Dáil Éireann - Volume 370 - 04 December, 1986

Supplementary Estimates, 1986. - Vote 49: Health.

Dr. McCarthy: Before the Minister introduces the Estimate, with your permission a Cheann Comhairle, I would like to give some of my time to Deputy Tunney.

An Ceann Comhairle: Strictly speaking, we can only do that by the agreement of the House. Under an Order of the House the Minister has 45 minutes and the first speaker for the Opposition has 45 minutes. The suggestion is that Deputy O'Hanlon give some of his time to Deputy Tunney, and I can do that with the agreement of the House. Is this agreed? Agreed. How many minutes does Deputy O'Hanlon wish to give to Deputy Tunney?

Dr. McCarthy: Ten minutes.

An Ceann Comhairle: By agreement, Deputy Tunney will have ten minutes of Deputy O'Hanlon's time.

Minister for Health (Mr. B. Desmond): I move:

[1574] That a supplementary sum not exceeding £1,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1986, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.

The original net Vote for Health for 1986 was £1,153,476,000 including a capital provision of £58,160,000. As will be seen, I am taking a token sum in order to bring to account extra Appropriations-in-Aid which will become available before the end of this year.

This is in line with my strategy to maximise income wherever possible and, in particular, not to seek a supplementary sum for any extra costs — a commitment I gave at the beginning of this year. I want to stress that this has been an ongoing policy on my part. I am pleased that since the end of 1984 the consistency of that policy has been maintained, despite great pressures. The extra receipts are most welcome and will enable me, first, to provide for the Christmas bonus for cash allowance recipients directly out of the Health Vote, and then to alleviate to some extent, a difficult cash situation in health agencies, principally the General Medical Services (Payments) Board, the medical card area.

The components of the Supplementary Estimate are as follows:

£(m)

65 per cent bonus payment in respect of certain cash allowances

0.800

provision towards additional needs of the General Medical Services (Payments) Board

3.000

Additional payments to health agencies in respect of balances of grants for years prior to 1986

2.327

Provision towards the needs of research bodies

1.999

Sub-total

8.126

Less:

Additional Appropriations-in-Aid

8.125

Net Total

0.001

As I have mentioned, a bonus payment [1575] in respect of certain welfare benefits and allowances administered by the Department of Health is being paid this month. The health allowances included in this arrangement are, the disabled persons maintenance and rehabilitation allowances, the infectious diseases maintenance allowances, the blind welfare allowances and the constant care allowances in respect of handicapped children maintained at home. This is something which tends to be overlooked in the centering of attention on the social welfare payments, the 65 per cent, because this also applies to 33,000 recipients on the health side. They too will benefit from this arrangement. The extra provision of £0.8 million sought will bring the total provision for cash allowances administered by the Department of Health to £66.005 million for 1986.

The extra provision sought for general medical services is £3 million. This, together with the provision of £1.122 million from Vote 51 needed for the general and special pay awards approved under the 25th round, will bring the total provision for the General Medical Services (Payments) Board in 1986 to £105.622 million. This represents an increase of about 7 per cent on the 1985 provision. I stress, that that is a record provision. Contrary to the propaganda by the Opposition party about medical card holders the reality is that during a period when inflation was at 3 per cent, we provided a record figure of £105.662 million or 7 per cent over the 1985 provision.

The extra provision sought is required to enable the cash needs of the board to be met in 1986. The increase in expenditure on general medical services is largely a consequence of a continuing increase in the visiting rate, the extra cost of drugs prescribed at these more frequent consultations and an increase in the number of persons covered.

As regards cost of drugs and medicines, a reduction in the cost of drugs has been achieved following negotiations with the Federation of Irish Chemical Industries. The revised pricing structure which took effect last August will yield [1576] greater benefits to the Exchequer in 1987. The industry has also agreed to a significant level of additional rebates in 1986 in view of the favourable exchange rate against sterling. These measures have contributed considerably to reducing the extra funding which is now required.

I am aware that concern has been expressed regarding the adequacy of the level of resources that my Department are providing for the board. My officials are keeping in close touch with the board regarding funding and their cash requirements are monitored on a daily basis. I can assure the House that arrangements are now in place to ensure that the board's cash needs to the year end are adequately met.

I am concerned, however, about the demand led nature of the scheme, which is at variance with virtually every other health service and I am currently examining measures which will assist in controlling costs while at the same time ensuring that those in greatest need receive the best possible level of primary health care.

I am providing an additional sum of £2.327 million to meet the balances of grants due to health agencies for years prior to 1986. The disbursement of these funds will assist the cash position of the agencies and keep overdraft requirements to a minimum.

Statements made regarding an impending cash crisis in the health services are totally unfounded and in fact as of last Thursday the combined overdrafts of all health boards was £12 million as compared with £24 million in the first week of January 1986. One hears Deputies on radio and television hysterically working themselves into a frenzy about the provision of health services, a frenzy designed presumably to impress the electorate and with no regard for the facts of the occasion, but this statement puts that kind of political flurry into a correct perspective.

A sum of £1,999,000 million is being made available for grants to research bodies. A token sum of £1,000 was included in the original Health Vote for 1986 and this extra sum now brings the [1577] provision to £2 million. The extra funding is required due to the discontinuation of the Irish Hospital Sweepstakes. The two bodies involved, the Medico-Social Research Board and the Medical Research Council are in the process of being dissolved following the Government's decision to rationalise the very important area of health research. A new body, the Health Research Board, has been established and will become functional in January 1987 giving a new impetus to this vital area. I have no doubt that the basic rationalisation of research in the health area which has been achieved, not without some difficulty but with agreement, is a major advance and a very important advance for the future of health research in our country. The board will in future be funded from the Health Vote.

In regard to appropriations-in-aid I mentioned an increase of £8.125 million. This increase falls under two headings: firstly, receipts from health contributions.

The pattern of receipts from health contributions is not regular and consequently precise estimation is not possible. In the current year, an adjustment from 1984-85 resulted in a receipt of over £2 million. The additional £1.45 million arises from an increased buoyancy in collection and that is very much welcomed.

The second heading is recovery of cost of health services provided under regulations of the European Economic Community. In accordance with EC regulations certain health services are provided to employed persons, selfemployed persons, pensioners and dependants of such persons from other member states while visiting or staying in Ireland. The cost of these services is recoupable. The increased yield is brought about by a number of factors, firstly, the number of persons availing themselves of services in Ireland, secondly, increases in average costs agreed in Brussels, and, thirdly, changes in exchange rates which are extremely difficult to predict in advance. However, we have done well under this heading. We got an additional £4.675 million. Some [1578] of those who are preoccupied about the Single European Act might ponder on those benefits and receipts.

The draw from Vote 51 must equally be referred to in this Supplementary Estimate. A sum of £21.934 million is being drawn from Vote 51 by my Department to meet the cost of general and special increases under the 25th Round. That is the general remuneration Vote.

I wish to deal also with some of the features of our health services. These are entirely germane to the Estimate. They certainly refute the kind of scurrilous allegations made in the House last week by the third spokesman stringer for the Opposition, Deputy John O'Connell when he accused me——

Dr. O'Hanlon: And by Senator Higgins in Mayo this morning.

Mr. B. Desmond: ——of, in particular, acting in a totally parsimonious and, to use the phrase, callous manner. This is a classical example of scurrilous debate. I want to state very emphatically that our health services are by international standards extremely good. They provide a general practitioner service which is available free to almost 38 per cent of the population — that is almost four out of every ten, or over 1.3 million people. This is the first port of call for persons needing medical attention and is available at all times. Over £112 million will be spent on the general practitioner service in the current year. Secondly, we provide, hopefully on a rational basis, emergency and casually services on a 24-hour basis. That is very difficult in a country like ours with such a dispersed population.

Thirdly, we have high quality diagnostic and treatment services at hospital level which are available to deal with emergencies and, in addition — in a country with a population of three and a half million, which is quite unique to any in the world — we provide surgical techniques such as transplants, open-heart surgery, haemodialysis, and intensive care, particularly neo-natal intensive care [1579] where there have been major developments over the last ten years or so.

I have had particular concern on the paediatric side. There has been a substantial improvement in that area, particularly outside of Dublin. The services at that level are exceptionally good. We have a high level of psychiatric care services which are currently being re-organised, as the House well knows, with the objective of making them more community oriented. We have a comprehensive range of services for the mentally handicapped and services for the deprived and disadvantaged groups in our society. I am proud that in the past four years I have, with very limited additional resources, developed these services on a much better basis.

As regards the evolution of the health services, one of the most striking features of the health services in this country over the past 20 years has been their rapid evolution into a highly modern and sophisticated service from much humbler origins in the sixties and the fifties. This progress has, of course, brought its own problems. All inputs to health services are costly. The technological revolution in medical care over the last ten or 15 years has demanded the recruitment of very skilled and often highly specialised staff to provide services. In addition, the introduction of high technology items of equipment which have very significant acquisition, maintenance, operational and replacement costs has led to an escalation of non-pay costs.

I recall the debates we had when the Estimates for health services were £143 million a year. I remember in 1973-74 when my predecessor, Brendan Corish, had a budget of that amount, but the health services are costing £1.3 billion or over 7.5 per cent of GNP in the current year. This latter figure represents almost 20 per cent of total Government expenditure on current services.

During the period 1982-86 total Government expenditure on health has increased by 30 per cent and has kept pace with an increase in the consumer price index during the same period. In [1580] each of these years, expenditure on health services has been increased significantly as can be seen from the following table:

Gross Expenditure on Non-Capital Health Services 1982-86.

Year

Gross Espenditure

£ million

1982

999

1983

1,091

1984

1,156

1985

1,245

1,300 estimated,

1986

probably £1,305 million

The foregoing represents a very firm basis for a rational development of services in line with the Government's strategy as outlined in the national plan, Building on Reality. The level of funding provided by the Government has ensured that essential services have been maintained and that much needed developments have been implemented despite the serious financial difficulties which the country has faced.

Recent developments have included satellite renal dialysis units in Ardkeen General Hospital, Sligo General Hospital, Letterkenny General Hospital and Limerick Regional Hospital. We have a 100 per cent increase in the level of cardiac surgery at the Mater Hospital. We have a new cardio-thoracic surgery unit at Cork Regional Hospital—I think they will have performed approximately 150 open heart operations by the end of this year. We have the National Liver Transplant Centre at St. Vincent's Hospital. We have developments in orthopaedic services at Croom, Cappagh, Cork and Tullamore. We have developments in geriatric services at St. James's and the Royal Hospital, Donnybrook. We conducted a most successful measles vaccination campaign which achieved a 90 per cent coverage of the children targeted with the consequence that measles notifications dropped to 311 for the first eight months of 1986 compared with 9,363 notifications for the same period last year. As a general practitioner, I am sure Deputy [1581] O'Hanlon is aware of the phenomenal drop in the number of notifications. In ten years' time, the impact of this on general health, and particularly on young pregnant women, will be profound. This is on a par with other successful major campaigns which we have carried out against infectious diseases over a number of decades.

Regarding services for the handicapped, including the commissioning of St. Michael's House Adult Special Care Unit, Belcamp, we have had major renovation work at St. Mary's Drumcar — I am going back next week to open more units there — we have had the redevelopment of St. Patrick's, Upton, and the commencement of building of the new residential accommodation at St. Joseph's and St. Mary's Schools for the deaf in Cabra. In addition, there has been a considerable increase in the capital resources devoted to the health services during the period of the plan despite the overall financial constraints. Between 1982 and 1986 expenditure on capital has increased from £49 million to over £58 million and considerable progress has been made in the development of our general hospitals.

Since, 1983, I have approved a large number of capital schemes. These include new general hospitals or major new extensions to hospitals which have been completed or are under construction. Among them are major developments at St. James's, the Mater, Tralee, Cavan, Castlebar, Mullingar, Galway Regional, Portiuncula, Cork Regional, Victoria-South Infirmary, Cork, Limerick Regional, Ardkeen, Ennis, Tullamore, Croom and a number of Dublin voluntary hospitals. The Government have also recently provided capital moneys for the building of development projects at Ardkeen, Sligo and Wexford Hospitals. In fact, by the end of December this year £3.5 million will have been spent on Ardkeen, £800,000 on Wexford and £3.6 million on Sligo on design, planning fees and site works. The total estimated cost is £100 million for these three hospitals, and [1582] careful planning, design and rigorous tendering procedures are being implemented.

When these are finished, as they will be because the capital moneys will be provided in the capital budgets in the years ahead, we will have completed the major health capital programmes for the whole country. We will have some of the finest hospital complexes in the EC and we will have made an enormous investment in this area. The Government, who tend to hide their light under a bushel, have not emphasised the exceptional work that is being done on the capital side.

I want to pay a tribute particularly to the staff in the Department of Health who have been working very hard and have made an enormous contribution towards these developments. I have been accused many times during my period of office of indulging in health cuts. “Health cuts” have almost become part of the political folklore — they are like the GAA or going to Mass on Sunday. These accusations are completely false. I agree I have attempted to cut out waste and duplication, and God knows I came across plenty — not in the Department because it is a very small Department of about 350 people — in the delivery of those services. However, I have been, and always will be, committed to the provision of a high class health service that is in a position to respond to the real needs of the population. This involves not only maintaining existing services at an appropriate level but also identifying and meeting needs, particularly for the less well off sections of our population. Nobody can expect in the present financial climate that the growth in expenditure which has been a feature of our health services in the past can continue. In fact it is obvious we will have difficulty even in maintaining the existing level of funding in the short term. It is imperative, therefore, that a rationalisation of the use of the very significant amount of resources in financial and personnel terms must be achieved to eliminate unnecessary and wasteful expenditure if we are to respond to the needs of our [1583] society. We must create a rational, costefficient and integrated health service.

The financial constraints of recent years have required health agencies to place all areas of expenditure under close scrutiny. Given the present Exchequer position and the increasing demands on the available resources because of demographic factors, technological advances and the development of improved services, it is inevitable that the health agencies will need to continue to identify and implement cost saving measures to ensure that essential services can be maintained.

In any large organisation, potential cost savings exist and must be identified and implemented. Every effort is being made to obtain value for money in the health services. My Department have recently been re-assessing their own role in securing efficiency improvements in the health services. It seems clear that the best results will be achieved from a structured approach which enables those at local level and those at central level to contribute to the fullest extent. Without motivation and accountability at local level, the identification and implementation of potential improvements cannot be assured.

However, the central level can make an important contribution also, by providing agencies with the fullest possible support information, co-ordinating the exchange of new ideas to ensure that the benefits of worthwhile initiatives are widely shared, and also by providing agencies with a yardstick against which to measure their success in achieving savings through increased efficiency.

There have indeed been some exchanges of cost saving ideas and approaches on an informal basis between different health agencies, but it would obviously be far more effective to have a central source of information to ensure that all agencies are aware of new ideas and the experience in implementing them.

My Department will undertake this role in future. They will discuss with each individual agency the potential efficiency [1584] improvements which are most appropriate to their particular circumstances, and will ensure that each agency will have all the support information necessary in order to implement them. The Department will also monitor each agency's progress in implementing these improvements and in securing savings as a result. Agencies will also be encouraged to develop initiatives of their own, which can then be applied elsewhere as appropriate. I ask all those working in the health services to be alert to the opportunities for achieving such savings.

My Department will also continue and expand their work in the area of comparative costing. Hospitals will be given data on their costs under various categories, in comparison with those of similar hospitals. This type of information will help them to identify particular areas of weakness in their own operations as regards financial performance.

The Department of Health in the past four years have been and will be in the years ahead a more dynamic Department, taking a much more direct active role in the health services and in the implementation of Government decisions. I hope there will be the authority and the skilled personnel available in the Department to do that. That capacity has emerged in recent years and it is a welcome change from the ethos of the old Department, hoping that everybody would stay quiet and get on with their work. Those days are gone and the change will have a profound impact in the Department in future.

It is absolutely essential, in addition, that there be readily available detailed information and data on the financial consequences of decisions taken by the medical profession. We need to identify clearly the expenditure involved in treating individual patients and specified categories of patient categorised by specialty or otherwise. The new management information systems currently coming on stream will be extremely useful in this regard by providing ample opportunity and scope for the introduction of much more sophisticated costing systems.

[1585] The report Planning for the Future has pointed the way for the future organisation of our psychiatric services, based on a comprehensive service which is community based and which is an integral part of the general health service. Rather than the present large catchment areas, services will be organised on the basis of small sectors of 25,000 to 30,000 people with a multi-disciplinary psychiatric team based in the sector having responsibility for the psychiatric needs of the people of the sector.

Facilities, therefore, will be provided close to where people live and work. Obviously, the expansion of community services has implications for the largely institutional services now in existence which were planned at a time when more modern treatment methods were not available. The contraction of hospital services is a prerequisite to the expansion of community services.

The massive resources at present spent on institutional care in the psychiatric area have to be freed in order to develop new services in the community. The possibility for this redeployment of resources is not wishful thinking. A recent assessment of in-patients in psychiatric hospitals indicated that there are some 3,000 people in psychiatric hospitals who could be discharged to community residences. Faced with these statistics, it is incumbent on me and the Department to switch resources as quickly as possible to ensure that patients are given services in the appropriate location. I have already advised the health boards that I will provide the capital resources to enable this switch to take place and this year I have approved £2.2 million for the provision of new community psychiatric facilities.

Each of the eight regional health boards have drawn up plans to implement the report in their respective functional areas. My Department are actively following up the implementation of these plans with the individual health boards and considerable progress has been made to date. The reorganisation of the services will result in significant improvements for people suffering from mental [1586] illness and is one indication of the steady improvements which have taken place in the overall health services since I took up office.

Expenditure in the general hospital programme accounts for more than half of total non-capital expenditure on health. The last decade has seen a major review of the organisation of these services. The plans which emerged from this review have as their main elements the rationalisation of the multiplicity of small hospitals and the distribution of workload away from traditional in-patient care to other delivery modes, such as out-patient and day-care and special units like five-day wards and programmes investigation units. The plan envisages, therefore, the closing of many of our existing old, cost inefficient hospitals and the establishment of a lesser number of larger sized well equipped modern hospitals located in the major population centres. Considerable progress has been made in the implementation of these plans.

However, the full potential of the redistribution is very far from being realised and will require further impetus. Consideration must be given to the appropriateness of services being provided at present on an in-patient basis and to the precise role and function of each individual hospital in the acute hospital area.

The general hospital rationalisation plan adopted for Dublin which provides for the development of six major acute hospitals, that is, St. Vincent's, St. James's and Tallaght Hospitals to serve the south side of the city and Beaumont, the Mater and James Connolly Memorial Hospital to serve the north side of the city is well down the road to completion. The State is investing considerable resources in the programme and I am satisfied that this network of major acute hospitals will be more than adequate to meet the needs of the total population of Dublin both in the inner city and suburban areas.

Mercer's Hospital, Teach Ultan, St. Patrick's Infant and Sir Patrick Dun's Hospital have been closed, without reducing service levels and I propose to [1587] implement the other closures comprehended in the plan as the new facilities come on stream, starting with the closing of St. Laurence's and Jervis Street in mid-1987.

There has been much publicity recently about the opening of Beaumont Hospital — much of it ill-informed. I would like to take this opportunity of putting the record straight. This hospital should be fully operational in 1987.

I am unbending and unrepentant in respect of the unfortunate and quite wrong allegations that have been made about my role in that regard. I ask people to reflect sincerely on the mischievous information which some Deputies have been fed in this respect. Discussions with all of the unions involved in the transfer from the existing hospitals are progressing satisfactorily and should be completed in the near future. I propose to phase in services to Beaumont Hospital commencing in January 1987 and the necessary equipment to allow for this has been ordered. I have the full agreement of the St. Laurence's Board and of the St. Laurence's medical staff to the transfer of certain of their out-patient services from 20 January 1987, and I am hopeful that the board of Jervis Street and its consultant staff will agree to do likewise.

Other services will then follow as the equipment and other back-up facilities are put in place.

I want to thank the Beaumont board for having advertised the two psychiatric consultant posts on a joint basis with the Eastern Health Board in the past week or so. I have no doubt that with the applications in by about 14 January these appointments will be made in the very near future with the support of the Department of Health, Comhairle na nOspidéal and the other agencies directly involved.

I would like to make it perfectly clear, as Minister for Health, that my policy and that of my Department is that every child should be brought up in his or her own family. I stress that to particular Deputies in this House and I am unbending and unrepentant in respect of the [1588] unfortunate and quite wrong allegations that have been made about my role in that regard. I would ask people to reflect on the mischievous misinformation with which some Deputies have been fed in relation to this situation. Nothing in our present policies or our proposals for the future diminishes the principle that a child is best cared for in a family setting if at all possible and every effort will be made in that regard.

Every thoughtful and informed person involved with the child care services recognises the incomparable benefits of a family upbringing. The main thrust of future developments will, therefore, be to provide family support services which will prevent or diminish the need for parents to part with their children on either a short term or long term basis. There are, unfortunately, and will continue to be, unhappy, abused and neglected children from inadequate and broken families with multiple problems. The State, representing our collective responsibility as citizens, and operating through the health boards, has an obligation to seek a secure and a happier future for such children.

As the Deputies are aware, I have now two Bills before the House which will radically transform and improve our children care services.

There have been many calls over the years for changes in the adoption laws to enable the adoption of children born within marriage who, for varying reasons, have been separated from or abandoned by parents who are unlikely to resume, or incapable of resuming their parental role. Most of these children would at present be in the care of health boards and would be either with foster parents or in residential children's homes. Some of the children would, however, have been placed previously with friends or relatives and would be unlikely to have come to the attention of the public child care system.

The Adoption Bill provides in certain severely restricted circumstances for the adoption of a legitimate child with a parent or parents alive or of an illegitimate child whose mother has [1589] not given the initial consent to placement for adoption. It provides for such adoptions only in those instances where for a continuous period of not less than 12 months immediately preceding the time of the making of the application for adoption, the parents of a child, for physical or moral reasons, have failed in their duty towards the child; that it is likely that such failure will continue without interruption until the child attains the age of 18 years; and that such failure constitutes an abandonment on the part of the parents of all parental rights (whether under the Constitution or otherwise) with respect to the child.

The new Bill does not propose to change in any way the existing criteria for prospective adoptive parents. I am pleased that by and large within this House there seems to be a great unanimity that this legislation is long overdue and will be enacted, I would hope, with no delay on the part of the House. The Children (Care and Protection) Bill, 1985, aims to update and extend the law in relation to the care and protection of children, particularly those who are abandoned, neglected or abused. The existing law in this area is based on legislation dating from 1908.

The Bill provides for the following:(a) new arrangements for the regulation of certain child care services, namely, day care services (nurseries, creches etc.) private foster care and children's homes; (b) strengthening of the powers of health boards to provide child care and family support services; (c) updating of the law in relation to foster care; (d) new procedures to facilitate effective intervention in cases of child abuse or neglect; (e) the extension of the grounds on which the courts may place children who have been neglected, ill-treated or are otherwise at risk, in the care of, or under the supervision of, health boards; (f) new procedures for granting custody rights to foster parents and other persons having care of children; and (g) the repeal of existing legislation dealing with the care and protection of children.

Because of its complexity, this Bill has been referred by the Dáil to a special [1590] committee consisting of eleven members of the House under the chairmanship of Deputy Michael Bell. I am very pleased that our colleague, Deputy Rory O'Hanlon, has been so constructively involved in the work of the special committee in its initial stages to date.

It has been obvious for some time past that there is a clear need to up-date the Voluntary Health Insurance Act, 1957, so as to take account of the very significant changes which have occurred in health services structures since the Voluntary Health Insurance Board was originally set up.

At present VHI provides for full recoupment of hospital in-patient expenses but only limited cover for general practitioner and other out-patient expenses. The out-patient cover applies only after a threshold £105 for a single person and £170 for a family has been reached. The thrust of health policy in Ireland, as in many developed countries, is to reduce the demand for costly in-patient services and as far as possible encourage the provision of services on a community or out-patient basis.

I have been anxious to encourage the development of VHI's primary care coverage so as to influence patients to make greater use, in appropriate circumstances, of primary care rather than hospital treatment. I have commissioned consultants to examine voluntary insurance schemes in other countries and to assess their suitability for adaptation to meet our requirements. The consultants will also provide an analysis of how suitable models would operate under Irish conditions. The VHI are co-operating fully in this exercise and VHI executive staff are participating on the steering committee. I hope that all this will lead to the early introduction by the VHI of a comprehensive general practitioner and out-patient scheme. I think that such a scheme would be warmly welcomed and subscribed to by the general population. As part of this approach the VHI will also have to turn their attention to a radical re-appraisal of existing in-patient schemes. The re-appraisal will have to be [1591] radical if we are to achieve our long term objectives.

Ultimately this will all form part of a general re-organisation of our health services which I have in mind and which I will shortly be putting before my Government colleagues. Indeed as part of this exercise, as you are aware, I have already obtained Government approval to an amendment of the VHI Act, 1957. The drafting of that legislation is already in train and present indications are that I will be in a position to introduce it early in the new year.

I have referred many times previously to the need for a shift in emphasis in our demands and expectations of the health services. In summary, the essential thrust of the health services in the immediate future will be directed towards: measures needed to be taken to promote health and prevent illness; the provision of suitable services on a community or out-patient basis so as to bring about a redistribution away from institutional services; the closure of out-moded or non-essential institutional facilities in tandem with the commissioning of large cost effective “flag ship” hospitals which will be in a position to respond to the acute hospital needs of the population; the maintenance of a range of care and welfare services with particular references to children at risk, the needs of the disabled and other disadvantaged persons; increasing the efficiency and effectiveness of all services.

The adoption of this thrust is not motivated by any crisis in our health services however. Rather it is an attempt to maximise the benefits which the population can legitimately claim is their right from the major contributions which they make to the services by way of taxation. I make no apology to anybody for attempting to make the services for which I have responsibility more efficient and more responsive to the real needs of the community.

Dr. O'Hanlon: There is something unreal about a Minister coming in to introduce a Supplementary Estimate for [1592] £1,000 while at the same time the health boards and voluntary hospitals have an estimated deficit of £30 million to £40 million. All the health boards have increased their overdraft accommodation in the current year. For example, the Western Health Board have requested overdraft accommodation from the bank for £10.5 million to carry on to the end of this year, otherwise the board will be unable to pay wages, according to the chief executive officer. All the health boards and the larger voluntary hospitals will have a major deficit this year, as high as £5 million in the Western Health Board and the Eastern Health Board.

The Minister said that statements made regarding impending cash crises in the health services were totally unfounded and that last Thursday the combined overdrafts of health boards was £12 million as compared with £24 million in the first week of January 1986. What does that mean in the context of 1 January 1987? Is the Minister telling us that the combined overdraft of the eight health boards would be only £12 million in 1987 from 1 January? I am sure that that is not what the Minister is telling us or he would have said it in his statement. Last Thursday the combined overdraft was £12 million. In answer to a question in the House recently the Minister told me that at the end of September there was no deficit in the GMS. Presumably there was no deficit in the GMS because only three-quarters of the year had gone by, but obviously from the Supplementary Estimate before us there would be a serious deficit in the GMS which would have very serious consequences had the Minister not come into the House this evening and introduced this Supplementary Estimate.

The Western Health Board seem to have a problem because on Monday last they requested overdraft accommodation for £10.5 million. The also voted and gave authority to their CEO to change from their present bank if that bank persisted in implementing charges that would amount to £200,000. Again in this House on 22 October when I asked the Minister about the funding arrangements and what [1593] new funding arrangements might be made between the banks and the various health agencies, the Minister told me that there was no departure from what has happened in the past. I understand that it is a new departure for the banks to insist on charges to the health boards and it is an indication of how the banks feel about the position of the health boards. The estimated deficit between the health boards and the voluntary hospitals is between £30 million and £40 million effectively because of the Government transferring that money into the 1987 Estimate.

Why are moneys not included in this Supplementary Estimate to look after the necessary financing of the health boards and the various voluntary hospitals and health agencies? The Supplementary Estimates before us amount to nearly £100 million, not for health alone but for all the various Departments of State, but they indicate how wrong the Government got their figures. Add to that the deficit in the health boards and many other deficits and we see the very serious, precarious position the finances of the State are in after four years of this Coalition Government. Why has the Minister not included in this Supplementary Estimate the moneys to provide for the needs of the health boards and health agencies? Are his Department, like other Government Departments, accumulating debts which will have to be taken up by a future administration? There is no indication in this Supplementary Estimate before us that the Minister is prepared to face reality when he comes in and looks for £1,000 when we know the size of the deficit. Each health board in turn have had this serious problem.

This morning on radio Senator Higgins from Mayo criticised the health board members and executives for the manner in which they are providing the service at present and he was very critical of the effect this is having on the poor. In other words, he stated that a conscious decision had been made by health board members and executives to be hard on the poor in some way. No health board have sufficient money to deliver the services that [1594] are their statutory obligation. We have talked about this many times in this House not alone this year but over the last three years. For example, no dental service is available to adults who hold GMS cards in any health board area except to pregnant women, people awaiting operations and who must have their teeth attended to first and to the mentally handicapped. The Minister told us tonight he was satisfied that there was no fall off in the level of essential services, but I have just given an indication of one area. The same could be said about the optician service.

It is more difficult when looking at the hospital service to point out, say, the patient who should have been in hospital a week earlier only for the cutbacks. We cannot identify specific patients, although in the House just two weeks ago on a Private Members' motion I was able to point out to the Minister, with evidence in writing, the case of a patient who was delayed 13 weeks waiting for an appointment for what was potentially a very serious illness. That was a direct result of the cutbacks. In the hospital services there are delays for people waiting for outpatient appointments and for persons waiting to be admitted to hospital.

The Minister talked about comparative costing. Has anybody looked at the cost, first of all in human terms, to the patient of these long delays of, say, 13 weeks waiting for a hospital appointment which in the case I have mentioned was made for 5 August and postponed until 21 October? Has anybody looked in economic terms at the cost to the State, to the GMS where patients are coming along perhaps weekly to their doctor while they are waiting for their outpatient appointments or for admission to hospital? Has anybody considered the cost to the Department of Social Welfare of paying out sums of money to persons who are out of work and waiting for appointments at hospitals? Is any research being done into this? It appears that in the public service generally one of the problems is that one Department look very carefully at what they are doing without reference [1595] to what effect it may have on other Departments and on the expenditure of other Departments. However, to the people who are providing the money, the taxpayers, it does not really matter which Department of State the expenditure is in because at the end of the day they have to provide the finances anyway.

Therefore, instead of these ad hoc cutbacks — and there have been cutbacks in spite of what the Minister said — there should be some sort of proper planning to ensure that maximum efficiency is delivered in our service and that the proper level of service is available to all those people who are unable to provide it through their own resources. In relation to hospital services one area where there could be improvements is in the operation of outpatients' departments. Some of the buildings are very old, for instance the North Infirmary in Cork where one consultant operates from one room. A lot of time is wasted as the patients must undress and dress again in that room. It would be much more efficient if the consultant had appropriate working conditions and if there were an appropriate number of dressing rooms for the patients.

Something else that could be looked at is the waiting time for patients for operations. It is unacceptable that a person should have to wait six months for a surgical appointment. I know there are also long waiting lists, which are equally unacceptable, for persons suffering from severe joint pains and who are waiting for replacement joints. The number of times a patient returns to the outpatients is something that should also be examined. We should encourage closer co-operation between the family doctor and the consultant and between the family doctor and the hospital and we should encourage closer integration of the community care services and the hospital care services to ensure maximum efficiency in the delivery of outpatient care. Family doctors should have access to facilities in hospitals, to laboratory and X-ray facilities. There is something [1596] wrong where, if a family doctor sends a specimen to a laboratory, the patient can get a bill for £40 but if the person goes to the outpatients' department of a hospital where more expensive tests than the one the family doctor ordered may be carried out, they are carried out free of charge.

The length of time people have to wait in an outpatients' department is another matter that should be looked at. The Minister spoke about closing down hospitals without any serious effect on the level of service. One serious effect I could mention is in the area of nose, ear and throat services which were provided by Sir Patrick Dun's Hospital. The hospital is now closed but I understand that there is a very serious problem in St. James's Hospital which is not able to provide the necessary level of ear, nose and throat services to cater for the patients of Sir Patrick Dun's Hospital. This does not just affect south east Dublin, but many parts of Ireland including many areas in the North-Eastern Health Board region which used Sir Patrick Dun's.

The Minister referred to Beaumont. We have been talking about Beaumont for the last four years. The Minister and the Government did a U-turn on Beaumont. The Government should have accepted in 1982 when they came to office, what they accept now as sensible, that consultants should be allowed to carry out their private practices on the campus of Beaumont, provided there is no cost to the Exchequer, something that we always supported because it is in the best interests of all the patients, including public patients that a consultant should be on the campus for as long as possible. The Government rejected that, although they never had a logical defence of that rejection but over the last few months they have come round to accepting that that is the correct way to proceed. Now they are going to open one section in Beaumont, the outpatients' department, and ask patients to go to Beaumont for the outpatient facility and to go to the centre of the city for their tests, their bed and so on in Jervis Street or the Richmond Hospital. Consultants will [1597] have to go out to Beaumont to see their outpatients and then come back to the Richmond or Jervis Street as the case may be. It is another illogical approach to the development of the Beaumont complex. I would ask the Minister to reconsider that.

The CAT scanner in Galway is still idle and people are going to Cork and Dublin for CAT scans. The Minister for Finance in his budget told us that money is being provided to make the CAT scanner operational. That money has not been provided to date and so we have another area where cost effectiveness has not been considered. It costs a lot to drive patients to outside hospitals many miles away for this expensive high technology.

One of the areas in the Supplementary Estimate for which a large sum is being provided is the GMS. There is no doubt that there is greater demand on the GMS now because when the economy is not going well and people are dejected, there is a greater reliance on health services. People are going to their doctors more frequently because of the long waiting lists for outpatient facilities, for inpatient care and because of earlier discharges from hospital. Because district nurses are not being replaced when they go on holidays or for their first month on maternity leave this too increases the workload on the family doctor. It is not any wonder that increasing costs are involved in the delivery of the GMS. I wonder if any research has been done on the consequences of what is happening in the hospitals in the GMS, in relation to medical cards and so on. The guidelines are being rigidly imposed in all health board areas and indeed persons who would have got health care because of hardship in the past will not receive health care if these guidelines are rigidly imposed. Rather than being guidelines they are now a rigid cut-off point for medical cards in many community care areas.

I support the Minister in relation to the transfer of resources from hospital to community care. The transfer of resources and the building up of community care services sufficiently to ensure [1598] that we have an appropriate level of community care is not cheap. There is no indication in any country where they have done this that one can actually save money on it. It is important however in human terms to develop community care services. While it may not cost less, if we provide the essential services, more public health nurses, physiotherapy services, and chiropody services in the district, we will get to more people. Not alone will we get to those who would have benefited if they had been inpatients in hospital, but we will also get to a number of people who could avail of these services without going into hospital. It is important from that point of view and in human terms that we should try to ensure that as many people as possible can be treated in their own homes and communities.

The elderly will create a major challenge to the health services in the years to come because, in the next six years, the number of persons over 65 years of age will increase by 10 per cent and those over 75 will increase by 20 per cent. There is a problem at present in finding suitable residential accommodation for people who need it. There are not sufficient community care services to ensure that people can be looked after in their own communities, particularly those who are living alone. We must look into this area and, as well as the Department of Health, the Department of the Environment should be involved in providing proper and adequate accommodation for the elderly. Perhaps a more liberal interpretation of the regulations concerning reconstruction grants for disabled people could be made so that if a family wanted to bring an elderly parent to live with them they would get some assistance for building on a room. Economically, apart from the human value, the disabled person's reconstruction grant amounts to £5,000 and the average cost of keeping an elderly person in residential care for a year is £6,200.

I recognise that the Minister has provided new residential units for the mentally handicapped. Nevertheless, there are very serious problems as a result of [1599] the cutbacks and the most serious is that young adults are being sent home, having been in residential care for ten, 15, or 20 years, to parents who, because of age and infirmity, are unable to look after them. This is a very serious problem for which the Government must stand indicted.

I supported the Minister's campaign for vaccination against measles and I complimented him on bringing in that scheme. I accept what he said tonight, that we would see the benefits in the years to come. I have doubts about the amalgamation of the Medico-Social Research Board and the Medical Research Council because the Medico-Social Research Board, being directly under the Minister, might be influenced not to proceed with certain research for political reasons. I am not referring to the present Minister but a future Minister might influence them in regard to research.

We must face up to AIDS and there should be research into the disease. In the past we made a very valuable contribution to research in the world context, even with our limited resources. We must also ensure that people know about the prevention of AIDS. In this context education is necessary.

The Children (Care and Protection) Bill is held up on Committee Stage and has run into difficulties because the Minister is bringing forward a number of amendments. I am glad of the fact that, before the Bill was published, we did not press for its circulation because we always said we would like to see a good Bill introduced and that it was better for the Department and the Minister to take their time instead of bringing in an inadequate Bill. The Minister did not mention the Health (Amendment) (No. 2) Bill which would give him the power to close any hospital or unit of a hospital or to discontinue any service in a hospital without any reference — apart from some consultation — with the health boards. That Bill was introduced in the House about 18 months ago but we have not heard anything about it since. It is an indication that somebody recognised that [1600] it was a draconian measure which would be totally unacceptable to the Members of the House and would have had no chance of being passed.

We fully support planning for the future in relation to psychiatric services but I am critical of the Government for the way they turned that excellent document on top of its head and discredited it by starting at the last page and announcing on 30 January that they intended to close hospitals at the end of June. That caused tremendous anxiety to patients, their relatives and other interested parties who thought that all hospitals would be closed and that everybody would be back in the community without a proper service to care for them. We support that document in a phased programme of development over ten or 15 years.

The Minister referred to amending legislation in relation to the VHI. Will such legislation put more restrictions on the VHI? The thrust running through Government thinking at present seems to indicate that there will be more centralisation and the Minister referred to it tonight. He said that without motivation and accountability at local level, the identification and implementation of potential improvements cannot be assured. I do not know what that means, it is a very vague statement but it appears to be a further indication that the Government want more centralisation of services, which is something to which we would be opposed.

The Minister gave a comprehensive over-view of the health services as he saw them, far beyond what we would expect in a debate of a Supplementary Estimate. Perhaps it is his final major contribution to the record of the health services over the last four years. However, he did not mention drug addiction or the present position re facilities which were promised, including a detoxification unit and facilities for the inner city. The problem of alcoholism was debated last weekend at the seminar organised by the Irish National Council on Alcoholism. The Minister did not say when we would have the policy document of Dromoland before us. He said there would not be a [1601] Green Paper but, from everything he has been saying since, it appears that possibly there will be such a paper.

We are opposed to centralisation to the extent that it has been articulated in that document because it would do away with the local democratic input by the statutory bodies and the voluntary organisations. In terms of availability and accessibility of service I have no doubt that people living away from the centre would be much worse off. For that reason, we could not support that concept and it is totally in conflict with the stated policy of the Government and the Labour Party on decentralisation which advocates devolved power going back to local authorities and setting up regional boards for education.

The £30 million to £40 million estimated deficit is the responsibility of the Government. I should like to ask the Minister why he is not providing finance in the Estimate and who he expects to provide the money. Does he expect the incoming administration to pay the debts which appears to be the case in relation to other Government Departments?

Over the last four years the Government have presided over a serious reduction in the level of health services. There is no dental service for adults who are holders of medical cards. Patients, particularly the elderly, are on an intolerably long waiting list for admission to hospital and for out-patient appointments. Mentally handicapped adults have been discharged from residential care and their parents are unable to look after them. Much of this hardship could have been avoided had the Minister been more realistic and engaged in consultation rather than confrontation. He has succeeded in the past four years in creating undue anxiety and hardship for patients and their relatives. Morale among those working in the health services is at its lowest ever level.

In fairness to the Minister, he was not alone in getting involved in confrontation but, perhaps, his confrontation lasted longer. The Taoiseach's remarks in this House about the health boards, particularly the South-Eastern Health Board. [1602] the Western Health Board and the Southern Health Board, were totally unacceptable. In this House he accused the CEO of the Southern Health Board of producing fictitious figures, that not alone were they fictitious but they were known to be fictitious when they were produced. That is not how you run a health service or get co-operation from people in a time or recession. We all recognise that health care is expensive and money is scarce but surely the way to proceed is through consultation with the health boards and with the people who are working in the health services? I pay tribute to the CEOs, the staff and members of health boards for the manner in which they have contributed to ensuring that some level of health service was provided in the past four years.

Fianna Fáil are concerned and aware of the ever-increasing costs of health care, but that does not mean we must abandon what has been traditional in Ireland, which is a caring, social philosophy. Through consultation and planning we must ensure a proper and adequate level of health care for those who are not able to provide for themselves out of their own resources. It is the responsibility of a civilised government to ensure an adequate level of health service. Fianna Fáil in Government in the not too distant future will provide, as we have done in the past, a proper and adequate level of health care.

Mr. Tunney: A Leas-Cheann Comhairle, it would be fair to say that you, sitting in your neutral Chair, would over the past four years have noted in Deputies on this side of the House a sense of despondency, oft-times frustration, sometimes bordering on cynicism, at the lack of response to any request emanating from this side of the House. I am sure you detect also the inevitable feeling of uselessness when we find ourselves pitted against certain Ministers who seem to be concerned only with the cultivation of their own delusions and who resist any attempt at dislodging such delusions and who oppose any proposal that is contrary to what they articulate. [1603] I was a member of Clonliffe Harriers whose motto is Nil Desperandum. I do not include the Minister in the category to which I have referred. That is not to say I would give him full commendation but over the past four years there have been at least one or two occasions when I did receive a response and was heartened by that. I am taking the Minister entirely at his own word. I listened to his speech while in my office. He said he would make no apologies to anyone, that he was concerned with looking after the people and providing them with their rights in respect of health entitlements. Straightaway, I am going to give him a presentation of cases in my constituency, which I know are being reproduced in his own, and ask him, having listened to these cases, if he is responding to his own target of giving people their rights?

I am talking of cases where members of a household are expected to provide medical, psychiatric and geriatric treatment for an older member of the household. These cases do not exist in my imagination. I have been on to the hospitals and the health boards. One case comes to mind in the past fortnight, that of a family who because of their willingness to accept an aunt from hospital find that their house is now in total disarray and the domestic humour of the house is affected. The lady in question rises at 2 a.m. and goes into the bedrooms of the girls or the boys and upsets them. She interferes with the sleep and the studies of the young people. She has upset the whole household.

There is the case of a lady in Finglas who was referred to the Master Hospital by her local doctor and instead of being admitted to the general hospital, she was taken into the casualty ward where she was held for eight hours. She was asked for the name of her neighbour and, in the name of community care, that neighbour was asked to come into the hospital to collect her. That unfortunate lady even though there were no services and no free meals, was left to the tender mercy of her neighbour. Is this what the Minister is talking about when he speaks of looking [1604] after the rights of people? Is this what the Minister is talking about when he speaks of the introduction of community care?

Community care is a worthwhile objective but where we will the end we must also will the means. Community care is only a euphemism for a “do it yourself” type of health policy. In the past four years I am not aware of any improvement in community care. Rather am I aware, week in week out, of institutions which were designed to look after the needs of our people unloading patients in some cases onto reluctant relatives and in other cases onto relatives who feel they would be letting the side down by not accepting them. If the Minister thinks that the case I am making is wrong, let him say so, but I know it is not, I know that what is happening in my constituency is happening in every constituency in Dublin.

I am aware of another case of a young deserted wife in employment who has to look after her family. Because her mother is living alone and is in need of attention in a psychiatric home, this lady was obliged to give up her employment in deference to the understandable natural feelings she has towards her mother. The Minister spoke about the introduction of a new policy of community care. I hope he will apply himself to that policy in deference to his expressed hopes and objectives of attending to the rights of our people. I hope he will provide staff for our institutions and that he will see to it that elderly people are provided with the care they cannot receive at home.

My own mother who lived until she was 95 was blessed with good health and it was a pleasure to have her about. We were all delighted to have her but I can also visualise the circumstances which obtain in other homes where an elderly person is not capable of coping with physical or mental ailments. I hope the Minister will either dismiss what I say as being wrong — I know in all honesty he cannot do that — or indicate that he accepts it as part of the work which he should be attending to.

Vote put and agreed to.