Dáil Éireann debate -
Thursday, 8 Dec 1977

Vol. 302 No. 7

Vote 50: Health.

Minister for Health (Mr. Haughey)

I move:

That a supplementary sum not exceeding £24,978,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1977, 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.

The original Vote for Health in 1977 amounted to £298,400,000, including a sum of £10 million by way of a capital grant-in-aid of the Hospitals Trust Fund.

The Supplementary Estimate is for a sum of £24,978,000 comprised of a net sum of £21,448,000 for non-capital services and £3,530,000 for capital purposes.

The gross extra sum required for non-capital services is £22,398,000. From this there has been deducted a sum of £950,000 representing an increase in income from appropriations-in-aid. This leaves a net requirement of £21,448,000. This total extra expenditure arises as follows:—Staff Costs, £18,308,000; Increases in the rates of cash allowances, £1,500,000; Price increases, £1,500,000; Increase in Social Welfare Contributions (employer's share), £540,000; Increases in capitation payments to special residential homes for children, £550,000.

The estimated increased income of £950,000 from appropriations-in-aid is expected to be derived from health contributions (£750,000) and the recovery of cost of health services provided under regulations of the European Economic Community (£200,000).

The additional grant requirement for staff costs is £18,308,000. The additional expenditure arises under three main headings:—

—National Pay Agreement, 1977;

—Miscellaneous pay awards;

—Additional staff employed by health agencies in 1977.

Under the terms of the National Pay Agreement, 1977, pay increases were payable in two phases—generally from April and November. The general rate of increase for each phase was 2.5 per cent of basic pay plus £1 per week (subject to certain minimum and maximum levels of increase). The additional sum required to meet costs arising here is £7,435,000.

The amount required to cover additional expenditure arising from Labour Court recommendations and arbitration award comes to £2,023,000. This is made up as follows: clinical teachers and nurse tutors, £130,000; revisions of salary scales and service conditions in a number of grades, £86,000; general trained nurses, £406,000; certain grades of psychiatric nurses, £291,000.

The above items were approved following on Labour Court recommendations and arbitration awards.

The remaining areas where special increases applied were: decisions on equal pay, £800,000; increases in travelling and subsistence expenses, £310,000.

The amount needed to meet the additional cost of extra staff recruited by health agencies during the year is £8,850,000.

The cash allowances on the Health side which were increased following the 1977 Budget were: disabled persons allowances; maintenance allowances to persons suffering from specified infectious diseases; blind welfare allowances.

The allowances were adjusted in two phases—from 1st April, 1977, and 1st October, 1977. The total grant requirement in 1977 to meet the additional cost arising is £1,500,000.

The amount of supplementary provision now sought for price increases —£1,500,000—is to offset the additional costs incurred by health agencies during the year because of higher prices on items such as purchases of medicines and drugs, the cost of heat, light and power, maintenance work, replacement of worn-out equipment and so on.

The employer's share of the weekly insurance stamp was increased with effect from 1st April, 1977. Health agencies in common with other employers had to meet the additional cost involved. As this expenditure was not covered in the original allocations it is necessary to supplement the allocations of health agencies to cover the cost involved. The amount of grant required for 1977 is £540,000.

A number of the special homes which cater for children were experiencing severe financial difficulty earlier in the year. It became necessary to approve of considerable increases in the rates of capitation payments made by health boards to the authorities of the homes concerned. The rate which applied at the beginning of 1977 was £18 per week. This was increased to £30 per week. The additional grant required to meet the extra expenditure incurred by health boards in 1977 is £550,000.

The additional amount required for capital services is £3,530,000. These funds are required to meet the cost of a special programme which could not be accommodated within the original allocation. The programme enabled a commencement to be made on projects such as a new pathology laboratory at St. James Hospital, Dublin, a new centre for the mentally handicapped at Ballybane, Co. Galway and welfare homes at Navan Road, Dublin, Athlone and Edenderry.

I would ask the House to agree to the voting of the necessary supplementary funds for 1977—£24,978,000.

Mr. Boland

Almost all of the moneys required in this Supplementary Estimate relate to increased staffing costs, price increases and social welfare contribution increases in rela-to health board employees. From that point of view it limits the area of the general health services which may be discussed. I propose to confine my remarks mainly to the area of the health boards, their size and operation.

Some weeks ago in the House I suggested to the Minister that when the health boards were first mooted on foot of the famous McKinsey Report it was suggested by McKinsey that when the health boards had been in operation for five years a review of their structure and effectiveness should be carried out and necessary changes implemented. Such a review has not been carried out although the health boards are now in operation for some seven years.

Members of the House will recall that at the time of the setting up of the health boards many people suggested that the eight health boards would become monsters which would begin to absorb more and more of the budget for any one year and on an administrative basis would absorb more and more of the money devoted to the health services. That idea was scotched and denied at the time by the Minister in question, but when one looks at a graph of the costs, especially the administrative costs, one sees that there was a great deal of merit and validity in the case made at that time. Since the health boards have been in operation for seven years a review is overdue. It is time to have a look at how they are operating, the cost of operation and how relevant they are. That is not happening. We are now discussing a Supplementary Estimate in the sum of £24,978,000, about £20 million of which is to rescue or bail out the health boards on foot of additional costs which they have incurred in the course of the present financial year.

The Minister said some weeks ago that he felt that an overall review of the health services and the health boards could best be carried out by the all-party committee of the Dáil which was to be set up on health matters generally. I am sorry to say that although we are now coming to the end of this session that all-party committee have not yet met. Apart from beginning to carry out a review of the health boards, their cost and operation, we have not discussed any other area of health.

Many people would suggest that as the health boards have grown since 1970 they have become over large, autonomous and bureaucratic and divorced from local representation and in many respects they have become out of touch with the needs of the ordinary person. I would be the first to give credit to the health boards in that they conceived and brought into operation many worth-while changes and improvements in the health services and in many areas their operation has been enlightened. Nevertheless, the fears expressed in 1970 have validity in the circumstances of today. It was feared that they would become little empires of their own, employing a great number of people in a kind of Parkinson's Law situation in which the amount of benefit derived in comparison with the costs of staff, especially administrative staff, would not be in line with the amount of money allocated. In the figures given by the Minister there is no real breakdown in staff costs as between administrative staff, medical staff and para-medical staff.

I believe that there is a duty on the House or on the all-party committee at whatever stage they meet—let us hope it is sooner rather than later—to have a look at the cost of operating the health boards and see whether they are as effective as it was suggested in 1970. We should examine whether they are getting across to the people the services they have and whether the operation of those services is as effcient as it might be if it were operated by smaller authorities more in touch with what is happening at local level.

It has been suggested that, because most health boards span a number of counties and because their administrative centres are often many miles away from the area in which services are being provided, the manner in which services are operated is not as effcient as it might be. If that is true, it is part of the reason why we are voting some of the moneys in this Supplementary Estimate. When the Minister is replying I should be glad if he would outline to the House his ideas regarding a real and worth-while review of the operations of the health boards. I appreciate that the idea of asking the all-party committee to have a look at the health services is a good one, but it is also important that some outside body should be asked to examine the structure of the health boards, the administative costs as against the level of services and the percentage taken by administrative costs compared to the percentage that they represented in 1970.

An Ceann Comhairle

I cannot prevent the Deputy from going on but I must remind him that I will be putting the question at 12.15 p.m.

Mr. Boland

I appreciate that. One of the few areas in the Supplementary Estimate not involved in the cost of staffing the health boards is the increase in the rate of allowances. This amounts to £1,500,000 and arises on foot of the 1977 Budget in respect of allowances which were not contained in the original Book of Estimates as published. As the Minister has outlined, they are the increases in the disabled persons' allowances, blind welfare allowances and the rate of allowances paid to people suffering from infectious diseases. These in-increases allocated to special homes for children, where the capitation rate has been increased from £18 per week to £30 per week. I am sure everybody agrees that £18 a week is completely unrealistic in 1977 and must have posed great problems for the voluntary agencies who operate those homes.

There are increased costs in the Supplementary Estimates for staff. How many new jobs in relation to both capital and current services have been created and filled during this year? Does the Minister anticipate that there will be any sizeable increase in the number of new positions filled before the end of this month? I appreciate that 130 additional public health nurses were employed in the past few months. I also appreciate that the Minister told the House some time ago that up to the end of September approximately 2,000 were created on the current side. Has the Minister more up-to-date figures now about the number of posts that have been filled up to the end of November and the number that may be filled before the end of this year?

I welcome the Supplementary Estimate, which will not be opposed from this side of the House.

Mr. Horgan

I do not intend to take up the time of the House. I am operating on the assumption that the Minister would like to get in around 12 o'clock to reply. I am speaking in the unavoidable absence of our spokesman on health. I would like to make a few comments on the Supplementary Estimate and on some of the points raised by Deputy Boland.

I want to underline what the Deputy said about the all-party committee on the structure of the health services. The concern expressed by him has also been felt by many members of my party. It is a concern which is ultimately for the better functioning of the health services. The Deputy's plea for an early convening of this committee and a speedy completion of their work is echoed by a number of people on these benches.

The first part of the Minister's speech I want to refer to is the section relating to price increases, where an extra £1½ million is needed to offset the additional costs incurred by the health agencies with higher prices in items such as purchase of medicines and drugs, heat, light and so forth. I want to concentrate on the price increases in the medicine and drugs area. The Minister must be aware of the finding of the recent report into the health services that a substantial amount of the cost of providing health services was attributable to the prescribing practices of doctors. The question was raised as to whether or not doctors always had the cost element at an appropriate place in their minds when they are prescribing.

This is certainly true of a doctor friend of mine who got a report from the health board on his prescribing practice at his own request and was horrified to realise that he was prescribing in a year drugs which cost more than his salary from that health board. I doubt if that is unusual. I urge the Minister to consider this role of the doctor and his prescribing practice. I also urge him to look at it from the point of view of the manufacture and provision of drugs and medical supplies. We are all aware of the enormous cost variation between different brands of what are essentially the same drugs. We are also aware that of the many industries which have been established in the country over the past decade or so some of the most successful and profitable have been those connected with the pharmaceutical industry.

I urge the Minister very strongly to investigate this matter not just in terms of cost but also in terms of providing further employment and the possibility of direct State involvement in the manufacture of drugs and medical equipment generally, especially on the pharmaceutical side. I believe that in this area one can look to State involvement as something which will add to growth and reduce costs.

Like Deputy Boland I agree that the £18 a week capitation payment to special residential homes for children was not by any means a realistic figure. I think it is extraordinarily cheap at £30 a week. I can promise the Minister, whenever he comes back here looking for more money for those special residential homes, he will get a warm welcome from this side of the House.

Mr. Callanan

Deputy Boland has referred to many of the matters I intended to speak about. I want to congratulate the Minister for having increased the capitation grant from £18 to £30, which is only a realistic figure in relation to present day costs. This shows the concern the Minister has for those children.

I agree with Deputy Boland that the time has come for a general review of the work of health boards. I am not critical of the staff of the health boards when I say that. The staff of the Western Health Board are very efficient and very nice, but the boards have got very large. Could the administrative costs of the health boards be reduced if they went back again to county areas? The health boards are splitting up counties for community care purposes. A county is a unit for community care. Part of my county is put in with Roscommon. The County Medical Officer decides who gets a house. If a person is in a community care area which is in another county the County Medical Officer in that other county decides whether or not that particular applicant is entitled to a house.

I do not agree with splitting up counties in relation to community care. The county should be left as a unit for such purposes. I have opposed this and will continue to do so. There are many things like that which need to be looked at. The all-party committee should review the construction of the health boards. When an organisation get too big one gets away from the ordinary grassroots man who understands everything in the particular county. I am taking this opportunity of paying tribute to all the staff in my health board area for their courtesy and effciency, but there remains the fear on the part of ordinary people that decisions are being made by way of remote control. If one were to divide the western health board area into counties and to calculate the amount of money being spent per county on health services, one would realise that, even allowing for inflation, the cost has increased out of all proportion. After seven years of their operation, we should review seriously the health boards set-up. If such a review should show that the health boards are doing a better job than could be done by reverting to the old system the new system should be continued, but should it be found that a mistake was made, there would be nothing wrong in reverting to the old system.

There was much of the McKinsey Report with which I did not agree, particularly in regard to the down-grading of hospitals. However, that is another and a long story with which I shall not take up the time of the House except to say that in other countries there has been a complete rethink regarding the situation of hospitals. The Minister has been kind enough to give me a few minutes of his time so I shall not delay him further except to say that I agree with the speakers who are advocating a review of the present system. The Minister has shown his concern in this area and the increase in the payment to homes from £18 to £30 indicates further his genuine concern. I am sure that if a review should indicate a necessity for change in the present set-up, he would be willing to make that change.

Mr. McMahon

It is not my intention to take up the time of the House, but I rise to refer briefly to an anomaly that exists in respect of one of the services provided by the health boards. I refer to child dental benefits.

The position is that many children attending schools, other than the national primary schools, cannot benefit from this scheme. Indeed, in the case of children attending the national primary schools, dental examinations are carried out only once in four or even five years. That is not sufficient.

I should like the scheme to be extended so as to give a more frequent examination. The worst feature of the scheme is that if a child attends a private school the management of which do not invite the health board to undertake dental examinations, that child cannot benefit from the services that are available to children in other schools. In addition there are those children who do not attend school, for instance, the children of travelling people. They, too, are excluded from the dental scheme as operated by the health boards. Consequently I urge the Minister to encourage the health boards to extend this scheme to all children and, thereby, to eliminate what I would describe as discrimination in respect of those children not attending national primary schools.

An Ceann Comhairle

May I remind the Deputy that I am putting the question at 12.15 so that if the House expects the Minister to reply he should be allowed reply now.

Mr. McMahon

I would not wish to take up the Minister's time so I shall conclude by expressing the hope that the Minister will consider seriously the point I have made.

Deputy O'Connell rose.

An Ceann Comhairle

The same applies to Deputy O'Connell on behalf of whom a colleague said he was speaking because of the unavoidable absence of the Deputy at the time.

Mr. Haughey

I shall require only five minutes for my reply.

Dr. O'Connell

In that case perhaps I would be allowed a few minutes.

An Ceann Comhairle

The Deputy, then, may have a few minutes.

Dr. O'Connell

I thank the Chair. First, I would ask the Minister to have a clear look at the whole question of the community care programme. The Eastern Health Board has become so cumbersome and unwieldy that the necessary attention is not being given to community care. The change to the health boards system has resulted in the administration becoming so top-heavy with officials that the money that normally would go towards the care of those in need is being spent on the salaries of top officials. This is a complete negation of the whole concept of what we were aiming to do for our people.

We talk in terms of massive injections of funds into the health service, but unfortunately the emphasis is not on the distribution of these funds to deserving cases. People who find it necessary to have recourse to the health boards for the type of assistance that was available under the old health authority assistance scheme find that they may have to wait for months before their applications are considered. Last night I spoke again with a person who had approached me at the beginning of October seeking some form of either supplementary social welfare allowance or disabled person's maintenance allowance. After writing to the health board about the case early in October I received a reply on October 8 acknowledging my letter. It is now December and nothing has been done for this man, who is in extreme poverty. He has no means what-ever. This is not an isolated incident. Hundreds of cases are brought to my attention in which the health board cannot or will not act. These are cases that require urgent attention. Such delays are a shocking indictment of the whole community care programme. I am asking the Minister to give the matter his personal attention. He must be aware of the considerable hardship and suffering that results from such a situation.

The other point I wish to make relates to medical cards. There is provision in the Health Act for the taking into consideration of special circumstances in a case where a person's income may be somewhat greater than the statutory limit. Unfortunately, though, this clause is not being availed of by the health boards. Perhaps the Minister would urge them to exercise a certain amount of latitude in this regard. The position is that people whose incomes may be only 70p or 90p greater than the statutory limit for qualification for medical cards are not granted medical cards although their circumstances may warrant this benefit. Even in cases where the amount is a few pounds greater than the limit specified, there may be special circumstances that warrant the granting of medical cards. The health boards are not prepared to say what constitutes special circumstances. Consequently, I have asked them how people are expected to indicate special circumstances when there is no way of knowing what constitutes special circumstances, but even as a member of the health board I cannot obtain this vital information. If the Minister could get action on these two points, he would be doing a good day's work for the people concerned.

Minister for Health (Mr. Haughey)

Perhaps the best thing I can do is to give some factual information. Drugs cost £30 million a year at present. That is a considerable sum of money and it would indicate that every aspect of the supply of drugs should be examined. I hope to go carefully and in depth into the price of drugs supplied, into the consumption of the drugs, the sort of drugs used and whether expensive drugs are being used where less expensive drugs would be equally effective, and into the prescription patterns of doctors in the GMS and elsewhere. This is an area which calls for very careful attention. Nobody wishes that there should be any skimping in drugs which are necessary and valuable, but on the other hand everybody will support me in my endeavour to eliminate any element of waste which exists.

On the question of jobs raised by Deputy Boland, on the capital side we created 350 jobs during the year and all of those have been taken up. On the non-capital side we created 3,800 jobs. At the end of November 3,200 of these had been filled. At the end of December 3,600 will hopefully be filled, and the remaining 200 may not be finally filled until January or February. Deputies will understand that in an operation of this sort there will naturally be difficulties from time to time which, even with the best will in the world, would prevent us from reaching the targets we set ourselves.

The committee of the House will be set up very shortly and I look forward to them performing a very useful and important role in the administration of the health services. I am trying to ensure that I get a good spread of Deputies from around the country representing the different health boards so that we will have people on the committee who will be able to bring a very important pool of practical knowledge and experience to bear on their discussions. I will be fairly flexible in the subjects that we will discuss. I believe there will be very widespread agreement among Deputies who will be members of the committee that we should look at health boards, their effciency, their effectiveness and other aspects of them. That will probably be one of the first things we will look at, I hope that I will be able to bring a discussion document on our mental health services before the committee. I assure the House that the committee will be fully operative during the next term. I am sure that they will make a valuable contribution to the discussions on the different aspects of our health services.

Vote put and agreed to.