Dáil Éireann debate -
Wednesday, 3 Mar 1976

Vol. 288 No. 8

Private Members' Business. - Financing of Health Boards: Motion (Resumed).

Debate resumed on the following motion:

That Dáil Éireann deplores the failure of the Government to provide adequate funds in 1976 to enable regional health boards to maintain the health services at their existing level.

—(Deputy Haughey.)

Dr. O'Connell

In his speech last night, Deputy Haughey called on Labour backbenchers to demonstrate the sincerity of their concern for the medical welfare of our people, a concern he said which the Labour Party have always been quick to claim as an essential tenet of their philosophy. As a Labour backbencher I welcome his call as I welcome any opportunity to contribute to an important debate concerning our health services. However, Deputy Haughey, in my opinion, has committed a logical error in equating concern for the medical well-being of our people with support for his motion which, in my view, fails to manifest a grasp of the problems facing us.

I agree the Labour Party are concerned about the present health situation, but they do not embrace the limited soultion proposed by Deputy Haughey in this motion. He seems to imply that this solution is the only one possible for those who are honestly concerned about the health services. We cannot propose an emergency reallocation of funds without rooting that proposal in a general context which displays a grasp of the role played by bureaucracy and inefficient administration.

As I said last night, more money will not buy better health. As Deputy S. Flanagan correctly pointed out, we have had a six-fold increase in funds allocated to the health services but we have not had a six-fold increase in the health of the country. Therefore, pouring more money into the service is not necessarily the solution because we could be throwing good money after bad, without getting the desired results.

I recognise the need for emergency funding. There is a need to give adequate notice to health boards that there should be proper planning. I appeal to the Minister to look at this aspect. As I said some months ago, if we are to have a proper rationalisation of the health services, the Minister should set up an all-party committee of the House to examine the whole structure of the health boards. Emergency funding can only be a temporary measure to assist those boards which are threatened with cutbacks. The health boards have been in existence for almost five years and we have yet to undertake an analysis which would locate those areas where proper economies could be carried out. Such an analysis would minimise the possibility of future crises where, due to lack of planning, foresight and efficient organisation, administrators are panicked into cutting back in essential areas.

The appointment of an all-party committee would represent a giant step towards the goal of rational administration. The Minister could play a significant role in this advance by immediately establishing such a committee. I recognise the predicament of the administrators, the doctors and those involved in the health services, and strongly recommend that until the committee can get to work and introduce some order into the present chaos, no cuts in expenditure be made which would endanger essential services.

I suggest the Minister take steps to alleviate this administrative nightmare by taking on himself the responsibility of protecting those essential services. It is not right or proper that administrators should take political decisions. I realise the great difficulty and responsibility involved in determining cuts which affect essential services but the job must be done. This is not a pleasant situation and we must respond to immediate needs. We cannot respond in a limited and deficient way or we will perpetuate the problem and make future crises of even greater proportions inevitable.

The health boards have failed. They have lacked planning and foresight. I will propose at tomorrow night's meet-of the Eastern Health Board, of which I am a member, that planning and finance committees be set up. I appeal to the Minister to request each health board to set up these committees. The present structure of the health boards is top heavy and ponderous. They are administratively cumbersome and have not achieved the objectives envisaged when they were set up. Each operate on their own without any attempt by the Department to co-ordinate these efforts. The Minister for Health should be responsible for co-ordinating these efforts and having frequent and regular consultations with them to see they have an objective in mind which, I fear is lacking at present.

I would hope that the establishment of committees within each health board would help to bring order into them. I also hope the Minister will give serious consideration to my proposal for an all-party committee because we are all genuinely concerned about the health services. The all-party committee should consider every aspect of each health board and make recommendations to the Minister. This will not take away from the functions of the Department or the power of the Minister. The committees would not interfere with the day-to-day running of the service. It is time we examined and reviewed the operations of the health boards.

I want to digress for a moment to tell the House that the health boards are operating in such a haphazard manner that a very essential preventive service is being temporarily stopped. The programme manager of community care of the Eastern Health Board suggested that £105,000 could be saved by the temporary discontinuance of routine school child health examinations. This would be a disastrous step and would have untold effects on the health services and our children would suffer. This decision was taken by a programme manager without any regard to the nature or importance of this service.

I will give an indication of what it can achieve. It identifies children with physical defects and concentrates on finding children with learning difficulties, emotional and social deprivation, children with hidden handicaps, mental and physical. These doctors identify children who are battered and abused and help is brought to these children by contact with other agencies. That is some indication of their work. It is a preventive service performed by identifying these defects in time and it can considerably reduce costly and wasteful hospital expenditure which is involved if these defects are not detected in time.

To curtail this service is a retrograde and suicidal step. I could not condone it and because of that and because of the haphazard and unplanned approach, the panic measures that are being taken by programme managers, I am asking the Minister to consider calling in the chief executive officers of the health boards and analysing the areas where cutbacks can take place without necessarily imperilling vital services.

Mr. Haughey

And vote for the motion.

Dr. O'Connell

I am not asking for the money. It is important to say this: the Swedes have estimated that at the rate their health services are absorbing the gross national product they will shortly reach the stage when the health service proportion will exceed the GNP.

Mr. Haughey

That is not happening here.

Dr. O'Connell

You cannot necessarily buy better health. Bevan in 1948 assumed that if he produced his special national health service the health of the people of Britain would be perfect. Here we are in 1976 with queues for hospital beds and the health of the country is no better, perhaps much worse, than it was in 1948. Unless the money is ploughed into the right areas you are wasting it. The logic of my argument is that you will not necessarily buy better health with more money. The fact that funds were curtailed at short notice has created a panic situation.

Mr. Haughey

Vote for the motion.

Dr. O'Connell

No, I do not think that is the answer. I am asking the Minister to call in the CEOs, examine the areas, provide emergency aid and then have a proper plan. It is very different from Deputy Haughey's motion which assumes that money will solve the problem.

Mr. Haughey

I only want the cuts restored.

Dr. O'Connell

I do not agree because I do not think it is the answer to the problem. I am asking the Minister to do this to allay the fears of the personnel in the service——

Mr. Haughey

You are dodging the issue.

Dr. O'Connell

——and of the patients and the people most in need. I ask the Minister to take over responsibility for that aspect of the matter, away from this situation. He could ensure that those most in need of the service will benefit from it. If he does this he will achieve a great deal. By considering an all-party health committee I think he would contribute enormously to our health services.

Mr. J. O'Leary

The financial position of each of the country's health boards is very serious. As a result of statements issued by CEOs to board members it is clear that the boards were told by the Minister to cut back considerably in their 1976 budgets. The Southern Health Board must cut the budget by £930,000 or nearly £1 million. The Minister and his Parliamentary Secretary have said that there is no serious cutback; CEOs and board members say otherwise. Medical and nursing professions, which have done tremendous work in difficult circumstances in recent years, have issued statements that the position is so serious that even emergency cases may find it difficult to obtain treatment after certain times at night and at weekends. There is grave conflict of opinion about the reality of the situation. The Minister should have come out and told the House exactly what the position is and how serious the cutbacks are long before this motion was tabled.

Fianna Fáil are seriously concerned about the ruthlessness with which the less well-off section of the community is being hit; concerned that noncontributory old age pensioners and widows will no longer automatically qualify for health cards; concerned that the guide scale for eligibility for a health card laid down by the Minister is as low as £28.50 per week for a married couple; concerned that every effort is now being made by health boards to cancel health cards and reduce the number of holders in each board's area. Fianna Fáil deplore the fact that health boards, with the Minister's approval until now have to be so low as to cancel health cards held by small farmers by taking grants paid through the Department of Agriculture and Fisheries into consideration when calculating their means, grants required to enable these smallholders to develop their farms. Does the Minister consider that a married man with an income of £29 per week could, in the case of illness, pay general medical practitioner fees and also pay for drugs for himself or for his wife or perhaps for both, particularly when the value of money is dropping rapidly as a direct result of the failure of the Coalition Government to control inflation and implement any form of price control for essential goods including drugs and medicines?

The real cause of the collapse of the health services is the mismanagement of the country's financial affairs by this Government. It is despicable that medical card-holders will no longer be entitled to free transport to clinics and hospitals. Yesterday I met a man who had to get a day off from work and get a friend to do likewise to travel to Dublin and bring back by train at his own expense his retarded son in a wheelchair from a Dublin hospital to a home for handicapped children in County Kerry, having been told by the Southern Health Board that they were no longer allowed to send nurses or other trained staff on such business and that ambulances would no longer be travelling to Dublin as often in the months ahead as in the past five years. This is a clear example of how Government policy in a panic financial situation leans heavily on the less well-off people.

I reject the allegation that the transport scheme to clinics and hospitals was abused to the extent that it should be cancelled altogether. Health boards have sufficient senior managerial employees to ensure that the very few abuses which exist are rectified. I also reject completely allegations that the medical profession are negligent and are over-prescribing. As a layman with a large young family I can easily visualise a situation where £500 worth of drugs could go into a particular home in any health board area in a case where through sheer bad luck one member of a family after another becomes ill in one year. In fairness, such isolated cases should not be made in defence of Government failure to provide necessary funds for essential health services for those entitled to them.

I would not expect new works to begin this year on projects being undertaken by health boards but I expect, and the people expect, a service this year which is at least equivalent to last year's level in respect of all services being provided for the lower and middle income groups.

It is a dreadful state of affairs that geriatric units in homes and hospitals are about to be closed down and that patients are being evicted out of geriatric units attached to hospitals. I cannot understand why health boards were not told last October or November that they should cut back on essential services in 1976. Is it the case that the bubble did not really burst until mid-Jauary this year? I strongly advocate that the Government provide the necessary funds for health boards by changing their priorities. The Government have got their priorities all wrong. This is the kernel of many of their problems.

I am sure the Minister is genuinely concerned about the plight of the less well-off section of our community: his problem is that he gets very little assistance or encouragement from some other strong members of the Government around the Cabinet table. I appeal to him to go back to the Government for the necessary funds and avoid putting back the clock at this point in the development of the health services.

Minister for Health (Mr. Corish)

We have had a limited discussion here. I want to be as quick as I can and to say as much as I can in the limited time afforded to me. First of all, I applaud the outspoken and constructive comments of Deputy Flanagan and the suggestions of Deputy O'Connell. I certainly cannot say the same about Deputy Haughey in his carping speech in which there was gross exaggeration. Everybody is concerned about the cost of the health services, but when one tries to provide economies without damaging the services one gets the sort of contributions made by Members of the Fianna Fáil Party.

Deputy O'Connell said that the financing of the health services is a growing dilemma for practically every country in western Europe and what we have got to do is to try to get value for money. However, Deputy Haughey talked about the economy. It must be obvious to everybody who spoke on this motion that the Government, as indeed Governments throughout the world, have not willingly—I include Great Britain in this —taken action to restrict the rate of growth in health expenditure. Needless to remark, we would have liked to have seen significant progress recorded in our health services during the year, and particularly in 1976, but this is not possible because of the serious economic situation in which this country and other countries in Europe find themselves.

There is no need for me to spell out or to detail the gravity of this situation. The cause of the recession is well known and, despite what has been said, is largely outside our control. We are sharing a recession which is experienced by most western countries and we are coming through that international downturn with greater confidence than many others. If it were not for the courageous and liberal monetary measures adopted by the Government our present position would be far worse than it is. Indeed, if it were not for the fact that the Government have deliberately adopted a policy of large budgetary deficits combined with substantial borrowing not only would our overall economic position be much graver than it is now but our health services would have undergone restrictions in expenditure not only this year but last year as well. I have no hesitation in saying that if Fianna Fáil were in power at the present time our economic position in general and our health services in particular would be considerably less healthy than they are under the present Government.

Mr. Haughey

They could not be worse.

Mr. Corish

The Deputy will hear me out for half an hour. I did not interrupt him. He will have his say later on and he can make his points then. Deputy Colley, the colleague of Deputy Haughey and spokesman on Finance and former Minister for Finance, has said continuously, even during the Ard Fheis, and particularly over the past three years, that the Government's budget deficits should have been maintained at much lower levels than has been the case. He is an exponent of economic orthodoxy, as we all know from his years as Minister for Finance and subsequent to that. The effect of this kind of budgetary conservatism would have been to plunge our economy into a far greater crisis than we now face.

Mr. MacSharry

I thought it was over.

Mr. Corish

One does not have to be an economic genius to know what the effects of this kind of balanced budgetary policy would have done to our social services. Deputy Colley's call for more balanced budgets was combined with demands for cuts in public expenditure, not once but frequently. I believe this disastrous recipe which he consistently advocates would have meant not only a deepening of the economic recession in Ireland during the past two years but also cuts in real terms in our social welfare services and in our health services as well.

The Government did not take that road of economic repression. We cast aside the economic orthodoxies of the past and worked instead for a balanced policy which sought to maintain the highest possible level of economic and social activity consistent with the international difficulties we faced. Our policy of economic liberalism has enabled us to weather the acute economic storm with remarkably little damage considering the open nature of our economy and its vulnerability to international economic trends.

One would imagine from statements from the Fianna Fáil Party that we were a complete island and could remain unaffected by outside events. As far as our social services are concerned the fiscal policy adopted by the Government has enabled consistent gains to be made throughout the period of recession. That has been a remarkable and almost a unique achievement. In the case of our health services there can be no doubt about the gains made during the past three years, two of which were years of extreme economic difficulty.

Deputy Haughey does not like figures, or so he said last night, when one talks about health expenditure, but I want to give him some figures. The total public non-capital expenditure on health increased from £107.4 million in 1972-73 to an estimated £233 million in 1975. This represents an increase of 117 per cent in money terms and approximately 16½ per cent in real terms. The rise in the Exchequer's contribution to health expenditure has been even more dramatic during that period, rising from £67 million in 1972-73 to £213 million in 1975, an increase of 318 per cent. Therefore, nobody can allege that the Government have stinted on the health services.

Health expenditure as a percentage of gross national product rose dramatically during the period in question. It rose from just under 5 per cent in 1972-73 to over 6 per cent last year. I believe this figure more than any other indicates the progress that has been made in health during the last two years of recession. It demonstrates clearly the Government's commitment to this service since by deliberate policy we have enabled our health services to grow at a faster rate than the economy as a whole. Deputy Haughey appeared to be generous last night, as generous as he was when we had a dispute with the doctors early last year and with the pharmacists later in the year. His solution to the whole problem was to give them the money, no matter what they demanded. Of course, he was not Minister for Finance then, but when he was he was not so lavish or so givish as far as the health services were concerned. I think I will be right when I mention years during which Deputy Haughey was Minister for Finance. In the year ended 31st March, 1967——

Mr. Haughey

That is a long time ago.

Mr. Corish

It does not make any difference. It is an example of the Deputy's generosity.

Mr. Haughey

Talk about today.

Mr. Corish

I will talk about today in a few moments. I will refute some of the allegations, I will not call them lies, that the Deputy made last night.

Mr. Haughey

There were no cutbacks in my time as Minister for Finance.

Mr. Corish

The Deputy is ashamed of the record but I will quote it. As a proportion of GNP, at 31st March, 1967, the health services got 3.2 per cent; at 31st March, 1968, it was still 3.2 per cent; in 1969, it was the same percentage and in March, 1970, it was 3.4 per cent, an increase, as a proportion of GNP, of 0.2 per cent.

Mr. MacSharry

What is the present proportion of borrowing in relation to the GNP?

Mr. Haughey

I never cut out meals-on-wheels.

Dr. O'Connell

There never were meals-on-wheels in those days.

Mr. Corish

That is not a record to be proud of. It emphasises our achievement compared with Fianna Fáil. We deliberately set out to continue growth in our health services at a faster rate than growth in the economy as a whole. This is the policy that is under attack by a party whose budgetary policies, if they had been in office during the past two years of recession, would have been to reduce budget deficits and to cut expenditure, including expenditure on health. If we are to take the policy of Deputy Colley it means that though various services are demanded the policy is to borrow less, to have a smaller deficit and to have less taxation. I am sure if he returns to the Department of Finance he will want to work that out and it will take him quite a long time to do it.

Mr. MacSharry

That is where good management comes in.

Mr. Corish

The substantial increases in health expenditure to which I referred have enabled major progress to be made in our health services since this Government took office. This progress has been recorded throughout the whole range of services for which I am responsible, and I propose to list some of the more outstanding examples.

One of the main items has been the dramatic increase in employment in the health services. In 1972-73, 42,000 persons were engaged in delivering health services at all levels. Today that figure is 47,500, an increase of 5,500. This increase has benefited our employment situation throughout the country in a time of recession and has also led to an undoubted qualitative improvement in all the health services offered to our people. The percentage of the population covered by medical cards has increased from 28 per cent to 36 per cent since we took office in March, 1973.

Mr. MacSharry

There is more poverty now.

Mr. Corish

This was done in an attempt to ensure that the expense of primary medical care would be removed from as many people as possible who suffered hardship through medical expense. There are also the illnesses for which drugs and medicines are provided free of charge to all patients, that is, without means tests. A constant care allowance of £25 per month in respect of handicapped children was introduced, again regardless of the income of parents. The number covered by disabled persons' maintenance allowances was increased from 25,700 in 1972-73 to 27,000 in 1975 largely as a result of the easing of the means test for eligibility for this allowance. Financial support and other assistance have been provided towards the establishment of a network of community advice centres throughout the country and our social work, home help and so on, have been improved dramatically. In the case of the home help service, expenditure has risen from £150,000 in 1972-73 to an estimated £1 million this year. Training facilities for handicapped people have been improved at a rapid rate.

I could continue with this list of improvements if time let me do so. I will content myself by stating that the significant increases in expenditure which I have outlined have led to substantial improvement in our health services overall. The fact that 5,500 more people are employed in the services is an indication of this because in a labour-intensive service like health every additional person employed, particularly in the professional field, adds to the quality of the service provided. There can be no doubt that the health services today are a significant improvement on the services we inherited when we took office.

These improvements have been brought about despite the economic recession. Unfortunately this will not be possible in 1976 for sound economic and social reasons. During the past two years because the economic recession was deepening internationally the Government deliberately pursued a policy of large budget deficits, the objective being twofold: one, to cushion our people against the potential ravages of recession by boosting public expenditure, including social service expenditure; and two, to maintain internal demand at the highest possible level. This, in effect, meant that the Government pursued a policy of considerable borrowing to pay for current services. That policy has proved successful. Our people have been cushioned against recession to a considerable degree, to a far greater degree than if Deputy Colley were Minister for Finance.

However, this year our policy had to be changed somewhat in relation to social services, with the exception of social welfare benefits, and I will be completely honest about the reason for this. In the first place, I think it is generally agreed that with prudence we cannot allow our budget deficits to increase beyond the present level. This would involve us in borrowing in excess of the level that would be prudent at this time. Secondly, within the limits imposed on us by the present level of deficit, the Government have decided to shift additional resources towards industrial development and job creation, something to which Deputy Haughey seemed to take exception last night.

There has been a reason for this. It has been done because it appears an international upswing is on the way and because it is necessary to prepare ourselves for this and to move towards higher levels of economic growth as rapidly as possible, and so to produce the wealth which will finance further development in our social services, including services for health. As far as health services are concerned it will not be possible to undertake any new development in 1976 for the reasons I have mentioned, which are that we have got near the prudent limit of deficit financing, and the social services, with the exception of social welfare, should stand still in 1976.

The short-term objective of Government policy as far as health services are concerned is to maintain the 1975 service levels throughout 1976. This objective has been notified to health boards and will form the basis of their decision-making throughout the year. It is an objective which I note from one of last Sunday's newspapers and from his own comments on the motion last night to which Deputy Haughey subscribes. Now we ought to be honest with ourselves. It is the only responsible objective any Government could have for our health services at this time. No one with any knowledge of the economic facts of life facing the country could expect anything but a holding operation in our health services in 1976.

In the time remaining to me I would like to spell out in as much detail as possible the steps we are taking to ensure that the 1975 service levels are maintained throughout the year. Non-capital health expenditure will rise from an estimated £231 million in 1975 to an estimated £262 million in 1976. This represents an increase of approximately 13 per cent in non-capital overall expenditure. Direct expenditure by each health board will rise by approximately the same percentage. It is my view that given reasonable economies by health boards and given very tight control over every item of expenditure it should be possible for each board to maintain its 1975 service levels throughout the year with this level of increase in expenditure. I must admit their task is not going to be an easy one. The demands on them are great and they are increasing day by day, month by month and year by year. I know it will be very difficult to effect economies in face of these demands but I believe our economic situation requires that every possible economy which does not affect the level of service should be made.

When the 1976 allocations were notified to health boards in January last officials of my Department immediatley entered into consultations with officials of the boards both on the question of the kind of economies that could be made in each case and on the need for month by month monitoring of expenditure. I am pleased to say that these consultations, although not yet completed, are working out extremely well. As far as economies are concerned, my objective has been to see that these are made in areas which do not affect service levels or, as far as possible, the quality of the service. The consultations which have taken place have shown that considerable economies can in fact be achieved. I think I should indicate what these are before I go on to refute the wild allegations made last night by Deputy Haughey concerning supposed cuts in services. First of all, 63 per cent of non-capital expenditure is accounted for by the remuneration of staffs. Inevitably therefore economies which would not affect the level of service had to be sought in this area of expenditure. As a result of our examination I am satisfied that economics involving leaving non-essential vacancies unfilled and tightening up on the use of substitutes and locums, unnecessary overtime and similar economies can be made without affecting the service. There is no question of reducing the number of permanent or temporary wholetime staff. All that will be involved are measures to achieve greater productivity from existing pay expenditure. I am aware that the co-operation of professional staff organisations will be necessary in this regard.

Secondly, I am satisfied that economies can be achieved in the purchase of supplies and equipment of all kinds. This has also been discussed with the health boards' officials and it appears this can be done although it will, of course, mean that a certain catching up will be necessary next year. Thirdly, savings can be made on maintenance costs without affecting services and this too will be done. In all a deduction of £1.26 million on maintenance budgets has been identified. This involves leaving such things as painting and repair work until next year. That is not a desirable thing to do but which of us would not put off work of this kind in our own homes in times that proved somewhat difficult? I am satisfied in short that a wide range of economies can be achieved without affecting services and that these economies will enable existing service levels in the main to be maintained.

I mentioned earlier that consultations have been taking place between officials of my Department and officials of the various health boards on the question of the economies necessary for them to operate within their 1976 financial allocations. These have not yet been completed in respect of all health boards. They have been completed in respect of the Southern, MidWestern, North-Western and NorthEastern Health Boards. In each case I am satisfied the economies of the kind mentioned which have been identified can be carried through without affecting 1975 service levels. In the case of the Western, South-Eastern, Eastern and Midland Health Boards consultations have not yet been completed. In these cases also my objective will be to help secure economies which will enable the 1975 service levels to be maintained. In the case of the South-Eastern and Western Health Boards I am confident that this objective is reasonable. The Eastern Health Board present a somewhat more difficult programme. Considerable progress has however already been made towards achieving a satisfactory solution here as well.

Since Deputy Haughey dealt particularly with the Eastern Health Board last night I would like to comment in some detail on its position at this point. Deputy Haughey rightly pointed out there was a gap of £3.7 million between what the board estimated it would require to maintain the 1975 service levels and what it got by way of financial allocation. I would like to remind him that he should be aware from his years as Minister for Finance that it is abnormal for any estimate of any subsidiary body to be accepted without examination and seldom to be accepted without reduction. In the nature of things, the body providing the money, in this case the Department of Health which provides practically 100 per cent of the money, must have a say in the examination of estimates of cost prepared by the body looking for money, in this case the Eastern Health Board. Examination between my Department and the board showed a number of instances where it was agreed items could be repriced. For example, provision made by the board for overdraft interest was reduced by about £200,000 and it was agreed the estimate provision for miscellaneous receipts could be increased by £120,000. The board's budget for maintenance was looked at. They sought £1.9 million. This is a very high figure which might be justifiable in normal times. However it was put to them that before they thought of cutting into services it would be better to reduce maintenance to a minimum. Accordingly it was agreed to reduce this provision by £700,000, which brings it back to the allowance for 1975.

These economies, together with economies associated with leaving nonessential vacancies unfilled, reducing but not eliminating locum cover, reducing overtime provision, and other economies of this kind, have resulted in an identified gap of about £700,000 in the case of the Eastern Health Board on a direct expenditure level in excess of £33 million. Discussions between my Department and the board will continue to eliminate this. In the meantime I understand the board will be considering the matter again at their meeting tomorrow night and I am sure that in the light of the studies now presented they will accept that their original figures and the possibility of particular service cuts were unfounded.

All our efforts therefore have been directed towards making reasonable economies in health service costs without affecting 1975 service levels. I think it is unreasonable that anyone either in this House or outside it should not accept that economies of the kind I have mentioned are necessary in the present economic climate. I would submit that they are both necessary and reasonable. It is unreasonable to expect that, at a time when every sector of our economy is under pressure, the health services should not be under similar pressure. It is not only unreasonable but also malicious.

Deputy Haughey, in the course of his contribution last night, made a number of allegations in which he mentioned specific cutbacks in services which he felt were about to happen. Almost all of these allegations are without foundation and I refute them here and now. The general medical service will not be cut back, as he asserted here last night. I do not know on what grounds he made that assertion, but I am stating here and now that there is no truth in it whatsoever.

Mr. Haughey

What assertion?

Mr. Corish

The general medical service will be maintained at its 1975 level in 1976.

Mr. Haughey

The Southern Health Board do not agree with it.

Mr. Corish

Of course they do not agree. They want more money.

Mr. Haughey

No. They are cutting out medical cards for old age pensioners. We have it in writing.

Mr. Corish

I do not know what the Deputy has in writing, but it has been alleged that this direction came from me. It did not come from me. Deputy Haughey also referred to the situation in the Dublin voluntary hospitals in terms which could cause undue alarm. I hope he did not mean to do that.

Acting Chairman (Mr. Pattison)

I would draw the Minister's attention to the fact that his time is just up.

Mr. Corish

Deputy Haughey alleged cuts of up to 20 per cent in the budget and said in respect of the voluntary hospitals that if hospitals were to maintain staff they could not keep patients. He said that the essential back-up service for accidents would be affected and that the Mater, Jervis Street and St. Laurence Hospital would each have to close down 50 beds. There is no question that these hospitals will have to close down 50 beds. The rumour he mentioned is only a rumour and a malicious one at that.

The differences he mentioned between allocations and budgets in the case of the Dublin voluntary hospitals are grossly exaggerated. In the case of the health boards, expectations of voluntary hospitals always differ from what they get, but discussions are going on between the voluntary hospitals and my Department.

Deputy Haughey also referred to certain proposals for savings listed by the CEO of the Eastern Health Board for consideration by the board members. They were listed by the CEO, as Deputy Dr. O'Connell said, as possible ways of bridging the gap of £3.7 million which he then believed required to be bridged. These proposals which Deputy Haughey indicated, namely, a reduction in the limit from five to three years for free milk, the introduction of a means test in the constant care allowance scheme, and the discontinuance of the routine child health examination scheme were not accepted by the board and certainly have not been accepted by me.

Acting Chairman

I would ask the Minister to conclude.

Mr. Corish

I thought I might have got a five-minute warning as other Deputies did. However, there is quite an amount to be said as far as health expenditure is concerned. Deputy Haughey seemed to sneer at the fact that I was getting less than was my due. I am getting 18 per cent of total expenditure and that is the same percentage as I got last year.

People are concerned with the expenditure in the health services and I am also concerned. I certainly would subscribe to the idea that has been mooted by Deputy Dr. O'Connell and by Deputy Séan Flanagan of a review body and the establishment of a finance board committee in the board. I will certainly recommend that to the various health boards, and I will give consideration to the establishment of a committee which would consider expenditure on the health services. It was never my intention or the Government's intention to look for cuts, but in view of the fact that Fianna Fáil themselves have complained about over-expenditure——

Mr. Haughey

Are you going to enforce the time-limit, Sir?

Acting Chairman

I have asked the Minister to conclude.

Mr. Connolly

I gave the Minister the benefit of the doubt.

Mr. Corish

I thank the Deputy very much.

Mr. Connolly

It was most interesting to hear the Minister for Health on this subject, because he went away back to 1967 and referred to the statistics at that time. The two periods are not comparable, because there is a different situation now altogether. All we are asking for in the motion is that the services that we had last year be maintained. In the Midland Health Board area there is a reduction of £900,000 involved. At a meeting of the Midland Health board three weeks ago, all we were able to pare off that was £500,000. They have to make various cuts in the personnel, and when it comes to personnel it is always the man or woman at the bottom of the ladder that is affected. The Jubilee nurses, who are involved in relief work, will have to go. That is the position in the Midland Health Board area and I am sure it is the same all over the country.

The Midland Health Board need £400,000 to give the same service as last year, but they may not have the personnel to implement it. Co-operation is needed from the personnel available and it will be recalled that when the Minister tried to bring in free hospitalisation—or should I say bulldoze it in—he had to abandon it because he did not get co-operation. He is now depending on the co-operation of the personnel, and there is great concern among the staffs in the health board areas that redundancies or termination of employment may take place. If the boards have to enforce cutbacks they will affect services, medical cards, meals on wheels, home help and so on. How can we give the services we gave last year without an increase in finance? Everybody knows that inflation has increased the cost of services. I estimate that the total cut-back in all areas on the original estimates they submitted to the Department of Health is close on £10 million.

We must take into consideration that the health board's estimate was only an estimate and it can fluctuate. There is always a short fall in estimates. If inflation increases by 10 per cent what will the position be? Can the health boards then go back to the Department of Health and ask for more money when they are not able to get the money they are looking for now? Before the end of the year I can see the boards being caught up in a very serious situation unless additional money is made available. Recently the Offaly Health Committee and other health committees all over the country had this community care booklet before them. It is very elaborate and there is a lot of good material in it. At that board meeting I said that I knew what was in it and that most of it could not be implemented, because we needed money to implement it and I knew that the money would not be forthcoming from the Minister for Health. What is happening now is that the patients in the Midland Health Board area who should be getting extern hospital treatment are being sent into what I call convalescent homes in the region, whereas previously if the various hospitals were not able to treat them they would be sent to the Mater, St. Vincent's, or other hospitals in Dublin, where they would get the right treatment. I believe that is all being done away with due to the financial position.

I have never known the Fianna Fáil Party to reduce the health services. Any Government that reduce the services are not worthy of the name of Government because they are attacking the health of the people and the children who will be running this country in the years to come. This Government are also hitting the underprivileged, the people who are less well able to defend themselves. If heating breaks down in a hospital and there is expense involved, will the hospital be told that it must remain out of action? It would be a sad day if that happened. With regard to drug abuse, in the area I come from I could not say that this happens. I could not say that the medical profession have been guilty of abuse in that line. The only drug abuse I can think of is in the care of the mental patients who attend outpatient clinics. As you all know, this is a very complex illness and there may have been some abuse in the drug line, but it was through no fault of any doctor. Now there is talk also that the GPs have been exploiting medical cardholders by making calls that are not needed. If a doctor fails to call on a medical cardholder, and that man gets a heart attack, who is going to take the blame then? It will not be the Minister for Health nor the CEOs of the health board. It will be the doctor.

In regard to transport, I do not know of any transport being abused in the Midland Health Board area. Only medical cardholders have transport in the Midland Health Board area. I can assure the Minister that it was well checked out before transport was given to anybody.

In regard to the care of the aged, the people who are looking after community care will have to go around the health board areas to see who is fit to go home. Some of these people have no homes to go to because some of them are over 80, but if they are able to walk out of hospital they will have to go. I do not want to paint a very black picture and I hope I am not doing that but that is the position in my area. At a recent meeting the health board said they would not be able to give the same services as last year unless they received £400,000 more. As I said earlier, it is only an estimate. I can see expenditure increasing before the end of this year by another half a million and I would not be surprised if it went up to a million pounds.

I hope the Minister for Health and the officials of his Department, whatever cuts are brought about, will not tamper with the welfare of the patients. Money from other Departments should have been channelled into the Department of Health to keep the services up to last year's standard. I hope that common sense will prevail and that no drastic cuts will be made.

Mr. MacSharry

In relation to this financial allocation for the health services, the Minister accused many of us at Question Time of political propaganda in relation to the cutbacks that may take place in the financial allocations made by him to health boards. On the one hand the Minister is still stating that there will not be any cutbacks in services, and on the other hand that there will be and has to be an elimination of overtime, that people on holidays will not be allowed to have a locum, people who are sick will not be allowed to have locums provided for them. Is that not in effect a cut-back in the level of service? In some rural areas it will mean a complete elimination of medical cover in many respects.

The Minister accused us initially of making political capital out of the fact that sufficient money was not being provided to have a level of service in 1976 compared with what was there in 1975. We have had health board meetings all over the country and many of the CEOs have gone into print and stated quite clearly that with the allocations they have received they cannot survive and give the same kind of service in 1976 as in 1975. Some of them, particulary in the north-west, say that there has to be a 6 per cent cutback in the 1975 level service. Those are not my words but the words of the Minister's chief executive officers administering health services on the Minister's behalf. The allocation, as it is known, is going to mean an effective 6 per cent cutback, and this does not take into account the rise in wages that may and will come according to the Minister for Labour's statement over the weekend.

Is the Minister not going to allow the health boards to pay the increased cost of wages if they come, which they must? There is no provision either for any increase in commodity prices which the Minister knows well are going to rise at least 10 to 15 per cent in the course of this year. What will our health boards do then? Are they not to buy the required medical goods for distribution, let them be medicines or materials needed for all the hospital services? The Minister in his circular letter to the health boards, HSG 354, stated that it was his intention to implement section 31 of the Health Act, 1970 so as to fix the limit of expenditure which may be incurred by health boards in 1976.

This is the dictatorial attitude that has many people involved in the operation of the health services very worried. If this section is operated, bearing in mind the fact that there must be wage increases and also commodity price increases, and the Minister knows well there will be, he is being dictatorial in relation to his side, that the health boards will not be allowed over-expend on the financial allocation given to them by him.

An Leas-Cheann Comhairle

Deputy Haughey is now entitled to the remaining 15 minutes unless he gives way.

Mr. MacSharry

I am very pleased to give way to Deputy Haughey. I would like to be allowed one final word. We are all concerned about the unemployment level, and the Government have a £600 million capital programme allocation for this year. The total amount for capital works allocated to health is £11 million. Is the Minister satisfied? I do not think he should be.

Mr. Haughey

A Leas-Cheann Comhairle, attempts have been made to introduce irrelevancies into the discussion on this motion which we have put forward. Three different sorts of irrelevancies have been introduced. First, the economic recession has been put forward as the scapegoat. Indeed, the Minister for Health in replying to this motion on financial provision for the health services in 1976 talked a great deal about the world economic recession and the economic recession in this country. I want to suggest that the economic recession, either in the world at large or in this country, has nothing whatsoever to do with this motion. We are concerned in this motion with the financial disposition of the Exchequer for health during 1976. We could deal with this problem in regard to the health services entirely within the context of the existing budgetary provisions. If the proper priorities were adhered to by the Minister for Finance and the Minister for Health this problem that we are highlighting in this motion could be dealt with and settled.

We have also had trotted out the old reliable that the new regional health boards are unworldy, bureaucratic institutions and that is where all our troubles lie. Allied to that is the argument that there is a great deal of abuse of the existing services and therefore our resources are being wasted. Always in times of cutback of this sort you will find some Colonel Blimp type of person leaping to his feet and complaining that there is scandalous waste in the administration of the services, as we have in the case of the Southern Health Board's taxis. The whole trouble in our health board services apparently emanates from the over-use of a few taxis down in County Cork and County Kerry. I think Deputy John O'Leary dealt satisfactorily with that.

If there is excessive bureaucratic machinery, if there is abuse and waste of the health services, there should be a continuing, ongoing process to deal with that situation. I suggest it has nothing whatsoever to do, except in a remote and indirect way, with the problem to which we are directing our attention in this motion. We are not concerned with the fundamental restructuring of the health services. We are not concerned with the long-term financial implications of the health services as part of our budgetary problems. They are important matters, and perhaps if this crisis does nothing except focus attention on the need for some thinking about them by the Minister and his Department, it will have served some purpose. They are matters which should engage the attention of this House and its Departments at another time in another way. What this motion is concerned with is the immediate critical situation which confronts us now, in 1976, in regard to the specific financial implications for 1976, and nothing else. It is no good Deputy O'Connell coming in here, decent, honest and sincere person though he is, and trying to divert the argument into these channels. That is not what is relevant or what we are concerned with. We are concerned with the cutting out in 1976, starting now, with urgent essential health services, basic services to which this community is entitled and must have, and which it is the duty of any competent Government to provide.

By all means let us have all-party committees of the House to look into the health services, restructuring of the regional health boards, in-depth examination of the relationship between the cost of health services and the GNP, all very useful and important, but not concerned with the situation that is confronting Dáil Éireann now in 1976 in regard to fundamental community services and to the essential care of sick people in our hospitals, because that is what we are concerned with here. What the hospitals want to know is, are they going to get adequate budgets to enable them to carry out a normal service during the coming year? What the health boards and the programme managers want to know is, are they going to get the funds to enable them to carry through their basic programmes during 1976? That is the key question and that is what this motion is all about, and nothing else.

The secretary of the Department of Health stated categorically to the CEOs, and indirectly to the health boards, that section 31 is going to be invoked and not another penny is going to be forthcoming and that the moneys which are now allocated and made available are all that is going to be produced. There is no good in the Minister waffling here and giving us all sorts of irrelevant statistics and percentages. The fact is we know the figures of the allocation.

The Secretary of the Department has said that those figures will be adhered to. We know further that the basic essential services cannot be provided on the basis of those allocations. Speaking about the CEO's and the regional health boards the Minister said that they should be able to maintain services at the existing levels with the allocations they have been given.

In this context let me quote the CEO of the Eastern Health Board who said:

...the Board is accordingly faced with the task of securing a major reduction of £3.72 million in expenditure in 1976 and it is clear that the level of services must be affected

Either he or the Minister is correct and he is the man on the job. He went on to say:

Paragraph 11 of the Department's letter stresses that adequate provision must be made to support certain items throughout the whole of 1976. It is clear that it would not be possible to achieve a reduction of £3.72 million in our estimate of £10.29 million. It is difficult, therefore, to see how the Board can avoid reducing the level of services including staff numbers and the payments to extern agencies.

Is this man a fool or is he a competent reliable official?

Mr. Corish

Can the Deputy give the date of that letter?

Mr. Haughey

It is dated 19th January, 1976. He is not alone in that. The CEO of the Southern Health Board, who, presumably, is equally honest and competent says:

The cut-back of expenditure of close on £1 million to meet the cost of existing services cannot be achieved by minor economies here and there....

It is not merely a question of postponing some little bit of painting, for instance. He continues:

It will necessitate quite severe measures and no area of the Board's service can fully escape their consequences. It is necessary that this situation should be clearly understood by everyone....

He might have added the words "and the Minister for Health".

The Board has been able with the moneys available to pursue a steady programme of improvement of services over a number of years. The changed position in which it now finds itself is that not alone is there no money for new services of any kind but a severe cut-back in spending on present services must be made.

The CEO of every other health board has made the same sort of report. These are reports based on the figures before them. Therefore it is totally dishonest for the Minister to pretend here that somehow or other this situation will be attended to. I have heard nothing from the Minister which in any way would deflect Dáil Éireann from passing this motion. The Minister has talked a great deal about the economic situation and about various irrelevant matters. He has given us percentages for the years but these do not in any way affect the validity of the motion before us. It is clear that our health services, on the basis of the allocations made, are facing a major dislocation this year. The provisions that have been made are totally inadequate and there is no way in which they can permit the services being maintained at their present levels.

The voluntary hospitals in this city and elsewhere are in a state of total disarray. Medical staffs, nurses and lay staffs are all threatened either with dismissal notices or are facing serious interference in their working conditions and their hours of duty. The budgets that have been put before the managements of these hospitals are clearly inadequate to meet the basic needs for the coming year. That would not be too bad if they could be assured that somewhere during the year they would be rescued but we know from the Secretary of the Department that there will be no additional moneys provided. We want the additional moneys provided now or, at least, promised now.

Last night I gave details of the shortfalls in the operating budgets of each health board, starting with £3.72 million for the Eastern Health Board. We know that the various deficits are those which are only obvious on paper at this stage but with increasing VAT, increases in wages and taking into account all sorts of contingencies and emergencies these deficits will be increased considerably. The allocations will result in curtailment, reductions and closedowns, as I indicated last night.

I could elaborate again on the various aspects of the services that will be interfered with. One such area will be the basic humanitarian community service such as meals-on-wheels, free milk for children and so on. One of my colleagues here told me of an incident which occurred a couple of days ago in an old person's home in Ennis when an old person of 80 was ordered out by the authorities and had to go home to live in a cottage with an elderly unmarried brother. This is the sort of thing we are talking about here. We are not concerned with normal economies. We agree with good budgeting and with effecting savings, but we are concerned at the cutbacks and the restrictions that will result in positive hardship and suffering and which will interfere with the standard of medical care that our people will receive. This situation is resulting in those dedicated humanitarian people engaged in the health services being driven to engage in mean, despicable, shabby experiences, and in brutal and uncaring things in order to endeavour to operate within their budgets.

I extend again an invitation to the Labour Party backbenchers, who down through the years have been telling us of their great humanitarian and social principles, of their concern for the poor and for the underprivileged. In particular, when Fianna Fáil were in office we heard this hail of consideration for the poor and weaker sections. Now is their opportunity to show that they really meant those statements. I know that there is none of them present at the moment, but at least that decent, honest man, Deputy O'Connell, had the courage to come in and talk about the motion. We on this side of the House have not enough voting strength to make the Government do their duty, to make them provide simple, basic elementary health services for the people.

An Leas-Cheann Comhairle

Does the Deputy wish the question put?

Mr. Haughey

The Minister went over his time by a couple of minutes and I intend to do the same. We cannot do much because of our voting strength but if three or four of those Labour Deputies who always maintained their great humanity vote for us on this motion we would make the Government do their duty. We would stop the Government putting out meals-on-wheels, closing down hospital wards and puttng old men out of homes. If the Labour Deputies would stand by their principles Dáil Éireann would show that it is the protector of the weak and the disabled sections of the community.

Mr. Corish

That is a lot of exaggerated bull and the Deputy knows it. He was not very generous as Minister for Finance.

Mr. G. Collins

The Minister should not lose his temper.

Question put.

The Dáil divided: Tá, 61; Níl, 66.

Tá

• Allen, Lorcan.
• Andrews, David.
• Barrett, Sylvester.
• Brady, Philip A.
• Brennan, Joseph.
• Briscoe, Ben.
• Brosnan, Seán.
• Brugha, Ruairí.
• Burke, Raphael P.
• Callanan, John.
• Calleary, Seán.
• Carter, Frank.
• Collins, Gerard.
• Connolly, Gerard.
• Crinion, Brendan.
• Cronin, Jerry.
• Crowley, Flor.
• Daly, Brendan.
• de Valera, Vivion.
• Dowling, Joe.
• Fahey, Jackie.
• Farrell, Joseph.
• Faulkner, Pádraig.
• Fitzgerald, Gene.
• Fitzpatrick, Tom (Dublin Central).
• O'Connor, Timothy.
• O'Kennedy, Michael.
• O'Leary, John.
• O'Malley, Desmond.
• Power, Patrick.
• Smith, Patrick.
• Flanagan, Seán.
• French, Seán.
• Gallagher, Denis.
• Geoghegan-Quinn, Máire.
• Gibbons, Hugh.
• Gibbons, James.
• Gogan, Richard P.
• Haughey, Charles.
• Healy, Augustine A.
• Hussey, Thomas.
• Kenneally, William.
• Kitt, Michael P.
• Lalor, Patrick J.
• Leonard, James.
• Loughnane, William.
• Lynch, Celia.
• Lynch, Jack.
• McEllistrim, Thomas.
• MacSharry, Ray.
• Meaney, Tom.
• Molloy, Robert.
• Moore, Seán.
• Murphy, Ciarán.
• Nolan, Thomas.
• Noonan, Michael.
• Timmons, Eugene.
• Tunney, Jim.
• Walsh, Seán.
• Wilson, John P.
• Wyse, Pearse.

Níl

• Barry, Peter.
• Barry, Richard.
• Begley, Michael.
• Belton, Luke.
• Belton, Paddy.
• Bermingham, Joseph.
• Bruton, John.
• Burke, Dick.
• Burke, Joan T.
• Burke, Liam.
• Byrne, Hugh.
• Cluskey, Frank.
• Collins, Edward.
• Conlan, John F.
• Coogan, Fintan.
• Cooney, Patrick M.
• Corish, Brendan.
• Cosgrave, Liam.
• Costello, Declan.
• Coughlan, Stephen.
• Crotty, Kieran.
• Cruise-O'Brien, Conor.
• Desmond, Barry.
• Desmond, Eileen.
• Dockrell, Maurice.
• Donegan, Patrick S.
• Donnellan, John.
• Enright, Thomas.
• Esmonde, John G.
• Finn, Martin.
• FitzGerald, Garret.
• Fitzpatrick, Tom (Cavan).
• Flanagan, Oliver J.
• Gilhawley, Eugene.
• Governey, Desmond.
• Griffin, Brendan.
• Harte, Patrick D.
• Hegarty, Patrick.
• Hogan O'Higgins, Brigid.
• Jones, Denis F.
• Keating, Justin.
• Kelly, John.
• Kenny, Enda.
• Kyne, Thomas A.
• L'Estrange, Gerald.
• Lynch, Gerard.
• McLaughlin, Joseph.
• McMahon, Larry.
• Malone, Patrick.
• Murphy, Michael P.
• O'Brien, Fergus.
• O'Connell, John.
• O'Donnell, Tom.
• O'Sullivan, John L.
• Pattison, Seamus.
• Reynolds, Patrick J.
• Ryan, John J.
• Ryan, Richie.
• Spring, Dan.
• Staunton, Myles
• Taylor, Frank.
• Thornley, David.
• Timmins, Godfrey.
• Toal, Brendan.
• Tully, James.
• White, James.

Tellers: Tá, Deputies Lalor and Healy; Níl, Deputies Kelly and B. Desmond.

Question declared lost.