I move:
That a sum not exceeding £249,983,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of December, 1976, 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.
As is now the established practice, I have circulated a volume of statistical material on the health services and on the population which they serve. It contains a statistical description of the different programmes as well as information on population structure and on vital statistics. I arranged that Deputies would have copies of this document in advance of this debate so that they would have the opportunity before this debate of having up-to-date information.
I might mention that I am thinking of having the statistical volumes for this and future years published and placed on sale, so that they will be generally available.
When this Government took office in 1973, it committed itself to securing that there would be considerable improvements in our social services. Few would deny that this undertaking has been fulfilled within the limits of our resources. In particular, the Government undertook to remove health charges from the rates on a phased basis. This undertaking has been almost fulfilled by now and there will be no charges for health on the rates in 1977.
As well as fulfilling this undertaking to remove health charges from the rates very generous additional provision has been made to enable health services to be developed at an unprecedented rate. Growth rate in real terms over the three years up to 1975 was 16½ per cent considerably in excess of the growth in the economy generally.
It was inevitable that in considering what could be provided for Health in 1976 account would have to be taken of the serious economic difficulties facing the country, of the competing claims of other branches of the public services and of the very real development in the health services in recent years which I have mentioned. The Government had to think in particular of the need to give reasonable priority to job creation and preservation, national security and social welfare.
While it was not possible to provide for continued growth of health services in real terms in 1976 it should be noted that the Health share of over-all non-capital Exchequer allocations is not less than it was in 1975. The total non-capital allocations provided in the 1975 Estimates for all services was £960 million. The Health share, excluding capital, was £171 million or about 18 per cent. Of the total non-capital Exchequer allocations of £1,347 million for 1976, Health got £242 million, which is also 18 per cent of the total.
In 1976, therefore, the general aim is to maintain services at 1975 levels. Because of the circumstances which I have mentioned, it was recognised that growth in real terms in the health services in 1976 would not be possible. I have admitted this before. Because of the considerable expansion of services undertaken in recent years, our health services are better geared to face a relatively brief period of pause than would otherwise have been possible.
The response to my appeals to health agencies to make every possible effort to maintain services at 1975 levels has been encouraging. Health boards, which have been the subject of so many criticisms and strictures, have demonstrated their willingness to get on with the task of effecting reasonable but necessary economies. So have other health agencies. I would like to take this opportunity of thanking them publicly for their efforts.
It has to be accepted in present circumstances that no health agency can be free to determine on its own what its expenditure programme will be. Control of expenditure programmes is unavoidable. Good management postulates that constant reviews of expenditure and budgetary allocations take place and that reasonable remedial action is taken if this should become necessary.
There has been much talk about whether we are getting value for money. One of the primary tasks of management is to review expenditure in detail, to effect economies where this is possible and to eliminate waste wherever it is found. This tightening-up process will ensure that value for money is being obtained on the existing pattern of services. A further task of management is to review existing expenditure patterns and evolve proposals for diverting some of its resources to areas where it is considered that greater benefits would result.
I indicated in a reply to a Dáil question last month that in response to suggestions from health boards I was considering making certain changes to the existing health services regulations to provide for the amendment of the base figures which apply in the case of the scheme for the subsidisation of drug purchases. Regulations have now been made and will be laid before the House. The effect will be to increase the levels fixed in April, 1972, in line with changes in the consumer price index since that time. I am satisfied that it is a reasonable approach and consistent with similar action taken in other spheres of activity.
I should perhaps mention at this stage that, in accordance with the statutory requirements contained in the Health Act, 1970, I am arranging to have copies of the audited abstracts of health boards' accounts in respect of the years 1971-72 and 1972-73 laid before each House of the Oireachtas.
The health boards assumed responsibility for the administration of the health services on 1st April, 1971. Their first accounting year was the financial year 1971-72. The audit of the accounts for the years 1971-72 and 1972-73 was only recently completed in the case of each of the eight health boards. The audit of the accounts for the year 1973-74 and the period April-December, 1974, is expected to be completed in the present year, and the audit of the accounts for 1975 will then commence. There were a number of factors which delayed the completion of the earlier years' audits. As Deputies will appreciate, some considerable time elapsed before the newly constituted health boards could recruit the appropriate staff and were in a position to organise their accounting systems and procedures on a centralised basis. Indeed, for the first year or so of their operation much of the administrative work of the boards was discharged for them by the former local health authorities on an agency basis. These problems have now been resolved, however, and, as I have mentioned already it is hoped to catch up with the arrears of audit during the current year.
The abstracts of accounts as presented to both Houses are in the format which obtained for local authorities generally prior to the establishment of the health boards. This format has been continued as an interim arrangement but a working party which I set up last year are at present examining the question of a standardised form of accounts more suited to health board requirements. I understand that good progress has been made by the working party and that it is expected that these standardised forms of accounts will be prescribed for 1977 and ensuing years.
I should now like to turn to the specific developments in the past year in the various services. First, I will deal with general issues on eligibility.
As I explained recently to the House, I propose that the level for limited eligibility for health services be raised to a uniform level of £3,000 and I have circulated draft regulations for the approval of the House, with some explanatory notes. This is a complex matter but I will try to explain the essentials of it as simply and as briefly as I can.
Persons with limited eligibility are entitled to certain health services, principally hospital in-patient and out-patient services. The categories who come within the "limited eligibility" definition are, first, insured workers and their dependants, secondly, farmers with a valuation of £60 or less and, thirdly, other non-insured persons. Different rules for calculating eligibility apply to each of these.
Insured workers and their dependants make up about 70 per cent of the total eligible and I will deal with them first. They can be divided as between manual workers and non-manual workers. For the manual workers, there never has been and there is now no income limit, so that the change to £3,000 a year which I propose does not affect them in any way.
For non-manual workers, the limit originally fixed in 1953 at £600, has been adjusted from time to time to allow for wage rounds, and so on. The present limit, which was fixed in April, 1974, is £2,250. General increases in pay since 1974 would now equate that figure of £2,250 to a current one of about £3,000 or, perhaps, somewhat more. Non-manual workers who were in the less than £2,250 category in 1974 are thus now in the less than £3,000 category. A number of them have already passed over the existing limit, but they are still eligible because they retain their eligibility for a period of time after their remuneration exceeds the limit. For many this extension of time for eligibility is running out, however, and if the present limit were not increased an estimated 5,000 female insured persons would lose their eligibility by next July, while the total number of insured persons and their dependants who would have lost their eligibility by the end of the year, when the contribution year for male insured workers changes, is estimated to be of the order of 85,000.
The proposed limit of £3,000 is designed to retain eligibility for most persons who already have it and who have had no relative improvement in their financial position. It has been pointed out to me that there may be cases where the income of eligible persons has exceeded the £3,000 limit due solely to increases under the terms of the national wage agreements. I am looking into this anomaly to see if, in the detailed regulations on the entitlement of insured persons, it will be possible to cover it.
For the second category of those with limited eligibility—farmers— where entitlement is tied to land valuation, the change in the income limit will not affect eligibility in any way.
For the third category—other non-insured people—the present limit of £1,600 a year goes back to 1971. For these, entitlement is related to the income tax year and a continuance of eligibility after the income limit has been exceeded does not operate as it operates for the insured. Because the present limit for these people has so clearly gone out of date, the chief executive officers of the health boards have been applying the "hardship provisions" liberally so that, in reality, the fixing of a new limit of £3,000 a year would but formalise a situation which has been largely established by administrative practice.
Taking the pattern as a whole, the proposed change in the limits will not give rise to any substantial change in the proportion of the population which has been traditionally eligible for these services, which is about 85 per cent. In effect, this change will maintain the limit at its traditional level in real terms. Discussions have been held with the medical organisations, so that they will be aware fully of what is involved in this change.
What is involved here is a "holding operation" to maintain the existing levels of eligibility. I hope the House will see its way to approve of the draft regulations before it.
To turn to the full eligibility group, which is the group entitled without charge to all the health services, admission to this group is decided by the chief executive officers of the health boards. The chief executive officers fix uniform limits, which they use as guidelines in deciding on applications for medical cards. These limits make allowance for whethere a person is married, the number of his dependants and for fixed outgoings on his house. They are now standard for all areas. They are reviewed regularly so that they can be adjusted to keep pace with inflation.
During the past 12 months, because of the rapid rate of inflation, the income guidelines were reviewed twice—in July, 1975 and again in January, 1976—and they were increased to compensate for increases in the cost of living. The total number covered by medical cards at the begining of 1975 was 1,083,136, or 35.1 per cent of the population: at the end of 1975, it was 1,162,386, or 37.2 per cent.
The number of patients treated in our acute general hospitals continues to increase steadily but this has not led to any substantial increase in the total number of hospital beds, because the average duration of stay in hospital has declined noticeably. In 1960 there were 16,204 hospital beds. A total of 254,000 patients were treated in that year and the average duration of stay was 18.7 days. In 1974 the number of beds had increased only slightly to 16,478, but the number of patients treated had increased to 435,000—an increase of 71 per cent. This was made possible by a decline in the average duration of stay from 18.7 days in 1960 to 11.6 in 1974. This indicates more efficient use of our hospital facilities and we will continue in the future to study measures to improve this still further.
I would instance some work on hospital management in Cork which was sponsored by the Department. The new Cork Regional Hospital will be completed and should be ready for commissioning in 1978. This will be the largest general hospital in the State, with 600 beds covering practically every medical and surgical specialty. It is likely to cost more than £5 million a year to run.
To prepare for the efficient management of this new hospital it was decided to engage a firm of consultants to examine the organisation and management of St. Finbarr's Hospital, Cork, the staff of which will be transferred to the new hospital when it opens.
The purpose of the study, which commenced last year, is to develop effective management systems which can be transferred to the new Cork Regional Hospital. It will clarify lines of authority and responsibility within the hospital. It is expected that valuable lessons are being learned which should help to improve the efficiency of hospitals in the future.
Though all hospitals and health boards were given increased allocations in 1976 over 1975, quite a number of hospitals had to introduce economy measures to keep within their allocations for 1976. This has been a difficult exercise for hospital managements and staff. But it is not without some compensations, in so far as it has made everybody more cost conscious and more aware of the need for economies. It has helped to concentrate people's minds on the selection of priorities. These are worth-while lessons to learn, particularly in relation to hospitals, which are expensive to run.
The range of hospital equipment increases regularly and also the scope of medical and surgical treatments. In short, hospital administrators and consultants are involved in very complex and expensive organisations which require efficient and economic administration.
When I introduced the Supplementary Estimate for my Department in December last, I made a detailed statement on the Government's decisions in relation to the future development of general hospitals in this country. I dealt at some length with the comprehensive consultative process which had been undertaken and the reasons why the various decisions had been made. I should now like to inform Deputies of the progress which has been made since then in the implementation of those decisions in each of the health board areas.
It is accepted that for many reasons the development of general hospitals in the Dublin area is particularly difficult. I considered it essential that there should be a rational approach to the development of specialities in and between the major hospitals in Dublin. This is being considered by a joint Comhairle na nOspidéal/Department of Health Working Group who are considering the development and allocation of specialities in and between the Dublin hospitals. I understand that the group have made good progress.
In the meanwhile, it has been possible to progress on other aspects of the development plan in Dublin. A project team established to prepare a planning brief for the development of St. James's Hospital have been meeting regularly since October, 1975. The planning of St. James's Hospital is a complex issue but I am informed that good progress is being made by the project team.
As Deputies are aware, the development plan called for two new hospitals in Dublin—one in the Beaumont area and one in the Newland's Cross area. Negotiations have been in progress for a site at Beaumont Convalescent Home and the owners, the Sisters of Mercy, have agreed in principle to the acquisition of the site. Discussions have also taken place with Dublin Corporation regarding town planning and service matters in relation to that site. These discussions have proceeded satisfactorily and I hope that progress can be made on the negotiations for the site. Various sites in the Newland's Cross area have been examined as to their suitability for the siting of a major hospital and I am hopeful that a suitable site can be obtained there.
It is important that the decisions taken under the plan should be implemented in a co-ordinated fashion throughout the country; this is particularly important at present to ensure that the available resources are distributed in an ordered and equitable manner between the health boards. To achieve this I decided that a priority for development should be designated in each health board area and that the planning processes should begin in respect of these priorities as soon as possible. Discussions have been held with all health boards regarding the identification of these priorities and agreement was reached in most areas. I hope the position will be resolved in the other areas shortly.
The three main stages in planning are—agreement between the relevant health board and my Department as to the bed complement of the proposed hospital; the establishment of a project team representative of the health board and my Department to prepare a planning brief for the hospital setting out the functional content of the new hospital, and the drawing up by a design team working from this brief of detailed plans in preparation for building. These steps must be followed logically and in sequence. They cannot, without harm to the project, be telescoped and the interval between the decision to plan and having the plans ready for going to tender is quite long. Therefore, although capital is scarce now, it is wise to get our plans ready for the better times to come.
As regards the Mid-Western Health Board area Deputies will remember that it was not possible to arrive at firm conclusions in relation to the development in the Limerick area. A special sub-committee of Comhairle na nOspidéal had examined the situation but they were not able to make any agreed recommendations. Further studies were necessary to enable a decision to be arrived at—discussions and studies are taking place at the moment and I hope I will be able to put my proposals to the local bodies quite soon.
One of the decisions which was made in respect of the Mid-Western Health Board area was the retention of Nenagh County Hospital with joint staffing arrangements with one or more of the Limerick hospitals. In this regard, discussions have also taken place between officials of my Department, members of the hospital staff, and officials of the health board. I shall be writing soon to the health board on this subject.
In the north-east, the health board have designated Cavan Hospital as their priority. Discussions have been held with officials of the health board on the catchment area for the new hospital and on the number of departments and beds which would be needed to serve the projected population of that catchment area.
In the North Western Health Board area, it was agreed that Letterkenny should be the priority for development. The project team have recently completed their planning brief and the board have submitted it for my approval.
The South Eastern Health Board have recently informed my Department that they had decided on the maternity and paediatric sections of Ardkeen Hospital, Waterford, as the first phase of the development project to be planned. This will involve general decisions on the size and composition of Ardkeen Hospital and I propose that my Department will shortly have discussions in the matter with officers of the health board.
In the Southern Health Board area, the project team for the Tralee Hospital have completed their brief and the design team, working from the planning brief, have been involved for some time in drawing up the detailed plans.
The House will recall that in December I referred to the rather complex situation in Cork. The recommendations of the sub-committee of Comhairle na nOspidéal which had considered the hospital pattern there were not fully agreed to by the various interests concerned. I also indicated that I considered that further discussions with the parties concerned would be necessary before the final pattern of the Cork city development could be determined. These discussions have been held and I shall be in touch with the parties concerned soon.
Discussions have also taken place between officials of my Department, officers of the health board, and members of the staff of Mallow Hospital, which is being retained, regarding the joint staffing of the hospital in association with one or more of the Cork city hospitals. I shall be writing soon to the health board on the subject.
The Western Health Board are to consider which of the two proposed major projects in their area should be the priority—the extension of the maternity unit at Galway Regional Hospital or the development of Castlebar Hospital. In the meantime a project team have been established in respect of Castlebar Hospital. As regards the Midland Health Board area, I am in contact with the board on the choice of a priority between the two hospitals chosen for development.
This, therefore, is the situation at present regarding the implementation of the hospital development plan. Deputies will appreciate that the preliminary preparations for planning are most time consuming having regard to the amount of discussion and study which has to be completed. The progress which has been made to date is reasonably satisfactory and I can assure the House that the further stages of implementation will be pursued. I regard the implementation of the plan as one of my priorities and I would like here and now to reiterate my commitment and that of the Government to the decisions we have taken.
I would remind Deputies of the estimate which I gave in December of the cost involved in implementing the plan. I explained that until detailed evaluation is made it would not be possible to indicate a firm cost but on the basis of tentative estimates gross capital expenditure, at 1975 prices, is likely to be of the order of £65 million—excluding the cost of development in Cork and Limerick cities.
I should now like to refer to the concept of the community hospital which is an integral part of the general hospital development plan. When announcing my decisions on the general hospitals I indicated that following discussions with the health boards, a number of hospitals throughout the country would be classified as community hospitals. There has been a certain amount of misunderstanding as to the precise role of these hospitals. I have, in this House, on various occasions spelled out in some detail the probable functions of a community hospital. Despite this, the part which the community hospital will play in the general hospital services is still not fully appreciated. I would therefore like to give Deputies once more a general outline of the services which will probably be available in these hospitals. The community hospitals will have an important and significant role to play and they should provide the bridge between the specialised services of the general hospitals and the services of the general practitioners. Comhairle na nOspidéal has published a discussion document on the role of the smaller hospitals and copies have been circulated to all Deputies. This document suggests the type and range of services which would be provided in the community hospitals and I intend that this will form the basis for consultation between the health boards and my Department on how each of the designated community hospitals will operate
It could be expected that in most areas community hospitals will have a wide range of consultant out-patient services; and that apart from services at out-patient level such as medical, surgery, obstetrics, gynae-cology and psychiatry, radiology and pathology services would be available for both out-patients and in-patients.
As far as in-patients are concerned the community hospital would make available a range of services which could adequately be provided by local general practitioners working in association with consultants from the general hospital. The benefits which will arise from this arrangement are that the patient will be able to obtain certain treatment in a hospital in his own area and the demand on the highly specialised and expensive services provided by the general hospital will be consequently reduced. It is also envisaged that patients who have been treated in a general hospital and whose course of treatment has been concluded there, can return to the community hospital to convalesce. The community hospital, therefore, has a most important role to play in the provision of general hospital services. I have indicated that consultations would take place between the health boards and my Department to formulate in a detailed way how each of the community hospitals would operate. This consultative process has begun and it will, of course, be necessary to involve other interested parties, including the medical and nursing professions. It is hoped initially to formulate an agreed tentative policy for the provision of services in the hospitals and to apply this on an experimental basis to a small number of selected community hospitals.
I would like to mention some of the major developments which have taken place in the hospital capital programme during the last year.
The largest project in the programme is the 600-bed Cork Regional Hospital to which I have already referred. The main six-storey patient block was "topped-off" in October last and progress towards its completion at the end of 1977 is being maintained.
At St. Vincent's Hospital, Elm Park a new psychiatric unit and a geriatric assessment centre have been completed.
Also completed were: a new maternity unit at Wexford County Hospital; nine new welfare homes for the aged dispersed throughout the country; a new ophthalmic unit at Ardkeen Hospital, Waterford; large-scale schemes of rehabilitation and extensions at St. Laurence's Hospital, St. James's Hospital and the Mater Hospital, Dublin; reconstruction of Linden Convalescent Home, Blackrock, County Dublin; detoxification unit at Jervis Street Hospital, Dublin; a new psychiatric unit and improvements to sanitary annexes at St. Finan's, Killarney.
In addition, a wide range of other major hospital building projects are in progress at present. These include: a psychiatric unit at Letterkenny County Hospital; a new 30-bed district hospital at Donegal; paediatric, psychiatric and laboratory units at Limerick Regional Hospital; provision of new facilities for treatment of cancer at St. Luke's Hospital, Dublin; a new accident department at Jervis Street Hospital, Dublin; a new delivery suite at Airmount Maternity Hospital, Waterford; theatre improvements and other works at the Mater Hospital, Dublin; a new Cheshire Home, Bohola, County Mayo; a new 72-bed unit and other works at St. Ita's, Portrane; acquisition and adaptations of premises at Cloonamahon, County Sligo for the care of the mentally handicapped; a new centre for the care of adult mentally handicapped is nearing completion at Bawnmore, Limerick; new accident and emergency unit at Dr. Steevens's Hospital, Dublin.
These are but a selection of the ongoing new works and improvements at hospitals. In addition to these, a number of other developments are at planning stage. These include: a new pathology laboratory and other improvements at St James's Hospital, Dublin; five welfare homes for the aged; a new maternity unit at Ardkeen Hospital, Waterford; development schemes at Letterkenny and Castlebar County Hospitals.
As the House is aware, new projects for start in the present year have had to be deferred but I am optimistic that this is but a temporary set-back and that in the next year we may be able to resume new starts in our hospital building programme.
Persons eligible for hospital treatment under the Health Act, 1970 may enter an approved private hospital or nursing home and obtain a daily contribution from the health board towards the cost of maintenance. The rates of contribution payable in such cases were increased by 10 per cent as from 1st January, 1976. They now range from £4.40 a day for treatment in private hospitals and homes which have acute treatment facilities to £1.95 a day for geriatric homes. This 10 per cent increase may not have been as much as the proprietors of these homes had wished for, but it is a significant increase at a time of financial difficulties.
There has been some criticism that eligible persons who enter private hospitals and nursing homes have to pay more to obtain treatment in a private hospital than in a private ward of a public hospital. This may well be the case in many instances but, if so, it is simply the result of the way the two hospital systems work and are financed. Public hospitals are non-profit making organisations financed almost entirely from the Exchequer. Many of them are training establishments for doctors and nurses and provide a range of treatment far greater than that obtainable in private hospitals or nursing homes.
Nevertheless, I think we can all recognise that the private hospitals and nursing homes have an important part to play in supplementing the public system. It will be my aim that they will continue to receive reasonable subventions towards the cost of treatment of persons eligible under the Health Acts.
An efficient ambulance service is a necessary adjunct to our hospital services and for this reason it is important that the operation of the ambulance services should be kept under review. Health boards have about 200 ambulances and 50 minibuses. The ambulance men are specially trained for their job by means of a five-week's course in first-aid and resuscitation. All the health board ambulances have radio-telephone equipment with which they can keep in touch with their ambulance control centres.
Though the service has improved greatly within the past decade there is still room for improvement. Improvements are needed especially in the organisation of radio-telephone communications for ambulances. In many areas these radio communications still function on a county basis, with the result that ambulances in one county may not be able to contact the radio control centres in adjoining counties. This needs to be rectified. Short-term and long-term proposals for improvement of the radio-telephone arrangements have recently been received in my Department from each health board. After examination of these proposals by the committee on ambulance services, they will be discussed with officers of the Department of Posts and Telegraphs so that agreed improvement measures can be undertaken.
By these measures it is anticipated that the availability of ambulances for accidents and emergencies will be speeded up, particularly in some rural areas where delays sometimes occur in getting an ambulance to the scene of an accident.
Mental illness continues to be one of the most pressing of our health problems. Psychiatrists and sociologists and others in touch with the problem are divided as to whether its actual incidence is increasing. What is certain is that more people are seeking care for it and that every year the demand on the psychiatric service grows. This year health boards will spend over £36 million on our psychiatric services. But this figure does not include the concealed cost of mental illness in other health services, notably in the family doctor service and in the general hospital service. Indeed if it were possible to identify accurately the impact of mental illness on the demand for health care as a whole there is no doubt that it would be found to be an exceedingly important one.
Because of the seriousness of this problem for the individual and the family, not to mention the financial implications for the State, a Minister for Health must feel obliged to review constantly the strategies being used to tackle it. We are fortunate in having the very comprehensive recommendations of the Commission on Mental Illness to guide us and even though it is now ten years since its report was published most of its views are still valid. Nevertheless, a decade has elapsed and I think we should stand back and look critically at what has been achieved during that period and look also at what needs to be done. Experience may show that our priorities should be different, that the emphasis may need to be shifted to problems that have become more acute in recent times. This is the type of review that I am having undertaken in the White Paper now being prepared in my Department and which I propose publishing later in the year.
In introducing my Estimate for last year I pointed out that the biggest problem facing all those concerned in the provision of residential services for the mentally handicapped is the ever increasing proportion of places in the residential centres which are occupied by adolescents and adults. The latest figures available to me show that this trend is continuing and now almost 50 per cent of the available places are occupied by adolescents and adults. This inevitably shows down the reduction of the waiting lists of children whose parents are anxious to have them received into residential care.
There is, however, a sufficient number of projects at various stages of development or planning to ensure that there should be, within a few years, a substantial improvement in regard to the places available for both adults and children. Unfortunately, like other aspects of the health services, the speed at which these places will become available must be influenced by the financial situation. All I can promise in present circumstances is that the mentally handicapped will continue to have a high priority where I am concerned.
I would emphasise, as I have done on various occasions in the past, that my Department will be basing their approach in regard to new developments on the maximum possible use of community services as opposed to residential care. We shall, in future planning, be considerably assisted by the census of the mentally handicapped carried out last year under the aegis of the Medico-Social Research Board. An analysis of the census has now become available and my Department have established a small group of Department and nonDepartmental persons to examine the results and to estimate our probable requirement of places, both residential and community, for the years ahead. Up to now our planning was based on our estimated needs. Now we have a more accurate picture of the situation and we can plan with greater assurance.
All advanced societies now accept that their obligations towards the individual citizen who is unfortunate enough to have a permanent or long-term physical or mental handicap should be comprehensive. It is not enough to provide treatment, or care in an institution, or a compensatory financial allowance. the handicapped person must also be given every assistance to become as fully integrated in society as possible. Full integration necessarily implies providing him with the training and the opportunity to lead a working life. My Government have accepted this duty as an important part of their social policy and despite the inhibitions of the present financial situation I am glad to report progress in this area during the last year.
All supervisory and training staff in existing voluntary and health board workshops for training handicapped persons have been given an opportunity to undergo a special course devised by the National Rehabilitation Board in association with each other. The aim of the series of courses which have now ended was to improve the training methods of the personnel concerned and the courses secured the recognition and financial support of the European Social Fund. Further courses for other personnel in the rehabilitation field are under consideration.
I am glad to say that, arising from the recommendations of the Working Party on the Training and Employment of the Handicapped, AnCO have found it possible to increase their intake of handicapped trainees and I would like to take this opportunity to acknowledge their efforts in this area. Because of financial constraints it has been possible only to a limited extent to provide assistance for the development of training and additional places in the workshops operated by voluntary bodies and health boards. But I have found it possible to authorise the expansion of the adult and young placement services of the National Rehabilitation Board and this means that some parts of the country now have an improved placement service for their handicapped services.
The board are also pushing ahead with their planning for the future. They have established a number of sub-committees which will, inter alia, recommend standards for the organisation and operation of workshops and explore new training opportunities for the blind. It has been possible to secure the participation on these committees of persons with expert knowledge and valuable experience and I have no doubt that as a result we can look forward during the next few years to better training facilities for all handicapped persons who require them.
In any event if we are to continue to get worth-while assistance for these facilities from the European Social Fund we will have no choice but to improve and develop them. Health boards and voluntary bodies must recognise that European Economic Community policy is directed at upgrading training standards for the handicapped in all Community countries. The grants available from the Social Fund are intended to assist the Progress of that policy and the various bodies concerned in this country must, with the passage of time, expect more stringent criteria to be applied by the Commission in dealing with applications.
In the final analysis the success of any policy aimed at providing employment for handicapped persons will depend on the goodwill of employees and trade unions and the community at large.
A study group which reported to the Minister for Health in 1967 on the child health services recommended the medical screening of all pre-school children at specified ages so as to monitor the extent to which they were developing within the normal range, to detect and keep under review any children who were showing deviation from normal development and to refer for appropriate care any suspected or identified cases of disease or defect. It was envisaged that initially the service would be provided in the cities and towns with populations of 5,000 and over. At a later stage, and in the light of experience gained in the operation of the service, it was intended to extend services to the remainder of the country.
With regard to pre-school examinations it was envisaged that there would be three examinations for pre-school children; one at six months, one at 12 months, and one at 24 months. In terms of total numbers of children eligible, achievements at the six-month examination—which in practice involves an examination carried out when the child is seven to nine months old—must be regarded as satisfactory with the percentage of eligible children examined rising from 66 per cent in 1971 to 79 per cent in 1974. A significant, if not very large, number of children have been examined at 12 months and 24 months representing in 1974 24 per cent and 10 per cent, respectively, of eligible children at the 12-months' and 24-months' examinations.
As regards school examinations, it was envisaged that in addition to annual testing of vision, posture and cleanliness carried out by public health nurses in all national schools, all national school entrants should undergo a comprehensive medical examination when they were approximately one year at school and that a further examination would be undertaken of a limited number of children including, in particular, children between the ages of nine and ten years, selected on the basis of information obtained about them from their parents, teachers, nurses or other interested persons. Other children on observation by the school doctor would also be medically examined. There has been a very satisfactory level of examination of school entrants, but the selective school medical examination is not, as yet, functioning at a satisfactory level. While developments in the past few years in reorganising the general medical services, in the establishment of community care teams, and in the appointment of directors of community care, have to some extent slowed down the pace of development of the school health examination services, the concentration of resources on pre-school development paediatric exams is perhaps the one single factor which has most contributed to this situation.
The public health nurse is a key figure in the delivery of community care services. The last decade has seen a very considerable development of the nursing service and the number of nurses employed has more than doubled in that time. An indication of the rate of expansion may be gauged from the fact that each year approximately 65 new trainees were recruited and given a year's special training in preventive work which they would not have received in the course of their basic general and midwifery training. The public health nurse is frequently the first point of contact between families and the health services; as a locally based nurse she gets to know the families in her area and is available to provide advice and nursing care, ranging from that required by the expectant mother or pre-school children to the sick nursing care of the aged and chronic sick.
A report submitted to me by a working group, which surveyed the workload of public health nurses, was published last July. The report contained a wide range of recommendations and a number of these recommendations are in the course of being implemented. These include better working conditions for public health nurses such as a 40-hour working week and arrangements for limiting week-end duty.
Other recommendations of this report are being considered within the Department with a view to establishing the extent to which they can be implemented, having regard to their nature and to the financial and other resources available. Perhaps I should mention two of these recommendations in particular; one relates to the provision of a full range of public health nursing service to persons in all income groups. At present only a limited number of services are provided by public health nurses for people in the higher income bracket. These include preventive services for pre-school children and children attending national schools and nursing help for mentally handicapped children living at home. The recommendation of the working group would, for example, extend home nursing services to all income groups.
The second recommendation which I would like to mention is the suggested increase in the number of public health nurses. This recommendation arises because of the suggested extension of a full range of nursing services to all income groups and also because the working group considered that a more intensive service should be given by the nurse to the community. The effect of the recommendation would be the recruitment of approximately 300 more public health nurses. As I already indicated approximately 65 nurses have been trained in public health nursing each year for the past decade. This, I feel, allows for a significant expansion especially as the loss through retirement, deaths, and so on is very small. It is more important, I believe, to select a limited number of trainees and thus ensure that the very high standard of public health nurse recruited is maintained than to allow that standard to drop through an extended recruitment scheme.
In the current year the general medical services will cost over £24 million for 1,162,000 persons. The costs have now doubled since 1972-73 when the service was reorganised.
The present scheme has been in operation nationally for just over three-and-a-half years and it is possible to make some general comments on the manner in which it is operating. In general the scheme is achieving the targets set for it when it was reorganised. The main aim was to provide a choice of doctor, as far as possible, to eligible persons and to enable them to obtain the necessary drugs and medicines from community pharmacists.
There are now about 1,300 doctors participating in the scheme and medicines are dispensed by about 1,200 pharmacists. The medical needs of eligible persons are met, therefore, by almost twice the number of doctors who operated under the dispensary system and the introduction of the community pharmacist into the service has greatly increased the number of outlets from which to obtain medicines. These changes, which have clearly improved the availability of services, have been welcomed by patients generally.
While the service has in general improved as a result of these changes there are aspects of it which give cause for concern. In particular I would draw attention to the very noticeable increase in the cost of providing drugs and medicines. It has risen from £8 million in 1973 to £10 million in 1974 and last year reached £15 million. Such increases are disproportionate to the increase in the number of persons covered by the scheme.
The increase in the cost of drugs has been such that in October of last year I established a working party to examine prescribing patterns in the general medical service, to consider the extent to which there might be over-prescribing or the prescribing of needlessly expensive medicines, to consider the question of prescribing with due regard to economy and to make recommendations to me on these matters. The working party was composed of officers of my Department, members of medical and pharmaceutical organisations and the drug industry. They had access to the statistical information about prescribing under the scheme and information from some other countries facing similar problems.
In setting up the working party I emphasised to them my concern not alone with the cost, serious though this is, but also the undesirable if not dangerous aspects of excessive prescribing. I have within the past few days received their report and I will have it examined as a matter of urgency. I shall consult also, on an urgent basis, with the other interests involved to establish quickly the extent to which the recommendations of the report can be implemented.
In the meantime there are certain aspects of the service which it is generally accepted, might be improved. The General Medical Services (Payments) Board have written to doctors seeking their co-operation in reducing the escalating costs of drugs. I am informed that the reaction to this approach has in general been favourable and some useful suggestions were offered. I am hopeful that doctors will critically examine their prescribing habits in the months to come.
There is also considerable support for the view that the scheme could be improved to the advantage of all if patients could be educated in making better use of the service. What I have in mind is that where patients can they should attend at the doctor's surgery rather than request a house call, but if a house call is necessary they should notify the doctor early in the day, say before 10 o'clock wherever possible. This would enable the doctor to plan his house calls better and thereby attend the patient more quickly. Advice on the proper use of medicine would also be helpful but special care would be necessary in the way it is presented. Of course any educational programme must be designed in such a way that it will achieve its results without inducing people to defer seeking timely advice from their doctor.
These are matters to which consideration must be given. I draw attention to them because they are shortcomings capable of being remedied without disadvantage to anyone and whose resolution would considerably improve the scheme.
During the past year I made further regulations extending controls over the manufacture and marketing of medicinal products in harmony with directives adopted by the EEC. The directives to which the regulations relate are an attempt by the EEC to further harmonise the licensing systems of the member states towards the ultimate goal of a common market in medicines. They do not of themselves confer a right of access of any product to the market of a member state but are merely intended as another step in that direction.
The principal effect of the new regulations is to extend a system of licensing to proprietary medicines which were already on the market on the 1st October, 1974—the date from which no new proprietary medicine could be put on the Irish market without a licence. These products will be licensed in a phased scheme which will be completed in 1983, beginning with anti-infectives, tranquillisers, hypnotics and sedatives which, with effect from the 1st April, 1977, may not be on the market here unless they are authorised by the Minister for Health. In the implementation of the schemes my Department are advised by the National Drugs Advisory Board who have also been given charge of the supervision of the observance of conditions imposed in licences issued upon their recommendation.
It is appropriate that I should pay a special tribute to the dedication and competence of the National Drugs Advisory Board in the discharge of their task of monitoring the quality, safety and efficacy of drugs and medicines available to the public in Ireland. For almost a decade now the members of this multi-disciplinary board have voluntarily given unstintingly of their time to serve the best interests of the community and we are all greatly indebted to them for this.
Also in the field of medicines control, I have recently made regulations amending the Medical Preparations (Control of Sale) Regulations, 1966, so as to extend the list of medicinal preparation which may be sold only on prescription. The preparations added include certain preparations contained in aerosols for the relief of asthma, corticosteroid compounds for external use and preparations containing phenacetin. The substances in question have been shown to present certain hazards if taken without medical supervision and on the basis of the advice given to me by the National Drugs Advisory Board it was clear that the public should be afforded this additional protection. I think I should report to the House that, while the number of new cases of tuberculosis showed a continuing decline up to 1972, when the figure was 1,147, it has since shown a small but disturbing increase. The figure for 1973 was 1,182 and for 1974 it was 1,204. This means that pockets of infection still remain in parts of the country.
Vigorous methods are being operated by the public health staff of the health boards to trace these sources of infection but the co-operation of the public in availing of the facilities offered for diagnosing and treating TB is essential. Having reduced the number of new cases of TB from 6,800 in 1952 to 1,200 in 1974, it would be a pity if we now became complacent about this disease.
My medical advisers are watching the situation regarding vaccination of children against diphtheria, tetanus, pertussis and poliomyelitis. The success of vaccination against diphtheria and polio is incontrovertible: we have had no notification of diphtheria in the past five years and only two cases of polio in the same period. In the case of vaccination against pertussis—whooping cough—which is normally given with diphtheria and tetanus vaccination to children at about six months of age the numbers availing themselves of this "3-in-1" vaccination have been falling off and this fact is, of course, a cause of concern.
The most recent figures available show an acceptance rate of 35 per cent for Dublin for 1975 as compared with a 70 per cent target figure which is accepted as providing a satisfactory level of immunity.
I can understand that parents may have misgivings about this vaccination when they read of cases of brain-damage to children alleged to have been caused by the pertussis element in the vaccine but these parents should also consider that there is no substantiated medical evidence to prove these allegations. The medical profession are well aware of the known contra-indications to vaccination and where no such contra-indications exist vaccination is still recommended as an extremely effective tool against whooping cough and the other diseases I have mentioned.
In keeping with the Government's commitment to ensure that maintenance allowances should retain their purchasing power, the maximum rates of disabled persons maintenance allowances and infectious diseases maintenance allowances were increased by 5 per cent in October last and by a further 10 per cent in April this year. In addition allowances payable under the blind welfare schemes and those payable to thalidomide children were increased this year to keep them in line with the general level of changes in the other allowances.
The overall effect of these improvements may be seen from a comparison of the maximum rates now payable as compared with the corresponding rates before April, 1975. For example, the disabled persons allowance has increased from £7 to £9.85 a week. For married couples the existing allowance under the infectious diseases maintenance allowances' scheme is £18.20 as compared with £13.00, while under the blind welfare scheme, a blind married couple can now receive a supplement to their joint pensions of £7.10 a week as compared with £5 before April, 1975.
It is estimated that additional expenditure in the order of £1 million will result from these increases in the period April to December, 1976. Of course, special additional funds will be made available to the health boards to meet this expenditure.
It is now almost a year since the reconstituted National Social Service Council came into office. As part of the reconstitution, voluntary organisations engaged in the provision of social services were given direct representation on the council. I am glad to say that this arrangement has worked very satisfactorily and that the council provides a very good forum for the discussion of both policy and operational issues affecting statutory and voluntary organisations in the provision of personal social services.
The council has made good progress in the establishment of community information centres. At this stage, a total of 45 have been established and it is hoped that the number will be about 60 by the end of this year. The council has been able to provide improved support services to the centres and the material which it produces is of considerable value to many other bodies, both statutory and voluntary.
The council has worked very closely with the National Committee on Pilot Schemes to Combat Poverty particularly in relation to the projects dealing with welfare rights and social service councils. Areas for co-operation and sharing of services between the council and the committee are being explored and it is likely that the council can be of particular value to the committee in the provision of information and information systems.
The council has arranged a conference to be held in Limerick at the end of May. At this conference, the work of social service councils from 1972 to date will be reviewed and both the policy and operational implications of statutory and voluntary co-operation in the provision of community services will be considered.
This question of how the statutory agencies and the voluntary organisations can best work together to provide community welfare services continues to be a matter of deep interest to the council and, indeed, to my Department. I think the time has come when it is necessary for my Department to take an initiative in developing and agreeing a policy document on the scope and structure of personal and community welfare services under health boards and the respective roles and relationships of the statutory agencies and voluntary organisations in the planning and provision of these services. Work has already commenced on the preparation of this document and it is hoped to circulate an outline draft to the health boards, the council and the various other interests concerned in the very near future. I would hope that the debate on this document would be objective and challenging and that at the end of the day there would be a satisfactory measure of commitment to the principles and practices contained in it. Because of its importance and the number of interests that must be consulted, it will necessarily take some time before it can be agreed and promulgated as a policy document.
In September, 1975, the task force on child care services submitted an interim report to me. This was published and circulated to Deputies on 18th November, 1975. The task force submitted an interim report because it considered that certain steps should be taken as quickly as possible to provide for the more urgent needs of some of the children with which it is concerned. The recommendations made in the interim report were particularly concerned with the needs of disturbed and homeless children.
Although it was an interim report, there are some very significant recommendations made in it and many of the recommendations are closely interconnected. Their full implementation will require considerable resources of finance and trained personnel which, in the current situation, cannot be quickly made available. Nevertheless, it has been possible, despite the obvious difficulties, to make some progress.
Consultations have taken place with the agencies who will be primarily concerned with implementation of the recommendations, notably the Department of Education and the Eastern Health Board.
Through the initiative of the Dublin itinerant settlement committee, and the support of the Department of Local Government and the Eastern Health Board, arrangements have been made for the provision of accommodation at Newtownmountkennedy for 17 travelling children in need of residential care. This is an admirable undertaking which deserves our full support. The Eastern Health Board have recently had discussions with representatives of the committee regarding the future arrangements for the management of the accommodation and the continued support of the children during this year. I have every reason to believe that mutually satisfactory arrangements will emerge from these discussions. I have asked the Eastern Health Board to examine urgently the feasibility of adapting an existing premises for use as a residential centre for severely disturbed boys and girls and discussions on this matter are continuing.
The Eastern Health Board are at present conducting a local survey to confirm the extent of the need for accommodation for homeless boys and young vagrants. Meetings will then be arranged with the agencies concerned to examine the extent to which existing accommodation can best be used to solve the problem and to consider the provision of such additional accommodation as may be required.
I would, naturally, like to be able to report greater progress on the implementation of the recommendations made by the task force. However, some progress can be made by fully utilising existing facilities and I would hope to give a high priority in the allocation of any funds that may become available during the next year to the implementation of the recommendations which require additional resources.
We have continued to make progress in the last 12 months in relation to the development of community-care teams, and in particular in relation to the appointment of directors of community care and medical officers of health.
There is now a wide acceptance of the concept of delivering services, outside the hospital programmes, through community care teams representative of the different disciplines involved in community care. The structure and boundaries of the community care areas have been worked out in detail and agreed with the health boards. Conditions of appointment of the directors have been agreed generally with the boards and with the medical organisations; in a number of areas, existing permanent chief medical officers have been appointed as directors of community care and I am hopeful that the position in relation to the appointment of some other chief medical officers will be resolved soon. Eight further posts were referred to the Local Appointments Commission last year and are currently in the process of being filled and discussions have recently been held to resolve the special problems arising in the Dublin area.
There are of course a number of problems which must yet be tackled before community care services can function with maximum efficiency. These problems will include the establishment and grading of a medical structure below the director level, and the provision of proper training and support for the director and the members of his team. Some of these problems have been considered by a working group on the public health medical services, who recently presented their final report to me. Given the goodwill which exists within the service, I believe that these problems will not present insurmountable difficulties.
At a seminar held in Waterford last May, in which the health services were reviewed by widely based working parties, consisting of officers and members of health boards and officers of the Department as well as outside specialists in various aspects of health care, a specific recommendation was made by the group which considered the community services to the effect that more resources must be allocated to those particular services. The recommendation concluded that the major proportion of developmental funds, capital and revenue, that are available to the health services should be channelled into the community care services. I would like to say at this stage that I regard the development of community care services as an area of very high priority. I say this for two main reasons. Firstly, I believe that in the generality of cases money spent on preventive and curative work in the community gives an excellent return in obviating expensive hospital care. Secondly, and at least as important, I believe that an effective community care programme will significantly improve the general health of the community and thus greatly reduce the incidence of certain avoidable diseases and defects.
I am glad to be able to report that, despite the difficult financial situation, I have found it possible to make a significantly increased allocation available to the Health Education Bureau. The bureau has a budget of £300,000 in the current year, as compared with £185,000 in 1975. This reflects the importance which I attach to this activity and the hopes which I have that it can produce positive and continuing results in the area of preventive health.
The bureau has consolidated and extended much of the work which was initiated under the aegis of my Department. In the educational field a number of significant developments have taken place. Pilot projects on health education based on post primary schools have been initiated in north east Dublin, in Monaghan, Cork and Ballinasloe. The objective of these projects is to introduce the whole concept of health education into the activities of the school.
The bureau is developing resources which can be made available to teachers when conducting health education in the schools. These resources include films, tapes and teaching kits, and are mainly geared for post primary schools, although some material for primary schools is also being developed. Progress has been made in injecting health education into the activities of educational authorities other than schools, including An Bórd Altranais and the National College for Physical Education. Efforts in this area will be continued during the coming year. The anti-smoking campaign was continued and an extra dimension was added through the introduction of large posters on billboards throughout the country. The anti-alcoholism campaign has continued as in previous years and later this year there will be a renewed concentration on this subject, and the subject of excessive drinking. It was a matter of considerable satisfaction to the bureau and to me that during the year the award for the best made and most effective commercial film went to the bureau on foot of one of the films produced for the alcoholism campaign.
In the months ahead a physical activity campaign, aimed at the population at large, will be initiated. This is something which I have been very anxious to see initiated and I am glad that the bureau has found it possible to make a start in this year. It is also intended to extend the objectives of the anti-smoking campaign by seeking to wean smokers off cigarettes or to persuade them to reduce the number which they smoke.
Work will continue on the development of coaching charts in association with the various sporting organisations.
The Health Education Bureau has made a very good start on the work which I have asked it to undertake. I know that they are most anxious to devote increased attention to research and to broaden the scope of their activities to areas of health education which have not previously been undertaken in this country. I look forward with interest to the initiatives which I am sure they will propose within the coming year.
The Medico-Social Research Board have developed an extensive programme of information collection and research in the field of epidemiology.
The work of this board is particularly important because it is concerned largely with health and social problems which have elements in them which are peculiar to Ireland and which are not therefore the subject of research in other countries.
The board's major current project— the hospitals in-patient inquiry—is designed to be a comprehensive source of information about the operation of our hospitals which will be invaluable for both research and administrative purposes. Even though all hospitals are not yet taking part in the project, a large amount of useful information is already becoming available.
The board continue to devote a large part of their resources to studies relating to the more vulnerable sections of the community—the aged, the mentally ill and the mentally handicapped. They have also undertaken studies on alcoholism, drug-taking and on suicide.
Some of the board's work is carried out in association with major international organisations, particularly the World Health Organisation and the EEC. This work includes studies on heart disease and strokes and on the effects of air pollution on the health of children.
Turning to personnel matters, the quality of any health service is largely dependent on the skills and commitment of the people which it employs. The service is, by its nature, a uniquely personal one. Despite other technological advances which have taken place, it remains essentially a service of person-to-person contact. This is naturally reflected in the numbers of people working in our health services which at present number about 46,000 in nearly 300 different grades. Annual expenditure on staff is now in the region of £156 million, representing about 60 per cent of current public expenditure on the services. This represents a very considerable investment both in terms of money and in manpower and highlights the importance of effective personnel policy and management in relation to the satisfactory functions of the service. There is, I believe, a growing realisation of this fact at both national and local level, and I need not stress that in times of difficulty and restraint it is of singular importance that staff are fully and properly utilised. In this regard, if due attention is paid to staff training and development as well as recruitment and manpower planning, the service itself as well as the people concerned will benefit.
It is only to be expected, of course, that the general economic climate brings in its wake tensions and frustrations over and above the normal. For that reason I think we should all be grateful that the past year has been relatively trouble-free and that, by and large, confrontation and dispute situations have been avoided. For this the staffs themselves must take the greatest credit and are to be congratulated for the restraint and sense of responsibility which they have demonstrated. For my own part I will continue in my endeavours to ensure that good staff relations are maintained and fostered. I would hope also that the revised and expanded conciliation and arbitration scheme for health board and local authority staffs which was recently agreed will facilitate this process. This factor combined with the extension of the membership of the Local Government Staff Negotiations Board to include officers of the Departments of Health and Local Government should help to improve and rationalise the approach to negotiations to the benefit of staff and management alike.
Legislation of the European Communities, commonly referred to as the doctors' directives, was adopted by the Council of the Communities on the 16th June, 1975. There are two directives and both are scheduled to come into effect in all the member states by the 19th December, 1976.
The directives aim at making provision, firstly, for the recognition by each member state of the medical qualifications, both at general and specialist levels, awarded in the other member states; secondly, for giving effect to the right, contained in the Treaty of Rome, of free movement of doctors within the Community for nationals of the member states and, thirdly, for setting and maintaining specified minimum standards of medical training in all the member states.
To assist in the implementation of the provisions of the directives, the council decided on the 16th June, 1975, to set up two committees. They are the advisory committee on medical training and the committee of senior officials on public health. These two committees have now been established. The latter consists of officials belonging to the health ministries of the member states. The former contains representatives of the practising profession of the medical faculties of the universities and of the national registration bodies.
Arising from the EEC doctors' directives, it will be necessary to adapt our domestic legislation before the 19th December, 1976, to meet the requirements of the directives. This could be done by regulations under the European Communities Act, 1972. I was aware, however, that there were other aspects of the statutory regulations of the profession which were pending for some time. Some of these were matters which the profession itself had been pressing; others had come to notice from different sources.
I, therefore, last July decided to set up a committee and asked it to examine and report to me on the changes necessary in this area generally. In addition to representatives from my Department, the committee had representatives from the medical schools, the Royal College of Surgeons in Ireland, the Royal College of Physicians of Ireland, the Medical Registration Council, Comhairle na nOspidéal, the Council for Postgraduate Medical and Dental Education and Training and the Irish Medical Association with the Medical Union. The committee submitted an unanimous report to me last December recommending some important changes in the law regulating the profession in addition to the changes required solely to meet the requirements of the EEC directives.
The recommendations are that there should be a new and more broadly based Medical Council, more representative of the practising profession, to replace the Medical Registration Council and which would have functions in relation to postgraduate as well as undergraduate education and training. The new council would also have functions in relation to doctors' fitness to practice by reason of illness or infirmity or other reasons; functions which would be capable of being used in a more flexible, and humane manner than those available to the existing council.
The recommendations made by the committee are being examined. Prima facie, I can say that the changes recommended appear sound and they are, in general, acceptable to me. I would hope to bring legislation before the House in the autumn. Before leaving this subject I would like to place on record my appreciation of the contributions made by the various interests represented on the committee which produced these recommendations.
Deputies will already be aware of the circumstances leading to the setting up of the review body on consultants' remuneration in the summer of 1974. It resulted from the breaking down of negotiations which had been in progress for some months with the medical organisations about a new uniform type of contract for medical consultants in the health board hospitals and in the public voluntary hospitals in the light of the Government's decision to abolish income and other limits for eligibility for hospital services.
The terms of reference given to the review body were to examine and report on the systems and rates of payment and conditions of employment of consultants in hospitals providing services under the Health Act, 1970, which would be appropriate in the context of the abolition of income and other limits related to eligibility. The members of the body are Mr. W. Finlay, Governor Designate of the Bank of Ireland, Mr. J. Ivers, Secretary General of the Incorporated Law Society and Mr. M. Cosgrave, Deputy Chairman of the Labour Court. I am informed that the body has carried out extensive examinations of the matter before it and expects to be in a position to report to me in a matter of months.
In September, 1972, the then Minister for Health requested Comhairle na nOspidéal to suggest to him a common selection procedure for consultants' appointments which would be generally acceptable to the interests concerned and which would apply in the case of all public hospitals providing services under the Health Acts and to indicate in broad outline the machinery for the implementation of such a selection procedure. The aim is to integrate into a single system of selection two existing procedures, one, in the case of the health board hospitals, based on the Local Appointments Commission and the other, in the case of the voluntary hospitals, based on individual and mostly unco-ordinated procedures.
In their report submitted to me in March, 1974, the comhairle set out the procedure and the machinery for a new selection system as requested. The comhairle stated that they were satisfied, following the consultations which they had carried out, that their proposals were generally acceptable to the majority of the interests concerned. I am grateful to the comhairle for the expert manner in which they tackled this issue. Their report is still under examination in my Department. Deputies will appreciate that the problems involved in marrying two very different systems of selection into one uniform system acceptable to all interests are quite formidable. However, I hope to move to a resolution of this issue in the present year.
In August of last year I established a working party to examine and report to me on the various issues affecting the role of the general nurse in this country. The membership of the working party is widely representative of all the various bodies and staff organisations concerned with this area of the health services. The task which confronts the group is a formidable one, but I am satisfied that the group of people appointed are well equipped to undertake the work. The nursing organisations have long felt the need for an examination of this kind into the whole question of the role of the nurse and the education training and structures necessary for the fulfilment of that role. The terms of reference which I have given the working party are sufficiently wide to enable them to explore all aspects of the problems involved and I am sure the outcome of the exercise will be to the benefit of the nursing services and at the same time improve the job satisfaction for the nurse herself. The nursing services are a most vital and important sector of our health services and we cannot afford to ignore any measures which will help to improve the efficiency and effectiveness of these services. I look forward to receiving the views and recommendations of the working party.
A working party with representatives from all the member states was set up in February, 1975, to examine the position of general trained nurses on the same basis and with the same objectives as in the case of the directives on doctors. My Department and An Bórd Altranais represented this country on the working party.
They have now completed their examinations of the subject and a small number of unresolved issues, none of them originating in this country, have been referred for decision to the Committee of Permanent Representatives of the EEC.
I will conclude by referring to some points on the organisation of the services and their administrative structure.
The first term of office of Comhairle na nOspidéal ended on 31st December last. Following wide-ranging consultation with the various organisations and interests concerned, the 23 members who will hold office for a three-year period from 1st January, 1976, were appointed.
The comhairle, since their establishment in 1972, have carried out their primary function of regulating the numbers and types of consultant appointments in hospitals most effectively. They have also played a significant role in the field of hospital services generally. They made a major contribution to the formulation of the national hospital development plan by preparing and submitting reports on various aspects of the development of our hospital services, including the pattern of major hospital developments, the future role of the smaller hospitals and manpower requirements. As I have said earlier, proposals for a common selection procedure for appointments of consultants to hospitals were prepared. They also have prepared valuable reference documents on specific services in the hospital field.
I must express my appreciation of the great value of the work done by the comhairle. The members have contributed greatly to plans for the health services. I thank them, and particularly the chairman, Professor Basil Chubb, for the work they have done and are doing.
I referred recently in this House to the work being done by the organisation unit of my Department. I mentioned the work undertaken with health boards to improve their financial control and budgetary arrangements to ensure that money was spent in the best direction and with the best results, and the pilot studies undertaken in St. Finbarr's Hospital, Cork, and the Mater Hospital, Dublin, regarding the steps necessary to improve their administration systems. With limited resources the overall approach to management services and value improvement has therefore been to select a number of key areas which are broadly representative of situations which will be encountered throughout the health services and to develop and test solutions in these chosen sites which can to a large extent be effectively transplanted to other areas of the service. At the same time emphasis has been placed on the need to monitor developments abroad and to utilise to the full approaches which have been successfully tested elsewhere and are likely to be suitable to our needs.
I also indicated that to speed-up efficient improvements in the field of administration in the health services I would strengthen the organisation unit of the Department as well as the planning unit. I cannot overstress the importance of effective management services. The need to develop good information, accounting and analytical systems to enable planning and review functions to be carried out efficiently is self-evident.
The organisation and provision of computer services, where this is seen to be feasible and economical, is also part of the management services remit. The major effort in this field is being devoted to consolidation of the facilities which have already been provided. Planning for the future expansion of facilities is not being neglected however and a work programme incorporating a number of key developments has been agreed with the users of the computer facilities.
When replying to the debate on the Second Stage of the Health Contributions Bill on 30th March I spoke on suggestions which had been made during that debate that there should be an examination of the health board system. What I said is recorded in columns 511-513 of the Dáil Official Report for that day.
I gave my own tentative views in relation to the need for an examination of the system and of possible methods for conducting the examination with some of the advantages and disadvantages of each. I would propose to discuss shortly with the Government the question of setting up the machinery for this examination. However my statement in the debate on the Health Contributions Bill was made at the end of that debate. Other Deputies had not the opportunity to comment on what I had said. Therefore, before asking the Government to take a definitive decision, I would welcome contributions during the present debate from Deputies on the options which I mentioned.
While I do not think it is necessary to repeat in full what I said in the earlier debate, I would remind the House that, in my view, the options seem to rest between a simple all-party Committee of the House and some body which would have representatives of all parties and outsiders involved in the practical administration of the services, including of course the professions and the trade union interests.
I would ask Deputies to read the report of what I said earlier and let me have their views on the options and ideas which I then mentioned.