the required funding, restrictions on resources do not allow it. The board's funding was cut to £90,000 per quarter. We are examining the possibility of providing subvention per job to enable the projects to proceed.
There are also long waiting lists of A, B and C categories for orthodontic treatment, but most health boards are able to take people from categories A and B only. It is not a pointless exercise to place people in a category from which there is no hope of them being called? While additional funding has been provided for orthodontic services, it is not adequate and that is evident from the number of representations I receive from people on waiting lists.
I spoke earlier about funding per head of population for health boards. Replies to parliamentary questions indicate that the North-Eastern Health Board lags far behind other boards in terms of services. We do not have as many speech or occupational therapists. A reply to a recent parliamentary question indicated that we receive £330 per head of population compared with £403 for the Southern Health Board, £434 for the South Eastern Health Board, £542 for the North-Western Health Board and £451 for the Midland Health Board. The figure of £290 for the Eastern  Health Board is difficult to accept because in 1995 it was £702 per head of population and in 1991 it was £453. There appears to be some discrepancy there. While in many cases the Department has acceded to demands, resources should be allocated equitably. When politicians query this matter people wonder if they are getting their fair share.
There is an increasing demand for accident and emergency services in all health board regions at a time when the number of joint GP services is increasing. A reply to a parliamentary question I tabled last March indicated that the demand for accident and emergency services in the six major hospitals in Dublin has increased by 39 per cent. GPs are developing closer links with hospitals by improving facilities and equipment in their practices, some of which are funded. Therefore, it is hard to understand this increased use of accident and emergency services, which at weekends can cause serious problems for paramedical and medical staff in some hospitals on top of their normal workload. Some hospitals in our health board area do not provide those services but leave it to the GPs to do so. When a charge of £6 was imposed, which was later increased to £12, it did not make much difference because people continued to use the accident and emergency services when they could have attended their GPs.
Another area which I have continuously pursued is the cost of generic drugs, on which positive action was recently taken. The health services in the US issue directives to hospitals to use generic drugs, provided they are of proper quality. Massive savings could be made by doing so. Admittedly, over the last seven or eight years more of an effort has been made to get value for money from drugs, but it does not happen on a large scale. Health boards and hospitals should use their combined purchasing power in this area. The health authorities in the North should  also examine how they could gain by this.
There is a serious problem in our health board area with the recruitment of speech therapists. The Minister stated in reply to a recent parliamentary question that it is a matter for the Higher Education Authority. He said his Department, in association with Trinity College, Dublin, and the Higher Education Authority, would take steps to remedy the situation by arranging for six extra training places. This is a matter of urgency which I would like to see attended to.
There has been a continuous increase in the number of asthma sufferers. Asthma is not a specified disease but public representatives are contacted by many parents whose children suffer from it, complaining that inhalers are very expensive. The causes and treatment of asthma should be investigated.
Mr. Bradford: I am not a member of a health board but, in common with all public representatives, I am very interested in monitoring how the health board system delivers an appropriate level of service to the people I represent. The Minister stated that the Department of Health's budget for 1996 is £2.4 billion, a huge sum which, not too many years ago, would have run the entire Government services. A huge proportion of that £2.4 billion is expended by the health boards and it is important to ensure consumers and taxpayers get the best possible value for money. Value for money is slightly different in terms of health services from other services delivered by the State because a person's health is of primary importance. However, while it is probably impossible to tag a precise value to a health service, we must ensure taxpayers' money is spent wisely.
We are, unfortunately, stuck with the health board structure. If a Minister was designing a health system from scratch now we would not end up with this system. Perhaps the system we inherited suited the Ireland of the late 1960s and early 1970s, which was changing  dramatically and quickly. People felt services had to be modernised and rationalised and the county health system was considered unsuitable. There were difficulties with the county health system but, perhaps, we threw out the baby with the bath water. There were many advantages to having services determined locally and delivered by people living within the community who knew the problems there. While removing that level of local service had administrative advantages, it also had disadvantages. There are arguments in favour of both local and national management but, in retrospect, the regional structure has not worked particularly well. However, we must make the best use of the system we have.
The first difficulty is the lack of discretion and power at management level in local hospitals. That has been a big disadvantage. It is not simply improper but also damaging that every minor management decision in the county hospital network, and some of the regional hospitals, has to be passed to the Department of Health. Presumably, the passage of this Bill will change that to some extent, which would be welcome. There has also been a total lack of discretion at regional health board level. I hope this Bill will also make changes in that regard and allow a greater degree of local and regional discretion. The greatest weakness has been the lack of control of local expenditure and decision making. I hope the passage of the Bill will also improve that position. I welcome the debate and the Bill, which will give greater powers to the health board members, define their role and that of the executive and improve decision making.
This Bill is in line with policies which are being implemented in other Departments, whereby there is a slow but sure devolution of some degree of power to local offices. This is the answer of the Department of Health to that devolution. In so far as it goes, I welcome it, but greater devolution of powers locally is necessary.
The structure of our health boards  leaves much to be desired. Health board members and representatives of the various medical organisations play equally important roles. Within the past couple of weeks we had an example of a scare story to the effect that there was not any money left to pay for nursing home subventions. The story was incorrect, but such stories are often generated by the more media conscious members of the board, invariably Oireachtas members. I have mentioned before that while the dual mandate has served us well over the years, it warrants reflection as to its usefulness beyond the 1990s. We have a weird and wonderful electoral system which puts a premium on being on the ground looking into the potholes etc. However, the country is not well served by that system, and health boards are not entirely well served by the fact that quite a number of their members have other jobs to do and do not always have the time and energy to do both jobs properly. However, this is the system we have, and we must make the most of it.
Section 3 deals with the role and powers of members. It defines the members' power to appoint the chief executive and take control of the overall service plan of the health board. In that respect it is important that members should take their responsibilities seriously because appointing a chief executive and taking control of and directing the service plan of a health board is an extremely responsible job that requires the full co-operation of all the members of the board.
The distinction between the role of the chief executive and that of the health board members is also defined. Health board chief executives, as a rule, are not as newsworthy as chief executives of semi-State bodies or county managers, etc. However, in the light of the budget of health boards, one must recognise that the person who holds the post of chief executive in a health board has a major task. His job is as important as that of a chief executive of a semi-State or major private company. It is appropriate, therefore, that the  responsibilities and duties of the chief executive should be laid down here.
In 1989 there was an unfortunate difference of opinion between the Southern Health Board and the Department of Health which resulted in officials from the Department being transported by helicopter to “seek a head” from the Southern Health Board. Now that the lines of communication are clearer and the roles of the members and chief executive of the health board more clearly defined, we should not have similar difficulties in the next few years.
Section 2, namely, the section which requires health boards to co-operate fully with local authorities and other public bodies, has always been unofficially in place. There has been co-operation between the Department of Social Welfare and the Southern Health Board vis-á-vis the return of the disabled person's maintenance allowance scheme to the Department of Social Welfare from the health board. Although funding for such items as rent allowance and supplementary welfare allowance is being passed on to health boards from other Government Departments, it would make more sense and remove another layer of bureaucracy if such items were transferred from within the health board system and streamlined into the local Department of Social Welfare office. The section also calls for appropriate consultation with local authorities and other public bodies. I expect under this section there will also be a requirement that health boards have full dialogue with the private hospitals and people involved in private medicine in their catchment area to eliminate duplication of services where possible and ensure that each agency, public or private, is best placed to get on with the job of providing the best possible service to the people in its community.
Section 5 deals with multi-annual budgeting. We have had difficulty enough with annual budgeting in health boards and other areas of public life. We should not, therefore, rush headlong  into multi-annual budgeting. However, there are aspects of health care and health policy which are not always possible to determine and react to within the narrow period of 12 months. In so far as discretion is now given for multi-annual budgeting, I welcome it, but I hope it will be used with caution and where appropriate. I look forward to suggestions from health boards. Perhaps the Minister could indicate where he envisages multi-annual budgeting would be effective.
Section 16 provides for the dissolution of regional health boards and local health committees in the interest of rationalisation and modernisation. However, health boards are regional and quite large from the point of view of the local community, and local health committees, which were in place from the 1970s until the mid 1980s, played an effective and practical role in their catchment areas. As a member of a county council, I was appointed a member of a health advisory committee when first elected in 1985, and I found it was possible for members, through the committee system, to put forward worthwhile proposals and suggestions to the health board. When the health committees were unofficially abolished in the late 1980s the members continued to meet without being paid expenses and in the absence of appropriate health board officials. However, for a period of over 12 months the members met once a month and continued with their system of meetings because they considered it a valuable vehicle for discussing local health issues and for transmitting problems and suggestions back to the health boards. It is disappointing that we must now dissolve the local health committees because it was a system that worked reasonably well.
Section 17 mentions health promotion programmes. While Irish people are perhaps the best in the world to talk about how ill they are and the best cures available, they are very bad at health promotion and disease prevention. What proportion — is it less than 1 per cent — of the health budget of £2.4  billion is spent on health promotion? What level of co-operation exists between the Departments of Health and Education in this area? Health promotion in the form of newspaper, radio and television advertisements is fine in so far as it can reach communities, but such promotion must begin within the schools. We need the maximum possible resources at national school level. The only health promotion I ever see in the educational system is in respect of dental protection. However, given increasing worries and dangers, we must invest much greater resources in this area. The Department of Education has a big role to play in this respect. How are we linking up with the Department to ensure value for money and a successful campaign?
With regard to section 20, regulations will prevent the creation of unofficial nursing homes. However, I am not so much concerned with the number of such homes but with the fact that we do not have a sufficient number of official, regulated homes. It is an issue which we have repeatedly debated. While the Department of Health has a care of the elderly programme, we cannot claim to be unaware of the fact that, over the next ten or 15 years, we will have a major crisis resulting from our ageing population profile.
We must prepare now for this problem. The provision of sufficient nursing home beds must be high on the agenda. While I welcome the measure taken to weed out unofficial nursing homes, I am concerned that we are not yet doing enough to put in place a sufficient number of official homes and beds to deal with the growing problem of an ageing population. I hope that we will make progress on this over the next number of years. While it is not our problem today it will be everybody's problem tomorrow. Now is the time to prepare for it.
Mr. Callely: The primary purpose of this Bill is to strengthen the arrangements governing the financial accountability of health boards and to clarify  the respective roles of the members of the health boards and their chief executive officers. The Bill is welcome because it gives us an opportunity to participate in discussions on accountability and the undertakings made in the health strategy document, Shaping a Healthier Future, the purpose of which is to improve the organisational and management arrangements of the health boards.
The Bill also begins the process of removing the Department of Health from detailed involvement in the operational matters of each board area. It also dispenses with the need for the health boards to obtain ministerial consent to the purchase and disposal of land and the making of section 65 grants to voluntary bodies.
As a member of the Eastern Health Board, I wish to be informed on matters of accountability and financial implications. I have endeavoured, through every avenue available to me, to ascertain the position regarding the proposals for the reorganisation of the Eastern Health Board. Regrettably, on every occasion I have approached this matter I have been unable to receive satisfactory answers. In his last response to me on 1 May, the Minister advised that he intends to submit proposals on the future administration of health services in the Eastern Health Board area to Government. He went on to indicate that the submission will address the financial implications of the proposals and that he intends to make a further statement when the Government has made a decision on this matter.
I understand there are serious problems regarding the proposals. If this is the case, a Member should be informed of the situation. If they prevent the proposals on the reorganisation from being implemented, the sooner decisions are taken the better for all concerned.
I acknowledge there is a problem in the Eastern Health Board area with regard to the statutory authority, the EHB, and the other authorities assisting in the provision of needed and worthwhile services. The ideal solution is to  bring all under the one umbrella. However, I am concerned about the cost of the proposals on the new eastern regional authority. I understand that this is the bone of contention in the Cabinet.
As a member of the Eastern Health Board for a number of years, I am supportive of the management structures in place and of the provision and delivery of services to people within the catchment area. The voluntary organisations and other bodies involved in the provision of services could be brought into a system within the Eastern Health Board's existing structure, where they would be satisfied to work. This would not have the cost implications of the proposals that I understand are before the Government. I would welcome the Minister or the Minister of State indicating at what stage the proposals are and the hurdles before them.
I congratulate the chief executive officer and management team of the Eastern Health Board on the enhancement of their delivery of ever widening daily services. I pay tribute to their financial controller, Mr. Martin Gallagher, whose exemplary accountability and achievements by way of his saving plans in recent years have been well recognised. They ensured continued satisfactory delivery of services while achieving huge savings in the various avenues open to him through purchasing power, group buying and exerting leverage on financial institutions to obtain reduced interest rates and charges.
While welcoming the principle and objectives of this Bill, I envisage some problems in their implementation. When replying I should be greatful if the Minister would respond to my questions. With regard to the accident and emergency services within the Dublin area, which have presented many recurrent problems, I have always advocated tackling such problems head on. Whenever I raised this problem with the Minister he has been inclined to quote precedents, to the effect that this is not a  problem confined to Ireland; it is a feature which has developed in other countries and has continued during former Ministers' terms of office. That is of no assistance to people within the Dublin area who must avail of accident and emergency services. I assure the Minister and anybody else under a false impression, that people in the Dublin region do not like to go to hospital, to queue for anything between 48 and 72 hours, or to be placed on a stretcher bed. People are despondent about and dissatisfied with the attention devoted to resolving the problem. The relevant figures for the year 1995 and the waiting periods over the first ten weeks of this year show an escalation in demand for accident and egmergency services and in the relevant waiting periods.
Shortly after my tabling a parliamentary question, the Minister launched a campaign advocating greater recourse to general practitioners than to accident and emergency departments, resulting in some slight reduction in attendances at hospitals. The argument has been advanced for several years that people resort to accident and emergency services more in winter months whenever there is an influenza epidemic or an increase in respiratory complaints. I understand that last year a number of representatives of hospitals in the Dublin area — under the chairmanship of the general hospitals programme manager — met on a number of occasions to determine how best to address these recurrent problems. My understanding from those involved with the problem is that there is a lack of beds, a need for greater numbers of long-stay, short-stay, acute and day beds in addition to greater post-hospital facilities. What action has the Minister taken since those problems were brought to his attention? What detailed examination of their rectification and its associated costings has been undertaken?
To ask the Minister for Health the  recent studies or surveys, if any, that have been carried out to evaluate the need for a Dublin city centre general hospital, particularly in view of the large number of people working in the city and the number of dwelling units occupied in the city.
I asked him to bear in mind the greatly increased occupancy of and numbers of dwelling units in the city centre and the number of hospital closures with resultant loss of beds. I take it the Minister accepts there have been a number of hospital closures and many more occupants of city centre dwelling units. I was frustrated by the last sentence of the Minister's reply which read:
Accordingly, I am satisfied that people who reside in the city centre and those who work there are catered for to the extent that there is no need to build another general hospital in the centre of Dublin.
Will the Minister review that opinion and accept the need for another city centre hospital? Too many hospitals have been closed. The Meath Hospital is about to be closed. Perhaps an existing structure could be developed as a general hospital.
I have also requested the Minister's opinion on the closure of hospital wards and beds on account of insufficient funding — which is what this Bill is all about, accountability and funding. Needy people are denied access to beds for that reason. Perhaps the Minister would furnish me with information on the number of wards and beds involved.
I am concerned about long-stay hospital accommodation. I tabled another parliamentary question to the Minister to ascertain what progress, if any, had been made to address the need for post-hospital facilities and community care of the elderly, particularly those living alone. I am not satisfied that any substantial progress has been made on this matter. The Minister tends to establish committees, appoint chairpersons to establish facts and figures and then do nothing more.
 I hope the Minister will communicate with me on the questions I have raised. There is an army of workers in social services yet we do not harness that good will by addressing the level of pay to home helps and, more importantly, by providing care in the home for people who otherwise have to live in institutions. The carer's allowance is in the region of £69.50. If memory serves me correctly subventions are in the region of £70, £90 and £120, we are buying beds in private nursing homes costing anything up to £200 to £300 and in the Alzheimer's unit on the north side of the city a bed costs £420. I am baffled as to why the Departments of Health and Social Welfare cannot create a package that would encourage a spouse, family or friend who is prepared to give a level of care to somebody who requires it on a constant basis in the atmosphere of a family home. However, we opt to buy a bed in a private institution for £420, to pay subventions at the levels I referred to or pay approximately £250 for a bed in a private nursing home instead of bringing the carer's allowance into line and tapping the potential that exists. I look forward to the challenge when some day I may be in the Minister's seat and if something has not been done about it before then I certainly will do it.
Will the Minister indicate how he will address accountability for the demandled free schemes? His Department failed in recent years to take responsibility for cutting schemes it had introduced, without being prepared to say so publicly. It put the squeeze on the financial controllers in the health boards by not giving them overruns on demandled schemes. Is there not a conflict when we talk about an overrun on a demandled scheme? However, that is the language of the Department of Health and I would like the Minister to comment.
I am concerned about indicative drug targets. To save money, doctors are being encouraged by the Department of Health to prescribe cost effective drugs and there is a pay back for those who prescribe them. Do we realise the huge  sums of money drug companies invest in research and development? Would we even have an antibiotic if they did not carry out this level of research? The revenue from drug companies is of benefit to the economy.
Under this Bill chief executive officers will be appointed to a health board for a fixed term similar to secretaries of Government Departments. This is a welcome move, however the Minister has not specified the period of appointment. People employed for a fixed term perform better and I would welcome the Minister's comments on that.
It is vitally important that meaningful talks on the nurses' dispute are resumed urgently to deal with the three issues highlighted by the nursing unions: first, the inadequate increase in pay for ward sisters; second, the proposed reduction in the starting pay of staff nurses; and third, the question of early retirement.
Finally, if drug addicts are to be treated in the community by the GP, the way to do so, as GPs have indicated, is by allowing them to use the health centres. I would welcome a note from the Minister on the progress that has been made in making health centres available to GPs.
Minister of State at the Department of Health (Mr. O'Shea): Tá fhios agam nach bhfuil mórán ama fágtha agam inniu ach ba mhaith liom mo bhuíochas a ghabháil leis na Teachtaí uilig a ghlac páirt sa díospóireacht seo. Tá áthas orm go raibh fáiltiú leathan roimh an Bille.
I thank the Deputies for their contributions to this debate and I am pleased with the broad welcome the Bill has received. This important Bill aims to modernise the management system in the health boards and sets down new financial accountability provisions which will change the way health boards conduct their business. It introduces a planning framework which is linked to specific targets and resources. In short, the Bill requires health boards to carry our their tasks in a context which  emphasises planning, strategic management and accountability.
I listened carefully to all the contributions and there is broad agreement on all sides on the need for the type of change envisaged in the Bill. A number of Deputies questioned the need for fundamental changes in the administration of the health services, including the possible return to a county based system of administration. The Government has no plan to move from the system of regional health boards which, by and large, has served us well during the past 25 years. Given the scale and complexity of the health services in the greater Dublin region, there is a general acceptance of the need for some restructuring of the Eastern Health Board. In response to Deputy Callely, I reiterate that my colleague, the Minister for Health, intends to submit proposals to Government on the future administration of the health services in the Eastern Health Board area. He will make a further statement when the Government has taken decisions in this matter.
In response to the criticisms of the substantial increase in the expenditure on health services, let me make the following points. Recent Governments have identified health as a priority area for investment. Additional funds have been provided for child care services, services for the mentally handicapped and nursing homes for the elderly. The Government has funded additional residential places, additional respite care places and increased the capability of the health services to respond to those most in need. Value for money initiatives have contributed £20 million towards these developments.
The health service is labour intensive providing services 24 hours a day, 365 days a year. Year on year increases in the Health Estimates include provision for items such as national pay agreements, compensation for general inflation and increases in the various cash allowances paid. These increases account for almost half the overall  increase, a further 20 per cent approximately is accounted for by the community drugs scheme legislative obligations and European Union commitments.
Once again, I thank Deputies who contributed to the debate. This is very important legislation, I look forward to an interesting Committee Stage and to the amendments which will emerge from the Opposition. Obviously, if the amendments contribute to making the legislation more effective, we will look on them in a positive fashion. I commend the Bill to the House.
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