Skip to main content
Normal View

Dáil Éireann debate -
Thursday, 21 May 1987

Vol. 372 No. 12

Health Policy: Statements.

There has been an adequate opportunity over the past two days for all sides of this House to dwell on the past in relation to health policy and the current budgetary difficulties faced by the health services. The Dáil in the votes last night has accepted that the financial parameters within which the health services must operate this year should not be altered. The health boards and other health agencies have been notified of their allocations and in the first place they must ordain their affairs to live within those allocations. All but two of the health boards have drawn up their plans to live within those allocations and I would hope that those two, the Western and the Mid-Western Health Boards from whom I met representative deputations yesterday will now draw up their plans to do likewise.

Senior officers of my Department have met with all boards and agencies in the past fortnight and with the submission of the two outstanding plans they will be enabled to complete their global analysis of what is proposed. They will be able to determine both the reality of what is proposed and proceed to the rationalisation and integration of the plans to ensure that the services available locally, regionally and nationally are capable of meeting the essential needs of the Irish people. I emphasise it is the fundamental responsibility of the health boards, with their local knowledge, to produce a plan to live within their allocation.

It is high time we raised our sights beyond the immediate difficulties and gave some serious thought to the steps needed to move the Irish health system from the position in which it now finds itself to the type of system we would like to see developed, and which we need to develop, in the future.

Of course, the present financial constraints make any form of developmental thinking difficult and they cannot simply be wished away. However, financial problems are not an excuse for doing nothing other than compressing the existing system. If anything, the financial constraints within which health services will have to be provided for the foreseeable future underline the urgent need to think afresh about the whole approach to health policy and to question in an open and unrestricted way the assumptions which underlie the health system as it currently operates.

I have already outlined, in the course of the past two days, some of the main elements of the change now needed in the health system. They include a review of the funding arrangements; the rationalisation of the acute hospital system; the development of primary health care services; the development of health promotion and preventive services; and an improvement in managerial arrangements at all levels in the system.

The funding question is of fundamental importance and is closely related to other policy issues such as the nature of the health system we want in terms of "demand lead" or "supply constrained" and the distribution of available resources towards high priority services and high risk groups in the population. The choices facing us in this regard have wide implications and it is of crucial importance that decisions are made on the basis of a sound analysis which draws on the best expertise available.

The phasing out of the contribution from local revenue sources towards funding the health services over the period 1973-1976 had the effect of shifting virtually the entire burden to central taxation. The current concern to contain the volume of health spending reflects the broadly acknowledged need to redress the imbalance in the public finances by placing limits on the volume of public spending generally. Obviously, major spending areas such as the health services come under particular scrutiny in these circumstances and, given the scale of the adjustment to be made in public spending, the constraints applying in 1987 are likely to be a continuing feature of health service provision, if funding remains almost entirely reliant on the Exchequer.

The alternative is to consider other options for funding the health services or contributing towards the cost of particular services. The pressure on Exchequer support for health services should not rule out a modest growth in health spending, even if that growth can be funded from other sources.

In speaking of growth, I am not suggesting that we return to an era of unbridled growth in health spending. Apart from the concern about public expenditure on health services, any unreasonable growth in total spending on the health services would also be a matter for concern. It may be appropriate to agree on some guidelines, expressed, for example, as a proportion of gross national product, which would define the parameters of total health spending and within which the contribution from the Exchequer and other sources could be determined.

Apart from the overall size of the allocation of public funds for health services, the distribution of that resource also needs examination, bearing in mind the service priorities which have been articulated for many years and the particular onus to protect and provide for those most in need of health care and least able to afford it from their own resources.

These are some of the issues which I expect will be addressed by the Review Group on Funding the Health Services, the establishment of which I announced on Tuesday last. I will be asking this review group to report to me as soon as possible and I see their report as one of the basic elements in framing future health policy.

There will also be a concentration upon value for money. I have set up a special cost containment and efficiency unit in the Department to provide a support service to all health agencies to seek to make savings through efficiency improvements. The purchasing of supplies is clearly one area upon which they will concentrate.

I have already announced a review of the acute hospital system, the progress of which will now be accelerated. The purpose of this review, which will reach conclusions within a matter of months, is to identify precisely the adjustments now needed to adapt the acute hospital system to present requirements. The acute hospitals represent the single largest care programme in terms of the amount of resources they absorb. Therefore, they must be a particular target of scrutiny in attempting to reconcile the size and nature of the health care system with the level of resources now available for health services. It is beyond doubt that the outcome of this exercise will involve the phasing out of a significant number of beds from the acute hospital system. The proposals developed in this regard will provide a good litmus test as to how genuine are the motives of those in this House who have repeatedly criticised the inefficiency of the health system.

On a point of order, I take exception when the Minister comes here and mentions Members of this House not being realistic——

Deputy Farrelly, this clearly is not a point of order. The Deputy is deliberately behaving in an unruly fashion.

I take exception to the Minister——

Deputy Farrelly, please. This is a limited debate.

I take exception to this——

There is a time limit on this debate and the Deputy is eroding the time allocated to the Minister by disorderly conduct.

He is saying we are not responsible——

I shall ask the Deputy to leave the House if he persists.

I take exception——

Deputy Farrelly, please leave the House.

I take exception to the Minister——

Deputy Farrelly must leave the House or I will name him.

I take exeption to the Minister saying we are not responsible Members——

Please leave the House.

Deputy Farrelly withdrew from the Chamber.

A particular concern in health policy internationally is the diffusion of and growth in high technology medicine. This concern is rooted in the belief that high technology medicine has played a significant role in the escalation of health care costs in recent decades. Health policy internationally now favours a more critical and cautious approach to further diffusion and development in this area.

This is an issue which will be explicitly addressed in the review of acute hospital services, which I announced in the Dáil on Tuesday night. The review will be a comprehensive consultative process at local health board level and will involve the boards, the voluntary hospitals and the staff interests concerned. My Department will collate the work nationally and a definitive plan for the hospital services will be drawn up following a national conference in July. The review will also consider particularly the distribution of the higher specialties, like cardiac surgery and organ transplants and specialised treatment units, such as the bone marrow transplant unit in St. James' Hospital and the sexual assault treatment unit in the Rotunda Hospital. Decisions on such services will not be made in the context of short-term funding problems of individual hospitals but rather on the basis of an objective assessment of national needs and the most efficient way of meeting those needs.

One objective of that review will be to free resources which can be deployed to the development of a quality primary health care service. The development of primary health care has been one of the most frequently announced objectives of health policy over many years. While a certain amount of progress was made in the development of the community care programmes in the seventies, the limited extent of investment in these services belies the publicly proclaimed priority they were supposed to enjoy. Despite the attempts made by the Department of Health over a number of years to ensure that community services were protected in implementing the cutbacks in health spending in each of those years, it is quite clear that individual health agencies did not totally comply with this guideline and that community services have suffered.

The reality is that if we want to develop a quality primary health care system and reduce dependence on institutional care, resources will have to be set aside specifically for this purpose. Obviously, in the current economic climate when no new money can be provided for this purpose, the necessary resources must be freed up within the system and within the total current spending level. I recognise that the transition period, during which additional investment will be needed to strengthen primary care services before institutions can be phased out, will present difficulties and this is another area on which I will be seeking the advice of the review group on funding.

The picture which has been painted therefore, of a health service which is in total decline is a totally false representation of the true position. Certainly, change is necessary. I can assure people that nobody will suffer unnecessarily or unduly as a result of the savings being effected.

God forgive you. How can you say that?

The majority of the Members of this House accept that savings have to be made. I am satisfied that we are providing sufficient resources to ensure that proper and adequate services will be provided for all those who need them.

Change is necessary. That change will involve a decline in some services and development in others. Many objective commentators, looking at our health system, have concluded that it is overbedded and that the alternatives to institutional care are under-developed. It is now time to redress that imbalance. The working principle that now needs to be emphasised is that all health problems are dealt with at the lowest level of complexity in the system. This is no more than good commonsense but it will also make for a more efficient system and a better use, overall, of resources. It is also a more humane approach that people should be treated in their own community where possible rather than having to go into hospital where they very often feel vulnerable.

There is no community care.

The development of primary health care, as an alternative to institutions, will also facilitate a more humane approach to patient care, resulting in a better quality of life particularly for the chronic sick.

Specifically, we now need to give more attention to the development of general practitioner and community health nursing services and the broad range of other community based health and personal social services.

You are closing down the vocational training schemes. You could give a better service there.

In relation to the former, while there remain a number of obstacles to be overcome, we have a clear idea of what now needs to be done in terms of developing the service. A review of the community health nursing service has started and should lead to a set of planning guidelines for the development of this key service. Similarly, other service reviews, either recently completed, as in the case of the psychiatric services, or currently in progress, as in the case of services for the elderly and the mentally handicapped, have adopted a perspective which seeks to maximise the potential of community based care.

Allowing a reasonable period of time for the completion of service reviews now in progress, we will shortly have up-to-date planning guidelines for virtually the whole spread of the health services, which take account of more recent social and demographic developments as well as changes in practice, and the overall budgetary constraint under which the health system will have to operate for the foreseeable future. I see the combination of these various review exercises, coupled with the work of the review group on funding, as providing a firm foundation on which rational decisions can be made about the future allocation of resources in the health services.

While this process will set short term decision making in the health area on a more rational footing, we also need to broaden our horizons somewhat, if we genuinely want to generate debate on health policy. Our health policy must go further than simply deciding which of the curing and caring services get what level of available resources. Even the most cursory analysis of recent epidemiological trends suggests that there is great potential in this country for a preventive health strategy in its broadest sense.

The Irish health system has been likened to one which has as its objective the provision of an efficient health repair service rather than a system which promotes health in a positive way, a point which Senator Robb made very effectively in the Seanad last night.

While undoubtedly there are significant elements of primary, secondary and tertiary prevention incorporated in our existing services — the vaccination and immunisation programmes are good examples — it is my view that there is a lot more we can do in the whole area of health promotion and prevention.

In the first instance, we need to debate and clarify the divide in responsibilities for health. While it seems reasonable that each individual should be prepared to accept personal responsibility to some extent for maintaining his or her health, how far should personal responsibility be expected to go and what should be the residual role of the wider community or the State in the protection and maintenance of health?

Clearly, there are aspects of health promotion which, because of their wide implications, can only be effectively undertaken by the State, through public policy. This leads on to the question of what priority should be accorded to health relative to other national objectives.

Under present circumstances there may be a temptation to de-emphasise areas of public policy which do not immediately impact on economic growth and employment. The counter argument is that in the medium term a healthier population may well be an economically more productive population and that the resources currently absorbed by the treatment of avoidable morbidity would be available for other uses.

In arguing the case for health promotion, the most fundamental and immediate problem we face, therefore, is one of attitude. In what might be termed our "national value system" we have not, as a community, tended to rate positive health as a high priority. While the significant contribution of health to general wellbeing is frequently acknowledged we have not tended to reflect this strongly enough in the practical workings of everyday life.

The question being posed is whether we are genuinely committed to maximising the contribution of positive health to human wellbeing. The real extent of our commitment will be measured by the changes we are prepared to make in society towards that end. Of course, this is not just a health sector problem. Within the public domain, the policy issues extend across practically the entire spectrum of public policy. Inevitably, the private sector — in industry, agriculture and the services sectors — will also have to be involved.

The pursuit of a health promotion policy can only be realistically contemplated if there is a broad consensus across the community that it is worth the effort. That is why it is so important to encourage informed public debate on the various issues involved. That debate has been considerably assisted by the publication last December of the consultative statement on health policy "Health — The Wider Dimensions" and the health promotion report "Promoting Health Through Public Policy".

Some will find it convenient to argue that the whole notion of developing health promotion as a significant element of health policy is irrelevant to our immediate problems. Taking a short-term perspective, this is probably valid. However, we have responsibilities beyond 1987 and 1988, and if there is a genuine concern to develop a health policy for the longer term, these are the issues we should be debating.

This is not just an abstract concept. In my two months as Minister, I have introduced the AIDS information programme which is a very positive attempt to encourage people to be responsible in their sexual behaviour and in their approach to drug abuse. I will soon be introducing a tobacco Bill which will control smoking in public places. This Bill adds to the promotion and advertising controls on tobacco products which have been in place for some years. I have set in motion the work necessary to develop a comprehensive strategy to take on the problem of excessive drinking and alcoholism in our society.

The arrangements for managing the health services have become one of the standard targets of criticism in the current debate about the health system. Unsubstantiated allegations about the cost of administration and management failures are made with abandon. It is time that such loose allegations were challenged. While clerical and administrative staff account for about 10 per cent of all staff employed in the health services, in fact less than 2 per cent of the total staff are engaged in central administration.

Neither was there any substance to the allegation that clerical and administrative staff were being specially protected against the effects of the embargo. Given the facts, as distinct from these unsubstantiated and inaccurate allegations, I do not regard the administrative overheads in the health services as excessive. That is not to say that some improvements are not possible in the current organisational structure and we are looking carefully at this matter. I have already stated in the House that many people working in administration, while they are not directly in the frontline, are essential to the delivery of a proper health care service. I refer to persons such as community welfare officers, secretaries involved in making appointments and typing reports and many others.

Over the last year or more there have been a lot of rumours floated about proposals for the reorganisation of the health boards. These rumours varied from the total abolition of the boards, to a reduction in the number to five or three or one, to the transfer of their functions back to the local authorities. It was stated that proposals were before Government and that in due course announcements would be made. Because of the secrecy it was impossible to comment, let alone debate, the issues that might be involved.

I have yet to be presented with clearcut evidence that would convince me that such a reduction is necessary. I will retain that view until such evidence is presented to me.

It is the Minister's job to find it.

I have made no secret of my own confidence in the health board system as an appropriate model for the delivery of an efficient and responsive health service in this country. My belief in the health boards stems from my own long membership experience which has given me an appreciation of the strengths and weaknesses of the current system.

Much has changed since the boards were established in 1970. The range, sophistication and cost of services has changed dramatically. While earlier, the boards acted very much as development agencies, latterly, the nature of their role has of necessity moved in the opposite direction.

Every organisation needs an in-built monitoring and review mechanism so that, as circumstances and conditions change, its ability to effectively carry out its remit can be assessed and the necessary changes made. It is now appropriate that such an assessment be carried out in relation to health boards.

Basic aspects of this assessment, I believe, must include a renewed understanding of the service needs of the population, how these needs can best be met and the most efficient and effective organisation of the provision of the services. Within this, we must have an agreed assessment of the kind of health service we should aim for in the future. We must look at the existing statutory functions and responsibilities of health boards and agree where and to what extent these should be strengthened or changed.

It will be necessary to examine the management needs of health boards and the lines of demarcation between the management function and the functions of the health boards. In addition, the relationship between both the management and health board functions and the Minister for Health and the Department of Health requires review.

I would not make any assumptions about the outcome of this exercise. I have my own views on areas which require examination and the direction which might be taken in resolving problems but, given the recent history, it is more important that the exercise be seen as a genuinely consultative and co-operative undertaking, rather than the imposition of decisions by diktat.

The approach I propose is that a suitable area or areas should be identified which would be used as pilot sites for the development and testing of new organisational options. The level of need for each service would be assessed, as would the service requirements to meet that level of need, and how best to organise the delivery of those services. From this should emerage a clear picture of what requires to be done, who should do it and the relationships necessary between the various levels of responsibility. New organisational structures could then be developed which could be tested, monitored and modified as appropriate. The result would be that, rather than having untried, conceptual propositions for organisational development, there would be available options which have been proved on the ground.

In taking such an approach, there would have to be an explicit understanding among all concerned as to its scope and purpose. The exercise would be futile unless it were fully accepted by all the relevant bodies, including staff organisations, health boards, health board staff, health board management and the Department of Health. It would have to be carried out without commitment to the permanency of the arrangements tested or their application elsewhere.

It should not be seen as a replacement for the normal negotiating mechanisms. It should be seen as an experience-based action oriented approach to developing future arrangements for health service reorganisation. I intend now to set in motion the process of getting agreement on the establishment of these pilot projects as soon as possible.

Given the critical resource problems we currently face, there are two possible reactions. One is to do nothing but compress the present health care system — warts included — to match the more limited resources available from central taxation.

The other is to analyse the problems in an objective way and to seek to develop solutions which will achieve our objectives for health policy within the financial constraints and in a way which is acceptable to the community.

Any responsible Minister would always take the latter course and that is my objective in the range of initiatives I am now taking in relation to health policy.

Over the past eight weeks I have visited half of the constituencies. Everywhere I go I meet people who are frightened by what they see as a collapse in the health services. This is the Government's responsibility, however much they might try to disguise it.

The Minister for Health could have told the health boards to cut back more on administration and less on the delivery of services. The bureaucracy of our health boards, in spite of the general philosophical considerations in which the Minister has just indulged, has increased faster in the past 17 years than the provision for the delivery of services. Yet the Government chose not to tackle this bureaucracy, not to direct the health boards to make economies in administration rather than in services. The result is that vital services are threatened. These cover a very wide range including the bone marrow transplant unit and the haematology unit in St. James's Hospital; the sexual assault treatment unit in the Rotunda Hospital; the vocational training programme for GPs in Dublin and Cork; the young persons' unit in St. Stephen's Hospital, as well as the psychiatric section of that hospital; the national cardiac surgical unit and many more. All these services are now in danger or in doubt because the Minister and the Government did not give the health boards any direction as to the way in which the expenditure reductions were to be brought about. We see it all around the country.

The tragedy is that a great deal of the trauma of recent weeks could have been avoided even within the context of getting our finances in order. A large part of the problem is, as the Government say, due to heavy overspending by health boards in recent years. Have the Minister and the Government forgotten that Fianna Fáil controlled the health boards over those years? They cannot avoid the responsibility for that and I would applaud the Minister for his enthusiasm in bringing attention to that overspending if he had the decency, not to speak of the guts, to admit that the overspending was due in very large part——

To the Government of the day.

——to the insistence of the Minister and his colleagues, as members of health boards, on resisting for four and a half years almost any proposals for the rationalisation of the activities of the health boards.

The provision of a good health service, while making the service more cost-effective for the taxpayer, takes some skill and imagination.

Which was sadly lacking for four years.

The Government have shown none of the foresight needed to manage our health services successfully and compassionately. I will deal with each of those points. Section 31 (1) of the Health Act, 1970, provides as follows:

A health board shall not, save with the Minister's consent, incur expenditure for any service or purpose within any period in excess of such sum as may be specified by the Minister in respect of that period.

That section gives the Minister a key role in guiding the provision of services by the health boards. It gives the Minister and the Government both the opportunity and the means of determining the range and level of services to be provided. It is important that that be so in a small country like this, particularly when some services, including those I have mentioned, for any one of a number of reasons cannot in practice be provided in each health board area. The Minister and Deputies will know what I mean. The EHB, for example, provide certain services which cannot be made available in other health board areas.

The central point is that the Minister and the Government have the means of playing a determining role in the level and range of health service provisions. The Minister has so far abdicated his responsibility in this regard. He has said in this House that he provided guidelines for the health boards at the beginning of April. I have read the guidelines. I have read the letter sent by the Department to the health boards on 2 April last setting out those guidelines. They are set out in the most general terms. They make no reference whatever to the pattern of service which the Government think desirable. There is no indication whatsoever of the priorities as to the different types of service nor is there any indication that the Government have the slightest idea about the tailoring of resources to meet essential needs. Perhaps that is simply because the Government have no idea what the essential needs might be.

If this is so it is, in some respect at least, in sharp contrast with the relevant section of The Programme for National Recovery which, for those who might, have forgotten, was the Fianna Fáil election earlier this year. Ironically enough, that section is entitled “A Sensible and Caring Approach to Health”. It starts off with a ringing declaration, and I quote:

Fianna Fáil will shift the emphasis towards the promotion of personal health care through better lifestyles and to community rather than hospital-based care.

It goes on to say:

An equally fundamental shift will be the gradual transfer of resources from hospital care to community care... Upgrading out-patient and day hospital facilities, which are inadequate at many centres, will be part of this change in emphasis. Residential care will continue to be provided for those who need it.

It declared also:

Our overall aim will be a comprehensive health service geared to the future needs of all the Irish people.

Those declarations now have a very hollow ring. It may be that the rest of us misunderstood what that document really meant. It appears now that the Government are clearly determined to bring about not just a gradual transfer of resources from hospital care but a rapid transfer of patients from hospital care, but they seem to have forgotten about the community care aspect. There is no indication of this in the Department of Health's letter to the health boards. There is not a single indication in that letter of any sense of priority as between schemes and services.

Let the Minister not try to pretend that this lack of specification arises from a concern with local democracy. He pleaded in this House last Tuesday night that he failed to understand how any Minister for Health could be criticised for allowing local democracy to have an input into decision making. He pleaded that he had made the allocations to the health boards and to the voluntary hospitals and left it to them to decide how they would effect the savings. He did not want to be accused of being dictatorial or of not giving local people an opportunity to decide what their priorities were in their own areas. Then he went on to say that he had sent a team of senior officials to every health board and every voluntary hospital to examine how the savings are being made and to report back to him.

The Minister cannot have it both ways. He cannot pretend that he should not have his own views — or at least the Government's views — on where the priorities should lie. He cannot pretend that he will be doing wrong to the health boards in giving them some inkling of the Government's view of priorities. However, it is just possible that what he really meant to convey to the health boards was that the Government have no sense of priorities. If that is the case, let him say so clearly and we will all applaud him for his honesty and wish him God-speed and the sooner the better. Yet, though that might be the honourable thing for him to do, it would not be consistent with his other actions. I will take only one example. In the Government's allocations to Subhead G.4 of the Health Vote the Minister appears to be saying to the health boards that grants will be given on their behalf to hospitals, homes and so on other than hospitals and homes administered by the health boards, with no indication as to priorities but with the proviso that the grant for the North Infirmary, in Cork, for example, is to be reduced by 19.8 per cent, that the grant for the Monkstown Hospital is to be reduced by 22.4 per cent, that the grant for the Drogheda Cottage Hospital is to be reduced by 22.7 per cent, that the grant for Portiuncula Hospital is to be reduced by 9.9 per cent, and so on. The Minister is in grave danger of inventing a new paraphrase of the saying of the great Henry Ford, "You can have any hospital you like as long as it is smaller."

In a letter dated 23 April last to the CEOs of the health boards, to the secretary — managers of public voluntary and joint board hospitals and to the administrators of homes for the mentally handicapped the Department of Health directed that "every effort is to be made to spread staff reductions evenly across the grades, and frontline staff should be protected as much as possible in the interests of maintaining services". That is a laudable objective, but I find no evidence of effect being given to it in practice. Everywhere we turn we see that the staff reductions being contemplated are at the front line as far as the delivery of services is concerned. Take the example of the national cardiac surgical unit where two non-consultant hospital doctors, two perfusionists, two theatre nurses and ten intensive care nurses appear to be about to be let go: where is the concern there for protecting frontline staff as much as possible in accordance with the prescription of the Department of Health? No attempt at all is being made to ensure that even that vague guideline — if it could be called a guideline — is being given effect.

We are told that the Minister's investigation teams have now reported back to him and that he is considering the results of their travel around the country in order to ensure that we have a rationalised health service in place. If his officials are reporting to him now on how savings are being made by health boards and voluntary hospitals around the country and if the reports we have heard and seen in public are a true reflection of what the Minister is being told, I have no confidence whatever that we will see a rationalised health service as a result.

The Minister has biased the whole operation by his failure from the very beginning to give any indication of the Government's priorities and by his failure even to consider the rationalisation of the administration of our health services. I am appalled that the Minister could deliver today a fairly lengthy speech introducing the debate on the health services and not reach until quite late in that speech any consideration of the structure of the machine we have for delivering services. He then spent some part of that consideration in philisophical discussion about models, pilot programmes and his own conviction that the present structure has served us well. Does the Minister not know that since 1970, in the last 17 years, even the simple business of telecommunications, document transmission and data transmission have revolutionised management of a service like that?

Is the Minister not aware we have eight structures around the country all doing the same job, all replicating functions that could be carried out centrally? The Minister comes into the House to tell us he is not convinced there is any better way of carrying out that job. I cannot see any great hope that we will see a rationalised health service as a result of the Minister's efforts. The sad part of the matter is that his refusal even to consider that seriously will mean we will have a continuation of this year's scenario in which people who need health services delivered to them will be denied them because resources are being used unnecessarily in an over-elaborate structure.

Questions have been raised in this House about the relevance of that structure. On all occasions in the past four years when such questions were raised we have seen one predictable knee-jerk reaction from the Minister and his colleagues. I believe the problem is that the Minister, his colleagues in Government and in Fianna Fáil will not consider rationalisation of the structure of our health services because they have been trapped by their own repeated intransigence over the past four-and-a-half years on those issues. During that time the slightest hint of rationalisation of structures was enough to send Fianna Fáil members of health boards into paroxysms of indignation about local democracy, to prevent them from giving any consideration to the fact that local democracy also requires that taxpayers, people who pay any kind of tax, have a right to demand that public expenditure be managed efficiently to give value for money. The Fianna Fáil Party have been the biggest single obstacle to the rationalisation of our health services.

That leads me to the spurious claim, the most spurious of all the claims made by the Minister and parroted by his Minister of State last evening in relation to the health services, that is the claim that the level of over-spending undertaken by health boards in the past four years was due in some way to negligence by the previous Government. It is not. Responsibility for that problem must be laid fairly and squarely at the feet of those who have consistently obstructed every effort to control——

What about section 31?

——and rationalise expenditure in that area.

What about section 31? The Deputy is contradicting himself

The one reaction a Minister for Health in that Government could always be guaranteed to get was a howl of protest any time he gave any kind of clear direction to the health boards because Deputy O'Hanlon, a member of a health board, and umpteen other members of health boards from that side of the House, started screaming about local democracy, about the structure of the service they wanted to have in their areas. It was nothing more than a smokescreen.

Where was section 31 for the past four years? Ten minutes ago the Deputy told us section 31 gave the Minister power.

They did not want to think about giving taxpayers value for money.

The Minister got his half-hour and did not do much with it.

Let the Minister and the Government not try to claim they have not had time to do this. The Minister keeps reminding us he is the third Minister for Health this year. I must say he is a damn poor third at that. Let them not say they have not had time to examine what might be done to rationalise the structures, to reorganise. They have had access to the benefit of four-and-a-half years of work on the part of Deputy Barry Desmond in defining what needed to be done to rationalise the health services. Their problem is not that they have not had time but that they have wasted four-and-a-half years of their time in Opposition in a profligate refusal to make a single proposal about the rationalisation of health services.

The same applied to public expenditure generally. The only proposals that party when in Opposition made in terms of rationalising public expenditure was the magnificent proposal by the current Minister for Agriculture and Food that we should save public money and cut the AnCO budget by not admitting married women to training programmes. That is the only provision of any kind that ever emanated from them. They spent four-and-a-half years sitting, looking and doing nothing about rationalisation of health services.

The price this Government are now paying — and it will be a heavy one — is the price of having opposed for the sake of opposition. That would not be important were it not for the fact that the old, the sick and the handicapped are now being obliged to pay the price of Fianna Fáil's irresponsibility. That need not be the case. The Government can still decide to adopt a more caring, compassionate and enlightened approach to the health services, such as the one set out in the budget proposals on January last. If the Government wished they could tailor those proposals still further to remain within the overall allocation they have proposed for this year. Yes, the Minister may indeed prompt his colleague to talk about prescription charges. He can take that out and look at it. I suggest to the Minister that there are a great many people all round this country who would find that a far more efficient way of reducing the expenditure on our health services, on doctors services and on drugs——

Not the old, the sick and the handicapped.

——than the unspecific directive, guideline, given in the letter of 2 May that expenditure on drugs has to be reduced by £1.5 million — or is it £3 million — simply by wish of the Minister without any indication as to how it is to be brought about.

The Minister must rethink his approach for this year. He must say today he has changed his mind, that he now has some clear view of the priorities in the provision of health services. He must give a clear indication to the health boards, the voluntary hospitals and the people that he is giving priority to the needs of those who require health services, that he will not allow them to be crushed by the burden of an over-elaborate administration. In a time of financial stringency he must show that concern for people's needs can and must be accommodated in an enlightened fashion within the financial restrictions imposed on them. Unless he does that, the Government of which he is a member and he himself will stand accused of an attempt to deceive the people, of putting an uncaring, unfeeling, unimaginative and inefficient approach to public expenditure before the needs of people who have no option but to have recourse to the State to safeguard their health and well-being.

It is not impossible to do that. The Minister, I am sad to say, shows a great reluctance to venture into this area. At the beginning of his remarks the Minister set out some of the main elements involved in the change now needed in the health system. There are five areas, which include a review of the funding arrangements, the rationalisation of the acute hospital system, the development of primary health care services, the development of health promotion and preventive services and an improvement in managerial arrangements at all levels in the system, all of them needing revision. But we are talking now about things that will not happen in a way that would make a difference within the span of 1987. There is nothing here about the structures of the health services.

As a general matter of philosophy in relation to the health services, we find the following suggestion by the Minister:

It may be appropriate to agree on some guideline, expressed for example as a proportion of gross national product, which would define the parameters of total health spending....

Why should he propose that? There is no magic in any proportion of gross national product being spent on the health services. There is no magic in 7 per cent, 6 per cent or 7½ per cent. What we want to examine is the level of service we can provide for our people, not a percentage of gross national product. If the Minister goes off along that track he could very happily spend the next three months working on something that is basically irrelevant.

Then the Minister goes on to talk about the review of the acute hospital system. I have no doubt that will be a useful exercise but he continues to say:

It is beyond doubt that the outcome of this exercise will involve the phasing out of a significant number of beds from the acute hospital system. The proposals developed in this regard will provide a good litmus test as to how genuine are the motives of those in this House who have repeatedly criticised the inefficiency of the health system.

The Minister need have no worries about that bit of litmus paper. The real test will be whether the Minister himself, his colleagues in Government and those on the back benches of Fianna Fáil, will have the guts to put up any analysis of how we should adjust our acute hospital service in order to meet the needs of this country within our present financial constraints.

The Deputy's time is up.

I have just one more point to make. The Minister has shown more than his slip in his speech today. He tells us of a proposal for a conference in July that will review acute hospital services and that will deal particularly with the distribution of the higher specialties. He said: "Decisions on such services will not be made in the context of short term funding problems of individual hospitals but rather on the basis of an objective assessment of national needs and the most efficient way of meeting those needs." We hold the Minister to that. So far, he has not given any indication that he has any notion of where the priorities lie and basically that is what we must accuse him of today. That is the injustice he has done, not just to the health boards but to the people generally. The Minister and the Government should tell us what they believe are the priorities in our health system and not hide behind these spurious guidelines that have been sent out to the health boards. The Minister could have said, and he has the power to say, how the finances should have been allocated and he should have attempted in some way to make them meet our needs.

The Minister for Energy.

On a point of order——

Visitors to this country will be forgiven——

Deputy Keating wishes to come in on a point of order.

Will the Leas-Cheann Comhairle indicate the order of speakers? Why are you not calling on Deputy Wyse who, from our understanding, is the next speaker, and then on Deputy Barry Desmond? That has been the practice in this House for the last number of months.

It is our understanding, too, a Leas-Cheann Comhairle, that you would rotate between the spokespersons of each of the parties before returning to the Government benches.

The position is that this is different from a limited debate and as it is going to move from side to side, I hope to call the Minister now and then I will call the spokesperson for the——

On a point of order, it is not a debate, it is a series of statements being made by the party spokespersons in the first instance to be supplemented by statements on the available time. That is our clear understanding. If the debate is to go back and forth between Government and Opposition on the basis of statements, that is a completely new precedent. It is different from any debate I have ever witnessed in this House.

Deputy Desmond will appreciate that whoever occupies the Chair occupies it to interpret the order made. The point the Deputy makes now might have been or could have been made initially. So far as I am concerned, and having discussed the matter with the Ceann Comhairle, the debate on the statements will move from side to side.

On a point of order——

Deputy Keating, on a point of order.

May I ask you to indicate please whether, in the Order of Business agreed this morning, there was any implicit or explicit addendum or suggestion that the new order, this very cosy arrangement, should obtain? Surely the standing practice is as I mentioned earlier, that you would call first the spokespersons on health. The only limitation referred to in the Order of Business this morning——

The standing practice is that the debate moves from side to side.

The only linmitation on the Order of Business this morning was with regard to the time limit on speakers. I want the Leas-Cheann Comhairle to explain please why Deputy Wyse is not now being called on.

On a point of order——

Let the Leas-Cheann Comhairle answer first.

On a point of order——

Excuse me, I am answering one point of order. The Standing Orders which refer to debate in this House indicate that debate should move from side to side and there is no countermanding instruction to me in the Chair to do otherwise and that is why I am proposing this. This is the position.

Since the resumption of this Dáil the practice has been as I have outlined. This is not a debate moving from side to side, it is a series of statements within which context it is perfectly logical and only to be expected that the appropriate spokespersons for each party would get an opportunity of putting their views on record prior to the statements going from side to side. We happen to be in the somewhat unfortunate position of being in the middle. Are we to assume that we will not get in at all?

I will call you next. The Deputy appreciates that scarce time is being wasted.

That is not my problem.

The Chair has been tolerant with the Deputy in explaining the nature of the debate. In respect of statements as provided for in Standing Orders, a spokesperson from the Government is called followed by the appointed spokespersons for the parties but I am following an agreement made this morning.

Made by whom?

It is an agreement of the House, an Order of the House.

It is not an agreement of the House.

The House was not informed.

On a point of order——

It is not an order that the statements be taken in this form? You have just said it was an agreement of the House and I ask you to produce the evidence for that.

A Leas-Cheann Comhairle——

There was no agreement to the contrary. The Deputy is being disorderly now. He will allow me to proceed. I am calling the Minister for Energy who has already lost some time.

I took the liberty of discussing this matter with the Ceann Comhairle this morning. I not only discussed the order of speakers but indicated the precise time the Labour Party spokesperson would get in. That was indicated at 11.40 a.m. I asked if the time could be shared and that was agreed by the Ceann Comhairle. I wish to quote a precedent to you on statements.

You should send for the Ceann Comhairle now.

On a point of order, I am continuing. I had that discussion with the Ceann Comhairle. I wish to quote a precedent to you, Sir. The last time we had statements, that was on the issue of the environmental grants being cut, the debate rotated between the parties and we understood that the same would apply this morning. There was no indication to me this morning from the Ceann Comhairle to the contrary and, Sir, if you are going to continue with that ruling I ask that you send for the Ceann Comhairle.

I am calling on the Minister for Energy.

I accept you are right most of the time but you just might be wrong on this occasion. Will you be good enough to consult with the Ceann Comhairle to see whether what Deputy Howlin said is accurate and whether what I said earlier, which relates to the standing practice of this House and which bears very strongly on the rights of smaller parties, is accurate.

I am as often wrong as the Deputy is. If I tell you now that I have already consulted with the Ceann Comhairle you will appreciate what I am doing.

Will you consult with the Ceann Comhairle now?

The Minister for Energy to proceed without interruption.

As this discussion goes on——

On a point of order, I am entitled to make a point of order——

If it is a point of order.

You will realise it is a point of order when you hear it? The Taoiseach indicated that in response to a series of statements to be made in the House the Minister would be called at 4.40 p.m. to reply to that series of statements. In this House when statements are made by a Minister it is unprecedented not to call a spokesperson on behalf of each party immediately thereafter.

Will you resume your seat and I will answer that question for you?

I have not finished my point of order.

You are astray in so far as you are relating this to a normal statement under normal Standing Orders and it does not apply because we have already agreed——

When my party agreed that instead of having a debate with a related motion we would have a debate confined to statements only, it was on the clear understanding that in the first instance the party spokespersons would be called and that we would not be in the situation in which we now find ourselves where only one person from the Progressive Democrats is allowed to speak, one from the Labour Party and two from Fine Gael. In that way the whole day would be taken up, and automatically the Government take over 50 per cent of the time of the debate. This is unacceptable and, in the interests of rational debate, I urge——

The Deputy is making a speech and he is not entitled to do that. Would the Deputy resume his seat and listen to me?

I ask the Government——

This is my final explanation.

A Leas-Cheann Comhairle——

Please resume your seat. Today's order reads: "...notwithstanding anything in Standing Orders, statements on the health services shall be made today and the following arrangement shall apply: The opening statement of the Minister for Health shall not exceed 30 minutes. The statement of any other speaker shall not exceed 20 minutes..." The normal procedure in respect of a debate flowing from one side of the House to the other is what will take place here. I am now calling the Minister for Energy and I ask Deputies to listen to him.

I want to ask——

I have already listened to you and I have accepted that both of us can be wrong.

On a point of order, you have just clarified the Order of Business and it is precisely in line with our understanding which is that the only limitation in it, implicit or explicit, is on the length of speeches. The standing practice, particularly in the context of statements is, as logic would dictate, that various parties get a chance to express their views, not that these be a cosy arrangement between——

Deputy Keating, you have already received my answer when you suggested that I was acting contrary to what the Ceann Comhairle had said.

You are out of line.

I ask you now——

You are aiding and abetting a new cosy arrangement to exclude from equal treatment the small parties in this House. We will not stand for that.

Deputy Keating knows that I have never aided or abetted——

Not consciously.

——except in interpreting what I must do. I am asking you to allow me to proceed with the Order of Business and if you are not anxious to listen to the Minister——

It is not a question of not——

A Leas-Cheann Comhairle——

You are being disorderly and I ask you to resume your seat.

May I make a point?

You have already made a point and I have answered it. I will not hear any other points from you. The Minister for Energy without interruption.

Will you hear one sentence from me?

I have heard from you.

Will you hear just one sentence?

On a point of order——

You are being disorderly. I am calling on the Minister for Energy.


There is no point in proceeding——

There is no agreement on this matter and the sooner you realise it the better.

That is right.

If this debate is to be suspended——


The Chair is not going to have the minor parties eliminated from this debate.

Deputy Desmond, I ask you to resume your seat.

We will be on our feet——

The Chair will not respond to threats from anybody in this House.

May I ask a question, Sir?

If it is a point of order. Is it?

Yes. The point of order is that we were misled on the Order of Business this morning.

I have not misled you.

We agreed to an Order of Business on an understanding which has been reneged upon. I put it to you, Sir, that that invalidates the Order of Business. The parties were misled this morning. I spoke to the Ceann Comhairle and he indicated that the Labour Party spokesperson would be called at 11.40 a.m.

Please resume your seat.

That is what he indicated to me. I ask you, please, to send for the Ceann Comhairle.

I have had no instructions along those lines and I ask you to resume your seat.


We are not responsible——

We are not going to be railroaded by you or the Ceann Comhairle.

We are not going to fade away——


We will propose a motion of censure on you and the Ceann Comhairle insisting that the Progressive Democrats and the Labour Party be not excluded from this debate. With due respect I urge you to send for the Ceann Comhairle to clarify the Order of Business.

This argument has already taken 20 minutes.

That is not our fault. We did not interrupt once this morning. We are not interested in wasting anybody's time, least of all our own.

Would you resume your seat?

We are acting in accordance with precedent. We are asking you to send for the Ceann Comhairle.

The Deputies are trying to bully the Chair.

A case has been made for this debate because of the urgency of——


We have already spent 15 minutes discussing the Order of Business when it would have been more appropriate for this matter to have been clarified this morning.

It was clarified.

Deputy Howlin, please sit down.

Deputy Howlin was told he would be called at 11.40 this morning and you are calling a Government speaker.

Deputy Desmond, please be quiet.

I can hardly restrain myself but——

If the Chair was going to change things he should have told us——

There is an inference that a private arrangement was made as to who would be called at a certain time. As far as I am concerned, that is not part of the Order of Business. I have indicated to Deputy Keating that I understood the Minister for Energy was to be called next. Deputy Keating and Deputy Howlin have insinuated that is not correct and that they are not prepared to allow the business ordered to proceed. Therefore, in respect of the charges which have been made, I have no option but to suspend the sitting of the House.

That is——

I have no option but to do that because you would not agree to the order of the House.

On a point of order, may I ask a simple question?

No simple questions. You have indicated that you are not prepared to allow the Order of Business to proceed and I am formally.——

You are not proceeding with the Order of Business. May I ask a simple question? The arrangements made on the Order of Business were in accordance with precedent——

The Ceann Comhairle will come into the House and tell the Deputy the Order of Business. Deputy Keating, please resume your seat.

I want to ask a simple question——

You will get the medicine you were looking for. I am sending for the Ceann Comhairle. I am suspending the sitting for ten minutes.

Sitting suspended at 11.50 a.m. and resumed at 12 noon.

I very much regret the disorder which has arisen which has resulted in such a loss of very valuable time in this important debate.


Hear, hear.

I am bound to tell the House that the Ceann Comhairle does not review a decision of the previous occupant of the Chair. Consequently, his choice of speaker must be upheld. However, it is my desire in this limited debate that the spokespersons for the various parties should be heard and heard quickly in the debate. Therefore, when the Minister has concluded his remarks, spokespersons for the various parties should be heard. I have already heard Deputy Dukes of the Fine Gael Party, the Progressive Democrats spokesperson should be heard, the Labour Party spokesperson should be heard and also the spokesman for The Workers' Party. I also hope we will not forget the rights of minorities, the voice of Independents should also be heard.


Hear, hear.

On that basis I ask you now to give a good hearing to the Minister, Deputy Ray Burke, and we will proceed in an orderly fashion.

May I clarify a point? I gather it is your intention that we will now hear the Minister, after that a spokesperson for the Progressive Democrats followed by a spokesperson for the Labour Party and then by one for The Workers' Party. I am not quite clear what your intention is for the minority, is it then your intention to revert to the Government and to begin the rotation with the Fine Gael Party?

That is so. It is also my desire in a debate of this kind to make up any imbalance in respect of the Government party by calling additional speakers on that side of the House even if at some stage two Government members are called successively. If any imbalance arises the Chair will seek to redress it and will choose speakers in the ordinary way.

The Fine Gael Party have 51 Members in this House and we are the largest Opposition Party.

Where were they last night?

The House should leave this matter safely in the hands of the Chair.

I want to ensure that we get our fair share of speakers in relation to the size of the Opposition. There is no point in saying you will protect the Government side without also protecting the Opposition.

I have indicated my desire as to how the debate should proceed and I ask Members not to waste any further time.

This party shares your dismay at the serious waste of time this morning and I assure you it is not a practice in which we wish to engage. May I draw your attention to Standing Order 41 which is the only one relevant to the issue we are discussing? It says that a member of the Government who has given prior notice to the Ceann Comhairle may make a statement in the House on any matter. No debate shall be permitted on any such statement but further statements may be allowed at the discretion of the Ceann Comhairle from a spokesman nominated by a party in Opposition. It is clearly implicit in that order that the logical order of debate in relation to statements in the House is——

I must interrupt Deputy Keating. The Order of Business of the Taoiseach this morning stated "Notwithstanding anything that may be contained in Standing Orders".

On a further point of order——

Let us not have any more argument.

We are establishing a precedent——

I have asked you to leave this matter in my hands. You will observe the fairness and impartiality of the Chair, his desire to hear every Member and to ensure every point of view in the House will be heard.

With respect, no Member need be over-grateful to you for being allowed to express a right——

This argument is wasting precious time.

Do you intend to accept, for ever and ever, the principle you just established which apparently was that you would not contradict the ruling of the Leas-Cheann Comhairle regardless, presumably, of whether it was right or wrong, when it is clearly in breach of precedent? Point out to me the precedent in respect of which you made a ruling calling Deputy Burke.

I am calling on the Minister.

Where is the precedent for such a ruling?

Please, Deputy Keating, you are being disorderly and wasting the precious time of this House.

I should like to express the appreciation of The Workers' Party to the Chair in seeking to establish a degree of balance and impartiality.

That is quite unnecessary. All Members can be assured of the impartiality of the Chair.

Nonetheless, I wish to express the concern which arose last night and again this morning that if the previous ruling had stood it effectively would mean that groups like The Workers' Party who have something to say on these issues would be——

The Deputy need not elaborate on that point.

I hope we can agreee a procedure which I understand was the practice, that on major issues where a statement comes from a Minister the spokesperson of the various parties and indeed the minority groups would be heard——

It is becoming more evident to the Chair that where a limited debate is envisaged in the future the Whips ought to figure more prominently and decide how the time should be allocated.


Hear, hear.

I very much regret that the House, by virtue of the precedent it is endeavouring to establish, will force at least two parties — maybe three — to leave the House in protest. That will be a matter of profound regret. It is bad enough to have people marching in the street without Deputies being forced to march out of the House.

There is no necessity for that.

The Chair should reverse the wrong ruling.

We should revert to the long-established precedent in this House that where a statement is made by a Minister it is followed immediately by a statement from the other spokespersons from the Opposition parties. Thereafter, it can swing back and forth. If we concede this fundamental principle the precedent will be established. We have no intention of allowing that to happen.

There is no question of establishing a precedent. I indicated to the House how I should like debate to be continued.

With due respect, the Leas-Cheann Comhairle called on a second Government Minister immediately after——

I am aware of what has transpired. I will advise the House again——

That was wrong.

—— that it is traditional in this House that the Ceann Comhairle does not review rulings of the previous occupant of the Chair. I am ruling that the Minister for Energy, Deputy Burke, should now proceed to make his contribution. I have given the House an assurance that I will hear in succession the spokespersons for the other parties immediately afterwards. I can do no more than that and if the House persists I will proceed to adjourn the House for this day.

You will have no option as the procedure being adopted is grossly unfair to the Opposition parties.

If Deputies do not wish to avail of the time at their disposal——

A wrong decision was made creating a precedent for two parties, excluding the Progressive Democrats, The Labour Party and The Workers' Party. In a three-hour debate we would get no spokesperson in at all.

I ask Deputy Desmond to desist, to resume his seat and to allow the debate to proceed.

On a point of order——

Deputy Howlin, please——

On a point of order, the difficulty we have——

Deputy Howlin, the Chair is on his feet.


Remarks of that kind, Deputy Desmond, will not be tolerated by the Chair.

It is unusual for Deputy Desmond.

I am now calling on the Minister to proceed.

Can I raise a point of order?

Order, the Minister to proceed.


On a point of order, may I ask you how can you defend a statement of yours that you will under no circumstances——

I have given full explanation and I have nothing more to add. I am calling the Minister.


Because we cannot accept such a preposterous ruling we have no option but to express our utter and profound disapproval and to put you on notice that we will consider whether or not a motion of censure is appropriate. We will leave this House in protest because we have no other option. I want to put down a marker for the other two parties that we will not tolerate——

The Deputy can do as he likes in the matter. I have heard a variety of points of order. It could go on interminably. I am now bringing the matter to a conclusion and calling on the Minister.

The public debate which has been going on over the past number of weeks has highlighted a number of fundamental issues which I would like to touch on today.


On a point of order, may I ask you a question?

Is the Deputy going to allow this debate to continue or not?

Can I ask a question?

A wrong ruling has been made which you have condoned. You have suggested that the Whips should get together to make arrangements about these matters. That only highlights the further farce which has taken place where the Fine Gael Whip will not attend a meeting where the Whip of the Progressive Democrats is present. It is time these cosy arrangements between Fine Gael and Fianna Fáil were exposed so that the other parties in this House can get the opportunity to make their case. That is what has happened. We cannot accept the ruling by the person who sat in that Chair before you came in after the Adjournment. We are disgusted. You have indicated to the House that his ruling was wrong but you have allowed it to stand.

It is traditional that the Ceann Comhairle upholds the decision of the previous occupant of the Chair.

There is no logic, justice or fairness in that and we appeal to you to reconsider your decision in that matter. It is intolerable that it should have been allowed.

On a point of order——


Can there only be points of order from the other side of the House? Have we no rights over here?


We want this matter straightened out once and for all. We are not going to sit aside and allow cosy arrangements between Fianna Fáil and Fine Gael——

This is gross disorder——

On a point of order, I want to make a brief point.

We did not create the disorder.

I was going to say, Deputy Dukes, if this gross disorder continues I will adjourn the House.

In order to allow this debate to proceed and so that the Government will not be accused of trying in any way to interfere with an open debate in this House I am prepared to concede my speaking position to the Debate you wish to nominate from the other side of the House. The Government and I do not want it to be taken that we are in any way afraid of an open, full and frank debate in this Chamber on the health services.


Hear, hear.

In relation to a remark which was made a moment ago and which was repeated by Deputy Molloy, I want to make it clear to Deputy Molloy that the remedy he seeks is not in his hands. The remedy he appears to seek will be in the hands of the electorate at the next election.

I am calling on a spokesperson from the Progressive Democrats to proceed.


Order, Deputy Wyse to continue the debate.


Will Deputy Wyse please proceed?

There were people prepared to play to the gallery for cheap publicity.

Deputy Barrett, this is most unseemly.


The Deputy was supposed to be supporting the Single European Act.

Deputy Barrett, will you please allow the debate to continue. Deputy Wyse, without interruption.

First of all, I would like to thank the Minister for acceding to the wishes of the House this morning. I am sorry there was such a waste of time in an effort to eliminate contributions on this very important discussion on the health services. It is sad that children present in the House this morning were able to see that performance. I will say no more about it.

All this week in the Dáil the Progressive Democrats have sought to separate fact from rumour and threat so far as the health services are concerned. The matter has now been further confused by the claims in the Dáil this week by the Minister for Health that all is well and that the system needs no change. In particular, the Minister's satisfaction with the existing health board system is deplorable. His failure to address this party's call for the abolition of local health committees is regrettable. These are expensive talking shops and they are a luxury we cannot afford when frontline key medical care personnel, such as doctors and nurses, are facing the sack.

Hear, hear.

In the Southern Health Board area which covers Counties Cork and Kerry there are four of these committees. The travelling expenses run up by the three committees in County Cork amount to £144,000 or £3,000 per meeting. There is no justification for this when health boards are sacking nurses. The Progressive Democrats also believe it is time for an urgent review of the health board system. I am sure the Minister will verify that I have on many occasions expressed this view to him. It has spawned a huge administration bureaucracy in the past 50 years and makes no sense, especially when all the money spent is raised centrally by the Exchequer. It means that the taxpayer ends up with the worst of all worlds. He or she provides all the funds through the Exchequer but retains little or no control over the Government on how money is spent. That powerful position passes to the health boards and the voluntary hospitals.

What we are trying to achieve is greater accountability and to ensure that there is no waste of the taxpayers' money. This party also are very concerned to ensure that any health cuts are apportioned fairly. The brunt being felt on the frontline now by the doctors and nurses is entirely disproportionate. I know that the Minister said in the House on Tuesday night that clerical and administration grades in the health agencies comprise of only 10 per cent of total staff and that less than 2 per cent of total staff in the Health Boards are employed in central administration. He went on to claim that the demands for possible savings and staff reductions in these areas had been greatly exaggerated. We would get a different picture if we were to categorise health workers into medical and non-medical. That would be a more accurate distinction to draw in the present controversy; if those figures were provided, then clearly the non-medical staff would total much more than 10 per cent. In that regard I do not believe that the burden of the cutbacks is being shared fairly between medical and non-medical staff. Also it is vital that we discover what the picture is regarding overtime payments to staff in the health services and what level of absenteeism levels exists in different areas.

I believe that the Government were panicked into measures without calculating the severity of the consequences throughout the service. They have shown clearly in recent weeks that they are not in control of the situation. This is plainly underlined by the more recent decision of the Minister to send out officials from his Department to the health boards around the country to examine how the cutbacks are being administered. What is most deplorable about the ongoing controversy is that fear and panic are being engendered among the ordinary members of the public. They are being caught between the Government's ineptitude on the one hand and the undoubted scare tactics being resorted to by many of the unions in the health area and some health professionals on the other. The latter have been making very alarmist and irresponsible statements about the possibility of people dying as a result of the cuts but the Government must take ultimate responsibility for this deplorable situation. They have failed to govern, to get up front and run the system. The vacuum they have created is being filled by sectional interests working within the health system.

I appeal, even at this late stage, to the Minister to forget his pride and put the interest of the people first, to alleviate the hardship he is inflicting on the aged, the mentally ill and the handicapped children who depend on institutional care and the thousands who depend on our existing health services to an enormous dimension. I have worked on health boards for many years and know of the many abuses that exist within the structure. We have been spending additional millions of pounds every year and seeing no worthwhile improvement in our health services. We are no better off now than we were 20 years ago.

I should like to deal with some aspects of our health services. The Minister mentioned community care and I have heard many of his predecessors talk a lot about community care which, of course, is the most economic and worthwhile service for any community. When we talk about community care, we are talking about preventive medicine but we never make available sufficient money to make this service effective. For instance, let us take the geriatric service as an example. It costs something in the region of £230 per week to keep an old person in long term care in a health board institution. I want the Minister to take note of this because I have been expressing it in the health boards and on any other platform available to me where the care of an old person is concerned; we have a number of private homes throughout the country, well organised and which comply with all the regulations, but health boards refuse to pay a subvention in addition to a person's pension which could maintain an old person at less than half the cost of a health board hospital or institution.

Good point.

Why on earth can we not see what is happening in this field? I have visited a number of private homes and have been amazed at the efficiency that exists there, the comforts and every possible facility available. When a person is admitted an application to the health boards is made for some subvention to help the family to maintain that unfortunate old person in a private institution but these requests may be refused. I would ask the Minister to remember that there are hundreds of these homes throughout the country, well run and well organised. Above all, now that nurses are losing their jobs in hospitals and in health board institutions, there may be an opportunity for those girls to get employment in the private homes.

God help us.

They are the things about which we should be talking rather than preventing these girls from exercising their skills. These girls' one dream of life was to become nurses, they qualified but now they are running around Great Britain in the hope of finding some employment.

The Minister mentioned on Tuesday last in the Dáil that he had directed agencies that community care services should be protected as far as possible, including key services for the old and the house-bound, such as community nursing services, services for the mentally handicapped, home health services, meals on wheels, child care services and particularly day care and pre-school services for the deprived and disadvantaged communities and after care programmes for children leaving long term residential care. These are all essential and cost saving. There is no doubt in the world about that. Community nursing services are practically non-existent because sufficient money is not available to health boards to ensure the effective working of such services. When we take on such a range of services as I have just mentioned, we are not talking about costs, we are talking about savings. For that reason, I would make a very special plea to the Minister to devote much of his attention and of the attention of those especially appointed to go around the country investigating as to how health boards and hospitals are going to exist with the present cuts, towards ensuring that community care services get top priority at all times.

Whenever one talks about waste and deficits, one must direct one's attention to management. If management are not efficient and capable of carrying out their responsibility we have a duty to examine their function. The working of health boards must now come under careful scrutiny as to performance and effectiveness. Members of health boards are very far removed from the daily working of a hospital or institution. I speak from my knowledge of being a member of the South Eastern Health Board for many years. How can members of the Southern Health Board who live in Cork be aware of what is happening in hospitals in the Kerry Area? What do the members of that board who reside in Kerry know about the Cork hospitals? That anomaly should have been obvious to the Minister and his predecessors. The Minister should examine the position of voluntary hospitals. It is my view that small boards of management, representing politicians, doctors, trade unions and the business community, should be established.

That sounds like a big board.

"Voluntary" is the operative word for the members also. I am on two such boards.

I accept that and the Minister of State is aware of the position. Each member of such boards should be aware of what is happening in the hospitals. Such small boards would be more efficient and the members would get more information than they get at present. We should try to have more efficiency in our hospitals.

There is a lot of unnecessary waste in regard to the purchase of drugs, appliances and disposable items in our hospitals. The Minister should consider establishing a central distribution centre for such items in each health board area. Those in charge of such centres would be in a position to get more information about the drugs on the market and, above all, the cost. It must be remembered that our concern is to save jobs while at the same time making our hospitals and health boards more efficient. I have no doubt that the setting up of distribution centres would result in huge savings. The recommendations of the working party on the general medical services in regard to drugs are worth considering. I hope the Minister will have them investigated.

I am convinced that unless something positive is done now the hospital services in the Cork area will be in disarray within a few months and that the general public will suffer untold hardship. There will be chaos during the holiday period when staff who are on annual leave are not replaced. I am sure the Minister of State, Deputy Lyons, is aware of the position in the North Infirmary in Cork. That hospital caters for a very big working class area and has given a great service to the people. Another important hospital in Cork city is Erinville on the Western Road. I understand that a block and a half of that hospital has been closed and that during the summer the gynaecology unit will be closed. The Minister must do all in his power to prevent any further disruption in the health services in Cork. There is room for greater efficiency and I appeal to the Minister to give serious consideration to the workings of the health boards because in my view they have come to their end. They are not serving the purpose for which they were established and it would be better if we established small boards of management in our hospitals. Such a move would result in more efficiency.

I should like with the agreement of the House to divide my time with Deputy Barry Desmond because the Labour Party will have but one slot in the debate.

That is not unusual and I am sure the House agrees. Agreed.

The Labour Party appreciate the efforts of the Chair to include us in the debate. I am glad the important point of principle has been resolved and we appreciate the efforts of the Chair to resolve it. This is not the type of debate needed to discuss the one issue that is fundamental in the country. Every village and town is in uproar about the savage treatment of the health services by the present administration. It is unfortunate that we are not having a longer debate so that all Members can get an opportunity to present his or her views on the issue. It is unfortunate that at the end of the debate we will not be having a definitive vote. To allow parties to make statements on the matter is the minimum acceptable to us. I regret we are not having an open-ended debate so that we could suggest amendments to the decisions by the Government. The Labour Party will not let the Minister, or the Government, off the hook in regard to the health services. We will raise again and again the issue of the destruction of essential services which were built up over generations but are now being demolished in one fell swoop by the Government. Those services cannot be replaced.

As the spokesperson on Health for the Labour Party I will avail of every opportunity to highlight the implications of the policy decisions of the Government and the complicity of two Opposition parties, Fine Gael and the Progressive Democrats, in those decisions. Those parties support the basic strategy on cuts and have tried to distance themselves from the logical consequences of that strategy at local level.

I want to put the issue clearly for Members who wish to raise the position of their local hospitals for the benefit of the local newspapers.

Does the Deputy wish to close Wexford County Hospital?

I voted against the budget that proposed those cuts. The Labour Party withdrew from the Coalition Government when Fine Gael proposed similar measures. The Progressive Democrats subscribed to the overall Estimate and in the course of their motion debated this week stated: "That Dáil Éireann, wishing to remain within the 1987 revised Estimates for Health...". Last night Fine Gael stated that they wished to remain within the 1987 revised Estimates for Health. That is the kernel of it. We can hide behind local issues and gyrate and indulge in all sorts of humbug but the reality is that the net Exchequer allocation to the health services has been reduced. The provisional outturn for last year was £1,117 million. The Fine Gael alternative budget, rejected in the first instance by the Labour Party and then by the people, was to provide £1,115 million for this year. The Fianna Fáil solution and budget provision, having gone to the people on the basis that health cuts hurt the old and the sick, a national scandal and an unprecedented con job, was to provide £1,111 million, a decrease below even the Fine Gael miserable allocation. In order to maintain services at even the level of last year, an increase of at least 3½ per cent over the £1,117 million spent on the health services last year would be required. However, roughly £35 million have been lopped off with the consequent loss of 3,500 jobs. This has obviously led to closures of hospitals because there is not enough staff to provide the service. I listed last night every single area of operation that has been adversely affected. Transport has been reduced to cater for emergencies only. Acute hospital wards have been closed in every single instance. Five support hospitals are gone in the south east and at least 20 more are gone throughout the country. The community care budget has been slashed leaving no opthalmic and dental benefits. If the Minister is so convinced that his policy is correct, let him at least recognise what is happening on the ground and recognise the confusion and anger his policies on the health services are causing.

An area highlighted in a recent RTE programme was in relation to child sexual abuse which has become a grave and serious problem, a problem with which every member would be concerned. The only child psychiatric service in Munster is provided at St. Stephen's Hospital in Cork. This unit has assessed and treated 598 children on an in-patient basis since it was opened in February, 1987. They have treated children suffering from sexual abuse, physical abuse and children who are emotionally disturbed. Some of these children are there under "unfit persons" orders or "place of safety" orders from the courts. There is no place else for them to go and yet that unit is being closed down. The out-patients' department in the same unit is treating some 250 cases. The Minister's public assertion that it is his ambition to ensure that nobody will be left without an adequate health service, is patent nonsense, given the situation which exists.

I listened with rising anger to the PD spokesperson, Deputy Wyse, whose only solution to the health crisis is to talk in terms of reducing the bureaucracy. The Deputy said he would save £150,000 here, and another £150,000 there, but that is only peanuts in the overall context. The Deputy was only providing a useful smokescreen for the Progressive Democrats to screen their fundamental support for this policy of cutting public expenditure, a policy which they put before the people but the logical consequences of which they are afraid to address. Similarly the Fine Gael proposal accepting the strategy but refusing to accept the downstream consequences is a smokescreen.

We have raised repeatedly the issue of private medicine. Applications are coming in in increasing numbers for extensions to the Blackrock clinic and all the private hospitals around the country. Deputy Wyse now wants to privatise care for the elderly. The UK experience surely indicates that we have enough grotty private homes which are inadequately monitored into which to dump old people. What we want is a proper public service available to those who need it regardless of ability to pay. The Government have tried to smokescreen the whole issue with all sorts of gyrations over public spending. Deputy Desmond last night indicated the supplementary budgets that were brought in by Fianna Fáil Ministers year after year and indicated that when he came into the Department he refused to allow those supplementary estimates and insisted that the Fianna Fáil controlled health boards would live within their budgets. The health boards overspent and had yearly rows with Deputy Desmond as Minister and Deputy Desmond had to meet deputations supported by Fianna Fáil members of this House demanding more and more money. This has been an unprecedented U-turn by the Government. We have a crisis in the hospital health service and it can only be solved by providing resources. We can get those resources by restoring a land tax, by beginning to tax capital, by beginning to collect the VAT outstanding, some £700 million, by beginning to collect health levies due from the self employed——

You were in Government for four years. Why did you not do some of those things?

There is no commitment from this Government to tackle the vested interests. They see as fair game the services to the weakest and the poorest but their friends who are well off they will protect to the best of their ability.

You were in Government for four years.

A clear choice exists between providing a service and paying for it, or allowing the wealthy sections of our community to contribute nothing to the Exchequer, and demolish the services we have built up.

I will concede now to my colleague, Deputy Barry Desmond.

I thank the Minister for Energy for his intercession in the difficult situation this morning. His co-operation is much appreciated.

The Minister's speech has been criticised, but I would prefer to regard it as a somewhat thoughtful contribution to the future development of health policy. The Minister asked if it were possible perhaps for some political consensus to emerge as to the proportion of GNP which would define the parameters of total health spending. The Minister has set up a review group on funding the health services and he is accelerating the special cost containment and efficiency unit within the Department. He is holding a national conference in July on the plan for the hospital services. The Minister is preoccupied about the distribution of the higher specialities and so on. The interesting point in his speech was the equally interesting reply by the Taoiseach this morning that he proposed to set up in the Dáil a number of the revised committees, including the Committee on Women's Affairs to which he referred specifically in reply to Deputy Colley. I strongly suggest to the Minister for Health and to the Taoiseach that in view of the proliferation of statements made in the House relating to the health services in recent weeks and in view of the massive media attention related to the health services and of the many multitudes of comments made, it is essential that there be a political awareness and a true political understanding in the Dáil as to policy indications of the health services. I hope we will not see the return of that awful committee on public expenditure. I would implore the Taoiseach not to bring that about as the committee's reports were abysmal in their analysis of public expenditure. We will have the Committee on Public Accounts, but then it is time to have a select committee of the House on the health services. There have been such committees before. I know that many of us take a jaundiced view of Dáil Committees but if a select committee of this House could dispel some of the mythology which relates to the health services and could secure an education of public opinion as to what constitutes real health in this community, then we could do a great deal of work and it would not be circumscribed by the very attentuated and emotionally charged debates such as we have today. The Taoiseach would be well advised to set up such a select committee which would receive submissions from the public at large and interested bodies. A political consensus might emerge as to what proportion of GNP we should devote to the health services and how they should be financed.

We have the ludicrous position that health boards are dominated by members of local authorities, although the funding from local authorities ceased in the mid-1970s. In terms of the review of the structure and management of the health boards and their relationship with the Department of Health, I would implore the Minister not to make 24 political appointments to the health boards. He should give himself some breathing space to deal with the critical issues. A select committee would remove the necessity for a Committee on Public Expenditure which made so many erroneous comments and analyses of health expenditure.

No Government will ever succeed unless we amend the health legislation, particularly the Health Act, 1970. Deputy O'Malley asked last night why the Minister did not close down voluntary hospitals. The Minister cannot close down voluntary hospitals unless there is an amendment to the 1970 Act. Voluntary hospitals are self-appointed, self-perpetuating and independent. The only way they can be closed down is by removing their budgets. The Minister has taken decisions relating to some voluntary hospitals and has half closed down half of them. We need amending legislation to clear up the position between the Minister and the health boards. The Minister cannot close down a health board hospital — the Monaghan Hospital fracas proved that conclusively — without a public inquiry held in the emotionally-charged atmosphere of a local community. The 1970 Act is riddled with ambiguities and is in dire need of amendment. It must be amended to give statutory control over the registration and operation of voluntary hospitals and health board hospitals. One cannot open a psychiatric hospital without a licence from the Department of Health.

It is ludicrous that we are to have a proliferation of new private hospitals. Health boards will close down small local hospitals which will be bought by a group of consultants or local GPs who will open them up under some other guise. Mayhem will ensue in the health services.

I make an earnest plea to the Minister to bring in revised statutes. I know, not from the Department of Health, — lest my sources be regarded as exceptional — but from Government gossip that the Minister put specific proposals before the Cabinet but they were thrown out in the helter skelter rush to bring in the £10 charges. There is a great need for statutory control. I am glad that the Progressive Democrats are not opposed to the control of the voluntary hospital sector. I have nothing against voluntary hospitals but some of them are so preoccupied with what other politicians think of them that they imagine they will all be closed down. Many of them have done very good work.

The Finance Bill will bring in a retention tax in relation to professional fees, but simultaneously the Government have failed to deal with a retention tax in relation to consultants' fees paid by the VHI. I know that the payment is made to the subscribers, not directly to the consultants. All hell will break loose when the GPs discover that they are to be docked 35 per cent by the GMS payments board while the consultants, who are effectively receiving money through a State-sponsored body subsidised by tax relief, are not obliged to pay any retention tax. That anomaly had better be rectified fast or this Finance Bill will face great difficulty in the Dáil. The Minister for Finance failed to bring the VHI into the schedule of the bodies mentioned.

I appeal to the Minister to lift the embargo in relation to the staffing of the Department of Health. I found it excruciatingly difficult to deal with a situation where we were shedding and losing staff due to the embargo, yet we were expected by the then Ministers for Finance and the Public Service to run a massive budget of £1,300 million gross. At least remove the embargo on the internal staffing of the Department. Let the Department take on an additional coterie of qualified health economists, not the kind of nonsense that floats about in some of the public sector areas. Let them take on specialists capable of rationalising the health system. The Department is denuded of staff, with a very limited number of middle management staff to operate the system. The Minister for Finance should endeavour to rectify the position. This is a personal observation; I am not making any special pleading on behalf of any staff in any Department. I admire the heroic efforts of the Department of Health to deal with changing political cultures and changing political decisions as we go from one mad political decision to another. Expectations were raised by Fianna Fáil which had to be stifled when they faced the exigencies of the public finances.

I would equally ask that we deal with the management expertise of voluntary hospitals. It is ludicrous that a voluntary or health board hospital with a budget of anything from £15 million to £30 million is run by a secretary/manager who is paid £16,000 or £17,000 to administer it. He has no status or remuneration. Major budget centres in the Health Vote should, perhaps, be run on a public service contract basis. People should be well paid to look after the budget for five or seven years so that it will be run on an effective basis. We must also try to improve the management expertise and organisation of such hospitals. Generally speaking, both are miserable.

I would ask the Minister in relation to the GMS vote, which is now back up at £107 million, to bring in a capitation system for GMS payment. It is possible to do so and save a great deal of money on drugs, on which we are currently spending £60 million a year. A capitation system would have exceptional payments for exceptional visits, with incentives to doctors such as some prospect of a non-public service superannuation scheme, just as the common contract provides a pension scheme for consultants.

With these positive observations I urge the Minister to consider the setting up of a select committee of the Dáil so that we can continue to make a rational contribution in an atmosphere which is less emotionally charged.

The public debate which has been going on during the past few weeks has highlighted a number of fundamental issues which I would like to touch on to-day. It has shown the deep and widespread concern of the whole community regarding the highly emotive and personal public service, the health service. It has demonstrated that generally the community have come to expect a level of services which has been dramatically developed in the past 15 to 20 years. It also raised, possibly for the first time in such stark terms, the cost of providing and maintaining that level of service. The public debate generally has revolved around the argument that it was essential that the level continue to be maintained.

It is unfortunate that the debate has not been infused with a consideration of some of the basic matters that are at the kernel of the problem. At this stage, I would suggest it is accepted by virtually everyone in the country that for too long our demands for services — not just health services but all public services — have not been matched by our capacity to pay for them. I think it is generally recognised that the country has finally come to the stage where everyone has to have the courage to say "halt". It is time that someone checked the uncontrolled slide into economic chaos with all the horrifying implications of that. That is what this Government are doing.

So far as the health services are concerned, there would appear to be an attitude in some quarters that, while measures were necessary to protect the fabric of the economy, the health services should remain immune from the consequences. A similar attitude applied in relation to other public services. It is an attitude that just is not sustainable. Certain measures are necessary. That has to be accepted generally. It is, therefore, a question of how best to implement these measures so that at least the essential components of the services are preserved. This has been the intent of the Government from the start and we will ensure that this is carried through.

Surley the message must now be coming home to everyone that for some time past something has been seriously wrong in our health services which demanded an ever-increasing input of resources. Each year saw a further escalation of the demands being made on the services. Did this mean that, despite the resources being poured into the services, the health of the nation was such that even further levels of service were required? There are no statistics I have seen which would suggest that the general status of health in the country was deteriorating on such an alarming scale on an annual basis. Even the motion which was before the House last night recognised that this Government increased expenditure on health services from £1.298 billion in 1986 to £1.315 billion in 1987.

I listened this morning to Deputy Dukes' contribution to this debate, and one would be forgiven for wondering if Deputy Dukes had ever served in Government. Was he really the Minister for Finance for three of the last four years? Was he a senior member of that administration? Was he one of the front spokesmen on behalf of the Fine Gael party during the last general election? When he talks about cutbacks in health, let me remind him and this House that the 1987 Fine Gael projected allocation for health as published in their document in January last was £1,293 million. The Government turnout in our budget for our Book of Estimates is £1,315 million, an increase of £16 million on what Deputy Dukes and his party were going to do for the people.

What about the net figures?

In relation to the contribution of the Labour Party, the Labour Party Member who has just spoken was Minister for Health for a considerable number of years. In fact, he remained Minister for Health even when his Taoiseach wanted to fire him at one stage. He refused to be fired and stayed on as Minister for Health. The Labour Party, the PDs and Fine Gael come into this House and criticise this Government, a Government who have increased expenditure on health this year despite the Government restraints.

The Government hit the most vulnerable section of the community.

It is interesting that the Deputy mentioned the most vulnerable section. One section of the community would have been severely damaged by one of the Fine Gael proposals, that was the proposal to introduce prescription charges. Something which we in Government found so totally unacceptable that we omitted it from our budget proposals.

A bad mistake. You cut total services.

By implication, it is recognised that to keep the same level of service in 1987 as in 1986 would have required a significant increase in the amounts made available. The unfortunate facts of life are that it just is not possible to continue to provide indefinitely for that kind of annual incremental increase which the Opposition parties are now calling for but which they did not call for while in Government. The time had to come when it was necessary to ask what is the country receiving for this huge expenditure of taxpayers' money.

It was time to ask whether the whole and complex range and level of services which were being made available should be examined as to how necessary they were. The exercise, which really should have commenced some years ago, to determine what should constitute a proper health service and at what cost, is now being undertaken. That exercise will have to be completed as a matter of urgency as most certainly time is not on our side. The Minister for Health, Deputy O'Hanlon has clearly spelt out the main areas in which a special and urgent assessment of need would commence immediately.

Let me say when I mention my colleague, the Minister for Health, that a sustained, vicious and personal attack on that Minister has been carried on in the past couple of weeks by vested interests around this country and by political opponents. Deputy O'Hanlon is the Minister for Health fronting the Government decisions on behalf of the Government. It is not Deputy O'Hanlon as an individual Minister for Health, it is Deputy O'Hanlon as a member of a Government who are making the running on this issue. We have collective responsibility which was so sadly lacking in the last administration. Let there be no misunderstanding about it, Deputy O'Hanlon is carrying out Government policy in this issue and in that he has the full support of everybody in Cabinet.

For my part, I hope that the undertaking which Deputy O'Hanlon is involved in in relation to the review will be seen and its outcome accepted for what it is — that is an essential and rational look at elements of the health service to meet real rather than perceived needs. I am well aware that during the years a number of similar studies were undertaken, and from that experience I know there is a danger that these new studies could degenerate into talking shops and excuses for discussion without any meaningful results. This cannot be allowed to happen and it will not be allowed to happen. With the agreed plan of reform, there will be a strategy for carrying it through and this Government's determination will not be deflected.

I heard Deputy Dukes this morning refer to the need for review, the need to carry out changes within the health services and the need to look at the structures. For all of his failings, and they were many indeed, the former Minister for Health, Deputy Desmond, at least was putting forward some proposals. I would have disagreed with many of them vehemently, but he got no support at that time from his Fine Gael colleagues for proposals for reviews of the structures of the health service.

The concern being expressed at the moment about the health services and the implications of the resource curtailment for them is understandable. Individual apprehension about specific services and specific institutions is also understandable. What is a grave disservice is the impression being given by many people who should know better that the health services are in immediate danger of total collapse. This, of course, is not the position. Certain cutbacks will be necessary but there is no doubt that the essentials can and will be maintained. Yet these wild statements continue to be made. They are not justified. It is of particular concern that, unfortunately, these allegations are being believed. I know from my own experience that many people, especially the old and the less well-off, are very worried that their basic health requirements will not be met. I want to emphasise here today that this is not the case. This Government have been especially conscious of the need to protect the most needy in society. In introducing charges for out-patient and inpatient services these were the criteria used and I think any objective person will admit this is how they are operating. Those elements in our society, whether in this House, or vested interests outside it, are doing no good to the less-well-off and the old by their scare-mongering tactics.

The need to curtail the level of provision of some services, the need to trim the number of staff employed in the service, constitute part of the measures we have to take. The fact that it is possible, arising from the plans which have been considered by health boards, that some institutions may have to change their character or may have to close is being presented as a particularly draconian measure arising from the resource curtailment.

It seems to me this is a very narrow way in which to look at the problem. I would have thought it is really a question of putting the right mix of services together in the most efficient way and if that means an institution or part of it is not required — that should be accepted. Such resources, as become available, can then be redeployed to support those aspects of the service which are regarded as essential.

If the Opposition were to be honest they would acknowledge that this is also the way in which they have seen things for many years. Like so many other aspects of Irish life, whether economic or social, unfortunately they had neither the will nor the capacity to see it through. They wanted to be all things to all men at all times. An example of their mismanagement allowed an overrun to the tune of £55 million up to the end of 1986 in the health boards. Unfortunately, again — from a national point of view — they were too divided among themselves to take effective action.

We just cannot continue along this path of self-delusion and double-think. There must be an ordering of priorities and the pattern of expenditure must reflect these. We cannot sustain every facility just because it happens to be there. I do not want to give the impression that this will and must lead to a major change in the quality of service which will be available. Indeed, as the Minister for Health said on Tuesday evening last, there is now a golden opportunity to emerge from this period of difficulty with a leaner, fitter and more effective health service.

It is not just in the health services that this process of rationalisation and renewal is taking place. In other sectors of the public service, similar adjustments have had to be made and out of what is often a painful processs a new realism has emerged.

The Opposition are no strangers to this reality. I would have thought from their experience of the commercial semi-State area in recent years they would have a full appreciaiton of the task facing the Government and the Minister for Health now. When we were in Opposition we were not found wanting when difficult choices in the interests of the country had to be taken in this House. I should like to think that patriotic approach would be reciprocated now.

Given the terms of the motion before the house during this week, I do not see any reason why we cannot work together to reshape the health srvices. I want to make a special appeal to the staff in the health services. I know many of them are angry, perhaps fearful, about what is happening and about what may happen. Many, particularly those who are young and anxious to make a career in the service of people, may well feel, that their contribution is poorly appreciated. They may feel they are the victims of an unjustified assault on the service to which they are committed. I want to take the opportunity in this House of saying to them today that nothing could be further from the truth. It is well recognised that the provision of a good health service requires particular personal dedication and a wholehearted giving of one's talents and energies. We know that in many areas of the service people have had to work a great deal harder in recent years and that the advance in technology has made acute medicine a great deal more complex for all involved in it.

The health services have not been discriminated against by the Government. They happen to be very expensive and in some respects, they become more costly as they gain in efficiency. Our commitment to the services is demonstrated by the Government's decision to maintain non-capital public expenditure at 7.2 per cent of estimated GNP, a level which is well above that of many other European countries. For example, only ten years ago the percentage of GNP devoted to such expenditure was 5.9 per cent.

All of these figures, all of this commitment, all of the increases in funding that this Government have given above the outturn of the previous administration in 1986 and the projected expenditure in the Fine Gael budget of January last seem to have been forgotten by the Opposition at this time. It suits them to jump on band wagons but the reality is that this Government have increased the expenditure by £16 million at a time when other services are being severely constrained.

If we are to put the country back on a sound footing, ready to avail of the opportunities for growth within the western economy, for a while all of us will have to accept sacrifices. Different sectors will be affected at different times. I need hardly remind the House of the impact on people in the industrial and commercial sector of the enforced changes of recent years. Much though we might like to do so, it is just not possible to protect the public service from the harsh reality of our difficult economic position.

I hope that staff will appreciate the reasons such unpopular decisions have had to be taken by the Government, the Minister for Health and the health authorities. I want to emphasise that the actions of the Minister for Health are part of overall Government action. The scurrilous attacks on him are just that — scurrilous — because he is not acting as an individual but rather as a member of a combined and united Cabinet. The sooner we sort out what has to be done now the sooner will certainty and assurance be reinforced in the health services. We in this House should not add to the difficulties of achieving that aim.

I am calling Deputy Jim Kemmy.

May I ask if I am likely to be allowed to speak since I have been sitting here since the debate commenced, representing a group with 51 Deputies in the House. We have had one speaker to date. Is there any democracy in what has occurred?

We have had only two speakers.

In respect of the new interpretation of this morning's order we are reverting to the custom that had established itself — as I would see it — in respect of a Second Stage debate. That seems to be the new interpretation of this morning's order. When spokespersons for the major parties have contributed followed by a spokesperson for the Government the practice and tradition has been to call on a speaker from a smaller party or a combination of the minority groupings. That is exactly as the practice has been. We had one order this morning which we subsequently altered. We are not going to alter that now. I would ask Deputy Flaherty to allow me to proceed now with the new order and call on Deputy Kemmy.

Does that indicate I will be called after the next Government speaker?

The occupant of the Chair will then decide who will follow. I am calling on Deputy Kemmy.

A wise decision.

I sympathise with Deputy Flaherty. I, too, wait around this House for many hours, sometimes longer than anybody else, to be allowed to speak. Sometimes the rules of the House work against me as much as anybody else. I have to take my medicine.

In this context I am pleased to have the right to speak here today, to make my protest against the health cutbacks. It is the democratic right of Deputies like myself to be allowed to speak in this House and to have our voices heard. It is also the right of people to protest peacefully on the streets against these cutbacks. Democracy is a two-fold exercise in this context. People such as myself in this House should speak out loudly and clearly on this issue and the people outside the House who are opposed to these health cuts should do likewise and should march in support of their case. These cutbacks are not only cutbacks on jobs but they are a violent assault on vulnerable people such as the sick and the poor. They are also an assault on health workers, not only on nurses and doctors but also on tradesmen and others operating in the service. They have all been targeted in terms of the cutbacks in health services.

Lower paid workers will be among the first casualties of the cutbacks and the poor will suffer most of all. Socialists like myself cannot stand by and allow this to happen without opposing these cuts on all fronts. Not only the people in this House but also the nurses' trade unions and the entire trade union movement should fight these cuts. The politicians and parties should not be let off the hook on this issue. I hold no brief whatsoever for Deputy Barry Desmond, indeed I had many disagreements with him and his party both inside and outside this House but not one health board worker lost his or her job while Deputy Desmond was Minister for Health. At least that can be said in his favour.

He also tried to do something about controlling the power and the wealth of consultants within the health service but sadly, he got very little help from anyone in the House or from the trade union movement. Consultants are faring very well from the health services. I do not see much sharing in that area. Consultants and doctors speak a great deal about the sanctity and the privacy of the relationship between themselves and their patients. That privacy is often very profitable for them. The consultants have the best of two worlds; they have the very best of the VHI service and also of the public health service through the health boards. Among themselves consultants have a saying, that these hospitals are milking parlours for them because they can milk both services quite easily and they are quite adept at doing that. They have become very wealthy from the health services in dealing with the poor and the sick. At the same time they use the public facilities we provide for them. We allow them to use for their private patients private beds and private rooms in public hospitals and we allow them the full range of nursing and secretarial services. Deputy Desmond, while he was unsuccessful in this regard, tried to pin-point that scandal and that abuse within the system. The present Government and the Minister do not seem to be making any effort to take on these people.

When talking about waste of public money it is essential that we have some sharing process in this area. There is no point in some people at the top of the scale faring very well from the system while the lower paid workers are being turfed on to the streets and made pay the price for this waste of public money. There should be some equity in the system. I would like to see the Minister and the Government following up that area because in a society like ours, in a small country with a small population, we should have more of a caring and compassionate concept. This, unfortunately, is not coming across in the Minister's proposals. Far too much money is going to the wrong areas in our health services. Far too much money is going into private pockets. It is time to stop this lopsided development of our health services and it is also time to stop the drift towards a two-tiered system of health services, one system for the rich and one for the poor. I can see that happening if the Minister's proposals are allowed go through.

There are blueprints for this in America where the President, Ronald Reagan, took on the welfare lobbies. He did so successfully from his point of view but at a terrible price. In his own city of Washington there are very many poor people within a short distance of the White House and that is a very obvious indictment of the system. It reflects on the American system of competition. That kind of system is very much involved in the present attempt to cut health services here. I am in favour of a return for public money; I am not in favour of wasting public money but unfortunately the blueprint is there and it is a very obvious one which we must follow.

Similarly, in Britain Mrs. Thatcher succeeded in dismantling a good deal of the welfare system. As somebody who lived in Britain and saw the welfare system there working I realise that it had very good and valuable points. Despite the fact that we look at Great Britain as a different kind of society with a different ethos we could learn a lot from their compassion in that regard. Mr. Nye Bevan did an excellent job in putting in place that welfare system after the war, against very strong opposition at that time from the doctors. Unfortunately, Mrs. Thatcher was able to dismantle much of that system. We are now going down the same road and I deplore that.

Unfortunately, the crunch has come for us in this regard. In this House it boils down to numbers, as to who will stand up and be counted? I am glad to say that I voted against every aspect of this budget because I felt it was a badly balanced budget but it went through, cuts and all. The reality is that all the votes on the various aspects of this budget have been passed, including the one on the hospital charges which involved a division here three weeks ago. Last night the health cuts were again approved. It should be stated loudly and clearly that only 16 Deputies out of 166 in Dáil Éireann voted against the health charges being imposed. Last night only 12 Deputies out of 166 voted against the health cuts. That is the reality facing this House and facing the Irish people. This is not only about the whole question of health cuts, it is about politics and about the policies and priorities of our parties and politicians. The electorate must decide what kind of parties and politicians they want to send to Dáil Éireann to legislate on their behalf.

As I said elsewhere, there is no point in marching to the polling booth one day to vote for a politician or a party and a few months later marching around the streets protesting because that party or politician has taken away your job, has imposed health cuts and has refused to do anything about tax equality. It is about time that our people woke up to the consequences of their actions in this regard. Above all it is time for them to do something to change the position. It is time that Irish politics became more responsive and amenable to the interests of the PAYE earners and to the unemployed. As I said elsewhere, if the 250,000 people who are unemployed joined forces at the ballot box and the 70,000 PAYE earners and the families of all of them Irish politics could be transformed in a relatively short time. Unfortunately, the unemployed and the PAYE sector stop short of taking action and pull back from the consequences — more is the pity. Sadly, they have been unwilling to learn the obvious lesson from their inconsistent record so far as what they do at election time and what they do otherwise is concerned. It is a savage indictment of our society that at a time when health cuts are being imposed and the Government state they have no money, hundreds of millions of pounds of public money in the form of VAT remain uncollected. This tax has to be paid by the ordinary person. Similarly, hundreds of millions of pounds in income tax are also uncollected.

As was mentioned earlier, the farmers have been most reluctant to pay modest health charges or to pay land tax. I will confine myself to their reluctance to pay health charges. About two years ago the health boards were given permission to collect these health charges from farmers but unfortunately they were unsuccessful in doing so as were the Revenue Commissioners. At the same time as we are facing those health cuts there are other matters such as the hundreds of millions of pounds in VAT collected by individuals, which is going into private pockets instead of to the State and which will soon be written off. A vast amount of income tax remains to be paid by farmers, professional people, the self employed and others. The farmers refuse to pay any kind of taxes at all. They refuse to pay rates, income tax and health charges. They have no qualms about making the poor pay for the crisis in our economy.

It is time that all people created a party that will not stray from the issue of social justice in our society. It is time our people created a party that will stand up to the powerful and influential vested interests that dominate our society. This party will come about, not of its own accord but only when the people who are marching and protesting loudly outside the House realise this. I hope the people will come to this conclusion and will make the necessary action to bring this about. In this House I will continue as best I can as a lone Deputy to oppose the health cuts and to speak out against them as much as possible. I do not know and I do not think anybody knows, what the final outcome of these health cuts will be. They have been far too drastic and unplanned. They are an assault on the sick, the poor and the working people. I do not know how the Government can expect health boards to provide the same level of services they provided over the years while imposing these cuts. Commonsense tells us it is not possible to give the same treatment to the sick, the handicapped and the poor if the same level of money and resources are not provided.

I want to go on record as condemning these health cuts as being insensitive and utterly lacking in compassion. I know more about the operation of the Mid-Western Health Board and the private hospitals in Limerick than I do about the health boards throughout the country. The officials of the health boards have told me and other public representatives that hundreds of health board workers are about to lose their jobs. For instance, there has been a cutback of more than £5 million in the budget allocation for the Mid-Western Health Board. I do not know how the Government can introduce such a cutback and still expect the same services to be provided. Commonsense would decree that that is not possible.

Lower paid workers have come to me because they have been given notice from the Mid-Western Health Board. Some of these people, strangely enough, have been on short term contracts for four or five years. It is an abuse of the work of the Employment Appeals Tribunal when workers are kept on short term contracts to frustrate the aims of the tribunal. Since these people are on short term contracts, they are not in line for redundancy payments and so on. All they will get is a week's wages when they finish with the board after four of five years. This is a flagrant abuse of the labour legislation.

This is a fact which is not generally known.

I listened very carefully to the Minister, Deputy Burke. He said the Government's aim was to reshape health policies and put the health services in order. These are very laudable objectives and everybody would agree that reshaping the health services is long overdue, but it is the manner in which the Government are doing it which calls for opposition. The Government cannot take these measures without expecting some trouble from Members of this House and on the streets. Even at this late stage I appeal to them to draw back from the brink of this upheaval in society. This would not be a sign of weakness. In my opinion it would be the civilised and compassionate response of a Government to the pressures of public opinion.

I am not directing any abuse towards the Minister concerned because I do not see any point in personal abuse. I am against that because, as has been said, it is the Cabinet who are responsible and I do not see any point in singling out the Minister for that sort of abuse.

I ask the Government to rethink their position. I realise the Government are not bloodyminded. The Fianna Fáil Party have the record of being a populist party I do not like Fianna Fáil, their record, or their performance and I have many ideological differences with them. They are certainly not being bloodyminded in dismantling our health services and imposing these health cuts. This step is insensitive and perhaps is a measure of the gloom and doom felt throughout the country, but I do not believe making the health services the scapegoat for cutbacks in wasteful expenditure is the answer to the problem. This is tackling the problem at the wrong end. It would be more profitable to tackle the areas I have mentioned rather than taking on the poor lobby, the welfare lobby or the health lobby. In my view, the Government are wrong, insensitive and these steps are too drastic. I appeal to them, even at this late hour, to rethink their attitude to these cutbacks. While there is a need to save money and to make more productive use of public money, the Government have made a fundamental major error. It will not be to Fianna Fáil's credit if they persist with these measures in view of the wave of opposition inside and outside this House.

I should like to commend Deputy Kemmy when he said he would refrain from any personal abuse of the Minister for Health. It is only what I would expect from him and he is to be commended.

The Fianna Fáil Party will never follow a philosophy of one law for the sick and another for the poor. Fianna Fáil is the largest party in this House, representing every sector of the community, and has done so for over many decades. While I agree with some of the sentiments expressed by Deputy Kemmy, when he talks about areas of social deprivation he should realise that the new measures do not affect medical card holders. I am putting it on the record of the House that the very modest VHI scheme covers people who are in somewhat better circumstances and will, I believe, be very effective.

We are not copying the modus operandi of any other Government or any other country. I appreciate what the Deputy said about the construction of the health schemes in a neighbouring country. I was working in that country at the time and was very much in support of the Minister who brought them in. As I said, we are not copying the existing policies of any Government in any other country. We are dealing with the situation as we find it.

Over and over again it has been brought to the attention of the House that we inherited a situation where £55 million overspending took place last year, and this had to be dealt with now. I will be referring to the North-Eastern Health Board area later, but if their example had been followed throughout the country, we would not have the present serious financial crisis in the health boards.

When the Government assumed office just over two months ago there was a broad consensus among the parties representative of nine-tenths of the electorate that the containment, and where possible the curtailment, of Government spending was an essential prerequisite to economic recovery. I want to stress that I would not like to be part of containment or curtailment which was taking place for its own sake. Containment, and where possible curtailment, with the objective of bringing a stimulus to economic activity and employment is the purpose of the exercise. Divergences were apparent between the parties as to the relative emphasis to be placed on economies in the different sectors, but the fact that urgent action was imperative was not disputed at that time by anybody. Excessive public spending — and I mentioned the £55 million overspending a few moments ago — and the inexorable growth in the proportion of the country's resources which were being spent by the State, were recognised as playing a key role in depressing efforts at effecting growth. A fall in interest rates resulting in new investments and the spirit of renewal so critical to turning the tide of unemployment and the general malaise which has paralysed our economy for the past few years were all seen as dependent on restraint in Government spending. As far as the fall in interest rates is concerned, the movement has started. It may not be as rapid as some of us would wish but it has started and is a healthy indication that the economic objectives are being achieved.

The budget introduced by the Government endeavoured to re-examine expenditure and effect economies in a wide range of areas. Since then, attention has focused almost exclusively on the current year's provision for health expenditure. Interestingly, while two of the parties opposite proposed global Government spending levels broadly in line with those being adopted by the Government, they have tried to slither away from the practical consequences of spending which they had exhorted. The pretence of unspecific assertions about how expenditure savings in health and other areas could be effected peacefully and effortlessly, coupled with assurances that the parties of which they are members retain a commitment to refloating the economy and lifting the burden of excessive spending, must be rigorously exposed in this House.

I must refer to the targeting of Government members as individuals which was referred to by Deputy Kemmy and for which I commended him. The House should bear in mind the words of Article 28 4.2º of Bunreacht na hÉireann which says:

The Government shall meet and act as a collective authority, and shall be collectively responsible for the Departments of State administered by the members of the Government.

The targeting of the Ministers for Finance, Environment, Education or, in this case, the Minister for Health as individuals, is a dishonest exercise in the light of the words in the Constitution about collective responsibility which I have just read. Deputy Kemmy pointed out that personal attack and abuse were not part of his strategy for which I commend him. I also wish to express my appreciation to Deputy Barry Desmond for stating that the personal attack should be avoided and that any political attack should be directed at the Government who are collectively responsible for policies.

Deputy Desmond got a fair bit of vilification over the last four years.

That remark is not relevant to my argument.

It is the truth.

Deputy Barry Desmond was never attacked by me.

Was he defended by the Minister?

If Deputy Flaherty had defended the policies which Deputy Desmond was advocating he might have had an easier time or if she had tried to restrain the then Taoiseach from moving Deputy Desmond from the Department — of course he refused — she might at least be entitled to interrupt me.

Who is slithering out now?

The Minister without interruption.

The Minister is provocative.

I am far from provocative and I never was. I am like the quiet lion, I only attack if provoked. If we are serious about curtailment of expenditure as one of the vehicles to propel the drive towards economic recovery, it is inevitable that health spending must come into the reckoning. To pretend otherwise would be a dishonest denial of the facts.

The health sector is one of the big eaters of public money, responsible for about one-fifth of Government spending. The Irish share of gross national product devoted to health is significantly higher than that obtaining in other countries. I will give a few examples and confine myself to smallish countries which might be properly compared with Ireland. The figures I will give are taken from the NESC report — A Strategy for Development. Ireland's share of GNP is 8.2 per cent; the figure for Austria is 6.9 per cent; for Belgium 6.5 per cent; for Denmark 6.6 per cent; and for Finland 6.6 per cent. The figure for a large, wealthy country like Japan is only 6.7 per cent. Norway, which is roughly equivalent to Ireland, although it has better resources of oil and fishing, spends 6.9 per cent.

None of these countries has our population structure.

I am quoting the NESC figures. Our population structure should help us in this regard because we have so many young people and health can be predicted for the most part for young people rather than for an older population.

We have a huge dependency level.

That is different from health.

We have an elderly population.

Health services have tended to assume what one might describe as an unhealthy dependence on Exchequer financing with some 85 per cent of the income of the health service coming from central funds.

The inexorable increase in spending of money and use of personnel have not produced a significantly healthier community. By definition, health outputs are difficult to perceive and quantify—I concede that to the Deputy opposite— but my overall impression is that the Irish race has not become healthier in recent years in direct proportion to the deployment of more money and more people.

The type of health care system we have developed is a very laudable and compassionate one. It has allowed guaranteed access to a range of resources tailored according to income and contribution levels. Unfortunately, in some cases, what we get too easily we tend to appreciate too little and use too freely and wastefully. Anyone who has ever seen a hospital bill will know that the cost of the maintenance of a patient in hospital is extremely high. Overnight charges in the most exotic hotel pale into the bargain class by comparison; you will notice my input from the tourism area. Yet, in applying their budget to the range of services they provide, there is an impression conveyed that economies are being effected to a disproportionately high degree on services and facilities which have a high public profile. It is strange, to say the least, that what is a very minor reduction in real terms in the health budget should provoke a relatively wide-ranging withdrawal of services. We do not know but that a more staid and fundamental review of the deployment of resources at the disposal of the health boards — the Minister has hinted at this —might reveal possibilities for economies which have yet to be explored.

I said I would refer to the North Eastern Health Board. I have no expertise in the area of health but I should like to quote the remarks of a consultant in the area which covers counties Cavan, Monaghan, Louth and Meath, a substantial area where the financing of the health services has been carefully monitored over the years and which could provide an example for the rest of the country. I am not being chauvinistic in that regard but if the Members care to examine the situation they will see that I am right.

At an estimates meeting of the North Eastern Health Board a surgeon from Drogheda, Mr. Michael Shine, said this country had an excellent health service and would continue to have an excellent health service. He said people were confused as they had been told they had a free health service but, in fact, like every other country they had a tremendously expensive health service. His message was to tell the people that they need not be afraid as they had an excellent service. He would prefer to be ill in Ireland today rather than in any other country in the world. That was said by a person of experience in the health field and is relevant to what was said earlier by Deputy Kemmy who spoke about the position in the United States—and I am no expert in this field either—where the cost of medical services is very high.

Is he a medical doctor?

He is a medical doctor.

He is hardly a dispassionate commentator.

He is hardly dispassionate but if he were passionate one would think his remarks would go the other way because, as has been pointed out already, he belongs to a sector of the professional people supplying services who are being so-called punished by the Minister for Health.

That is the point.

They have had a bonanza.

I think that Deputy Keating has not grasped the relevance of what I have said. This man stands to suffer from some of the policies of this Government.

He does not.

Nevertheless, from his experience he sees this as a country in which he would prefer to be ill rather than in any other country because he regards the service as a good one and is on record as saying this.

Private medicine has had a bonanza.

What would his patients say?

Acting Chairman

The Minister has five minutes left—no further interruptions, please.

I like the imperious manner of the Chair.

It commends itself to you?

Yes, it appeals to me. The fact is that that area had a deficit in its 1986 budget of £690,000, not the £5 million or the £10 million as has been suggested elsewhere. That area, covering a substantial sector of the population, was able to organise itself in such a way that they will not be withdrawing any services this year. There may be some quantity reductions, as was stated at the annual general meeting, but they have to be commended for saying there will be no deterioration in the quality of the services to be provided.

Public discussion of the health spending cuts has failed to address the tendency towards uncontained growth—this is relevant to what I have said—and a wasteful and abusive drain on scarce resources which are endemic to the type of comprehensive Exchequer funded network which we in Ireland have developed. If this discussion has been weak on intelligent political appraisal it has been strong on personal abuse and scare-mongering. To repeat what I have said already lest anyone be under any misunderstanding, the members of this Government adhere to and are bound by Article 28 of the Constitution which requires us to meet and act as a collective authority, collectively responsible for the Departments of State we administer.

The levels of expenditure which were provided in this year's budget were based on well-considered Estimates of the optimum balance between what the country needs by way of public spending and what it can afford to sustain. Those decisions were taken collectively by all the members of the Government and are ones we will continue to endorse. No amount of pressure exerted locally or nationally will weaken our resolve to carry out decisions and policies which we have decided to be the correct ones. No amount of personal abuse will soften the resolve of the Government to see through to implementation the policies on which we, as a Government, have decided. The collective responsibility for and commitment to policies cannot and will not be fractured.

Acting Chairman, thank you for the opportunity to speak. I would like to congratulate the Minister who has just spoken for coming into the House to support the Minister, Deputy O'Hanlon. It is rare to see Ministers coming into this House, as they have done today, to support, and indicate their political responsibility for the decisions we are discussing.

I am concerned at the way in which the debate has gone today. The Minister, Deputy O'Hanlon, opened the debate with an incredibly general and woolly contribution in which he referred to desirable reforms and a wide range of issues and theories. His contribution was academic and irrelevant. The reason for this debate has been caused by the crisis in the health services. The decisions which have been taken have resulted in many people coming out onto the streets. I do not encourage industrial action or protest or seek to whip it up but this debate was meant to respond to the level of concern which has been expressed at what is happening in the country. Instead, by and large it has been irrelevant to the current crisis. It has been very general debate, one we can have at any future time.

Having listened to Deputies from the left, the right and the middle, as I see ourselves, there is room for a broad consensus on the direction the health services should take and on the desirable reforms. There is a broad consensus on having an all-party committee to examine this matter and for a White Paper which could be debated but that does not help anyone running the health services who at present are coping with the immense cash crisis.

I do not want to make a personal attack but I think the Minister and the Government must accept responsibility for what is happening in the health services and for the cuts. I resent the Minister and the Government attempting to wash their hands of responsibility for the cuts in the health services. I do not know whether he is fooling himself or his party but he is certainly not fooling us or the public who are feeling the brunt of these changes. When he was a spokesman for his party while in Opposition it was Deputy Wilson's custom to hold Ministers accountable, individually and collectively, and I hope to continue that tradition. I refuse to allow him and the Government to wash their hands of what has been going on. They have tried to wash their hands by placing the blame on the health boards, which is absolutely unforgivable and indefensible.

Since the local elections of 1985 the health boards have been dominated by the Fianna Fáil Party. Therefore, even if you take it at the meanest level, which I do not, the responsibility still lies with Fianna Fáil. The Government, on coming into office and having examined our budget, accepted the greater part of it. The areas in which they made the greatest changes were in both the health and education sectors and I am sure the same kind of crisis will arise in the education sector as budgets begin to run out in the autumn. The Government have made major changes in what we proposed.

We do not stand for irresponsible spending in the health services but we certainly do not support the view which was presented by the spokesman for the Progressive Democrats that all that has happened in the health services during the past 20 years has not contributed to improving the health of people. Many valuable services have been built up during the past ten to 20 years and it is proposed that these will be cut out of the health service in one fell swoop. We ask the Minister not to stand by the harsh position which was outlined by the Minister, Deputy Wilson, that they are going to stand firm on every element. We ask that they stand firm on the broad principles; we will support them on that and we have said so. But we will not support the measures taken in other areas, particularly when there are other options which were outlined by us in our proposed budget of last January. Those options and the ones which I will propose before the end of my contribution could be looked at.

The figures have been juggled about and there is no doubt that Mark Twain was right when he said you have lies, damn lies and statistics. It is often difficult to get the true position from statistics but looking at the figures for the first time there is a net reduction in moneys allocated to the services. If you look at our proposed budget of last January you will find that the Government have taken an extra £16 million from the services. They have made a further reduction of £10 million in the area of recruitment and £6 million to be saved through these mysterious efficiencies.

We have proposed a modest increase in the net estimate for the health boards which would allow them, with the increased cost they would have been facing inevitably, to have pruned gently. I am particularly anxious about these health cuts because they represent a major blow to women. Women form the vast majority of the workforce in the health services which is being reduced, at the Government's own estimate, by £200,000 this year. They are in the frontline for services with their children, their longer life span; they are particularly affected by the cuts, even in geriatric beds. The bulk of the jobs lost will be female workers, the majority of these being nurses. The bulk of those lost already have been nursing jobs. Why has this happened? It is particularly because many nurses are part time and temporary. This might make people feel that it is not too serious to get rid of temporary and part time jobs, but if looked at a little more closely it is not quite as fair as it sounds.

Many of the nurses in the health services have been temporary full time nurses for up to 14 years. Some were originally forced to resign by marriage bars and came back to work when they were too old to be made permanent. This is something which has been inadequately taken up and perhaps the nurses are not as well organised as the medical profession who are organising and lobbying to oppose the losses in their own area much more actively. The nurses are being hit when perhaps nurses who were recruited in the last year and have been made permanent are not being affected. Will the Minister look into this area to ensure that this group of workers are protected and that the women who have been discriminated against twice in their history will not find themselves as usual being the first victims of the cuts in this area? My mother was a 15-year-long temporary public servant in the public nursing area and I had direct experience of the consequences of all of this right through to her retirement. These people are the easy and the soft options in reducing numbers.

In the end of the day what will we have? The Minister, Deputy Burke, held up for us the wonderful prospect of having a fitter, leaner health service. I can remember that being presented to him as an option by us when on that side of the House and he was not terribly impressed with it. I am not a bit impressed by it because at the end of this year we shall have achieved none of the radical reforms. All we shall have will be services lopped off here and there with what remains not necessarily any fitter or leaner. We may have all the unhealthy, wasteful elements still in place and vital services gone because of the way in which it is proposed to implement these cuts. The Minister cannot wash his hands of it. If he has views on it, he must make the health boards follow them. The Minister and the Government have tried to have it every way in these cuts. On one hand they are not responsible for the health cuts being implemented by the health boards and the services but on the other hand he has given them broad instructions on what they are to do. That was to include protecting community services. It is common knowledge and certainly to my direct knowledge that community services are already being affected. Does the Minister intend to act on this?

Let me outline some of the cuts of which I am aware which are very worrying because of their impact on public health. They go against the whole theory of moving into the area of community care and prevention. These are, in the Eastern Health Board area, the ending of school medical examinations and the curtailment of social work services in deprived areas; major preventative programmes in the Finglas area which were under way and on which work has been done have now been brought to a halt and the social workers involved have been called back into mainstream activity. Developmental check-ups are to go, largely because they are operated by temporary doctors. Travel assistance to child guidance clinics are to go. All these mean that the poor and the deprived will have fewer services, and there will be less likelihood of diseases in their children being caught early. If the services are there and happen to be far flung, it will be expensive or perhaps impossible, or enough of a disincentive for the people not to attend them. Will the Minister wash his hands of his responsibility for this backward step in the health services?

One other area is worrying most people and if the Minister could resolve this in the area of community care he might have dealt with some of the worst elements of the proposed health cuts, that is, the number of unique national services that are to go in the proposed cutbacks. The Minister has constantly maintained that essential services will be maintained. This was repeated again by the Minister, Deputy Burke here. He said that we would have an order of priority. Other Deputies have dealt at length with the sexual assault unit in the Rotunda Hospital. There has been something of a disagreement between the Minister and that assault unit as to whether the unit are funded directly. They were funded directly by his Department and it is his responsibility to ensure that that service and that this welcome development are maintained. The unit is only two years in existence and has given some hope, counselling and future to the hundreds presenting themselves over each of the years, increasing numbers of young people with severe problems. I would make a particular plea to the Minister to tell us what is the future of this service which was not funded from the Rotunda budget but directly from his Department. Would he at least give us a clear guarantee that that would be maintained?

I am also very concerned about the bone marrow transplant unit in St. James's, the infertility clinic there and the haemophiliac unit, all of which are unique. Certainly these, at a minimum, must be protected. The maternity unit in St. James's is to go. It is a unique service in that it is the only maternity unit in a general hospital and one of the smallest. It can, therefore, offer specialised care for high risk patients that cannot be offered anywhere else, encompassing high blood pressure or liver problems. It is the only place that can be said to be adequate. It is clear that with the falling birth rate we are going to have to rationalise maternity services in the Dublin area, but it will not be an answer to close this small unit. It will only be a very short term answer. I argue very strongly that in whatever rationalisation occurs in the future that unit should have a place which is guaranteed.

I wish to give a few moments of my time to my colleague, Deputy Taylor-Quinn, but I wish to refer briefly to services, again unique, in Cappagh Hospital. Orthopaedic work is being done there almost uniquely in the country—there may be one more service in the Southern Health Board area. The cutback of £75,000 to that hospital will mean that they will have to reduce by half their number of joint replacements. That means that the existing two year waiting list will extend to four years. That will affect only public patients. The private patients who have this operation done in the Blackrock Clinic will have no problem. This is one of the saddest and most indefensible matters. It is something that will mark out this party from the party on my right. We are anxious in our commitment to the development of the health services to ensure that a public service is available for those entitled to it. We support rationalisation but we do not support the development of an American style system which will create second class citizens and give them a totally inadequate health service. We will not support an attitude that the care one gets is decided by the size of one's purse. In Government we participated in a slow and careful pruning of the health services. The Government should have continued in that direction and not have embarked on the extensive cuts introduced by the Minister.

I should like to thank Deputy Flaherty for giving me some of the time allotted to her. I am amazed at the response to the debate from the Government benches. One would not think that throughout the country patients are being discharged from general and regional hospitals earlier than they should and that old people are being told they had better find some place to stay other than the geriatric and district hospitals. Because of the closure of maternity units pregnant women are wondering where their babies will be delivered. Thousand of people in the health services are wondering where they will get their next job. Listening to the response from the Government side one would not believe that there is such chaos in the health service.

I should like to tell the Minister that the Mid-Western Health Board are proposing to close the district hospitals at Kilrush, Ennistymon and Raheen. The board propose to close 50 beds in the General Hospital in Ennis, 75 beds in St. Joseph's Geriatric Hospital and the entire maternity service at Cahercalla Maternity Hospital. As a result of the proposal in regard to Our Lady's Psychiatric Hospital in Ennis there will not be any treatment programmes. It is sad that the health services have been cut back in this way but it is indicative of a Government who are not concerned about the public. There is little indication that the Government are caring or compassionate.

The people of Clare contend that they are being asked to bear an unfair percentage of the proportion of cuts suggested by the Mid-Western Health Board. I had hoped that today the Minister would have something positive to offer for that area but all he said was that all health boards, with the exception of two, were able to work within their allocations. He said he had met the two health boards concerned, the Western Health Board and the Mid-Western Health Board, and he hoped that they would follow the examples of the other boards. Will the Minister tell us what the Mid-Western Health Board propose for that region, particularly in County Clare? I understand that the board propose to leave a skeleton service in the county and cut the number of jobs by about 300. Many of the temporary nurses who have been employed for the past seven or eight years are being made redundant. In the General Hospital in Ennis 17 nurses have been made redundant and it is expected that a further 14 will be made redundant at the end of the week. The out-patient department at that hospital has closed and ante-natal clinics are not being provided. The people of County Clare do not know where they will get a service in the future.

The position in regard to the health services is so serious that the public are in a state of shock. It is serious when one finds a 96-year old patient crying because she does not know where she will stay when she is discharged. That lady does not have any relatives or anybody to care for her. Where will she end her days? It appears that the Government are not aware of what is happening. We all agree that there is a need for rationalisation and the matrons of the hospitals in Clare are prepared to do that. Those matrons have prepared plans for their hospitals and will, if asked, submit them to the health board.

I was depressed to hear the Minister's statement in regard to health boards. The arrogance of some of the senior officials of the Mid-Western Health Board leaves a lot to be desired. The Minister should accept that he has responsibility for their actions. In the course of his speech the Minister said he made no secret of his confidence in the health board system as an appropriate model for the delivery of an efficient and responsible health service. However, in my view the health board in the mid-west region is not capable of delivering an efficient and responsible health service and the Minister should examine its activites. It is not efficient or effective.

I should like to congratulate the Minister for Health on being the first holder of that office in 15 years to face up to the problems in the health services here. I should like to refer Members to the problems that exist in the service. These did not arise in the last three months. They arose because other Ministers ran away from them. The Minister listed the main issues involved. He said that to correct the problems of the health service we must review the funding arrangements and he announced those details this morning. He said that to correct the problem of the service it was necessary to rationalise the acute hospital system, develop the primary health care services, develop health care promotion and preventative services and achieve an improvement in managerial arrangements at all levels in the system.

The Minister has had to face those problems but his predecessors mortgaged the future. When Old Mother Hubbard went to the cupboard she did not find anything but the Minister found a bill for £55 million in the cupboard. We should congratulate the Minister on his efforts to ensure that we will have a proper health service in the future. I do not accept the emotive statements about the number of people who will suffer as a result of the cuts. The Minister did not take away the entire allocations, as some people seem to imply. He has reduced it in an effort to bring order into the system and will be remembered for bringing about an orderly development of the health services.

As Minister for Labour I have special responsibility for the maintenance of good staff relations and I have had some direct involvement in the health services, particularly in the hospital system. Before I became a public representative I worked in the administrative area of the service, a group that has been attacked in the House and outside in recent days. The impression has been given that it is only in the last few weeks that the closure of some institutions was raised. I should like to remind the House that as far back as 1968 plans and proposals were prepared on the future direction of the hospital services. They pointed to the need for rationalisation, a change in the type of services provided and, consequently, the demise of a number of institutions. A number of institutions have been closed and the type of service provided changed. They include Mercers Hospital, Teach Ultan, Sir Patrick Dun's and Manorhamilton.

Since 1968 we have succeeded in greatly improving the acute hospital sector but we have not done so in the most effective and efficient way. There has been no shortage of proposals and plans, yet outside Dublin the hospital system in terms of numbers, location and size of hospitals remains largely the same as it was 20 years ago. We cannot now sustain at the appropriate level of competence and capacity all the acute beds and hospitals in the system. This is obviously a matter of grave concern. We must have a viable acute hospital system in our health service.

We should reflect on why it has been so difficult to achieve rationalisation in an area in which so much sound advice has been available and when there has been so much unanimity in the general context of the advice. There are too many reasons for this continuing problem. First, there is a perhaps erroneous view among the public and among politicians about what now constitutes an effective and an efficient acute hospital service. Secondly, our arrangements for implementing agreed plans in this area of the service have not been sufficiently adaptable to achieve the task and to tease out various problems and challenges. In trying to make progress we must have regard to these factors. We need to explain to the people the factors which would guarantee the availability of a good caring service. We also need to ensure that we have sufficient statutory and effective authority to carry through the necessary changes. The action the Minister now proposes to take will finally bring to an end a long chapter in our attempt to come to grips with the acute hospital problem.

In relation to health staffs, the health services are and will continue to be highly labour intensive. Nearly 70 per cent of all expenditure on the health services is devoted to pay. Health boards and hospitals have tried over the past few years to avoid reducing staff numbers by constantialy paring away at the non-paying expenditure, which was only 30 per cent of their costs. That brings its own inefficiencies and in any event it is limited in its capacity. The Minister for Health has already made it clear that we wish to bring about such changes as are necessary after consultation with the various interests concerned. The Minister is necessarily limited in the amount of time he has for this. However, a very important initiative is being taken next week when the Minister will meet with the representatives of the alliance and health service unions. At both national and local level this alliance which has grown out of the present difficulties presents a very good opportunity to the Minister for real and rapid consultation with staff interests. In the nature of things, much of this consultation must take place at local level. I am pleased to note this is happening in many cases. I hope that the alliance will greatly facilitate local consultation in matters such as the future shape of the acute hospital system by arranging for representative groups to participate in discussions.

The Government are committed to involving staff through their trade unions in evolving approaches to problems which will take account of their difficult economic situation. There is room for co-operation, innovation and flexibility and there is a need to explain fully to people the nature of the decisions which are being taken, the reason for them and their likely effects. That is successfully being done in a number of areas. The Minister for Communications has done that in relation to B & I. The unions have accepted this and if all the ranting and shouting and the emotion that is about the House was used in the same constructive way that the trade unions have used such forces, we might make more progress. The Minister for Health will have the full and continued support of all his colleagues in quickly putting in place structures to ensure that this can be done. I, as Minister for Labour with a particular responsibility towards staff, now put on record the Government's commitment to continued consultation and involvement of staff interests in making strategic decisions.

I have been distressed to hear the cynical and unfounded attacks which have been made in relation to the contribution of clerical and administrative staffs of the health service. None of these attacks was based on proper research and they did not have much regard to the facts. Most people do not know anything about the administration of the health services. The Minister for Health has already made it clear that about 10 per cent of all health services staff can be included under this category. Of these, about 80 per cent are directly and critically involved in the delivery of services, in the establishment of eligibility and in the essential support functions which make the work of doctors, nurses and others more effective and efficient. A major contribution is made by clerical staff working in records in outpatient departments in hospitals. Without their involvement the records necessary to check on and look after patients would not be there. Anybody who knows anything about hospital work would know that, but those staffs are included under the heading of administration. It is regrettable that people who persist in talking about the staff would not take an hour off and go and visit a hospital to see what the administrative staff really do.

In relation to X-rays, it is the clerical people who organise X-rays and it is the same in pathology where they are involved in the tests. Because one is in administration does not mean that one is not directly involved in health care. I hope there will not be any more unjustified attacks on people who are generally among the lower paid staffs in the health service and who are among the most committed. Indeed, at a time when the wholehearted commitment of all staffs in the health services is vital, great care must be taken to avoid unhelpful comments which will be resented.

The Minister has already made clear it will be necessary to take an initiative in relation to the common contract of consultants. Such a review was scheduled but it is now a matter of urgency. In this instance there is need for a rapid and positive response from the IMO. They, as an organisation, have a number of issues which they wish to get resolved. There are many in the ranks of the medical profession who would like to see a different contract, one which has greater regard for the professional and vocational nature of the work and the reality of the consultants' commitment to patients. If we try to maintain a unified system of health services, it would be a great pity if as a result of the adaptations which must now be made we were to end up with a dual level service and lose much of the valuable groundwork which has been done in the past 20 years. However, it must be acknowledged there is considerable unease among politicians and the public regarding the present arrangements in the contract, particularly in relation to private practice. We hope that in the forthcoming discussions this matter can be dealt with fully and frankly and that the primacy of the public service dimension in our hospitals will be fully acknowledged.

There is a need and an opportunity for medical consultants to become much more involved in policy decisions in their own hospitals, the decisions about the allocation of resources and the use of those resources. Equally, it is scarcely conceivable that we can go for very much longer without a much greater degree of accountability from people who are making decisions on the use of major resources and are uniquely in a position to control both the demand and the supply. Medical consultants generally would welcome the development of much clearer accountability measures and a revitalisation of the management arrangements in hospitals. The Minister, Deputy O'Hanlon, has outlined how we will approach the allocation of resources to the acute hospital sector and to primary health care. This approach would permit appropriate provisions to be made for essential and desirable developments. In order to give the people of Dublin a good hospital service, it is essential that the hospital at Beaumont be opened as quickly as possible, for development of the Mater and St. James's to be completed and the work at Tallaght to take place. These are clear priorities and we must do what is necessary to bring to fruition this necessary revamping of our services.

In relation to the problems besetting the non-consultant hospital doctor grade, the House will recall that industrial action by these doctors was averted through a Labour Court recommendation last October which led to the establishment of a joint review group which is now nearing the end of its work. There has been a great deal of co-operation between management and the IMO in the conduct of this review. It would be a great pity if this work were not now to be completed and used as a basis for determining future arrangements for the deployment of non-consultant hospital doctors. I hope, through the established consultative machinery and in the consultations which will now take place about the active hospital sector, that there will be a continuance of the constructive approach which has marked discussions in this area during the past six months.

I hope this House will give the Minister for Health the support and co-operation he needs in effecting the necessary changes in our health services which will in the long term safeguard the integrity of services built up over many years. It would be a matter of regret if the various elements which make up the services were not to work together to overcome the present difficulties. We have found ways to deal with other major problems in recent times with the co-operation of the trade unions and others. I hope the people involved in the health services will now think and act prudently and constructively for the betterment of those who need these services. I am sure that with the vision and co-operation of people involved in the health services sector, this will successfully be done in the short term. I congratulate the Minister for his efforts to overcome a problem that has built up over the past 15 to 20 years.

I welcome the opportunity to put a few points on record. I have four points which relate first to the very simplistic notion which has underlined much of the debate in this House this week, that money and more money equals good health. I question that basic notion.

I hesitate to interrupt Deputy Keating, but the time has arrived for questions. Perhaps the Deputy will adjourn the debate?

Debate adjourned.