I move:
That a sum not exceeding £978,602,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December 1983, 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 a grant-in-aid.
The World Health Organisation have become increasingly concerned, not alone about the escalating costs of health services throughout member nations, but also as regards the strategy which should be adopted to safeguard the health of the populations. The organisation advocate a decreasing emphasis on expensive technology and a concentration on—health as a way of life; the prevention of ill-health; and community care for all.
The organisation advocate a reappraisal of life styles so as to bring about the awareness of the injury to health that results from excesses of various kinds; increased attention to the prevention of disease; and the development of primary care services with emphasis on the role of a caring community.
The World Health Organisation's strategy merits serious consideration by all member states. However, significant changes in the use of resources cannot be brought about overnight. Besides, hospital services must be maintained at a level commensurate with need and thus the scope for shifting resources from institutional to the community area is extremely limited in the short term. This is particularly the case in the present difficult financial situation which rules out the prospect of extra funds in the immediate future which could be applied to develop community services. Our basic approach as long as current financial difficulties persist must be to contain expenditure on all services within budgetary levels. In the hospital area this will involve the regulation of activity to the level dictated by available funds. This will not be easy, but it is inescapable if expenditure is to be controlled.
The gross non-capital provision in the Estimate amounts to £1,009.102 million. Allowing for Appropriations-In-Aid at £83.5 million the net non-capital grant provision is £925.602 million.
The net non-capital grant provision represents an increase of about £79.5 million on the out-turn for 1982. A further £7.53 million is included for Health in Vote 50 (Increases in remuneration and pensions) to meet the three months' arrears portion of the 1982 agreement on pay in the public services.
The capital provision included in the Estimate amounts to £53 million.
The policy decisions taken by the previous Government in relation to departmental allocations were reflected in the original published Estimate for Health.
The revised Estimate now before the House shows a reduction of £10.3 million on the non-capital side, allowing for the inclusion of a provision of £3 million in the later Estimate for budget increases in rates of allowances, as compared with the earlier Estimate.
Most of the policy decisions which were reflected in the earlier Estimate have been maintained. The only exception is that the decision taken by the previous Government to introduce public ward and out-patient charges has not been implemented. The resultant loss of income estimated at £13 million together with the cut of £10.3 million meant that corresponding savings totalling £23.3 million had to be achieved. The savings are expected to be realised through savings on drugs costs, including adjustment of the drugs refund scheme and a reduction of £5 million on institutional budgets. The savings have been reflected in the 1983 allocations which have been approved for health agencies.
The non-capital expenditure on health services in 1983 is estimated at £1,070 million in gross terms, or £1,013 million taking account of income from various sources. This figure represents about 7.7 per cent of GNP. The net estimate of £1,013 million comprises £663 million in respect of pay, £297 million in respect of non-pay, excluding cash allowances, and £53 million in respect of cash allowances.
The very major increase in expenditure on health services in the last decade — it has increased almost tenfold since 1972-73 — has been adverted to time and time again. It must be remembered, however, that while the increases in costs were due largely to pay and price increases, substantial amounts were applied to developing and improving health services. Among the major achievements in the last decade were substantially improved services for mentally handicapped persons; development of community psychiatric facilities which have made it possible to care for many psychiatric patients in the community rather than in an institutional setting; development of welfare elements in the health services such as children's services, home help services and meals on wheels together with improvements in welfare allowances; introduction of a choice of doctor scheme for persons in the lower income group; a substantial increase in the numbers of consultant and other medical staff together with corresponding increases in nursing, para-medical and other staff resulting in improved diagnostic and care facilities; introduction of new treatment techniques, accompanied by sophisticated technology in acute hospitals; the extension of eligibility for free hospital services to the entire population.
There is no disputing the fact that the quality and scope of our health services have shown a vast improvement in the last ten years.
There has been much criticism of the manner in which health services resources have been deployed. It has been contended that too high a proportion is spent on hospital services to the detriment of community based services. The figures are certainly revealing. If we turn to the programme and services presentation of estimated health services expenditure in 1983, as set out in the appendix to the published Health Estimate, we find that £726 million, or about 71 per cent of the gross expenditure this year, will be applied to institutional services; and £237 million, or about 22 per cent of the total, will be applied to community services. The balance of the expenditure is taken by ambulance services, superannuation payments, research and administration charges. The actual amounts spent and the percentages of total expenditure used by each of the various programmes are as follows:—
|
£M |
||
|
Community Protection |
17.5 |
(1.6%) |
|
Community Health Services |
139.8) |
(13.1%) |
|
Community Welfare |
79.7 |
(7.4%) |
|
Psychiatric Programme |
132.0 |
(12.3%) |
|
Programme for the Handicapped |
102.0 |
(9.5%) |
|
General Hospital Programme |
547.4 |
(51.2%) |
|
General Support |
52.1 |
(4.9%) |
|
TOTAL = |
1,070.5 |
The absence of extra funds for development purposes means that no developments will be possible unless funds can be released from the overall resources at present available. It is imperative, therefore, that all services be appraised on an on-going basis to identify opportunities for eliminating or modifying services and for improving efficiency. Work in this area is under way in my Department.
Last January I circulated to Deputies copies of the most recent volume of statistical information relevant to the Health Services. The information in this is divided into sections, each of which deals with one of the main health programmes or another aspect of the health service. Deputies will find this a useful aid to understanding what is happening in the health service. I will refer later to the different programmes but first I should like to refer to certain vital and health statistics which are of particular importance.
The section of the population aged under 15 or over 65 is the section which makes the major demands on the health services. The 1979 census of population indicated that people in this section made up 41.3 per cent of the population of the country. This is higher than the corresponding percentage for any of our EEC partners.
The Irish birth rate was 21.0 live births per 1,000 population in 1981 during which 72,355 births took place. This rate is by far the highest birth rate in the EEC. Over 99 per cent of these births take place in hospitals.
One of the important indicators of the general state of health of a community is the infant mortality rate. This has declined from 30.5 deaths of children under one year old per 1,000 live births in 1961 to 18.0 in 1971 and in 1981 it was 10.6.
In 1981 there were 560,000 admissions to acute public hospitals or 163 per 1,000 of the population. This area is being closely examined in order to identify any potential areas of saving in what is a very expensive part of the health service.
The population is now divided into three categories for purposes of eligibility for health services.
Category I consists of persons with full eligibility. These are persons who are unable to afford general practitioner services for themselves and their dependants without undue hardship. Persons in this category are entitled to the full range of health services without charge and they are issued with medical cards for presentation when services are needed.
Category II are persons, other than those in category I, whose income in the year ended 5 April 1983 was less than £11,000. Persons in this category are entitled, without charge, to hospital services as in-patients in public wards or as out-patients at public clinics and to maternity and infant welfare services. They are also entitled to avail of the drugs refund scheme, which ensures that nobody will have to meet excessive costs for prescribed medicines.
Category III consists of those persons whose income in the year ended 5 April, 1983 was £11,000 or more. Persons in this category are entitled to the same hospital services as those in category II except that they are liable for the fees of the consultants involved in their treatment. They are also entitled to avail of the drugs refund scheme.
In effect, the £11,000 income limit is the dividing line above which persons are required to pay the fees of hospital consultants. This limit had been £9,500 but I have increased it to £11,000 with effect from 1 June. I am currently giving consideration to the question whether this limit might be abolished entirely. To do this would mean that everybody would be free of the worry of having to meet hospital costs at a time when their ability to do so may be at its lowest. It would also have major implications for other aspects of the health service such as the interests of the medical profession, the Voluntary Health Insurance Board, the health contributions scheme and the relative use of public and private hospitals. These are matters which will need further consideration and consultation before any final decision is made.
Persons liable for consultants' fees or who wish to make private arrangements for services may insure against the cost of these services with the Voluntary Health Insurance Board. To give an example, in the case of a married couple with three or more children who are insured under the V.H.I. boards plan B — the most popular plan — the group subscription payable is about £315 a year. When income tax relief at the standard rate is taken into consideration, the cost is reduced to about £205 a year or about £3.90 a week. The care provided includes the cost of maintenance, cover against consultants' fees in the minimum basis recommended by the VHI board, and benefit related to certain out-patient expenses including prescription costs, doctors' fees and specialist consultation fees.
As Deputies are no doubt aware, health boards are responsible for collecting health contributions, and, indeed, the youth employment levy and the tax levy, from the farming population. Down through the years farm income for the purpose of health contributions was determined on the standard basis of farm valuation and a multiplier, but in July 1982 the High Court ruled that determining income on this basis was contrary to the Constitution. To cope with this situation, in February 1983 I amended the relevant regulations to provide that for this purpose farmers' income will be determined on profits or gains from farming activities less expenses actually incurred in earning these profits. This means that farmers' income and the health contribution payable will be determined on the same basis as for self-employed persons. Similar arrangements have been made in respect of the other two levies.
This new situation, however, has raised the question of whether health boards are the most suitable agencies to collect health contributions and the other levies from farmers. This does involve some element of factual assessment of farm income by health boards and, of course, the overall position has changed in that, from the current year, liability for income tax has been extended to cover the entire farming population. It is obvious that the health board collection arrangements must be reviewed in the light of the changed treatment of farmers for tax purposes.
An inter-departmental working party have been set up to review the whole situation and are expected to report shortly. While health boards will be required to collect these contributions and levies in the current year I expect that these arrangements will be changed in the near future.
I regard it as important that this House should be fully aware of the manner in which I perceive the development of acute general hospital services proceeding over the next number of years. The programme of development has been on-going since the mid 1970's and during that time the pace of implementation has had to be adjusted a number of times in the light of the prevailing economic circumstances. This has led to a ‘stop-go' situation which has had a detrimental effect both on the service itself and on the morale of the staff involved in the delivery of these services.
It is now clear that the current economic difficulties are the most serious we have had to face so far and it is also clear that their effects will be with us for some time. Consequently, given this situation, I have found it necessary to take a fresh look at the development programme with a view to ensuring that an orderly pace of progress can be made in the next few years. We have to accept that the level of capital resource which we can realistically expect for development will fall considerably short of that required for the existing plans as already drawn up. Therefore, it is necessary that our approach to planning in the medium term should be the application of the scarce resources which can be made available in such a manner as to ensure that a reasonable pace of development is maintained and the service in general made as effective as possible.
The dilemma for any Minister for Health is that when the capital cost of the priority demands made by the health agencies for the continuance of existing work, the replacement of refurbishing of existing structures, the building of additions to existing institutions or the building of new institutions and the replacement of equipment are added up, they come to a sum of £630 million. I have £53 million for health capital expenditure in the current year and in the period from 1983 to 1987 the previous Government aimed to provide £271 million.
The problem does not end there. New buildings attract revenue-cost increases. It was recently found that replacing the same number of acute hospital beds in a new facility cost an additional £2 million in a full year.
In these circumstances, I am convinced that the only logical approach to the major task with which we are faced is to draw up a capital development programme which can be realistically implemented in the next five years or so. The basis of such a programme must be to identify absolute priority areas of development. The criteria which must be used in such identification are:—
projects for which there are contractual commitments; developments involving the replacement of seriously sub-standard accommodation and facilities;
developments in areas where there are no services or where services are seriously deficient; and,
developments which give rise to little increase in revenue expenditure.
The capital budget available for health in the current year is £53 million. For planning purposes, budgetary control and expenditure projections, this cannot be considered in isolation and must be taken in the context of the medium term, five-year programme of capital developments covering the period 1983-1987 inclusive. It is envisaged that a total of £271 million (at 1983 prices) will be made available to finance such a programme — that is an average capital budget of £54 million per annum.
The capital resource, therefore, available must mean that this five-year programme will fall considerably short of the expectations which have been raised throughout the country in the past few years. It is my intention that the programme will provide a mix of projects in the general hospital, geriatric, psychiatric and community-care areas.
So far as the general hospital area is concerned, plans for the development and rationalisation of the system have been agreed for some time. The resource required to implement these plans in total, is very great indeed and can only hope to be made available on a long-term basis. So in drawing up the general hospital content of the medium-term programme, the criteria I mentioned earlier have been applied. On this basis, the programme will include a number of major projects, throughout the country, which, though limited, I am convinced will provide an appropriate infrastructure on which we can advance our agreed plans to finalisation as resources become available.
Of particular concern to me at the moment, is the blatant need to bring the accommodation and facilities for geriatrics up to acceptable standards and level of provision. It is an unfortunate fact that to a large extent this area has been neglected, by successive administrations. This situation cannot be tolerated any longer in a society which claims to pride itself in the esteem in which it holds its elderly citizens. It is regrettable that the demands made by society in general and, I am obliged to say, by the medical profession, at acute hospital level in particular, over the years for development in the health services have largely ignored the needs of this very vulnerable group. I intend in the next few years to remedy this situation in so far as I can within the constraints of the limited resources available. This will mean inevitably that some major projects in the acute general hospital programme will have to be deferred in the short term, or at least reduced in scale, if we are to be serious in demonstrating our concern for the elderly and other vulnerable groups in our society.
The psychiatric services have, without doubt, received less than a fair share of resources in the past. I intend to continue in my endeavours to rectify that situation. This year my Department will be spending in the region of £150 million on the psychiatric programme. Despite the difficult financial climate I am totally committed to providing a realistic level of Government support for our mentally ill population.
I will of course be seeking a high level of co-operation and flexibility from all involved in the direct provision of the services. I am happy to report that health boards have been especially conscious of the need to supplement in a positive fashion, the attempts by central Government to modernise and develop the services. A planned programme of improvement schemes in our district pyschiatric hospitals commenced last year. It was funded by my Department with health boards also contributing out of the resources at their disposal. Much good work was achieved and it is the Government's intention to continue to support the scheme in this and future years. This year I am making a sum of almost £2 million available. Living conditions have already improved for many patients and I am convinced that the continuation of the scheme will effect considerable further changes in the environment of long-stay patients in particular. This development is long overdue. Whereas the number of in-patients is on the decline we still had, at the end of last year, over 13,000 psychiatric beds. Almost 60 per cent of those patients had been in hospital for five years of more. This is an appalling statistic and it very clearly demonstrates the need to continue in our efforts to provide a decent standard of living for those who are spending long periods of time in old and uncomfortable institutions.
The emphasis in the development of further services will, however, be on the provision of community facilities. With the improvements of chemotherapy and medical and psychiatric skills many people, who previously would have had to be treated as in-patients, can now live outside of the hospital environment. There has been considerable development of community-based services throughout the country, most district hospitals having been involved in establishing hostels, day hospitals, day centres and workshops to cater for discharged patients and for people presenting for the first time with psychiatric disorders. I have proposals before me for the further expansion of community facilities. While there are many difficulties I would hope that a number of the projects will be in operation by the end of this year. Health boards are being asked to give serious consideration to the concept of redirecting resources to the psychiatric services from within the totality of the health services and I am confident from my discussions with them, that they will make every effort in this regard.
In view of the continuing shift in emphasis away from institutional care and the need to set out in a clear fashion the most appropriate range of services — both community based and hospital based — which will be required in the future in each health board area my Department established an informal study group at the end of 1981 to prepare an overall planning framework for the development of the psychiatric services. Such an exercise has already been carried out with success in other areas of the health services and I look forward to receiving the report of this group in due course.
There is one particular area which falls within the ambit of the psychiatric services programme to which I would like to make a particular, brief reference. I will come back to it later; it is the provision of treatment facilities for drug abusers and addicts. The Government have established a special committee of Ministers of State to review the drug problem urgently. Their recommendations will be available within the next few weeks. In the interim, however, I am sufficiently convinced of the magnitude of the problem in the greater Dublin area to have recently approved of the provision, by the Eastern Health Board, of community based facilities for drug abusers. I have also recently approved tenders submitted by the health board in respect of the provision of a youth development centre in the grounds of the Central Mental Hospital, Dundrum. It will provide secure accommodation for young people whose behaviour has resulted in their having difficulties with the law. Such behaviour will include drug-related offences. I shall return to this subject later in my statement when dealing with the community protection programme.
Since becoming Minister for Health I have had a number of opportunities to discuss the present state of the mental handicap services with representatives of voluntary organisations. They have impressed on me the need to maintain the existing level and high standard of our mental handicap services, and also to give due consideration to the need to provide further development in relation to providing services for sub-groups within the mental handicap population, particularly the adult mentally handicapped. The Government and myself are committed to regarding the mental handicap services as having a particular priority within the health and social services.
The Medico-Social Research Board published earlier this year preliminary findings of the census of the mentally handicapped in the Republic of Ireland, 1981. The publication of these findings allows us to compare them with the results of the previous census of the mentally handicapped carried out by the Medico-Social Research Board in 1974. In the intervening period, a number of trends have become apparent. In line with the increase in population generally, there has been an increase in the actual number of mentally handicapped persons. This is due to an increase in the number of adult mentally handicapped and these people present a severe challenge to us to provide adequate accommodation and activation for them. The preliminary findings also show up that there seems to be an apparent drop in the number of severe and profound mentally handicapped which is a welcome finding. Another interesting result is that there has been a notable reduction in the number of mentally handicapped maintained in psychiatric hospitals which decreased from 2,744 to 2,377. This figure should be further reduced when additional residential places for adult mentally handicapped, currently in planning, come on stream.
When the complete findings of the census are available, I will be requesting my Department to examine them with a view to adjusting the projections which were contained in the 1980 Department of Health Working Party Report on Services for Mentally Handicapped.
I was pleased earlier this year to confirm the out-going Government's decision to exempt certain new priority projects in the mental handicap services from the effects of the current embargo on recruitment of staff to the public sector. This allowed 150 new jobs be allocated to the mental handicap services so that units which had been lying vacant up to a period of two years could be opened. However, I am conscious that there are a significant number of places for the mentally handicapped which cannot yet be commissioned. In addition, the new Centre for the Mentally Handicapped at Cheeverstown House, Templeogue, Co. Dublin which will provide 130 residential places and 154 day places is now nearing completion. I am considering ways and means in which these places can at least be phased in.
As I have indicated, there has been a decrease in the number of mentally handicapped persons resident in psychiatric hospitals. In general, psychiatric hospitals are not places for the mentally handicapped whose needs are different from those who are mentally ill. However, many of our mentally handicapped already in psychiatric hospitals will probably spend a significant portion of their lifetime there. Much of the moneys allocated to the improvement scheme for psychiatric hospitals will go towards alleviating poor living conditions. However, I would hope that there would be a parallel effort to ensure that adult mentally handicapped person in psychiatric hospitals receive an appropriate level of stimulation and care rather than mere custodial care.
The contracts have now been signed for the construction of a new centre for the mentally handicapped at Swinford, County Mayo. This facility will provide much needed places for an area which has a significantly higher incidence of mental handicap that most other areas in this country. In addition, I have a number of proposals before me regarding the provision of further residential accommodation for the mentally handicapped and I intend to look at these as sympathetically as possible within the resources available to me in order to ensure that at least planning on this accommodation is progressed further.
There has been great emphasis, particularly in recent years, on the development of community and welfare services. Everybody agrees that caring for people in their own communities is far preferable to institutionalisation. But to some extent we have only being paying lip service to this ideal. While one must acknowledge the very rapid development and progress in the area of community care in the seventies it is disappointing to note that in recent years the percentage of the total health budget allocated to this programme has been decreasing. Quite frankly, successive Governments have simply not lived up to their many commitments in relation to the development of community care and personal social services and this is clearly reflected in the budgetary allocations for these services in recent years.
The notion that our health services can only advance if every local community has a hospital, and the bigger the better is wrong. As politicians we have a very serious responsibility to educate ourselves and the public in regard to the most effective way to provide health services rather that blindly to lead local campaigns for more and more hospital accommodation without giving a thought as to whether or not there are not more beneficial and less expensive alternatives. It will be my policy as Minister for Health to reverse the present trend.
There are many valid reasons why we must concentrate on the development of our community care and personal social services. We cannot but be concerned at the escalating cost of hospital treatment and the fact that an increasing proportion of the total health resources is being swallowed up by our institutions, especially the acute hospitals. Yet when one looks closely at admissions it is evident that in every institution, be it an acute hospital or a long stay nursing unit, there are some people who should not be there.
These people could, with adequate community services, live at home and get whatever care they might require while living independent lives as integrated members of their community. A large proportion of our health expenditure, therefore, goes on what I would term "meals and accommodation" costs. If the treatment and care which is needed can be given in the out-patient department or in the home this element of health expenditure could be greatly reduced. But I am not simply looking for cheap alternatives. The further development of our community based health services will be very expensive and will not be possible without a switching of funds from the hospital programme.
In promoting more community care I am conscious of two important considerations: that in many instances treatment and care in the community can be as effective as treatment in a hospital or other institution; and that, generally speaking, it will be more acceptable to the patient and to the patient's relatives.
Sometimes there is no difficulty in persuading patients and relatives that home care is preferable to admission to hospital. This is particularly true of illness in children. On the other hand, there may, understandably, be considerable resistence on the part of the relatives if the burden is likely to be heavy and continuous as in the care of the physically or mentally disabled elderly patient. It follows that community care, whether for children, the elderly, the disadvantaged or the handicapped, must be designed to aid the relatives as well as the patient.
I fully recognise that there are conditions for which there is no alternative but admission to hospital and that, once admitted, patients are entitled to the highest quality medical treatment and care that is available. Equally, I recognise that there are many serious deficiencies in our community services and that these cannot and will not be tackled unless we are prepared to allocate a greater proportion of our total health resources to this area than we have been doing in recent years.
With regard to the general medical service, with effect from 1 October last year nearly 900 items were withdrawn from re-imbursement under the general medical service scheme. I have had the position reviewed in relation to items for which payment continued to be made and to the items which had been excluded. This extensive review has been completed and I have been able to re-admit some preparations to the scheme. These included drugs in a number of categories among them
—analgesics for persons suffering from rheumatoid arthritis
—simple iron preparations
—tablets and capsules for the treatment of allergies.
These will meet the needs which have been widely expressed by both doctors and patients. The changes I have made represent the maximum improvement possible at present. I have continued to urge the health boards to ensure they identify and help those who, because of particular individual circumstances, might need assistance in relation to excluded items. I was glad to hear that both the medical and pharmaceutical organisations commented favourably on the helpful approach of the health boards in this regard.
I expect to receive by September the report of a working party which is currently reviewing the operation of the general medical service. The terms of reference of the working party are such that its report should be of major significance for the development of primary care in Ireland. One of the principal issues to be addressed by the working party is the basis on which doctors should be remunerated for their services. This is a topic on which I have an open mind. I am sure that the working party will approach this sensitive issue aware of the differing considerations that must be taken into account, not least the requirement of value for money, which now more than ever must be met by all services. When I have received that report I shall be in a position to take decisions on the future development of this important service.
Earlier this year I concluded an agreement with the Federation of Irish Chemical Industries. Since the great majority of drugs used in this country are imported from the the United Kingdom the agreement set a relationship between prices here and those in the UK. The effect of this has been to reduce the prices of many medicines. The total savings which will accrue throughout the year cannot readily be estimated in advance, however, as this will be dependent, to some degree on the performance of the punt vis-á-vis the pound sterling. I am still evaluating progress in this area. For the majority of drugs and medicines the agreement provides, for the first time, a formal link between prices here and in the country of origin, and sets a limit on prices here. I believe it will be shown to be a considerable advance from my Department's viewpoint on the earlier agreement.
The Health (Family Planning) Act has been reviewed in my Department and I have received a detailed report on that review. The House will be aware that I am not satisfied with certain provisions of the legislation. I am considering these reservations in conjunction with the report on the review to establish the extent to which the Act requires amendment. The programme for Government includes, among the items relating to health, the provision of full family planning advice and facilities in all cases where needed. I intend to submit this review to the Government in the very near future.
Last year, due to financial cut-backs, the level of dental and ophthalmic services to medical card holders was severely curtailed by health boards. In fact in most health boards the ad hoc arrangement for the provision of dental services by dentists in private practice and the scheme under which ophthalmic surgeons and ophthalmic opticians in private practice provide a sight testing service were discontinued entirely for a period of the year. For the current year the health boards have been requested to ensure that as far as possible essential dental and ophthalmic services are provided for medical card holders throughout the full year.
A general review of the public dental services is being carried out by the Departments of Health and Social Welfare with representatives of the dental profession. There are problems associated with the existing arrangements and one of the main objectives of the discussions is to identify these and see what can be done to eliminate them.
The Report of the Restrictive Practices Commission on its public inquiry into the restriction, imposed by section 45 of the Dentists Act, 1928, of the practice of dentistry, including the supply of dentures, to registered dentists has recently been published. The report recommends that the legislation be amended so as to provide that the general prohibition on the carrying on of dentistry by a non-dentist does not apply to the provision of dentures to a person of eighteen years of age or over provided it does not involve work being done on living tissue. Obviously, it will now be necessary for me to consult with the different interested parties in regard to this recommendation. Following these consultations I will make recommendations to the Government as to what action they should take in the matter. Should the Government's decision involve a change in the legislation this could be dealt with in the context of a new Dentists Bill, preparation of which is well advanced. This Bill will replace the Act of 1928 which is obsolete in many respects. I expect to be in a position to introduce the text of the new Bill after the summer recess. I know that this long-awaited legislation will be welcomed.
One aspect of the public dental service which is often the subject of criticism is the orthodontic service. Arrangements are being made at present to appoint a number of consultant orthodontists to the health boards. These appointments should result in a quick reduction in the present waiting lists for orthodontic treatment.
I think it goes without saying that careful attention to the planning and operation of the preventive public health services makes sound economic sense. The impact of many diseases and conditions of ill-health which are prevalent in Ireland is considerable in terms of human suffering and pressure on primary health care and hospital resources. In view of this, there is a need to develop programmes aimed at the promotion and maintenance of healthy practices and the prevention of disease.
In the area of infectious diseases control, I have been concerned that the levels of acceptance for the routine childhood vaccinations against diphtheria, tetanus, whooping cough and polio have declined in recent years. As a result large numbers of children are not protected against these diseases and their distressing and often disabling consequences. In an effort to maintain acceptable levels of immunity, I have issued comprehensive guidelines to the health boards asking them to implement as fully as possible the Department's recommended programme of vaccination and immunisation.
I have also reviewed the current programme relating to the prevention of rubella — german measles — in women.
In view of the importance of the rubella vaccination in reducing congenital malformations and the general level of physical and mental handicap, I have asked the health boards to extend the rubella prevention programmes to women of child-bearing age additional to those categories covered by the programme which were previously in operation.
Tuberculosis and sexually transmitted diseases are also causing concern at present. I recently initiated reviews of policy relating to those diseases. The objective of the reviews is to evaluate the true incidence of the diseases in question and ultimately to devise revised programmes aimed at their prevention and control. About 2,000 new cases of sexually transmitted diseases are notified to my Department each year, the vast majority of which have been brought to our attention through hospital clinics. For a variety of reasons, including the intimate nature of sexually transmitted diseases and a reluctance on the part of doctors to report them many cases are never notified. It is extremely difficult, therefore to determine the true incidence of sexually transmitted diseases.
I do accept that the incidence of sexually transmitted diseases is high in this country and it is apparent that steps have to be taken to develop a cohesive programme aimed at prevention and control. Towards developing such a programme, I have initiated a review of my Department's control measures. An integral component of a central programme for sexually transmitted diseases is the dissemination of information aimed at increasing an awareness amongst the public of the dangers of contracting such diseases and the means and facilities available for their treatment. Prevention and control through public education will, therefore, be an important feature of the revised programme.
A sexually transmissible disease causing widespread concern is Acquired Immune Deficiency Syndrome — or AIDS as it is commonly called — and the indications from other countries are that it is fast becoming an extremely serious public health problem. On the basis of the information available regarding AIDS, the syndrome is thought to involve a breaking down of the body's immune system thus rendering the sufferer prone to serious conditions of ill-health, such as cancer or even death. Mortality rates as high as 40 per cent have been reported from some countries.
Initially, AIDS appeared to be confined to male homosexuals but gradually it became clear that persons other than male homosexuals were also susceptible to the syndrome. Those included intravenous drug-users, immigrants from Haiti, haemophiliacs — as a result of treatment with contaminated blood products — women — through infected sexual partners — infants — possibly by perinatal transmission — and children — possibly as a result of exposure in a high risk household.
The cause of AIDS and the mode of transmission are unclear. Initially, it was thought that there was something in the lifestyle of male homosexuals which predisposed them to the syndrome. However, when persons other than male homosexuals began to develop AIDS, the possibility of a transmissable agent, possibly a virus, being involved was seriously considered. The most up-to-date information from the World Health Organisation about AIDS is that multiple factors, rather than a single novel virus, possibly induce the syndrome.
My Department have asked each director of community care and medical officer of health to investigate whether any cases of AIDS have occurred in his community care area and where cases have occurred to give detailed information regarding such cases. To date, two cases of AIDS have been reported in this country. One of the persons subsequently died. My Department will continue to liaise on a regular basis with the directors of community care and medical officers of health to ensure that up-to-date information about the occurrence of AIDS is available so that appropriate measures may be taken to protect the public health.
At international level, my Department are in constant touch with WHO to ensure that information about the syndrome, its possible causes and modes of transmission is routinely available. The availability of such data will complement our national information and is vitally important to my Department to enable it to implement interventions to protect the public health.
It has been established that our food supply and our food consumption patterns are closely linked with our health status. For example, we have high morbidity and mortality rates associated with heart disease, strokes and certain cancers. Many cases of these diseases are preventable and require little adjustment in lifestyle. At my request, the Health Education Bureau are conducting public education programmes on nutrition. These programmes will be developed in the long-term to include nutrition education programmes aimed at health professionals, teachers and school children. I am also examining other elements of a food and nutrition policy for this country in consultation with other appropriate organisations with a view to developing a co-ordinated approach to the planning, implementation, monitoring and evaluation of such a policy.
One prominent feature of Irish life which merits particular attention and which does not involve any financial outlay is the general casualness in relation to matters of hygiene. The primary purpose of the national hygiene campaign which was launched in 1977 was to improve the living environment of the Irish people to make our country a better and healthier place to live in. It was the hope that this campaign would inaugurate a permanent change in the style of Irish life.
These were ambitious targets. It is generally acknowledged that the campaign did raise the level of public awareness of the need for food and personal hygiene but it must be conceded that our standards are generally less than would be tolerated elsewhere, particularly with our Continental neighbours. This reflects very badly on us as a nation. It affects our health and we have to suffer deserved criticism from visitors with such consequences for our tourist industry as that may entail.
If we are serious about national hygiene it will require a determined effort. My Department have initiated consultations with the agencies concerned to see what can be done to increase public awareness to the need for hygiene. In the course of these discussions it is hoped to identify target areas and the groups to whom efforts to raise hygiene standards should especially be directed.
Drug-related offences have, in the past two years, become a major problem. They are liable, in particular, to arise from the addiction of individuals to heroin. This addiction has been growing and is now a major problem in Dublin and its incidence in the inner city area has recently been shown to be of the order of 10 per cent among those aged 15 to 24. It can cost an addict about £100 a day for his supply of heroin and money is found, in the majority of cases, by recourse to crime. The action which should be taken in relation to those who are currently addicted and the steps necessary to prevent further increase in the numbers abusing this drug are being given priority consideration by the special Governmental Task Force on Drug Abuse. While most concern is currently being expressed about heroin there is also evidence of the abuse of other hard drugs such as cocaine. Cannabis usage is also widespread and it is the drug most widely abused at present.
I am convinced that there is a major problem to be dealt with and, as I have said, we are taking action to deal with it. In doing so it is important to keep our problem in perspective and to remember that all our European neighbours are having to cope with drug abuse problems, which in many cases are more serious than ours. There is, throughout Europe, and in other continents, a general problem of substance abuse which all countries are striving to contain.
Alcoholism has now assumed the proportions of being at once a major health and a major social problem for our country. Alcoholism is now the most frequent primary diagnosis for admissions to our psychiatric hospitals. There were over 7,000 such admissions in 1980 and we know there are at least 45,000 alcoholics in the country. Also, there are almost 600 deaths and 9,500 serious injuries each year due to road traffic accidents. A high proportion of these accidents are caused by over-indulgence in alcohol.
The Health Education Bureau have recently completed the design of a special alcohol education programme for second level schools. The aim of this programme is to develop a responsible attitude in young people to the use of alcohol. The programme will be made available to schools in September 1983.
Young people will be provided with educational experiences and exercises to enable them to develop healthy, mature attitudes towards the use of alcohol. The programme is attractive in that it lays emphasis on examining self-esteem and relationships while, at the same time, presenting factual information. The bureau will also be launching a teacher training programme at 15 centres around the country to facilitate the entry of the alcohol programme into schools.
The bureau have produced a set of alcohol fact sheets which explore various facets of alcohol and alcoholism. These are available on request to educators and others dealing with alcohol abuse. The bureau have also produced a pamphlet on alcohol abuse for distribution to the general public.
For those for whom health education is too late, effective treatment services must be provided. Our psychiatric services are broadening their scope to include specialised treatment programmes and I will be keeping them under close review. I will be encouraging the expansion of community-based services in this as well as other areas of psychiatry. A significant development in recent years has been the introduction of specialised counsellors dealing with alcoholism. They are playing a crucial role in helping not only problem drinkers but the family and friends who are suffering also because of the addiction. I will be giving careful consideration to increasing significantly the number of counsellors in the coming year.
Tobacco smoking is now recognised as the largest single preventable cause of premature death and disability in our society. Two decades of continuous research overwhelmingly ratify the original scientific indictment of smoking as a contribution to disease and premature death. In Ireland we are in the unenviable position of having the heaviest smokers in the EEC and our smokers have been substantially increasing their consumption in recent years. The notable increase in smoking among women and young people is particularly worrying.
I have been reviewing the position generally and I am satisfied that urgent and more stringent measures will need to be taken if we are to combat this smoking epidemic. I am thinking specifically of action in such areas as, health warnings, smoking in public places, health education and the strengthening and enforcement of the tobacco legislation. These measures will indicate clearly the Government's resolve to tackle the serious damage being done to the nation's health through smoking.
In the period 1974 to 1981, the number of staff employed in the health services increased by 46 per cent. This, in effect, meant that total numbers employed overall went up from less than 40,000 to about 58,000, an increase of more than 18,000 staff. This increase was not uniform among the different categories of staff employed. The biggest increase was in areas where skills had perviously been in scarce supply such as para-medical grades which went up as much as 91 per cent. Medical and dental staff went up by 67 per cent. The supply of nurses went up by 35 per cent, clerical and administrative staff by 72 per cent and catering and domestic staff by 58 per cent. This period of continuing growth was brought to an end in July 1981 when the Government effectively embargoed any further increase in the number of posts in the public services. Subsequently, the Government devised further measures designed to reduce numbers progressively as vacancies arose.
The underlying purpose of the policy adopted is to improve administrative efficiency and to bring public expenditure into line with our resources. Essentially, therefore, we are looking for cost containment while maintining and, if possible, improving the level of services. Unfortunately, the containment strategy forced on us by present circumstances includes not only curtailment of funds, but a reduction in levels of employment at a time when alternative employment opportunities are scarece. When the strategy was formulated, it was expected that target reductions could be achieved by leaving unfilled a proportion of the vacancies which arise through natural wastage. It now appears that the rate of turnover has significantly decreased, making it more difficult to achieve targets within the time scale set down. This strategy will, therefore, need to be reviewed and consideration given to alternative approaches.
I intend to make a definitive statement shortly on the many recommendations and views contained in the report of the Working Party on General Nursing. These recommendations and views range over a whole spectrum of nursing matters, such as the role and education of nurses, administrative structures and the control and disciplining of the profession. The working party was widely representative of the nursing profession and contains the considered views and recommendations of highly qualified and experienced persons involved in the nursing area. In addition, we have now received the observations, and comments of the various interested nursing bodies and organisations — too numerous to mention here — and for which I am very grateful.
New nursing legislation is now being prepared in my Department. It will replace the existing Midwives Act and the Nurses Acts and it will provide for the restructuring of An Bord Altranais along the lines recommended in the report of the working party. The new board will be more representative of the various branches of nursing and will be able to exercise greater control over the profession and its future development, as indeed has been sought by the profession itself. I would hope to be in a position to put the draft legislation before the Oireachtas before the end of the current year.
The working party have recommended that a central application bureau should be set up to deal with applications for entry to nurse training schools and it is intended that the new Nursing Bill will contain a provision giving An Bord Altranais statutory powers to enable them to set up a central applications arrangement. In the meantime, the board are carrying out a feasibility study with a view to introducing an arrangement on a voluntary basis. I know that such a development will meet with almost universal approval.
Investment in reseach may not yield immediate results and because of this there is always the danger of it losing out to the pressing needs of hospital and community services. Yet the fruits of research whether of an evaluative, epidemiological or clinical nature, can chart the course of an effective and modern health service.
For these reasons and notwithstanding the pressures from other sectors of the health service a total of just over £2 million has been allocated between the two reseach agencies under the aegis of my Department. These agencies are the Medico-Social Research Board and the Medical Research Council. It is a fact that the potential number of researchable topics by either body is indeed very large. Therefore, an attempt has to be made to select researchable items on the basis of their relevance to Ireland and also their urgency. A major consideration must also be research work done in other counties and in this regard contacts established through the machinery of the European Community can prove very valuable.
The Medico-Social Research Board carry out a wide range of epidemiological reseach. This includes studies of the activiety and morbidity patterns in general and psychiatric hospitals and also in homes for the mentally handicapped. The board also engage in reseach in the area of mother and infant health much of which is aimed at the prevention and detection of disease and handicap. Another area of immediate relevance which the board investigate relates to the incidence of drug abuse especially in urban areas.
The Medical Reseach Council, on the other hand, are concerned with basic clinical research. They, too, within the limits of their budget, try to tackle those conditions which either because of their origin or incidence have a special relevance to this country. They have recently concluded special work on brucellosis and are continuing their investigation on alcoholism, coeliac disease, hypertension, lung fibrosis and hospital infections. The council also promote medical reseach in our hospitals by giving research grants to medical personnel with appropriate research projects.
I have been considering the whole question of private health care and, in particular, the provision of State funds to subsidise this care. In this connection, I have already discontinued the subventions which were formerly payable by health boards for patients in private general hospitals. I am also looking into the question of the use by consultants of public hospital facilities in the treatment of their private pateints.
I have also decided that the development of a private hospital in association with a public hospital will not in future be facilitated by me by, for example, providing a site for its construction. I am examining the possibility of my taking the legislative powers necessary to control the provision of such private hospitals.
Finally, regarding a discussion paper or White Paper on health services I have already stated that it is my intention to publish before the end of the year a discussion document on the health services and their future development. I have not, therefore, gone into great detail today on all facets of the health services. This will be done in the discussion document and will provide an opportunity for all involved in or concerned about our health services to put forward suggestions for changes and improvements. In moving this Estimate I was, therefore, somewhat selective in the choice of topics on which I have commented this morning.
