I move:
That a sum not exceeding £1,168,791,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December 1987, 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 gross non-capital provision in the Estimate amounts to £1,237.228 million. Allowing for Appropriations-in-Aid at £126 million, the net non-capital grant provision is £1,111.228 million.
The net non-capital grant provision represents a decrease of £3.946 million on the corresponding outturn for 1986 (£1,115.174 million). The decrease is due largely to additional Appropriations-in-Aid of over £18 million, which have the effect of reducing the funding requirement from the Exchequer. These additional funds, which represent a 17 per cent increase on the 1986 outturn, arise mainly as a result of the increase in the rate of health contributions. There is no provision in the Health Estimate this year for the cost of the Health Education Bureau. These costs will be met from the proceeds of the national lottery. An increase of 3 per cent from July in the rates of allowances to disabled persons is provided for.
The provision in the Estimate for capital schemes is £57.563 million.
The level of non-capital expenditure in 1987 which can be approved on the basis of the subhead provisions in the Estimate is about £1,315 million in gross terms, or £1,216 million taking account of income which is received directly by the health agencies, such as, payments for maintenance in private and semi-private accommodation in public hospitals, and the in-patient and out-patient charges introduced last month. The gross estimated expenditure of £1,315 million represents an increase of £41 million on the original provision for 1986. It comprises £823 million in respect of pay, £424 million in respect of non-pay (excluding cash allowances) and £68 million in respect of cash allowances. About 83 per cent of the gross expenditure will be met from Exchequer funds.
The approximate breakdown of estimated gross expenditure of £1,315 million in 1987 between programmes is set out in Appendix I to the circulated script.
As can be seen from the data presented the general hospital programme absorbs some 50 per cent of the total non-capital budget. This programme must therefore come under particular scrutiny in seeking to free up the resources necessary to strengthen primary care services. Steps have already been taken in this direction in that the general hospital programme accounted for £51.1 per cent of total expenditure in 1985. My Department's letter of allocation for 1987 calls on health agencies to examine institutional costs critically with a view to targeting the greater part of the savings necessary in this area, thus protecting, as far as possible, community services.
In discussing the current provision for health services we need to be conscious of the rapid growth in health expenditure that occurred particularly over the last 15 years. In 1973-74 net expenditure amounted to about £143 million, representing about 5.2 per cent of GNP. In the current year it will be of the order of £1,216 million, representing about 7.1 per cent of GNP. While this percentage is high, it has, in fact, declined from a peak of around 7.9 per cent in 1982.
The factors responsible for the increase in expenditure over the years are pay and price inflation, extension of eligibility for certain services and improvements and developments of services. In recent times the range and sophistication of our services have grown rapidly, embracing many new technological advances as well as considerable expansion in the area of personal social services. Not unexpectedly these improvements gave rise to significant extra costs.
If we are to maintain and improve the quality and scope of our services, we must rationalise, particularly in the institutional area.
Health agencies, including health boards, public voluntary and joint board hospitals and homes for mentally handicapped persons were notified in April of the approved non-capital allocation levels for 1987. On 2 April I met with the Chairmen and chief executive officers of health boards and discussed with them the difficulties and opportunities which face the health services in the current year. I advised the health boards of the need to produce action plans for 1987 spelling out in detail the measures necessary to contain expenditure within the approved allocation levels.
In the series of earlier debates on the health services there have been frequent criticisms by the Opposition of the measures which are required of the agencies to contain expenditure within the targets set for 1987. I would remind Deputies that the previous Government allowed the agencies to exceed the notified allocations consistently over the last few years. As a result overruns of £55 million had accumulated up to the end of 1986. Thus funds which should have been on the treatment and care of patients in 1987 are instead being used to make interest payments on past debts. It is largely this mismanagement of our services over the last number of years which has given rise to the present situation.
Given this situation, I am very aware of the difficulties facing our health service managers and I fully realise that all available skill and expertise will be required to manage our resources throughout the year. I have in general been encouraged by the positive response that has been forthcoming from the agencies and am firmly convinced thet the resources available will be sufficient to enable vital services to be maintained.
An area to which I am paying particular attention is the potential for savings through efficiency improvements in the health services. There must be an emphasis on getting better value for money.
I have established a cost-containment and efficiency unit in the Department of Health to co-ordinate the rapid exchange of information between health boards and hospitals on cost-saving initiatives, good practice, best prices for supplies, evaluation of alternative products — in short, all the support information which manages at local level require in order to achieve greater efficiency.
The Exchequer capital allocation for the health services in 1987 is £57,563 million. In the current difficult financial situation, this is a substantial allocation which will be deployed to improvements in the infrastructure necessary for the efficient delivery of health services.
On the general hospital side, the emphasis will be on the rationalisation of services to ensure that an efficient and effective service is available throughout the country. Construction or equipping work will be continued on a number of major general hospital projects, including St. James's, the Mater, Cavan, Mullingar, Castlebar and Loughlinstown. Provision has also been made for major new schemes where construction has commenced in 1987, such as the provision of a new maternity unit at Our Lady of Lourdes Hospital, Drogheda, and the construction of the new Waterford Regional at Ardkeen.
The planning of the new Tallaght Hospital will be continued and further planning will also be carried out for many other general hospital projects, such as St. Luke's Hospital, Kilkenny and Naas General Hospital. Major hospital developments at Sligo and Wexford are at tender stage.
Apart from the major general hospital schemes which I have mentioned, the policy of improving out-patient and day hospital facilities will be maintained in the current year, to the extent that resources permit.
The recommendations contained in the policy document which was published some time ago on the psychiatric services —Planning for the Future are being implemented as quickly as possible and the diversion of capital resources away from the psychiatric hospitals and into the community psychiatric services is beginning to be reflected in the composition of the psychiatric capital programme. Hostels, day hospitals, day care centres and other community facilities are being planned throughout the country for psychiatric patients. In Dublin, psycho-geriatric units, which will improve standards at St. Brendan's Hospital, are being built at Clonskeagh and similar units are being planned for Ballymun and Dún Laoghaire.
In the case of the mental handicap services, the aim is to develop facilities which will enable mentally handicapped persons to reside in the community and the capital programme includes projects geared to the achievement of this objective. On the physically handicapped side, construction work is well advanced on the provision of new residential accommodation at St. Joseph's school for the deaf at Cabra and a major development scheme is in progress at St. Mary's school for the deaf, Cabra.
Planning will proceed on a number of other important developments including the provision of a new national centre for the blind at Rathmines. Planning has been largely completed for the provision of new children's accommodation at St. Mary's School for the Blind at Merrion.
The provision of facilities for the care of the elderly will continue to be a priority. The construction and furnishing of the new geriatric unit at St. Oliver Plunket Hospital, Dundalk, will be completed and work will continue on the provision of a new 100 bed replacement geriatric unit at the Sacred Heart Home, Carlow. Planning has been completed for the provision of a new geriatric hospital at Dungarvan.
There has been an extensive programme of building health centres and clinics in recent years in line with the policy of bringing the health services into the community. This policy will be continued in 1987 and funds will be made available for various projects in this area. For example, building work commenced in the current year on important health centre developments in Athlone and Gorey, while tenders have been received for a new health centre at Portlaoise. Also, community-based treatment facilities for drug abusers will be developed and provision will be made for a number of community welfare projects.
As a guide to the way in which resources are applied in the health services, I would refer Deputies to my Department's annual statistical publication, the 1986 edition of which was recently published and circulated. I hope the 1987 report will be published before the end of the year, representing an improvement on the normal lead time for such reports.
One of the more notable statistical trends in recent years has been the decline in the birth rate. Since 1980 the birth rate has fallen quite dramatically from 21.8 births per 1,000 population to an historic low of 17.4 births per 1,000 in 1986. This is paralleled by a decline in birth numbers from an historic high of some 74,000 births occurring in 1980 down to approximately 61,500 births for 1986. This is the lowest recorded number of births since 1968.
An additional source of information on activity in the health services is the report on the health services, which was last updated to December 1986. That report covered the period 1983-1986. I intend to continue the practice of producing such a report on an annual basis.
Eligibility for medical cards is normally determined by the chief executive officer of the appropriate health board by reference to agreed income guidelines. The new guidelines with effect from 1 January 1987 compensate fully for changes in the cost of living during 1986.
I have increased the income ceiling for health contribution purposes to £15,000 with effect from 6 April 1987. The Revenue Commissioners are responsible for the collection of current health contributions from all sectors. Health boards remain responsible for the collection of arrears due from farmers for periods up to 6 April 1984 and while £6 million is still owed by farmers to health boards, the health boards have been very successful in collecting arrears of over £2.5 million in the last two years.
One consequence of the limited resources available to the Exchequer for health and other services was the recent introduction of charges for in-patient and out-patient services. Given the general budgetary situation and the dependence on the Exchequer for virtually the entire burden of funding the health services, the Government had no other responsible choice. The only alternative course would have resulted in a serious deterioration in the availability and quality of services.
In advance of the introduction of charges I requested the Voluntary Health Insurance Board to make available a low cost and easily accessible insurance scheme to cover the new charges. The new scheme has gone a long way in allaying people's anxiety over the charges. For less than the cost of the out-patient charge or a single daily charge of £10, an adult in a group scheme is insured for a full year against the in-patient and out-patient charges. This scheme, at my request, applies regardless of age or a person's present state of health.
Structures for the delivery of health care in Ireland are based on a balanced mix of public and private facilities. This arrangement has worked well to date, has enabled us to provide a high standard of health services and is clearly an approach which is very acceptable to the community. The cost of the private element is met largely by insurance cover made available by the Voluntary Health Insurance Board. As the House is aware, the VHI Board were set up in 1957 and they have served us well in the interim. I am looking at the possibility of introducing legislation in the near future to amend the VHI Act and I have asked the VHI Board to prepare a scheme that would provide comprehensive cover for community care services, general practitioner, dental, optical and drug costs etc.
While virtually all of the current debate about the health services has focused on the financial aspects there are many positive policy developments across the entire spectrum of the services. As part of the Government's legislative programme a number of significant pieces of health legislation will be processed.
The Children (Care and Protection) Bill was before this House before the last Dáil was dissolved. Rather than reintroduce that Bill, because as many as 150 amendments were proposed, most of them by the then Minister, I have decided to introduce a new Bill, the Children (Care and Protection) Bill. That Bill will be circulated during the summer recess. Earlier this week the Adoption (No. 2) Bill, 1987 was presented to Seanad Eireann and circulated to Senators. It is hoped that Second Stage of that Bill will be taken within the next week to ten days in the Seanad.
The Control of Clinical Trials Bill, 1986, which provides for a statutory scheme of control of clinical tests, has been passed by the Seanad and is currently at Committee Stage in this House.
While the penal measures provided for persons convicted of drug pushing have been significantly strengthened in recent years, the Government are satisfied that these measures will not be complete until we introduce legislation providing for seizure of the assets of drug pushers. We regard the introduction of such legislation as a priority and, while it gives rise to certain constitutional questions in this country, it is currently the subject of consultations between my Department and the Attorney General's Office.
I propose to bring a new tobacco Bill, to control smoking in public places, before the Dáil in the autumn.
Apart from this range of legislative developments, progress on service development is being made on a number of fronts within the various health care programmes.
In relation to the acute hospital system I have already indicated that change is now needed. We must have an acute hospital system which is geared to our ability to pay, which is effective and caring, and which is efficient. It must be closely and constructively linked with a primary health care system which is capable of doing many of the things now done in hospitals.
Since 1968, we have succeeded in greatly improving the acute hospital sector. I do not think we have done so in the most effective or efficient way. There has been no shortage of proposals and plans. Yet, outside of Dublin, the hospital system, in terms of number, location and size of hospitals, remains largely the same as it was almost 20 years ago. We have now arrived at a situation where we cannot afford to sustain, at an appropriate level of competence and capacity, all the acute beds and hospitals which are in the system. This is obviously a matter of great concern.
As indicated in my address to the House on 19 May, I have set in motion the process of adaptation which is now necessary and likely to be welcomed by those most vitally concerned with the delivery of acute hospital services.
A rationalisation of acute hospitals does not mean that all hospitals no longer providing acute services must close. There are other uses to which some of these facilities can be put. I have particularly in mind the improvement of accommodation and services for the chronic sick and terminally ill. There are areas in which new or additional health clinics are required and, in large urban areas, there may be a need to provide a casualty service where in-patient care is no longer available.
The future management of acute hospitals can be greatly improved. There are many exciting developments taking place in this sector. Work is being done on development of systems to measure the output of hospitals in ways which would be clinically acceptable. This will provide a much improved basis for allocating, budgeting and control. Modern computer systems can help communications within the hospital, can help provide support for clinicians and nurses and can aid all aspects of management. There are many new approaches to hospital management emerging in other countries which we must monitor and assess with a keen eye on own requirements.
It is not sufficient to rationalise the system without improving its management. My Department are at present considering, in association with the relevant training interests, the introduction of a management development programme geared to the complexity of a modern day health service.
In relation to the psychiatric services the detailed planning of the re-organisation of the service is continuing. The intention is to move away from the traditional dependence on the large, old psychiatric hospitals and to base the service for the future firmly in the community. There will, of course, be need for in-patient care but, more and more, this is being provided in units in general hospitals. Further units of this type are in planning at present. A wide range of facilities has already been provided in the community. It is our intention that this will continue. The overall expenditure for 1987 on mental handicap services is estimated at £113.48 million. This compares with a total of £107 million at Estimates stage in 1986, which indicates an increase in line with inflation.
Despite the present critical financial position, in making the allocations between the various agencies, I took steps to protect the mental handicap agencies directly funded by my Department. I recognise that many areas of weakness still exist in our mental handicap services. We are examining those to ensure that proper and adequate services will continue to be provided for the mentally handicapped. Similarly we are examining the possibility of implementing more of the recommendations contained in the Green Paper on Services for Disabled People, Towards a Full Life.
One of the crucial elements in the maintenance of the handicapped in the community is the provision of an adequate community care service. In this regard I have made clear my intention — despite the limited resources available — to protect community care services, particularly in the case of the handicapped. In the development of their budgetary strategy for 1987 I specifically requested health boards to protect community care services for the handicapped as far as possible.
A major challenge to the health services over the coming years will be the provision of an adequate level of services to the increasing number of elderly persons in our society. A comprehensive review of services for the elderly, which commenced in August last, is being undertaken by my Department.
The General Medical Services scheme provides a first rate general practitioner service to some 37 per cent of the population or 1.3 million persons. This service is a vital front line element of primary health care and is the first port of call for many persons needing medical attention. In 1987, £108 million will be spent on the General Medical Services. In so far as the funding of the General Medical Services in the current year is concerned I might remind Deputies that, despite the difficult situation confronting the Government on assuming office, an additional £25 million was made available over and above the allocation of £82.8 million provided originally by the outgoing Government. In this respect I should say that I have been in contact with the Irish Medical Organisation. I expect negotiations on the General Medical Services to resume in the very near future.
In June 1986 the then Minister concluded an agreement with the Federation of Irish Chemical Industries, representing the pharmaceutical industry, governing the terms of supply of drugs to the health services. My officials are at present in negotiation with the Federation of Irish Chemical Industries to try to achieve improved terms. Hopefully we will succeed in the current year.
I am particularly concerned at the level of the dental and ophthalmic services for eligible adults. I am at present actively reviewing those services. In regard to the orthodontic services, one of the difficulties encountered was that, when posts were advertised by five of the health boards, one post only was filled because of a scarcity of orthodontists. The programme of developing health centres is continuing. Many new centres will be opened this year and work will continue on others.
I have already referred to the legislative developments in relation to child welfare. I should like to refer briefly to the widespread public concern about child abuse, particularly child sexual abuse. Some time ago a working group was established under the aegis of my Department to review services and provisions in relation to child abuse. Arising out of that review it has been decided to establish two new units to cater for the victims of child sexual abuse. These units will be located at Our Lady's Hospital, Crumlin and at Temple Street Hospital. I might mention also that my Department will be publishing shortly revised guidelines on the investigation, management and treatment of child abuse.
The most significant development in decades in the public health area has been the spread of the AIDS virus. In the past week I answered questions in the House on the AIDS virus. I will circulate with my script details of what my Department are doing and have been doing in recent years to combat this very serious illness, the most serious threat since tuberculosis 40 years ago.
The health services now form a major component of public health sector employment. Since the health boards were established in 1970 numbers employed in the health services have increased considerably. For example, in January this year, there were some 62,000 people employed while, ten years ago, the corresponding figure was 51,000. I find it difficult to accept that this increase in numbers has produced a corresponding improvement in the quality of service delivered to patients. Given that pay costs comprise 70 per cent approximately of overall costs, and in the light of the general budgetary difficulties, the growth in numbers could not be allowed to continue.
In his Budget Statement the Minister for Finance announced that no public service vacancy could be filled without the express approval of the Minister for Health with the consent of the Minister for Finance. Following discussions with the Department of Finance, it was agreed that, because of the late stage in the financial year and the random effect on services by not filling vacancies as they occurrd, a package of, first, non-filling of some vacancies, second, reduction in current temporary employees and, third, reduced scale of locum cover — to achieve an overall reduction of 2,000 posts by 31 December 1987 — was agreed. Apart from the 2,000 posts, health managements may have to effect further reductions in personnel as part of their overall plans to work within approved limits of expenditure this year.
I am convinced that the future of the health services can best be served on the basis of full consultation and, where possible, consensus among all those involved. I have met the Irish Medical Organisation, the Irish Nurses' Organisation and the Alliance of the Health Unions. I have also met representatives of the Irish Congress of Trade Unions together with my colleagues, the Ministers for Finance and Labour. In the context of industrial relations, I appeal to the Irish Nurses' Organisation, who are members of the alliance, to avail of that forum to pursue their issues and problems and not to take strike action which can only be to the detriment of patients.
Discussion on the reorganisation or rationalisation of health boards in the recent past have concentrated almost entirely on the question of how many boards there should be. This is somewhat peripheral to the more central question of how best to achieve efficient, effective and accountable management and delivery of services. A number of the initiatives to which I have referred elsewhere, particularly on the question of funding of services and hospital rationalisation, may suggest changes in the future organisation of services and the structures required. I am not convinced that a reduction in the number of boards as an end in itself would necessarily be of benefit.
I do accept that the statutory functions and responsibilities of health boards require examination as they have remained virtually unchanged during a period of major development in the services they provide and the general environments in which they operate. It is important that any changes required be brought forward in a constructive manner with due regard to the major contribution already made by health boards and voluntary agencies in the development of health and welfare services over the years. In the development of any new solutions in this regard I see a role for pilot schemes which could be used to evaluate, without commitment, any new arrangements proposed.
In the succession of debates on the health services in this House since I assumed office, including the motion on the hospital service charges, the various Adjournment debates on particular aspects of the services, motions on health expenditure, and the debate on health policy, there have been frequent references to panic measures, a lack of co-ordination and poor planning overall. On all occasions I have refuted such allegations and have provided many examples of the extent to which the adjustments to the health system are planned and co-ordinated and the steps taken to ensure that established priorities are observed in the allocation of resources. My review of developments this morning provides further evidence of a health system which is meeting essential needs and adjusting in an orderly way to the new environment in which it must now operate.
I must in this respect comment on reports of a statement made by Deputy Dukes in Tullamore recently in which he castigated Fianna Fáil for a failure to plan properly for the health services while in opposition. This is an amazing approach from the head of a party whose draconian and abrupt about-face on health policy and funding ended a four year partnership with the Labour Party in Government.
I want at this point to draw a distinction between what is necessary to cope with short-term management of the health services and the macro adjustments that now need to be considered to gear the health system to the needs of the nineties and beyond. Initiatitives are now being taken in relation to various aspects of the system, for example, the various service reviews I have mentioned, the rationalisation of the acute hospital system and the establishment of the Commission on Health Funding which I have set up and which, under the chairmanship of Dr. Miriam Hederman O'Brien, held their first meeting on Wednesday last. The outcome of these exercises will be fundamental to the long-term development of the health system. Some of the modern concepts in health policy being promoted, for example, by the World Health Organisation and being actively pursued in other developed countries, demand fundamental changes in attitudes towards health on the part of the individual, the wider community and the health professions. A change in the balance of responsibility, as between the individual and the health care system, also seem to be indicated, if we are to seriously think in terms of a greater reliance on preventive services with a concentration upon accident prevention, vaccination and immunisation programmes, the development of a nutritional strategy and a broad policy of health promotion in which there will be in current circumstances a concentration about the abuse of drugs and alcohol, responsible sexual behaviour and smoking of tobacco. These issues were raised by the publication of "Health — The Wider Dimensions" last December. I am committed to pushing ahead with them and I would intend to hold a national conference on health policy in the next few months. It is my earnest hope that the culmination of this period of consultation and debate will be some new public consensus on the nature and scope of health policy.