Deputy Conaghan, and he has ten minutes.
Private Members' Business. - Health Services: Motion (Resumed).
The following motion was moved by Deputy O'Hanlon on Tuesday, 20 November 1984.
That Dáil Éireann condemns the cutbacks in the Health Services and calls on the Government to take immediate steps to provide the necessary financial assistance so as to restore the standard of general medical services and of patient care to the levels which have hitherto prevailed.
Debate resumed on amendment No. al:
To delete all words after "Dáil Éireann" and substitute the following:
"notes that the Government has continued to provide an excellent standard of health care within the allocation of £986 million for 1984 and will continue to do so within the allocation of £1,019 million for 1985, £1,078 million for 1986 and £1,123 million for 1987."
— (Minister of State at the Department of Health)
I would like to put on record that the present position in relation to the health boards and the allocations that are being forwarded now to them indicate clearly that the boards will find themselves in severe difficulty over the next 12 months. The unfortunate situation as I see it, as chairman of the North Western Health Board, is that the unfortunate people who are going to suffer as a result of the present economic problems facing the health boards are the poor and underprivileged. The cutbacks of £30 million in the 1984 allocation to the eight health boards will not be met, and it is clear now that a target of only £20 million will be met, resulting in a £10 million overspend by the eight health boards which will have to be met out of the 1985 allocation. The 1985 allocations are cut by 2 per cent and the effect of that together with the 1984 overrun will be a collective shortfall of £37 million or 5 per cent in 1985. This will create great difficulties for the boards.
For the Minister to claim that we can have reductions in money allocations and that on the other hand we can increase services is stretching the imagination. In 1984 the boards endeavoured to comply with the money allocation given to them and the resulting £10 million shortfall over the eight health boards which must be met out of the 1985 allocation means that over the next two years this ongoing reduction in the money allocation is bound to result in cutbacks in services, closing of hospital wards and a lesser degree of health services to the communities which the boards serve. It is not fair that the Minister should endeavour to suggest that increased services can be given for decreased moneys. He must recognise that the boards had endeavoured over the last two or three years to cut back on what one would consider unnecessary spending. This cannot go on indefinitely and the effect of it must ultimately be the laying off of staff, closing of hospital wards and reduced services.
The health boards face a problem in relation to their allocations. Let me refer to the Road Traffic Act decision, the increase in PRSI, the delay in social welfare payments and the withdrawal of food subsidies, all of which in turn have had an adverse effect on the financial aspects of the boards during 1984. No recognition whatever was given by the Minister in relation to giving extra remuneration to the boards in order to compensate for these unforeseen cutbacks or shortfalls in 1984. The Road Traffic Act decision taken in the High Court means that people involved in road accidents are now eligible for full health services in the health board hospitals, and no claims are being made against insurance as was the case heretofore when the insurance companies paid up for the hospital bills. That is no longer legal and the boards are faced with these problems and they will receive no rebate from the insurance companies. Also there was no compensation for the increase in PRSI last year. The withdrawal of the food subsidies also had its effect. All these have resulted in the boards not being able to live within their allocation during 1984. They face 1985 with a shortfall and the problem of the moneys not being available to meet the services.
How can the Minister say that the boards have ample resources? Cuts have been made in ongoing services each year since 1981. We have a cut of over 5.5 per cent in 1984 and we will have a further cut of over 5 per cent in 1985. Further similar cuts are projected for 1986 and 1987. These cuts are so high that they cannot be achieved without cutting services and shedding staff. It is not helpful for the boards in the very difficult job they face to inform the public and the staff that the boards have ample resources. It is essential that the Minister say now openly and clearly that real cuts have been made in health funding, that further cuts are being made and that the quality and quantity of services will be affected. It is time for the Minister to face up to this situation.
As chairman of a health board dealing with the board over number of years, I see the problems now facing the administrative staff of the board. They will have problems with the people who are operating the services. Nobody wants confrontation with the people who are responsible for carrying out services of the health boards. Therefore, in order to avoid this situation, which is bound to crop up if the Minister pursues the course he is on at present and which is going to create terrible problems for the community the boards serve, the Minister should look seriously at it.
In the document Building on Reality the Minister indicates that there are areas where he can make savings and collect moneys. He says that he can save £2 million in the GMS. How can this be done? No indication is given. Is it to be done by the doctors or will there be a cutback in medication supplied to the patients concerned? If the cutback in consultant's fees is to be introduced I hope that we are not going to level that charge on to what we know as the new poor. If this is done as indicated in the plan it will mean that that charge will go directly to the people whom the consultants are attending, therefore it will have no effect whatsoever on the consultants. The people who will have to avail of the service will have to pay.
The Minister has indicated that he is concerned about the mentally handicapped. I appeal to him that if that is so he must provide the moneys to implement the communty services that are needed by the mentally handicapped in the various health board areas. This is an area where the Minister must take action and provide health boards with sufficient money to enable them introduce these community services. Fianna Fáil have a record of building up community services within the eight health board regions. With regard to the care of the aged they were responsible for introducing the best community service in Europe. I hope that continues but, unfortunately, the indications are, following the Minister's meeting with the chairmen and CEOs of the eight health boards on Friday, that there is no great prospect of that. That will have a disastrous effect on those who avail of those services.
I appeal to the Minister that before he meets those chairmen and CEOs in January he will rethink the various aspects of the proposals be put before the boards. He should recognise the attitude of the chairmen who met him. The Minister should have a rethink of his attitude as to how the boards should be run within the funds allocated by him. Clearly that money will not be adequate to keep the health service going. There is no point in fooling the public and saying that the boards can give a better service than before. This amounts to the biggest confidence trick played on our people and I am surprised that a Labour Minister is guilty of attempting to foist it on our people.
Yesterday evening the House was given a comprehensive overview of the performance of the health services in the ougoing year, 1984. The House was also provided with quite a detailed prospectus for the future of those services over the next three years 1985, 1986 and 1987, under the aegis of the decisions arrived at in formulating the framework of the national economic plan, Building on Reality.
One of the most striking features of the health services here over the last 20 years has been their rapid evolution into a highly modern and sophisticated service from much humbler origins in the sixties and fifties. Of course, as observed in so many other developed Western countries, progress has been accompanied by particular problems. Principally, the intrinsically expensive cost nature of health services has tended to intensify, apart altogether from any consideration of general inflation and price movements. Nearly all inputs to health services are costly. Most staff need to have a very high level of basic skills to begin with, and the technological revolution in medical care over the last ten or 15 years has demanded the recruitment of yet more skilled and often highly specialised staff to provide services. The services are, by nature, demanding on the pay costs side as regards the numbers of staff needed, the type of staff needed and the presence of certain unavoidable elements of staffing outside of normal 9 am — 5 pm hours.
In addition, of course, non-pay costs have escalated as well with the introduction of high technology items of equipment which have very significant acquisition, maintenance, operational and replacement costs.
It is widely recognised, both within and outside the health services, that this country has in recent years already reached the maximum upper limits of what we can afford to spend on health services, given our size, population and level of material wellbeing and wealth generation as witnesed by indicators such as GNP.
Inevitably, this realisation, and the need to act responsibly and with maturity in tackling the consequences that flow from it, gives rise to problems. A health service, which for so many years had tended to look upon the unprecedented real growth in the financial and personnel resources made available to it, as no more than its fair due, now finds that the era of boundless growth has ended, as indeed it has ended for public expenditure generally, not only here in Ireland, but throughout Europe.
The readjustment which is now called for in response does not merely involve the much maligned exercise of book balancing, rather, it places greater emphasis and, lets face it, greater strains on the managerial capacity of those charged with administering and managing the health services. The readjustment is psychological also.
Roughly speaking, non-capital expenditure on health services will have to be marginally reduced in real terms over the course of the next few years. This implies that the health agencies themselves will have to become very involved in the construction and implementation of many and varied cost saving initiatives.
Indeed, more generally, each and every aspect of service provision must henceforward be subject to an educated, informed and rational critical appraisal. Many would argue that this exercise is long overdue in any case, and it is long overdue, and that the current severe economic difficulties which we face as a people may yet serve a useful and productive purpose.
There are three major essential headings which call to be discussed in the context of health costs over the next three years. The first is the need to reduce and to eliminate all significant areas and practices of waste and inefficiency within the services. That should be done in regard to all services, health and local authorities. It is long overdue. We must remember that we are spending taxpayers' money. Taxpayers have reached the limit of their patience and are demanding real value for their money. As far as we are concerned they are going to get it. It is easy for the Opposition to suggest the spending of more resources. We can all fall into that trap but the provision of the necessary finances is the problem. Where is the extra money to come from? Where are the cuts to be made? There must be a balanced approach to this. Any person who looks at what is happening in our health services will see that the schemes will operate in a balanced and orderly manner.
The Government should try to collect the unpaid taxes.
We will.
I understand that Revenue are 500 staff short.
The second essential heading is the need to examine the contemporary raison d'être of services, programmes and individual institutions, in order to ascertain the degree to which real human needs in the community are being met in a positive, efficient and effective way.
Finally, decisions must be taken identifying clearly priority areas which must be protected and strengthened to the extent that resources and their redistribution permit and unambiguously setting out practices and services which serve no real need, which are uneconomic and inefficent and which continue in operation due to tradition more than to any rational criterion.
In the recent past the Department, with the co-operation of relevant agencies, have embarked upon a number of in-depth studies of particular aspects of health services provision. These studies have focussed on aspects such as cost efficiency and comparative costings as between comparable institutions and services in different regions. I was in the Department of Health for a short time and I was surprised to see the difference in figures between one institution and another. It was an eye-opener.
Cost efficiency studies already undertaken in a number of areas in the general hospitals sector have ranged over purchasing, heating-lighting, housekeeping and transport. Further cost efficiency studies are now being undertaken in the area of hospital admissions policy, the excessive use of hospital laboratory services and arising from these studies, an examination is under way into the potential of five-day wards and indeed day beds as a real alternative to traditional practice for the many persons who do not require total continuous hospitalisation, but yet who find themselves subject to long and inconvenient stays in hospital at present.
I do not think anybody could argue with that. I was listening to the radio yesterday and somebody was talking about the five day hospitals and ridiculing it, saying people cannot arrange to get sick on a five day week. We are well aware of that but a number of routine things can be done on the basis of a five day week. We should not bring people in on a Friday afternoon to lodge them over the weekend, taking up beds and imposing on staff when it could be done in that way. That is basically what we mean when we talk about a five day hospital. Of course there is a need for continuous hospital attention, but we must look at the other side of the coin. This move is long overdue and when we go into it in greater detail, we will see the merits of such a move and the savings that can be made.
These new initiatives are not an academic exercise. The findings which emerge will be of considerable significance for the future of the services. Already, useful and practical recommendations have emerged from these types of studies and have been communicated to the executive agencies in terms of principles of good practice.
It may well be possible in future to set down criteria for admission of persons to hospital in order to eliminate the great bulk of unnecessary admissions. I have no doubt that many other diverse elements of expenditure in the health services will need to be subjected to further studies in the future.
In the area of comparative costing the Department have made available to various hospitals data as to how they compare with similar sister hospitals as regards costs and prices, etc. This type of information will hopefully help agencies to identify particular areas of weakness in their own operations as regards financial performance. It is also intended to develop and to refine these comparative cost data as an integral part of the accelerated movement towards greater value for money in the health services.
Who can deny the philosophy of the value for money? I do not think anybody can. Like many other services, the health services grew fat when we borrowed too much, but now when we have to be prudent and to pay our way, and help the beleaguered taxpayer and assure him that we are not going to mulct him further, we are making this move.
It is absolutely essential, in addition, that there be readily available detailed information and data on the financial consequences of decisions taken by the medical profession. We need to identify clearly the expenditure involved in treating individual patients and specified categories of patient, categorised by specialty or otherwise. The new management information system currently coming on stream, will be extremely useful in this regard by providing ample opportunity and scope for the introduction of much more sophisticated costing systems. Again, this highlights that this is the way to do it.
In particular, a pilot project on specialty costing has already been established in a particular hospital. Hence, it will be possible to determine very accurately the level of financial resources required to support each consultant. Arising from this, it is anticipated that clinicians will become more acutely aware of the fact that medical responsibility must encompass a broader financial cum managerial aspect, as opposed to a strictly medical role which is fulfilled without due regard to cost parameters. One cannot argue about that. The people must be aware, and the specialists in particular, that there is a cost element involved and they cannot continue reaching for the moon because this has been the tradition.
It will be necessary to press ahead rapidly with the development of computer facilities which will facilitate the provision of reliable data on cost implications arising from de novo service developments or expansion of existing facilities and services, as well as the budgetary and output data which will be needed to establish budgetary responsibility at levels which are responsible for generating significant expenditure.
It is possible, although challengeable, that the growth of expenditure on health services over the past ten years has meant that there is much greater room for cost reduction and reallocation of resources than was previously the case. The need for this rationalisation of services will have to be achieved in two ways. First, as the national plan makes clear, we need to shift resources away from cost-intensive institutional services and towards the community services, which in the case of a substantial number of patients, is likely to offer equivalent, or indeed superior services overall at much lower cost to the taxpayer, and I believe a much more personal service to patients. Moreover, within the framework of the institutional services themselves, much needs to be done to streamline services by removing from service old, outmoded institutions which are no longer appropriate to the needs of a modern health service. Here again, the national plan faces reality.
It seems to me that there is an undue emphasis at the present time on the effect on our services of the levels of Exchequer allocation which it has been possible to provide. Our health services are, however, by international standards, extremely good. The past two decades and particularly the seventies have seen many advances in medicine, often involving the provision of new and expensive high technology equipment, and an increasing tendency towards specialisation in the practice of medicine.
These advances have expanded the scope of diagnosis and care. Some examples of the improvements in treatment which have occurred are as follows: open heart surgery; haemodialysis; joint replacement surgery, in particular, total hip replacement, which has given new life to many people who are suffering intense pain; intensive care, particularly neo-natal intensive care, where there have been major developments over the past 15 years. These developments have given new hope to many persons.
Developments in diagnostic techniques include computerised tomography which was introduced in the seventies and has had a major impact on the investigation of brain lesions and the detection of cancer; diagnostic ultrasound, now widely used in many specialties; endoscopy which has greatly enhanced the information available to clinicians on many internal parts of the body; and laboratory investigation, the range of which has expanded enormously.
At primary care level there have been a number of significant changes over the past decade in the services provided. The introduction of the choice of doctor scheme in 1972 was a major advance on the former dispensary system. The past decade has also seen a rationalisation and improvement of the public health nursing service. Both of these developments contributed to a substantial improvement in the quality of primary health care available to the community and particularly to the less well off sections of the population. Improvements in community care also favoured particular target groups — for example, the mentally handicapped and many psychiatric patients who can now be treated in the community rather than in institutions.
We can see over the past few years the way our health care service has expanded and the way our society has become so health conscious. When we hear criticism of our health service we wonder what people are talking about. Our hospitals and our services are first class. What is the great problem? Who is without health care?
Additionally, the scope of the health services has widened to encompass new services principally in the community care sector. A prime example is the increasing role of the health agencies in the provision of personal welfare services in the form of financial and non-financial supports for the relief of social stress in the community.
In commenting, therefore, on the large increases which have occurred in spending, this range of improvements should also be borne in mind. It is not simply an escalation of costs that we are talking about; it is a health service which has changed significantly in terms of the quantity and quality of the service it provides.
On the capital side there is much that is positive to report. The 1985 allocation is £58 million. The provision for 1986 will be £58 million, and the provision for 1987 will be £61 million.
This will be sufficient to meet the cost of the continued development and improvement of facilities. It will of course be necessary to align the pace and emphasis of capital development with the funds available. One good thing about the plan is that it sets out a three-year programme. We know what the capital programme will be and the agencies can fit in with the capital allocation that will be available rather than wondering from year to year how much they will get. That is the kind of planning that is long overdue. This plan will give us a better health service.
The priority development areas in the capital programme are: rationalisation of the acute general hospital services. In this context, developments undertaken will essentially replace existing outdated institutions, and facilities surplus to essential service requirements will be closed. There is no point in filling a building with beds just because it is there. An improvement in standards of facilities for psychiatric patients, the mentally handicapped and the elderly. The provision of facilities for the treatment and rehabilitation of drug abusers. The provision of further community health centres and clinics. The development of facilities for the physically handicapped. It is noteworthy that the 1985 capital allocation will provide construction work for an average of 1,750 people throughout the year. That clearly indicates the commitment of this Government over the next three years and the type of programme they are undertaking in a prudent and caring way.
I would urge all concerned to approach the future financing and organisation of the health services on a more constructive and optimistic note than has hitherto prevailed. Once there is any mention of the budgets coming out a number of health boards become paranoid about their existence. Of course they will continue to exist, but like any other operation they must exist within their budgets. Certain moneys are being allocated and they have a duty to operate efficiently within their budget. That is not imposing any hardship on the health boards but it is imposing a responsibility on them to manage well and to give a good and caring health service. It is scarcely too much to expect that with the goodwill and co-operation of all concerned the other side of the equation can be spelled out in the detail necessaay to produce a workable plan.
Having given the information as to what we are prepared to spend over the next three years on the capital side, it is a question right across the board of ensuring that the taxpayer is getting value for money. If we did not do that we would be irresponsible. We all recognise that taxpayers are being taxed to the limits. The Government recognise it and have to act accordingly. We are acting prudently and humanely and I am satisfied that our health service will continue to be excellent and that the people involved will give the same dedication and service they have always given.
Deputy Hyland has been allocated 15 minutes.
I welcome the opportunity to speak in this debate which was opened last night in a very reasoned and responsible way by our spokesman on health, Deputy O'Hanlon. Everyone who heard him will agree that his contribution was extremely fair, dignified and reflected not only the views of this party but also the concern and the worry of the vast majority of the Irish people, particularly the poorer sections of the community and the parents of young families who are most dependent on the health and social services provided for them by the State.
I support the view that there is a need for a regular review of all our services and, in particular, the cost of providing those services. I am honest enough to admit that health services are no different from any other service provided by the Government. As a member of the Committee on Public Expenditure it is my business to be interested in such costs and the benefits derived generally from the expenditure of taxpayers' money which was referred to on so many occasions by the previous speaker. It is entirely different when the Government decide for purely monetarist reasons to cut back on a service which is so basic to the health and survival of our people and on which the poorer and middle classes in society are most dependent.
The speech we heard tonight from the Minister is no different in content and in philosophy from the economic lectures we have been getting from the Government side of the House over the past two years. In recent months we have seen Government Ministers pursuing such courses and such action with almost sadistic pleasure, and with no attempt or obvious desire to monitor the social cost — I emphasise the social cost — of their decisions which are great, particularly when you relate them to the health and social services. There was no attempt to monitor or measure the economic cost of some of these harsh decisions in terms of job losses. The cost in job losses is not the only cost to the State. We have to try to gauge and to measure the social costs associated with the problem of unemployment when this philosophy is extended into the personal and sensitive area of health administration to the point where services are likely to collapse.
The Minister said the health boards were becoming paranoid about their inability to continue to provide services. They are not becoming paranoid. They are extremely concerned about what 1985 will bring in terms of their inability to cater for the health needs of their areas. They are concerned about the fact that many lives may be put at risk. I do not want to sound sensational but, if you speak to members of health boards, you find that they are concerned that the cutbacks could lead to essential hospital services not being provided for the people who are most dependent on them. When we have reached this stage in relation to health administration, this House must call a halt and warn the Minister of the inevitable outcome of his actions.
Regardless of what the previous speaker had to say it is a fact — and this is not a political statement — that health boards are not able to discharge their statutory responsibility to provide for the health needs of the people in their respective areas. If the Minister is in touch with the situation he must surely realise that. One is tempted to ask a question which was raised here last night by Deputy O'Hanlon. How much is the Minister in touch with the situation? Last night Deputy O'Hanlon read to the House two replies to questions tabled by him in the Dáil seeking information about serious deficiencies. In both cases the Minister's replies were seriously evasive which would tend to indicate that he is not in touch with the realities in his Department.
At a recent meeting some members of the Midland Health Board considered whether it would be more honourable for them to resign rather than to become whipping boys for the Minister or the Government. They debated at length and with great concern the inevitable result of undermining the services in the Midland Health Board area. On reflection — and they were right — they decided to stay together to resist in so far as they could the further consequences for the people in their area if the services were to be administered by the Minister or his Department. That is what would happen if the members of the board found it necessary to disband themselves. It was a responsible decision and, in the long term, it will bring the best possible benefit to the people they represent on the board.
I cannot understand what has happened to Government back benchers. Have they not conveyed to the Taoiseach and the Minister the realities as conveyed to them day after day in their constituencies? Have they too fallen the victims of this remote and totally insensitive Administration? In the Midland Health Board area the CEO and the board are faced with a further cut amounting in real terms to £2 million. The revenue allocation is £55 million from which unavoidable over-expenditure in 1984 and additional costs for the general medical services scheme have to be deducted, not to talk of the removal of food subsidies. So far this year, these have cost the board £26,000. The allocation must also absorb all price increases in terms of drugs and essential medical supplies. The Minister should know that this is an impossible task for the board, coming as it does for the third year in a row. It is tantamount to the closing of one of the larger hospitals in the Midland Health Board area, the closing of perhaps two geriatric hospitals there, or making redundant some 200 nurses. That is the extent and effect of the proposed cutback of £2 million. Members of this party on health boards have acted in a reasonable and responsible manner over the past two years. They have refrained from making political capital out of a service which is so personal and vital. They have resisted the temptation to organise protests, which were very much a part of the scene when this party were in Government. I would encourage them tonight to retain this dignified stance and let the public coolly judge what has been happening for the past two years to the services on which they are dependent and is going to become progressively worse in 1985.
Hospital staffs and employees of health boards have displayed a great willingness to maintain services under difficult conditions. Indeed, members of the public have displayed patience and understanding in relation to some of the cutbacks with which they have had to contend, over the past year in particular. By his continuing determination to run down the services, the Minister is now totally disregarding and ignoring this commitment on the part of doctors, nurses and health board personnel at all levels. I am inclined to ask, in conclusion, where is the social conscience of this Government which has been so vocally outlined by them in this House over the past two years? Where is the commitment to a healthier society, to which they referred in the recent so-called policy document for the next two years? The only commitment displayed in this House was the recent announcement to extend our licensing laws, to put young people more at risk in relation to alcoholism, drug abuse and shamefully, to use them for the purpose of extracting additional taxation in an area which no public representative should condone or promote. That is the situation in which we find ourselves tonight debating Deputy O'Hanlon's motion. I hope that the vast majority of the Members of this House, if they have any interest in or commitment to the social requirements of our community, will vote in favour of the motion which has been responsibly tabled and credibly debated by Deputy O'Hanlon and the other speakers who contributed.
Deputy Tunney, to conclude at 8.10 p.m.
Go raibh maith agat. It is difficult, with the time limitation, to express oneself fully on the question of the appalling cutbacks in our health services. One can take it that the adage which speaks of prevention being better than cure in all probability emanates from the culture or subculture of medicine. If that is so, I am afraid it is not being honoured in the Department of Health or by the Minister or Ministers of State.
We all know, in respect of last year especially, that there has been an appalling neglect of our people in respect of the medical care to which they are entitled and to which they had been accustomed under better and more caring Governments. Other speakers have dealt comprehensively, in the time available to them, with certain matters. I would hope, with your permission, a Cheann Comhairle, to substantiate what I say be referring to specific cases. Straight away I refer-to the position of the older people in our community. The present Government and their spokespersons are the best people I have ever heard for enunciating verbal commitments. They have a verbal commitment to everything that is virtuous, but a practical commitment to nothing except things that are negative. They talk about their commitment to the old aged and I give two instances.
Let us take the case of the old person who is not in need of direct medical attention and whose family are happy that he or she should be accommodated in one of our institutions. We all know that over the years the situation there was that when those people entered the institution they yielded up their old age pension book. The manager took from it a certain amount of money and returned to the people in question an allowance which was called comfort money. In the Eastern Health Board in 1983 that comfort money was £10.50. We know that since then the old age pension has been increased, but not one penny has been given to these people. They have been obliged on that amount to look after their personal needs in the area of laundry, toiletry, newspapers, nipping out for a drink, buying a box of matches and attending to those normal requirements. Remember that there was one famous Fine Gael Government that went down in history when the Minister took one shilling from the old age pensioners. This Government under the present Taoiseach — that man who was referred to today as being full of tenderness for Mrs. Margaret Thatcher, a lady who could do without his tenderness — is showing such tenderness to the old ladies of Ireland that under his Government the allowance which existed in 1983 has not been increased by one penny. Those unfortunate people are expected to attend to their normal comforts on the same money as in 1983.
Before they were elected, this Government boasted that they would provide what they called dental and opthalmic treatment for people. That has not been extended to any great degree, but again I stay with the elderly. Those elderly who are holders of medical cards were entitled, under our Government, to obtain free opthalmic treatment. I hope the Minister is listening, because I trust he will reply to specific cases being made to him and to his junior Minister and tell me how it is that, notwithstanding promises made, any medical card holder at the moment is unable to get opthalmic treatment, and has been unable to get it over the past two months. The Minister and his junior Minister will say that they have not cut back on any service, but they are not issuing any forms in respect of that service. Elderly people who are in urgent need of spectacles but who are unable to pay for them are groping around while the Government speak of their commitment. They give verbal commitment to everything that is negative. Likewise, married women with families must neglect their own teeth because of the failure of the Government to provide for them in that respect. That is the gratitude we show to those great ladies who work so hard to rear their children and who look after the children's dental care at the expense of their own. It is a measure of the commitment of this great Taoiseach who, according to today's papers, was full of kindness for the British Prime Minister, this Taoiseach who, we read, is such a kind man that he would not wish to offend the Prime Minister or cause her pain. He is full of tenderness, but what tenderness has he displayed for the women of Ireland who are going around with mouths full of bad teeth?
Did all this come about overnight?
I can give another instance which underlines the lack of commitment to the handicapped on the part of the Government. Last week I asked the Minister about a handicapped person in my constituency who up to September of this year was in receipt of both a mobility and a domiciliary allowance. He is in a wheelchair. Fortunately for him he married and he notified the Eastern Health Board accordingly in the hope, foolishly as it transpired, that he might thereby be entitled to bigger allowances. Instead, the allowances he was getting as a single man were removed. In reply to my question in that regard the Minister said that, because of the operation of a means test in respect of the two allowances in question, the allowances were withdrawn. This means that little Terry Boland in his wheelchair and newly married must, apart from all his other problems, suffer the embarrassment of trying to exist with his new wife without any allowances whatever. Neither the social welfare workers who are paid to look after such people nor the health board nor indeed the Department had the commitment to request the Minister for Finance to make the adjustment in the relatively small income of Mr. Boland's wife. That is a measure of the respect the Government have for the institution of marriage, not to talk about people. If this man had not notified the health board of his marriage he would have continued to draw both allowances. Likewise, if the lady had merely gone to live with him without marrying him, the allowances would have been continued. Where, then, is the evidence of the Government's commitment to the handicapped?
Last evening the Minister of State accused us of criticising without indicating what should be done. Is there a new concept that we are to have Government by Opposition? I would remind the Minister that the budget deficit is now one and a half times what it was when we were in Government and that borrowing has increased out of all proportion to what it was then. Why can the Minister and the Government not maintain the standard of service to those people who are ill? If they have not got the money for health services they must have it for something else. Their commitment to other requirements must be greater than to the one they talk so much about.
I have given as examples the situation of the elderly in our institutions whose comfort allowances have not been increased for the past year and a half. I have given the example of Terry Boland whose allowances have been withdrawn because of his having married a lady whose total income is about £75 per week and from which she must pay income tax and so on. I have given the example of the old age person who is to be found in any constituency in Dublin and who, under Fianna Fáil, was entitled to free spectacles but who is told now, having waited two months, that application forms in that respect will not be available for the next three months.
To prove my point about the Government's commitment only to what is negative, I will conclude by remarking that for the past year the Government, and especially the Minister for Health, appear to have a decided and practical commitment to the provision of condoms. Their attitude in this respect would lead one to believe that the non-availability of these devices free of charge is going between young people and their sleep. I know 99 per cent of the young people in my constituency. They can speak freely to me but I have not yet heard any of them complain about the non-availability of condoms. Instead, they are concerned that they have no employment, that there are no worthwhile leisure activities available for them. They are concerned, too, that their parents and their grandparents cannot get from the State the assistance to which they were entitled when Fianna Fáil were in office.
Week after week there are leaks from Fine Gael Party meetings and from the Government to the effect that the big question at the moment is whether condoms should be made available to people at 18 or at 16. Is this because the Minister is unable to keep open many of the maternity units? Are the parents of these young people concerned about the non-availability to them, free of charge, of condoms? How many young people are concerned about it? It is just a diversionary tactic taking emphasis away from the elderly who are in urgent need of medical attention and cannot get it; from the housewife who is in urgent need of dental treatment and cannot get it; from Terry Boland who in any Christian society would still be receiving his allowances; from the fact that the deficit is higher now than ever recorded, that the budget deficit next year will be higher than ever it was, that the borrowing is higher than ever. Yet the Taoiseach's concern is for the tender feelings of Mrs. Margaret Thatcher.
Our amendment deals with two specific matters. Its aim is to highlight the brazen hypocrisy of Fianna Fáil in putting down a motion demanding that health services be restored to the level which has hitherto prevailed. We have asked that the level be restored to that prevailing prior to 1982.
Apart from highlighting the inconsistency and brazenness of Fianna Fáil we wish to highlight the hypocrisy and inconsistency of the Government. This is precisely what they were demanding in October 1982. Tonight and last night Government spokesmen have been repeating practically word for word what the Fianna Fáil Government were saying in 1982. Fianna Fáil in Opposition tonight are demanding what the Coalition, then in Opposition, were demanding in 1982. If you change the names on the speeches you will have Tweedledum and Tweedledee, with very little to choose between them.
That is why our amendment has been worded in the way it is. Very few Government spokesmen have indicated that the budget for health services will be increased in the next three years. Of course they have not indicated that 3,000 jobs will be lost in the health services in that time. The loss of jobs will have a very dramatic effect on the standard of the services provided, particularly with our expanding population. It is fair to say that many services already have been pared to the bone.
The treatment we give to our sick, our handicapped and our elderly must be the yardstick by which we judge ourselves, and it is precisely those people who are affected by health cuts and by the manner in which the Government and previous Governments cut our health services. It is clear that there was an attempt to create two health services, a health service for those in the private area who can afford to pay and a basic service with long waiting lists for those who cannot afford to pay. It is fairly common for those who cannot afford to pay to have to wait from four to eight months for tests and there are two year waiting lists for dental treatment. A report from the Eastern Health Board gives a long list of the kind of waiting periods there are for dental treatment.
Various Government spokesmen have made the point that they have not got the money to provide health services, yet the report of the Comptroller and Auditor General announced that £3,500 million tax is uncollected. At the same time it is announced that in the Revenue Commissioners there is a shortage of 500 staff. The £3,500 million of uncollected tax is three and a half times the total cost of the health services in a year.
Therefore, I ask the Government and the Minister for Health, rather than pursue the financial management epic which they have developed, to set about ensuring that those responsible for paying tax would pay it as the PAYE sector are doing, and that those who should be paying their health contributions should have it collected. The Revenue Commissioners should be brought up to full strength to ensure that all outstanding taxes will be collected. Then perhaps we would not be here debating cuts in our health services.
We put down this motion because of our concern at the rapidly falling health care. Having listened to the two Ministers of State we are even more concerned because it appears to me that the Government do not know what is happening in the health services. Indeed the Government are uninterested.
I will make a few comments on Deputy Donnellan's contribution. He told us last night that all health agencies would be informed shortly of the level of permissible spending in 1985 and in the light of the funds that can be provided have to determine the measures that can be taken. That was told to us on Tuesday night. On Monday I was at a health board meeting and the CEO of the board told us that the board had been notified of the allocation for next year late on Wednesday, 15 November. Our allocation for 1985 will be £56.980 million, £1.5 million short.
It is obvious the Government do not know what is happening. Deputy Donnellan said last night that it is difficult to be precise at this stage about the extent of the problem. He was referring to the 1984 deficit. On Friday last the Minister for Health told the CEOs and chairmen of health boards: "On the basis of information supplied by the boards the deficit could reach £10 million". Last week somebody, somewhere, seemed to know the allocations which the health boards would be given and what the deficit would be, but this week it appears that nobody knows, that the allocations have not been made yet and therefore it is difficult to know at this stage what the deficit will be.
I have here a document called Building on Reality. It is a bound volume presented to Fine Gael and Labour Deputies and Senators. Not once in any of the paragraphs on health does it appear that there will be any hardship in 1985. There is not as word about the allocations being reduced by £37 million in the next few years; there is nothing about the two thirds of the vacancies that will occur in 1985 being left unfilled; not a word about the £45 million deduction from the payroll. In this document they admit there will be £10 million taken off the health board payroll each year and that £6 million will be collected from private patients using State hospitals and from consultants using equipment. I am totally confused as to where the Government stand on this serious issue of the provision of proper and adequate health services.
The amendment to the motion states:
To delete all words after "Dáil Éireann" and substitute the following:
"notes that the Government has continued to provide an excellent standard of health care....
Anyone who listened to the debate or to the two Ministers of State who spoke knows that we are not providing an excellent standard of health care. In regard to the excellent health care, ask the man who had his eyes tested and whose spectacles are now ready but who cannot get them until next year because the health board has no money to pay for them. Ask the young man I referred to last night who was bleeding from a kidney. His surgeon wrote to him saying they would have the investigations carried out as soon as possible. He stated: "As you are very well aware we have some problems with cutbacks in so far as 40 per cent of our beds in the GU unit are closed at present". Ask that man what he thinks about the excellent health service. Ask the doctor from the midlands who wrote to Our Lady's Hospital for Sick Children in Crumlin in seeking an appointment for a child. He was told: "Unfortunately in the absence of approval from the Department of Health of staff required to support the outpatient clinic it has been necessary to reduce from 1 May 1984 the extent of services available. We regret, therefore, it is not possible at this time to make the appointment you request". Ask the people in Wilton Hospital in Cork. Ask those who sit around for five hours looking at empty beds and who cannot get into them what they think about the excellent service.
An optician in the north-west sent me this letter:
Dear Sir, it is with regret that the above scheme has been suspended for the time being due to financial constraints.
That was the choice of optician scheme. Ask them what they think of the excellent health service. Not one of them would agree with the level of service that is being provided.
Last night we enumerated the problems that were created this year — the cutback in the number of beds available and the cutback in the number of admissions because wards were closed. As regards admissions a theme which has been running through the Minister of State's speech is that the Government are assessing methods of admittance and who should be admitted to hospitals. It is essential that the people who are qualified to decide who should be admitted should make the decision and not the Minister or the Minister of State. There has been a cutbacks on locums, on overtime and on overtime at weekends. Orthopaedic units have been closed and there are no knee joint or hip joint replacement being carried out in some of these units. There is an increasing demand for psychiatric services. There is an increasing demand for admission to hospital by the elderly. They cannot survive outside because of the total inadequate services provided for them both in health and social welfare. One psychiatrist told me that more people are coming to his outpatient clinic with depression and loss of confidence. That is the direct result of the Government's economic and social policy. I am convinced the Government do not know anything about it. Last week they knew about the allocation, this week they do not. Last week they knew about the deficit, this week they do not. That is how they operate.
While we are primarily concerned with the health services tonight the economy is being run in the same way. My colleague, Deputy Tunney, referred to the London summit and even there we find the same kind of attitude. We do not know where we are going.
Valuable equipment in many hospitals is not being used because the staff are not there to use it. Buildings are not being used. There are no staff in 14 mental handicap units, yet in the national plan we were told that development of mental handicap services was a priority. Community care services, dental services and opthalmic services have been reduced. Essential drugs have been removed from the list.
We have been told that next year two-thirds of the vacancies that will occur will not be filled. How can one run a health service if two-thirds of the jobs are not filled? How can one run an operating theatre if one is short of a nurse? That would put a life at risk. If two-thirds of the staff are dropped there will be a theatre but no operations. Some areas will be left with no services. This was stated in the document the Minister gave out last Friday. The same paragraph was read out by Deputy Donnellan last night pointing out that the criteria which applied throughout the Civil Service will apply to the health boards. In the Minister's Department there were three nurses and two vacancies occurred but neither was filled. If this is how the service is to be run there will not be any service by the end of 1985. The Government should rethink this.
As regards the reduced stay from seven days to five days Deputy O'Brien explained his concept of that reduction. It is obvious that people do not get sick on a five-day week basis. It would be ideal if we could arrange it that way. There is reduced locum coverage, substitution is to be eliminated and premiums to staff are to be done away with — in other words, there is to be no overtime. Advertising is to be eliminated. God be with the days when all advertising by health boards was to recruit staff. The latest advertisements are to inform the public of the services they can no longer provide. The reason they can no longer provide them is because the Government have given them an insufficient allocation.
The Government have statutory responsibility for policy and the health boards have responsibility to implement that policy. What can the health boards do? They cannot fulfil their statutory obligation. There are non-statutory services such as grants to voluntary bodies and home help. Are they to abandon these? The Minister told them last Friday to reduce sick leave levels to not more than 4 per cent. How do you do that particularly if there is a flu epidemic?
The Government have no concept of what is happening. Last week when the Taoiseach was speaking to the Simon Community he said that poverty in Ireland was now affecting groups of people other than those previously identified as poor. Insufficient and insecure incomes and poor housing were the more obvious aspects of poverty. At least the Taoiseach identified it but for the last two years he has not done anything about it. In fact, he made it worse. He created a new poor. Those who are above the medical card limit have to pay for school buses, drugs and so on. They now have to pay £28 for drugs before they get any refund. When the Government came to power the limit was £12. The means test is administered more strictly than ever before. I call on the Government to review the position. Their policies will create unprecedented hardship. It will become worse in 1985. I have no doubt but that throughout 1985 we will see the serious consequences of the way the Government are administering the health service.
It is significant to note that the Government had only two speakers, one last night and one tonight and that they did not use the time available to them from 8.10 p.m. to 8.15 p.m.. I would have liked if the Minister had come in and explained to us——
(Interruptions.)
Order.
There was Government time at 8.10 p.m. until 8.15 p.m.
Deputy De Rossa had that time.
How can the Minister explain that the Minister of State said the Government did not know what the allocations were at this stage, whereas the health boards have already been informed in writing what the allocation will be? The Government did not know what the deficit was, while the Minister was able to tell the chairmen of health boards on Friday last that the estimated deficit would be £10 million. Last night we were told here that it was not known at this stage what it might be, that an estimate of it could not be given.
You have plenty of money.
Come off the downhill course and back to reality and offer the people a proper and adequate health service; otherwise there will be tragedy in the coming years.
I am putting the question that amendment No. a 1 in the name of the Minister for Health be made.
Question put.
The Dáil divided: Tá 75; Níl, 69.
Tá
- Allen, Bernard.
- Barnes, Monica.
- Barrett, Seán.
- Barry, Myra.
- Barry, Peter.
- Begley, Michael.
- Bell, Michael.
- Bermingham, Joe.
- Boland, John.
- Bruton, John.
- Bruton, Richard.
- Burke, Liam.
- Carey, Donal.
- Cluskey, Frank.
- Collins, Edward.
- Conlon, John F.
- Connaughton, Paul.
- Coogan, Fintan.
- Cooney, Patrick Mark.
- Cosgrave, Liam T.
- Cosgrave, Michael Joe.
- Coveney, Hugh.
- Kelly, John.
- Kenny, Enda.
- L'Estrange, Gerry.
- McGahon, Brendan.
- McGinley, Dinny.
- McLoughlin, Frank.
- Manning, Maurice.
- Mitchell, Gay.
- Mitchell, Jim.
- Molony, David.
- Moynihan, Michael.
- Naughten, Liam.
- Noonan, Michael. (Limerick East).
- O'Brien, Fergus.
- O'Brien, Willie.
- Creed, Donal.
- Crowley, Frank.
- D'Arcy, Michael.
- Deasy, Martin Austin.
- Desmond, Barry.
- Desmond, Eileen.
- Donnellan, John.
- Dowling, Dick.
- Doyle, Avril.
- Doyle, Joe.
- Durkan, Bernard J.
- Enright, Thomas W.
- Farrelly, John V.
- FitzGerald, Garret.
- Flaherty, Mary.
- Glenn, Alice.
- Griffin, Brendan.
- Harte, Patrick D.
- Hegarty, Paddy.
- Hussey, Gemma.
- Kavanagh, Liam.
- Keating, Michael.
- O'Leary, Michael.
- O'Sullivan, Toddy.
- O'Toole, Paddy.
- Owen, Nora.
- Prendergast, Frank.
- Quinn, Ruairí.
- Ryan, John.
- Shatter, Alan.
- Sheehan, Patrick Joseph.
- Skelly, Liam.
- Spring, Dick.
- Taylor, Mervyn.
- Taylor-Quinn, Madeline.
- Timmins, Godfrey.
- Treacy, Seán.
- Yates, Ivan.
Níl
- Ahern, Michael.
- Andrews, David.
- Aylward, Liam.
- Barrett, Michael.
- Brady, Gerard.
- Brady, Vincent.
- Brennan, Mattie.
- Brennan, Paudge.
- Brennan, Séamus.
- Briscoe, Ben.
- Burke, Raphael P.
- Byrne, Hugh.
- Byrne, Seán.
- Calleary, Seán.
- Collins, Gerard.
- Conaghan, Hugh.
- Connolly, Ger.
- Coughlan, Cathal Seán.
- Cowen, Brian.
- Daly, Brendan.
- De Rossa, Proinsias.
- Doherty, Seán.
- Fahey, Francis.
- Fahey, Jackie.
- Faulkner, Pádraig.
- Fitzgerald, Liam Joseph.
- Flynn, Pádraig.
- Foley, Denis.
- Gallagher, Denis.
- Gallagher, Pat Cope.
- Geoghegan-Quinn, Máire.
- Gregory-Independent, Tony.
- Harney, Mary.
- Hilliard, Colm.
- Hyland, Liam.
- Kirk, Séamus.
- Kitt, Michael.
- Lenihan, Brian.
- Leonard, Jimmy.
- Leonard, Tom.
- Leyden, Terry.
- Lyons, Denis.
- McCarthy, Seán.
- McCreevy, Charlie.
- McEllistrim, Tom.
- Mac Giolla, Tomás.
- MacSharry, Ray.
- Molloy, Robert.
- Morley, P. J.
- Moynihan, Donal.
- Nolan, M. J.
- Noonan, Michael J. (Limerick West).
- O'Connell, John.
- O'Dea, William.
- O'Hanlon, Rory.
- O'Keeffe, Edmond.
- O'Kennedy, Michael.
- O'Leary, John.
- Ormonde, Donal.
- O'Rourke, Mary.
- Reynolds, Albert.
- Treacy, Noel.
- Tunney, Jim.
- Wallace, Dan.
- Walsh, Joe.
- Walsh, Seán.
- Wilson, John P.
- Woods, Michael.
- Wyse, Pearse.
Tellers: Tá, Deputies Barrett(Dún Laoghaire) and Taylor; Níl, Deputies V. Brady and Barrett (Dublin North West).
Question declared carried.
Amendment No. 1 may not be moved.
Motion, as amended, agreed to.