Before the Minister moves his Estimate perhaps he would be kind enough to explain why the Estimate is required so urgently?
Vote 49: Health.
As far as the debate is concerned, there is no great urgency but I have been informed that the allocation to me for this year is four-fifths last year's Estimate which was only three-quarters of the expenditure for a full year and I am informed I need it before the 31st May.
The Minister only has enough to carry on to the 31st May?
It is in accordance with arrangements whereby I get four-fifths of three-quarters.
Interesting.
(Interruptions.)
I move:
That a sum not exceeding £177,022,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1975, for the salaries and expenses of the Office of the Minister for Health (including Oifig na Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.
I am pleased to inform the House that despite the economic difficulties which affect the country in the current year, it will be possible to increase public, non-capital expenditure on our health services from £169 million, in the national twelve month period for 1974, to an estimated £198 million for 1975.
This increase in estimated expenditure will not only enable services to be maintained at the high level provided for in last year's Estimates, but will, in addition, allow some further developments and improvements to take place during this year.
It is difficult to predict with accuracy the real rate of increase in expenditure at this time of the year, but I believe it should be possible to achieve a real growth rate of around 1½ per cent in our health services in 1975. This growth rate will be achieved, of course, after allowance is made for the effects of inflation on health expenditure.
I feel it desirable to make this point at the beginning of my statement today, since I have heard it said that there are dangers of cut-backs in health service provision in the current year. There will be no cut-backs, either in services or in expenditure in real terms in relation to last year. Indeed, the opposite will be the case. New and additional facilities will be provided, although not obviously to the extent they would if our economic climate were more favourable. We will, therefore, be able to continue the progress made, since the Government took office in the spring of 1973, in extending health service provision as rapidly as our national economic circumstances allow.
Our achievement to date in this respect has been considerable. In 1972-73, the total amount of non-capital health expenditure was £107.4 million. This year, as I said, it is estimated at £198.0 million. This represents an increase of 84 per cent in money terms and around 17 per cent in real terms. In addition, capital expenditure has risen from £6.63 million in 1972-3 to an estimated £10 million in the current year.
Public health expenditure will, therefore, increase by an average of almost 6 per cent per year in real terms, in the three years 1973-4 to 1975. This represents a considerable achievement and, it is in this context, that this year's real growth rate must be seen.
Indeed, it is expected that health expenditure will constitute an estimated 5.7 per cent of gross national product in 1975, as compared with 4.8 per cent in 1972-3. No matter what financial yardstick is used, therefore, our health services are seen to be expanding in a real and sustained way. If the international and national economic climates had been more favourable in the current year, our achievements, since taking office, would have been even more marked. However, we must take the good years with the less good. That is the lesson of economic history.
I am satisfied that we will, nonetheless, maintain our progress to date and will end the year with a higher level of health service activity than we began it. I feel it might be useful to Deputies if I explain at this point, the funding sources of the public expenditure figures I have quoted. In doing so, I will be able to demonstrate the relationship between the monies I am seeking today and total public health expenditure for 1975.
Total public expenditure, capital and non-capital, will amount to £208 million. The Estimate before the House provides for £177.02 million of this amount. The remainder will be funded as follows:
£9.6 million from the rates; £8.5 million from health contributions; £2.0 million from receipts under EEC regulations; £0.4 million under the Supplementary Estimate, approved earlier, to provide aid for thalidomide children; £1.85 million to increase the rates of various allowances and provided for in the budget; for which there will need to be another Supplementary Estimate later; £4.3 million non-voted capital, that is, from the Local Loan Fund and Irish Hospital Sweepstakes receipts; £1.5 million from sweepstakes receipts, for non-capital purposes; £2.83 million to be provided for in next year's Estimate to meet balances of grants due on the basis of final accounts.
Deputies will see from the figures I have quoted that the Exchequer will meet about 90 per cent of the total expenditure involved. This proportion compares with a figure of 63 per cent in 1972-3 and is explained primarily by the Government's continuing commitment to transferring health charges from the rates to the Exchequer. In 1975, a further transfer of about £9 million to the Exchequer is provided for, so that only £9.6 million of total expenditure will be met from rates this year. This continuing reduction of health charges on our rates is in line with the Government's pre-election commitment in this regard.
The Exchequer is now, therefore, almost the exclusive source of funds for our health services. This situation has been brought about within a very short period of time, due mainly to the need to remove health charges from the rates on grounds of equity. If we add to this the fact that health services, because of their labour-intensive nature among other factors, are particularly prone to rapid cost increases, we are faced, as a society, with the need to study in depth both the future financing of the services and the need to derive the best benefits from them.
Because of the rapidly rising cost, the increasing demand, and the rapidly changing technologies associated with health care. Governments all over the world are being forced to find vastly increased sums each year simply to maintain health services at their current levels. We are not unique in this respect. The richest countries in the world are faced with this problem and on a larger scale. We must carefully look at the resources available for health care, so that we may continue development in the future.
It will not be enough to look at financial questions. As was pointed out clearly at the seminar I organised in Waterford last week-end, we must also look at the services we are operating. We must analyse the value of each individually and determine priorities between them. Each service must be continuously evaluated to ensure that the benefits derived from it in terms of health care are, at least, commensurate with the money being spent on it. If not we must be prepared to shift new resources to high priority programmes. This is a problem of the correct allocation of human and financial resources to meet the needs of the future. It is one which we must face up to also.
I, of course, have determined some major priorities, since becoming Minister for Health. These include, the development of our community services, the training of handicapped people for employment, the provision of free hospital care to all, the adoption of a general hospital plan, and the development of our psychiatric services and services for deprived children. I will speak about these in some detail later. My point here is that the task of defining and refining priorities must go on continuously and in depth.
In this decade, more than any other, Governments everywhere are being forced by spiralling costs to look more closely at priorities within the health services and to seek out the most effective health care programmes for development. We cannot escape this world-wide phenomenon either.
To help this country play its part in coming to grips with this twin problem which besets all countries— the problem of financing and determining cost-effectiveness within the health services—I have instituted a number of important measures.
Preliminary work is being carried out at present on a review of health service financing. This will continue throughout this year, with a view to exploring in depth whether we can make some beneficial changes in our financing arrangements. There is no obvious answer at this time but, as a responsible Government, we have an obligation to explore the question thoroughly and this we intend to do.
I think we will all accept, that our task in Ireland in future years will be to look much more closely at the effectiveness of programmes in terms of their contribution to health care. Because of high costs, if we are to achieve the best possible health service, we will have to utilise cost/ benefit, and similar techniques, much more effectively than we have in the past.
I would like to consider the problem in more detail before making arrangements for the development of this kind of evaluative approach.
I should say, however, that some steps have already been taken in this direction within my Department. I was concerned, when I took office, that the data and management structures on which this kind of qualitative approach could be based were not adequate and have taken steps to put this right. A special planning unit has been set up, a reasonably sophisticated system of data processing has been instituted and the concept of programme budgeting has been introduced. These recent innovations have taken place precisely with a view to initiating studies on priorities. I intend to consider this problem in more depth, with the intention of speeding up the process of introducing more sophisticated planning techniques within our health services.
Before concluding this section of my statement, I would like to emphasise that what I have said about the need to study the questions of financing and planning our health services, does not arise from any feeling of pessimism about the future. Rather it arises from the opposite feeling. Our health services will continue to improve, as they have done in recent years, even if we continued with the relatively unsophisticated techniques of the past. I believe, however, that we can devise better planning techniques, which will maximise growth in the future and which will enable us to make the best use of additional resources in order further to improve the health of our people. It is for this reason only that I am initiating the studies and new techniques which I have mentioned.
I would now like to speak about developments in our health services themselves since the last Estimate debate in November. Since that was only six months ago, I do not intend to deal with each programme in detail, but rather to highlight the developments which have taken place in the intervening period.
Expenditure on our general hospital services, including long-stay services, will amount to an estimated £110 million on current account in 1975. This figure represents about 55 per cent of total current expenditure on the health services. In addition, approximately £6.6 million will be spent on general hospitals on capital account, or about 66 per cent of total capital expenditure.
As I said during previous Estimates debates, I am concerned that such a high percentage of total expenditure is occurring in the general hospital programme. This reflects, it seems to me, essentially two fundamental difficulties.
The first is that precisely because over half our financial resources and about 43 per cent of total health care staff are engaged in the general hospital programme, the rate of increase of financial demands from this sector is higher than in other areas of health care. This emphasis on hospital care both in terms of expenditure and manpower, is one which I inherited, but it does mean that the major demands for additional health expenditure in any one year still arise from this source.
The second difficulty is the related one, that it is extremely difficult to shift the balance of additional expenditure in favour of community and preventive health care. If we had a high level and efficient hospital system and if we already had good preventive services of a high level, then it becomes easier to concentrate resources on prevention. But when the demands to improve hospital care are still at a high level, and when community health care is not sufficiently geared up to reduce the numbers seeking hospital beds, it is extremely difficult to initiate the shift in resources I have mentioned.
It is, therefore, difficult to arrive at the right balance between hospital care and community health care. We in Ireland started somewhat late in the day. Nonetheless I intend to press on in this direction as rapidly as is practicable, given that real demands exist on both sides.
I would now like to indicate the major on-going developments which have taken place within our general hospital programme since November last.
Progress in building the 600-bed Cork Regional Hospital is continuing. It is hoped that the main six-storey patients block can be "topped-off" during the autumn of this year. In addition, the architects for the hospital are confident that, without unforeseen stoppages, the hospital will be completed on schedule in December, 1977.
The Minister for Education has agreed that the planning of the Cork Dental Hospital should be resumed. It is hoped to enter into a contract to build the hospital in the autumn, on the same site as the general hospital. The cost will be met from the funds of the Department of Education.
At the Orthopaedic Hospital, Clontarf, adaptations have been carried out which will enable an extra 60 adult, post-operative patients to be transferred there from various Dublin city hospitals. The effect of this will be to relieve the pressure on acute hospital beds in Dublin.
In Dublin also, the adaptations to provide a cardiovascular unit at the Mater Hospital have been completed. Extra cardiac beds and a new intensive care unit are now being brought into use.
At Jervis Street Hospital, work on the detoxification unit for drug abusers is virtually completed and is expected to be brought into operation in July. Improvements to the accident and emergency department at Jervis Street Hospital are also well advanced.
At St. Vincent's Hospital, Elm Park, a new 26-bed geriatric unit and a new 24-bed psychiatric unit are in the process of being erected. A new intensive care unit has been completed in St. Michael's Hospital, Dún Laoghaire, as has a new pathology laboratory at the Castlebar County Hospital, and a new central x-ray department at St. James's Hospital. In addition, a new nurse training school was recently opened at James Connolly Memorial Hospital. Blanchardstown.
In addition to the projects I have mentioned a wide range of other major general hospital building works are in progress at present. These include: A general scheme of improvements and a new 30-bed ward at St. Laurence's Hospital; Improved kitchen and dining facilities at the Meath Hospital; A scheme of reconstruction at Linden Convalescent Home; A new gynaecology unit at Erinville Hospital, Cork; A new operating theatre at the Eye, Ear and Throat Hospital, Cork; A new Cheshire Home at Bohola, County Mayo; A new geriatric assessment unit and a maternity unit at Wexford County Hospital; The extension of the x-ray department at Portlaoise County Hospital; the provision of a public analysts laboratory and geriatric assessment units at St. Finbarr's Hospital, Cork; The provision of an intensive care unit, an x-ray department and a coronary clinic at Galway Regional Hospital; The provision of a new ophthalmic unit at Ardkeen Hospital, Waterford; The provision of a new 30-bed district hospital at Donegal.
These, then, are some of the on-going improvements which are taking place in our general hospital provisions at this time. In addition to these, a number of other development projects will commence in the current year. These include:
New pathology laboratory at St. James's Hospital, Dublin; new paediatric and psychiatric units and a laboratory at Limerick Regional Hospital; a new delivery suite at Airmount Maternity Hospital; extensions to the x-ray unit and out-patients' department at Letterkenny General Hospital; the provision of a theatre at Sligo General Hospital; the renovation of St. Kevin's Unit at St. Colman's Geriatric Hospital, Rathdrum; the reconstruction of theatre No. 3 at the Mater Hospital; the installation of a linear accelerator at St. Luke's Hospital, Dublin; additional accommodation for the mentally handicapped at Peamount Hospital, County Dublin, and Ballybaan, Galway and at Cloonamahon, County Sligo.
I am also proceeding rapidly in the planning of the new St. James's Hospital in Dublin. Discussions are taking place between officials of my Department and the authorities concerned with a view to reaching agreement on a plan for that hospital.
As well as this, I have given the North-Western Health Board permission to plan a major development of Letterkenny Hospital and this planning is going ahead in conjunction with my Department. I have made a similar decision in relation to the extension of Tralee County Hospital. Officials of my Department and of the Southern Health Board are currently devising a detailed plan for implementing this project.
As can be seen from the details I have given, a great deal is being done to continue the development of our general hospital services. More important than all of this, however, in terms of its long-term effects, has been the planning exercise which I have gone through to determine the locations of major, acute, general hospitals for the future.
This exercise has taken me the best part of 18 months, but I am pleased that I will shortly be able to announce the Government's decisions on the matter. As I informed the House previously, what I have been trying to do, during that time, has been to determine a national plan for general hospital development for the future.
The need for such a plan has been widely recognised for more than a decade. Up to now, however, a practical solution had not been found. When I took office, it was generally agreed that the Fitzgerald Committee recommendations, which had been accepted by the previous Government, were unworkable in our context. While it could be argued that they provided a solution amenable to the needs of the health services professions, it was generally accepted that sufficient account was not taken of the need for a reasonable geographic distribution of acute general hospitals.
I was aware of the urgency of adopting a suitable plan when I became Minister for Health. Without one, it will be impossible rationally to allocate resources in the future. Nonetheless, because of the general questioning of the Fitzgerald Committee's views, I felt it necessary to recommence the planning exercise from the beginning.
As the House is aware, this exercise has been going on for some time. I do not need to repeat the details of the exhaustive consultations which have taken place with all the health advisory and administrative bodies concerned. These are contained in my November Estimates speech and in other statements I have made.
The hospital plan for Dublin, which I have already announced, has met with widespread support. I believe that the plan for the rest of the country, when I announce it shortly, will prove equally acceptable. It cannot please everyone, of course, but when it is seen as a whole, I believe it will be accepted as one which reasonably balances the conflicting demands for larger, more centralised hospital units and the need for a reasonable geographic distribution of locations. In announcing their plan, the Government will have tackled and solved one of the most urgent health care problems facing this country. We will have taken the first step towards the creation of a fully modern, acute hospital system and solved a problem whose solution has evaded previous administrations.
Before concluding my remarks on our general hospital programme. I would like to comment on a number of other matters. As the House is aware, it is Government policy to provide free hospital care to the entire population, irrespective of income. The extension of free hospital care to all was to have become operative from 1st April, 1974. Unfortunately, the implementation of that decision had to be postponed, because it was not 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.
In an effort to resolve this impasse, I set up a review body in July last, to make recommendations to me on the system or systems of payment which should apply to consultants in the context of a free hospital service. The review body invited submissions from interested parties in September last. I made my submission in November. I am at present awaiting the review body's report. When I receive it, I would hope to resume negotiations with the medical profession with a view to implementing the Government's decision.
I would also like to inform the House that I will shortly be setting up a consultative body to carry out a general review of matters affecting junior hospital doctors, excluding matters which would be dealt with under the normal conciliation and arbitration scheme. The setting up of this body is a follow through on commitments I made to junior hospital doctors during their last dispute.
I would like to turn now to that area of our health services which is concerned with meeting the needs of the mentally ill and mentally handicapped in our society. Here again, I do not wish to repeat much of what I said in November last. I will concentrate instead on discussing only the main developments which are taking place. Expenditure on these services in the year will amount to an estimated £35.8 million on current account and £2.9 million on capital account. These figures represent 17.9 per cent and 29 per cent respectively of total expenditure on current and capital account.
I have been concerned, since taking office, to carry out a major review of these areas of our health services. I have said before that they were badly neglected in the past and that one of my priorities is to put this right.
As the House knows from my November statement, I decided to start this review process by focusing on a specific area of need—that is the need to provide adequate training and employment opportunities for our mentally ill and mentally handicapped. As Deputies are aware, I set up a working party of experts to advise me as a matter of urgency on ways in which we could rapidly meet this need.
I accepted and published their report in January last. I would now like to place on record my gratitude for the imaginative and effective way they went about their task. I believe their report offers a plan for a major breakthrough in this area of training the handicapped and I give my firm commitment to implementing its recommendations as rapidly as circumstances allow.
Already a number of its recommendations have been implemented. For example, AnCO have initiated training courses for instructors of the handicapped. About 40 instructors have either taken this course or are in the process of taking it. More will undertake it later in the year.
In addition, I have agreed that State welfare allowances, due to handicapped trainees, may now be paid directly to training workshops, to enable these workshops to pay more realistic incomes to trainees while they are undergoing training programmes.
I am engaged currently in discussions with the National Rehabilitation Board, with a view to seeing how I can help it to take on the major role recommended for it by the report. As the House may be aware, it is envisaged that the board will play the central role in planning training and job-placement services in the future. I intend that it should take on the overall responsibility of providing an integrated plan for the future and of putting that plan into effect.
All of this will constitute a major additional task for the National Rehabilitation Board. I am pleased to say that they have indicated a willingness to take it on. I have already strengthened the board to help them implement their new responsibilities. The discussions I am having with them now are concerned with agreeing on their need for additional management staff and technical expertise.
In short, I should hope that the National Rehabilitation Board will, by the autumn, have geared themselves up to carry out the major task which I have assigned to them.
I have entered into discussions also with the Commission of the European Economic Community, at the highest levels, to explore with them the amount of financial assistance we might expect from that source in implementing the other major recommendations of the report. These discussions have proved encouraging to date. My objective is to implement the main recommendation of the report in a planned way over a short number of years. To enable me to do this, I am at present breaking these recommendations down into "phases for implementation" and simultaneously seeking the necessary means of financing. I hope to make a more detailed statement on this matter later in the year.
I am satisfied, therefore, that we now have a coherent and workable plan for training our handicapped people in the future. As I said earlier, I consider this to be the first step towards reviewing the services as a whole for the mentally ill and mentally handicapped in our society. It is a logical first step, since if we cannot get as many as possible of this group into employment, we will not be able to achieve what must be the primary objective of this area of our health services, that is to help as many as possible of our mentally ill and mentally handicapped to live a normal life in our community. If we cannot create job opportunities for them, then that objective cannot be achieved.
Other aspects of our psychiatric services and our services for the mentally handicapped need to be looked at also, of course. These include such questions as determining the proper balance between institutional and community care; determining the relationship between statutory and voluntary agencies which will offer the best hope of coherent planning in the future; what to do about some of our excessively institutionalised and old psychiatric hospitals; how to develop better preventive techniques and measures; how to provide more suitable accommodation for the mentally handicapped who are now in our psychiatric hospitals and who should be elsewhere.
These and other questions have to be looked at and solved. As I said before, this area of our health services has been neglected in the past. It was neglected, I suppose, because these members of our community rarely speak out for themselves as other groups do.
We in this House, however, must speak on their behalf. We must bring the services which they need up to the level of effectiveness of our other health services. This is my objective.
The review which is being carried out at present into these and other questions will culminate in the publication of a major White Paper. I should hope to publish this in the autumn.
Already wide-ranging discussions have taken place in preparation for its publication. Officials of my Department have met with officers of health boards and with a wide range of psychiatrists to consider the issues involved. Further discussions will take place in the coming months. I intend to use the experience and knowledge of as many as possible of those working in these services to help me formulate my policy.
My approach is that of breaking the total service down into its component parts including child psychiatry, acute treatment, forensic psychiatry, rehabilitation, alcoholic addiction, drug addiction, prevention and education. The needs of each is being studied in detail. Ultimately, priorities for development will be determined as between them.
The publication of the White Paper will mark the second stage in the modernising of services for the mentally ill and mentally handicapped. Together with the report on training and employing the handicapped, it will provide a blueprint for planning in the future. The publication of these two documents will mean that this country will have a clearly defined policy in relation to this aspect of our health services. This will be a considerable achievement during this Government's first term of office and one of which we can all be proud.
These then are the steps I have taken to develop a coherent policy for the future. They will bear considerable fruit in due course. Needless to remark, however, a wide range of on-going developments are taking place and have taken place since November last. Again I shall not list all of these but I should mention some of them.
Major capital building works which have been completed since November last include: a geriatric assessment unit and hostel accommodation at St. Brendan's Hospital; industrial therapy units at St. Patrick's Castlerea; St. Otteran's Hospital, Waterford, and at St. Conal's Hospital, Letterkenny; a day centre in Bray; a day care unit at Cheeverstown House; an assessment unit at St. Vincent's, Cabra; a child development clinic and training workshop at St. Michael's House, Ballymun; a day care unit at Lady Lane, Waterford; a major scheme of extensions and adaptations involving 274 places at St. Raphael's, Celbridge; a 100-bed unit for adolescents and adults in Kilcornan, County Galway.
In addition to these, work of a capital nature at present in progress includes: an assessment and research unit at St. Patrick's, James's Street; a psychiatric unit at St. Finan's Killarney; a sheltered workshop at St. Brendan's Hospital; a psychiatric unit at Letterkenny County Hospital; adult units for 100 persons and an additional 60-bed unit at Cregg House, Sligo; a new village centre for 150 adults at Bawnmore, Limerick; an assembly hall and workshop at Carriglea, Dungarvan; an assembly hall, physiotherapy department and swimming pool at Moore Abbey; an assembly hall and gymnasium at Delvin; a village community for adults at Duffcarrig, Gorey; additional accommodation for 50 pupils at St. Anne's Corville; additional adult units and training workshops at St. Patrick's, Kilkenny.
Together with these, a wide range of additional projects are also at tender stage. I think I have mentioned enough, however, to indicate that a great deal of progress is being made in the current year. Progress of this kind, when seen in conjunction with the steps I am taking to plan soundly for the future, is indicative of the Government's commitment to this area of our health services. There is no room for complacency however. A great deal still remains to be done before we bring these services up to a level we can all accept as being reasonable.
Before concluding my remarks on this aspect of our health services, I should like to say that I have been concerned for some time about the shortage of clinical psychologists available to work in our health services. The greatest need for these is, perhaps, in the areas of working with children and in rehabilitation.
At present, there are very few qualified people available in the country. In an attempt to put this situation right, officials of my Department have had discussions with health board officers and with members of that profession, regarding the possibility of introducing a postgraduate training scheme for clinical psychologists. This is designed to ensure an adequate flow of members of this profession into the health services in the future.
If the agreement of the universities and of the professional body concerned is forthcoming, it is hoped that the proposed training scheme can be introduced in the autumn.
I would like to discuss now some of the main developments which are taking place within our community care programme. As the House is aware, this programme of health services activity is designed to provide a wide range of primary medical and welfare services in the community. Its objectives include the prevention of ill-health, the provision of as much health care and welfare as possible within a community setting and the reduction of demand for institutional care.
I said earlier that our health care system placed too much emphasis on institutional care, in both the medical and psychiatric fields. This reality still persists and will take a considerable time to alter and put right. My objective is to bring about a shift in resources in favour of community services, in the belief that this will lead to a better health service overall.
This is not proving easy, however. It is true that our community medical and welfare services have been improving rapidly in recent years, but I must admit that our institutional services are still taking the bulk of additional resources made available in any given year. This is so for the reasons I mentioned when discussing our general hospital programme. The primary reason is that, because so much of our financial and personnel resources are already engaged in providing institutional care, and because this is highly labour-intensive, the demand for additional resources from this sector far outstrips demand in other areas of our health services.
In short, because the traditional pattern of health care in Ireland places great emphasis on institutional care, this sector very quickly eats up most of the additional resources available for development in any year, and particularly in a time of high inflation. Nevertheless, a shift of resources towards community services is taking place, even if it has not been possible to proceed in this direction as rapidly as I would like.
I know that the central theme in the emerging health policy of the Opposition is that greater resources should be placed in community services and in preventive services generally. They do not need to convince me of the validity of this argument. I have held this belief since before I took office as Minister for Health, and I still hold it.
All my efforts have been directed towards this end, and with some success I may add. Nevertheless, I must point out that the task is not as easy as it may appear, for the reasons I have given. A further difficulty arises from the fact that it is not as if our institutional services are perfect and can, therefore, stand still, while community services are brought up to an acceptable level. As I pointed out earlier, nothwithstanding the needs of community services, our general hospital system needs to be rationalised and developed at enormous cost, and many of our psychiatric hospitals need to be improved or replaced.
Unlike the Opposition, therefore, I cannot focus only on the needs of community services, valid though these are. I have got to create a reasonable balance between developing these and modernising institutional settings. This is what I am attempting to do, bearing in mind my objective of shifting the balance towards community care services as rapidly as proves practicable.
In the current year, I expect that about £44 million will be spent on non-capital account on our community care services. This figure represents about 22 per cent of total non-capital expenditure. In addition, it is estimated that £0.5 million will be spent on capital account, representing approximately 5 per cent of total capital expenditure.
As the House is aware, our community care programme is broken down into two broad divisions of services—these of a primary health care nature and those which can be described as community welfare services. I propose to deal with these in turn, although the division between them is somewhat artificial, for reasons I will refer to later. As far as the primary health care programme is concerned, our on-going services are being developed.
In the case of the general medical services scheme, 1,095,919 persons were covered by medical cards on the 31st March last. This figure represents 35.2 per cent of the population. It compares with a figure of 864,106 people or 28.4 per cent of the population, covered on 31st December, 1972. Expenditure on this service has increased from £12 million in 1972/3 to an estimated £21 million in 1975, an increase of 75 per cent. These figures indicate clearly my commitment to improving the income guidelines, under which people become entitled to entirely free medical care, on a continuing basis. There are two very definite constraints on progress in this field, however.
I estimate that raising the income guidelines for eligibility to medical cards, in real terms, costs about £1 million per £1 increase. The guidelines are reviewed regularly now, of course, in line with inflation, but achieving a real increase in numbers covered would cost amounts of this nature. I would add that these estimated cost figures do not take into account any increase in fees which might be sought by the medical and pharmaceutical professions, as a result of increasing the percentage of the population covered by medical cards. This could be a significant additional cost factor, in so far as one medical organisation has already stated that it will seek a fundamental review of fees, if the percentage of the population covered goes beyond 40 per cent.
Secondly, before any major increase in the percentage of the population covered is brought about, I must have discussions with the professions concerned and reach agreement with them. This would be normal industrial relations practice, apart from anything else. I do not think the Opposition took sufficient account of these two major constraints, when they put forward the motion in this House recently to increase the percentage of the population covered by medical cards from 35 per cent to about 60 per cent.
The House can rest assured that I am acutely aware of the hardship caused by medical expenses on some families not now covered by medical cards. These include, in particular, these families just outside the present income guidelines and those who suffer from a high incidence of ill-health. As I said, I will continue to improve the guidelines and take other steps to eliminate hardship due to medical expenses. Our record in the past two years has indicated my concern in this area and I will continue to bring about improvements as rapidly as resources allow.
My efforts in this direction have not been confined to improving, in real terms, the guidelines for eligibility to medical cards. From April 1st last, I extended the list of long-term illnesses for which drugs and medicines will be available free of charge. The list now includes acute leukemia, parkinson's disease, multiple sclerosis and muscular dystrophy, in addition to those included before that date. The effect of this decision will be to reduce considerably the burden of medical expenses on those who suffer from these illnesses. In all, I expect that an additional 5,000 people will benefit from this decision.
In a further attempt to reduce the cost of medical expenses for those who most need help. I decided to retain the base figure for recoupment of the cost of drugs and medicines to those in insured employment and in the middle-income group. The figure remains at £4 per month per family. All expenses for drugs and medicines in excess of that figure, in respect of a calendar month, will still be recouped to the families concerned. The figure of £4 per month was set in 1972 and some would hold that the figure should have been increased in line with inflation. In an attempt to further ease the burden of medical expenses, however, I decided not to make any change.
In January last, I sought a supplementary estimate in the House to enable me to provide substantial financial and other assistance to the victims of the thalidomide drug. I am pleased to say that the House approved that estimate. It enabled me to provide those children with a monthly allowance for life, equal to the allowance they will get from the German fund. In addition, I was able to give each child a capital sum equal to four times the German fund capital awards. The cost of implementing these decisions will amount to an estimated £414,000 in the current year.
I also announced, at that time, that I intended that the National Rehabilitation Board would provide a continuing assessment service for these children and ensure that they were provided with a wide range of special services and facilities, recommended by the Irish Thalidomide Medical Board. I am pleased to say that the National Rehabilitation Board has begun to perform this task. The decisions which I took in relation to these children have been welcomed by their parents and by the House. I am pleased that this issue of social and moral concern has been resolved to the satisfaction of all those concerned.
These are some of the practical steps I have taken to improve our community health care services in the recent past. They constitute part of a significant trend towards the improvement of our health services overall. Many other facets of our primary health care programme are also being developed in the current year. The public health nursing service is improving annually, as are the full range of existing, public medical examinations, vaccination programmes and screening tests. I do not need to elaborate on these today.
An area which is still causing me concern, however, is the provision of dental and ophthalmic services for those with full eligibility. I have commented before that I am far from satisfied with the extent of availability of these services to those entitled to them.
While I cannot, at this stage, indicate what can be done, I will have the matter reviewed with a view to bringing about improvements, where practicable. I am conscious, however, that the cost of bringing about real improvements will be significant, and that has got to be borne in mind.
I would like to turn now to our community welfare programmes. As Deputies are aware from their experience in their local communities, the development of our social work, meals-on-wheels, and home help services is going ahead. It is too early in the year yet to indicate the rate of growth we can expect in these services during 1975. My objective is to achieve whatever growth is possible in the current economic climate and to maintain it at a level which will allow for rapid development in a more favourable economic period. I am confident this will be achieved.
The delivery of community welfare services depends, and rightly so, on close collaboration between the statutory and voluntary agencies involved. This collaboration has improved significantly during recent years and will become much more marked in the future, if present trends continue. The need for close co-operation is obvious. While statutory agencies should and do retain overall responsibility for providing welfare services in our community, it has been recognised elsewhere that this responsibility can best be met by utilising extensively the human resources available, on a voluntary basis, in each community.
This is not a question of the State doing the job on the cheap. It is rather a recognition of the fact that voluntary agencies can supply services and a concern which statutory bodies cannot expect to match. I am actively working to improve and develop this collaboration and sharing of resources between the statutory and voluntary sides of our social services system. It makes good sense to do so and, I have no doubt, it will pay major dividends in the future.
The National Social Service Council plays a major and increasing role at present in developing the voluntary side of our social services system. It has performed very valuable work in this field since its establishment in 1971, particularly in encouraging the formation of social service councils and in the provision of information and advice to individual voluntary agencies. In recognition of the work it has performed and in expectation of the increasingly vital role I expect it to perform in the future, I was pleased to accede to the views of the council concerning the structure of the council itself.
They proposed that membership of the council be extended from 25 to 29 members and that the base of representation be broadened by, in particular, including representatives of the voluntary councils themselves on a regional basis. I found these proposals to be acceptable and the new council has now been constituted on the revised basis.
Because of the high esteem in which I hold the National Social Service Council, I was pleased to give them responsibility for implementing the Government's decision to provide assistance to local community information centres. The council is now acting as the central agency to encourage the setting up of information centres, to set standards for registration, and to provide information, training and financial support to local staffs. Since the beginning of this year it has been selecting centres which will immediately qualify for Government support and has been preparing itself to carry out this new role extensively in the future.
The council hopes to be able to announce, in June, the first 20 or so centres which will qualify for support. This will, I hope, constitute only the beginning of the creation of a national network of information centres in this country. In providing Government financial support for these centres, we will be meeting a real and growing need to improve methods of conveying information to the citizen about his rights and entitlements under increasingly complex legislation.
I would like to take this opportunity of thanking the National Social Service Council for taking on this major new task, on behalf of the Government. I have no doubt that, under its guidance, the development of this aspect of social policy is secured.
I would like to comment on two other matters before concluding my remarks on our community care programme. The first concerns the increases in health allowances which became applicable from April 1st last. As the House is aware, the Minister for Finance, in his budget statement of 15th January last, indicated that all rates of social insurance and assistance payments, together with associated health allowances, would be increased by from 21 per cent to 25 per cent. The health allowances concerned are the disabled persons maintenance allowance, the infectious diseases maintenance allowance and the blind welfare allowance. The individual increases are shown in the statistical statement which has been given to Deputies.
It is estimated that the additional expenditure resulting from these increases, in the period April to December, 1975, will be in the order of £1,616,000. In addition, it is envisaged that the allowances will be reviewed again in October next, with a view to keeping them in line with inflation.
The second point I wished to mention, in concluding this section of my remarks, concerns the point I made earlier, that it is not possible to divide our community care programme clearly into separate programmes, dealing with primary health care and with welfare. The need for both clearly exists, but they should not be seen in isolation from each other. Each programme should complement the other, in providing for the health and welfare of families in our community.
It is for this reason that I am trying to arrange an administrative merger between the two. I am trying to bring into operation what are called community care teams, comprising a wide-range of health and welfare personnel, working together in a planned and organised way for the betterment of local communities. I hope that the directors of these teams will be appointed shortly and that the work of putting into operation the generic team approach, which I have mentioned, will follow rapidly.
I intend to publish a discussion document on this general issue of concern shortly, and look forward to receiving a wide range of views on it.
Before finishing, I would like to comment on two other matters which do not fit neatly into any of the three health programmes I have been discussing. The first concerns the need for health education. In January last I made an order concerning the Health Education Bureau. The function of the bureau as set out in the order includes:
Advising on aspects of Health Education which should have priority at national level, drawing up and implementing programmes with the co-operation of Statutory and Voluntary bodies engaged in Health Education, maintaining contact and giving financial assistance to these voluntary bodies and helping them in implementing their local programmes, promoting and conducting research, acting as a national centre of expertise and promoting greater concern for medical health education generally in the community.
I consider the setting up of the bureau a very important step in our preventive medicine programme. As many of you are aware, among the main causes of death in modern times are heart disease, cancer including lung cancer and alcoholism. All these diseases are preventable. The unnecessary deaths and suffering caused by them can be avoided provided if one is aware of the causes and takes normal health precautions. The task of creating awareness of the benefits of good positive health is by no means easy, but it is now an essential part of our health services.
The bureau itself was set up in February last and has shown an urgent appreciation of the task ahead of it. Its frequent meetings and deliberations show its competence to tackle these problems. Already a number of pilot schemes have been devised and are being put into operation. It has also commenced the assessment of the work engaged in by voluntary organisations. I hope to make funds available in the next year to enable it to further the efforts of these organisations.
I intend to set up in the near future an advisory council representative of these voluntary organisations to help both the bureau and myself in determining priority areas. The preliminary work in setting up this council is well under way. By means of these health education programmes it is expected to create a climate which will correct much of the present behaviour and attitudes which lead to ill health.
The second matter to which I wish to refer is the seminar which was held last week in Waterford. It had seemed to me for some time that it would be a good idea to seek some action to develop the processes of communication within the health services as a whole. From my own point of view, I had for some time felt that much benefit could be derived from an occasion where I could, over a period of a a few days, meet many people involved in the health services, hear their views and discuss with them in an informal way the problems which were presented to them. It was this thinking which led to the organisation of the Waterford seminar. Specifically, it arose at a discussion which I had last February with some members of the Medico-Social Research Board.
The development of this idea led to my issuing invitations to organisations involved in the health services which led to about 100 people participating in the seminar. The participants included representatives of my Department and the Departments of Finance and the Public Service, the health boards, the voluntary hospitals, the National Health Council, Comhairle na nOspidéal, the Council for Postgraduate Medical and Dental Education, the National Social Service Council, the Voluntary Health Insurance Board, the Medico-Social Research Board, the Medical Research Council, the Irish Congress of Trade Unions, and several professional organisations concerned with the health services. In choosing what bodies might make nominations, I had to make a selection. There are many other bodies both official and otherwise concerned with the health services, and if all were to have been invited, the total number participating would have become too large and amorphous. Hence, I had to be selective and could not extend invitations to many groups that had approached me about this. I regretted this but felt that it was inevitable.
The letters of invitation to the various bodies summarised the objective of the seminar as being:
to obtain a preliminary overall view of the state of the services, to direct attention to the major problems which beset them and to identify the key issues requiring further investigation and attention.
I did not expect any sudden, magical solutions to the problems which beset me as Minister for Health from the activities of the seminar and told the participants so. What I did hope for, as well as creating opportunities for the participants to communicate among themselves, was that important issues in each branch of the services would be pinpointed in the report on the seminar's proceedings.
I am told that some of the participants approached the exercise rather diffidently but, as the seminar proceeded, it became clear that its objective in providing for communications within the disparate groups involved was being achieved. What struck me most about the proceedings was the lack of acrimony between different groups, and the restraint in the pushing of vested interests. Specifically, the question of pay for individual groups did not come up for discussion at all.
Most of the work of the seminar was done in groups dealing with the four broad topics of community services, hospital services, organisation and personnel. There were 12 of these groups and, during the seminar, I found it possible to sit in and hear the discussions in most of them. In the final part of the seminar, reports from the work of these groups were presented. Deputies will have seen some of the conclusions reached in the media reports on the seminar. Very many valuable suggestions were made. Not all of these are, of course, new, but this is the first time we had an opportunity for a very representative group to list the matters which will have to be considered in further thought on health policy, and in the determining of priorities in developing the services in the future.
I think I can say, too, that there was a fairly general recognition at the seminar that impossible demands for resources for the health services could not be made and that development must be in accordance with a rational plan and related to the economic resources available. Many of those present were representing specific interests in the services and I think it was a good thing that they had the opportunity to see that there were several other representatives of other specific interests putting forward claims for priority in development. As far as I was concerned, and my Department, it was of great advantage to have these reports presented.
I intend that the basic documentation for this seminar and the reports which were presented at the end of it will be put together into a publication which I will have circulated to each Member of the House. I hope the Members will find the material which will be contained in this as useful and as interesting as I did.
Attendance at this seminar involved much hard work for many people. Those who came contributed much within a tight timescale and many of the participants worked late to produce the reports which were presented finally to the entire group. The meeting was I think, an unique experiment in communication in a complicated field of public activity. I think that my gratitude, and the gratitude of the House, should be offered to the many who participated in it.
There were literally dozens of very useful recommendations made from the groups who participated in the seminar. I do not intend to list all these or to discuss them. I intend that all the suggestions will be analysed and that the work of this seminar will greatly influence that of my Department and my own decisions in the future. I would mention, however, a few of the important trains of thought that were developed.
First, within the services, there was repeated emphasis on the need to develop community medical and welfare services as against services in institutions. This is not, of course, entirely a new idea and has been the basis of much planning in the past but it was most welcome to have suggestions from the seminar on the implementation of this planning. There was support also within the seminar for the more rational development of the hospital services and the wide recognition of the need to look at the working of the hospital system to ensure that the vast resources put into it were being used efficiently and satisfactorily.
On the personnel side, the most notable point made was that the use of auxiliary staff should be developed where this is practicable. This was raised particularly in relation to the dental services and it was interesting that there was general support for a change in the law which would allow ancillary staff to perform some of the less specialised aspects of the work of the dentist. I intend to look into this.
On the organisation of the services, no dramatic recommendations came forth for a change in the health board system but it was clearly brought forth that a hard look must now be taken at the regional hospital boards, which were recognised as not fulfilling the coordinating role for which they were set up. This, again, is something which we will have to look at now.
Another interesting suggestion on organisation related to the functions of the Department of Health vis-á-vis those of the Department of Social Welfare. It was proposed that the scope of the health services should be extended into the field of income maintenance except in so far as benefits not related to health conditions were concerned. This is an interesting suggestion which might, however, present some practical difficulties. However, I do intend to look into it in my capacity both as Minister for Social Welfare and Minister for Health.
To conclude in relation to the seminar, I think it was a well worthwhile exercise. It certainly was from my point of view and I hope that, when Deputies get the report on the seminar, they will find this a useful contribution to the work of the House in the health field.
I doubt if even the most ardent admirer of the Minister could regard his Estimate speech as other than pedestrian and uninspiring. In his whole speech the Minister could not announce one single significant new development. The whole tone of his speech is apologetic and it can be summed up best by this particular quotation from it:
No matter what financial yardstick is used, therefore, our health services are seen to be expanding in a real and sustained way. If the international and national economic climates had been more favourable in the current year, our achievements, since taking office, would have been even more marked.
That is the clearest possible admission by the Minister of the fact that in this current year he is not in a position to put forward a single, proposal for the improvement and the development of our health services.
The Minister had to put together an Estimate speech but in order to do so he resorted to reciting a list of minor developments, all of which we knew about already and for most of which this Government had taken full credit. It is very refreshing and encouraging for us all to know that the Minister proposes to increase the membership of the National Social Service Council from 25 to 29 members. That merits inclusion in any Estimates speech.
The Minister felt compelled to tell us again that he had been generous to the thalidomide children. In this House we have already dealt fully with the arrangements made by the Minister for these unfortunate children. We have given him full credit for his generous provisions. Apparently he feels he has to refer back to that tragic incident again.
The Minister has told us once more—and this is perhaps more outrageous than anything else in the Estimate speech—of the increases in the health allowances the Minister for Finance announced in the budget last January. These have been trotted out again. We have been told that they amounted to £1.6 million. Then, finally, as if the speech were not of sufficient mediocrity, he spent seven pages telling us about the seminar in Waterford. That seminar was first used, as I described it at the time, as a parliamentary tactic to divert attention from the fact that he was turning down our motion on the extension of eligibility for medical cards. The seminar in Waterford was fully reported in the newspapers. Indeed, it earned a fulsome and somewhat misleading leader in one of our national newspapers. But there are seven pages of the Minister's Estimate speech devoted not to analysing and assessing for our benefit any of the proposals or conclusions reached in Waterford, but merely thanking all those who came along. It was very like the chairman at the end of the dinner, thanking the hotel, management and staff for providing an excellent meal.
While on the question of the Waterford seminar, I do not wish to take from its importance, it represents a significant development in the administration of our health services and it is widely welcomed, and justifiably so. I hope that ultimately we will get the papers and the reports and be able to study them in detail. It seemed to me that, as a seminar, it was concerned with the administration of the health services and that a far more useful seminar could be held on the development of our health services, on analysing where we are going and trying to identify the trends, trying to set objectives, rather than devoting itself to discussing, to a large extent the trivia of the administration of these health services.
I confess to finding the Minister's Estimate speech disappointing. To a large extent, it is a procession of trivia, a listing of matters with which we are already fairly familiar. Surely it would have been appropriate for the Minister at this stage, to have announced the new hospital development programme. This is sufficiently urgent. In his speech the Minister contented himself with saying that he had spent 18 months considering it and that very soon he was going to announce it. He went on to tell us how useful it would be and how important it would be, when he would announce it. I suggest to him that the House and the people who are interested in the health services could reasonably and confidently have expected that he would have actually announced the programme in this Estimate speech.
There are two reasons why the Minister's speech was of such a mediocre and disappointing nature. The first is that the Minister for Health— no matter how well-meaning he may be—is totally and completely submerged by the financial disaster into which he and his colleagues have plunged this country. I have been looking at the latest Exchequer returns. They show that the situation in the Exchequer, as between receipts and expenditure is, already, £82 million worse than it was for the corresponding period last year, eighty-two million pounds worse, with only just over four months of the year having passed.
The simple situation is that the Minister for Health has no room for manoeuvre; he has no scope to put forward any proposals for improvements or developments, because the money simply is not there. That seems to me to be the message which emerged from this famous Waterford seminar. The Minister, in effect, said to the worthy people assembled there: "Please discuss the health services in detail. Come forward with any ideas you like, but you must understand that there is no money with which to do anything".
I have seen also a copy of a letter which was issued by the Minister's Department to the health boards some time in March. I have seen fairly draconian missives issued from the Department of Finance in my time but this letter issued by the Department of Health to the health boards is the most carefully worded exhortation to economy I have ever seen. It spells out, line by line, all the things the health boards must not or cannot do if there is any prospect of their costing money. The sad situation is that the Minister for Health, in proposing this Estimate to the House, is quite incapable of announcing any single proposal involving expenditure of any sort.
In considering this Estimate, we should address ourselves to a number of basic questions, some of them concerned with the present and immediate future, some of them looking forward into the longer term. The first question we must ask is in regard to the amount of the Estimate. Is the Minister providing enough moneys to ensure the existing structure is able to function adequately during the current year? Are these moneys being efficiently administered? Are the services we are providing the right ones or should there be any significant or important diversion from one particular heading to another?
Looking further ahead still we must ask ourselves the sort of questions with which the seminar in Waterford should have been dealing. Where exactly are we heading in the development of our health services? Are we going in the right direction? Are we pursuing the right objectives? Are we adopting the right priorities? If we continue to proceed along the lines we are following at present, is there any hope that, we will ever arrive at a satisfactory structure of health services capable of catering adequately and satisfactorily for our entire community?
To strive constantly to improve the health, physical and mental, of all its citizens is an essential aim of any enlightened society. That involves not just extending, and perfecting the existing structure of services but also seeking out and uncovering areas of hardship and suffering which up to then had been neglected or, perhaps, even unknown. How are we progressing in that regard? That is the sort of question to which I would have hoped the Minister would have addressed himself in his Estimate speech. Those are the sort of questions which I would think relevant for him to deal with in putting his annual Estimate before the House, instead of blandly informing us that he proposes to increase the membership of the National Service Council from 25 to 29 members.
I said there were two reasons why the Minister's speech is disappointing and discouraging. The second is that it is a mistake to have the same man as Minister for Social Welfare and Minister for Health. I do not say this by way of criticism of the Minister but I think health is a sufficiently important area of public administration to have one person in charge of it—someone whose sole responsibility and whose driving ambition are constantly and persistently to improve our health services both in their quality and in their extent. I believe that as long as the Minister has the dual mandate of Social Welfare and Health he cannot give to this vitally important area of health the purposeful, dedicated attention it demands in a modern community. I think the Minister's first love and main preoccupation is Social Welfare—perhaps if any of us were in this position we would have the same preference—but I think it reflects on the quality of the administration of our health services.
In order to form any satisfactory conclusion about the amount which is provided for our health services in this year's Estimate, £177 million, it is not enough just to look at that figure in isolation. It is necessary to go back over recent years and try to study the trends that have been emerging and the lines along which expenditures have been developing. I have sought to establish a kind of comparative picture for the six-year period which includes the current year and the previous five years. I have done so in order to try to fit this year's figure into some composite picture and see what the trends are and what the tendencies in expenditure are. In order to do that one has to contend with a number of difficulties. There are a number of factors which make valid comparisons over the last five or six years very difficult indeed. First of all, there is the unprecedented rate of inflation in recent times. Then there is the factor, which must be taken into account, of the change in the ratio of the expenditures which are borne by the local authorities on the one hand and the Central Exchequer on the other. Then there is this peculiar system of accounting which the Department of Health operate and which takes opening and closing balances into account in arriving at the net Estimate for a particular year. In order to arrive at the net Estimate, as published in the Book of Estimates, appropriations-in-aid are deducted and they, of course, have changed very significantly in recent years. They have been swollen by the addition of the receipts from the health contribution schemes and, more recently, by the receipts which are coming in from the European Community.
All in all, it is difficult to get an exact basis of comparison over the years. I think the Minister will agree that the figure in the Book of Estimates, given as the net Health Estimate for the particular year, is pretty meaningless for comparison purposes. I have taken out three principal elements in health expenditure and have sought to adjust them in a way that would make comparisons valid as between one year and another. First of all, I had to discount the different figures for inflation. In that regard I took the Central Bank figures for inflation—in 1970, 8.4 per cent, 1971, 9 per cent, 1972, 8 per cent, 1973, 11.3 per cent and 1974, 17.1 per cent. The projected figure for 1975 by the Central Bank is 25 per cent. I also had to make an adjustment for the nine-month period, which occurred during 1974, when we changed from the basis of the financial year April to March to the calendar year.
I believe the significant amounts of expenditure are those included under subheads G and H—not the figures given in the Estimate itself because these are subject to different sorts of calculations but the figures given for the subheads as set out in the detailed section of the Estimate. Subheads G and H cover the hospital services, general medical services and other services. In effect, they represent the bulk of our expenditure on health and they represent more accurately than the Estimate itself the growth in gross expenditure because they, in effect, account for the expenditure by the health boards.
These figures in actual money terms have increased from £55 million in 1970-1971 to £190 million in 1975. Those figures adjusted for inflation increased by 77.4 per cent between 1970/71 and 1975. In real terms, between 1970 and 1975, our expenditure on health services went up by 77 per cent, whereas, in money terms it went up by 350 per cent. It is important that we keep this element of inflation in mind in comparing the expenditure year by year. Over that six-year period there has, in fact, only been an increase of 77 per cent in real terms.
The question we must ask ourselves is whether the 77 per cent increase represents better services in extent or quality for the people or whether there is included in it some element of paying an increased cost for the same services. This is an area to which we must devote a great deal of attention in the future. The Minister referred to this but his reference to it was not very encouraging. He said:
Preliminary work is being carried out at present on a review of health service financing. This will continue throughout this year, with a view to exploring in depth whether we can make some beneficial changes in our financing arrangements. There is no obvious answer at this time, but as a responsible Government, we have an obligation to explore the question thoroughly and this we intend to do.
I am not quite clear what the Minister has in mind there. One possible interpretation is that the Government are exploring additional ways of raising from the public the money necessary to finance our health services. If that is so, we would all be very interested to learn in what particular way the Government propose to do that. Does that herald some new additional taxation on the general public or does it envisage some new type of charge specifically related to those benefiting from the health services? I would hope that it meant something completely different. If it did, it would be in line with our thinking on the health services.
I do not believe that the figure which I have given of an increase of 77 per cent over six years represents positive improvement in services, either in quality or extent. Therefore, there is a very real need for research into the cost of the health services. That task can only be carried out by some specialised body, whose sole job will be to carry out continuing on-going research into health costs with a view to seeing how the best possible value can be got for the money which is being expended. This is becoming increasingly important.
It is doubtful if any nation will ever be able to provide liberally for all the things it would like to do in the area of health. That being so, it is vitally necessary for a country like ours to get the best possible value out of the money we spend. This can only be done if we carry out a constant, rigorous effective programme of research into our health costs. It is particularly important now when we have eight health boards involved in this expenditure. It is important that their performance in regard to cost-benefit be compared constantly and that any lessons which are learned by one board and any benefits which can be procured in this cost benefit sphere should be immediately transmitted to all the other boards.
Last month, as the Minister mentioned, we put down a Private Members' motion asking the Government to extend the general medical service to a considerably increased sector of the population. We did so because we regard that extension as something which is urgently and vitally necessary. We believe that it is along that line improvements in our health services should be followed. It fits in with our general concept of moving medicine, in so far as we possibly can, out of the institutions and into the community. Our thinking envisages that the local health centre will play an increasingly important part in the whole structure of the health services. In that way the health services will become integrated into the local community and, correspondingly, there will be a reduction in the necessity for hospital admissions. Our motion sought to make the issue of medical cards automatic in the case of persons over 65 years, widows and persons suffering from long-term illnesses and also families whose net income did not exceed £40 per month, after certain deductions were made.
The Minister saw fit to ask the Dáil to reject that motion out of hand. He was not prepared to accept it in principle and possibly to postpone its operation. He was not prepared to amend it. He was not prepared to make some amendment to our motion which would go some of the way towards meeting it. In effect, all he could do in dealing with the motion in the House was to say that it would cost £15 million to put it into effect and he had not got that amount of money.
I want to reiterate our demand for some significant raising of these medical card eligibility limits. Inflation keeps galloping on. I have already indicated the Central Bank project a rate of 25 per cent for this year and this rate of inflation is resulting in many hard-pressed families, who should have medical cards, being denied them. The Eastern Health Board laid down their guidelines for the issue of medical cards on the 1st January of this year. If the Central Bank's estimate of inflation is correct, by now an inflation of 10 per cent has already taken place. If, for no other reason than that, these income limits for medical card eligibility should be revised upwards.
It is our approach to health policy that the extension of the general medical service should have top priority. We recognise that there are many other desirable developments, many other improvements, many other things that need to be done. But we believe that to provide the greatest possible benefit for the greatest number of people can only be done by an extension of the general medical service. We regard that as something which should be afforded top priority, something which should have first command on any resources which are available and something which is urgently and vitally necessary at this time. That is in keeping with our general approach. We favour a fundamental change in the approach to the administration of the health services. We believe, and the Minister paid some lip service to this, that the emphasis in future should be on community medicine, on the provision of medical aid, medical care, in the local community to the greatest possible extent that that can be done. That leads ultimately to a reduction in the need for hospital admissions. It seems to us that that makes good economic sense. It is also something which is desirable on humanitarian and compassionate grounds. In so far as you can possibly do so you provide medical assistance and health services for the people in their own community and preferably in their own homes. That is where we would like to see the emphasis put in future.
I criticised the Minister already for not announcing the general hospital development programme. That is one of the major developments which are needed at this stage in our health services. There are vital reasons for a planned, rational, national hospital building programme. I hope the Minister will not delay very much longer in coming forward with that programme. At Question Time week after week, it is disclosed that in practically every part of the country existing hospitals of all sorts are over-crowded. Overcrowding is really the norm rather than the exception.
This is something which is of vital political and economic significance. We need a great deal of additional new hospital accommodation. The resources available to us for the provision of that hospital accommodation are necessarily limited and will always be limited. There must be a rational plan. There must be an element of duplication or overlapping and the plans of the different regions must be co-ordinated at national level by the Minister. A very long term comprehensive programme and a co-ordinated national programme are called for. I hope that, through the Minister, all the latest modern techniques will be brought to bear on this programme.
I remember some years ago when the regional colleges of technology were being planned a group of experts were brought together, a team, by the Department of Education and they set out to achieve standardisation in the building of the regional colleges throughout the country. Perhaps the problem is not exactly the same in so far as hospitals are concerned but there is scope for some similar type of approach on this occasion if we are to do a good deal of hospital building, extending over the next ten, 15 or 20 years. The basis of it must be properly planned, then the manner in which it is done should be co-ordinated. I strongly recommend to the Minister that he look back at what was done in the case of the building of the colleges of technology.
I know there was much political controversy at the time about it and certain unfounded allegations were made about the team which was put together on that occasion but significant economies were achieved through standardisation. I suggest that in this new hospital building programme something of a similar nature be instituted by the Department. The old traditional methods of building will not suffice on this occasion. I do not mean the actual building techniques but the whole way in which these buildings are planned and the way they are brought to building stage.
The Minister mentioned, and I think rightly so, the very real need there is for improvement in the dental and the opthalamic services. I believe, in particular, there is an urgent need for extension of the dental services. I had the experience recently of a mother writing to me who said her husband was eligible for free dental service but that she was not. Furthermore, she pointed out that in order to write the letter to me she had to borrow his glasses because she was not entitled to free glasses either. That may be an over-dramatisation of the situation but I think there is a germ of realism in that incident. One of the areas in which improvement is urgently needed is that of eligibility for dental treatment. I think there is a need for a shift of emphasis, a change from corrective dentistry to reparative dentistry just as in medicine we must try to draw more attention to preventive medicine. The same sort of situation applies in the dental field. It is regrettable that some of the trouble in this area emanates from the poor state of relations which exists between the dental profession and the Minister's Department. I believe there is scope and need for a new far-reaching approach in this whole area of the dental services.
I understand that at the Waterford seminar very considerable emphasis was laid on the need for a massive and sweeping improvement in our whole approach to the mentally handicapped in our community. The Minister referred to the report of the working party which was established to consider the training and employment of the handicapped. There are certain aspects of that report with which I would not be very happy. I doubt the validity of certain conclusions they come to and certain suggestions they make. But, whether or not we accept the report in all its aspects I do not think, and I understand this was very clearly brought out in the seminar in Waterford, that a considerably extended programme in the whole area of the treatment of the mentally handicapped is urgently necessary. The position is that there are large numbers of persons in our mental institutions who should not be there at all but who should be in properly equipped mentally handicapped centres. There are a number of institutions which are, at the moment, coping with mentally handicapped children. When these children come to adult age, there is nowhere for them to go except into the institutions. There is a very urgent demand for positive, concrete action in this whole area. I am not in any way criticising the Minister in this regard because everyone accepts that this is one area in which we have failed to make any significant progress up to present. The time has now come when there must be a comprehensive approach to the whole problem of the provision of training, education and other facilities for the mentally handicapped.
One question to which we will have to give increasing attention is the success or otherwise of the regional boards. I think a reasonably balanced judgement would be that they have been quite successful. As an administrative device, the regional board has been a success. I think all of us in this House who have experience of the operation of the health services at ground level would agree that since the coming into operation of the regional boards there has been a very considerable improvement. There has been a change of atmosphere and emphasis and an overall improvement. That is the encouraging side of the picture.
Criticisms are made of the boards and of the manner in which they operate. I think there is a need for some sort of evaluation of their performance. I have already mentioned it is important that we examine and research their financial performance and compare the results achieved one with the other. We must also have a look at their general structure, the composition of the bureaucracy which they have created and their effectiveness and efficiency. If the experiment of devolving so much power down to these boards has been successful in the board outline, is there a case for devolving some power further down still? As the services which we will be providing increase and are extended is there a danger that the boards, even though they have been regionalised, even though the services have been regionalised into eight separate compartments, as it were, that these, in time, will become unregional? Should we now be looking ahead at some further devolution down to a lower level still? I believe the suggestions in the McKinsey Report in so far as these boards are concerned should be adopted.
There is a unanswerable case for giving the boards full budgetary powers. I do not think we can ever regard them as being in a position to totally discharge their responsibilities until they have these full budgetary powers. That is the next important practical step that can be taken in so far as these boards are concerned. There is also a case for a considerable amount of in-service training. These boards will in future be inaugurating and initiating more and more programmes. One of the most important factors in any of these areas—community care or any of the allied areas— is the quality of the manager of the programme.
Debate adjourned.