Dáil Éireann debate -
Wednesday, 17 Dec 1980

Vol. 325 No. 8

Supplementary Estimates, 1980. - Vote 50: Health.

Minister for Health (Dr. Woods)

I move:

That a supplementary sum not exceeding £33,161,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1980, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.

The original Vote for Health for 1980 was £541,860,000, including a capital provision of £27,500,000. The first supplementary estimate which was agreed to last June totalled £93,190,000. The Supplementary Estimate covered the amounts required to meet the cost of approved special pay claims which is £88,390,000 and the cost of increases in cash allowances which had been provided for in the 1980 budget, £4,800,000. This brought the total approved Vote for Health for 1980 to £635,050,000.

The net total additional grant now estimated to be required is £33,161,000. The gross amount required is £43,311,000 but deductions totalling £10,150,000 fall to be made because of an estimated increase of £10 million in the amount to be realised by way of appropriations-in-aid and an anticipated saving of £150,000 on Subhead G7 the Grant to the Voluntary Health Insurance Board.

As I mentioned, the gross supplementary requirement amounts to £43,311,000. This is made up of: £36,311,000 for non-capital services, and, £7 million for capital services.

The additional grant required for non-capital services arises under the following broad headings:

	£m.
Additional amount required to maintain essential health services in 1980	16
Pay costs arising from the second national understanding	10.7
Pay awards for certain grades of health personnel	7.261
Increases in social insurance contributions (employers' share)	1.85
Double payment for one week in weekly payment of cash allowances	0.5
Total	36.311

Despite the very commendable efforts made by health boards and other health agencies to effect all possible ecomomies in the running of the services in 1980 a number of adverse factors reduced to an extent the effectiveness of their programmes for securing economies, such as particularly heavy increases in certain commodities like heating oil, drugs and medicines, and medical and surgical appliances and equipment. It was found necessary in all the circumstances to provide additional assistance in the sum of £16 million to ensure that essential services could be maintained. Of the total amount of supplementary estimate sought, £2.35 million relates to the General Medical Services Scheme as financed through the General Medical Services (Payments) Board. The amount which relates to the drugs refund scheme and the long-term illness drugs scheme is £3 million. The balance of the increase is related largely to increases in costs associated with hospital services.

Of the gross amount required for non-capital services — that is £36,311,000 — pay accounts for £19.811 million made up as follows:

	£m.
Second national understanding	10.7
Special pay claims	7.261
Increase in social insurance contributions (employers' share)	1.85
Total	19.811

Non-pay expenditure accounts for £16.5 million.

	£m.
Drugs Refund Scheme and Longterm Illnesses Drugs Scheme	3.0
Double payment in one week to recipients of cash allowances	0.5
Other non-pay costs	13.0
Total	16.5

Pay accounts for about 54.6 per cent of the gross supplementary requirement for non-capital services and non-pay expenditure for about 45.4 per cent.

The provision for approved special pay claims covers cases which have already been approved, save in one instance where negotiations are still in progress. The cost involved in cases where approval has been given comes to about £7.131 million out of a total of £7.261 million included in the Supplementary Estimate. The major items are:

	£m.
Further adjustment of pay of general nurses arising from clarification by the arbitrator of his arbitration finding	1.06
Award of £7.60 a week for nonnursing staff in voluntary hospitals and homes for the mentally handicapped, together with an equal pay settlement for the same staff	2.2
Pay award for radiographers	1.1
Regrading for catering officers	0.5
Increased premium payments for non-nursing staff	0.36
Pay award for public dental surgeons and psychologists	0.33
Pay award for child care workers	0.25

If the outstanding claim has not been settled before the end of the month then the provision included in the Supplementary Estimate — £130,000 — which is referable to the claim will not be drawn.

Arising from the question of surrendering unexpended funds which are authorised by the Dáil for specific purposes, I should perhaps refer to statements made recently in regard to the surrender in 1979 of amounts approximating to £27 million. A sum of £25,918,000 was included in the Supplementary Estimate of £72,480,000 for Health in 1979 to cover the cost of pay claims where negotiations had reached an advanced stage or where offers in settlement had been made. If agreement was not reached before the end of the year in respect of any of the claims not so far finally settled then the provision made in the Supplementary Estimate which was referable to any such claims would not be drawn.

In the event the total amount falling to be surrendered on the voted subheads was £22,942,269 made up as follows:

(i) £22,804,000 in respect of offers on special pay claims which were not finally settled before the end of 1979, the main constituent of which was £21.25 million in respect of offers made to nurses;

(ii) surpluses on miscellaneous subheads offset by some minor excesses — £138,269.

The surplus realised on appropriations-in-aid amounted to £4,046,159. The combined total of the amounts falling to be surrendered was £26,988,428. This amount was certified by the Comptroller and Auditor General. The accounts as certified will be reviewed by the Public Accounts Committee, as is the normal course, probably early in 1981.

The procedure followed was in strict accordance with established practice. Public moneys may be appropriated only on the authority of the Dáil, that is, expenditure may only be incurred within the limits of and the purposes of the amounts voted. Any sums for authorised purposes which are not expended, including any surplus of appropriations-in-aid realised, must be surrendered. While virement may be exercised with the sanction of the Minister for Finance, in regard to excesses and savings as between subheads, it relates to authorised expenditures, generally of a minor nature. Virement, or the swithching of moneys between subheads, was availed of in that way in 1979.

An amount equivalent to the provision of £22,804,000 for pay awards which was not drawn from the voted Supplementary Estimate for 1979 was included in the 1980 Supplementary Estimate for Health which was voted by the Dáil on 20 June 1980. This amount was paid out during 1980 in espect of retrospection, almost entirely to nurses.

The rates of social insurance contributions — employers' share — were increased as from April 1980. The employers in this instance are health agencies funded from the Department's Vote. The estimated amount required to meet the expenditure involved is £1.85 million.

In line with the provisions of the second national understanding and the approval already given on the social welfare side, a double payment is being made for one week in the amounts of the payments made to recipients of disabled persons maintenance allowances, infectious diseases maintenance allowances, blind welfare supplementary allowances and domiciliary care allowances for handicapped children. This will cost about £500,000 and is in addition to the amounts provided under the Social Welfare Supplementary Estimate.

I am seeking an additional sum of £7 million to meet capital expenditure on health projects in 1980.

The amount voted earlier this year for capital works was £27.5 million and, in addition, £0.5 million was available from the Hospitals Trust Fund making a total capital allocation of £28 million.

I had sought this £28 million in the context of the need for constraints in public expenditure in the current year and I had expected that by placing certain restrictions on the capital programme it would have been possible to manage within this allocation. However, despite these measures, this did not prove possible, due mainly to inflation and the fact that the output of work on the projects in progress in the restricted programme has been maintained at an unusually high level. It is estimated that inflation added some £5 million to the cost of schemes this year.

Accordingly an additional £7 million is required to meet commitments arising from this year's capital programme. I would like to explain that despite the restrictions imposed this year it was possible to maintain progress on 79 projects which were in course of construction at the start of the year and to allow a limited number of new works to start, the major works being Cheeverstown Mental Handicap Centre and the first phase of the development of St. James's Hospital, Dublin.

The 1980 Vote for Health provided for receipts amounting to £42.8 million. It is now expected that income will amount to £52.8 million. The increase of £10 million is made up of an increase of £8 million in receipts from health contributions and £2 million in receipts under EEC regulations.

The receipts from health contributions have been more buoyant than had been anticipated. The amount originally provided for in the original estimate was £35 million. It is now expected that the amount received in 1980 will come to about £43 million. When the original Estimate was prepared in 1979 there was no previous experience of the operation of an income-related contributions scheme which had commenced in April of that year. The position was also affected by the difficulties caused by the postal strike in that returns from employers were delayed. In the circumstances the income realised from health contributions in the first half of the contribution year 1979—80 was considerably below the level eventually reached. An upward drift in the overall level of pay also meant that the income from health contributions was further boosted. The increased receipts from health contributions in 1980 will mean that the level of Exchequer grant that would otherwise have been required can be significantly reduced.

As a result of negotiations with the British Department of Health and Social Security agreement has been reached that an increase will be made in their payments in respect of health services provided for persons for whom they are liable under EEC regulations. The additional receipts in 1980 over and above the amount provided for in the original estimate — £7.3 million — are expected to amount to £2 million.

While the increase in grant requirements as set out in the second Supplementary Estimate is very considerable, the major proportion of the increase on the non-capital services end is due to movements in prices and pay levels and to unavoidable expenditure on the capital side to meet commitments. I now ask the House to agree to the Supplementary Estimate of £33,161,000.

Mr. Boland

By no stretch of the imagination can 1980 go down as having been a good year for health, for the Department of Health or for the progress of the health services, because it became clear very early on during the financial year that the best the Government were aiming for was to maintain, at the level of 1979 services, the existing health services. The fact that they failed even to achieve that objective is indicative of the lack of thought and foresight which was put into the planning of the current and capital budget by the Government at the commencement of the year and on the input made by the Department of Health and the Minister responsible in the prebudget negotiations and discussions which determine the share that each Department gets. Perhaps it was understandable. There was a new Minister in one of the largest spending Departments and one of the Departments that, traditionally, suffers when there is a recession or cut-backs.

At the commencement of the financial year we were constantly beleagured by statements and inspired leaks to the media by the Minister to give the impression that everything in the health garden was rosy and that there would be no cut-backs in the health services. That, more than anything else, has contributed to the sense of dissatisfaction, unease and unrest amongst the personnel in the health services because they were assured at the start of the financial year that all their needs would be met and that the new Minister had arrived, like a light from heaven, to implement all the necessary services. It was only as the year unfolded that we realised just how much of a shortfall there was in the Estimates provided, even for the continuation of the existing level of health services. The original Estimate of £541 million had, after a short while, to be supplemented by £93 million and, today, by this Supplementary Estimate which the Minister is seeking, of £33 million. On an original Estimate of £541 million the Minister has to look for a further £126 million — an increase overall on the original Estimate of 22 per cent.

As I said in relation to one of the accounting procedures in relation to the Department of Social Welfare, I do not think, even in inflationary times, that it redounds to the credit of the Government, or the officials in the Department that, at the out-turn of the financial year they have to admit that during the course of the year they had to come back twice to the House to seek increases of 22 per cent on the original Estimate.

I will give a supreme example of under-budgeting, which neither the Minister, his predecessor, nor his officials can say was outside their compass or had not been drawn to their attention. When legislation was being enacted to bring in the present health contribution system, to allow everybody over a certain figure to benefit from the refund in the cost of drug scheme, I pointed out to the Minister of the day, the present Taoiseach, that the amount he estimated as being necessary to pay for the refund of drugs and medicine scheme was totally inadequate and that he should think again. The Minister was adamant, presumably on the advice of his officials, but we see today on an original estimate of somewhere between £3 and £4 million, the cost of the scheme, the Minister having to ask for a further allocation of £3 million. in other words, in the course of this financial year, the cost of the refund of the drugs and medicine scheme has practically doubled over the original estimate.

A child going to primary school, with any knowledge of the trend in the health services, could have told the Minister and his personnel that the original estimate was inadequate and the scheme itself was designed to encourage people to seek prescriptions. It also encouraged the medical profession towards the prescription and dispensing of costly drugs. There should be far more care exercised on the part of the Department of Health, the General Medical Services Payment Board in relation to the GMS and the Health Education Bureau in relation to the prescribing and dispensing of over-expensive drugs and medicines. They are very often unnecessary for people who have them dispensed by chemists on the medical card scheme or on the refund of drugs and medicines scheme, at an unnecessary cost to the State and to the overall detriment of the health of people generally. I believe this scheme is encouraging the medical profession and the general public to develop into a pill popping society. I exhorted the Minister at the time to take care of the manner in which the scheme was introduced. I regret to say all the trends which I prophesied at the time now appear to be coming to light.

I appeal to the Minister and to the Health Education Bureau to redouble their belated efforts — I accept there are belated efforts now being made — to bring some sanity into drug costs and the prescribing of certain drugs, brand name drugs, rather than the generic type drugs. The Minister distributed to the Members of the House yesterday a document from the Health Education Bureau for 1981. That document shows clearly, in chart form, that certain drugs which have been widely prescribed have only the same remedial effect as other drugs which are not as popular in the public mind and can cost far more than cheaper drugs which perform a similar task. I have not got the document here but two of the most commonly used drugs which doctors prescribed are named valium and librium. There are similar drugs which can be prescribed far more cheaply and which are just as effective.

Unless an improvement can be brought about in the excessive cost of drugs and medicines provided by certain firms, action will have to be taken by the Department of Health on behalf of the taxpayers. It is not for me to say whether that involves the central purchasing of drugs in bulk or the setting up of certain machinery, price control and perhaps a prohibition on the sale and distribution of certain drugs. The situation is getting more and more serious and is not being controlled by the Department of Health.

I want to refer to the situation in our psychiatric services and to the physical conditions in so many of our psychiatric hospitals and institutions for the mentally handicapped. At last, thankfully, there is a growing awareness on the part of the general public of the deplorable conditions in which so many of our patients in psychiatric hospitals and mental institutions are living. The fault and the responsibility is ours. It is not good enough to blame society at large; the main responsibility rests with the House and with responsible, successive Governments who have not devoted the money which is necessary to improve the physical conditions in these hospitals. In the discussion on the Mental Services Bill we heard once again of the deplorable conditions under which so many of our psychiatric patients live. Many mentally handicapped patients who should not be intermingled with psychiatrically ill patients are now and have been traditionally accommodated in one institution under the same roof in outmoded, Victorian type institutions.

It is indicative of a lack of concern by the public and this House that, despite the fact that the media and some people in society are beginning to pay more attention to this area, in this year, when one might have hoped for a large input of a capital nature to bring about real improvement in the physical condition of the psychiatric services, we saw an increase of £500,000 — the capital estimate for 1979 was £27½ million and the Minister's estimate for 1980 was £28 million, with inflation running at 20 per cent. In real terms this means a severe cutback in capital services on the health side. Despite the Minister's reining in, restrictions and so on, the overspending for the year amounted to £7 million which forms part of this Supplementary Estimate of £33 million.

Within the last month a number of us got a document from the consultant psychiatrists employed in the Eastern Health Board. They made what has to be a very telling point. They said:

When requests are made to update the services to conditions more appropriate to this century — the stock answer is always that there is no money. There is money however, for General Hospitals. In the last few years the Department of Health has invested millions of pounds in this area with little or nothing being given to the psychiatric services. Does this mean that depressed patients are cherished less by the state than patients with Hypertension, or, Arthritis? From the state's track record this looks very much like the case. If this is so, it raises many questions about our society, particularly, constitutional ones.

They go on to say, and let us reflect on this for a moment:

Let us put it another way. If the state gave to the psychiatric and community services of the Eastern Health Board approximately twice the figure they promised to the electorate in Donegal in the recent by-election, the services could be updated. We are talking about thirty-five million pounds. Surely human dignity is as important as airports or will we use the airports to ferry the patients to destinations abroad where they can undergo treatment in more civilised conditions.

That is the question we ought to ask ourselves in this week before Christmas. That is the question the Minister for Health, now almost one year in office, should ask himself.

If the Minister has more muscle now than he had last year, when he was unable to get a fair share for the health services. I ask him to use it not for a real increase in the share of current expenditure in the health field for 1980, but for an increase of real measure on the capital side. The capital side has been starved of funds and consequently the improvement of physical conditions and facilities which bring about an improvement and updating in the medical services and standards of care being provided could not be made in 1980. I exhort the Minister for 1981 — I believe that it ought to be Government policy — that the emphasis should be on capital spending to improve services in a real way as well as providing much needed employment and a much needed boost for the construction industry.

I want to encourage the Minister to see a real increase in the capital services on the health side as part of an overall Government commitment towards the encouragement of employment and the boosting of the economy to expenditure on capital services. A large share of those capital services should be devoted, allocated and promised to the improvement of physical facilities in mental hospitals and pyschiatric institutions. I accept this will have to be over a phased programme but the need is there, and it is great, for a commitment to a five-year programme for the eradication of the Victorian workhouse for mentally handicapped and psychiatrically ill patients.

I promise the Minister the support of this party for any measures taken to help those who are mentally handicapped and the psychiatrically ill. The House realises that they are also constituents to whom we have a responsibility, which I do not believe we or our predecessors adequately exercised in the past.

An Ceann Comhairle

The Deputy will appreciate that he cannot deal with the future.

Mr. Boland

I have been reflecting on the existing level of services. The Chair might tell me how long I may speak.

An Ceann Comhairle

This debate must end at 12 o'clock

Mr. Boland

I appreciate that but I understand that the time allocated to each party may be shared among several speakers. Is that correct?

An Ceann Comhairle

There is an informal agreement——

Dr. Woods

I understand there are 25 minutes for each of the main parties.

Mr. Boland

I understand that in the time allocated to each of the main parties more than one speaker could speak in that time, rather than Deputies being called in rotation.

An Ceann Comhairle

That could be the position but officially I can only deal with the orders made.

Mr. Boland

I accept that. The Minister referred to the fact that it was reported in the press that the Department of Health handed back £27 million. I accept entirely the Minister's explanation but it is regrettable that the transfer of these unexpended funds was represented to the public in that way. It is clear that money voted by the Dáil for a particular purpose, but not expended must be returned. They cannot be taken out of one pocket and put into another pocket. The public finances and accounting procedures are, perhaps, rather cumbersome but it is necessary to realise that they are devised in that way to provide proper checks and safeguards on behalf of the public Exchequer and the taxpayers.

An Ceann Comhairle

On the basis of the informal agreement it would appear that the Fine Gael Party have until 11.15 a.m.

Mr. Boland

In fairness to the Minister and the Department I accept that while there is a need for the expenditure of not only £27 million but multiples of that figure, the fact is that this money was voted by the Dáil last year in the event of a wage agreement being settled and money being there to meet that wage agreement. If that did not come about, the money had to be transferred to the Exchequer and be revoted. To some extent it is regrettable that people who are very anxious to see additional money spent in their areas might have been misled into thinking that there was in some way an uncaring attitude on the part of the Department. In fairness to the Department I have to make these remarks.

It is also appropriate to point out that the junior Minister for Health, Deputy Nolan, has been nominated to become a member of the Cabinet, and, as shadow Minister, I offer him my good wishes in his new role. One always has to admire a clever politican. I suppose it is a fair trick for a fellow to be in the Department of Health for a year, with special responsibility for child services, and manage to get out of the Department without issuing the report about child services. That is a fair trick for any Minister to do, and do on his way up rather than on his way sideways—

Mr. Horgan

Diagonally.

Mr. Boland

Possibly it is fair enough also because he was following in the footsteps of the present Taoiseach who managed to spend three years in that Department with responsibility for child services, come into it and get out of it without ever issuing the report on child services either. Can the Minister give us any indication if we are ever to get this report or will he wait until he gets promotion also?

Mr. Leyden

Deputy Boland will not be there for much longer anyway.

Mr. Boland

Whatever chance I may have, on the basis of the speech on Health made by Deputy Leyden on the last occasion, he has none anyway.

An Ceann Comhairle

The Deputy has five minutes left.

Mr. Deasy

He watered down the oil; that can be seen from today's paper.

Mr. Boland

Their biggest achievement was to keep Deputy Doherty out of the Cabinet yesterday.

An Ceann Comhairle

The Deputy has five minutes left for his party.

Mr. Boland

I should like to give way because there are several other speakers anxious to contribute. In general I want to deplore the limited amount of time we have to discuss these Supplementary Estimates. This was not a happy year for the health services. In relation to the capital programme especially there was a real cutback which I hope will be reversed in real terms next year.

I was asked particularly to draw the attention of the Minister to the fact that he promised twice on recent occasions to announce the planning board for the new Tallaght Hospital in County Dublin. The composition of that board has not yet been announced, much to the detriment of that much-needed hospital. Perhaps the Minister would let us know when we may expect to see that board established and real planning for the provision of that hospital get under way.

I hope 1981 will be a better year than 1980, a year which can only go down in the memory of those employed in the health services as being the year when they did not have sufficient money even to buy elastoplast.

Mr. Deasy

I regret that the £33 million now being voted is merely to make up for the under-estimation in the provisions voted earlier in the year and that it is not an additional sum of money for new works so badly needed.

I want to refer to that part of the Minister's speech devoted to capital grants-in-aid for hospital works, the provision of new hospitals and extensions to existing ones. I have raised at Question Time on several occasions the necessity for a new 100-bed replacement geriatric unit in Dungarvan to replace the present St. Joseph's Hospital which has been due for replacement for the last 30 years. The conditions obtaining in this hospital have been described as Dickensian. I could not dispute that fact. Deputy Boland in the course of his speech referred to Victorian workhouses. Conditions at that hospital could be described as Dickensian or Victorian but certainly they should not be tolerated in any civilised society. At Cabinet meetings when the Minister is seeking funds for projects, especially hospital projects for 1981, I hope he will make a point of ensuring that projects such as these are given the go ahead. I also want to see additional moneys being provided for the new general hospital to replace Ardkeen in Waterford, long due for replacement, the plans for which were presented to the Minister's predecessor. Can the Minister give us any hope that the moneys for the provision of these two long sought projects will be provided in the Estimates for 1981? We in the South-Eastern region suffered severe cut-backs in our health estimates for the current year, cut-backs which are disproportionate to those being imposed on other health boards. The projects I have mentioned have suffered as a result of these cut-backs.

I should like to bring to the attention of the Minister also the fact that annoyance was expressed at last week's meeting of the South Eastern Health Board with regard to his recent visit to St. Luke's Hospital in Kilkenny. While I have always found the Minister to be most courteous in his dealings with public representatives, and with Deputies in particular, I should like him to know that there was a deputation chosen to meet him to discuss some capital projects which had been discarded in 1980. That deputation intended asking him to provide the additional moneys necessary in 1981. They felt snubbed at the manner in which they were ignored on that occasion. Perhaps the Minister could elaborate on that visit when replying because it was severely criticised at last week's meeting of the board. I know that some members of the board felt their position was virtually ignored and they felt aggrieved.

I wonder if the Minister could elaborate somewhat on the sum of £0.5 million referred to regarding the Hospitals Trusts Fund. Is that the total amount of money coming from that fund in the current year and, if not, what is the total? Moreover, how does the total amount of money from this fund compare with the amount granted in previous years. If such comparison shows a downward trend perhaps he could tell us whether there are any moves afoot to substitute it with an alternative type of fund. It may be that the type of project used for raising funds of this nature has outlived its usefulness and is due for replacement.

Mr. Horgan

The £33 million we are voting here today, as Deputy Deasy has said, is basically to allow for errors of estimation and matters which could not be adequately estimated when the original Estimate was introduced. It is crystal clear, however, that the Estimate does and can do absolutely nothing to meet the basic problem in this area. The basic problem in this area is that when the present Minister for Health assumed his present responsibilities he discovered that his immediate predecessor had done absolutely nothing for the preceding three years and had allowed the health services, our hospitals and other basic essentials of the health care system to, at best, mark time and at worst, actually get worse. Unfortunately, he did not have the option, available to some incoming Ministers of a new Government, of throwing up their hands in horror at the state in which they find the books of the Department with which they are entrusted, because the person who entrusted them to the present Minister is the person who had been immediately responsible for them just before he assumed office. The history of the Department of Health in the time of the Minister's predecessor was a tale full of sound and fury signifying very little. That is the basic problem the Minister faces and one that this Estimate will not and cannot solve.

I should like now to refer in some detail to some of the subheads being dealt with in this Supplementary Estimate. The first is in relation to the double payment being made to the recipients of certain cash allowances. These are identified as recipients of disabled persons maintenance allowances, infectious diseases maintenance allowances, blind welfare supplementary allowances and domiciliary care allowances for handicapped children.

When these allowances were first introduced we welcomed them from these benches, but we drew the Minister's attention to what we saw as a serious flaw in the scheme, one which I believe was drawn to his attention about the same time by the Irish Congress of Trade Unions under the terms of the national understanding. That flaw was that the double week's payment was being made only to people who became eligible in the week beginning 12 December, or who were already eligible at that date. It excluded a small number of people who will become eligible for these allowances in the final two weeks of December, including Christmas week.

I have no doubt that the number of people involved is relatively small. I have no doubt that the amount of money involved is relatively small. Therefore, it is all the more Scrooge-like of the Minister to deny the double week's payment to people who become entitled after the end of the week beginning December 12. I fail to understand how any excuse, such as administrative difficulties, could be pleaded in order to avoid giving a small amount of money to a very small number of people to make their Christmas just a little more bearable this year. I do not know what the final outcome will be of the discussions the Minister or his Department may have had with the congress people about this. Personally I regard this as a total breach of the spirit of the national understanding which is bitterly resented in many trade union quarters.

I should like to refer now to the drugs refund scheme. It is true, as Deputy Boland said, that very expensive drugs are over-prescribed. It is astonishing that an error of estimation of the order of 100 per cent should have been made in relation to the cost of this scheme. There are a number of other aspects of the scheme to which enough attention had not been paid up to now. In the first instance, over-prescribing of very expensive drugs predated the introduction of this scheme and will go on, no matter what refund of drugs scheme is in existence, for as long as the drug companies and their advertising agencies exercise so much control over the prescribing habits of our medical practitioners and are allowed to exercise so much control and influence.

It is also worth pointing out that it is not ultimately of very much satisfaction, except in cost terms, for a mother of six children whose husband becomes unemployed a fortnight before Christmas to be told that she is now being prescribed a less expensive but equally effective drug which will do the work of valium or librium. Drugs are not the answer to these people's problems which are rooted in a much deeper social and economic situation. We must beware of assuming that the answer to their problems is to reduce the prices of medicaments which are meant to keep people passive and docile in the face of appalling adversity.

I should like to ask the Minister a couple of questions about the refund of drugs scheme. First, is he aware of an apparently fairly recent practice by the Voluntary Health Insurance Board in relation to their own refund of drugs scheme. I am given to understand that a change of policy on the part of the board has meant that they refund their insured clients with £8 for drugs in any month. They point out, as they are entitled to do, that any excess of £8 for prescribed drugs can be recovered from the Eastern Health Board under the refund of drugs scheme.

I have no doubt that in some cases subscribers to the VHI will feel somewhat annoyed about this because the delays in the processing of payments under the refund of drugs scheme can be very considerable whereas, I imagine, the VHI administration is rather more efficient. What seems to be happening is that the VHI are off-loading a responsibility which they accepted at one stage in relation to their insured subscribers on to the public health services. I should like to ask the Minister the degree to which this may be partly responsible for the enormous percentage increase in the cost of the scheme.

The second question — and it is a key question — is to ask the Minister is he aware of the extent in which this scheme is being abused. I believe it is being abused in two significant ways. First, it is altogether possible that dockets and receipts issued by pharmacists for duly prescribed drugs can be altered by people who pay the bills and submitted in an altered form to the Eastern Health Board where the administrative staff, I would hazard a guess, are not remotely capable of doing any substantial amount of checking, much less checking back with the original pharmacist to find out what the amount of the original invoice was.

In the second place I believe that considerable pressure can be brought and is being brought by customers on pharmacists to issue receipts for non-prescribed medications in such a way as to make it appear that they were in fact issued on foot of a medical prescription. I have no doubt that the pharmacy trade is a very competitive one. The threat to a pharmacist of any substantial body of customers removing their custom to the pharmacist next door or down the street is a very real one and could put many pharmacists in an intolerable situation.

It would seem to me to have been essential from the outset of this scheme that a spot-check system should have been inaugurated and that sample checking should have been done in relation to the amount of the drug and whether or not it was actually prescribed. The scheme has now grown to such proprotions that one has to ask how much would it cost to adequately police and check out a scheme that involves the repeated processing of so many relatively small items of information over a very short period of time. The scheme is costing £6½ million now. I wonder how much would it cost the State to say in relation to all genuinely prescribed drugs that it would bear the cost. I tend to think the cost of adequately policing the scheme, added to the present cost of the scheme, would be very high.

The next thing I want to talk about is in relation to some detailed aspects of the Supplementary Estimate and in particular the work of the Health Education Bureau. On the whole, the Health Education Bureau does a magnificent job of work. It is an initiative in preventive medicine which was long overdue and, by and large, I would not grudge it a penny of the money it gets for this purpose.

I was offended in the extreme and disturbed yesterday to get through the post from the Health Education Bureau a 400-page expensively printed, expensively produced and expensively bound year book and diary. I have no doubt that every other Member of this and the other House got the same piece of literature. The relevance of this piece of propaganda to the cause of health education is marginal at best and almost certainly negative. I regard it as a total waste of money sanctioned by the same man who, wearing one of his other hats, closed down the combat poverty committee this month. I should like to ask the Minister to seriously consider whether the cause of health education or the cause of anything other than the fawning congratulations he may get from some of the recipients of this expensive piece of nonsense is well served in this way.

I should now like to deal with the question of Appropriations-in-Aid to which the Minister referred. It is interesting to note the substantial increase in the Appropriations-in-Aid but we have to remember that were it not for a particular aspect of the legislation which set up this inter-related scheme the Appropriations-in-Aid would be even greater. If I am not mistaken there is a cut-off limit of £7,000 for contributions under the income-related scheme. That means that anybody earning more than £7,000 — the secretary of a Government Department now earns £21,000 — is paying exactly the same as a person earning £6,999. That cut-off point is a real discrimination in favour of the rich in our society and one which removes further possible sources of resources from an under-financed health scheme.

In relation to the question of the money the Minister had to return to the Department of Finance during the year, I should like to state that we fully accept his explanation that in terms of normal accounting practices there was nothing else that could be done with the money and that the principle of virement only normally applies to relatively small sums and then with the sanction of the Department of Finance. I invite the Minister to consider this and give his personal views on the adequacy of this Victorian system of running a Government, or a Department of State, in the final two decades of the twentieth century. That Victorian accounting system adopted and perfected in Britain was basically designed to ensure that money was not wasted or expended for purposes for which it was not voted.

There is now substantial need to look at that system again and provide for much greater flexibility in the allocation of public finances so as to ensure that money voted for Health can be spent in Health on suitable projects with the approval of the Government, or the Department of Finance. One of the problems about public administration in this tradition is that it is basically a tradition which is devoted to the saving rather than spending of money. It is because it is a tradition devoted to saving rather than spending that it is not one which thinks in terms of always having, as every Government should have, on the shelf up to two dozen projects begging for money and ready to go into action at the drop of a Government cheque book.

Thinking positively about spending money would be a much better way of approaching the situation with necessary safeguards than the system we have inherited from the Victorians and should be reviewed, particularly at this stage in our history. This is a large Supplementary Estimate. It is a patching up operation, it meets the pay bills but it does not solve the basic problems and I do not think under this administration those basic problems will ever be seriously tackled.

An Ceann Comhairle

Deputy Leyden has five minutes.

Mr. Leyden

I should like to appeal to the Minister to provide money out of the Estimate for the provision of full maternity services in the county hospital in Roscommon town. This issue has been going on for many years, long before my membership of this House, and it has reached the stage where it is of paramount importance that a decision should be made to appoint an obstetrician-gynaecologist and paediatrician for the maternity unit at Roscommon County Hospital. The people of Roscommon have been patient in the negotiations between the Western Health Board, the authority of Portiuncula Hospital, Ballinasloe and the Department of Health. Our patience is almost exhausted now. It is in the interests of the mothers and babies of County Roscommon that the provision of the services I mentioned should be made without further delay.

The maternity wing at the hospital is fully equipped and there is a full back-up staff. The other medical personnel necessary, such as a surgeon and physician, are also available. Without the appointment of an obstetrician-gynaecologist and paediatrician the unit cannot be regarded as a full maternity unit. I appeal to the authorities of the Ballinasloe hospital to come to terms immediately with the Western Health Board and agree on an application for a joint unit between that hospital and Roscommon County Hospital so as to ensure we have full services in Roscommon. It is interesting to note that the chairman of the Portiuncula hospital board is none other than Mr. Sean MacBride, S.C., a former Member of this House and a man of outstanding ability. However, in this regard he has not contributed anything to the debate between the two authorities. In fact, he has set out to frustrate the appointment in Roscommon County Hospital.

An Ceann Comhairle

The Deputy should not refer to a person who is not a Member of the House.

Mr. Leyden

He is a former Member and a former Minister.

An Ceann Comhairle

That does not matter, he is not a Member at present.

Mr. Leyden

I appeal to the board of the Ballinasloe hospital to finalise the situation and indicate if they are not prepared to work in a joint union with Roscommon County Hospital so that the Minister can recommend to Comhairle na nOspideil that Roscommon should have a proper maternity unit, working with the Western Health Board and the maternity unit at the Regional Hospital in Galway.

An Ceann Comhairle

The Deputy's time is up.

Mr. Leyden

I would like an opportunity to finish the point. You did not give me warning that I would have only a short time.

An Ceann Comhairle

This is an informal agreement. I had nothing to do with it. All I am concerned with are the times that are arranged.

Mr. Leyden

I appeal to the Minister to finalise the arrangements this year to provide the consultants and to come and visit the hospital when those consultants' appointments are made and I assure him of a great reception. We in Roscommon have waited a long time for these appointments to be made and I hope that this Supplementary Estimate will go to some extent to provide those appointments in 1981.

An Ceann Comhairle

Deputy O'Brien has two minutes.

Mr. W. O'Brien

I am interested in an application which has been made for a special kidney machine for the mid-west region. At present it will be argued that the number of people seeking this specialised kidney service in the mid-west is small. Nevertheless, the number is increasing yearly and, as a result, when we survey the number of people involved and where they have to go for such a machine we find that most of those people have to go to Galway, Dublin or Cork. In one case in my county a person, a young girl, had to leave home and take up a job in Galway in order to be near this specialised service. I am here today to appeal to the Minister to give prime consideration to an application from the Mid-Western Health Board in the very near future for this service.

I have about half a minute to go. I would like to raise something in connection with the choice of doctor scheme. The number of patients allowed on a panel, 2,000, is grossly in excess of what any doctor could serve. In my county, and I would say that the same applies throughout the country, the doctors are not capable of giving the service to so many people and as a result we find bitterness and friction between patients and doctors because doctors are not able to come out late at night. The good reputation and the good name of the medical profession, of the GPs who always had the tradition of the bedside manner, are dying fast. I appeal to the Minister to do something about reducing the number of patients on a panel.

Minister for Health (Dr. Woods)

Perhaps I should say first and foremost that I am somewhat disappointed that none of the Deputies in the course of all the contributions thanked me for getting these funds to maintain the level of services during the year, which aspect, of course, is relevant. I take it from what has been said in the House that the Deputies all round welcome the provision of these additional funds to maintain the services and to allow in particular the opening of many new units which, unfortunately, once opened run into current continuing expenditure.

We have a large number of projects under way — I have mentioned 79. People have mentioned Donegal in the course of this debate. I should point out that I was responsible for opening a reasonable number of units in Donegal because this was planned from the beginning of last year. I had to leave the opening until late in the year because of the provision of finances for the running costs of these units, but it allowed me to open these units as the year went on, and this was always our intention.

Deputy Boland said that in his view this has not been a good year for the health services. The health services have improved in many aspects and a number of projects have gone ahead in very major ways in the course of the year. I mentioned 79 projects. These are all advancing to different stages. We commissioned a very large number of projects so far as these areas are concerned and I could not take up the time of the House at this stage to mention all of them, but it was a very good year for a very large number of units in the health services. Cavan Surgical Hospital, Ennis County Hospital, St. John of God's, Cahercalla, the Mercy Hospital and St. Finbarr's in Cork all have had additional units and pieces of equipment provided. There is the pathology laboratory and X-ray department in Letterkenny Hospital, Temple Street Hospital, Dr. Steevens Hospital, the Mater Hospital, a very large list of developments during the year. Of course, all of these developments were important and it was a worthwhile year.

Deputy Boland, particularly, criticised the Supplementary Estimates, especially the previous one for £93 million. It was always quite clear that there would be a requirement for the special pay awards of which he is very much aware as are all Members of the House, which was £88.3 million of the £93 million. This was not a question of a lack of estimation, it was a question of the conclusion of the work of an arbitrator.

Deputy Boland expressed concern about the drugs refund scheme and I would agree with him. I would be quite concerned to ensure that this scheme works as efficiently as possible without harassing people unduly in the course of any of our activities. I am looking at this at present and I think the Deputy gave me some credit for that. I will try to make it as efficient as possible mainly because I want to see the services working as widely and efficiently as possible for the community.

In particular, Deputy Boland raised the question of the psychiatric services. He talked about deplorable conditions and the letters circulated by consultant psychiatrists in the Eastern Health Board. There has been considerable debate in recent times on the question and a good deal of criticism about conditions in psychiatric hospitals. I would like at first to make quite clear one aspect which was involved in this criticism, that is that the Secretary of my Department of Health has been criticised personally and publicly by some of these people who were consultant psychiatrists. This was grossly unfair, inaccurate and ill-founded criticism and, because I regard the Secretary of my Department as one of the finest public servants that you will find within the public service as a whole, totally committed and dedicated to public service and regarded as such throughout the public service, I want to put on record that I refute totally and unequivocally the comments made in that regard. There has been general criticism about the conditions in the psychiatric units.

Mr. Boland

Did the Minister clarify by whom?

Dr. Woods

I did, I said by members in the public media.

Mr. Boland

Was it by consultant psychiatrists in the public media?

Dr. Woods

Yes. The Deputy should let me speak now. I did not interfere with him when he was talking. Since I became Minister for Health about a year ago I have visited a number of mental hospitals throughout the country in which institutional services for the psychiatrically ill are provided. In a number of them that I visited the standard of the environment in which the services are provided is of the very highest quality, and I want to make that quite clear. The atmosphere is warm and caring and the staff at all levels are totally involved in and committed to the care and activation of all the patients. It is significant that the Nurse of the Year Award recently went to Nurse Marian Doyle from St. Senan's in Enniscorthy, a hospital dealing with the psychiatrically ill. Many of the staffs in these services have been offended by the statements which have been made publicly, especially given the fact that they have been doing such an excellent and caring job and have improved their own environment so well. Buildings which are old and outdated by modern standards have been adapted and renovated so that they are functional and at the same time comfortable. They have been decorated and furnished with imagination with regard to the need to preserve the privacy and dignity of the individual patient.

Furthermore, where new buildings have been provided they have contributed to the comprehensiveness of the complex and have enhanced the services which the institution provides. I have mentioned some of the buildings I have visited and some which are quite outstanding in this respect include St. Fintan's, Portlaoise, St. Conal's in LetterKenny, St. Loman's in Mullingar, St. Davnet's in Monaghan, St. Dympna's in Carlow and St. Senan's in Enniscorthy. These are all units some of which are very old but which have carried out the kind of adaptation that was encouraged by my predecessor and indeed predecessors. On the other hand, there are buildings of the same general age in other institutions where there is a general air of neglect and where apathy rather than activity seems to be the order of the day. Incidentally, there are new buildings in these institutions which in some instances have assumed the aura of neglect which characterises the older buildings. I have found these contrasts very puzzling and this is something I personally intend to pursue.

If we take St. Brendan's, which has been publicised so much recently, and in particular the alleged failure of my Department to provide money for it, there are two aspects to this matter. First, let us take the long-run situation for the kind of patient now in St. Brendan's. This is a huge complex of buildings, some over 150 years old. The number of patients has been dropping steadily and in the past 15 years has declined from 1,614 to 1,065. Modern developments in psychiatric care which in the Dublin area have included considerable development in outpatient treatment facilities, including day hospital, outpatient clinics and hostels, have contributed to this decline in patient population. Nevertheless, it must be recognised that a number of patients must remain in psychiatric hospitals and that facilities in them must be satisfactory. As regards St. Brendan's, there have been many innovations and improvements in recent years, including a new admission unit, a new outpatients' department and new nurse- training facilities. In all, since 1966 £1 million has been spent on such developments.

Capital allocations to health boards are divided into two categories; first there are allocations for specific major projects which are selected according to the priority of the health board. In this regard I should say that the Eastern Health Board did not, in spite of all the protestations in recent times, list works—particularly to St. Brendans—at St. Brendans as a first priority for major capital development in proposals submitted to my Department for the years 1977, 1978, 1979 and 1980.

To take the specific major allocations first, in 1977 a total allocation of £600,000 for specific projects was made available to the Eastern Health Board. None of this was for St. Brendan's. In 1978, £1.15 million was made available for specific projects and £400,000 of this went to St. Brendan's. In 1979 £890,000 was made available for specific projects of which £370,000 was for St. Brendan's. In the present year the allocation to Eastern Health Board projects was £260,000 of which £150,000 was for St. Brendan's.

Secondly, there are minor capital schemes. For the years 1977, 1978 and 1979 each health board received an allocation from which it could spend money at its choice on capital schemes costing not more than £50,000. In 1977 the Eastern Health Board was allocated £300,000 under this arrangement. It assigned £62,000 to St. Brendan's. In 1978 the board received £350,000 for minor capital schemes. It allocated £92,000 to St. Brendan's. In 1979 it received £400,000 for minor capital schemes and it allocated nothing to St. Brendan's: so, of over £1 million available to the Eastern Health Board in the three years 1977-1979 for minor capital schemes, only £154,000 was provided by the board for St. Brendan's.

I am also aware that in the years 1977-79 the Eastern Health Board were provided with revenue resources amounting to £6.2 million for expenditure upon the upkeep and maintenance of their hospitals and clinics. I am, as I said earlier, somewhat puzzled by the contrast in the standards of some psychiatric hospitals.

(At this stage the proceedings of the House were interrupted by intruders.)

An Leas-Cheann Comhairle

We will proceed with the business.

Mr. Boland

Is there no security?

An Leas-Cheann Comhairle

The Chair will make some inquiries about the matter.

Mr. T.J. Fitzpatrick

(Cavan-Monaghan): Suppose they had guns what would happen?

An Leas-Cheann Comhairle

I presume they should never have got further than the main gates.

Mr. Boland

I fear we shall have to talk about security here if that sort of thing can happen, if people can get into the Chamber like that.

An Leas-Cheann Comhairle

The Chair deplores the fact that something like this could happen.

Mr. W. O'Brien

This is the worst effort I have ever seen.

Mr. T.J. Fitzpatrick

(Cavan-Monaghan): I want to say in restrained terms that it is rather alarming that what has happened could possibly happen. These people have got right into the Chamber and right up to your Chair. It is alarming in the extreme. If these people had guns with them there could have been a dreadful result here today. There is something lacking somewhere.

An Leas-Cheann Comhairle

The Chair felt a little frightened at one stage.

Mr. T.J. Fitzpatrick

(Cavan-Monaghan): I should be failing in my duty if I sat here and did not say that we have just seen an exhibition of complete and utter lack of security in and around this House.

An Leas-Cheann Comhairle

The Chair will have the matter investigated and will ask the Cheann Comhairle to report to the House.

Mr. W. O'Brien

This is a scandal. It would not happen in any other country.

Mr. T.J. Fitzpatrick

(Cavan-Monaghan): I am glad that the Chair will have the matter investigated, but it is significant also that even when these people got in here there did not seem to be adequate manpower to get them out.

An Leas-Cheann Comhairle

Things happen so quickly in some of these cases.

Mr. Mitchell

I do not think we can minimise the seriousness of what has happened.

An Leas-Cheann Comhairle

We cannot debate the matter now. The Chair has undertaken to have the matter investigated and to ask the Ceann Comhairle to report to the House.

Mr. Mitchell

I think I am entitled to express my point of view. Suppose they had attacked the Minister or one of the Deputies here and there was serious injury or even death in the House. Would we not look very foolish? Could I suggest that the Chair adjourn the Dáil to have the seriousness of this——

An Leas-Cheann Comhairle

The Chair has informed the Deputy that he will have the matter investigated and will ask the Ceann Comhairle to report back to the House. We cannot adjourn the House at this stage. I think things are under control now. I am calling on the Minister to conclude. He has only a couple of minutes left. I am sorry about all this.

Dr. Woods

I accept that the Leas-Cheann Comhairle will have the matter investigated. I want to congratulate him on his cool handling of the situation, which he dealt with very effectively.

As I said earlier, I am somewhat puzzled by the contrast in the standards of some psychiatric hospitals. I have seen for myself that parts of St. Brendan's are bad. Why should they be so bad when the board had at its disposal moneys of the order of £7 million in the three years 1977-79 to spend at their discretion? Why, in addition, did the board not accord St. Brendan's first priority in seeking resources for major capital projects? These are the questions and I intend to pursue them with the board. I do not intend to be diverted from this by the protestations of the people who are possibly attempting to divest themselves of responsibility which they themselves carry. I assure Deputies that this is a matter that I shall take very seriously in the coming year and I shall do what I can within the resources available to me to deal with the situation.

Numerous other points were raised by Deputies and I should be glad to reply to them in full but we do not have the time now. I will communicate with Deputies who asked specific questions. The report on child services to which Deputy Boland referred is with the printers and I expect we will have it early in the New Year.

Vote put and agreed to.