I wish to deal with my contribution in two parts, relating firstly to Health and secondly to Social Welfare.
The net non-capital provision in the Book of Estimates for Health is £963.612 million. This compares with an out-turn figure of £936.7 million for 1983.
The 1984 provision includes £4 million to enable the new Tralee General Hospital to be commissioned on a phased basis during 1984, to provide for improvements in child care services and to finance the drug abuse programme. The Estimates provision for health services will enable a sum in the region of about £1,062 million to be spent on health services in 1984 when account is taken of appropriations-in-aid. This represents an increase of £29 million on the 1983 out-turn of expenditure.
The problem of the escalating costs of health services is general in Europe. There is now a general acceptance that this growth must be contained at a level which is sustainable by the level of resources that can be applied to public services. Non-capital expenditure on health services in this country has increased from £400 million in 1978 to £1,033 million in 1983. This represents an increase of 158 per cent in a five-year period. As a percentage of GNP the growth in the same period was from 6.25 per cent to about 8 per cent. Clearly this trend could not be allowed to continue if the country was to maintain normal Exchequer support for the health services.
Before dealing with the 1984 situation, it would be useful to consider briefly the current financial position of the services themselves. I think it will be accepted that in the current year, 1983, there were no major financial problems. My Department's Estimate for 1983 will not be exceeded. This year, for the first time in many years, there will be no Supplementary Estimate. Despite the July reduction of £13.6 million in the net provision for Health, it has been possible to avoid reducing the 1984 allocations of health boards, voluntary hospitals, homes for the mentally handicapped, and other agencies. This situation contrasts with that which obtained in 1982 when, as a result of a decision taken by the previous Government in July 1982, substantial cuts were made in the allocation of health agencies. Coming at a stage when more than 50 per cent of the budgets for the year had been expended, this gave rise to considerable problems in maintaining services. The situation in 1983 was that services levels were maintained and it was even possible to effect certain improvements.
This, then, is the financial situation in global terms for the health services for the coming year. The allocation for 1984 is at this time being broken down and their individual allocations notified to the various executive agencies through which the health services are delivered. I will not attempt to deny that the year ahead will be a very difficult one for those administering and providing services — how difficult and with what consequence is, in fact, being measured at the present time. Let me say this, however, our health services are very wide flung and diverse and with the benefit of a year's experience in office behind me I am well aware of the fact that there are throughout the country a number of facilities and services which are not essential to maintain the fabric and quality of the services necessary to prevent and treat illness. Furthermore, I am satisfied that there is scope for rationalisation of services, for the redeployment of financial and personnel resources on an identifiable priority basis, for the dropping of wasteful procedures in the ordering and stocking of consumables and so on. It is also, for example, obviously all too easy in many instances to gain admission to hospital and there is an indiscriminate use of diagnostic facilities which must be eliminated. We must from now on continue the systematic streamlining of the services and elimination of inessential uses so that the efficient and vital elements will continue and even be developed by the reallocation of resources. I have been involved in the current year in a number of closures, for example Teach Ultain and Mercer's Hospitals have closed. These were, I might say, hospitals which is the past served the community well but had outlived their usefulness in terms of the requirements of modern medicine. Trim and Dungarvan maternity units have been closed in the interests both of the safety of mothers and children and of the valid use of resources. Bantry maternity unit could not be continued as an in-patient obstetric unit because it would not be possible to appoint the necessary consultant staffing in the light of the likely user of obstetric services. This process will, of necessity, have to continue because it is clear that this country could not, in the light of economic circumstances which are likely to obtain for some years ahead, afford the apportionment of a greater share of the gross national product to the health services. For that reason, I have avoided making what I would call rash promises. In fact I spent a good part of the year trying to clear up the mess which I inherited of so many party political promises in the area of health made for the most part by my predecessors, my immediate predecessor in particular.
Rationalisation could not, I accept, be expected to be achieved if there were no resources made available to improve the health capital infrastructure and I am therefore glad to be able to say that I have obtained a capital allocation of £55.5 million for the coming year which will enable me to keep major capital programmes of improvement of facilities on stream — the total value of the projects currently before me for consideration is no less than £520 million. I have completed a review of the programme in a medium term five year context and the allocation for 1984 enables me to build or to continue planning all of the projects which I consider essential to maintaining the fabric of the health services. The programme has a greater number of projects in it with a realistic prospect of financing to completion because of the rigorous in-depth examination of all projects I have undertaken and of the pruning from projects of all but basic essential elements.
Accordingly, the planned rationalisation of the general hospital scene with its concentration upon the development of six major hospitals in the Dublin conurbation would enable the closure of obsolete facilities in the Dublin area as a result. The hospitals around which our plans now centre in Dublin are St. James's at Tallaght, St. Vincent's, James Connolly, Blanchardstown, the Mater and Beaumont hospitals. Elsewhere in the country the work of planning and building as appropriate will continue at, for example, Letterkenny, Tralee, Sligo, Castlebar, Mullingar, Ardkeen, Wexford, Kilkenny and Ennis General Hospitals. Unfortunately, I am precluded from referring to Cavan hospital, much as I would wish, but I can assure the House that that matter has not been forgotten.
On the mental handicap side, major developments at Cheeverstown, Swinford and Loughlinstown will be funded. Developments as in the case of Enniscorthy will be planned for inclusion in the programme at a future date.
The schemes of upgrading the accommodation and other improvements in psychiatric facilities will be continued, as will the provision of accommodation for geriatric patients of which St. Oliver Plunkett Hospital in Dundalk is probably the major example.
In line with the policy of developing community facilities, the 1984 programme provides for the replacement and/or provision of health centres, day care centres, hostels and clinics throughout the country.
The 1984 programme also provides for the development, in service areas in particular, of paediatric and orthopaedic services. A feature of the programme also is the continued provision of an allocation for the replacement of essential equipment in hospitals.
The promotion of community care is now generally accepted as a priority by all Governments. While the evidence suggests that it is in fact very difficult to bring about a significant change in the structure of health care, I am not, however, discouraged by this. I believe that there is a basis for optimism in the fact that we have a very well developed network of services within the community. For example, our traditions of general medical practice are widely respected and the general practitioner plays a very significant role as the point of first contact in most episodes of illness. We also have an administrative structure within our health boards which has the capacity to focus upon the needs of individual communities and to combine the range of services and facilities which are required at community level. Finally, we must all be greatly heartened by the evidence all around us that families, relatives and neighbours continue to provide a very effective informal network of care in the community. I am not suggesting that all is perfect in regard to these services or that they are available in sufficient quantity relative to need. I do believe, however, that they constitute an effective foundation upon which future policy can be built.
There is a substantial and growing body of evidence available internationally which demonstrates the real potential of community care services in meeting health needs. For example, trends in the provision of care to the mentally ill and the mentally handicapped demonstrate that all of those professionally involved in these services are convinced that the appropriate way forward is to promote normal living within the community with adequate support services. The emergence of a strong professional consensus in so many disciplines in respect of promoting care within the community is very encouraging.
Another factor which leads me to conclude that community care will receive a much heightened role is the pressure which our present economic difficulties places upon all of us involved in decision-making in the health care area. We now have to examine very carefully the rationale for existing services and policies which were introduced many years ago in very different circumstances. I am convinced that all of those involved in health care will be forced to the conclusion that our only hope of preserving and improving the health status of our population will be by a well-planned health care system which emphasises personal responsibility for health care, prevention of avoidable diseases and a restriction of specialised and institutional care only to those whose needs cannot be adequately met elsewhere in the community.
The practical implications of the issues which I have raised are now being carefully examined. For example, a review of services for the mentally ill has been in progress for some time and involves representatives of all those involved in the provision of services. A working party is reviewing the operation of the General Medical Service and, in particular, the role of the general practitioner in the context of a strengthened framework for community care. I look forward to receiving in the near future the results of both of these reviews which will go far towards putting in place the practical arrangements necessary to achieve effective community care. I intend to elaborate on my views on these issues in a Green Paper on the future of the health services which is now in course of preparation. However, at this point I can say that there are a number of steps which I believe must be taken, as a matter of urgency, in order to develop our community care services.
In the first instance, we must increase the level of resources available to services in the community, in particular through the up-grading and provision, where necessary, of appropriate premises in which these services can be made available. Therefore I shall be paying particular attention to capital investment in these community facilities, over the coming year.
We need also to have more effective collaboration between general practitioners, the medical and nursing staff of health boards and those engaged in the provision of personal social services. These are issues which are receiving particular attention from the Working Party on the GMS. They have also been raised in the course of the review of community care structures which are initiated some time ago. A related issue, that of the relationship between voluntary and statutory bodies in the delivery and planning of care, was raised in a discussion document from the National Social Service Board sometime ago also. The main priority in this area is that we get the many skilled and caring professional and other staff operating as an effective team at local level so that all opportunities for prevention and early cure are taken.
The third priority I propose in relation to community care concerns public perception of health and health care. We must inform the public — indeed we must inform ourselves, as political leaders — of the full significance of community services and the over-riding importance of their development. I must confess, in that regard, I am appalled — as one who has learned a great deal very quickly — at the abysmal level of ignorance within the Houses of the Oireachtas in terms of a perception of health care. There is an absolute obsession amongst Deputies and Senators with hospitals, with structures, with buildings, with beds, as though they were the equivalent of health. Health in the community is something quite often very different from that. The intensity of feeling often evoked by a decision to rationalise a local institution is indicative in many respects of our general lack of understanding about health in the community and the causes of illhealth about which most Deputies do not want to know. If I am critical in that regard it is because my ignorance also was profound until relatively recently, and I have been 14 years in the Dáil. Therefore I join the company in terms of retrospective ignorance in that regard.
Lest it should be thought that I am concerned only about the future of community care I should like to give the House some indication of the practical steps that have been taken in the current year. For example, this year we distributed £500,000 which had been made available to me through the Social Welfare Vote to help community-based projects. Altogether I found it possible to aid about seventy different local voluntary initiatives, mostly concerned with the elderly, the disabled, children and young people. I would also remind the House that the various health benefits such as the disabled persons maintenance allowance and the constant care allowance payable to the mothers of disabled children were increased by 12 per cent last July.
I have been giving particular attention to the needs of children requiring care. As Deputies know, there was in the past a regrettable practice of keeping children who had to be taken into residential care in large institutions, sometimes a considerable distance from their native area. We have been moving away from that situation for some time now towards a position in which children's homes generally are more domestic and localised in character. This year I have been able to give that movement a considerable push by offering to pay off the debts which have accumulated in these homes over the years, on the understanding that the homes will operate in closer association with the health boards and are clearly seen as an element in the local community services for children.
I am happy to say that the religious orders and other groups operating these homes are themselves most anxious that their services should continue to evolve in that way. I would emphasise that I envisage fewer children being taken into children's homes generally. The basic philosophy of our child care services is that the best place for a child is in its own home and that where families are at risk and at a disadvantage, we must at all times do our best to keep them together.
Finally, on the health side I might mention that I am preparing a difficult and complex Children's Bill and making considerable progress on that at this stage. I hope to have the Bill before the House early in the New Year. Likewise I intend to bring forward proposals for changes in the adoption laws. At present I am awaiting a report of a special review committee I expect to have early next year. On the question of public perception of health and of health care generally, the Health Education Bureau is at work. I am continuing to encourage their work and have no doubt that, under their chairman, Mr. Donal O'Shea, during the year they will initiate campaigns which will make us look somewhat more critically at our lifestyles, helping us realise that, where good health is concerned, the main answer lies in people themselves rather than in multi-million pound hospitals throughout the country.
That, then, is the situation regarding our health services. It will be very difficult during the coming year. For example, we have had to take a number of difficult decisions. There is, for example, the withdrawal of medical cards from students who are not already dependants of medical cardholders. In that regard I might stress that, of course, students will continue to be entitled to free hospital services, including the services of consultants, lest there be any misinterpretation of that. In the very near future I will be issuing, within a matter of days, revised guidelines in relation to medical card eligibility. These guidelines are currently under discussion and a decision in that regard is imminent.
May I make a few comments regarding the Social Welfare Vote. As Deputies know there were increases in the budget provision in the middle of 1983. I do not propose to comment on those except to say that recently in relation to the Supplementary Estimate I had to provide a further £20 million to meet the additional unemployment benefit and associated pay-related benefit costs. I had to provide money also for the double week payment at Christmas as this was not provided for by my predecessors in 1982 when they were preparing the budget for 1983. In addition, I had to meet the cost of the 5 per cent increase in October for those on long-term unemployment.
The Estimates just published for 1984 show that the Exchequer cost of supporting the social welfare programme will be in excess of £1.185 billion. The balance of more than £900 million is borne almost entirely by employers and employees by means of their PRSI contributions. These figures show the huge scale of social welfare expenditure which amounts to more than 14 per cent of GNP. I strongly repudiate any comment that these facts are indicative of cuts in social welfare spending.
I would point out that the 1984 net Estimate of £1,185,354,000 is based on the current rates of payment. It does not include any provision for budget increases in 1984 nor for a double payment at Christmas next year. These are matters that will be considered in the context of next year's budget.
Payment to the unemployed in 1984 by way of unemployment benefit, pay-related benefit and unemployment assistance are expected to amount to £105 million more than in 1983. This depends on the unemployment situation not going beyond what we have calculated. For every extra 1,000 on the live register the cost in terms of benefit and assistance payments is £2.4 million per year.
There has been a lot of alarmist talk and nonsense about cut-backs in social welfare. In 1984 the total cost of unemployment payments is expected to reach £559 million. This will be made up of £325 million for unemployment benefit including pay-related benefit, and £234 million for unemployment assistance. That is £105 million more than for 1983 without taking into consideration any budget increase.
I wish to pay a particular tribute to the excellent staff in the Department of Social Welfare. They are working under very considerable difficulties. We have a very minor number of extra staff but these extra people are required to process the increased numbers of claims, a factor which is putting tremendous pressure on existing resources. However, the staff have coped with this situation very competently and with dedication.
The estimated income of the Social Insurance Fund by way of PRSI contributions in 1984 is increased. The estimate is on the basis of current rates in contributions and on the current ceiling of £13,000. The figure of £853 million for 1984 is an increase of £91 million over the expected outturn of £762 million for 1983.
Regarding pay-related benefit, the floor taken into account in determining the amount of pay-related benefit to which a person is entitled is £36. The original floor which was set in 1974 was £14 and it remained at that figure until 1981 since when it has been increased regularly. It is of interest to note that if the same basis was used now as that which applied when the figure of £14 was decided, the floor would be £87. But I do not propose introducing such a drastic increase. However, in continuation of our recent policy, in order to bring the floor more into line with current benefit levels, I have decided to increase it from April next by £7 to £43. I emphasise that it will apply to all new pay-related benefit claims which arise from April 5 next. The saving in 1984 will be £2.8 million. This saving cannot by any assessment be described as a major cut. In 1983 the Estimate provision for pay-related benefit was £48.7 million in respect of unemployment benefit, £20.5 million in respect of disability benefit and £6.7 million for maternity allowance, making a total of £75.9 million. In 1984 the total Estimate provision will be £88 million for pay-related benefit as against £75 million in 1983. It is in this overall context that one must consider this relatively minor adjustment for new claimants.
Likewise, in determining the maximum amount a person may receive by way of disability benefit any pay-related benefit, a wage stop is applied. At present, this operates to limit the aggregate amount of disability and pay-related benefit to 80 per cent of a person's reckonable earnings in the relevant tax year. In order to bring about a more equitable relationship between take-home pay and income while in receipt of benefit I am reducing the 80 per cent wage stop to 75 per cent. This also will apply from April next and will result in a saving of £380,000 in 1984. I wish to make it clear that only the amount of pay-related benefit a person on disability benefit receives will be affected by this measure. His flat-rate disability benefit will remain unchanged. I would stress that in 1983 we spent no less than £20.5 million on pay-related benefit for disability benefit.
I intend making a minor change in respect of the maternity allowance scheme. As part of the Second National Understanding for Economic and Social Development, it was agreed that a maternity allowance scheme would be introduced for women in employment. The scheme was brought into operation in April 1981 and the details were worked out with representatives of employers and employees. The purpose of the scheme was to ensure that women would be compensated fully for loss of earnings after all deductions. The formula devised at that time, taking account of tax and other deductions, allowed for payment of an allowance amounting to 80 per cent of reckonable weekly earnings. It is evident now that because of changes which have occurred in the meantime in tax and other deductions, the original formula can provide levels of benefit which are very much higher than those that were intended originally. They are now in the region of 114 to 120 per cent in terms of the original Second National Understanding Agreement. Accordingly, I am taking steps to deal with the anomaly by reducing the maximum to 70 per cent of reckonable earnings from April next. As a consequence of that change the minimum payment of £64.88 will remain at that figure for 1984. These changes will result in a reduction in expenditure of some £1.13 million in 1984. I should like to stress, however, that women benefiting under the scheme will still receive the equivalent of their normal net take-home pay.
In regard to old age pension committees, I should like to tell the House that I have been examining their function for some time. I am sure all Members agree that those committees at local level have long outlived their usefulness. They have been operating since 1908 with no statutory functions as such and, as they are no longer necessary in the context of a modern social welfare system, I do not propose to continue them next year.
I have been in office for one year and I have found it an extremely difficult one spending as I do not less than £2,000 million of public funds. Whenever I spoke to the Taoiseach, or the Tánaiste, I was always confident that I had been dealt with in an honest and open manner by them. They have shown me at all times absolute honesty, frankness and honoured assurances on agreements reached. I have been proud to serve Garret FitzGerald and Dick Spring as a member of the Cabinet and deputy leader of the Labour Party. Looking at the files of my Department, and Government files, during the past 12 months I know I would not have enjoyed the same honour had I served in a similar post under the Leader of the Opposition. That is more than one good reason why I should support the Government and continue to do so in 1984.
