I want to take this opportunity to make four main points in relation to the general question of public policy regarding health. It is important that we should bear in mind that this discussion is not just about financing the health services.
First, there is the underlying mistake that has permeated the discussions all this week, that throwing more money at the health service is synonymous with having improved standards of health care, or indeed improved standards of general public health. That is a simplistic and somewhat blinkered approach to the issue. It does the kernel of the problem a disservice. The kernel is not so much the level of resources we use but how we use them pursuant to policy. The assumption is based on a very artificial notion about our health services. That notion is that we have a health service. I submit that we do not. I believe that we have a sickness service, one which deals with illness and does not deal with education towards good health and the prevention of those problems that create ill-health.
Secondly — and to me this is fundamental and I would really appreciate if the Minister could address it — there is the need to change from the present system of disbursement of public funds in the health service, a system which is loaded with built-in vested interests at every level, where all involved receive payments, grants and disbursements based on the amount of service, the frenzy of activity rather than the quality of results or the absence of illness. How can we seriously expect a system to be efficient if it depends for its financial benefits, in terms of who receives them, on there being more illness, more beds, more wards, more hospitals?
Thirdly, there has been a great deal of unjustified, unsustainable and irresponsible comment during the last week about the funding of the health service. The bottom line is that this year, as every other year, there is more money being spent on the health service than last year. That is in keeping with what happens each year when the amount spent is greater than that for the year before. But it is never enough and there are people in this House who will always ask for more. They have no responsibility and no prospect of having responsibility as to where it comes from. I have no doubt that in years to come we will look back at this era and in view of the incredible pressure and ferment of criticism that has developed over the last number of weeks, we will perhaps come to the conclusion that we have had the worst of all worlds, that we have had all of the controversy, the vilification of the Opposition and the political shenanigans arising from the health cuts but, unfortunately, we have not had the economic benefits of genuine constraint in the health services.
My fourth point is our absolute lack of confidence in the present capacity of the Department of Health, to some extent by virtue of the statutes which affect them, either to shed new light on improvements in the health care generally, or indeed in the specific context of financing health, to be adequately accountable for taxpayers' money. There is ample evidence of that.
The simplistic approach that our sickness service demands more and more money, that if it does not get more money we will naturally have a decaying service is fundamentally wrong and based on a false notion of what good health is about. We have an acceptance that it is essential that everybody be bombarded with a campaign to buy more drugs, to attend hospitals more often, a whole approach which is about making profits, about generating business. The health services as they operate now are essentially a business, not a social service. I will quote from a book called Holistic Health by a writer called Lawrence LeShan who said:
There is a tremendous amount of propaganda from drug companies and their advertising agencies to the effect that our bodies do not work and are constantly in danger of decomposing from one thing or another. We must, we are warned, keep a large variety of drugs available, or we will certainly be overcome with everything from dandruff through haemorrhoids to athlete's foot. Not a single system of the body (excluding those like the lymphatic that the lay public does not really believe exist) is exempted from the threat that it cannot function well by itself or recover unaided if it becomes disordered.
He develops that theme that we need constant pepping up, sedating down, medical attention, trips to hospitals, and prescribing. I doubt if there is a house in the country that has not one or two boxes of outdated unwanted drugs in a cupboard somewhere. This is about business, not about good health. Good health should take into account the fundamental need to have on our schools curriculum a programme for education for health which embraces the issue of diet, physical and mental exercise and a whole range of issues which have nothing to do with a drug-addicted society, a whole positive attitude towards the fact that the body is self-healing given reasonable opportunities. That is a fundamental approach to redressing what we have assumed to be the way to good health.
The second thing which arises logically from that is that we have a system which is permeated by the profit motive. That profit motive extends right down to the health boards. It is a preposterous notion that the health boards should have on them members whose incomes depend on how they disburse public funds. Do we really expect them to do what is necessary in the public interest? It is asking too much to think that they will never succumb to the temptation to make a profit. That profit motive permeates every level.
There are other societies where those engaged in medicine are rewarded in direct ratio to the amount of time they are not called upon, implying that if they are doing their job well they are not active. A system that allows people to be paid in relation to the number of calls on them is nonsense and inevitably people will be tempted to use the opportunities for maximising their income. That is fundamentally wrong. It is wrong when we see it at health board level, where the people involved are at least open to the suspicion that consciously or otherwise they are developing an environment in which they can maximise their own incomes and where if there are cutbacks they affect those at the cliff face, and that is what we are witnessing. George Bernard Shaw summed it up relatively well when he said that any sane nation having observed that one could provide for the supply of bread by giving bakers a pecuniary interest in baking, and should then go on to give surgeons a pecuniary interest in cutting off one's leg is enough to make one despair of political humanity. That sums it up well enough.
If I were politically cute, I would keep my head down and say nothing, but the allocations this year surely do not justify the headlines we have seen saying that the health services are in chaos and the particularly emotive, offensive and exploitative programmes which have used old people for the purpose of putting pressure on this House to obtain more scare resources, a highly questionable procedure. Those allocations, limited and constricted as they may be, do not justify that kind of heat and steam. Those allocations show that in the case of every health board except one, there is this year a greater allocation than last year. I would be the first to admit that in areas there might not be enough. Nobody has ever had enough yet. The reality is that we are living way beyond our means and it cannot continue. Those who cry and bleat for more should say where it is to come from.
The one health board did not get more; it got £600,000 less which I am sure is a matter of discomfort for them but it should not result in the closure of hospitals and hospital wards in sensitive areas relating, for instance, to child assault and rape, unless there is a deliberate policy for some reason. Those who are at local and middle management level who administer these allocations in a selective way are being deliberately selective for reasons that have nothing to do with the wellbeing of those who attend those hospitals.
Over the past number of years the health services have expanded dramatically. Since the mid-seventies the health service has grown tenfold, and more than double in real terms. Staff totals in the health boards have grown from less than 24,000 in 1971 to 57,000 today and yet some people ask for more. It is not a question of more resources, it is a question of making better use of existing resources. There are no more resources and there will not be any more resources. The miracle is that these resources are available because most of them are borrowed. The sad part about the use of the resources is that it is very difficult to have confidence in the way they are overseen. The Comptroller and Auditor General in his report, Appropriation Accounts 1981 in paragraph 72 under the Health Estimates said:
The accounts of certain Voluntary Hospitals are audited by Local Government Auditors whose reports are made available to me. One such report examined by my officers in the year under review related to the audit of the 1979 accounts of a Voluntary Hospital which in that year had 94 per cent of its running costs financed by grants from this subhead. In 1981 grants paid to this Hospital amounted to £7 million approximately.
And he goes on:
In his report dated 28 July 1981 the Local Government Auditor referred to a number of deficiencies in internal control and accounting procedures. These included erroneous and inconclusive bank reconciliations....
The position was the same in 1982. In regard to that year he said:
The Accounts of the Health Boards are audited by Local Government Auditors whose reports are made available to me. In his report dated 16 August 1982 on the audit of the accounts of the Eastern Health Board for the years 1979 and 1980 the Local Government Auditor drew attention to a number of accounting and control deficiencies as a result of which he was unable to satisfy himself as to the accuracy, reliability and completeness of the Board's accounts and records and was unable to form an opinion as to the fairness of the results and financial position as presented....
In 1983 referring to the expenditure of the North Eastern Health Board he said:
The Board's expenditure in the three years totalled approximately £71 million ... As control deficiencies such as those referred to by the Local Government Auditor can lead to an increase in the Board's grant requirements I asked the Accounting Officer what action was being taken by the Department of Health to ensure that such deficiencies are rectified.
The deficiencies he was referring to were his inability to obtain "satisfactory audit evidence of the proper receipt, issue and custody of stocks of such goods including medical supplies and equipment". He said that the value of such items purchased in 1979 was £3.3 million.
The position was the same in 1984 when he stated that——
A concerted attempt had been made to charge expenditure incurred in 1982 to the 1981 accounts and that the measures employed to achieve this included, inter alia, the alteration of the dates on suppliers' invoices....
To my way of thinking that would be a criminal activity. He went on to develop the same theme in 1985. Those reports are available annually to the Government. What has been done about those systematic deficiencies and distortions? The former Minister for Health, Deputy Desmond, said he had told the health boards they could not spend what they had not been allocated but they did so while he was Minister and continued to do so.
There are many other issues one could raise in the context of these anomalies but this boils down to our inability to have confidence in that accounting procedure. For example, we have not heard a word from any side of the House about the fact that on average it costs more than twice as much to provide a hospital meal for staff in hospitals than the charge made for it and that the menu is different from that for the patients. What about that subsidy? We have not heard any suggestion about the fact that it costs four times as much to issue a birth or death certificate than the charge made for them. Could that be corrected? We have not heard any suggestion about the failure of the Department of Health to deal with their statutory obligations in a number of areas relating to the provision of services or in regard to a list of matters some of which I referred to in a written question today. What about the significantly higher level of doctor visitation and prescribing to GMS patients over private patients? That cannot be explained away by the supposed inferior health status of medical card holders. We have not heard anything about the virtual non-existence of a dental service for medical card holders although that is a statutory entitlement.
The confusion, costs and duplication in the system of inspection of food and food premises by the Departments of Health and Agriculture has not been referred to. The Minister has failed to insist on up to date audited accounts. It is preposterous that every year we allocate to these health boards moneys where they have not shown — in some cases they have shown with certain unhappy overtones — that they have used wisely or well previous allocations. I suggest that we should insist on an annual report and accounts for the previous full year prepared to an acceptable standard and laid before the Dáil at least 90 days before any budget which includes an additional provision for them is considered by the Dáil.
I asked the Department of Health a long time ago to answer questions about Jervis Street Hospital but the hospital refused to give that information. I am not saying that the Department of Health get sufficient money or that discomfort and distress is not being caused but some attempt to redress the imbalance is appropriate. A lot of the over-reaction engendered this week is unjustified. In all fairness the general thrust of the Government's policy should be supported although I wish they scrutinised general guidelines on how the cuts are to be adopted.
If they remove the profit motive from the prescribing of medicines and so on we might get better value for our money and better health which is what this is all about.
