Vol. 330 No. 14
I move:
That a supplementary sum not exceeding £80,568,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1981, 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 net Vote for Health for 1981 was £691,500,000, including a capital provision of £39,500,000. The gross provision included in the Supplementary Estimate amounts to £91,418,000. Extra receipts from appropriations-in-aid amounting to £8,300,000 and savings on certain subheads amounting to £2,550,000 reduce the amount required to £80,568,000.
The gross amount of £91,418,000 provided for in the Supplenmentary Estimate may be broken down as follows:—
|
£m. |
|
|
Additional grant requirements arising from the levels of the original non-cap- ital expenditure allocations approved for certain health agencies in 1981 |
37.5 |
|
Extra grant requirements of the General Medical Services (Payments) Board |
9.3 |
|
Special pay awards for health agency staffs |
31.207 |
|
Budget increases in rates of cash allowances, cost in 1981 of the scheme of allowances for dependants of disabled persons and an extra week's payment of allowances in December 1981 |
6.673 |
|
Extra grant requirements arising from certain unavoidable increases in expenditure of health agencies |
4.920 |
|
Extra grant requirements arising from the commissioning in 1981 of certain new units of accommodation and approval of certain new posts |
0.688 |
|
Provision for increases as from April 1981 in rates of Social Welfare Contri- butions (Employers' Share) |
0.500 |
|
Provision for special grants to residential homes for children |
0.500 |
|
Provision for grants towards the cost of activities associated with the Inter- national Year of Disabled Persons |
0.100 |
|
Extra cost of Post Office services |
0.030 |
|
Total |
91.418 |
The partially offsetting reductions totalling £10.85 million are as follows:—
|
£m. |
|
|
Extra receipts from Health Contributions |
6.4 |
|
Extra receipts under E.E.C. Regulations |
1.9 |
|
Savings on Subhead K—Hospitals Trust Fund—Capital Expenditure (Grant- In-Aid) |
2.5 |
|
Savings on Subhead A.2—Consultancy Services |
0.05 |
|
Total |
10.85 |
I now propose to explain in greater detail the provisions of the Supplementary Estimate in the order in which I have mentioned them above.
When my Government assumed office we found that there was a serious discrepancy between the levels of non-capital allocation approved for 1981 for health boards, voluntary and joint board hospitals and homes for mentally handicapped persons and the corresponding grant provisions in the Book of Estimates. I should explain in this connection that in the case of health boards it is customary to make provision in the Health Estimate for 95 per cent of the non-capital allocations approved for the health boards for a particular year. Most of the balance is recouped in the following year and the grants are finalised when audited accounts are available. The total of the non-capital allocations approved for health boards direct expenditure in services in 1981 amounted to £477.1 million. Thus the provision in the Health Estimate for 1981 for grants in that year towards that level of expenditure should have been £453.25 million, representing the customary 95 per cent of the approved level of spending. In fact, the combined grant provisions in the relevant subheads, that is, subheads, G.1. and G.2. amounted to £427.755 million which was about £25.5 million short of what should have been provided in relation to the non-capital expenditure levels actually approved.
The provision for grants to voluntary and joint board hospitals and homes for mentally handicapped was also deficient in relation to the levels of non-capital allocations approved for 1981. The grant provision for all those agencies is contained in subhead G.4. The actual provision in that subhead in the 1981 Health Estimate was £188.723 million. It should have been £200.723 million if the customary percentage rates of recoupment within the year had been applied. The under-provision was thus £12 million.
The total grant under-provision for health boards and the other health agencies referred to was accordingly £37.5 million.
It must have been clear from the outset that the provision of £53.7 million in subhead G.3. for the General Medical Services (Payments) Board would be significantly deficient. It represented an increase of only about 8 per cent on the provision for 1980. The amount which it is now estimated will be required to meet cash requirements in the present year is £63 million — an increase of £9.3 million on the original provision.
The provision for the board has two main elements — provision for paying doctors' and pharmacists' fees and provision for the ingredient cost of prescriptions. The cost of doctors' and pharmacists' fees is influenced by adjustments in the level of fees and variations in the scale of visiting and prescribing. The adjustments in fees in 1981 were limited to increases based on the second phase of the second national understanding. The level of visiting by doctors is expected to show an increase from an average of 5.77 visits per person covered by medical cards, on which the Estimate was based, to about 6. The number of items prescribed per visit is also expected to increase marginally in 1981 as compared with the level provided for in the Estimate. These two factors combined are estimated to cost an extra £2.9 million over the provision in the Book of Estimates.
The ingredient cost of prescriptions is estimated to increase by about 21 per cent above the inadequate level of costs provided for in the original Estimate. This is due largely to increases in the price of drugs and medicines. An extra £6.4 million is needed to meet the extra cost of prescriptions. I am somewhat concerned about the difficulty in controlling expenditure on drugs under the General Medical Services Scheme and in other sectors of the health services. There is no dispute about the value of the service to disadvantaged sections of the community. However, in the present difficult financial climate it is essential that all aspects of health services should be closely examined to see where savings could be achieved without detrimental effect to the sections of the community which benefit from them. In the case of the General Medical Service there has been criticism of the increasing cost of prescriptions under the scheme. The Trident Report on approaches to drug purchase and usage contained a number of recommendations as to how expenditure on drugs might be reduced. The necessary consultations with the various bodies concerned have now been carried out and the recommendations made in the Trident Report will be actively pursued with the bodies concerned during the coming year.
The provision made in the Supplementary Estimate for special pay awards for health agency staffs relates to awards already approved and to further awards which are expected to be approved within 1981. The total provision made in the Supplementary Estimate is £31.207 million, of which about £21.5 million relates to awards already approved. The more costly awards approved for which extra funds are needed were as follows: Award for para-medical staff, £5.4 million; Award for laboratory technicians, £3.6 million; Award for clerical and administrative grades, £5.2 million; Awards for non-nursing personnel, £2.3 million; Provision for consultants' common contract, £3.3 million. With regard to the provision made for further awards which are expected to emerge in the current year I will, of course, arrange for the surrender of the provision made in respect of any awards which it may not be possible to implement before the end of the year.
The extra provision of £6.673 million for cash allowances is needed to meet the cost of the original and the July budget increases in rates of cash allowances, £5.543 million, the introduction as from 1 October 1981 of a scheme of allowances for dependents of disabled persons, £0.400 million, and the cost of an extra week's allowances in December, 1981, £0.730 million.
In the case of certain services difficulties arose for health agencies in containing expenditure within budgetary levels. I should explain in this connection that the original 1981 approved allocation levels for health agencies, although they exceeded levels based on the grant provision available, were fairly tight and required significant economies to be achieved by health boards, hospitals and homes. Consequently when situations arose which gave rise to extra costs such as increased demands under the drugs refund scheme and in the cost of certain elements such as postal and telephone charges it was not possible to achieve in full the further economies needed to fully offset the extra costs. The net extra grant being sought towards the net additional expenditure which is expected to arise is £4.92 million.
When the allocations to health agencies were notified in March 1981 the agencies were informed that the funds allocated made no provision for the commissioning of new units of accommodation which would be completed during 1981. In the month of May last, however, my predecessor in office approved of the commissioning of a limited number of new units of accommodation and of a small number of extra consultant posts. The grant provision needed in the current year in respect of the extra costs arising is estimated at £0.683 million.
The pay-related social insurance contribution rate — employers' share — for fully insured workers was increased from 9.8 per cent to 10.25 per cent from 6 April, 1981. It is estimated that extra grant amounting to £½ million will be needed in respect of the extra expenditure arising for health agencies as employers as a result of the increase in the rate of contribution.
The residential children's homes provide care and maintenance for children placed by health boards in the homes or referred to the homes on court orders. The homes are financed by means of a capitation rate which is currently £54 a week. Because of increases in costs resulting from essential improvements in staffing strengths and rates of pay and price inflation the rate has tended to fall behind actual costs and substantial revenue losses have been incurred. This has given rise to financial problems. The provision in the Supplementary Estimate will help to ease the financial position of the homes.
A provision of £100,000 is needed in respect of the commitment of the previous Government to provide grant assistance from the Health Vote towards the cost of events and activities associated with the International Year of Disabled Persons. A national committee was established to co-ordinate activities and to undertake a public information campaign. Special grants have been provided on the basis of the recommendations of the national committee.
The extra appropriations-in-aid comprise £6.4 million by way of extra receipts from Health Contributions and £1.9 million extra receipts under EEC regulations. About £2 million of the extra income from health contributions represents payments of arrears due from earlier years and the balance arises from buoyancy of income over and above what had been anticipated when the original estimate was made in July, 1980 and before the terms of the National Understanding, 1980, were finalised.
The additional receipts under EEC regulations arise largely from a reassessment of the liability to be discharged by the British Department of Health and Social Security in 1981 in respect of health services provided under EEC Regulations. Under the regulations each EEC country is liable for the cost of health services for persons insured in that country and their dependants provided in any of the other EEC countries. The effect of the regulations in the case of this country is that there is a net transfer of funds to the Health Vote from the British Department of Health and Social Security representing the British authorities' liability to this country under the regulations as partially offset by this country's lesser liability to the British authorities.
Savings amounting to £2.5 million arise on subhead K. — Hospitals Trust Fund — Capital Expenditure (Grant-in-Aid). The capital allocation for health services in the current year was increased from the original level of £40 million, of which £39.5 million was provided by way of grant-in-aid of the Hospitals Trust Fund and £0.5 million came from the proceeds of sweepstakes, to £47 million. The extra £7 million was raised by a specially negotiated bank loan.
Following the Government review of the capital programme in July last in the light of the serious economic situation certain capital projects which were at the stage at which contracts could have been entered into were stopped and as a result there is a saving of £2.5 million in the grant-in-aid. The other item of saving — £50,000, arises on subhead A.2. — Consultancy Services. The savings arise from a slowing down of progress on certain assignments.
I trust that I have explained the reasons why the Supplementary Estimate of £80.568 million is required. I ask the House for its approval.
I would like to congratulate the Minister of State on his appointment. As Chief Whip I had the experience of serving opposite him. He is a man of very considerable experience in the House and is noted for his humanity. We had many difficult situations to resolve during that period and I always found him to be a gentleman and a man of his word, although he was not always allowed to keep his word. I wish him every success in the new Department. I thank him for a very clear statement here this morning on the Supplementary Estimate.
I hope the Minister of State will forgive me if I have to change to a different mood because I find that at last the suspicions we have had of the behaviour of the Government in relation to the health services are now unfolding very clearly before us. I believe this is a tight fisted Scrooge-like, heartless Coalition who will stop at nothing to meet the requirements of the economists who are quite disinterested in the realities on the ground. The best place to face realities and the problems which arise in relation to health is the Department of Health.
The figures are particularly revealing because the Minister of State with what is almost a statutory conclusion now for all Departments had a swipe at the former Government about what is referred to here as a serious discrepancy — this is a very serious word which looks as if it needs an investigation — between the levels of non-capital allocation approved for 1981 for health boards, voluntary and joint board hospitals and homes for mentally handicapped persons. We go on in the same vein.
I know my figures very well in this respect. I did my homework well at the time with the assistance of very competent and capable officials in the Department of Health.
As I have said before, the officials there have the reputation of being among the most competent officials in the public service and I make no exceptions in that respect. Earlier in the year they did very detailed homework for me. I said in the House before that we had to review the situation and decide if a Supplementary Estimate would be necessary at the end of the year. Given the economies the Government then required and taking account of all the circumstances, we decided we would need a Supplementary Estimate at the end of the year. We considered it wiser to put the cards on the table at that time, having had thorough consultation with the health boards. The Minister may check with the chairmen and chief executives of the health boards with whom I had regular meetings and with whom we worked out the requirements in considerable detail.
I should like to refer the Minister to Question No. 563 of 11 November, which I put down. The Minister will see that for each year up to 1980 a Supplementary Estimate was required for the Department of Health. Indeed, it would be very hard to operate any kind of economic control and tightness in budgeting if one did not have the flexibility of a Supplementary Estimate at the end of the year. It is very difficult to budget to such an accurate degree at the beginning of the year and finish up exactly on target. It is an impossibility in real terms.
I would point out to the Minister the following facts. In 1980 there were two Supplementary Estimates, one for £93 million and the other for £33 million. In 1979 there was a Supplementary Estimate for £72 million based on the original Estimate of £440 million and, as can be seen, percentagewise that is quite considerable. In 1978 there was a Supplementary Estimate for £35 million while the figure for 1977 was £24.9 million. The Supplementary Estimates go back to the period of office of the National Coalition as well as for periods of office of Fianna Fáil Governments.
What is revealed in the figures is that since this Government took office there has been an additional very deep cut in the provision for the health services. When the Minister for Finance presented the figures as they were known to be at the time, there was a requirement for a Supplementary Estimate of £43.8 million at the end of this year. I should like to ask the Minister what he would do with regard to the special pay increases. Would he give them or would he not give them? Is he committed under the national understanding, the general agreements and the conciliation and arbitration agreements to the granting of these special awards which, in effect, are the tailend of the awards in the health services, the more major awards having taken place earlier? The awards I have mentioned represent the finishing up of the rounds which leaves the Minister in a very satisfactory position at this stage.
If we deduct from the Estimate of £80.5 million the amount required for special pay awards, we have a figure of £49.3 million. There are also the increases the Minister mentioned of £5.5 million, which arose from the direct budget of the Minister for Finance, and this brings the figure down to £44 million. If we take account of the post and telephone charges, which amount to £5 million and the PRSI extra charges for the health boards, the figure comes to £38.5 million. We must also deduct the sum in respect of the double week at Christmas which, in any event, had to be provided for in a Supplementary Estimate — as I pointed out here, that was a commitment we made — and we are left with a figure of £37.7 million. Quite apart from the direct inflationary impact on the health boards of the measures adopted by the Minister for Finance, there was a further knock-on effect of inflation and we can deduct several million for that effect. Taking account of all the deductions we have a figure of approximately £33 million. Where has the other £10 million gone? Have there been other serious cuts?
As the Minister said at the outset, the health boards are working in a very tight economic situation. Yesterday the Minister for Finance circulated an answer to a parliamentary question put down by Deputy Gene Fitzgerald and in that he said that the cuts, excluding the £19.9 million in which health was involved also, came to £148 million. He referred to a sum of £2.4 million for the drug refund scheme and hospital charges. We know now that he made further cuts in this area. The reality is that since this Government took over there has been a further cutback on what was regarded as prudent budgeting.
The Minister stated there was a saving of £59 million in energy. I am sure he realises that the health boards and the hospitals are large energy consumers. The increased ESB charge of 25 per cent has had a dramatic effect in reducing the cash available to health boards for their operations.
In the past few weeks it appeared to me the Minister was actually taking back capital sums that were allocated to the health services for this year, and especially for the provision of services for the adult mentally handicapped. In the Minister's statement today there is the following comment:
Following the Government review of the capital programme in July last in the light of the serious economic situation certain capital projects which were at the stage at which contracts could have been entered into were stopped and as a result there is a saving of £2.5 million in the grant-in-aid.
This saving of £2.5 million, so hard fought for by the Minister's predecessor, has been to easily given up by the Minister now holding that portfolio. I realise that the Minister of State has only recently come to that office and he can be absolved of any blame. However, I wish to make it quite clear to the public that this £2.5 million, which was allocated capital for which a Supplementary Estimate was not required, has been clawed back and this will have a devastating effect on the health services in general because many valuable projects will be stopped.
Perhaps today we are witnessing a very important Supplementary Estimate in the sense that it represents the end of an era of growth and improvement in the health services. I say that having given reasonable thought to the subject. We now see the end of this period of very necessary growth. Those who take a facile view of the health services may say we have to control our finances and that health is one of the big consumers. We heard the Minister for Finance say ominously that the big spenders must be got at. We have never denied that there is a lot of work to be done in a management sense and in relation to savings and redistribution of resources within the services.
Many facilities, especially those in the mental handicap and psychiatric services, date back to the mid-19th century. Even some general hospitals, such as Jervis Street, the Richmond and St. Brendans, date back to that time. To the public servants who operate the health services I say "Congratulations and well done". They have been castigated by the Government and wrongly so because they did a difficult job this year in difficult circumstances. They had to face an increasing population situation for which no credit is given when financial considerations are discussed. The health boards, voluntary hospitals and people working throughout the services have done an excellent job at economic management and control this year and that is illustrated in this Supplementary Estimate. I am sorry they had to bear further economies to those introduced of necessity at the beginning of the year.
It is clear from the services that they are being run down. Most dental services are grinding to a halt or have stopped. The choice of doctor scheme in many health boards has been dropped since September. The choice of dentist private practitioner scheme has been stopped and the funds cut off entirely. Shortly before I took office my predecessor had been working hard to get a new scheme going which invited private practitioners to become involved in the dental services. It is scandalous to treat them on a stop-go basis as the Government are doing at present. This has been clearly illustrated at Question Time over the last few weeks. I say to hospital staff, health board staff and public servants in the Department of Health, those who have had the headache of managing such an enormous operation this year, congratulations and well done. Keep up the good work and do not be put off by people castigating the public service in the House and at various functions. You are doing an excellent job. I have every confidence that the service will make further adjustments which they know are necessary.
If we take out the special pay increases in the Supplementary Estimate, we are talking about a 5 or 6 per cent increase. In real terms it is considerably less. The health boards and voluntary hospitals have no option in relation to special pay awards which come from those valued institutions, arbitration and national understandings, but to pay them. They should not be castigated for doing so. The Department had only a 4 per cent increase in salaries, wages and allowances. Postal services had a 26 per cent increase and in fairness to the Minister he pointed out this was something the Coalition brought in themselves. Where one has 60,000 people employed in looking after the health of the country naturally with the goods, materials, energy used, any supplementary budget such as the one in July will have a devastating effect. The grants to health boards, taking the overall increase, is 11.8 per cent. If we take into account the special pay allowances, that is nothing like what people have been suggesting.
I am very sensitive about this because I spent much time with chairmen and chief executive officers of health boards and officials of the Department introducing economies and trying to manage services at a lower real cost. There is a limit to which one can go on this. When we prepared the Supplementary Estimate the Minister referred to we did so on the grounds that we did not want to stop services or let staff go. We were prepared to switch staff within the services but not to let them go. That is the option which faces the Government and which will be brought home to them by their own backbenchers and the health boards. The health boards have had to take a lot of action because of the financial cutbacks. The simplest thing to do when making a financial cutback is to write a figure on a page, stand back and tell someone else to do something about it. That is what the Government have done to the Minister for Health. They have taken money back and told the Minister to manage. She has to pass that on to the health boards and tell them to get on with it. The most manly way to go about it is to sit down with the health boards and see what can be done. If it will lead to serious disruption, the Minister should say to the Government that it is not possible to do it in the time suggested. As regards the standards of the services, we are working to make economies in a situation in which the population is expanding, and that has great implications for the health services because of the lack of availability of maternity facilities generally and of specialists in that area. There are many other related areas. It was necessary while we were in office and it is necessary now to update the health services fairly vigorously and dramatically. That process has been going on for some time. The signs are not good now and the Government are anxious to cut back severely here, but a great deal still needs to be done in the maternity services particularly. Fortunately we got in a few contracts before the Coalition came into office. It is quite obvious from the capital allocation here that anything that was not signed, sealed and legally bound at that time was set aside. In regard to maternity services generally in order to see that all one has to do is to go to some of our major Dublin hospitals without going to the country at all. The Rotunda and Holles Street are working under great pressure and are in great need of capital facilities for which we had a programme under way. We will be watching the Government to see what they will do with that and the general hospital programme. There is a need to update and modernise our general hospitals in a way in which the people can participate. When I was Minister for Health the view was put to me that we could have more private hospitals, more people could go into voluntary health and look after themselves in that way. We have always gone for a mix of private and public and we will be watching this Government to see how they tamper with or adjust that mix. If they attempt to do that in any adverse way we will come to this House and make our views on that clear.
An area of greatest need at the moment is that of psychiatric services and the mentally handicapped. Our record over the four-year period, my own period as Minister and that of my predecessor, shows clearly that we put a great deal of attention into that area in general. In that respect I refer to the general capital programme. In 1976 the capital programme was £11.2 million for the health services; in 1977, £16 million; 1978, £21 million; 1979, £27.5 million and in addition to that £.5 million from the Hospitals Trust, making a round figure of £28 million; in 1980, £35 million and, as the Minister has said, in 1981, £47 million. That makes clear what we were doing in the health services. If the Minister looks at the situation he will recognise the difficulty in 1980, when the budget limit was £40 million and we spent £35 million in developing new health services with special emphasis on mental handicap and, of course, on our general hospital services. We were already committed contractually to £35 million. With additional costs and making some allowance for contingencies and inflation, we could not make a new start in developing, but one might say that we were not doing too badly. We had some major projects under way. The big one was Beaumont Hospital, the biggest development since the building of the Richmond and Jervis Street Hospitals in the middle of the nineteenth century which are now outdated. Letterkenny and Tralee were other major projects, but there could be no new starts. This was the stark reality of the financial position facing the Minister at the time and is likely to face the Minister again coming into next year.
If we had accepted that situation then in 1981 we would have been spending £40 million but in 1982 we would have been spending only £22 million and in 1983 about £11 million. Everybody forgets that on these major capital projects we have periods of heavy expenditure and periods when the expenditure is declining. The amount spent on Beaumont Hospital this year would be of the order of £10 million and next year that would be down to a very small amount. Likewise with Tralee and Letterkenny the expenditure next year would be small against that of this year. You have a tailing off of these major projects which has an effect on the general hospital programme. We set out to get a commitment from the Government that at least we could continue with the £40 million for some years ahead. The Government agreed to that which meant that we were coming back next year to a demand of £40 million and we had hoped to get an allowance for inflation. In view of that we entered into a special arrangement for a further £7 million which the Minister has mentioned in his speech. The purpose of this was that there would be no repayment during the present year and repayment would be spread between 1983 and 1986. It meant in effect that if the £40 million could be available this year we could continue serving a fairly even investment plan for the next four or five years, but it meant also that we could get a substantial number of projects, both medium and major, under way, and that was what we set about doing. This series of projects has been referred to in the House.
I had some difficulty as Minister in explaining to some of the Members on that side how this worked. The Minister is now in a position to see for himself from the records that in terms of the future of the health services this was a very important plan which meant that we could get on with some of the projects, especially that for the adult mentally handicapped which is so urgent now.
I refer Deputies to the Official Report for Wednesday, 13 May 1981, volume 328, columns 2743 to 2748, inclusive, where one can see listed a very substantial number of projects which were given in reply to a question by Deputy Fitzpatrick, now a Minister. The list includes projects like a certain amount of upgrading at St. Brendan's and St. Ita's, a new health centre at Ballybrack, a new mentally handicapped centre at St. Columcille's, Loughlinstown, a very major development costing £6.8 million. That project could go ahead. Redevelopment phase 1A at the Mater Hospital cost £18 million, and that project could go ahead. The redevelopment phase 1B costing £5.8 million and phase C costing £16 million at St. James's Hospital could go ahead. The extension to the James Connolly Memorial Hospital, Dublin, could go ahead. A sum of £2.5 million was sanctioned for the residential home at St. Mary's School for the Blind, Merrion, and that project could go ahead. The sum of £1.3 million to provide residential accommodation for 100 boys at St. Joseph's School for Deaf Boys, Cabra, could also go ahead. In the Year of the Disabled these were worth-while projects which this House could support. It also meant that the extension to the County Hospital, Mullingar could go ahead.
At that time, the Minister for Fisheries and Forestry, Deputy Fitzpatrick, was interested in the New General Hospital, Cavan, and wanted to find out what we were doing about that hospital. It was estimated this hospital would cost £15 million. It meant that the replacement of the County Home, Dundalk, could go ahead. The media have caught up with this hospital because it seems to be in trouble. We provided this money — the Minister is clawing back some of it — from capital resources earlier this year.
There was a major development at St. Mary's Drumcar (Mental Handicap), costing £1 million. This hospital provides for severely handicapped adults. Another major development at Sligo General Hospital was able to go ahead. The General Hospital, Ardkeen, County Waterford, was in the news recently. We allowed the planning phase, costing £28 million, to go ahead. When planning was finished the hospital board were to seek tenders and give out contracts. I heard on the RTE News that the planning phase is complete. I do not know who brought this to our attention, whether it was the Minister taking credit for what was done there or if it was the hospital authorities who were trying to ensure that this proposal would continue. The money for that project was provided in this year's Estimate. If the Government stay at the level of investment we introduced, they will have no problem in completing this new and much needed facility at Ardkeen.
There has been a great deal of emphasis on mental handicap. There is a mental handicap centre at Upton and the Brothers of Charity, Lota, are putting in a therapeutic pool. We sanctioned the extension of the maternity unit at Galway Regional Hospital. If the Minister does not think that is necessary, he should visit that unit and see the pressure under which people are working. There is a major development at Castlebar General Hospital. Four new operating theatres for orthophaedic departments are being provided at Merlin Park Regional Hospital, Galway. Hip operations carried out at this hospital have been very successful and there is a backlog for operations. There were other developments for which the Government gave approval, among them one at Swinford, and we will see what happens to them under this Government.
We heard today that this money is being clawed back. That is a scandalous situation. The officials in the Department, the chief executive officer of the health boards and people in the health services generally must be very disappointed, after all their efforts, to find that the Minister for Finance is taking back money which had been allocated to them. I am sorry some of our so-called socialist Deputies are not here because I would like them to recognise this fact.
The Allied Irish Banks expressed an interest in mental handicap and psychiatric illness. I had discussions with them about the situation. We said we could not do anything about this terrible situation because of our financial position and if we had additional funds available from outside sources we could get quite a few schemes under way. They were very interested in this and were prepared to make available a special loan at the best Government borrowing rates on terms designed to meet our requirements, in other words, no payment would be involved this year and we would be paying back over the next number of years. We found a very satisfactory way of doing this. Here again I must congratulate the officials on their involvement in this area. This move was sanctioned by the Minister for Finance and went into operation. I am sorry that after all this work the Minister for Finance is clawing back some of this money. I want to place on the record my appreciation for the banks' participation in this area.
Adult mental handicap was one of our priorities. We were spending £6.55 million in this area. I had to ask myself if we were prepared to set aside the money necessary to care for the mentally ill, whether we, as a society, recognised the potential of our mentally ill and their needs, and if we were prepared to commit ourselves and our financial resources, both voluntary and statutory, to caring for them. As a community our record in this area is not good. I suppose it is largely through fear based on ignorance that we tended to put our mentally ill people into homes and institutions which were often very secluded and awesome. According to a recent report we did not visit these people very often.
Very little real and sustained interest has been shown by the community in mental illness, but we are entering a new era. I would like everyone to take a positive view of this illness. I believe that the end of the closed institution mentality is in sight. There is a new awareness about mental illness and a growing appreciation of the role of the community. The ground work for this new development has been done by those in the health services, in the professions and by parents and friends who have been increasingly playing a leading role in this area. Although these new beginnings are important and valuable, momentum must be maintained and developed and they will not be maintained unless the capital resources are committed to such developments. I will always give my support to any developments for those who are mentally ill.
During my period of office I introduced a Bill designed specifically to deal with the 10 per cent who must be confined in institutions for long periods. It was designed to update the legislation in relation to registration, supervision and discharge and the safeguarding of patients while detained in such institutions. It is time that the review body established under that legislation should be appointed. There has been no indication that they will be established and the Minister should tell the House the current policy in relation to them. The needs of the vast majority of that 10 per cent were to be catered for under that legislation and a Green Paper to be published later was to include the mentally handicapped as well as the physically handicapped. What has happened that the Green Paper has not been published? I did not see any action following the passing of the legislation. We had hoped to publish the Green Paper last summer but the advice at that time was that if we pushed too hard to have it released in June or July it might not be as well developed as it would be if it was left to September or October. However, we are almost at the end of the year and there is still no sign of that important document.
We are approaching the end of the International Year of the Disabled and I was pleased to see the second report published by the committee, as they were asked to do at the beginning of the year. The report is comprehensive and useful and I should like to congratulate the committee on its publication. It will prove useful to those concerned with the handicapped. It was disappointing, however, that the Green Paper was not published at the same time. We were so ambitious about this matter that we had considered publishing a White Paper. The report I mentioned deals with the importance of training, employment and the responsibility of the State in the employment field. It recommended that the Minister for Labour should vigorously pursue the quota of 3 per cent of public service jobs for the disabled. The report welcomed the recent special competition for entry into the civil service confined to disabled persons and suggested that local authorities, health boards and semi-State agencies adopt the same kind of positive action.
I should like to raise a point in relation to the question of employment because I got very disturbing news recently in relation to competitions which were held by the Civil Service Commissioners for clerical assistants and were confined specifically to disabled persons. I received documentation in relation to one of those candidates but it is the principle of the matter I am anxious to highlight rather than the individual case. I ask the House to imagine the feeling of a partially sighted candidate who had gone through all the study to get a leaving certificate with honours found a new arrangement set up by the predecessor of the present Minister for Labour, a commitment carried on by the new Minister. That individual ultimately received a letter from the Commissioners stating that the Civil Service Commissioners can recommend a person for appointment if, and only if, they are satisfied that he is in good health and free from any physical defect or disease which would be likely to interfere with the proper discharge of his duties in that position. The letter went on to state that the commissioners, after considering the case at length, were of the opinion that the applicant's eyesight was not such as to enable him to discharge the duties of the position efficiently. What are we talking about here? What was all this machinery set up for in this instance if partially-sighted people are not to be included among the acceptable disabled within the public service? Why do we bother coming here if that is the case? We understood that places would be made available in the civil service for those who are definitely and clearly disabled. The Minister should have words with his colleagues in the Department of Labour to get him to alter the terms of reference so that they comply with the wishes of Members.
The Minister should indicate his views on this matter. I assume he agrees with the general intention that disabled people who are partially sighted should be included in these positions. Indeed, there are some very effective, totally vision-impaired people working in a number of organisations. It is very impressive to see how those whose sight is totally impaired can work so effectively. It brings one to recognise the potential of the disabled and how myopic we have been about their potential. The problem is not one in relation to one individual but in relation to those who are studying to try to improve themselves and cope with the disadvantages of disablement, especially those with an impairment of vision. It should not be beyond the wit of the civil service to involve partially-sighted people within the system. It may be found that having done so those people have a lot more to contribute than was thought initially. I hope the Minister will look into that case, details of which I will give him afterwards. If I might repeat a comment of one of the other young students on hearing of this development, it was: "What does it mean? Does it mean that we are committed to making baskets for life? Is that society's view of our potential?" I do not think that was the view of this House and I hope it is not that of the Minister. I do not believe it is.
There remains a tremendous amount of work to be done on the geriatric services. It is one area greatly deficient at present. When one remembers that there are in excess of 500,000 people over 65 years of age, one can see that that constitutes a large group to be provided for. In the negotiations at present taking place I would urge the Minister to ensure that further provision is made for these services.
We all know that the development of community services is vital to the longer term economic viability of our health services generally. The development of out-patient departments in hospitals and of community related services has met with great success in recent years; but unless they are developed further the pressure on our major hospitals — so great because of the facilities they provide and their level of staffing — will become impossible. We had a major programme under way in regard to general hospital development. A good deal of that is contractually under way now, a situation with which I am very happy and one which I am sure will be appreciated by all in due course.
The developments about which we have spoken here ultimately will lead to a budget allocation annually of approximately the order we had this year. If further much-needed resources become available they will be very welcome in the health services area.
Orthopaedic services are in acute demand throughout the country. The Minister mentioned in his figures the common contract introduced. It is a very important contract and will afford hospitals, health boards and their staffs generally considerable flexibility. Indeed, it does effect a saving on the other side not shown in the Minister's figures in that the bed fee pool system runs in conjunction with the contract, a particularly useful but nonetheless expensive development.
During our period of office I was very glad that at long last the nurses had been upgraded. The Minister has shown here the final phases of that general upgrading. I believe they carry out very valuable work and this whole development was long awaited. Their position has now been greatly improved and I hope this will lead to a happy relationship between the Minister and those working within the services generally.
Having had the family planning legislation under way for a year, I might mention that a review was to be undertaken. I understand from some statements of the Minister recently that this review is taking place, something which will be much welcomed.
From my experience of the operations of the Department, the Health Education Bureau have made a valuable contribution to the development of positive health and education in regard to the whole question of drugs and their abuse. In the Estimates at present being prepared I hope provision will be made for the continuance of this work because it forms a very important, positive side of the whole health area. From the early days, when there was a great deal of advertising and promotion, this work has progressed in more recent times into tuition in schools and of juniors generally. This has been a very useful part of the development of the Health Education Bureau. It may not be as visible as heretofore but is certainly getting to the core of problems particularly in the area of prevention which is so crucial.
The Minister mentioned the question of medical cards. I note that the Government did not review the terms of eligibility for medical cards in relation to the changes which took place in the July budget. I should have thought there would have been at least a 5 per cent revision, as a minimum, at that time if only for the sake of consistency. Of course a major review is due in January next. We will give the Minister every support in that review because we are aware he will be facing difficulties in achieving an adequate review of that scheme. We are hearing alarming reports around the country of medical cards being withdrawn and of considerable cutbacks in that area. We are all aware that there can be wastage in terms of their usage. There remains a great deal of work to be done in this respect. The cutbacks being effected are demonstrated in the figures before us this morning. It all emerges after some little time. We had suspected what the Government were at, but one cannot really prove it for some time and we have today seen some of this proof emerge very clearly. I hope that will be recognised by those who follow developments in an intelligent way.
My main fear would be the damage occasioned by further delay, especially in regard to capital projects already under way. For instance we discovered from questions in this House that the centre for Mentally Handicapped at Kilcornan in County Galway, for which a contract had been approved and work on which was to go ahead, has been stopped. That was to have provided a major facility for adult mentally handicapped.
I agree with the Minister that the drugs scheme is one worthy of a great deal of attention. It is an area in which he will experience great difficulty because of the escalating cost of drugs when viewed against the economies he will be required to effect. I appreciate also the need for improvement in the general administration of the drugs scheme. Even meeting budget requirements after the estimates have been fixed will constitute a problem in itself. We have seen that drugs have become more expensive without any improvement. We know that the limit for the refund scheme has been increased from £8 to £12 without there being any improvement in the scheme or arrangements under it.
There remain some areas worthy of particular attention. I hope the Minister will see his way to do so early next year. I am thinking of special illnesses like arthritis, bronchitis, those continuing illnesses which lead to a very heavy demand on the scheme generally. Indeed, we had a new scheme drawn up for implementation had we remained in office, having planned to change the scheme dramatically to meet these requirements. I await with interest what the present Government will do in this respect.
We know the Government have promised to introduce dental care for the wives of those who are at work and who are not covered by existing schemes, plus the 12 to 16 year olds. These were objectives we had. So far we have seen nothing emanating from the Government in this respect. There has been no development. Since it was a priority of the Government one would have thought that some indication would have been given by this as to what it is intended to do. There have been cutbacks in dental services. This is a very important service and it is one to which attention should be given in order to resolve some of the problems that exist. There will be some improvement when the dental hospital in Cork becomes operative. It should result in an increase in the number of dentists. They are in short supply at the moment.
I am very concerned about the Green Paper in relation to the handicapped. We heard nothing about it this morning. It was well under way and should have been ready by mid-summer. At the latest it should have come out in September or October. Nothing has been said about it and that makes me very concerned indeed.
With regard to review boards for psychiatric institutions, I would like to see some development in that area fairly soon. The Minister mentioned some of the steps we took in regard to the International Year for the Disabled. So far as we were concerned it was decided we would have an initial package. That was introduced at a cost of some £6 million. Part of the figure appears under this Supplementary Estimate and part under the Estimate for Social Welfare. We asked the committee to make their report available at the end of the year following on which we would have had a further package. I trust the Minister will bear this in mind. It may become part of the budgetary arrangements. He should remember particularly that the steps taken were merely a start. Considerably more remains to be done. I would hope to see some benefit from the new structure set up in the very near future.
I understand the home council for the aged is well under way. This is very important because it will keep us reminded of our responsibilities in regard to the aged and the contribution they can make to society generally, together with the facilities and resources necessary to enable them to make that contribution.
The National Social Services Board was reorganised and strengthened. I wish it every success. There will be a question of how it will relate to the Government's new proposals anent the poverty committee. One of the weaknesses of the National Social Services Board was the fact that it covered neither research nor development. It was mainly information, communication and co-ordination. I wanted to give it more teeth to enable it to do some of this work and that process was taking place. Various steps had been taken. I appreciate there will be some question of working out the relationship between it and the new body and I trust the Minister will bear in mind the very valuable work the board has done and is capable of doing.
With regard to the Council for Children, had we remained in office that council would now be in existence. Of course the Government have their own priorities, but I hope the Minister will get down to doing something concrete about this council in the very near future. We would like to know what the Government's reaction is to the implementation of the task force report which was published earlier this year. I appreciate that we could not see a great deal of action because of the change of Government and the intervention of the summer recess.
Home helps can play a major part in local services at very reasonable cost. I trust the Minister will strengthen these bodies.
With regard to the ten year review of the health boards, I trust the Minister will build on the experience gained by the boards over the decade.
With regard to the leukaemia bone marrow trust I gave a personal undertaking that we would support that development. Technical difficulties had to be overcome. These have been sorted out and the trust has collected a considerable amount of money. We gave the trust some £50,000 initially and intended to continue that development. I understand there is now a question mark over the development and I would ask the Minister to give sympathetic consideration to the proposals made by the trust. All the home work has been done and every Member would support this development since it would offer an opportunity of life to such a high percentage of children.
I am disappointed that the new units for the mentally handicapped in Ballymun and Carriglea in Waterford are not being commissioned. I trust the Minister will prevail on the Scrooges in the Coalition Government to go ahead with the Christmas bonus. I refer to pocket money for the mentally handicapped and those in long term institutions, I appeal to the Minister to double the pocket money. We increased it to £4. While some may think that is very small there are practical difficulties because one has to get the money from the Minister for Finance. I hope it will be included in the Christmas double week. When we made this arrangement last year we included the domiciliary care allowance. This is a residential pocket money allowance and I ask the Minister to include it in this Estimate. It would only mean shifting around a few pence. I thank the Minister for his clear, forthright statement which indicates what is happening in the health services. They are being run down but how much remains to be seen. I wonder how much it is intended to run down the health services next year. We will be watching that situation very closely. I am disappointed and horrified that our worst suspicions have been confirmed and that the Minister has clawed back some of the moneys which were voted here for capital developments in our health services and which are so badly needed.
I congratulate the Minister on his appointment and wish him every success in what will be a full-time occupation.
In considering this Supplementary Estimate of £80 million we have to look at the total bill for 1981 which is a round figure of £800 million. Having regard to our population, this is a formidable sum and it is, therefore, incumbent on us to ensure that the best possible value is secured for that substantial amount of money.
We have now had 10 years' experienced in the operation of the regionalised health service when, under the 1970 Health Act, eight regional boards were set up. There is still much thought among local authority elected representatives that a more efficient and more economical health service could still be operated on the basis of the old county council and corporation regions. Having regard to the experience over 10 years, an opportunity might now be afforded to reviewing the manner in which the regionalised health boards have operated the services and whether an over-emphasis has been put on expenditure in administration rather than a direct input of moneys into the health services.
Dr. Woods has already spoken about the mentally hanidcapped. It is a problem which has been with us since the foundation of the State. No Government has effectively or positively tackled this question. Were it not for religious orders and the voluntary bodies that have played such a part in the establishment of institutions to care for this section of the community, our policies and our record would have been deplorable. In my own area the Franciscan Order established an excellent centre for the residential and educational treatment of the mentally handicapped. I should like to take this opportunity to thank the present Minister for Education for giving not only immediate clearance but very generous funds for the development of a special school for the handicapped in that centre. Despite the excellence of this unit, there are still many young children who cannot get into that centre because no provision has been made for the adolescent handicapped who have to be retained in that unit or transferred to a psychiatric hospital, which is most undesirable. Proposals have been shelved for two years because of financial constrictions but in this field, as far as possible, financial constrictions should be ignored for units such as these. They do so much for the adolescent handicapped and also for children who are waiting to gain admission to the centre. The Minister should endeavour to meet the situation in regard to all units of that nature.
People who are not used to psychiatric hospitals are frequently shocked when they visit them and see mentally handicapped children and adults confined to these institutions. The conscience of the nation was shocked in a TV programme in 1980 when people saw the standard of accommodation provided for the psychiatrically ill. That programme did not shock the conscience of the medical and nursing staff who had, down the years, made strong representations for an improvement in the appalling conditions which existed in some of these institutions. Those representations fell on deaf ears, because the necessary expenditure, reconstruction and refurbishing and provision of new buildings has not been proceeded with. I am well aware of the difficulties involved, because of the age and structure of buildings which were aimed at purely custodial care. There are problems facing architects and those desirous of reconstructing these buildings to meet modern needs. Nevertheless, substantially more will have to be done if we are to remove this serious insult to the dignity of our psychiatrically ill. In this field constrictions and economies should be reduced to the minimum. Within this service certain stigmas have been attached which have not yet been finally removed, despite the excellent work done by the hospitals staffs and others concerned.
There is fortunately greater emphasis now on community-based treatment for these illnesses. This sort of treatment can be much more beneficial than hospitalising people, a practice which for so many years imposed a heavy burden on the various institutions who dealt with these long-stay patients. Every effort should be made to treat people at home or at health centres and, consequently, to keep them out of hospital, thereby reducing substantially bed usage in the hospitals. For a long number of years we had the highest percentage per head of the population in Europe in terms of long-stay patients. Apart from the provision of additional community centres more development in the day-treatment centres should be considered as a basis for reducing bed requirements.
I am glad that Deputy Woods raised the matter of orthopaedic surgery. There is tremendous development in the area of hip replacement but because of a colossal backlog of patients waiting for the operation, a large number of people continue to suffer intensely while waiting for this surgery. Mainly these are people in the older age groups and in many cases they are living in rural and, very often, isolated areas where they are far removed from the domiciliary medical and nursing services that they need. I urge the Minister to take whatever steps are possible to ensure an extension of the facilities that are required urgently to meet the needs of those waiting to avail of the new development in orthopaedic surgery.
I wish to deal now with the operation of our district hospitals. The district hospital is a major and very important health centre for the local community. I understand that in many of these hospitals the position is that one medical officer is in charge of patients once they are admitted. Surely this is totally against the concept of the choice of general practitioner within the scope of the free medical service. What I am advocating is that all GPs serving a catchment area should be given the opportunity to follow through with the treatment of their patients who are admitted to hospital. In this way the patient has the benefit of the confidence that he placed in his GP in the first place. Though this may happen in a number of cases, there are many instances in which it does not apply.
Apart from the provision of general health services there are excellent maternity units attached to various district hospitals. In this respect a woman should be in a position within the health services to have at the time of confinement the services of the doctor whom she consulted in the first place. Because this is not the practice many women chose voluntary hospitals in order to ensure that they continue to have the services of the doctor that they have been attending during their pregnancy. Perhaps the Minister would take action immediately in this matter and arrange discussions with the health boards and perhaps with the medical officers concerned so as to ensure that every doctor has the right to continue to treat his patient in any health board hospital. This is fundamental to a proper and free health service. Otherwise the choice of doctor concept is negatived.
I am concerned about the absence of a proper school medical and dental service. I do not know what the situation is in urban areas but in many schools in rural areas there have not been medical or dental examinations of many children during the school-going years. This is a very serious situation having regard to the importance of detection at an early stage. Such early detection must lead in many cases to the prevention of long-term illnesses and to the saving of much expenditure. We must have a proper primary school medical and dental scheme if our health services programme is to be satisfactory.
A further factor is the question of health regulations information for the community. As public representatives we find that many people are ignorant of their rights within the health services. Very often we find people coming to us after they have been in private or semiprivate accommodation in health board hospitals or in voluntary hospitals and telling us that because they have a medical card they consider that their hospital treatment should be free. I suggest that all places of public communication such as libraries, health centres and so on be well furnished with informative literature indicating a person's rights in respect of either free or subvention treatment. This would prevent the sort of situation I have outlined.
The cost of drugs has been mentioned. This is a very big factor. Many people especially those with children are often astonished on taking prescriptions to pharmacists to find how much the drugs cost. Every effort should be made to ensure that the public are protected in this regard. It is a field in which they can be very vulnerable. Consequently, drug prices should be monitored regularly.
There has been reference also to the question of medical card abuse. Deputy Woods has asked for a mid-term review of the situation but I would remind him that when he was Minister a decision was taken to discontinue the mid-term review, a concept that was introduced by the last Coalition. However, it is the intention of this Government to have a bi-annual review of the system. This is very important in the interests of the lower-income groups in particular. I would ask that within the terms of any such review, consideration be given to those people who, though outside the medical card level of income, are having difficulty in meeting medical expenses because of large families. The cost of drugs and visits to doctors in respect of children up to 16 is usually considerable and that is why I am suggesting that the larger families be given special consideration. I trust that the Minister will take note of the points I have made and I look forward to hearing him refer to them in his reply.
I am pleased to find a neighbour and friend in the Office of Minister of State at the Department of Health. The Minister and I have known each other for a long time. He will probably recall that the first time I saw him he was running a mile race in Street.
And the Deputy was playing football.
He won the mile race but we trounced the County Westmeath champions in the football match. I am very glad he is there because I have certain fears that arise from the known attitude of the Minister for Finance to health expenditure and also education expenditure. There is an old Irish proverb which says: Is fearr cara sa chúirt ná punt sa sparán. I will have to change that around and say: Is fearr cara sa chúirt agus punt sa sparán. In this particular case, I have a friend in court and I hope we will have a pound in our purse.
I may as well declare my interest straightaway. It is with regard especially to the Cavan general hospital. There have been red lights flashing because of the Government cutbacks with regard to that hospital. The previous Minister, Deputy Woods, came down to Cavan and outlined the programme. I want an assurance from the Minister that that programme, with which we were all very pleased, is not interfered with. There is a grave medical need for the general hospital in Cavan. I regret to read the Minister's statement that following the Government review of the capital programme in July last and in the light of the serious economic situation and all the flummery in between, there will be a cutback of £2.5 million in the capital budget. I want to say that not merely is this a concern for the Cavan-Monaghan constituency but, as it was put to me by an officer of the board, it is the pinnacle priority of the North Eastern Health Board, and, consequently, the local area and the North Eastern Health Board in general will be very disappointed if the Minister decides to cut back on that development.
There is, as the Department and the Minister know, a very fine site at Lisdarn. There was some trouble with the contractor on the site preparation works which we got over. Deputy Woods had his programme all lined up on that. I ask for an assurance from the Minister that that time schedule will not be interfered with. The site is a very beautiful one. It is landscaped with beautiful shrubberies and flowers. It wins prizes quite regularly for this particular feature. Consequently the planning is important and it is very important that when the building is taking place it will not interfere with this environmental bonus which we have in that particular area.
The old surgical hospital in Cavan is a dangerous slum. For many years, a dedicated matron, dedicated nurses and surgeons have provided a surgical service there. If there were strong trade unions there those people would have refused to work there long ago. That is an indication of the urgency of having this processed. It is well known that it is dangerous as a hospital building. We have had highly qualified specialists coming to our provincial towns over the years. Those people have had experience in other countries. The many surgical skills which those people bring to that area is a great amenity for the social and cultural enrichment of the life of the provincial town and also, being sophisticated members of the community, they are anxious for the development of the town they come to. It is difficult to keep them if there is a very poor building for them to work in. They can be kept there with good equipment but we must have something better than what we have in Cavan town at the moment.
I am worried about the figure of £2.5 million mentioned in the Minister's speech. I would like an assurance from him that the neighbour's child will not be neglected when it comes to capital expenditure in the area.
I know there is some concern with regard to the Monaghan hospital. I praised Deputy Woods, when he was Minister, for the development at Drumcar. Deputy Moynihan in a very good speech devoted a good deal of time to the older child who is mentally handicapped. Children from my constituency go to Drumcar and this development is very important as far as we are concerned. I want to draw attention to that as well. Hip operations are performed very well in Cavan but the same problem is there as there is in the south west. There is very high pressure on the surgeons there and a very long waiting list. This should also get attention.
The present reckoning with regard to the cost of the Cavan hospital would be about £20 million up to the final year. There have been various estimates at different times but it is an ongoing situation and, taking inflation into account, this is a substantial sum of money. I would like the Minister to tell me when he thinks tenders will be invited and when he thinks a contractor can be on the site. I know that a very famous firm of architects with considerable resources have been appointed. If the Minister wants to apply a little pressure with regard to time on that particular firm they have the resources to cope with that kind of pressure and speed up the planning process.
I would like to refer to the question of the review of entitlement to medical cards. Deputy Moynihan said that when Deputy Woods was Minister he did not have the mid-year review. I would like to call the attention of the House to the fact that the Fianna Fáil Government reduced the rate of inflation in their early years in office to such an extent that a review was not as necessary as it became later on in our period in office and now in the period of office of the Coalition Government. Nobody will forget the budget last July and the consequences of it. It is agreed that over the range of goods the increase in the cost of living was 5 per cent, which is a substantial increase and indicates to me that there was a necessity this year for a mid-year review for eligibility for medical cards.
I know we are restricted on time. Earlier on I declared that my interest was in regard to the Cavan general hospital, which is a large undertaking and is very important for the area. I want an assurance from the Minister that the schedule laid down by his predecessor will not be interfered with. If I get that assurance it will allow me to sleep more comfortably at night. I know there is a commitment to retain the Monaghan hospital and improve the services there. The mentally handicapped provision at Drumcar is essential for the whole area because people are taken in from the whole health board area into that unit. Parents are very anxious about such developments when their children reach a certain age level. It is my view that we should give more attention to this sector. Up to now most of the attention has been concentrated on the younger age group but there is the situation that some children become difficult or even impossible to handle in the family context.
This year has been proclaimed a special time for the handicapped. I know the Irish Wheelchair Association have been holding celebratory functions throughout the country. I should like to call the Minister's attention to the good work of that association, of the voluntary workers, of the wheelchair occupants themselves — this is a very encouraging aspect — and of course to the good work of the professional staff.
When a review of the income limit for medical cards is being undertaken by the chief executive officers of the health boards, there must be a substantial increase in the income limit. The present limit of £56 for a man and wife and £6 for each child is not adequate. The result is that mothers of young children who go to a doctor are not going to the chemist for the necessary drugs and medicine because they cannot afford them. It is estimated that some 40 per cent of the people have full eligibility. The Minister should look at the possibility of a one per cent charge on PRSI contributors in order to grant full eligibility for medical services. This is the only way to provide a proper health service. If people get medical treatment at an early date very often they do not need hospitalisation. Many people are in hospital because they could not afford to get the medical attention that was necessary at an early stage.
The time has come for the Minister to look again at the GMS scheme to find out if the State is getting full value for the vast sums being spent on the scheme. In my opinion it is not, and evidence is available to prove that. There should be a capitation grant or allowance to doctors rather than the fee per item system presently in operation for doctors and pharmacists. This scheme is being abused wholesale and the people are not getting a proper service.
A serious situation has arisen at the Regional Hospital, Cork, where equipment for radium treatment has been sought for more than two years but has not been provided yet. A very good service is being provided there under bad circumstances, and attention should be given to this matter.
We welcome the upgrading of the Mallow Hospital to a full-scale general hospital. However, there is now a greater volume of out-patient work but provision was not made for the development of this service. There is an absolute need for an improvement in this area.
The provision of geriatric services in the North Cork area is not adequate. I am sure the Minister is aware of the number of times the health board and other bodies have asked for capital to build a geriatric hospital at Fermoy and have also asked that the services in Nazareth Home, Mallow, be developed. This is for the entire county. I ask the Minister to take account of the points I have raised.
I wish to congratulate the Minister of State on his appointment. I hope he will give attention to projects in the west of Ireland to which Deputy Woods referred. We have not much ministerial muscle in the west but I regard the Minister of State as a neighbour.
I am concerned that £2.5 million has been removed from capital expenditure as this may affect the Kilcornan centre for the handicapped, the orthopaedic section at Merlin Park and any other developments. I ask the Minister to consider especially services for the aged. The Western Health Board have been looking for a welfare home in Ballinasloe. If the money is not available for this, will the Minister consider some of the applications from private nursing homes for status under the Health Acts so that the subsidy that can be given by the health board will be paid to relatives of the aged who are in such nursing homes? There may be some criticism of these homes but I know the Department will investigate the services available.
I support the other speakers who referred to the twice yearly review of the medical card system. The income limit for a married couple is too low. The health boards have to be very lenient if they wish to grant a medical card to a married couple. Obviously the best hope for such a couple is to have a large family. I am afraid there is discrimination in the provision of hospital services so far as large families are concerned. The limit of £8,500 is the same for a single person as for a man with many dependants. Deputy Sherlock mentioned levies. There is much talk about, for example, the youth employment levy, but unfortunately that is across the board. In my view it does not help people with dependants.
With regard to medical cards, there is much documentation involved for people in rural areas who apply for such cards. It reminds one of a character in one of the novels of Dickens who proudly boasted he had solved a problem and said "You never saw so much paper in all your life". I am glad to say that the officials in the health boards are not proud of the fact that so much paperwork is necessary. I hope a more simplified method will be introduced in the operation of this scheme.
I hope the Minister of State will study the dental services as they operate in the Western Health Board area. We are much concerned about the gap that exists for children between primary school and 16 years of age. Children in that age group are not getting a proper service.
I wish to thank Deputy Woods for his kind words. I assure him I appreciate them. As Chief Whip I found him an honourable man and a person who always kept his word. Also, I wish to thank Deputy Wilson and Deputy Kitt for their good wishes. I have been very friendly with Deputy Wilson for many years and I hope that friendship will continue. I can assure Deputy Kitt that I will keep a close eye on the west of Ireland and the neighbouring county of Cavan. I shall bring Deputy Sherlock's points about the GMS, medical cards and hospital space to the attention of the Minister. Deputy Wilson mentioned the Drumcar community. We are committed to this and it will be finished. Planning at the Cavan hospital is going on at present and has not been stopped. As regards 1982 it would be inappropriate for me to say what will happen then. Deputy Moynihan raised the question of the mentally and physically handicapped. It will be a priority of the Government's to improve facilities for the care of such people. Mention was made about a Green Paper on the disabled. Work on the draft of this is well advanced and I hope to publish it early in the new year.
There has been much talk about the double payment and different people have claimed credit for it. It does not matter who gets the credit provided that the people get the double payment. It was introduced in 1955 by a Coalition Government. The Minister is making arrangements to pay it to long-stay patients. Deputy Woods mentioned new units which were to be opened. When he was in office many of these were ready. He did not open them. I cannot understand, listening to Fianna Fáil speakers say what they would have done as regards building hospitals and so on, why they did not stay in office until 1982 and accomplish all these great things. Surely if they had done so they would have had no trouble in winning a 1982 election. They knew the recession was upon us and knew they had borrowed too much. They knew it could not continue. They had set the house on fire around them and were anxious to get out as quickly as they could. They had not got the money and ran away from their obligations and promises.
Deputy Woods made much play about agencies being left short of money in 1981. That is not so. The fact that I introduced this Supplementary Estimate is a clear indication that I am concerned to make good the deficit which he and his Government calculatedly left in the provisions for the health services. When the House passes this Supplementary Estimate the health agencies will be notified of their additional allocations and my Department will discuss with them in detail any problems they may have. I was surprised to hear Deputy Woods mention shortfalls, because if he had provided properly for the health services there would be no need for this Supplementary Estimate of £80 million. The shortfalls allowed for in the 1981 Book of Estimates was £652 million including £60 million for the cost of meeting the terms of the national understanding. This means that the grant available for meeting the cost of the 1980 level of services was £592 million, about £44 million short of what the Department had indicated was required. It was clear from the outset that the Book of Estimates provision was inadequate, and that was pointed out by our spokesmen last February. The Book of Estimates provision for the general medical service payments board was £53.7 million whereas the 1981 Departmental estimate was £60 million. The actual requirement is £63 million. Deputy Woods contended today that provision would have been made later in 1981 to make good the shortfall by way of Supplementary Estimate. This is not good enough. he should tell us where he would have got the money. Would he borrow it? There have been under-estimations in all headings, social welfare, Garda pay, army pay, agriculture, CIE and so on.
Last year there were Supplementary Estimates amounting to £474 million. This was borrowed and that is why we are in the trouble we are in today. These shortfalls began with the 1981 Book of Estimates. after the last Government decided on the provisions to be made for the health services in 1981, it was quite clear that if the expenditure allocations of the main health agencies were to be computed by reference to the amount of grant available, as is normal practice, there would be a significant shortfall in the expenditure of allocations and reductions in levels of health services. The dismissal of thousands of staff would also be necessary.
Having discussed the situation with the chairman and CEOs of the health boards the then Minister decided to approve expenditure allocations in excess of those which would be justified by reference to the grant provision in the Book of Estimates for 1981. His intention was that the under-provision by way of grant Estimate of £43.8 million would be met by making further provision by grant or Supplementary Estimate. It is reported in The Medical Times of 30 October 1981 that in the spring of this year the Minister got approval from the Cabinet for the expenditure of £43.8 million on the health services over and beyond the £652 million provided for in the Estimates. He did this following a series of meetings between himself, his secretary and finance officer of the Department and the chairman and CEOs of the health boards. While he may have discussed the issue with the Cabinet there is no official documentation in the Department to prove that it happened nor is there a record of a Government decision having been formally taken in the matter. Word of mouth counts for nothing. These are always written down, but it was not done so on this occasion.
I have a copy of it here. The Minister is making a serious insinuation.
I should like to quote from the non-capital health allocation of 1981 dated 20 February and from the Minister's documents left in the Department. The Minister had a meeting with the health boards and prior to that the expenditure limits which could be allowed within the approved grant allocation had been indicated provisionally to the chairmen and CEOs. They had met to discuss the situation. When the Minister met them to let them know the result of the joint consideration of the position they said that the allocations which had been indicated to them were so deficient that they thought it unwise to let the health boards as a whole know of them. They said reaction would be adverse and the services seriously affected. At their request the Minister agreed with the chairmen to adjourn the meeting and said the allocations provisionally notified to them would not be conveyed to their boards. It was agreed there would be an urgent in-depth analysis of the situation in each health board area between the Department and CEOs with their managerial teams. A team from the Department, headed by the secretary, visited most of the health boards and met in Dublin.
