I move:
That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the period commencing on the 1st day of April, 1974, and ending on the 31st day of December, 1974, 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 and miscellaneous grants, and for payment of a grant-in-aid.
The Estimates which were approved by the House this morning cover the period April to December 1974. The Vote requirement for the nine-month period totals £101,378,000, made up of an original Estimate of £96,746,000 and a Supplementary Estimate of £4,632,000.
In addition, the Minister for Finance will shortly be seeking a Special Vote for Remuneration, which will include a provision for £4,349,000 to meet pay increases under our national pay agreements, for personnel employed in the health services.
The total Department of Health voted requirements for the period April to December 1974 therefore, including the Special Vote for Remuneration, amounts to £105,727,000.
In order to compare my Department's Vote for 1974 with the voted moneys for the year 1973-74, it is, of course, necessary to translate the nine-month figure for this year into a notional 12-months' amount. The Vote requirements for 1974 on a notional 12-months' basis amount to £141,000,000. This figure represents an increase of £40.5 million over 1973-74 or an increase of some 40 per cent in the Health Vote between this year and last. This is a very significant increase indeed and demonstrates once again this Government's commitment to improving our health services as quickly as our resources allow.
It will be useful to Deputies, I think, if I break this 12-month increase of £40.5 million down into its basic elements. In this way it will be possible to isolate the real improvements, exclusive of inflation, which have taken place in our health services during the past nine months.
Of the £40.5 million, £20 million will be devoted to pay and price increases, a further indication of the impact of inflation on health expenditure. The additional cost in a full year of the substantial increases in rates of allowances provided for in the 1973-74 budget, including the new constant care allowance, and the increases in rates of allowances provided for in this year's budget is estimated at £2.5 million. A further £9 million is attributable to relief of rates, arising from the Government's decision to transfer all health charges to the Exchequer. The remainder, £9 million, is related to expenditure on real improvements in the range and standard of services provided for in the Health Vote.
I should like to emphasise this last figure. On a national 12-month basis, some £9 million was spent this year on real improvements to our health services after account is taken of inflation, rates relief and increased allowances. This represents a real increase of approximately 7 per cent in voted expenditure over 1973-74, a remarkable achievement by any standards.
In March last, I told the House that there had been an 8 per cent real improvement in expenditure on our health services in 1973-74. I can now tell the House that we have achieved the almost same real rate of increase this year with a figure of 7 per cent.
The £9 million which this Government spent this year on improving our health services in real terms was well spent and was widely spread across our health services. The figures can be broken down as follows:
£4.5 million will be spent on improving our general and psychiatric hospitals, including the provision of new units and improving both services and staffing within them.
£1.5 million will be spent on the provision of extra places in homes for the mentally handicapped and the aged.
£1.3 million represents increased real expenditure on our general medical services.
£1.7 million is being spent on improving community care services, especially the home help, child health and social work services.
This then has been the scale of this Government's achievement in the health field in the current year. On a 12-month basis, we have increased voted expenditure by some 40 per cent over the figure for last year and have managed, in a period of serious inflation, to increase voted expenditure on real improvements by £9 million or by approximately 7 per cent in real terms.
As I have said, total voted expenditure on our health services will amount to £105,727,000 for the period April to December, 1974. This figure does not tell the whole story however. Total public expenditure for the nine-month period is estimated at £125,047,000.
The difference of £19,320,000 between the two figures is made up as follows: contributions from rates, £13,200,000; health contributions, £4,200,000; payments under EEC regulations, £1,300,000; other sources (including miscellaneous grants from the Hospitals Trust Fund), £620,000.
On a notional 12-month period, total public expenditure on our health services would amount to approximately £166,000,000 in the current year. This compares with a figure for 1972-73, the year before this Government took office, of £105 million. In the two years since the Government took office, therefore, total public health expenditure has risen by approximately 58 per cent.
In the same period public expenditure on our health services has risen in real terms by a remarkable 15 per cent at a time when real gross national product has risen by 7 per cent at constant prices. This transfer of resources towards our health services has not happened accidently. It has happened because the Government believe that the development of our health and social services is a priority. Concrete expression of that belief has been demonstrated clearly in our last two budgets and must be now well beyond dispute.
The Supplementary Estimate passed by the House is for an amount of £4,632,000. The need for this Estimate has arisen from the following factors:
A net sum of £2,532,000 is required to meet the extra costs which have arisen during the year due to price increases.
A sum of £800,000 is required to provide for increases in the rates of various allowances announced in this year's budget.
A sum of £200,000 is required to pay for arbitration awards made to clerical officers employed by health boards.
Increases in the rates of social welfare contributions and in superannuation allowances are estimated to cost £600,000.
In addition, there is need to provide for a deficiency of £500,000 in Appropriation-in-Aid estimates. The short-fall is due mainly to a reduction in anticipated revenue resulting from my decision to defer the extension of limited eligibility services to the entire population.
I think the House will agree that increases in expenditure to improve services during this year have been exceptional. I have outlined the increases and the rate of increases in some detail.
What is important, however, is the use to which additional expenditure is put. I think I can best demonstrate the progress being made in this regard by discussing the policies I am pursuing under the main programme headings I have instituted in my Department.
Expenditure on our general hospitals for 1974, on a 12-month basis, amounts to £73 million. This figure represents 44 per cent of total expenditure on our health services and constitutes by far the largest single element in terms of cost in our national health programme.
General hospital care is costly both in terms of capital and current expenditure. My objective, as Minister for Health, must be to set about the long-term reduction in the percentage of total expenditure devoted to hospital services. This does not, of course, imply a reduction in hospital standards. Rather I would hope to see the opposite, an overall improvement in hospital services.
My objective is to develop a national network of efficient, first-class general hospitals, backed up by a highly developed community-based, health and welfare system. As the latter develops, it should be possible to reduce the percentage of the population requiring hospital care because of the existence and operation of an efficient primary medical care system in our communities.
This approach makes sound economic sense. It also makes sound medical and social policy sense. If we can improve our preventive health services, we will have contributed more to the general health standards of the community, than we could ever do by continuing to rely excessively on hospital services. We must create a proper balance between the two. This implies in the long run a reduction of the proportion of health expenditure devoted to hospital services and an increased proportion devoted to community care or primary health services.
During the current year I have concentrated, within our general hospital programme, on continuing to improve our existing services, while at the same time, continuing my work on the development of a general hospital plan for the future.
As far as on-going improvements are concerned, it would, I think, be useful if I list some of the main developments which have taken place under this heading in the current year.
In Cork, work is continuing on the new 600-bed regional hospital which is scheduled for completion in 1978. In addition, a new operating theatre is being provided at the Eye, Ear and Throat Hospital and a 26-bed gynaecology unit is being provided at Erinville Hospital. At St. Finbarr's Hospital, an extension to the X-ray Department has been completed and work is in progress on further improvements there.
In Dublin, a new 40-bed unit was completed at Peamount to replace St. Bridget's Pavilion. Accommodation for eight additional patients was provided at the National Medical Rehabilitation Centre and work commenced on an extension to the canteen and a new aid-to-daily-living unit at the same hospital.
Extensions to the child guidance clinic and the pathology laboratory commenced at the Mater Hospital and adaptations to provide a cardio-vascular unit are also in progress there. At Jervis Street Hospital, work has commenced on a detoxification unit as an addition to its existing facilities for the treatment of drug abusers. Improvements to the accident department at that hospital are also in hand.
A major scheme of improvements, including neuro-surgical facilities, X-ray and out-patient accommodation is nearing completion at St. Laurence's Hospital. At Linden Convalescent Home work is proceeding on the replacement of the old main block and the provision of improved dining and kitchen facilities. Additional out-patient facilities and staff dining accommodation are being provided at the Meath Hospital. Finally, in Dublin, work is in progress on a major scheme at St. James's Hospital, comprising a central X-ray Department, a child guidance clinic and the up-grading of the mechanical and electrical services there.
In Carlow, a new maternity hospital has been completed. At Ardkeen Hospital, Waterford, a new paediatric unit has been completed and work is in progress on a new ophthalmic unit. In Tullamore, an extension to the X-ray Department at the county hospital has been completed.
At Castlebar County Hospital, a new pathology laboratory has been completed and work is in progress on a new casualty department and stores. A new pathology laboratory has also been completed at Tralee County Hospital, while at Galway Regional Hospital work is in progress on an intensive care unit and an extension to the X-ray department. In Wexford, work is continuing on a new maternity unit and on a geriatric unit.
These are some of the main on-going developments which are taking place within the context of our existing general hospital services. A full and complete list has been circulated to Deputies in the statistical document which I arranged to have circulated. Before I leave this section of my statement, I would like to comment briefly on some developments which are taking place in the provision of suitable accommodation for the aged.
A new 100-bed unit for the chronic sick has been completed at St. Ita's Hospital, Newcastlewest, and a 30-bed geriatric unit has been completed at Baltinglass District Hospital. Major improvement schemes are in progress at St. Vincent's Hospital, Athy and at St. Colman's Hospital, Rathdrum. In addition, the number of homes for the aged now available for aged social cases has risen to 16, with the completion of homes at Donnybrook, Bray, Manorhamilton, Claremorris, Westport, Nenagh, Roscrea, Newcastlewest, Dungarvan, Waterford and Birr. Work is already in progress on further homes at various centres, including Ballymun, Clonskea, Drogheda, Mohill, Galway city, Fermoy, Youghal and Belmullet.
The overall picture, therefore, is one of significant improvements to our existing hospital services and institutional services for the aged. I am deeply aware, however, that as far as our general hospital system is concerned, more than on-going improvements are required in the longrun. If the structure of our acute hospital system were basically sound, then all that would be required of me would be to identify and meet needs which would arise from time to time in the normal way.
It has been recognised for many years, however, that a restructuring of our hospital system is required if a high quality hospital service is to be provided for the future. It is recognised that a hospital system which met the needs of the past will not necessarily meet the needs of the future, because of the changing pattern of medicine and hospital care.
I have been considering for some time now the kind of general hospital system which this country requires in the future. My objective is to find a solution which combines the provision of high-quality hospital care with reasonable accessibility for the people for whom the hospital system is designed.
This is an extremely difficult task. If one looks at the problem from the point of view of sound medical planning, the tendency would be to concentrate hospital resources in a limited number of large centres. This was the general approach of the Fitzgerald Committee in its report in 1968. The objection to this kind of approach is that it underemphasises the importance of easy access to a hospital for a patient who needs urgent care and for his relations who must visit him. This approach also underemphasises the socio-economic importance of a general hospital in many parts of the country.
On the other hand, it is obviously impractical to suggest that each town in the country should have a general hospital. This would solve the accessibility problem, but it would create inconceivable economic demands on our resources, while at the same time, preventing the provision of high quality care in the hospitals provided.
A middle-ground solution must, therefore, be found. I am not prepared to rush my decisions in this matter. I have said before that I have a grave responsibility to weigh up competing advice carefully and without imprudent haste. Decisions taken today about our future hospital system cannot be reversed later without enormous wastage of resources, so that careful consideration of all the issues involved is an obligation on me and on the Government. Having said that, I believe that significant progress has been made towards reaching decisions on this question in the 20 months since this Government took office.
When I spoke last March on the 1973-74 Estimate for my Department, I outlined in detail the wide-ranging consultations which I had initiated throughout the country on this question. I have consulted the health administrative bodies, and, in some cases, individual hospital authorities. They have responded to a guideline document prepared by Comhairle na nOspidéal at my request and have offered me their views. For some parts of the country, the views I received about future hospital development were unanimous. For other areas, there is disagreement on a strategy between the bodies consulted.
As far as the Dublin area is concerned there was unanimity on the basic structure recommended by An Chomhairle. This provides for six major general hospitals in Dublin, including two new ones at Beaumont and in the Newlands Cross area. Because of the degree of unanimity and because of the urgency of providing a new general hospital structure in Dublin, the Government announced a decision for this area in October last.
The decision announced by the Government provides for the locations of major general hospitals in Dublin for the future. The plan will involve a very considerable capital investment in new buildings to replace many of the old hospital buildings which have served the city for, in some cases, hundreds of years. I am pressing ahead with the planning process for these hospitals as quickly as possible. We have, therefore, found a solution for the Dublin area and this constitutes a considerable achievement within a period of 20 months. As far as the rest of the country is concerned, I am still engaged in the consultation process which I have described. I am anxious to hear the views of as many interests as possible before reaching final decisions. The termination of development programmes for Cork and Limerick cities poses special problems. Here we are faced with rationalisation problems within city areas, problems similar, if on a smaller scale, to those solved in Dublin. My approach to finding solutions for these areas is similar to that which proved successful in Dublin. With my agreement, Comhairle na nOspidéal set up a special sub-committee for each of these cities to examine the situation and make recommendations as to the most suitable strategy for hospital development.
I have sent copies of the report of the Comhairle on Cork to the different interested parties and have asked them for their views on it. The committee on Limerick did not agree on a report, but I have the result of their consideration. I will seek the views of local interests on this also. When these consultation processes have been completed, I will ask the cabinet sub-committee on hospital development to consider suitable proposals for these areas.
As far as the remainder of the country is concerned, I am at present meeting representatives of those areas which are in dispute as far as hospital services are concerned. Having already consulted the health administrative bodies, it is right that I should now consult with those who disagree with majority recommendations for their areas.
Meeting minority areas groups in this manner may seem unusual, but it must be remembered that the decisions which the Government will take on this matter are of the first order of magnitude. As I said before, I feel it my duty to consult as widely as possible, so that every available piece of advice is given to the Government when they come to make their decisions.
I intend to continue these consultations in the weeks ahead. This Government will take the necessary decisions where previous Governments failed. But we will not be rushed or forced into quick decisions without weighing carefully all the arguments put forward. We owe that much to those who will work and be patients in our hospitals for many years to come.
The community care programme, as I have defined it, encompasses two broad areas of policy, services in each case being provided in the community as opposed to within an institutional setting.
The first area provides for primary medical and para-medical services, that is, services provided by general practitioners, public health nurses, dentists, ophthalmologists and so on. The second broad group of services coming within the community care programme can be described in general terms as personal social services and community welfare services. These would include services provided by social workers, home helps, meals-on-wheels organisers, and staff in day-care nurseries.
The total cost of the community care programme this year, on a notional 12-months' basis, is approximately £36 million or 21.7 per cent of total public expenditure on our health services. The proportion of total expenditure under this heading should rise in future years as greater emphasis is placed on the provision of community health and welfare services. This is certainly my intention at this time.
I would like to comment first on those services of a primary medical or para-medical nature which health boards provide within their community care programmes.
The general medical services scheme constitutes by far the largest single cost element in the programme nationally. The cost of this scheme is now in the region of £13 million annually. Some 1,143 doctors and 1,210 pharmacists participate in the scheme, which provides a free service to about 34 per cent of the population.
As Deputies will recall, the general medical scheme, which replaced the old dispensary medical services, came into operation in the area of the Eastern Health Board on 1st April, 1972, and came into operation in the rest of the country on 1st October, 1972. Provision was made, in the negotiations prior to the introduction of the scheme, for its operation to be reviewed and, in particular for the scale of fees which had been provisionally agreed on, to be reviewed one year after the full implementation of the scheme and not later than two years after its initial introduction, i.e., between 1st October, 1973, and 1st April, 1974. It was agreed that, during the course of the review, the medical organisations and the Department would have at their disposal returns prepared by the central pricing bureau indicating the patterns of visiting and patterns and details of payments during the first full year of operation of the scheme.
The detailed information regarding the first full year of the operation of the scheme, including information on the payments made to doctors and pharmacists, the total expenditure on drugs and medicines, the visiting and prescribing rates which had emerged during the first year of the scheme's operation and other data was made available to the medical organisations prior to the inception of the review. It was agreed, at the request of the medical organisations, that the review should not be confined solely to an examination of the fees and fee schedule, but should be a wide-ranging review of the operation of the scheme.
The review of the scheme began at the end of March and has been continued at regular meetings which have taken place since that date. The medical organisations put forward about 25 items which they wished to have discussed and my Department, for their part, suggested nine items which they felt should be discussed during the review of the scheme. Of the items put forward, those which ultimately emerged as the most difficult and time consuming were the question of the appropriate level of fees under the scheme and the right of entry of general practitioners to the revised scheme.
Between mid-May and mid-July discussion took place, and written submissions were made by the medical organisations seeking a substantial increase in the fees which had been fixed at the inception of the scheme. The medical organisations sought an increase in the basis fee for a surgery service from 80p to £2, an increase of 150 per cent, with similar increases in the other fees which operate in the service. This claim was examined, and discussed in detail, and I concluded that it was not one which I could entertain nor one in relation to which I could make an offer of increased fees. I told the medical organisations this on 6th August and, in accordance with the procedure which had been agreed on prior to the introduction of the scheme, the medical organisations referred the matter to arbitration on 9th September.
The report of the arbitrator has been received within the past few days and he has recommended that the basic surgery fee of 80p should be increased to 90p, an increase of 12½ per cent and that other fees should be increased by a higher percentage than the increase in the basic fee, the highest recommended increase being 34 per cent. The arbitrator's recommendation has been transmitted to the medical organisations and I am currently awaiting their reaction to it.
So far as I am concerned, I welcome the fact that we have now before us, for the first time, an independent assessment of the appropriate level of fees under the scheme. The cost for a full year of the award is about £734,000 and in 1975, the total commitment, including arrears, would be of the order of £1,600,000, assuming the arrears to October, 1973, were payable in that year.
The other item to which much time has been devoted during the course of the negotiations was the question of the right of entry of general medical practitioners to the service. When the scheme was introduced provision was made for the entry to it of former dispensary doctors and of those doctors who were in practice prior to a specified date. After the scheme began, entry to it was on the basis of competition for vacancies which arose, in different areas, from time to time.
The medical organisations represented most strongly that all practitioners, who had certain minimum qualifications and experience, should have the right to provide services under the scheme for medical card holders. It was, and continues to be, my view that entry to the scheme should, to the greatest extent possible, be on the basis of open competition.
Within recent weeks there has been continuing discussion on proposals which I put forward to end the impasse which had been arrived at, and on other proposals to this end which had been put forward by the Irish Medical Association. I have now sent to the medical organisations proposals which would allow doctors in practice for two years prior to 1st October, 1974, to enter the service without competition. These proposals would also facilitate the creation of partnerships and group practices and would, exceptionally, admit in the future to the service doctors who had been established for seven years in private practice.
I hope this will result in the resolution of this very difficult question in a manner which will be acceptable to me and to the medical profession. At a recent meeting agreement was reached on action which could be taken in relation to a number of proposals made by the medical organisations and this is now in train. There are a considerable number of items yet to be discussed and I hope that these discussions can be brought to a speedy conclusion. Certainly, I am anxious to do all that is possible to ensure that such matters as are outstanding in relation to the general medical service are resolved effectively and speedily.
I recently announced that I intend to extend the list of long-term illnesses for which drugs, medicines and appliances will be available free of charge to persons irrespective of income. I intend to add Parkinsonism, acute leukemia, muscular dystrophies and multiple sclerosis to the existing list and the extended list will become operative no later than 1st April next. The estimated cost of extending the list is £200,000 in a full year.
Apart from those which I am adding to the existing list, I am aware that there are other long-term illnesses which can impose serious financial strains on individuals and their families. Unfortunately, it was not possible to include them all, but I will certainly keep the list under review in the future.
I would remind the House, however, that the drug recoupment scheme is available to all persons in the limited eligibility group. Under this scheme, an individual would not have to spend more than £4 on drugs or medicines in respect of any particular month.
Revised child health services were introduced towards the end of 1970 following on the report of the Study Group on the Child Health Services.
The study group had recommended in particular that provision should be made for: scheduled medical examinations of all children at the ages of six, 12 and 24 months; comprehensive medical examinations of all national school children between sixth and seventh birthdays, that is, after the lapse of a suitable length of time from the child's commencement at school; selective medical examinations of national school children at about nine years of age and that each school should be visited by a medical officer at least once a year.
In the period which has elapsed since the introduction of the revised services, the available medical resources have been concentrated on the provision of the six months examination and the comprehensive medical examination for new entrants to national schools. Shortage of staff, and concentration on these two priority examinations have meant that the introduction of the 12 and 24 months developmental examinations and of the selective examinations of schoolchildren have proceeded much more slowly.
In the period from 1st January, 1971, to 31st December, 1973, 70 per cent of eligible children in urban areas were given the six months examination. This rate of response is, on the whole, very satisfactory and staffs of health boards have tried to ensure that it is maintained at as high a level as possible.
The merits of the six months examination are twofold. Defects are discovered at an early age, and appropriate action or surveillance can be undertaken. If no defects are discovered there is the benefit to parents, which cannot be measured, of the assurance which can be given to them that their child is developing in a normal way.
The comprehensive medical examination of the new entrant to school is a much more time consuming exercise than the old routine medical examination. In 1971, 1972 and 1973 over 40 per cent of national schools were visited and in each of these years over 130,000 children were medically examined. The limited medical resources available, and the concentration on the two examinations I have just mentioned, have meant that we have not yet attained our limited objective of visiting at least all the bigger schools—those with over 200 pupils—annually.
A departmental examination is now being made of the recommendations made by the study group in the light of the experience gained since the revised child health services were introduced. It has emerged that the age of six months for the first examination may have been set too low and seven or eight months of age may be more suitable. A number of medical officers are now undertaking the initial examination at this age.
It is now clear also that additional resources of medical personnel would be necessary if the scheduled examination service were to be made available for all children. Among the other matters being examined, therefore, are the utility of the 12 months and 24 months' examinations in the ascertainment of defects and the appropriate extent of the involvement of the public health nurse in the further screening of children of national school age.
For a number of years past there has been a continuous increase in the number of wholetime dental surgeons employed in the public dental service, the operation of which depends mainly on these full-time officers. During the past year this increase has been maintained and the total number of dental officers now employed by health boards has risen to 167, about a 50 per cent increase over the number employed five years ago. The removal of the marriage bar on women in the Public Service, has resulted in an increase in the number of married women dentists who have been successful in the competitions held by the Local Appointments Commissioners for permanent appointments to that service.
During the year under review most health boards made special provision for the improvement of their existing dental clinics or for replacement of dental equipment where this was necessary. This should lead to a better quality of service being provided in the clinics for the children who form the majority of those currently receiving treatment under the service. The policy of expanding the wholetime dental staffs of health boards and of improving facilities at clinics will be continued as resources permit.
Prevention of dental decay is preferable to treatment and there is a growing realisation that much can be done to prevent or lessen the onset of dental disease by giving more attention to oral hygiene. The Department have available for issue to interested bodies and persons a leaflet and series of posters illustrating in simple fashion the techniques for personal care of teeth. The leaflet and posters and also the two short films on dental health recently shown on RTE television were made for the Department in consultation with the health education committee of the Irish Dental Association. Much credit is due to the committee for their excellent promotional work in the field of dental health education. In the current year the Department are matching up to a limit of £15,000 in value, in services or in finance, the amounts which the committee raise from voluntary sources for their dental health campaign.
I know that there are shortcomings in the dental services at present available to eligible persons. While we have been effecting gradual improvements in the services, we have not been in a position to devote to them the very big sums which would be required to make them fully satisfactory. The extent to which further improvements can be made, as resources permit, is under review and in this review we will be consulting with the Irish Dental Association, which has put forward views on the appropriate methods of developing the services.
As far as the personal social services and community welfare elements of our community care programme are concerned, I can inform the House that considerable developments have taken place in the current year. In dealing with last year's Estimate I referred briefly to the difficulties which health boards were having in attracting social workers with post-graduate training to their employment. We have attempted to overcome this problem by organising a sponsorship scheme for post-graduate social work students.
In the academic year beginning in October, 1973, 12 post-graduate students were sponsored by health boards, while in the current year this figure has been increased to 33. In addition, the National Social Service Council has this year sponsored five students.
In a further attempt to increase the number of trained social workers employed by health boards, I have suggested that they should employ trainee social workers with basic qualifications, in anticipation of sponsorship for professional training in 1975. Ten such trainees have been employed this year.
Apart from professional training, 16 social workers were released for refresher courses in universities this year. More such courses are planned for future years. Overall, I am confident that these and other arrangements will lead to a significant improvement in our social work services in a relatively short time.
The home help service, instituted in 1972 with a budget of £150,000, has developed rapidly since the Government took office. This scheme enables health boards to provide domiciliary services for families in stress situations and for the aged, especially those living alone. The primary objective of the scheme is to assist and encourage persons who can remain in their own homes to do so rather than seek institutional care.
I have expanded this scheme as quickly as possible since I became Minister for Health. In the financial year to March last, the latest period for which figures are available, expenditure amounted to £344,000. Of this amount, £203,000 was spent directly by health boards, while £141,000 was granted in subsidies to voluntary agencies involved in the service. In the same year, 56 whole-time, and some 3,000 part-time home helps, were employed by health boards and voluntary agencies, in addition to 23 home help organisers. Some 3,000 old people benefited from the scheme, together with 452 other individuals and 303 families.
It is my intention to help this vital service to expand still further in the future. I will, in particular, encourage the employment of more home help organisers and the provision of further training courses for home helps generally. I cannot attempt to list all the improvements which have taken place under the community care programme in the current year. I would however like to mention two further decisions taken by the Government which have great significance for the future.
The first is the decision, announced in October, to provide Government support for the establishment of a national network of community information centres. This decision was taken in response to the obvious difficulties which individuals in our society face in discovering their entitlements to services and benefits provided by the State.
While it is obviously necessary for each government department to inform people of their entitlements as clearly and accurately as possible, it is also true that specific provision should be made at community level to ensure the widest possible dissemination of information. This task can best be performed, in my opinion, by local representative groups, backed-up and supported by a national agency. The job of the national agency will be to encourage the setting up of information centres, to set standards for registration and to provide information, training and financial support to the local staffs.
I am very pleased indeed that the National Social Service Council has agreed to perform this task. The council will work through its own staffs, with the advice and guidance of a committee representative of Government Departments, of key voluntary and community interests and of nominated members of the council itself.
As well as the functions I have mentioned, the council will be given reserve power to establish information centres directly in areas where it is felt desirable to do so, but where local initiative is not forthcoming. Financial support for the establishment of the centres will be provided through the council from the Health Vote.
In October last also, the Government decided that I, as Minister for Health, should have the main responsibility for children's services in the future. My immediate task now is to prepare a new Children's Bill, to prepare proposals for improving the range of services available to deprived children and children at risk, and to suggest the administrative changes which are desirable to give effect to these proposals.
To assist me in this task, I have appointed a full-time task force of experts in the field of children's services. The task force has commenced its work and I hope to have its recommendations within a matter of months.
The Government's decision to concentrate responsibility in one Minister has been widely acclaimed. It will help to overcome the present fragmented nature of their children's services and enable integrated planning to take place. I believe it will inaugurate a new era for our deprived children, although I recognise clearly that we have still a long way to go before a modern and humane children's service is created. A sound beginning has now been made.
I have, up to now, been dealing with a range of individual services within our community care programme. I could have mentioned others in my comments. What is really important however is not only the individual services but how these complement each other in practice.
The community care programme, as I envisage it for the future, is more than simply the sum of individual services. It must be an integrated programme capable of seeing to the total health and welfare needs of individuals and families in their communities.
This implies that there must be close integration of service provision and close co-operation between the personnel engaged in the delivery of services. My objective in this regard is to create a team approach at community level. Each community care area should have its own multi-disciplinary team capable of responding over the range of health and welfare needs which exist in all communities.
During the current year a good deal of progress has been made towards this objective. Community care teams have begun to operate on an ad hoc basis in a number of areas and reports from these areas are encouraging. I hope that the new system will come into operation formally next year. It is envisaged that the director of each community care team will be a medical doctor and that the team itself will comprise doctors, public health nurses, dentists, social workers, home helps and home assistance officers, among others.
Discussions have taken place with interested groups about how voluntary organisations can fit into this scheme and I am greatly encouraged by the outcome of these discussions. I intend to circulate a discussion document on the role and organisation of community care in the near future with particular reference to the role of voluntary organisations.
If we can get the community team idea off the ground next year we will have taken the initial and major step towards creating a modern primary health and welfare system in this country. No matter how good individual services are, they can be no substitute for a comprehensive, integrated service which can respond to the total needs of a community in an organised way.
The third major programme area for which I am responsible is concerned with the provision of services for the mentally ill, the mentally handicapped and the physically disabled. This programme will cost approximately £46 million in the current year or 27.7 per cent of total expenditure.
I believe that it is widely recognised that services for these groups in our society have not developed as rapidly as they might down the years. They came off second best far too often when it came to deciding policy in the health field with the result that services for these people have fallen behind when compared to other health services.
During this decade we must attempt to put this relative neglect right. The mentally ill and the mentally or physically handicapped have as much right to top class services as the rest of the community.
When I looked at this problem first, shortly after taking up office, I decided that immediate priority should be given to improving training and employment opportunities for the handicapped. I set up a working party of experts to help me prepare a policy in this area and they have now reported to me.
In an interim report, which the working party sent me last June, they made recommendations on the training of trainers and supervisors who deal with the handicapped. I immediately accepted their recommendations and arranged with AnCO to start an initial course for trainers already engaged in work with the handicapped. This course commenced on Monday last, 25th November, and will be of four weeks' duration. It will be followed by further courses.
The provision of skilled trainers is only one aspect of a comprehensive policy towards training the handicapped. I am now considering the other recommendations of the working party, which cover a much broader field.
My general objective is to devise a streamlined system of training opportunities with employment in the open market or in special employment facilities as the end result for as many as possible of our handicapped people. Achieving this objective will take time and it will be costly. Nevertheless I am convinced that the long-run benefits to the economy and to the individuals themselves will far outweigh any costs involved.
In trying to achieve our objective I look forward to continuing assistance from the EEC's Social Fund. In the current year training centres in this country will benefit by some £400,000 from that source. This money is welcome since it will ease the cost burden on the national Exchequer. I hope that as we in this country improve our training facilities for the handicapped EEC aid will increase commensurably.
I decided to concentrate initially on the question of training and employment opportunities since this area of policy offered the best scope for rapid development. It also has the great social benefit of helping to make as many as possible of our handicapped people self-reliant and no longer dependent on welfare benefits. The provision of a welfare allowance is no answer to the needs of a handicapped person who is capable of working. What that person needs is training and employment opportunities if he is to achieve his full potential.
Having almost completed policy development in this field I am at present preparing a White Paper on services for the mentally ill and the mentally handicapped over a wider policy range. The White Paper will outline proposals to deal with some of the major defects in our present system.
It will deal with such questions as the proper relationship or balance between institutional and community care, the failure to adequately stream patients suffering from mental illness or mental handicap so that each patient is provided with the kind of treatment and care appropriate to his particular illness or handicap, the improvement of the child psychiatric services, and the administration of services for the mentally ill and the mentally handicapped.
In general terms I believe that as far as the mentally ill are concerned we need to provide a greater emphasis in expenditure on non-institutional treatment and, more especially, on preventive activity. I have begun a review within my Department to see how these objectives can be achieved.
My priorities for the mentally handicapped, apart from the training and employment question which I mentioned earlier, include streamlining the system of administration and planning the services in question. This will involve setting up an administration system which provides for far greater co-operation between health boards and voluntary bodies. Health boards have the statutory responsibility to ensure that health services, including mental handicap services, are available to those entitled to them. For historical reasons the extent to which they have been involved in the provision of these services has been minimal.
This will obviously have to change. Voluntary agencies cannot bear the burden alone and they themselves are the first to recognise this. What is required is close co-operation between the statutory and voluntary agencies so that integrated planning can take place. I hope to initiate discussions on this issue shortly.
A cursory glance at our services for mentally handicapped people reveals a further glaring defect in our present arrangements. At present it is estimated that 2,600 mentally handicapped persons are accommodated in our psychiatric hospitals.
This type of accommodation is unsuited to their needs. In order to provide the right type of accommodation the building programme for the adult mentally handicapped will have to be extended. This is also necessary to reduce the adult population in residential accommodation designed for children. I hope to extend this building programme as quickly as our resources allow.
In speaking to the House on services for the mentally ill and the handicapped I have avoided detailing the specific improvements which have taken place during the current year. These important details are provided in a separate statistical document which I have circulated separately.
What I have tried to do today is to indicate some of the major defects in our present arrangements and to indicate how I propose to deal with them. The White Paper will deal with these and other proposals more extensively.
I hope I have conveyed to the House my concern to see substantial improvements in our services for the handicapped and the mentally ill. As I said earlier, these groups in our society have suffered relative neglect in the past and we today have an obligation to redress the balance. This process has begun with the report of the working party on training and employment for the handicapped. It will continue with the publication of my White Paper. Each document will be backed up with concrete action during the life-time of this Government.
I have dealt in some detail with the progress which has occurred during the current year under the three main programme headings for which I have responsibility as Minister for Health. I would like to comment now on a number of other developments which have taken place during the same period.
I recently announced my decision to set up a working party on nursing. I did so after agreeing with the Irish Nurses Organisation, the Irish Matrons' Association and An Bord Altranais, that a fundamental review of general nursing is called for. This will be the first such review since the foundation of the State and I am very pleased indeed that it will commence shortly.
I have been awaiting nominations to the working party until recently. I expect that about 20 persons will be nominated, about half of whom will be nurses. I am confident that it will make very valuable recommendations not alone for the improvement of nursing services but also to enable the nursing professions to meet the challenge of rapidly increasing changes in techniques and practices.
The budget for health education and publicity in my Department in the current year amounts to £100,000 for the nine-month period.
The main emphasis in our health education programme this year was on the twin problems of alcoholism and excessive drinking and on our anti-smoking campaign.
Excessive spending on alcohol has caused me great concern and I am particularly concerned with the emergence of a serious drinking problem among young people. In various seminars and lectures to parents, teachers and other groups organised by my Department the necessity of developing correct and mature attitudes to drinking has been emphasised. Our current advertising campaign stresses that there are many alternatives to excessive drinking and I hope that this message is getting across, especially to young people.
Our health education programme covers a wide range of preventive health issues at present and is pursued with a wide range of techniques. Leaflets are widely distributed, seminars and lectures are organised throughout the country and an extensive media campaign is undertaken. All of these are having an impact, and must be continued vigorously.
Nonetheless I have felt for some time that we need a central institution to co-ordinate and develop health education nationally. We need to create a coherent health education programme which combines the resources available to statutory and voluntary agencies.
I was very pleased therefore to accept the main recommendation of the Committee on Drug Education that such a body should be set up. With the agreement of the Government, I have decided to establish a health education bureau and I am now in the process of appointing members. I also propose to appoint a broadly-based advisory committee, which will be representative of all the bodies engaged in various aspects of health education.
The bureau will be responsible for formulating integrated health education programmes in accordance with agreed national priorities. It will also be responsible for carrying out those programmes in co-operation with the statutory and voluntary bodies already engaged in this vital area.
I have every reason to believe that the bureau, with the help and advice of the advisory committee, will successfully tackle the important tasks it has been given. Demand for health services invariably outstrips the resources available at any one time. We need therefore to concentrate the greatest possible efforts on preventive measures. Health education is one of the best such measures.
I am very pleased to inform the House that Mr. Bunny Carr, who was chairman of the Committee on Drug Education, has agreed to act as chairman of the bureau. I would like to place on record my thanks to him for accepting this onorous task.
Deputies will recall my statement in the House on 27th March last, when I indicated that the Government's proposal to extend "limited eligibility" health services to the entire population would have to be deferred. I outlined in considerable detail then the reasons why I felt that there was no option but to postpone the scheme for a period in order to avoid any danger to human life and to avoid confrontation with the medical profession.
I announced on that occasion that, in an effort to resolve the impasse which had arisen, I proposed to set up an independent review body to make recommendations on the system or systems of payment which should operate when the income limits from health services were abolished. It was my belief that the findings of this independent body would make a substantial contribution towards achieving a settlement which would allow the full implementation of the Government's scheme.
The medical consultants again declared their opposition to what I am sure all Deputies would consider to be a very reasonable proposal. The medical consultants and I had failed to agree on the appropriate method of remuneration. Therefore I proposed the establishment of a completely independent body simply to make recommendations on what they considered the most appropriate method.
In May there were a number of further meetings between the consultants and officers of my Department and I myself met them on 23rd of May. At that meeting the consultants again indicated that they wished direct negotiations to continue and were opposed to the establishment of the review body. I appealed to them to co-operate and repeated my appeal in writing on 28th May. In separate letters from the IMA and Medical Union on 17th and 26th June respectively it was indicated that the organised profession would not participate in the activities of the proposed review body.
On 11th July I established the review body with the following terms of reference:
To examine and report on the systems and rates of payment and conditions of employment of consultants in hospitals engaged in the provision of services under the Health Act, 1970, which would be appropriate in the context of the abolition of income and valuation limits for limited eligibility.
The review body have invited submission from persons or organisations wishing to make them. I have made my submission. I look forward to receiving the recommendations of the body as soon as possible and I am confident that they will make a substantial contribution towards resolving a very complex and difficult matter.
Finally, before leaving this subject, I wish to pay tribute to the unselfishness and public spiritness of the members of the review body in agreeing to accept such a difficult and timeconsuming assignment. I would also like to repeat my determination and that of the Government to ensure that there is full implementation of the free hospital scheme with a minimum of delay. I expect to resume discussions with the medical profession as soon as the review body's recommendations are available.
The year 1974 has been an exceptionally good year as far as the development of our health services is concerned. I have already indicated that expenditure increased by some 7 per cent in real terms during the period, enabling substantial improvements to take place over a wide range of individual services. In addition a great deal of forward-planning has been undertaken, particularly in relation to the general hospitals programme, the development of community care teams and the provision of services for the handicapped and mentally ill. The long-term planning exercise which I have undertaken in these and other areas will chart the way forward towards major developments in the future.
I must state at this point however that it will not be possible for me, as Minister for Health, to maintain the same rate of expansion in our health services in 1975 as I was able to achieve during the past two years.
Next year, as the House knows, will be an extremely difficult year for this and many other countries in an economic sense. All industrialised nations are going through a period of serious economic recession combined with high inflation. Ireland cannot escape the effects of this world-wide phenomenon. Our economic prospects have been seriously affected and there is very little we can do about it in the short-term since the causes of our problems are largely outside our control.
In this situation it is inevitable that the present growth rate in health expenditure will not be maintained in 1975. I feel that I must inform the House of this reality since it would be pointless to pretend that services can be developed as quickly as any of us would like in this new situation.
I expect to maintain our existing range of services at their present level overall. In addition I will be able to provide for a limited range of new developments. These will have to be carefully analysed so that priorities are established. I intend to undertake the task of establishing these priorities shortly.
