That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1974 for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chlaraitheora) and certain Services administered by that Office, including grants to health boards, miscellaneous grants and certain grants-in-aid.
This is the first opportunity the House has had to debate a Health Estimate since the present Government took office. I propose in my opening statement to deal with the major developments in our health services which have taken place during the current year. I have already circulated to Deputies a statistical document which provides more detailed data on trends within the health service and which provides detailed information on developments in aspects of the service which I may not deal with today.
The original Estimate for 1973-74, as approved by the House, was for an amount of £92,557,000. It was necessary in February to seek approval for a Supplementary Estimate amounting to £7,891,000. This Supplementary Estimate was required to allow payment of increased prices and pay, to cover the cost of the 1973 budget improvements, to provide a further grant-in-aid for the Hospital Trust Fund, and to cover the cost of increased demand on our choice of doctor scheme.
In total, therefore, the Department of Health's Estimate for 1973-74 was for an amount of £100,448,000. This figure shows more than a 50 per cent increase on last year's Estimate of £66,493,000 and indicates clearly the commitment of this Government to improving our health services. The fact that the Health Estimate has increased by £34 million in the current year is no accident. The Government, before the last budget, took a deliberate decision to concentrate all available financial resources in the social policy areas. When this major increase in the Health Vote is added to the £60 million increase in social welfare expenditure, then the extent of the Government's commitment to our social services becomes apparent. The Government did what they had promised to do in the last budget. We began, in a very real way indeed, the task of bringing about radical changes and improvements in our overall social system and services.
I propose now to demonstrate in some detail the very real improvements brought about in our health services during the current year. I can do this most simply, I think, by showing the increases which have taken place in public current expenditure on our health services in the first instance and then translating those public expenditure figures back into actual Vote requirements to be approved by the House.
Public expenditure on our health services, exclusive of the £9 million provided by reducing the health element in local rate charges, increased in the current year by an estimated £27 million over 1972-73. This is a very major increase indeed and is, in fact, the largest single increase on health expenditure since the foundation of the State. Of this amount, £8,750,000 was spent on real improvements in both the scope and quality of our services, that is an improvement after allowance has been made for inflation. This means in effect that an 8 per cent real improvement in expenditure on our health services took place in the current year, again by far the biggest single improvement in real expenditure in the history of the State.
This radical improvement in real expenditure took place, I must emphasise, despite the fact that rising prices and pay added £18 million to health service costs in the current year, and despite the fact that £9 million will be spent in relieving rate charges this year also. I feel that this is an achievement the Government can feel justly proud of and one which amply demonstrates our commitment to fulfilling our pre-election promises.
I would like to spell out in some detail those areas of our health services where real improvements took place. Of the £8,750,000 spent on real improvements.
Approximately £5,400,000 will be spent in the current year on the provision of extra beds in our hospitals and other institutions, on the provision of additional health personnel, and on the additional cost of our general medical services scheme;
£740,000 will be spent on improving health boards' welfare payments; the easing of the means test for welfare payments will cost an estimated £1,575,000;
£500,000 is being spent on improving our community care services, especially the home help and social work services;
The creation of a new allowance for the domiciliary care of handicapped children will cost £450,000 in the current year;
An additional £40,000 is being spent on improving services for children.
All of these measures have led to real improvements in our health services. In addition, they show a reasonable balance between institutional and community care.
When the total additional public expenditure of £27 million is translated into actual Vote requirements and added to the amount for rates relief, the increase in the total Estimate for our health services is, as I said, in the beginning of my speech, £34 million. This has been a good beginning for the Government in the health field.
Before leaving the estimates in general, I should like to make two further points. The first of these refers to appropriations-in-aid of the Vote. This year appropriations-in-aid are estimated at £6,583,400. The two main sources of revenue under this heading are health contributions and payments to which this country is entitled under EEC regulations.
I expect that health contributions will yield £5 million in the current year. Most of this will be collected by the Department of Social Welfare and the Revenue Commissioners. The contributions of farmers are collected by health boards, at the usual rate of £7 per year, but I regret that despite this reasonable rate of contribution revenue from the farming community has been disappointing. I would remind all who are liable for the contribution that there is a statutory obligation to pay it and that those who fail to do so may have court proceedings instituted against them for recovery of the sum due.
In addition to revenue for health contributions this country is due £1,500,000 in the current year from the United Kingdom under EEC regulations. These regulations provide that the country where a person is insured for social security purposes is liable for the cost of health services for the insured person or for any of his dependants in another country.
The second point in relation to the estimates in general is that my Department have been considering for some time how the present system of financing the revenue deficits of certain voluntary hospitals and other institutions might be streamlined. The present system for the voluntary hospitals involves payment by health boards for in-patients and out-patients based on capitation rates and sessional fees and the subsequent making of grants from the Hospitals Trust Fund to cover revenue deficits which result from the disparity between capitation rates and actual costs for eligible patients. Expenditure by health boards in fulfilling this arrangement is recouped to the extent of 75 per cent from the Health Vote. Similarly, since sweepstakes' income is not sufficient to cover the revenue deficits of the voluntary hospitals, grants-in-aid of the Hospitals Trust Fund have also to be provided for in the Health Vote.
This system of meeting revenue deficits is obviously cumbersome in the extreme. Commencing in the next financial year it is proposed to make payments directly to the hospitals on behalf of health boards from the Vote for the Department of Health. This method will result in considerable saving in administration and other charges. The details of the new method have been worked out in consultation with health boards and voluntary hospitals and come into effect on the 1st April, 1974.
These then are some general comments on this year's health estimates. I should now like to deal with developments in a number of specific health policy areas and to indicate to the House my general thinking on these matters.
A matter of special concern to me is the provision for all parts of the country of a high quality general hospital service, adequately staffed and equipped. Investment of a high order will be necessary to achieve this objective and it is therefore essential to determine a rational programme of hospital development.
When I took up office in March last year I discovered that the previous Government had not reached the point where they had laid down a programme for future hospital development. The result was that capital investment in our hospital services was being held back quite simply because no one knew where this investment should take place. Obviously this state of affairs could not be allowed to continue indefinitely.
I was concerned to devise as quickly as possible a development plan for the whole country. The problems involved in devising such a plan are many and obvious. While the need for hospital reorganisation is seen by most people and by Deputies, there has been considerable controversy during the last few years about the possible location of major hospitals. In addition areas of low population density and difficult geographical features do not easily lend themselves to general solutions. Nevertheless planning is necessary. The general hospital services absorb half of the total annual health care expenditure and the cost of these services is rising rapidly. In the present year the estimated cost is £57 million. The needs of our patients, together with the requirement of cost effectiveness, require a rational plan for the future.
I took a number of steps during the year to help me devise such a plan. At my request Comhairle na nOspidéal drew up guidelines on minimum consultant staffing standards for general hospitals and on the population and catchment areas which should be served by hospitals conforming to these standards. Early in October I circulated these guidelines to the various health administrative bodies and asked them to form joint working groups for each health board area to work out the alternative solutions for their area which would conform with their guidelines. I asked the working groups to report their views back to the administrative bodies concerned, who would then furnish me with their views on the options for their areas.
I have now received the reports from the administrative bodies and am considering the options for development. The value of the consultation process which I have just described is that all health board areas in the country have had the opportunity to discuss the future of hospital development in their regional areas. Their advice will be invaluable to both the Government and myself when we come to make decisions.
The Dublin situation posed complex problems and was the subject of a special study by Comhairle na nOspidéal. They, with my agreement, set up two subcommittees to explore the options for north and south Dublin. The reports of the subcommittees were accepted by the comhairle and forwarded to me. For north Dublin, the comhairle recommended that there should be three major general hospitals, the Mater, Blanchardstown and a new hospital at Beaumont. The Mater and the new hospital at Beaumont would each have 500 to 600 beds, would provide a wide range of general and specialist services and work on a complementary basis.
In south Dublin three major general hospitals were also recommended: Saint Vincent's, Saint James's and a new hospital in the Newlands Cross area. Each of these would have 500 to 600 beds and provide a wide range of general and specialist services.
I have asked the Dublin Regional Hospital Board, the Eastern Health Board and the hospital authorities concerned for their views.
Devising a plan for future general hospital development is a time-consuming exercise. I have tried to involve as many health agencies as possible in free and open consultation on the matter while at the same time pressing ahead as quickly as possible to the point where decisions can be taken. Deputies will agree that the creation of a plan for hospital development is highly desirable, both from the point of view of providing a better service to patients and from the point of view of making the best possible use of scarce capital.
Public capital expenditure on hospitals in the financial year 1973-74 is expected to total about £9.0 million as compared with £3.6 million in 1970-71, £4.2 million in 1971-72 and £6.55 million in 1972-73. This figure represents a significant increase, in real terms, in the rate of capital investment in hospitals as compared with earlier years and is an indication of the Government's determination to improve, so far as our resources permit, the overall level of hospital services in the country.
A major part of the capital expenditure in the year under review relates to the improvement and extension of the accommodation and facilities available for the mentally handicapped, the aged and the mentally ill. A number of projects for reequipping and improving the general hospitals are completed though, for reasons which I have already outlined, major building projects in this field have necessarily been restricted pending decisions on the re-organisation and development of the general hospital services for the country as a whole.
The more important current hospital projects are as follows. In Cork, building commenced in January, 1973, on the new 600-bed regional hospital, and progress to date is satisfactory. The building of a gynaecological unit at Erinville Hospital has commenced, and a new nurses home has been completed at the Victoria Hospital. The Southern Health Board's revised proposals relating to the planning of a new 300-bed general hospital at Tralee are being examined in the Department.
In Limerick, the development of the regional hospital is proceeding by the provision of a 50-bed paediatric unit and a 50-bed psychiatric unit. Both these projects are at an advanced stage of planning. A new pathology laboratory is also to be built here and this scheme should be ready to go to contract this year.
At Galway Regional Hospital a new 50-bed psychiatric unit has just been completed, a new bio-chemistry laboratory is in course of construction and schemes for an intensive care unit and an extension to the X-ray unit are at tender stage. An additional 25 paediatric surgical beds are also being planned. At the nearby hospital of Merlin Park a second orthopaedic theatre and an extension to the X-ray department are at a very advanced planning stage.
In Donegal the tenders for a new 30-bed hospital have been obtained and building will commence shortly. In Wexford the building of a new maternity unit at Wexford County Hospital is now in progress and it has been agreed to increase the size of the unit from 22 beds to 60 beds. The building of a 50-bed geriatric unit at this hospital is also in progress. In Carlow the building of a new maternity hospital is progressing satisfactorily and should be completed this year.
In Dublin a number of improvements are in progress or in planning at the Mater Hospital. The building of a new cardio-vascular unit at the Mater has already commenced and other proposals in planning include an extension to the child guidance clinic and an extension to the X-ray department. The conversion of Drumcondra Hospital for use as a maternity hospital in association with the Rotunda Hospital is nearing completion. A major extension scheme is in planning for the Rotunda Hospital.
At St. James's Hospital, Dublin, improvements are in progress at Hospital 7 and a new central X-ray unit and child guidance clinic are being provided. Progress continues on the provision of suitable new accommodation for the aged chronic sick in replacement of old county homes. Major schemes completed in recent months include those at Castlebar, Sligo and Roscommon. At Tullamore a 100-bed geriatric unit has been provided at the county hospital.
Welfare home accommodation for aged social cases is now available at Kilrush, Clifden, Boyle and Carlow. Welfare homes at present under construction will become available at 12 other centres before the end of this year. Others are at tender stage or at an advanced stage of planning. Details of the hospital capital projects completed since 1st May, 1972, and projects under construction, at tender stage and at an advanced stage of planning as at 31st December, 1973, are contained in lists which have been circulated to Deputies.
I should like to discuss now some developments in our specific services which have taken place during the current year and to indicate policy areas where considerable groundwork has been done in preparation for major policy developments. The choice of doctor scheme was introduced in the Eastern Health Board Area in April, 1972, and in the rest of the country in October of that year. I am satisfied that the scheme is, in general, working reasonably satisfactorily at present and that it has lead to a significant improvement in the medical services provided to medical card holders. Approximately one million people are now covered by the scheme for free medical services and over 1,100 doctors participate in its operation. The scheme will cost approximately £12.3 million in the current year, or £2.4 million more than anticipated. This figure gives cause for some concern and every effort will be made to control increasing costs of operation in future years.
The visiting rate for doctors services in the year to 30th September, 1973, was 5.5 visits per eligible patient. The prescribing rate by pharmacists was 9.1 items per person, compared to a Northern Ireland rate of 7.0 items. Every effort must be made therefore to maintain reasonable visiting and prescribing rates in the coming year if costs are to be kept within reasonable bounds. A review of the scheme has begun this week with the medical organisations and the pharmacists. This will give each party the opportunity to ensure that financial resources are used as effectively as possible.
The scheme for assisting with the cost of drugs, which started to operate in every health board in October, 1972, is operated by the health boards in co-operation with local retail pharmacists for the limited eligibility group. To obtain assistance towards his drug and medical costs an eligible person simply sends a claim docket for each prescription dispensed together with a completed claim form for his total costs to his local health board. If the total cost is between £3 and £5 in a month he will be refunded half of the amount in excess of £3 and if it exceeds £5 a month he will be refunded £1 plus the full amount in excess of £5. This ensures that no person in the limited eligibility group need spend more than £4 a month on drugs and medicines. The scheme has been of considerable benefit to persons with limited eligibility and it will be extended to every insured person in the community from next April so that no family will have to spend more than £4 a month on their drugs and medicines.
There are two schemes in operation for persons suffering from certain long-term conditions. The first scheme provides for hospital inpatient and out-patient services to be provided free of charge for children under 16 years of age suffering from certain conditions. The second scheme provides for drugs and medicines to be made available free of charge to all persons, including adults, suffering from those long-term illnesses covered by the first scheme with the addition of epilepsy and diabetes. While representations have been received for the extension of the list to cover other conditions the extension of the assistance scheme towards the cost of drugs and medicines from next April will go a long way in ensuring that persons suffering from long-term illnesses need not have heavy expenditure on their medical expenses.
At present children who are found at pre-school or school health examination to require dental treatment and medical card holders and their dependants are eligible for dental services provided by health boards. The operation of these services depends mainly on the employment of whole-time dental officers employed by the health boards. Difficulties experienced by health boards in recruiting whole-time dental staff, coupled with the high incidence of dental decay, have made it impossible for health boards to provide a separate dental service for all those who are eligible. It is necessary for health boards therefore to accord priority to the dental needs of children and the service for adults is in the circumstances limited. However in the services for adults health boards are expected to give priority to expectant and nursing mothers and to persons who require dental treatment for urgent medical reasons.
According to latest information 155 dental officers are now employed in the public dental service. Despite recruitment difficulties this represents a substantial improvement, over 50 per cent, compared with the position some five years ago when important changes were made in the conditions of appointment of whole-time dental officers in order to make these posts more attractive. Also the removal of the marriage bar on the employment of women in the public service will, it is expected, have a beneficial effect on recruitment to the public dental service in future years.
It is the policy of the health boards gradually to expand their whole-time dental staff. A particular objective of this policy has been the appointment of senior dental officers, usually one for each county, to organise and supervise generally the operation of the health board dental services in the local areas assigned to them. The position has now been reached where a public dental officer has been appointed to each local area throughout the country, with the exception of the Carlow-Kilkenny area for which a senior post has been approved by my Department and which will be filled soon. Thus a basic structure has been provided in all areas on which an expanded dental service can be developed according as the available financial resources permit.
At present under the child health services dental services are confined to pupils of national schools and children attending child welfare clinics. It is not intended to extend the child dental service to other schools— though there is provision for this in the Health Act, 1970—until the services for national school children generally have been brought up to a reasonably satisfactory level. The Health Act, 1970, also provides for the making available of dental services by health boards to persons with limited eligibility. This provision has not been brought into effect as, so far, health boards have not been in a position to provide reasonably adequate services for even the categories of persons at present eligible for dental services. An extension of the health board dental services to persons with limited eligibility would inevitably mean engaging the private dentist to provide services for eligible persons on a fee per item basis as they do under the Department of Social Welfare's dental benefits scheme for insured workers. An expansion of dental services on these lines would not be feasible in present circumstances having regard to the extra costs involved and their priority in relation to the many other demands which are currently being made for improvements in the health services.
The current services I have described are on-going and developing over time. No significant new factors have arisen in relation to their operation during the current year although they are being kept under constant review. I have taken a special interest however in four other policy areas during the period and would like to indicate to Deputies the prospects for development in these specific areas during the next few years.
I am concerned that training and sheltered employment facilities for handicapped people are inadequate at present. Most of the work done in this field up to now has been done by voluntary bodies. While these have performed a very valuable role within the limits of the resources available to them, they have lacked real support and guidance from the State itself. The problem of training handicapped people and providing sheltered employment facilities should not be left to voluntary bodies to the extent that is now the case. The State has a very definite responsibility for these members of our community and one which it must seek to meet more fully in the future.
At present we do not have a national policy for training handicapped people for open or sheltered employment. Indeed policy in relation to overall services for handicapped people is limited and piecemeal as things now stand. I intend to look at the general question in the coming year, but I decided in last October that most immediate progress could be made on the question of training facilities and opportunities. I decided to set up an informal working group of experts to study the present situation and to make concrete proposals to me on the type, quality and extent of training services which were required in the short to medium term.
I expect to receive this group's report in the next few months. I will have it examined rapidly with a view to beginning as quickly as possible in the coming year the task of up-dating, improving and extending our existing services. I hope to define a national policy on the matter within the coming year—one which creates the maximum possible opportunities for handicapped people in the area of training and sheltered employment facilities.
The same sort of preparatory work is being done at present in relation to children's services. At present responsibility for administering these services is divided between a number of Departments of State—Education, Justice and Health primarily. This divided administrative situation is not conducive to good planning or good administration. It certainly does not lead to an integrated approach to the provision of services to children at risk or children in need of care.
I have been concerned about this situation for a considerable time now, as indeed have other Ministers. Unfortunately pressure of work in other services has prevented us from making much progress in this area to date. About six weeks ago however a small inter-departmental working group was set up to identify the key administrative, legal and services problems in the area of children's policy. This group has now identified the main problems under the headings I have mentioned and the Government will consider its report in the immediate future.
This Government are determined to set about reform in relation to children's services. Many children are getting an extremely raw deal in our society at present. I hope that reform will begin in the coming year and continue during the life of this Government.
While I am on the subject of children, I should like to speak at some length on the subject of our thalidomide children. The tragic story of these children attracted renewed public attention during the year as negotiations on compensation with the manufacturers in Germany and Britain, respectively, were approaching conclusion. It was the German-made product that was on sale in Ireland. In spite of, or perhaps because of, the widespread sympathy and controversy surrounding this subject, there has at times been some confusion about the facts and Deputies might therefore wish me briefly to outline the background and the present position.
Thalidomide, a sedative drug, was marketed in this country from May, 1959, to January, 1962, when it was withdrawn from sale by the manufacturers because it had come under suspicion in connection with the incidence of certain types of congenital deformities, mainly limb defects. The preparations on sale in this country were manufactured by Chemie Grunenthal of Germany, whereas in Britain the drug was manufactured and marketed under licence by the British firm of Distillers Ltd. The Irish children's claim is therefore against the German compensation fund, which is approximately the same size as that set up by Distillers. However as there are 2,500 children, including 34 Irish children, sharing the German compensation, the average available per child is considerably less than under the Distillers fund, as there are only 400 British children involved.
The law governing the administration of the German fund provides for capital payments of between £158 and £3,950 plus, in severe cases, monthly allowance for life of £16 to £70, the amount in each case to be decided in accordance with the severity of disablement. It is understood that over 50 per cent of the children will get the maximum rate of allowance.
It is the disparity in compensation between Irish and British children that has been the main complaint of the Irish parents and it is indeed a disappointing situation for them. However, I am afraid I have not been able to see that there is any prospect of getting a settlement for our children from the German fund equivalent to the British one. The Germans have pointed out that Irish children are sharing equally with their children in the German fund and that they did not see how they could give preferential treatment to Irish children as against their own nationals.
This being the position, the Government announced last May, shortly after taking office, that it had decided in principle to augment the awards to Irish thalidomide children and their parents from the German fund. I then established an expert Irish medical board, including a leading British authority on thalidomide, to provide me with a detailed picture of the degree of permanent incapacity and treatment and care required for each child. This will enable me to consider, in discharge of the Government's decision, in what way the special needs of the children can best be catered for. The board's findings are intended also to re-assure parents that all aspects of their children's disabilities have been taken into account by the medical assessors of the German fund. The establishment of the board was widely advertised and all persons in charge of children with disabilities which they thought might be attributable to thalidomide were invited to bring their children for examination. About 112 children came forward in response to this invitation and I am informed by the board that they consider that 34 Irish children have disabilities linked with thalidomide. The board are proceeding with the job of a detailed assessment of social and medical needs, both immediately and in the future, of those children whose disabilities, in its opinion, are attributable to thalidomide. This is necessarily a time consuming task.
For example it involves the admission of children to hospital for observation and a wide variety of specialist tests. It is important that this work should be done thoroughly and not rushed. I expect it to be completed by April.
I hope therefore I have helped to refute any suggestion that the Government have pushed the problem of these unfortunate children aside. Deputies will, I trust, understand that it is not possible to give effect to the Government's offer of further help until the detailed reports on the requirements of the children are to hand.
I might add that all Irish thalidomide children have been accepted as eligible, free of charge, for the full range of health services, including family doctor treatment, without regard to parents' means. Also, I have agreed to look sympathetically at details of expenses incurred by the parents in connection with their children's disabilities in the past, with a view to reimbursement of reasonable claims, either by health boards or in due course from the additional funds promised by the Government. A great deal of preparatory work has been done therefore in preparation for the Government's decision on the extent to which the German fund moneys should be augmented from the Exchequer. Again the Government will take decisions on this question in the coming year. I regret the delay on this matter, but in fact I had to start this process from the beginning and it is, the House will appreciate, a time consuming task and a task which must be performed carefully.
A considerable amount of preparatory work also has been carried through in relation to the development of our community care services. I need not emphasise to the House the vital importance of community care in our overall health policy. Prevention and care in the community are critical aspects of modern health policy and ones which help provide a better health service generally at less cost than would be the case if the major emphasis were on institutional services.
Two related problems must be tackled if we are to provide a good community care programme in this country. In the first place more specialist personnel will be required. These would include public health nurses, dentists, social workers and home help workers among others.
I have increased the number of social workers employed by the health boards from 74 to 120 in the past year. A great deal more remains to be done in this regard. I hope that the number of social workers with postgraduate training employed by health boards will increase rapidly in the next few years. I have also asked the health boards to start trainee schemes for social workers from October next and to continue to recruit qualified social worker personnel as a matter of urgency. The results to date have been dramatic in comparison with previous years, but a great deal more remains to be done before we can claim to have an adequate social work service in this country.
I have also increased the number of home helps employed by health boards during the past 12 months. Expenditure on the home help service increased from £150,000 in 1972-73 to almost £400,000 in the current year. As a result there are now approximately 1,400 home helps employed in the country and the number continues to rise. I have also asked health boards to employ and train home help organisers so that the service is placed on a sound footing for future development.
The number of public health nurses employed has increased by 39 to 834 in the current year and I have to expand this number still further next year. I also intend to increase the number of dentists employed by the health boards in our community.
In all the services I have mentioned it is my intention to increase numbers employed. These personnel all provide a valuable community health care service and one whose value is recognised by the communities in which they are involved. However as the personnel numbers increase it becomes increasingly important to create proper working relationships between the specialists concerned. There must be a co-ordinated team approach to community health care if the best possible service is to be provided.
This brings me to the second problem in community care—the problem of structures and correct working relationships between the personnel concerned. It is my intention that community care teams be set up in our local community. The task of each team will be to provide an integrated community health service under a team director. Discussions have taken place with the professions involved, with the health boards and within my Department on the working relationship of each team. I am frankly disappointed that we have not yet got the teams working. I intend during the next two months to make every possible effort to reach agreement in this question with the professional organisations concerned, because without their co-operation the concept cannot be turned into a reality.
As far as community care is concerned I am attempting to create a situation where highly qualified teams of health and welfare personnel are working in each community area. They should work as a team and they should be easily accessible and responsive to the needs of the people they serve. The idea is to create in each community a team capable of helping individuals with health or welfare problems which do not require institutional care and as a result to reduce the numbers receiving institutional care at present. The idea is to provide a preventive, supportive and rehabilitative service at a high level in each community. This is my goal and this is what I am working towards at present.
In regard to the psychiatric services, recent years have seen profound advances in psychiatric knowledge and methods, due in large part to therapeutic possibilities opened up by pharmaceutical discoveries. One of the most significant results of this new potential is that the treatment pattern nowadays in the service is one of out patient or short-term residential care backed up by support services in the community. As a corollary of this there has been a marked fall in the number of patients requiring long-term hospitalisation.
The impact of this new approach is amply illustrated by the dramatic fall in the numbers of patients receiving hospital treatment in our public psychiatric hospitals—from 20,046 in 1958 to 14,449 in 1973. This is a clear validation of the new approach and for my part I shall encourage health boards to press forward with the development of all aspects of community care.
Psychiatric units are now functioning at many of our general hospitals and are in planning for many others. While progress on this front is satisfactory, I should like to see health boards placing greater emphasis on the establishment of day hospitals and day centres and on the development of hostels. I am convinced that these types of unit have a very important role to fill, not alone in eliminating the need to admit many patients to hospital but also in contributing to the earlier discharge of patients to the community. Naturally the development of treatment structures outside hospital settings will prove of no avail if a sufficient pool of ancillary personnel is not made available. My Department are currently examining ways in which psychologists, social workers and other therapeutic personnel can be attracted in greater numbers to our expanding psychiatric services.
It might be opportune for me here to pay a well deserved tribute to the Irish public. For generations the approach to mental illness has been one of isolation and safe-custody. Almost overnight this was replaced by one of treatment in the home and in the community. This new approach, to be successful, demanded a willing acceptance of the new status of psychiatry by the population at large. I am happy to say that Irish people have responded in a most sympathetic way to the new approaches and have accepted the development of community treatment procedures in a most enlightened way. The emphasis upon community care does not mean that residential treatment facilities can be neglected. Indeed the need to upgrade residential facilities in many of our psychiatric hospitals is very apparent and this is an area into which I am channeling an increasing amount of funds.
There are also other areas of the psychiatric services which need to be developed. One of the most important of these is the services for children. Our main difficulty here is the world shortage of the highly specialised personnel involved but it can be taken that once these become available I will certainly provide the funds to develop this important branch of the service.
During the last year the need to improve accommodation and facilities generally at the Central Mental Hospital, Dundrum, has been receiving special attention. It is in this mental hospital that psychiatrically disturbed persons who have been before the courts are detained. It has been a matter of concern for some time that because of the limitations imposed by the out-of-date accommodation in the hospital it has been extremely difficult to carry out treatment programmes based on a modern approach towards the care of the disturbed offender. This is particularly regrettable in the case of young offenders who in a disturbed society tend to grow in numbers. They clearly require some special provision based on an enlightened approach towards their care.
A working party consisting of representatives of my Department, the Department of Justice and the Eastern Health Board has had a critical look at what can be done specially for the young offender at Dundrum. Members of the group visited centres in the United Kingdom and in a number of continental countries where a certain amount of experimentation in this field is being carried on. Based on their consideration of the most up-to-date thinking on the problem they have recommended the provision of a special 30-bed unit at Dundrum for young disturbed persons, male and female. While its primary purpose would be to treat young persons in detention the working party has recommended that it should also be used for other young persons who may be referred there other than through the courts. The treatment programme envisaged for the unit is based on the idea of a therapeutic community involving therapists drawn from various disciplines, with emphasis in selecting staff on youth and on social commitment.
During the current year the amount voted for health education and publicity was increased from £90,000 to £150,000.
The publicity campaign to discourage young people from smoking was continued. Television is the main vehicle for this campaign but many youth and sport magazines are also utilised. New leaflets and posters on other health topics were published and made available.
The on-going campaign to inform the public of facts of drug abuse was extended and 20 seminars were held throughout the country. Every post-primary school was given the opportunity of sending one or more teachers to these discussions. Seminars were also held for doctors, nurses and clergy and over 100 lectures were given to adults, mainly parent groups, to acquaint them with the facts of drug abuse. In addition a two-week intensive course on health education was conducted for 25 selected post-primary teachers during the summer vacation. All these courses and seminars also dealt with the problem of the socially accepted drugs, for example, alcohol and tobacco.
Deputies will recall that since I became Minister for Health I have given special attention to the all-pervading problem of alcoholism and excessive drinking. I accepted the report of the Irish National Council on Alcoholism relating to ways of combating this. I directed that a substantial part of the Department of Health's advertising budget should be allocated towards the promotion of an advertising campaign to inform people of the nature of alcoholism. This resulted in the Alcoholism Education Fortnight which was held last year and in the current "Sensible Drinking Makes Sense" television advertisements. I also requested health boards to increase their subvention to the Irish National Council on Alcoholism.
In order to achieve a concerted effort from Government Departments against this addiction I am in touch with other Ministers in order to explore ways in which the undesirable consequences of alcohol in Irish social and economic life can be abated.
However I am well aware that moral persuasion alone will not have such an impact if these are not backed up by adequate treatment facilities. My Department are currently engaged in reviewing existing institutional services for alcoholics in order to find out in what way they can be improved and rationalised.
I should now like to deal with some matters concerned with the administration and planning of our health services. While the content of services is obviously of vital importance it is important that we also create the right administrative structures and planning approaches within the overall context of health administration.
The health boards have been responsible for the local management of the health services since April, 1971. Their establishment marked a significant development in the administration of the services. It provided an opportunity to bring about a desirable devolution of authority and responsibility from the centre and this opportunity is being exploited.
It is, in my opinion, too early yet to come to any definitive judgment on the suitability of the health board structure. The boards' initial tasks were rendered more difficult by the necessarily slow build-up of experienced management teams. Despite this it would appear that a good working relationship has developed between the various interests on the boards and that they are receiving good support from their management teams while in turn giving them the necessary encouragement and freedom to get ahead with the job.
Already there are a number of positive developments which are encouraging indicators of the boards' performance. They have shown considerable aptitude in identifying and gaining agreement on major local needs and in reflecting these in their budgets. The process of agreeing and controlling the annual budget has steadily improved in each year since their inception, and during the past year each board have produced the first longer-term plans which will facilitate decision-making and resource allocation in the future. I would also refer to the co-operation which has been received from the boards in utilising the computer facilities made available by the Department of the Public Service, thus maximising the benefits of this major installation and contributing to the early development of an integrated health information system.
Comhairle na nOspidéal have been in operation since September, 1972. During that time they have effectively discharged their key function in deciding on the number and types of consultant appointments. They also submitted to me a report on the future development of general hospital services in the Dublin area. These recommendations included proposals for the future management of the Dublin hospitals. Certain of the key functions envisaged for the management bodies in relation to these hospitals are very similar to those which have already been allocated to the Dublin Regional Hospital Board. Consideration of the management proposals must inevitably include an assessment of the future role of the regional hospital boards. This conclusion is reinforced by the clear evidence that, under the aegis of Comhairle na nOspidéal, there is a readiness and indeed an anxiety among the various hospital interests to come together and propose agreed solutions aimed at achieving the objectives allocated to the regional hospital boards.
This matter will undoubtedly demand a lot of careful thought, particularly if somewhat similar proposals emerge from the studies now being conducted in relation to Cork and Limerick areas. Before coming to any decisions on this difficult issue I would of course seek the views of various interests concerned. I have no doubt that the members of the health administrative bodies would agree that the valuable time they so generously give should be utilised efficiently. I want to be satisfied that the structures through which their advice and guidance is obtained at all times ensures this.
Deputies will already have received a copy of the reportThe Separation of Policy and Execution dealing with the restructuring of my Department. The report examined how the Department might be restructured in order to give effect to one of the key recommendations in the report of the Public Services Organisation Review Group, namely, the separation of policy making and policy execution.
The Department of Health were one of four Departments selected to test on an experimental basis the implementation of this concept. The proposed clearcut division of policy and execution in relation to my Department represented a logical development of the trend which had emerged over the years. The Department have concentrated on policy formulation and the executive functions have mainly been discharged by bodies under their aegis.
The recommendations in this report have been accepted by the Government and are being implemented in co-operation with the Department of the Public Service. Many of the procedures involved are technical and detailed in nature but I am confident that the streamlining of the organisation will improve its capacity to plan and organise the provision of a better health service. I want to make it clear to Deputies that this reorganisation in no way curtails the Minister's powers, duties or responsibilities. In fact the overall objective of the exercise is to better assist the Minister to discharge his functions and to identify clearly those areas of the services calling for special attention.
The Consultative Council on General Medical Practice have submitted their report containing a number of recommendations, the adoption of which would have far-reaching consequences. For this reason the Government decided that it should be published thereby enabling the various interests involved to consider the report in depth.
This report is concerned with the future of the family doctor. It makes recommendations on vocational training and continuing education to ensure that the general practitioner will be able to provide the highest possible standard of care for the community. There is considerable emphasis on community service and there are recommendations on the relationship between the general practitioner and those involved in nursing and social care, proposing that these should form part of a practice team. The council favoured more active steps towards the creation and support of group practices which would facilitate the practice team concept. These were the priority recommendations. One item of major significance is the recommendation that eligibility for hospital services and general medical services should be the same. This is tantamount to recommending a comprehensive national health service. The extension of services on this scale is not a project which could be immediately considered in view of the cost, which would now be in excess of £30 million. The report has been published and is being considered by the various interests concerned before decisions are made. It will also have to be considered in detail by my own and other Departments.
I spoke in the House yesterday about the Government's decision to postpone the extension of limited eligibility health services to the entire population. This decision was taken because it has not been possible to reach agreement with the medical organisations on the method by which consultants would be paid in future for work done for public patients.
I deeply regret, as I said yesterday, the postponement. I had hoped to introduce free maintenance at least in public wards from April 1st in the belief that the consultants had no grounds on which they could object to such a proposal. When they indicated that they would not co-operate in implementing even this part of the scheme I had no option but to postpone the scheme. I could not risk a situation where people might be denied hospital services or where hospital waiting lists might be allowed to build up to serious levels. I cannot use brinkmanship tactics when people's health or even lives may be involved.
I intend, as I said yesterday, to set up a review body in the immediate future to recommend to me the rate and method of payment for consultants in the future in the context of the free hospital service. I intend to discuss the constitution of this body with the medical organisations and expect that the members of the body will proceed with their work with maximum speed. It is still the Government's firm intention to bring in the proposed scheme and within the shortest possible time.
I should like to take this opportunity of replying to some of the points made by Deputy O'Malley yesterday. He implied in no uncertain terms that the extension of the free hospital scheme would only benefit the rich. Is he really serious when he says that those who will benefit can be described as rich? Is he serious when he says that people over £1,600 per annum income or farmers over £60 valuation are all rich and therefore undeserving of free hospital care?
In fact most of those who will become eligible for free hospital care are far from rich or even well-off. I expect that a minimum of 300,000 people are at present not entitled to the free service. These include such groups in our society as gardaí, school teachers, members of the Defence Forces, civil servants, medium-sized shop-keepers, bank officials, insurance officials, local authority employees, together with their dependants and yesterday I was reminded that journalists could be included as well. Many of those employed in jobs such as those I have mentioned are not now entitled to free hospital care, but they certainly cannot be described as rich. For example approximately 27,000 teachers, 14,000 civil servants, 10,000 local authority employees, 10,000 farmers and 7,000 gardaí are outside the present limits for eligibility. If one takes into consideration the fact that the majority of these are married the figure can be multiplied by three or four. Are these rich? I do not think they are. Yet, Deputy O'Malley has helped to exclude these people from free hospital care for a further period of time. I hope he can justify his position. I would not like to try.
I regret that Deputy O'Malley chose to misinterpret my remarks yesterday on the question of free post-primary education. In fact I was complimenting the late Donogh O'Malley. I believe he took the right decision in introducing free post-primary education for all children regardless of the income of their parents. I am doing the same thing now in relation to free hospital care and the point I was making yesterday was that if Deputy O'Malley was consistent he would also have opposed the free education scheme. I take it he does not refute the free education decision now. Logically therefore he cannot refute the hospital scheme either.
He says I should have devoted the additional expenditure involved to other aspects of our health services, notably the general medical service. I have increased overall health expenditure in the current year by approximately £34 million. Of this increase a large proportion was devoted to improving our general medical service. The number of persons covered by medical cards has increased from 890,000 in March, 1973, to about one million now. I think these figures indicate that I have not been unconcerned about the need to improve our general medical services during my term of office. I have spread this year's additional expenditure across a wide range of health services. I see no good reason why some additional expenditure should not be devoted to abolishing a means test for hospital care.
There are a few points incidental to the delay in the commencement of this scheme to which I should like to refer specifically. First, there is the matter of the health contribution of 15p per week which, from 1st April, will be payable by all insured workers, that is, all persons working under a contract of employment. As it has not been possible to arrange that all insured workers and their dependants can from that date use the hospital services, it would clearly be right and just to exempt those who will be excluded from the liability to pay the health contribution. I intend to arrange for this by making special exemption regulations in relation to the machinery for collecting health contributions. However it would not be practical—certainly within the time available—to arrange for different rates of stamps to be used by employers for those employees who will be excluded from health services' eligibility. Therefore what I propose to arrange is that the employer will be asked not to deduct the 15p health contribution from such an employee but to bear the cost of it himself temporarily.
I intend to arrange through the Department of Social Welfare for the refund to employers of any such contributions borne by them. If an employer has made arrangements— through a computerised system, for example—whereby deductions of contributions for all employees are scheduled from 1st April, I will ask that the employer should arrange to see that employees excluded from the hospital services will receive a refund of the health contribution and in this case also the employers will of course be able to obtain a refund of the amount of contributions from the Department of Social Welfare. I know that these arrangements will cause some inconvenience for employers. I regret that it is necessary to cause this inconvenience but I hope that it will be accepted as unavoidable in the circumstances which have faced me.
A further point of difficulty could relate to some persons covered by voluntary health insurance. In recent months the Voluntary Health Insurance Board have in good faith advised persons renewing their policies to reduce their cover for maintenance on the understanding that subsidies from the health boards would be available to meet at least part of the cost of maintenance for all persons from 1st April. In the case of any person who has thus reduced his cover and who may not therefore be fully insured from 1st April I have asked the board to make arrangements so that any such person can readily get supplementary cover if he wishes to have it. The board have agreed to do this and I appreciate their co-operation in the matter. They will be issuing appropriate announcements about it shortly.
Finally, on this issue, I should make it clear that the scheme whereby assistance is given in the purchase of drugs and medicines exceeding in cost £3 in any month will become available to all insured workers and their dependants, without any income limit, from 1st April next. This service does not of course in any way affect the conditions of employment of consultants.
In making these detailed arrangements I have endeavoured to see that as far as possible the deferment of this scheme for some time will not cause undue hardship or inconvenience or impose unfair charges on any group of insured workers or other persons. I hope that thesead hoc arrangements need not be retained very long. They add too much complexity to already complex rules about eligibility for health services and the conditions for availing of health services. The sooner that we can sweep away these complexities on the basis of the scheme without any means test that I propose. the better it will be both for the public and for those administering and working in the service.