Supplementary Estimates, 1985. - Vote 47: Health. – Dáil Éireann (24th Dáil) – Friday, 13 Dec 1985

Supplementary Estimates, 1985. - Vote 47: Health.

Minister for Health (Mr. B. Desmond)

I move:

That a supplementary sum not exceeding £13,375,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1985, 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 original net Vote for Health for 1985 was £1,070,828,000 including a capital provision of £57 million. The components of the Supplementary Estimate are as follows:—

	£(M)
Special pay awards not reflected in the original Estimate for 1985	8.875
75 per cent bonus payment in respect of certain cash allow ances	1.000
Provision towards additional needs of the General Medical Services (Payments) Board	2.000
Shortfall in Appropriations-In- Aid	1.500
Total	13.375

The special pay awards relate to a considerable number of grades including doctors employed in the general medical services, administrative and para-medical staff. As regards bonus payment in respect of cash allowances, as already announced, a bonus payment in respect of certain social welfare benefits and allowances administered by the Department of Health is being paid in this month. The health allowances included in this arrangement are the disabled persons maintenance allowances, the infectious diseases maintenance allowances, blind welfare allowances and domiciliary care allowances in respect of handicapped children maintained at home. The extra provision of £1 million sought will bring the total provision for cash allowances administered by the Department of Health to £62.95 million. As in the case of the bonus payments for Christmas, it has never been the practice to make provision for such amounts in the Estimate and it is customary at the end of the year to bring in a Supplementary Estimate, as happened in the case of Social Welfare, for £21 million and this £1 million is part of that sum.

The extra provision for the General Medical Services (Payments) Board sought is £2 million. This, together with the provision needed for the special pay awards to which I have already referred, will bring the total provision for the General Medical Services (Payments) Board in 1985 to £98.745 million. The extra provision sought is required to enable the cash needs of the board to be met in 1985. The increase in expenditure on general medical services is a consequence of an increase in the visiting rate.

The increase in the visiting rate in the GMS in 1985 is a matter for concern. Visiting rate for 1984, at 6.12 was already quite high. It is likely that the visiting rate for the current year 1985 will be approximately 6.4. In addition to the costs of doctors' fees, there is the important cost of drugs prescribed at these more frequent consultations. The rise indicates the open-ended nature of the scheme, which is at variance with virtually every other health service.

Proposals for changes in the GMS have been under negotiations with the Irish Medical Organisation for the past year. The proposals derived from the report of the working party on the GMS, which provided a comprehensive review of the service and how it might be changed to the advantage of doctors, patients and the taxpayer alike. Essentially, proposals would entail providing incentives for doctors to see patients less frequently but for longer and more meaningful consultations. As a consequence, it would be possible to curb the cost of drugs and apply the savings to the development of general practice. Given the shortage of funds this is a rational way of ensuring that the best possible service is provided.

I am very disappointed that the discussions with the IMO have as yet not reached a conclusion. The trend in activity and expenditure in the GMS demonstrates that we cannot be satisfied to leave the present scheme unchanged for very much longer. The sense of urgency which one must attach to these talks will be conveyed to the IMO at the next meeting with representatives of my Department. It is not unreasonable to aim to know with some precision, the level of expenditure that will be required for an important service such as this and to aim to channel the resources so ear-marked into activities which yield most benefit for patients.

The shortfall in appropriations-in-aid arises from the net effect of an increase of £1.7 million in receipts from health contributions and a shortfall in receipts under EC regulations. A sum of £30.985 million has been drawn by the Department from Vote 49 to meet 24th round pay expenditure.

As regards the overall Exchequer expenditure on Health Services the original Vote provision for 1985, together with the amount drawn from Vote 49 and the supplementary sum now being sought, will bring total Exchequer provision for Health in 1985 to £1,115.188 million.

In 1971-1972 net non-capital expenditure on health services amounted to £86.6 million, representing 4.54 per cent of GNP. The net non-capital expenditure level for 1985 which can be supported by the total Exchequer grant provision already provided, including the draw from Vote 49, together with the supplementary amount now sought, is estimated at £1,168 million, representing about 7.57 per cent of GNP.

As regards health services policy generally, I will make some comments as they relate to expenditure during the year. As outlined in the national plan, Building on Reality, the main thrust of health policy will be directed towards disease prevention, community care services and care for the poor and the disadvantaged. However, that does not mean that the acute hospital service will be neglected. There is a need to improve efficiency in the acute hospital services and to scale down the infrastructure by reducing bed numbers. At the same time it is necessary to ensure that patient care does not suffer and that new technological advances can be accommodated within the resources available.

Some controversy has arisen in relation to my decision to designate St. Vincent's Hospital in association with Our Lady's Hospital for Sick Children, Crumlin, as the National Liver Transplant Centre and the subsequent performance in the Mater Hospital of a liver transplant despite their being warned, clearly and in advance, of the consequences of their action in terms particularly of the dilution of the expertise so essential to the carrying out of liver transplants. On Wednesday, 6 November 1985, approximately one month prior to that procedure being carried out, I made a statement and conveyed it to all the hospitals concerned that not more than one centre could be justified in this country and that I would not approve of transplants being carried out in any hospital other than St. Vincent's Hospital, Dublin, in association with Our Lady's Hospital for Sick Children, Crumlin. On 6 November I gave my reasons for that decision and I do not propose to elaborate on the matter. However, if any Deputy wishes me to comment on it, I am willing to do so.

I much regret the fact that the controversy centred upon an individual case but, in the interest of the proper organisation of the distribution of specialities between hospitals, I could not at that time have shirked the decision involved. In response to a number of inquiries subsequently, particularly from the media, which were critical of my decision, I indicated quite clearly that I had no option but to take a decision and to make it known lest there be any misunderstanding in the minds of those concerned as to the intention to implement that decision. I am happy to inform the House that the issue has been resolved and that at a meeting last Tuesday evening the board of the Mater Hospital unanimously decided to accept my decision to designate St. Vincent's Hospital, in association with Our Lady's Children's Hospital, as the National Liver Transplant Centre. In the light of that confirmation which I had awaited, I have arranged at the request of the board of the Mater Hospital that the Secretary of my Department will meet in the near future with a group from the Mater Hospital to arrange for co-operation between the consultants of the Mater, St. Vincent's and Crumlin hospitals in the work of the transplant centre. I am pleased to note that the matter has been resolved.

There has been to my mind unnecessary, alarming and inaccurate comments about the alleged hardship that has been caused by the level of allocations which have been approved for health agencies in 1985. Admittedly allocations have been tight. However, some agencies are heading for a break-even situation for the year. Others are fairly close to that target.

The health services have always been an area where even the suggestion of any need for some financial restraint is greeted with a spontaneous barrage of abuse and criticism. Rational and informed argument usually has a very short life expectancy in the environment generated by such abuse and such criticism. Emotionalism and, if I may dare to say so, an inclination towards a marked degree of hysteria, tend to set the pace and to infect the atmosphere. The constraints on public expenditure at the present time mean that options simply have to be selected. Real choices have to be made in pursuance of the twin objectives of the controlled reduction of high levels of borrowing on the one hand, and the need to reduce the penal burden of taxation most particularly as it affects direct taxation on the PAYE sector, on the other.

The necessity for prudent management of resources does not imply a dilution of essential services. Rather does it impose a discipline on management to make the best possible use of resources in the care of the sick and other vulnerable groups in the community.

The campaign of free immunisation against measles was launched at the beginning of October. This was the first public immunisation scheme to be provided through general practitioners. A special allocation of £650,000 was made to fund this new scheme. I am sure Members of the House will appreciate the co-operation of Deputy O'Hanlon in that regard. It was an investment which was considered to be well worthwhile in economic terms as well as in its vital contribution to child health.

The Department's target was for a 95 per cent up-take of the vaccine in a six-week intensive programme of vaccination. A 95 per cent up-take is required for eradication of the disease. It was recognised that this would be an extremely difficult target to achieve in the period allocated, given that measles is not regarded as a serious illness by the general public and by some doctors. It is considered that a 60-70 per cent up-take would be a good result in a voluntary measles immunisation campaign.

Unfortunately, the initial response appeared to be rather slow. To counter this the Department called a meeting of the Directors of Community Care and medical officers of health on 12 November to discuss the problem and to indicate how the better areas had already achieved an up-take of over 50 per cent in the first month. The Health Education Bureau were also asked to revise their advertising campaign and the College of General Practitioners renewed encouragement to their members to advise parents of the advantages of the service. A further meeting will take place on 19 December.

The net effect of these measures has been to increase up-take steadily. The average up-take is now 52 per cent. If the present trend can be sustained it is expected that we will achieve an up-take of up to 60 per cent by February-March. This would be a significant achievement when compared with the results of similar campaigns in other countries, in particular Northern Ireland, where it might be as low as 25 per cent.

We have invested a considerable amount of money to deal with the problem of AIDS which continues to occupy the headlines internationally. We are fortunate that the disease has been slower to reach here than many other countries and we have been able to make arrangements to monitor and control it, with benefit from experience and information elsewhere.

Detailed instructions have been given to health boards about arrangements for reporting and surveillance of cases and suspected cases of AIDS. These instructions are periodically up-dated to take account of new information about the disease as it becomes available. The surveillance system is working satisfactorily.

The Blood Transfusion Service board have made arrangements to provide our total requirements for blood products from domestic blood. These are important measures for the protection of our haemophiliac population. Persons in the at-risk groups are asked not to donate blood. All blood donations are tested for the presence of AIDS virus anti-body.

Arrangements have been made for routine anti-body testing of intravenous drug abusers. Other persons who suspect that they may have come into contact with the AIDS virus should make arrangements for AIDS anti-body testing through their general practitioner or at an STD clinic. Confirmatory testing as required is arranged at the Virus Reference Laboratory, UCD, Belfield.

In addition to the information already circulated to health boards, a general information booklet on AIDS for all doctors is in course of preparation. An information leaflet for the general public is also being prepared. In the normal way, counselling and education is a matter for the family doctor. I am satisfied that our arrangements for monitoring developments in Ireland and internationally relative to the disease are adequate.

I commend the Supplementary Estimate to the House for approval.

Dr. O'Hanlon

Since the Minister came to office he has boasted it has never been necessary for him to introduce a Supplementary Estimate. On this side of the House we have appealed to him to ensure there is no diminution in the level of services. I am glad that this year he has decided to introduce a Supplementary Estimate because most of the money allocated will ensure there is a general practitioner service available to medical cardholders until the end of the year.

The Minister told us he was convinced that sufficient money had been allocated to ensure a proper level of service this year. As every Deputy knows, that will not be the case. I was amazed that he referred to Building on Reality, because that laid down clearly that the amount of money to be spent in 1985 would be £1,090 million. The Estimate provides for £1,086 million with a further £13 odd million in the supplementary Estimates making a grand total of £1,115 million in round figures. That is almost £100 million more than provided for in the Government document and therefore, not alone on health matters but in regard to general Government policy, the document has been discredited. I was surprised the Minister spoke about it this morning.

The Minister said some of the money to be allocated would help to increase allowances to certain categories of persons for whom the health boards have responsibility. There has been condemnation of the Government for lack of increased allocations for social welfare recipients this year. There has not been any dependent allowance, and that was expected by social welfare recipients, who also expected a double allowance for Christmas as had become normal practice.

In regard to the GMS, we are not surprised at the amount in the Supplementary Estimate because the Government had got their figures wrong at the beginning. On 5 June last I asked the Minister by way of supplementary question what the estimated over-expenditure of each health board would be this year. The Minister was unable to give me the figure, in reply to Question No. 591 on 5 June 1985. A week before that, the GMS payments board were able to inform each health board what the estimated shortfall for the year would be — not just the total short-fall in the GMS but the amount for each board. The figure for the Eastern Health Board was £500,000, and the letter sent out by the payments board gave the figure to the North-Western Health Board, the North-Eastern Health Board in my constituency — the figure was £750,000 — and the others, making a grand total of more than £8 million of a deficit for the entire country. As I said, a week later the Minister was not able to answer my question here. Is it surprising, therefore, that the Government have their figures wrong in relation to the GMS this year?

Why did the Minister change the method of funding the GMS? Formerly it was funded directly by the Department, but this year the Government decided that the health boards should be responsible for funding the GMS and that any short-falls would have to be made up from other sources. It is obvious that the boards could not control expenditure and they are in a most difficult position because they had to assume the role of middlemen, the amount of money allocated by the Department not being under their control. Naturally, expenditure depends on the services given to the people who hold medical cards. This is variable depending on the circumstances, The Minister expressed concern today about the high visiting rate. We would all be concerned that expenditure should represent value for money, and in the health services we all have to say that they represent good value for money. There is a totally comprehensive GMS available to 32 per cent of the public, 24 hours a day, 52 weeks a year. We must always look for efficiency and it is my opinion that the GMS represents excellent value for money.

I was surprised here on 20 November when, in reply to a supplementary by me to Question No. 2, the Minister gave, as one of the reasons for the increased visiting rate, "There are many interesting reasons for that, not the least of which are the negotiations going on". The reason surprised me. It was what came to the Minister's mind. Everyone knows why the visiting rate is increasing. The first obvious reason is the economic policy of the Government. It is appreciated by all that when there is an increasing poverty rate and increasing unemployment there is consequent increasing morbidity and therefore an increasing rate of illness. That was very much realised in the thirties in a time of depression and rising unemployment. We know that unemployment today is a direct result of Government policy and that is why we have an increase in the visiting rate.

Another reason is the effect of the cutbacks. This morning for the first time the Minister admitted that there were detrimental effects from cutbacks. Generally, when we suggest that these are cutbacks the Minister pretends that he does not understand what we are talking about. Today, however, he admitted that there are bad effects from the cutbacks.

The reduction in hospital services means that people are paying more visits to medical practitioners. Naturally, if people have to wait longer for out-patient services they will visit their local doctors more frequently. This year, because of the bad weather in summer the visiting rate increased: people's health tends to be better when there are normal summers, but this year was particularly bad and so was the general health of the people. The Minister should consider these reasons rather than suggesting that in some way the doctors made a conscious decision to increase the visiting rate in the belief that that might have some influence on the negotiations. That type of thinking has very serious implications for the success of any negotiations. There must be trust on both sides. All the people working in the field — the Minister, the Department, the health boards, the doctors, nurses and the para-medical staff — are trying to provide the best level of health care at the most economic rate. It would be unfortunate if a "them and us" situation were to develop between the Department and the doctors. I appeal to the Minister to show trust in the profession. I accept that one or two people in any profession can cause problems, but the members of any professional group do not welcome any such action. People working in the health services would not be tolerant of any abuses of the system. We are very fortunate that in our health services all the professional personnel and staff are dedicated people who are committed to the welfare of those for whom they have responsibility.

On the question of generic prescribing it is simple to suggest that doctors should prescribe products by using their basic name but I have suggested here that there should be formulae whereby doctors would know when they write the basic name of a product, the type of product that would be prescribed. This is a matter on which the medical profession and the pharmaceutical profession could draw up their own formulae. There was a difficulty in this area some 25 years ago or so when local authorities provided drugs for the dispensaries in their areas and when some of those drugs were found to be inferior. These were drugs that were imported from the Far East. It is important that doctors should have confidence in the drugs they prescribe and that there should be much more prescribing of generic products.

Many people experience problems by reason of simple remedies such as white stomach mixtures and some cough bottles not being available through the health services. Old people living alone or those on non-contributory pensions, for instance, have difficulty in purchasing these products. Very often there is a temptation for a doctor to prescribe drugs that are more expensive and more potent. This is borne out when one considers the figures for a drug such as Tagamet which is costing the Exchequer more than £2 million in the current year. The drug is used for the relief of stomach complaints. I am convinced that for many people simple white mixtures would bring a good response.

The Minister referred to the financial restrictions in 1985 and suggested that there are too many alarming and inaccurate comments about the alleged hardship being caused by the level of allocations approved for health agencies for this year. He said:

The Minister might have been referring to himself because every elected public representative has a responsibility to draw his attention to the effects of Government action. I am not blaming the Minister personally for any of this. The Government must accept collective responsibility and it is their responsibility to provide an adequate level of service, but this is not being done.

It is not correct to say that any suggestion of financial restraint is greeted with a spontaneous barrage of abuse and criticism. What has been said in the past couple of years has been very moderate and constructive. A number of statements have been made by the chairmen of health boards drawing the Minister's attention to the effects of the cutbacks in the health board's allocation. In reply to a question here on Thursday last, the Minister admitted that there was a reduction in real terms in the allocation for each health board in 1985 compared with 1982, the last year before the Government came into office. I asked the Minister what the reduction in real terms of each health board was in 1985 over 1982 and his reply as reported at column 1428 of the Official Report for 5 December 5 was that the percentage change in non-capital allocations in real terms was as follows:

Eastern	+0.072
Midland	–3.627
Mid Western	–4.492
North Eastern	–3.054
North Western	–5.118
South Eastern	–3.644
Southern	–0.215
Western	–5.192

When one considers that the Eastern Health Board was the only one to get a marginal increase, and when one considers the rapidly expanding population, particularly the growth area of Tallaght, over that time, one realises that the net effect is a very major decrease in the EHB as well. It is not correct to say that there is hysteria when people complain about reductions of that nature. While opposing reductions of this nature, we are all in favour of more efficiency in the service. Some reduction was possible by improving efficiency of the service at all levels, but the Government committed themselves to expanding the service in a number of areas and there has not been any expansion as money has not been provided for it.

We have a real decrease not alone in the money allocated but in the level of service being provided. In the hospital services it is obvious that if one does not provide locums to cover for personnel absent on holidays, maternity leave or on weekends there must be a reduction in the level of service. If wards are closed and if out-patient clinics are closed there is obviously a reduction in the level of service. The Minister is not coming to grips with what is happening. Recently on a radio programme when asked a question about why hips were not being replaced by the South-Eastern Health Board the Minister replied that there was political connivance. If there is a reduction in the allocation to the South-Eastern Health Board of the order of £3.644 million it is understandable that the health board would not have the hips available for replacements and that is why there is a slow down of availability of operations coming to the end of the year. I cannot see, under any circumstances, how one could have political connivance between the orthopaedic surgeons and the executive of the health board because they are the principal people who ensure that these hip operations continue.

Is the Minister aware of the problems with the radiotherapy services in Cork? Patients have now to travel to St. Luke's Hospital in Dublin for radiotherapy because of the inadequate level of service in Cork. On the radio programme on which the Minister referred to hip operations, in reply to a question about dental services the Minister told a listener in Trim that while that listener might have a problem there were no problems in Cavan, Monaghan and Louth. The Minister told us time and time again in this House that there has not been a diminution in the level of dental services. We all know there are problems in Cavan, Monaghan and Louth. There was no service of a routine nature there for any adult with a medical card, on supplementary allowances or widows' pensions or on old age pension. One person in my practice in this area had a service before the he was going for a hip operation and he needed the dental service before the orthopaedic surgeon would operate on his hip. I have no doubt that the waiting list for adults must have reduced considerably, because nobody puts his or her name down on the list any longer. In relation to children, there are over 40,000 children on the waiting list for a service. This is unacceptable and still the Minister can go on radio and tell the people that there is an adequate dental service.

The same problems apply to the optical service. How ludicrous can we get when we have a situation in one community care area where a person who had optical services provided, in so far as he got his eyes tested, when he went to the optician who had the contract to supply spectacles at rooms in the same town, was told that he would have to pay for the spectacles there but that if he travelled ten or 15 miles to where the same optician had a similar clinic he could get the spectacles free? These are the areas to which we should look for improved efficiency.

In relation to community care services, care for the elderly and psychiatric services, what provision has been made to develop community care services to ensure that more and more people can be treated in the community and can remain in their own homes? The document The Way Forward recommended that the psychiatric services should become more community based. We all support that. During the debate on the Estimate in July the Minister said that he hoped to implement some of that suggestion, but what provision has been made for this? In the US and in Italy people were pushed out of the psychiatric hospitals into the community. Community care services were not provided and psychiatric patients ended up congregating in destitute groups and down and out. We do not want that to happen here. It is futile to talk about transferring people from hospital to community care services if there is not a service in the community to cater for them. In relation to the development of community psychiatric services it is important that there be close co-ordination between the family doctor service and public health centred services. I am just a bit worried in case the psychiatric services might develop independently. Care for the psychiatric patients should be developed in co-ordination and co-operation with their own family doctors.

In relation to the Green Paper on the handicapped, I would ask the Minister what special allocations he made to the health boards for the implementation of the recommendations in that excellent report. The Minister committed himself to making allocations to the health boards.

The Voluntary Health Insurance Board also have problems in meeting their commitments because the cost of their premium is so high. Much of this cost is the direct result of intervention by the Government in increasing the cost of private accommodation. We now have a situation in health board hospitals that a private room is more expensive than in the Mater Private Nursing Home or in Elm Park. The Minister was to collect £1.4 million from the consultants for the use of equipment in public hospitals for their private patients. We opposed that because it would increase the premium to those who insure themselves. At the end of the day it would be the consumer who would pay; it would not come directly out of the consultant's pocket. I understand that that money has not been collected, as we expected it would not be collected. The Minister promised us legislation on the VHI before the end of the year and we have not heard anything of that.

On the question of the Family Planning Act the Minister wrote to the health boards requesting them to set up family planning clinics. The health boards have resisted that request because there has been no demand in their areas for these clinics. Family planning is a matter for patients and their family doctors. More and more family doctors are providing a wider range of family planning services. Indeed, many younger doctors have diplomas in family planning. Yet, at a time when there is no dental service in the health board areas, the Minister requests them to set up a family planning service. I am not surprised that the health boards, with common sense, have resisted that request when they are unable to provide the statutory services in respect of which they have a responsibility.

I compliment the Minister on having initiated the measles eradication campaign. The Minister has the full support of every Member on this side of the House in ensuring that that campaign will be successful. We should like to see the highest possible percentage of children having the measles vaccination. When it comes to the final figures it will be difficult to say what percentage of children between the ages of 15 months and five years, who needed the vaccine, actually received it. I do not think any community care area has got up-to-date, correct figures for the number of children who would have had measles. That fact may not have been notified or, if it was, they may not be in a position to collate the names of the children. Therefore, the health boards may not have the names of children between the ages of 15 months and five years who have had measles and, therefore, did not need the vaccine. This means the percentage figure at the end of the day may be lower than the actual percentage who needed the vaccine and who actually received it. I believe that scheme will be very beneficial in the future to the children of this country. Hopefully we shall have eradicated measles, saving the trauma and upset occasioned by such an illness, sometimes with very serious complications. Also in economic terms it will have proven to be a worthwhile exercise.

The Minister referred this morning to the problem in the Mater Hospital. I agree with him. I believe it was unfortunate that the discussion should have revolved around one patient. However, I think it would be fair enough to blame the Minister for that. He rushed in too hastily to impose a penalty of £25,000 on the Mater Hospital. I agree fully with the Minister in his wish to rationalise high technology medicine. I accept that transplants cannot be carried out in every hospital and that we must rationalise the whole area of transplantation. However, one cannot just make a regulation on 6 November that, in future, all transplants will be done in such and such a hospital because if a hospital where transplants have already been carried out, such as the Mater, has a patient of long standing, in this case 13 years, then the consultants would have a certain obligation to that patient and this has to be considered. I believe the Minister should have made an exception in that case. I am very glad that the situation has now been resolved. The Minister did not tell us but I hope that, in resolving the situation, he revoked the decision to penalise that hospital in the sum of £25,000. When replying I hope he will be in a position to tell us that he did revoke that decision, that all is now well between himself and the Mater Hospital.

The fact that Beaumont Hospital has not opened is an absolute disgrace. The reason is that, in the present Government, there is some sort of a bizarre ideology that would not be accepted by any health care experts anywhere in the world or, indeed, by any patients anywhere in the civilised world — that a hospital should remain unopened because the Government do not want the consultants to have their private facility on the campus. In a country where approximately 20 per cent of the people do not have the right to full, free medical hospital services and are obliged to pay for the medical services we have, there is an obligation on the administrators to ensure that facilities are available to them.

Having said that, the Minister and the Government have decided that there should be no private facility, no private hospital, for the consultants moving there. The Leader of our party, as Minister for Health, and his successor, Deputy Woods, also as Minister for Health, decided to allocate land to the consultants for such a private facility. On returning to Government we, in Fianna Fáil, will make that land available to the consultants — the small amount of land they require — either by way of lease or sale at absolutely no cost to the Exchequer. Rather would it involve an income because, if the land were leased, there would be an annual income accruing therefrom.

The reason we would allocate such land is not, as the Minister suggested here some time ago to curry favour with the consultants, but rather in the interests of all the patients in the new public hospital, the one that is now lying idle and not open. In their interest we believe that consultants should be on the Beaumont campus for as long as possible during the day. We do not want to see a situation evolve in which they would carry out their work in the public hospital in Beaumont in the morning and then drive possibly two hours across the city to perform their private work in the afternoon. Surely nobody could argue from any point of logic that the consultants should not be allowed onto the campus, that it is all right to have a public patient in Beaumont Hospital, and the consultant there with that patient in the morning, then have him drive out to Dun Laoghaire, Mount Carmel or somewhere else in the afternoon?

While the measles eradication campaign has constituted a step forward in preventive medicine, looking through the Estimates it is always disappointing to note that less than 2 per cent of the total goes towards prevention. I ask the Minister to ascertain whether more money can be spent in that area. It is the policy of the Government, and indeed of all parties, that there should be greater commitment to prevention but, when we examine the figures, we find that that policy is not reflected in them. In that context we should compliment the Health Education Bureau on the excellent international seminar they organised here in the summer time. Hopefully that will prove to have been of benefit not alone to our people but to the personnel of all other countries who participated.

The Minister promised us legislation on control of tobacco advertising in 1984. To date there has been no sign of that. Is the Minister satisfied that the amalgamation of the Medico-Social Research Board and the Medical Research Council of Ireland, and particularly bringing them together into the Department of Health, is in the best interest of the people? Both bodies do excellent work and the Medico-Social Research Board are involved in many projects of a social nature. My concern is that if a Minister thought that a report was not going to be favourable to his Government he might say when he has them in his Department, "We should not go ahead with that project". They serve the nation well in their independent or semi-State status and I would like to see that continue.

The Minister since he came into office has been promising that we would have a Green Paper on reform of the health services. There has been no sign of that Green Paper. As far back as April 1984 he told us that we would have it before the end of 1984. When can we expect that Green Paper? From what we have been told here in answer to questions in the House it appears that it contains some radical suggestions. Some people are concerned that all eight health boards will be abolished and that there will be central control in the Department. The Minister has referred to the fact that services for the mentally handicapped are outside the health board as are the voluntary hospitals. Naturally, there is concern that the Minister has radical proposals for taking over control of the whole health service. It seems that this Green Paper either will not appear in time for the Minister to implement any of the recommendations in it because an election will be at hand or it will not appear at all in advance of an election. That Green Paper has been promised for a long time now. Perhaps the Minister will tell us this morning when we can expect it.

An Leas-Cheann Comhairle

Let me remind Deputy Durkan and Deputy Brady that the debate on the Estimate concludes at 12.30 p.m. I presume that both would like to have the Minister in to respond. I ask them to bear that in mind.

Mr. Durkan

I will be brief and speak for ten or 15 minutes. I welcome the introduction of this Supplementary Estimate the purpose of which is to allow the Department to discharge their liabilities for the various services. Deputy O'Hanlon spoke in relation to cutbacks in the health services as health boards generally and as a member of the Eastern Health Board, I must say that that board have done remarkably well over the years in providing services even in a difficult economic climate. They have provided a very good standard of service and I hope they will continue to do so. I pay a compliment to the chairman of that health board — who is not a member of my political party — who has excelled in impartiality and constructive approach throughout his term of office, as have all the previous chairmen.

In the change from institutional care to community care which seems to be the general thrust desired by most people nowadays in the health services, one must not forget that community care also costs money and to some extent this may be one reason for the increased visitation rate which I accept has caused considerable concern at health board meetings all over the country. However, perhaps more people are being looked after at home. The bad summer we have just had was a contributory factor, but one must remember that in the event of greater emphasis on community care we will in any event be involved in expenditure by way of attendance of public health nurses, doctors etc. That is as it should be. One must remember also that society has changed over the last 40 or 50 years. At one time in every household one or two people were at home all day to look after elderly or sick persons. In many cases now people are at work all day, and then an elderly person, a person who is sick or whatever, has not the attention that his or her counterparts would have had 50 years ago. Consequently there is a greater call on the services and we must face up to that just as we must face up to changing times.

Deputy O'Hanlon said that only 75 per cent of the social welfare bonus was paid at Christmas this year compared with previous years. He forgot to mention that it applies to a far wider range of people. Far more people are to be accommodated. I welcome that proposal which was announced by the Minister some time ago.

At present a fairly high standard of health services is available here in comparison with many other countries. Maybe we do not always recognise the very high standard of health services available. Politicians, depending on their stance at a given time, will criticise the lack of availability of service of one kind or another and there may be genuine reasons for that on occasion, but we must not forget that we have in a very small country with a small economy a fairly sophisticated standard of services which are costing and will continue to cost a great deal of money if we want to have them.

Deputy O'Hanlon referred to the move towards community care in the psychiatric services and the desirability of that move. I know the Minister's intentions are in that direction and I support fully any move towards community based psychiatric care and away from the large psychiatric institutions where in some cases patients have been housed for up to 50 years. In the past I have spoken many times about what I have seen at first hand, patients living intolerable circumstances and conditions. That is not in keeping with the standard we should have at present. To say the very least, some of the buildings in which they are housed are Dickensian. The Minister had indicated, rightly, his intention to tackle that problem. I have said many times that it would do us all good, particularly at Christmas time, to pay a visit to our psychiatric institutions and see at first hand the forlorn appearance of the buildings because of their age and structure generally, and the forlorn appearance in many cases of the patients. We would do well to ponder the length of time some of those patients have been living in those institutions, some of the more elderly patients for up to 50 years have been living in those institutions, some of the more elderly patients for up to 50 years in a single institution. Maybe in some cases they have scarcely left the building or even their room over that period. We should also reflect on the type of patient housed in those places. Not all the patients are psychiatrically disturbed. Many of them are elderly or psycho-geriatric. The only reason they are there is that there is no place else for them. That is a very sad reflection on our society.

When we hear criticism of alleged cutbacks in the health services, little emotion is generated in regard to the psyhciatric services. Yet in this city there are approximately 1,000 people in one major psychiatric centre, St. Brendan's Hospital, where the conditions are not what one would expect at the end of the 20th century. I do not wish to labour the point but I must appeal to the Minister to change those services and house the people involved in smaller institutions, in modern buildings where staff will have a reasonable chance to spend their time effectively.

There is no sense in having large numbers of patients in old fashioned, draughtly and sometimes dangerous buildings. To expect staff to give of their best under such conditions is asking too much. We have been fortunate over the years in that we have not had a major catastrophe in any of those hospitals. A few years ago part of the roof of St. Brendan's Hospital collapsed, but, fortunately, nobody was injured and it was possible to relocate the patients. To date we have been extremely lucky, but we should not tempt fate too much. The sooner we introduce a system on the lines that the Minister has in mind the better for all concerned. We will then have a chance to do something compassionate and constructive about the psychiatric service here.

The Estimate covers provision for domiciliary care and DPMA allowances. I have written to the Minister in regard to a number of cases. Many community based voluntary organisations are now providing services for the mentally handicapped. For instance, the Irish Wheelchair Association in north Kildare is doing a tremendous job in that area. However, there are problems. When recipients of DPMA enter a shelter workshop they have their free travel passes withdrawn. An exception should be made in such cases. The cost to the Exchequer would be minimal. For them to lose their free travel passes because they attend such work shops is not helpful and is unfair to them.

In spite of the difficult economic climate I am pleased to report that the Eastern Health Board have done a fairly good job in getting to grips with the problem of the orthodontic waiting list. Two years ago in one county alone there were thousands on a waiting list but we have managed to isolate the problem since. Those who may disagree with that comment should check the figures of four years ago.

I should like to deal with the question of transplants and the possibility of a duplication of specialisation in our hospitals. I do not think we can afford that. We should be moving towards getting our major hospitals to specialise in one area instead of the hospitals competing with each other. It would be in the interests of the hospitals, the health boards and the health of our people if that were done.

An Leas-Cheann Comhairle

Before I call on Deputy Vincent Brady I should like to indicate to Deputy Barnes that the Minister has expressed a wish to get in before the conclusion of the debate at 12.30 p.m.

Mr. V. Brady

I will be brief and, hopefully, Deputy Barnes will get a few minutes to make a contribution. It is a pity that the debate on the Estimate for Health which covers such a vast area is limited, but that is something we have to live with today. The Department cover practically every aspect of life here. We are all conscious of the effect of the cutbacks in the health and medical services whether in hospitals, health centres and so on. On the question of orthodontic services I must point out that the health centre in Marino has been without an orthodontist for two years. I raised the matter in the House on numerous occasions and I was informed earlier this year by the Minister that applicants were being interviewed but nothing has happened since. Hundreds of urgent cases are on the waiting list. Many of the children involved are over the age limit and no longer qualify for that service. I am very concerned about that problem.

I should like to pay a compliment to the voluntary hospitals who have made a major contribution to our health services down the years. Like most voluntary bodies, whether they are involved in education or in health care, we tend to take them for granted, but we owe them great credit. We owe a lot to the religious orders for their work in those areas. Without their contribution our health services would not have made the progress they have. We all accept that there has been progress but it is unfortunate that in recent years it has stopped. In fact, it has been retarded in the hospital and medical services.

I should like to refer to Beaumont Hospital, one of the major scandals in this city. That hospital on the north side of Dublin cost £57 million to build but it is empty because of a dispute which, in my view, arises out of the ideological views of the Minister. Not only is the hospital empty but it is costing £100,000 per month to maintain. From time to time the Department of Health remind us of the cutbacks and restrictions because of lack of funds, but it is a shame that such a facility has not been utilised for a number of years. Most of us are aware of the history in regard to that hospital. The Beaumont Hospital Board was established in 1977. Originally it was to replace the Jervis Street and Richmond Hospitals.

The north side of Dublin city has been deprived of good hospital facilities for a number of years. It has had the Mater Hospital which is excellent in every respect but, because of the vast population stretching further northwards, Beaumont Hospital is very badly needed and there is great concern about this in Dublin and elsewhere. The Minister has not given any indication of when the opening of the hospital might take place. The excuse being put forward continuously is that he will not waste public funds on private facilities. The truth is that he would not be spending any public funds on these private facilities. The consultants made it quite clear in the agreement and arrangements made at the very beginning that they would finance the building and the facilities themselves. There would not be one penny that the Department of Health would be called upon to provide. In those circumstances I fail to understand why the Minister should remain so rigid in this matter.

The situation on the north side is serious because of the insufficient number of acute hospital beds. Beaumont was intended to fill this need to a large extent. As my colleague indicated earlier, it appears that the Minister would have no objections to the consultants being provided with rooms on the north side of the city, but that is not workable. Even as a non-medical person, I can appreciate that the presence of consultants on the campus must be of benefit in a public hospital. I fail to understand why the Minister should think otherwise. It appears that the Minister has got himself into a corner and refuses to admit that he was wrong. I appeal to him even at this late stage to change his mind and open Beaumont Hospital. He went part of the way some time ago in agreeing to provide 70 beds in that hospital, but that surely is a penalty on the public patients. It is taking away 70 beds from the public hospital — 10 per cent of the capacity.

Under the original agreement favoured by a number of the Minister's predecessors he would continue to have those 70 beds available for public patients and at the same time the facility of a private hospital for those who wish to use it. There are many who, for one reason or another, are not in a position to benefit from publicly funded hospitalisation and they should have that choice. Who is to say that people living on the north side should not have Beaumont Hospital located nearby? I ask the Minister to meet the consultants and agree to open Beaumont Hospital without further delay, which would be in the interests of all. Certainly, the large population on the north side would benefit greatly because this facility is absolutely needed and the Minister would not be going back on his commitment as far as the expenditure of public funds is concerned. There are setups very similar to the one requested in Beaumont in other hospitals on the south side, such as Mount Carmel and St. Michael's, Dún Laoghaire. Nobody can say that those hospitals are any the worse for having these facilities. Many people in Dublin with a choice of hospitals opt for Mount Carmel and perhaps that is the reason.

Beaumont Hospital was designed in the same way with the same plans as Cork Regional Hospital. The purpose was to save time and expense. Recently I read a report in which the Minister indicated that the plans for Beaumont Hospital were all wrong. Is he saying that Cork Regional Hospital is wrongly planned? Beaumont was designed to be built exactly the same. His argument does not carry any weight. It would seem to indicate that the Minister's view is purely a personal one of ideology. I wish he would come face to face with the situation and solve this problem once and for all.

The last item I want to mention concerns dialysis facilities in Limerick Regional Hospital. I make this point because of having first hand experience of the difficulties caused to patients as a very close relation of mine, who is sadly no longer alive was one of these. As the Minister will know, the facilities there were provided on a voluntary basis, with something in the region of £80,000 being collected by local people to provide a kidney unit in that hospital. For some reason, the Minister refused to agree to finance the staffing facilities requires. I do not know how many nurses would be required there, but I have been told somewhere in the region of six. That is all it would cost the Department. There are 18 patients coming from Limerick to Dublin three times a week, travelling 140 to 150 miles — at public expense, mind you — having been collected from their homes in the country, brought to Limerick railway station, transported by train from Limerick to Dublin, collected at Heuston Station and brought to St. Mary's Hospital in the Phoenix Park or to Jervis Street. They spend three to four hours on a kidney machine and then have the same difficulties and painful travel home. This is happening to people who are seriously ill. To adopt such policy is not only heartless; it is inhuman. I am surprised that any Minister for Health, but particularly a Labour Minister who professes from time to time to be a champion of the people, should allow that situation to continue.

I invite the Minister on any Monday, Wednesday or Friday to visit Jervis Street Hospital or St. Mary's to meet and talk with those who had to endure such stresses and strains. If he had done so, I am quite sure he would have relented long ago. I know facilities were opened in Limerick Regional Hospital two weeks ago, but they are on a very limited scale, benefiting only from two to four patients. This is all wrong from the human, the moral and the financial point of view. It must be costing the Department a great amount of money to finance these travelling arrangements of 18 patients three times a week. In the interests of those patients still living, I appeal to the Minister to have a complete rethink on this and to grant full facilities to those living in that area.

There are many other aspects that I should like to have mentioned, but this debate is limited and I wish to give Deputy Barnes some time and would like to hear the Minister's reply. I hope we shall have an opportunity at some other time in the House to debate the Department of Health in much greater detail, because it has been drastically run down in recent years, with cutbacks right across the board. People are suffering all over the country, but particularly in Dublin city; hundreds are waiting to get into hospital, but wards are closed in various hospitals due to cutbacks. This must be laid at the door of the Minister for Health.

Mrs. Barnes

I thank Deputy Brady for allowing me a few minutes, which is all I shall take. I know there will be other opportunities to expand on this subject. I did not want this occasion to go by without highlighting a few issues raised, particularly in regard to the statement this morning by the Minister. I support him absolutely in working towards proposals for change in the GMS and in his negotiations with the Irish Medical Organisation to make the health service more streamlined and effective which would be to the advantage of the doctors, the patients and the taxpayers, the patients being the priority.

I want to highlight a few points which the Minister might take into consideration in the negotiations with the doctors. I share the concern of the Minister that there seems to be an ever-climbing cycle of visits to doctors, aligned with a greater tendency to prescribe drugs, perhaps because the doctors have not the time for longer and more meaningful consultations with their patients. I was reminded very forcibly of this fact recently at a press conference to launch the Health Education Bureau's publication Women and Health. The two women involved in the research for this publication repeatedly made clear that women, particularly those in the home, suffer from a high rate of depression, yet the fundamental reasons are seldom looked into. When they eventually go to the doctor, usually they are handed drugs to keep them calm, raise the depression or sedate them. One of the women who contributed to the book made the point that it has been said that when men come under pressure they usually end up in jail, but when women come under pressure they usually end up with a psychiatrist or sedated with valium.

That is all part of the cycle which the Minister is trying to being to a halt. I would join him in asking the Irish Medical Association and the health boards to look closely at this question and to bring the thrust of the health service back into the community, treating people in meaningful consultations without relying too much on drugs to sort out problems. Drugs do not solve the problems. The cost in human and in financial terms is with regard to the whole area of generic drugs? There is intensive marketing by multinational companies who have incredible power and financial resources. Are all of these drugs necessary and so many different kinds? I doubt it. The whole area of generic drugs and the cost will have to be closely examined.

I would refer to the publication Irish Women: Agenda for Practical Action produced by the Working Party on Women's Affairs and Family Law Reform. It contains several recommendations, including one on family planning which states:

General practitioners, public health nurses and hospital doctors should ensure that the needs of the mother in relation to family planning are met. According to the survey results, 48 per cent of mothers had no discussion on family planning with any of the professionals involved in maternity care; 39 per cent of these said that they would have liked a discussion; 48 per cent of Category 1 mothers indicated a need for such a discussion. As a general rule, it is recommended that the general practitioner in the scheme and the public health nurse should raise the question of comprehensive family planning with the mother and, if she wants advice, should give it to her.

I doubt if that recommendation is comprehensively carried out and implemented. I know the Minister has set in train through the health boards an attempt to find out what network of family planning services we have throughout the country. According to women themselves it is disparate and discriminatory on geographical grounds. I would ask the IMA to co-operate fully in this. I was rather depressed to read in a newspaper report this morning that the IMA have asked doctors not to return the forms which were sent to them in order to collect information for this survey. If this is the case, I deplore it and I ask the doctors to see this matter in the context of health, not only of mothers but of the whole nation. It is also a right which couples should have.

I will end my contribution by drawing attention to the needs of women in the area of cancer prevention. If the organisational, geographical and social criteria are met throughout the country, this disease can be diagnosed and treated in time. A cancer screening unit set up in Hume Street some weeks ago, with little previous publicity, already had a waiting list up to February next. That shows the incredible need for such cancer screening procedures. I know the Minister will share my view that this type of screening should not be only on an urban base, available to the affluent and the educated, but should be available to everybody throughout the country. The Minister may not have time to respond to these points but I should like him to think about them.

Minister for Health (Mr. B. Desmond)

I thank Deputies for their contributions on this Estimate and I will refer briefly to a number of points. I have been very much struck by the fact during the past three years that in relation to health, public reality is very often quite different from perceived allegations about what is going on. Recently in The Cork Examiner a great deal was written about the Tralee Hospital, that hip and knee implants had suddenly to cease as from the middle of October because the hospital had run out of money; consultants were leaving people in pain and no work could be done. It was banner headlines in The Cork Examiner and politicains of all shapes and sizes and parties got up on their tippy toes and went berserk at this appalling situation. A programme manager even wrote a letter to the Department of Health looking for £25,000 to buy this emergency equipment. There were questions here on the Adjournment. Deputy McEllistrim was in a white tizzy about the situation. What happened? The hospital has a budget of £9.7 million. It is a new hospital and they did not carry out any orthopaedic work in 1984. They began it in 1985 and have carried out about 104 operations. There are about 80 people on the waiting list but that will be cleared relatively quickly. Somebody said that the things were going too well and it was about time it was stirred up: “Let us give Deputy McEllistrim something to have a go at Desmond over”.

An Leas-Cheann Comhairle

Minister Desmond.

Mr. B. Desmond

They call me far worse. The programme manager sent a letter to the Department of Health demanding £25,000 or else all hell would break loose. What is the reality? The letter has now been withdrawn as they do not need the money but there is no publicity about that. We have told the health board to stop that kind of play acting.