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Dáil Éireann debate -
Tuesday, 1 Jul 1986

Vol. 368 No. 8

Estimates, 1986. - Vote 49: Health (Revised Estimate).

I move:

That a sum not exceeding £1,153,476,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1986, 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.

Allowing for appropriations-in-aid at £100 million, the net non-capital grant provision is £1,095.316 million, an increase of £81.5 million on the budget allocation for 1985.

The capital provision included in the Estimate amounts to £58.160 million.

The gross estimated expenditure of £1,274 million represents an increase of £79 million on the corresponding figure for 1985. It comprises £793 million in respect of pay, £416 million in respect of non-pay, excluding cash allowances, and £65 million in respect of cash allowances. About 86 per cent of the gross expenditure will be met from Exchequer funds.

I have, on many occasions, referred to the spectacular growth in expenditure on health services over the last decade or so. In 1973-1974 net expenditure was about £143 million representing about 5.2 per cent of GNP. In 1982 the figure had increased to £952 million representing almost 8 per cent of GNP. The expenditure level in 1986, which can be supported by the Estimates provision, will reach almost £1,200 million in net expenditure terms. When direct income from patients receipts etc. accruing to health agencies is reckoned the amount available for expenditure on health services in 1986 will reach a total of £1,274 million. This compares with an overall gross total of about £1,195 million at estimates stage last year and is an increase of £79 million.

There have been major improvements in the scope and the range of the services in recent years. For example, our acute hospital services are as good as any in Western Europe, providing emergency and casualty services on a 24-hour basis and access to high quality diagnostic and treatment services to the entire population. Acute medicine continues to develop and our services have managed to embrace recent advances, offering, for example, techniques like organ transplants, open heart surgery, haemodialysis and intensive care — particularly neonatal intensive care where there have been major developments in the last ten years or so.

Our psychiatric services are also steadily improving. In the wake of the recent planning report there is now a new drive to develop a more community oriented system with the objectives of better and more human patient care. A particular feature of these services has been the value in terms of improvement in the standard of accommodation in most psychiatric hospitals by the expenditure by this Government of £6 million on schemes of refurbishment.

We can also point to a comprehensive range of services for the mentally handicapped, being progressively developed with a particular emphasis on community services.

Our general medical services provide general practitioner service to almost 40 per cent of the population, currently totalling some 1,322,000 persons. Over £100 million will be spent on the general medical services in 1986. Apart from general practitioner services the community health services programme provides a range of other services including home nursing, family planning, dental ophthalmic and aural services as well as domiciliary welfare and the refund of drugs schemes.

Additionally, the Irish health services provide a range of personal special services, normally not embraced by a health care system, but absolutely vital to maintaining the independence and dignity of many of the disadvantaged groups in society.

Services under this heading, to meantion but a few, include, disabled persons allowances; domiciliary care allowances for handicapped children; home help services; meals on wheels; capitation payments for children boarded out; adoption services and welfare homes for the elderly.

In summary, we have succeeded in bringing our health services and health indicators broadly into line with the developed countries, many of which are wealthier and therefore in a better position to devote resources to health care.

In general, health boards and hospitals have faced up realistically to deciding what has to be done to keep expenditure within allocation limits in 1986. Some of the decisions taken were difficult and will undoubtedly impact on services and personnel. I do not accept the view that large scale disruption of services is likely to arise. The funds available, if properly used, will be sufficient to maintain essential services.

The capital allocation which I have received for 1986 is £58.16 million. This is an increase of over £1 million on the capital funds available to me in 1985. This allocation will permit me to continue with the programme of improvements already in progress and to undertake a limited number of additional projects.

The major general hospital schemes in progress at St. James's, the Mater, Cavan and Mullingar will continue to be developed. In addition, work has already commenced on a major scheme at Castlebar General Hospital which will provide additional ward accommodation, X-ray, theatre, OPD and kitchen. Tenders have been invited for the provision of a new OPD and theatre suite at St. Colmcille's Hospital, Loughlinstown, and the provision of a replacement maternity unit at Our Lady of Lourdes Hospital, Drogheda, should shortly go to tender. The urgent improvement works which I have approved for Ardkeen Hospital in advance of the overall development of that hospital are scheduled to be completed during this year.

The planning of proposed developments at Tallaght, Kilkenny, Wexford, Sligo and Naas will be continued and, in addition, smaller improvement works involving, for example, improvements of out-patient facilities and day hospitals, will be undertaken at other hospitals.

The programme of improving standards in the major psychiatric hospitals and the provision of new day hospitals and day care centres for psychiatric care will be continued. Tenders are currently being processed for the development of small psycho-geriatric units to improve standards at St. Brendan's Hospital, Dublin.

In the case of the mental handicap services, the intake of patients into Cheeverstown Hospital, Templeogue, has already commenced and further facilities at the centre will be commissioned throughout the year. When fully operational, the centre will provide 130 residential places and 150 day care places. It is expected that a day care centre for adults at St. Michael's House, Belcamp, will open shortly.

Work on the provision of additional accommodation for the physically handicapped should shortly commence at St. Laurence's Cheshire Home, Cork, while work is nearing completion on a major development scheme at Barrett Cheshire Home in Dublin. Construction work is well advanced on the provision of new residential accommodation at St. Joseph's School for the Deaf, Cabra and a major development scheme has commenced at St. Mary's School for the Deaf, Cabra. Planning is proceeding on a development at St. Mary's School for the blind. It is expected that building work on this project will commerce later this year.

The provision of facilities for the care of the elderly will continue to be a priority. Construction of the new geriatric unit at St. Oliver Plunkett Hospital, Dundalk, is expected to be completed at the end of the year and building is in progress on the provision of a new 100 bed replacement geriatric unit at Sacred Heart Home, Carlow. Funds are being provided for a scheme to upgrade accommodation at Leopardstown Park Hospital and planning will continue in respect of other major projects, at Dungarvan and elsewhere, for the care of the elderly.

We will continue to push ahead with a major programme of systems development. This will yield many benefits: in improved patient care, in more accountable management, and in the rapid provision of information relevant to research and policy formulation.

In the health area I published last April a report on the health services for the period 1983-86, copies of which were circulated to Members of the Oireachtas. This report set out in some detail the structure and financing of the health services, the rationale for the state of progress of the legislative programme, significant developments in each of the health care programmes and more general information on eligibility for services and other matters. This publication was significant and long overdue.

Given the labour intensive nature of health care, we have examined in great detail the manpower strategy.

Since the health boards were established in 1970 there followed effectively a decade of exceptional employment creation in the health service until almost 66,500 persons were employed in July 1981. At present there are approximately 62,500 people employed directly in the health services implying a reduction of some 6 per cent in overall numbers since 1981. The impact of this on the ground is a challenge to health services personnel to increase productivity by maintaining the overall quality of service while reducing the number of man hours worked. I will deal with this matter in detail if there are any inquiries.

It is interesting to note that there are over 500 different grades in the health services and many of these, such as nurses, doctors, dentists and the various paramedical grades are unique to the services. Large numbers of staff in other employments also play a significant role in the efficient running of the various health care programmers, such as catering, maintenance, clerical and administrative staffs.

At 31 December 1985, 36.69 per cent of the population were covered by medical cards as compared with 36.75 on 31 December 1984. The income ceiling for hospital service cards was increased to £14,500 on 1 June 1986. This revised figure applies to income earned in the year ending 5 April 1986.

In accordance with the medical card guidelines a married man aged 66 years or over can have up to £105.50 per week, or £111.50 per week if over 80 years, and be entitled to a medical card. The limit will be higher if he has dependants or outgoings in excess of £10.50 per week in respect of his house.

I have increased the income ceiling for health contribution purposes to £14,000 with effect from 6 April, 1986. The effect of the increased ceiling is to increase the maximum contribution payable from £130 to £140. With the introduction of the land tax the existing method of collecting health contributions from farmers needs to be reviewed. This is under active consideration at present.

The present structuring of VHI insurance coverage provides for full recoupment of hospital in-patient expenses but only limited cover for general practitioner and other out-patient expenses. The out-patient cover applies only after a threshold of £105 for a single person and of £170 for a family has been reached. The current thrust of health policy in Ireland, as in many developed countries, is to reduce costly in-patient services and as far as possible encourage the provision of services on a community or out-patient basis.

In line with this policy I have been anxious to encourage the development of VHIs primary care coverage so as to influence patients to make greater use in appropriate circumstances of primary care rather than hospital treatment. Accordingly, I have recently commissioned consultants to examine existing models for voluntary insurance in other countries which might be suitable for adaptation to meet our policy requirements. I have also asked the consultants to provide an analysis of how suitable models would operate under Irish conditions. The VHI are co-operating fully in this exercise. I hope that all this will lead to the early introduction by the VHI of a comprehensive general practitioner and out-patient scheme. I think that such a scheme would be warmly welcomed and subscribed to by the general population.

As Deputies will be aware, the Children (Care and Protection) Bill, which I introduced early last year completed its Second Stage some weeks ago. I hope to see a major advancement on the Bill in the near future.

I am pleased and gratified that the Bill has stimulated so much discussion. I have also been heartened by the generally favourable reception that it has received. Many suggestions have, nevertheless, been made for changes in the Bill, and I am reviewing the provisions of the Bill generally prior to Committee Stage.

The new Dentists Act was passed by both Houses of the Oireachtas in 1985 and has led to the appointment of the new 19 member Dental Council with wider powers particularly in the disciplinary area.

The passage of the Nurses Bill through the Oireachtas in November 1985 marked a watershed for the nursing profession. The new legislation allows the composition of An Bord Altranais to truly reflect the profession as it has developed in recent years. The members elected to the profession's own self regulating statutory body are drawn from all the major disciplines of nursing and represent the practical, teaching and administrative areas. I have every confidence that the new 29 board members will successfully combine their many skills and talents and will work together along the lines mapped out for them in what has been described as a visionary piece of legislation, the Nurses Act, 1985. It is expected that the new board will meet in the first week in September and in the next five years will make a distinctive contribution.

I intend to introduce the new Tobacco (Health Protection) Bill shortly. The provisions in the Bill will help to establish non-smoking as the normal social behaviour and should help to deter young people from taking up smoking. Of particular importance is the banning or restriction of smoking in certain public places.

New Tobacco Products Regulations on smoking have been made and will also be operative this year and will include stronger health warnings on cigarette packages and media advertisements, a rotational system of health warnings, increased controls on point of sale advertising, the elimination of outdoor advertising at point of sale and tighter controls on sponsorship of events by tobacco companies. They have been widely welcomed.

The Health (Amendment) Bill, 1985 — to amend the Health Acts, 1947 to 1970 to enable health boards to charge for services provided for certain victims of road traffic accidents — has recently been passed. Accordingly health boards and hospitals may now offset the loss of revenue, estimated at £4 million in a year, which they suffered as a consequence to the Supreme Court decision on Article 6 of the Health Services Regulations 1971.

Since the passage in early 1985 of the Health (Family Planning) (Amendment) Act, which came into operation on 1 October last, my Department has been in regular contact with the health boards. Boards have submitted to the Department their assessment of the current availability of the various types of family planning services within their own functional area. These assessments have been accompanied by an outline statement of the proposals of the appropriate health board with regard to future local developments which are anticipated in the area of family planning services generally. They are being discussed with the Department of Health.

The text of a Bill to provide for a statutory scheme of control of clinical trials has been circulated to all Dáil Deputies and Senators. The Bill has been initiated in the Seanad. The principle of a statutory scheme of this kind has been widely welcomed despite some incredibly mis-informed comment about it. There has already been in existence a voluntary scheme operated by the National Drugs Advisory Board whereby proposals for such trials have been notified to the National Drugs Advisory Board in the first instance. However, for the sake of the reputation of the pharmaceutical industry itself as well as to provide public assurance that satisfactory standard controls operate in relation to these trials, it is important that there should be a statutory basis for these arrangements.

The Bill has, as I have said, been initiated in the Seanad and I will, as is usual with me, entertain all reasonable suggestions for its improvement, provided that its integral design is not fundamentally interfered with.

The 1986 allocation to the Health Education Bureau has been increased to £2 million, which compares with, £1.75 million for 1985. The additional allocation is necessary for the bureau to widen its health education campaigns in a number of areas including the development of an educational campaign with regard to AIDS. The bureau also intends to intensify anti-smoking publicity to complement the new legislation to strengthen controls on the promotional activities of the tobacco companies to which I have already referred. In addition, funds are necessary to broaden and develop the lifestyles education programme in schools, including sex education and anti-drug abuse attitudes.

We are making progress in the area of drug abuse and shortly I hope to be able to announce progress on the provision of a walk-in out-patient facility in the inner city area of Dublin. A planning brief for this badly needed unit has been agreed and negotiations are in progress concerning the purchase of a suitable premises for this new facility.

The take up on the measles immunisation programme has been outstanding. In six months a national up-take of 90 per cent was achieved and I should like to thank those involved in making that programme a success.

Negotiations on the general medical services are proceeding. We have been gravely concerned about the increasing costs of the GMS in recent years and it is vital that we have agreement with the medical profession on this question. I am actively pursuing the prospect of bringing the negotiations to a conclusion. It will not be for lack of efforts on my part and I trust the profession will co-operate.

The FICI Agreement was signed recently. This will result as from 1 August in a 10 per cent reduction in the price of drugs at present on the market. The agreement also entails an increase in the rebate paid by manufacturers to the State in respect of GMS sales from 4 per cent to 5 per cent. I am very pleased about this agreement. It is a critical one dealing with a major industry and it shows what can be done where there is co-operation on both sides in negotiations.

More than 30 small health centres were completed during 1985-86 at a cost of £500,000 per annum. Many of the health centres were in very bad condition and work was urgently needed to help in this area. New major health centres were opened in Blanchardstown, Loughlinstown and Blessington in the Eastern Health Board area. A further seven centres are being planned at present for Dublin. I have also approved the development of major new health centres and community care officers in Athlone and Portlaoise. Planning for a centre in Carlow is practically completed and a major new and innovative project is being planned for Waterford. In addition, other centres are being planned for areas throughout the country. With regard to the review of services for the elderly, we are undertaking another major review. There will be no delay in bringing forward our policy guidelines. As Deputies are aware, I promised this in my Estimate speech last year.

With regard to the psychiatric services, I do not propose to go back over the major debates that have taken place here. I have been in touch with the Western, Eastern and South Eastern Health Boards on the matter. We have reached substantial agreement regarding the provision of hostel, day hospital, acute and longer stay units in the various counties. I have stressed my anxiety to provide the necessary capital funds to facilitate the immediate provision of these facilities. We have reached agreement on the designation of specific areas for mentally handicapped and the psycho-geriatric patients in those hospitals. I hope in the near future I will get the agreement of the health boards concerned regarding the siting of the acute psychiatric units in Carlow and Roscommon. Meanwhile, I shall continue the funding of these facilities on a month-to-month basis. I have had ongoing discussions with the trade unions on the matter.

I am extremely concerned with regard to the problem of alcoholism. As we know, alcohol abuse and alcoholic psychosis accounted for 7,100 admissions to our psychiatric hospitals in 1983, or almost 25 per cent of total admissions. This is a very grave problem and one we in Ireland are reluctant to tackle. It will require major action in the health services.

With regard to services for the mentally handicapped, this year we have had an overall expenditure of £107 million, compared with a sum of £100 million at Estimate stage in 1985, which indicates an increase in line with inflation. Where any of the agencies have individual problems I shall be quite willing to meet them to discuss such matters. However, the majority of the services for the mentally handicapped are ongoing. There have been major improvements on the capital and current sides, apart from one major policy change, namely, the interruption of the planning process for Loughlinstown and Enniscorthy. This was for valid reasons, particularly to dilute the intensely institutionalised character of the proposals. With regard to new developments, I refer to the provision of the 70-place adult special care unit at Belcamp in north Dublin.

With regard to the Green Paper on Services for Disabled People, we had a major conference on 21 May 1986 on the training and employment aspects of that paper. I should like to thank the many organisations who assisted us in that regard. Their response was very productive and was of benefit to us in considering what developments might be carried out.

With regard to residential care for the physically handicapped, I am pleased we made available a total of £1.45 million in capital grants, including a sum of £750,000 for the development of a new Cheshire Home at Monkstown, County Dublin. The new home will provide accommodation for 26 severely physically disabled people. This is vital in the greater Dublin area. The emphasis will be on independent domestic self-help accommodation for each resident. In addition, we have made moneys available to the Barrett Cheshire Home in Dublin. A grant of £200,000 was made available towards that project. A further sum of £500,000 is being made available towards the provision of 28-single bed accommodation units in the Cheshire Home in Cork. These are major developments. I am very pleased the Cheshire Home Foundation have co-operated so magnificently with the Department of Health in this matter.

Major work is on going in respect of general hospitals. In the mid-west area the new theatre suite at Croom Orthopaedic Hospital is nearing completion. Major renovation works are under way at St. John's Hospital in Limerick, and work is in progress on new theatres and structural works for the orthopaedic unit at Tullamore. We are going ahead with major development schemes at Limerick Regional Hospital and at Nenagh, Kilkenny and Navan hospitals.

In the Eastern Health Board area we have made major progress. On the north side of Dublin the first phase of the development of the new Mater Hospital is almost complete and is expected to be commissioned on a phased basis in 1986 and 1987. I intend to proceed as quickly as possible with the commissioning of Beaumont Hospital which has been referred to on many occasions in this House. This is a much needed facility which will replace inadequate accommodation at both Jervis Street and St. Laurence's Hospitals. I am concentrating particularly on opening the acute psychiatric facility at the hospital as part of the sectoral psychiatric service provided by the Eastern Health Board. The planning brief for James Connolly Memorial Hospital has been prepared and I am giving consideration as to how this development can be slotted into the programme.

On the south side, a major phase of the development of St. James' Hospital is currently under construction and is expected to be completed in 1989. Planning is proceeding on the development of the new Tallaght Hospital which will incorporate the services currently provided by the Meath, Adelaide, Harcourt Street and the orthopaedic service at Dr. Steeven's Hospital. A planning brief for the development of St. Vincent's Hospital is nearing completion.

Apart from the six major Dublin hospitals, major improvement or development schemes have been completed or approved at St. Michael's Hospital, Dún Laoghaire, the Rotunda Hospital, Cappagh Hospital, Harcourt Street Children's Hospital and the Meath Hospital while planning is proceeding on developments at Naas Hospital, Temple Street Hospital, St. Michael's Hospital, Dún Laoghaire and St. Columcille's Hospital, Loughlinstown.

The rationalisation plans for the south side of Dublin provide for the transfer of services at Sir Patrick Dun's Hospital, Baggot Street Hospital and services other than orthopaedics at Dr. Steeven's Hospital to St. James' Hospital Services which had been provided at Mercers Hospital have already transferred to St. James' Hospital.

Sir Patrick Dun's Hospital was originally scheduled for closure in 1989. With the co-operation of the parties concerned, I am confident we will succeed in having an orderly closure and transfer of patients. Already we have completed the closure of St. Patrick's Infants Hospital, Blackrock, with ongoing care being provided for the children concerned. In the Southern Health Board area progress is evident. We have had excellent co-operation with the South Infirmary and Victoria Hospital which have been amalgamated. The services now provided by the Eye, Ear and Throat Hospital will be transferred to other hospitals in the region with the ophthalmic services going to the Cork Regional Hospital and the ear, nose and throat service going to the South Infirmary/Victoria Hospital.

I am particularly pleased with what happened in the Midland Health Board area as regards Portlaoise, Tullamore and Mullingar. The paediatric service in Portlaoise is well under way and we are providing a service for the entire region pending the completion of the new development at Mullingar. This means that for the first time ever the people of the Midlands have a fully fledged paediatric and orthopaedic service. Many Deputies challenged me as to the provision of that service but the proof of the pudding is in the eating and I am pleased to record that the unit now has two full time consultants. I want to commend the officers of my Department who have worked long and hard to bring about the rationalisari tion of the services in the Midlands. I am very happy this has been so successful because it means no more comments for narrow vested interests of a political nature will be made in the future.

The Mid-Western Health Board agreed with my proposal that the old geriatric hospital at Edenvale be closed and the resources used to open the new maternity unit at Cahercalla and the renal dialysis unit at Limerick Regional Hospital. This has now been done and for the first time the mothers of County Clare have a top class modern maternity facility while patients with renal failure no longer have to travel long distances to Dublin, Cork or Galway for dialysis. New renal dialysis units have been opened in Sligo and Letterkenny. This service has been long over due.

The North-Eastern Health Board recently submitted a proposal to close the County Infirmary in Navan for inpatient use and to use the resources to open the new children's unit in the orthopaedic unit in Navan, to initiate a geriatric assessment service at the geriatric hospital in Trim and to establish a psychiatric day hospital at the County Infirmary in Navan. The proposal looks sensible and will have my support.

The new maternity unit at the Galway Regional Hospital has been opened. I hope to visit it shortly to see it in operation. In the South-Eastern Health Board area I am making additional funds available for the establishment of a consultant staffed paediatric service at Wexford General Hospital. This will be in operation very shortly and will provide a much needed and valuable service for the area. I am satisfied that the funding from the Exchequer of two bodies responsible for health research is by no means the most efficient means of disbursement of such funds. The amalgamation of the two bodies under a single statutory authority would be very successful.

I thank the Chair and Deputy O'Hanlon for their tolerance while I read a very lengthy script, but I thought I had longer than 30 minutes to make my contribution. I hope to deal in my reply with the reorganisation of the health services which is referred to in the final page of my script.

I understand the Minister's problems in relation to timing and I appreciate that he was under pressure to finish reading his script. However, he has given us a bird's eye view of the situations as he sees it but one of the major areas to which he did not refer was the morale of the people working in the health services. This is at an all time low mainly I believe because the Minister has not recognised that these people are working harder with reduced allocations. I do not intend to spend my time this morning going into the health cuts because we have been over that ground a number of times.

It is important that the Minister recognises that health board staff — management, medical, nursing, paramedical, maintenance, wardsmaids and so on — are making a very valuable effort with a reduced allocation. On a number of occasions the Minister said there was plenty of money for anything that needed to be done, but that is far from the reality. The Minister told us what was happening in the different health boards, but he read four lines dealing with the new maternity unit in the Western Health Board area. There are much more fundamental reorganisation plans in Merlin Park Hospital. We would like to have heard something about this from the Minister.

The question of the Department instructing health boards, as has been done on a number of times, brings into focus the relationship between the Minister and his Department and the health boards. This has been the subject of comment in this House often. On 30 January the Minister expressed his concern at the way the management of health boards behave in relation to their boards as against their relationship with his Department. This is another area the Minister should look at. It appears that he sees the personnel in the health services as his staff rather than as 58,000 people working for other health agencies. It is in this area that a lot of morale problems arise.

The Alma Mater Declaration, to which we all subscribe — to try to provide health services for all by the year 2,000 — is an ideal which it is unlikely will be achieved. That does not mean we should not work towards that goal. The major topics raised at that conference were the promotion of good health and the prevention of illness. Over the years there has not been a significant increase in the allocation from the Health Estimate to community protection programmes. This year there is an increase of £500,000 but there are many areas which need to be looked at by the Minister.

There should be more emphasis on personal responsibility for health. Coronary artery disease, one of the great killers of our time, can be prevented by a better life style. This is something the Government should be promoting. In the United States they were able to reduce the number of coronary artery disease attacks in the male adult population by a comprehensive education policy on a healthy lifestyle.

On the question of diet, food plays a major role in two directions. In the Third World the lack of food causes serious morbidity and mortality while in the western world over-eating causes the problems. The Minister and the Department of Health should look at this area.

We have a good record on immunisation and in the past I have complimented and supported the Minister in his measles immunisation programme. The prevention of illness is of great importance and health agencies should be involved more actively here. In the next 25 years the same attention should be given to the prevention of illness as was given to the treatment of illness in the last 25 years, particularly in the areas of science and education.

It is topical to say a brief word about one or two areas. One is the whole question of radioactivity and the role of health departments throughout the world and of Ministers of Health in this. Our Government here have not been sufficiently vocal on the question of nuclear fallout and radioactivity from nuclear stations generating electricity or places such as Sellafield. Ministers for Health around the world must interest themselves much more in influencing their governments to consider the dangers associated with radioactivity. Something which must be a matter of concern to us all is the definition of a tolerable level of radioactivity. There has never been a revised figure upwards. The figure for the level of radioactivity has often been revised of downwards on the basis that some new complication was discovered. We have never seen the physicists coming along to say that there is a much safer level of tolerance. The moral is that there is no such thing as a tolerable level of radioactivity. It would be a tragedy for mankind if we were to spend our time fighting against the proliferation of nuclear weapons because of the danger of massive radioactivity in the world as a result of a nuclear war and at the same time neglect to deal with the very serious problem of increasing radioactivity from nuclear stations. We had the example of Chernobyl and there is no doubt that that type of incident can be repeated nearer to us here. Therefore, I appeal to the Minister to use his influence not alone on his own Government but on other Ministers for Health around the world so that the whole question of nuclear activity will be taken more seriously.

Another serious problems in our country and in many others is the abuse of alcohol. While the Minister referred to the problems associated with the abuse of alcohol it is interesting that when he spoke about substance abuse and the allocation to the Health Education Bureau, he made no comment on what plans there are to deal with education in relation to this substance abuse. The figures the Minister gave are quite startling.

In 1970, 3,073 persons were admitted to hospital for the treatment of alcohol abuse and in 1983 there were 7,100, a very significant increase. Earlier in the year the Minister told us in reply to a question of mine that six person under 15 years of age, 19 persons between 15 and 20 years of age and a total of almost 300 under 25 years of age were admitted to psychiatric hospitals. These figures must create concern for Health Ministers and Health Departments, particularly now when new legislation is about to be introduced to this House in regard to the licensing laws.

I hope that the Minister will make a positive contribution at Government level regarding the seriousness of alcohol abuse and if anything special needs to be done that will be done in the legislation. I would like to see the Health Education Bureau financed sufficiently so that they might introduce the same sort of aggressive programme as was introduced in relation to smoking. It is significant that the Minister in replying to a question here said that £400,000 was spent on combating the abuse of smoking, £400,000 was spent on combating abuse of drugs and just £70,000 was spent on combating the abuse of alcohol which creates far and away the most serious problems of substance abuse in this country.

We get good value for money in the GMS which caters for almost 37 per cent of the population at a cost of £100 million, providing a very comprehensive general practitioner service for seven days a week 365 days a year. Obviously, areas in that service must be looked at. It is to be hoped that the present negotiations will be brought to a successful conclusion in the not too distant future and I appeal to the Minister not to delay them in any way.

I ask the Minister to look at the matter of ensuring that doctors who prescribe generic drugs will be aware of the drug that is to be dispensed. At present if a doctor writes the basic name of a product it is a matter for the pharmacist to dispense any manufacturer's product and we are all satisfied that one would not necessarily get the same product. I know that we have a licensing system, but this area needs to be examined to ensure that doctors can confidently use more and more generic products as we would like to see them do. There is no reason why a more expensive drug should be used if an equivalent which costs less is available.

The money allocated for the home nursing service is being increased by £0.5 million. This brings into question the whole thrust and support of the Government for a shift to community care. It appears that over the years there has been no significant shift in resources to community care. There has been a reduction in some health board areas in the travelling allowance of nurses by 10 per cent as a cost saving device. If we are to build up community care sufficiently to cut down the use of our acute hospitals and hospitals for elderly people we must have an efficient nursing service which we must not curtail in any way. The Minister told us that 2,100 new nurses were appointed over the last five years. Since the Minister came to office 452 nurses have been appointed to health boards. The Minister may not have the information, but I would like to know where the 2,100 nurses were appointed. When I asked a question in the House as to where they were appointed in detail generally the Minister was unable to provide the answer.

The question of travelling expenses for personnel working in the area of community care is also interesting. I raised the question of the deterioration of the level of dental service and the Minister listed the amounts of money which the health boards are paying for travelling expenses as being one area where they could perhaps make a saving in order to be able to improve the dental service. There is an obligation on the Government to provide an adequate and proper dental service. Such is not available at present. It is intolerable that people on the lowest income are obliged to go to a private dentist and pay for treatment.

We do not have time in this limited debate to go into great detail on the question of personal social services but I hope that an opportunity will be provided later in the House to have a discussion on the report of the Commission on Social Welfare because many aspects of the report impinge on the area of administration of the health service. For example, the disabled persons' maintenance allowance does not really fit into the scheme of unemployment benefit and unemployment assistance. There is also a social welfare scheme of disability benefit but there is none in relation to disability assistance administered by the Department of Social Welfare as that scheme rests with the health boards. The fact that it is not funded directly from central funds may mean that it is not as widely available because of cutbacks as it should be. One health board reduced the allowance for the rehabilitation maintenance allowance by £10 per week which is unacceptable.

Voluntary agencies have suffered over the years and they must be supported because it is obvious that elderly people suffering from acute illness should, if possible, be maintained and supported in their own homes if not by their community. If the community are maintaining them much of the support will be and has been traditionally given by voluntary agencies. We must ensure that nothing will diminish the quality of their work.

The psychiatric services have been debated here at length on a number of occasions and the Minister said on 30 January that St. Patrick's, Castlerea and St. Dympna's, Carlow, would be closing this year. There is now a reorganisation and I understand that they will be maintained as geriatric hospitals although psychiatric patients are still being admitted to them. There seems to be a certain amount of confusion in that regard. We fully support the recommendations of the report on the psychiatric services entitled "Planning for the Future" in which is recommended a phased development over ten or 15 years. It should be seen in that context. It would be a tragedy if we moved too quickly and ended up with the results which can be seen in Italy or indeed in the United States where persons were put out of psychiatric hospitals. This was unacceptable to the public and the whole idea of community psychiatry developed a bad name. However, the fact that these mistakes were made does not mean that the concept is wrong but it would be a pity to make the mistakes made in those countries.

Concern has been expressed by voluntary organisations, including religious orders, in regard to the mentally handicapped as their allocation for this year has been reduced in real terms. They would like to develop a community service but they will be obliged to maintain more and more mentally handicapped people in institutions. This is something we should be trying to get away from. Nevertheless, having said that, it is important that places would be available for persons who need residential care. I was perturbed to hear the Minister say that children are not a priority in this regard. I accept that there may be a larger number of adults waiting for admission to homes for the mentally handicapped and that probably a small number of children is involved but for individual families who are unable to cope with a severely handicapped or autistic child who is in their care for 24 hours of every day, it is not very comforting to be told that there is only a small number on the waiting list.

I wish also to refer to the impact of the National Lottery Bill on the services for the handicapped generally. I wonder if the Minister is aware of the consequences of that legislation for many of the voluntary organisations involved in the care of the handicapped. Have the Government taken advice as to what the impact may be on many organisations who depend on lotteries for support and maintenance?

We have discussed the question of the closure of wards in acute hospitals. I should like the Minister to look particularly at the impact of the closure of specialist units for longer terms than usual during the summer for maintenance, painting, etc. There will be an effect on the waiting list for admission to hospitals and also in terms of outpatients' departments. Perhaps the Minister will ensure that the situation will not deteriorate in the next 12 months to the same extent as it did over the past 12 months, where in some specialist departments consultants are unable to cope with the numbers on the waiting list.

Has there been agreement between the staff, unions and the health board on the sudden closure of Sir Patrick Dun's Hospital which is due to take place on 29 August although it was not supposed to close until the end of 1988 when patients would be transferred to St. James's?

The care of the elderly will be the biggest challenge to health care between now and the end of the century because there will be more people over 65 years of age. That figure will increase by 10 per cent and the number over 75 will increase by 20 per cent in the next six or seven years. There will be a need for accommodation for these people and perhaps more physicians should be specifically trained in geriatric care in homes for the elderly around the country. There should also be more support for these people in the community and co-operation with other departments in ensuring that good support facilities will be available, for example by the Department of the Environment and local authorities. We should also reconsider the question of extending the scope of the disabled persons' reconstruction grant to families who are prepared to take in aged parents and look after them. That would be the ideal solution.

It is a matter for concern that the amount of cannabis coming into the country is increasing. I asked a question recently of the Minister for Justice regarding the amounts of heroin, cocaine and cannabis which had been confiscated by the Garda during the last three years. I was told that the amount of cannabis confiscated went up from 97.31 grammes in 1983 to 293.17 grammes in 1985. While the amount of heroin confiscated seems to have levelled out, nevertheless it is an indication of the activity of people involved in substance abuse.

The Deputy has five minutes.

On the question of the Green Paper promised by the Minister on a number of occasions, I fail to understand the U-turn taken on this because it appears that a comprehensive debate on the health services generally would have helped the Minister in making his proposals to Government. Instead of that, having promised us a Green Paper over a number of years, we are told now that he has made the proposals without any Green Paper and without any major discussion with all the various agencies and people who would have wished to contribute.

Let us take the example of the Children (Care and Protection) Bill. The Minister told us here today that a number of changes would have to be made in it. I would not like to see the same thing happening to the whole reorganisation of the health services, to see the Government bring forward proposals that are totally unacceptable without a proper debate. We hear of a possible reduction in the number of health boards to three and that is moving away from the thrust of other Departments such as the Departments of Education and the Environment who are going for devolved administration. The Department of the Environment published a booklet in advance of the local elections last year, giving all the various duties that would devolve on the local authorities. In regard to health services, more and more power has been taken into the Department since the Minister came into Government. It would be unfortunate if proposals unacceptable to the public generally were brought into this House. It is unfortunate that the Minister did not bring his Green Paper to the House as he did in regard to the Green Paper on the Disabled and the report on the psychiatric services. It would have been a valuable exercise.

I am not sure that his Green Paper would be on the basis of what has been presented to the House in the past three years — the problems with Beaumont and the question of whether it would be opened, the whole question of the nurses' home on which work was commenced in 1984 and the reversal of that decision, the whole question of using part of the hospital for psychiatric services which I think is a mistake because I believe it should be opened as one major general teaching hospital for the north city, the problem with Monaghan hospital which was supposed to close and the reversal of the decision to do so, the question of more authority for State bodies involved in health on hospital management boards and the question of bringing the Medical Research Council and the Medico-Social Research Board under the aegis of the Department which I am not sure would serve the public interest in the long term because it might interfere with the independence of these two bodies who have been doing very good work.

Regarding the Control of Clinical Trials Bill I was glad to hear that the Minister will accept amendments that do not interfere with the general thrust of the Bill and I hope he will take account of the concerns of many bona fide groups who are concerned about that legislation.

I did not go into the whole area of cutbacks because we have been through that area before. That does not mean that we are not still concerned about it. I would ask the Minister, particularly during this year, to see if there is any way he can raise the morale of all the staff who are working in the various health agencies and ensure that adequate services are provided, particularly in areas where the services have deteriorated rapidly, for example, the dental service area?

I want to put on the record the fact that the health services we have here are among the best in the world. We should not lose sight of that fact which is a tribute to this Government, to previous Governments, to this House, to the Department of Health and to the doctors and nurses and the various attendants and public servants in the health services. It is not just our job to put the Department under scrutiny and complain. We should also give encouragement and recognition where it is due.

I want to refer to the question of cancer in our society at the outset lest I run out of time later. I did not hear it referred to so far. In reply to a Parliamentary Question in my name some weeks ago the Minister gave some startling figures on the death rate from cancer and on the variety of cancers in the community. I am aware of the Minister's concern about smoking and alcohol abuse which was mentioned also by the Opposition spokesman along with the question of drug abuse but cancer is one of the biggest killers of younger people and it is totally indiscriminate.

Three members of my own family have passed away, one in a tragic accident and two from cancer. Increasingly, it is the young — children, teenagers and those in their twenties and thirties — who are affected by this indiscriminate disease. It appears to be becoming more prevalent among those who would have been expected to have long and healthy lives ahead of them. I regret that there is no procedure for Parliament to become involved in the area of examining health hazards to the community connected with cancer. Parliament, in collaboration with the health boards, the Department of Health and the various medical experts, should be entitled to look into the whole question of this frightening disease and to discuss resources to fight it. This is not a party issue. In the US Senate such an examination has been carried out. Parliament must develop its committee system along the lines of other Parliaments and the model we are pursuing is probably nearer to the German one, but we have not gone very far along that road. New Zealand, of comparable size to us, has a structure which would entitle that Parliament to examine this question and we should, too. There should be a committee dealing in general with health affairs, but specifically with dreaded cancer.

Can we be satisfied with the growing nuclear hazard of Sellafield and the Holyhead area and others? Are we scientifically satisfied that problems there are not a contributing factor to the increased incidence of cancer among our young people? What are the other contributing factors? In any other era a disease which stood out so clearly as this would have been the subject of attention by the Parliament of the day. I ask the Minister to become the catalyst in getting together a committee of this House or a joint committee of both Houses to find out what gives rise to cancer, what can be done to cure it or minimise its effects, or to remove the hazards which give rise to it. Smoking is not the sole cause. Other matters need to be tackled.

For seven months when we were in Opposition on the last occasion I was junior spokesman for Health, with specific responsibility for health board reform, but I did not make very much progress before the Government were changed. No other issue prompted as much interest around the country as that of health reform. At the time of the dissolution of Parliament I had been invited to speak in about eight different counties, where people had very strong views on what should be done. We should not be establishing three health boards. We should be reducing the number, and should not be making health boards larger. The Eastern Health Board cover Dublin and part of the surrounding counties of Kildare and Wicklow. This is far too cumbersome and far too remote from the people. Above all, it is far too lacking in accountability. The Minister is not answerable for the day to day running of the health boards, nor are the local authorities, so these boards are in a particularly smug limbo, accountable neither to Parliament nor to local authority. They should be accountable to elected public representatives because of the problems which arise from time to time.

Dublin Corporation spend something in the region of £250 million a year, which is a great deal. The expenditure is made to work because the corporation, leaving aside the county council and the Dún Laoghaire Borough Council, have officials who work very closely with the elected councillors in the administration of the city. There should be some similar procedure for the health boards. I am aware that there was previously a Dublin Health Authority but I am not necessarily suggesting a return to that. However, there should be a greater involvement of councillors or of this House in making health boards more accountable. It is all too easy for the boards to blame cutbacks for all situations. An explanation such as that would not be tolerated by Dublin Corporation for any of the other services. That is happening because there is nobody to call in the official concerned to ask specifically what has happened in a case. I am urging on the Minister to involve councillors in holding the health boards responsible.

In the Dublin area the Dublin Corporation, county council and borough council — the three county councils as they will be in time — should be able to call in an official who would be answerable to an elected authority. This would bring the health boards nearer to the people and would cut out unnecessary bureaucracy and the blaming of all shortcomings on Department of Health cutbacks. The Department of Health are, after all, the second biggest spending Department in the State. This would be good for democracy and would serve the people, as it is our duty to do. I know one case of an elderly person who had a fall in the middle of the night and was brought into hospital by ambulance for X-ray and sent home at 4 a.m. in a taxi in a disorientated state. Nobody was held to account for that. I cannot put down a Parliamentary Question referring to such a case, even if one of my constituents were to die. The Minister would say it is a matter for the health boards. I cannot get a councillor to raise the matter at Dublin Corporation level because the City Manager has no responsibility for such a case. It is by making sure that cases such as that do not happen that we will get the system to work for the people. I earnestly ask the Minister to scrap the health boards and return the health services to some forum of directly elected people, such as local authorities, to bring back accountability.

The central purchasing of drugs was recommended by a report, with the use of prescriptions using generic terms rather than branded names, with a saving to the State, in mid-seventies terms, of somewhere in the region of £10 million. That recommendation was never followed up. The State may well have lost in the region of £20 million to £25 million because of that, although there is no way of measuring the amount. There should be a central purchasing of drugs for use by the health boards, with the requirement that drugs prescribed on a generic basis should be dispensed on a generic rather than a brand name basis. If somebody needs paracetemal, a branded produce should not be necessary. I understand from evidence recently given before the Committee of Public Accounts that in the region of 30 per cent extra cost is involved because of this. That is totally unnecessary. The attention of the House and of the Department of Health has been drawn to this in an expert report and ten years later nothing has been done. Perhaps the Minister will allude to this subject and put the House right if what I have said is incorrect. I should like to be able to read his reply in the Official Report so that the Committee of Public Accounts can pursue the matter. There is wasteful expenditure on a grand scale in that area.

There are three remaining aspects to which I wish to refer. The first is the Children's Hospital in Crumlin, in which I should declare an interest as I am a member of the board of management. I want to express my appreciation to the Minister and the secretary of the Department of Health for their assistance to that hospital to date, particularly in the recent past. I ask the Minister to ensure that the design stage for the development of the out-patient department of the hospital goes ahead urgently. It is the biggest children's hospital in Europe and probably one of the biggest in the world. It is an excellent hospital. It does not serve Dublin alone because children are brought there from all over the country. Parents travel long distances to see their children and this gives rise to parking problems in the area. If a proper out-patient department could be developed some children might not have to stay overnight in the hospital. That gives rise to stress for young children. I want to express my appreciation for the assitance which we have got to date.

I wish to refer to the dental service for married women, particularly women whose husbands are working and paying stamps but who are not working themselves. I urge the Minister to ensure equality of treatment in this regard. If it is not possible to extend the full treatment to married women then at least married women and their husbands should arrange to take turns when applying for the service. It is outrageous that the husband can qualify and the wife cannot. In many cases women are more in need of dental services because of the dental problems which sometimes arise on a post-natal basis. I ask the Minister to consider urgently the need for the extention of equality of treatment for dental services for married women whose husbands are full stamp contributors.

I ask the Minister to consider involving his Department in the training of judges in the area of drug abuse and misuse. Many of our judges still do not understand the serious difference between heroin and cannabis or similar drugs. In the past a person with a quantity of cannabis got a jail sentence but a person with a quantity of heroin got a suspended sentence. There should be some training in the area of drug abuse, drug identification and the difference between drugs. Members of the Judiciary should be assisted in dealing with the administration of the misuse of drugs legislation. Many judges are at sea. They have not been provided with professional courses to develop their knowledge in this area. All gardaí get initial training in regard to drugs. Some gardaí of higher ranks take refresher courses in the area of drug abuse. I presume our customs service are constantly getting advice on the variety of illegal drugs available. If not, they should be.

I ask the Minister to initiate steps to ensure that, through his Department, or the health education authority, whichever he considers to be the appropriate body, a course will be developed for members of the Judiciary so that they will be easily able to identify the variety and the seriousness of drugs. This would help them in the administration of the Misuse of Drugs Act. I ask the Minister to place on the record of the House the current state of play with regard to drug abuse in the community, if the situation is under control, if the trend is downwards and if he has figures or information to show the position on drug abuse in the community.

Will the Minister have an opportunity to reply to questions which is now the practice in Estimate debates? Is that the arrangement today?

We have Question Time at 2.30 p.m.

I believe the procedure is that the Minister can now respond to questions from Deputies in the House.

Provided it concludes at 2.30 p.m. when Question Time commences.

I hope I will be excused if I concentrate mainly on my own constituency and concerns in my constituency regarding the future of hospital services in County Roscommon and part of east Galway. Yesterday was D-day for the closure of St. Patrick's hospital in Castlerea. Fortunately, D-day has passed and the hospital did not close. I am delighted. I take this opportunity to appeal to the Minister to allow the retention of St. Patrick's Psychiatric Hospital in Castlerea and to withdraw his deadline for closure which I understand is now the end of August 1986. In case the Minister would accuse Deputies and Senators in the constituency of lacking in progress and being parochially minded, I make no apologies to the Minister, his secretary or his Department officials for my wholehearted support for the continuation of acute psychiatric services in St. Patrick's hospital in Castlerea and the development of full services in the county hospital in Roscommon. The county hospital in Roscommon has provided an excellent service over the years to the people in that county and in surrounding areas. At present, as a result of Fianna Fáil policy, we have an eminent physician, Dr. Pat McHugh, an eminent surgeon, Dr. Michael Relihan, and a full back up service to support them in their work.

In 1985 for a 12 month period there were over 2,106 admissions to the medical department of the county hospital in Roscommon. That makes it one of the busiest medical departments in any county hospital in the country. I request the Minister to approve the application by the Western Health Board to appoint a second physician to the medical department of the county hospital in Roscommon. The number of admissions whihc are documented, of which the Minister is quite well aware, would justify the appointment of a second physician to the medical unit of that hospital. In the coronary care unit of the hospital there were 422 patients over a 12 month period. As a constituency Deputy I visit the hospital on a regular basis. I can testify to the number of patients who have been treated successfully in the coronary care unit, the medical unit and the surgical unit of the county hospital.

The proposal by the Minister which was announced in the Dáil to close the acute psychiatric unit in St. Patrick's hospital in Castlerea and to transfer it to the county hospital in Roscommon was not welcomed in my constituency or in County Roscommon. It has been resisted by the elected members of the Western Health Board, and as chairman of the Roscommon health committee I can say that the committee fully voiced their objections to the proposal.

The transfer of the psychiatric patients from Castlerea would deprive the county hospital of 30 beds which are badly needed there because of overcrowding. Besides, it is undesirable to transfer an acute psychiatric unit to that hospital. I should like to know if the report of the specialists is available. I hope the report is not subject to duress on the part of the Department. I inspected the unit in the county hospital in Roscommon and found it totally unsuitable for use as an acute psychiatric unit.

The people of Roscommon are quite prepared to accept any fully equipped psychiatric unit in, say, the grounds of the Roscommon County Hospital. That is a reasonable request and it should be supported by the Minister. The Castlerea hospital is one of the newest such hospitals in the country and has been providing an excellent service. It is in very spacious grounds, suitable for the recuperation of psychiatric patients. I do not see any justification for the proposal to transfer those patients to a ward in the county hospital which cannot possibly be properly adjusted or adapted for such a service.

There is nothing but amazement at the Minister's proposal to retain the Castlerea hospital as a psycho-geriatric unit. The hospital should be retained in its present capacity until a new psychiatric unit has been built adjoining the Roscommon County Hospital. The staffs of both hospitals have agreed with this suggestion. Therefore, the Minister should postpone the closure of the Castlerea unit pending the erection and the completion — it would take five years — of the new unit in the grounds of the Roscommon County Hospital.

I regret that that decision was made. The Minister of Health is a Labour Party member of the Cabinet and the Cabinet are responsible for this objectionable decision. The Taoiseach disowned the decision of the Minister when addressing Fine Gael constituency meetings in Roscommon. This shows the total lack of cohesion in the Coalition. The Minister must be aware of the Taoiseachs decision to remove him from the Department of Health in order to be amenable to pressure from Fine Gael backbenchers from Carlow-Kilkenny and elsewhere in regard to the Minister's decision. The Taoiseach does not want the Minister for Health in this important Department, and the Minister knows the lack of loyalty and cohesion in the Cabinet in regard to Coalition policy.

Basically, the Minister is on his own in relation to these decisions affecting my constituency. Seemingly, he is in a position to prevent his removal by the Taoiseach and this indicates that the Taoiseach has no real ability to manage the Cabinet. Indeed that was amply illustrated last Thursday. I hope we will be able to fight a general election soon and in my constituency we will be fighting to provide proper health services which the people want and are not getting. The damage being done there by the Minister is untold. Those candidates put up by the Government in the general election will dissociate themselves from the Minister's decisions. I suggest that the Deputy representing Fine Gael in that constituency is not here today because he would prefer to refer to this matter behind closed doors locally and indicate his total objection to the Minister's policy in the constituency.

The proposal of the Minister is to transfer the maternity unit in the Roscommon County Hospital to St. Anne's maternity ward. Comhairle na nOspidéal agree that an obstetrician-gynaecologist and a paeditrician should be appointed to the unit in the County Hospital. The Minister promised me a few weeks ago during Question Time that he would make available the file of correspondence between Mr. Basil Chubb and the former Minister for Health.

The Deputy will have to get the permission of his Leader.

The Leader of my party gave his permission in the House.

He did not.

The Minister promised to make the file available to me. Deputies from the constituency would wish to see that file. As I said, it was agreed to appoint an obstetrician-gynaecologist and a paediatrician in the Roscommon County Hospital.

Appointed by whom?

Comhairle na nOspidéal approved the appointments for the maternity unit.

Was the Deputy present?

The paediatrician took up the appointment and he has not been replaced by the Minister.

He resigned before my time. He had no work to do.

There are more than 1,000 children born to Roscommon women every year in maternity units throughout the country. The children should have been born in the local maternity unit.

There is no demand whatsoever for such a unit.

There is no demand whatsoever for such a unit.

The Minister made sure there would not be a specialist there. I appeal again to the Minister. He has some motivation in relation to our hospital in Roscommon. It is quite obvious he is based against it. His trip there was of no use to the development of the hospital. I wish to say to the Minister that, since he became Minister for Health, he has not contributed one iota to the development of the health services in my constituency. In the Minister's speech today he allocated four lines to the Western Health Board. That is the only mention he made to development in that area.

I want to place on record my ambition that the Minister will be prevented from transferring the acute unit to the county hospital in Roscommon, that we will be in a position to provide services in the county hospital in Roscommon and that the Department will appoint a second physician and a second surgeon to both areas in the county hospital where the demand exists and where we have provided excellent services for the people of that area and surrounding districts. I appeal to the Minister at this stage to withdraw his deadline for the closure at the end of August of the psychiatric unit in Castlerea and not to transfer it or open an acute unit in the county hospital in Roscommon which is totally unsuitable. The Minister should set about the planning and development of an acute psychiatric unit in the grounds of the county hospital in Roscommon. That is a reasonable compromise to the proposals the Minister is making. They would have the full support of the Western Health Board and all medical and professional staff in both the county hospital in Roscommon and the psychiatric unit in Castlerea.

In relation to other areas of development, we have found since the change of Government four years ago that many people have been deprived of medical services through the withdrawal of medical cards. There has been a very high percentage of withdrawals. Enormous pressure has been put on welfare officers to come down against applicants. Even though we have had the hardest and most difficult of times in the farming community over the past 12 months, there have been enormous withdrawals of medical cards in counties Roscommon, Galway and Mayo. The Minister has deprived very needy cases of medical services. There has been a total collapse in relation to both ophthalmic and dental services in the Western Health Board area. There is an enormous waiting list for children seeking dental treatment. It is now an impossible situation. Nothing is being done by the Department to provide the services and specialists in the Western Health Board area. There is no solution to the problem. The families of young people being treated for dental problems are not in a position to provide the necessary finance to obtain private dental services. The Minister can investigate this development in the Western Health Board area.

Finally, the Health (Amendment) (No. 2) Bill seems to have died and will not re-emerge in this House. We oppose this Bill because the Minister is taking power to close hospitals. We will seek full support on all sides of the House to vote it down. If it causes a general election, so be it. It is one area which will not arise again. Maybe the price of the Minister staying in the Cabinet as Minister for Health was that the Health (Amendment) (No. 2) Bill would not resurface. On the list of legislation to come before the House before Friday it is not even mentioned for consideration. Furthermore, in relation to any closures or changes of status the Minister has to hold local inquiries before he can close the acute unit in Castlerea or close St. Anne's maternity unit in the county hospital in Roscommon. Those public inquiries must be held according to the Health Acts. I appeal to the Minister to set that in train so that at least we will have an opportunity to put our case to the Department's officials.

I would like to thank deputies on both sides of the House for their contributions to this attenuated debate. I would like to reply to a number of points raised. There are some additional points which need to be made. Deputy O'Hanlon referred to the situation in Merlin Park. I stress that Comhairle na nOispidéal, an independent professional body, made recommendations about the future use of Merlin Park in a recent report which they sent to the Western Health Board. The Western Health Board are studying the report. I stress that that report was not commissioned by me. It is aseparate matter. It was not a direct or indirect initiative on the part of the Department of Health. At all times, I welcome the various reports of the comhairle. I respect their objectivity in dealing with those matters.

Likewise, the comhairle have been reviewing the delivery of surgery services in the Western Health Board area. Unanimously they made observations and recommendations in a report relating to the surgery situation in Roscommon general hospital. Again, that arose in the normal course of events. The report is of considerable interest and concern to the Department and to the members of the medical profession in the Western Health Board area and in the delivery of surgical services for the Western Health Board area. Here, questionably I separate Deputy O'Hanlon professionally and as Opposition spokesperson, but it would be too much to expect that other politicians would desist from their massive intrusions of expertise into those areas. What matters in the long run is not where surgery is situated, not even where maternity is situated, but if you had to undergo surgery or if your wife had to deliver a child, where would you want to have the surgery done. That is a fundamental personal question. It is a matter of personal decision. Secondly, in what facility would your wife wish, as is her right, to deliver her baby?

They are basic questions. I am amazed at the capacity of middle aged, middle income and well married politicians to pronounce with such incredible certitude that maternity must be here, surgery must be there, and to milk it incessantly week in and week out as a local political issue with such endemic parochialism that one wonders how the health services have been able to develop at all. It is part of what we are. It is a very distasteful part of what we are. It shows how introverted our perceptions are as to what constitutes health care. What matters is that a mother should have antenatal services, delivery services and post natal services in the safest and best situation for herself and her child. That is what matters, not whether the child is delivered in Roscommon, Castlebar, Sligo, Portiuncula, Galway or elsewhere.

We are concerned with the reality of what happens to that woman and her personal health and with the paediatric back-up service for the child in a fully staffed consultant obstetric and paediatric unit. When Deputies come to me with incessant demands about certain hospitals. I ask them whether they would ask their wives to undergo surgery in the hospitals concerned, or to deliver her baby there. In many instances there is dead silence because what is sauce for the constituency goose is not sauce for the personal gander. I make these comments because it is essential that we keep before us at all times the purpose of the delivery service.

I referred earlier to the numbers employed and gave some data which I now wish briefly to supplement. I indicated that in the seventies there was major growth in employment in the health services. In 1981 there were 66,500 persons employed in the health services, while today the figure is 62,500. These figures must be put in context. In 1974 42,000 people were employed in the health services. There was rational growth between 1974 and 1977 and several thousand were added. Then all hell broke loose at the end of 1977 when letters went out from Fianna Fáil Ministers demanding that the health boards employ more people. They were berated because they did not take people on. When it was claimed there was no room in the hospitals to employ any more people, they were still told to take them on.

What about the 2,000 nurses the Minister appointed? Where are they? We cannot find them.

The number of staff rose from 42,000 in 1974 to 66,000 by 1981. It was quite incredible. It was purely a political decision.

What about the 2,100 nurses the Minister claims were appointed during the past five years? We cannot find them.

I could name them.

I have asked a question and I expect an answer.

At Tralee Hospital almost 150 extra nurses have been appointed. There is also extra nursing staff at the cardiac unit in Cork and at the renal dialysis unit in Limerick.

Labour constituencies, of course.

There are extra nurses in the Maternity unit in Galway and at cardiac units in Dublin.

Where there was Labour support there were appointments. This is the most cynical Minister appointed to that Department.

I have never hesitated to agree to the appointment of additional staff where they were needed within the system but the indiscriminate situation which devoloped in the 1979 to 1981 period will go into the history books on medical development in western European countries.

Deputy O'Hanlon suggested that we should have particular regard to the necessity for accurate descriptions of generic drugs. I share his view in this regard. I have noted his point with particular care and he may be assured that we will take note of that constructive comment in relation to the GMS and escalating costs. Deputy O'Hanlon said I made no reference to alcohol abuse in the context of the activities of the Health Education Bureau. The bureau's programmes give wide coverage to the question of substance abuse generally. In the case of alcohol, the board have produced a major second level schools programme on alcohol. They have produced fact sheets on alcohol and have co-operated with the Irish National Council on Alcoholism. Nevertheless I share Deputy O'Hanlon's view that a great deal more work must be done in this area.

Regarding the references by Deputy O'Hanlon to the situation in Italy and England in regard to mental health services, I think he would agree that our services are in many respects very superior to what can be seen in those countries. I recommend that Deputy Leyden have a look at Saint Davnet's Hospital in Monaghan and see how a model of progress can be made in the organisation and development of community psychiatric services. That is not in any way to detract from the very considerable competence of the psychiatric consultant staff in his own area, but there is the inevitable inertia from which we are trying to get away.

Could the Minister outline the position regarding Roscommon?

Regarding the voluntary agencies, I agree largely with the views expressed by Deputy O'Hanlon. Despite financial difficulties I have arranged for an increase in the rates of subvention payable by health boards in respect of persons in private long-stay homes. The increase is about 4 per cent, payable from today.

I thank Deputy Gay Mitchell for his constructive comments in relation to the cancer services. I have noted what he has said about cancer and I will consider his comments carefully. There is an increasing concentration in the acute medical area on oncology and cancer treatment services. I appreciate the concern of Deputies. I also noted what Deputy Mitchell said about the out patients' department at Our Lady's Hospital in Crumlin. As soon as resources permit I will approve of that scheme going to design stage.

Regarding Deputy Leyden's comments on Roscommon Hospital, I have dealt with the surgery end of it and that will be under review by the Western Health Board.

I will make a final comment on psychiatric services. I believe that any acute psychiatric unit should be integrated into the hospital, not operating on a separate, free standing basis in relation to a hospital. When developments of this nature are proposed everybody goes for the ultimate in terms of development rather than what can be achieved in the immediate future. Whatever is developed in Roscommon General Hospital, will be integrated into the general framework of the hospital. I am appalled at the attitude I have seen from some Deputies opposite, but not from Deputy O'Hanlon, that acute psychiatric services should be separate and should not in any way contaminate the general hospital services.

That is not fair. It is a matter of space.

This is something I would not accept and we will avoid it. I thank Deputies for their contributions.

Vote put and declared carried.