Dáil Éireann debate -
Friday, 19 Jun 1987

Vol. 373 No. 11

Estimates, 1987. - Vote 47: Health (Revised Estimate).

Minister for Health (Dr. O'Hanlon)

I move:

That a sum not exceeding £1,168,791,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December 1987, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.

The gross non-capital provision in the Estimate amounts to £1,237.228 million. Allowing for Appropriations-in-Aid at £126 million, the net non-capital grant provision is £1,111.228 million.

The net non-capital grant provision represents a decrease of £3.946 million on the corresponding outturn for 1986 (£1,115.174 million). The decrease is due largely to additional Appropriations-in-Aid of over £18 million, which have the effect of reducing the funding requirement from the Exchequer. These additional funds, which represent a 17 per cent increase on the 1986 outturn, arise mainly as a result of the increase in the rate of health contributions. There is no provision in the Health Estimate this year for the cost of the Health Education Bureau. These costs will be met from the proceeds of the national lottery. An increase of 3 per cent from July in the rates of allowances to disabled persons is provided for.

The provision in the Estimate for capital schemes is £57.563 million.

The level of non-capital expenditure in 1987 which can be approved on the basis of the subhead provisions in the Estimate is about £1,315 million in gross terms, or £1,216 million taking account of income which is received directly by the health agencies, such as, payments for maintenance in private and semi-private accommodation in public hospitals, and the in-patient and out-patient charges introduced last month. The gross estimated expenditure of £1,315 million represents an increase of £41 million on the original provision for 1986. It comprises £823 million in respect of pay, £424 million in respect of non-pay (excluding cash allowances) and £68 million in respect of cash allowances. About 83 per cent of the gross expenditure will be met from Exchequer funds.

The approximate breakdown of estimated gross expenditure of £1,315 million in 1987 between programmes is set out in Appendix I to the circulated script.

As can be seen from the data presented the general hospital programme absorbs some 50 per cent of the total non-capital budget. This programme must therefore come under particular scrutiny in seeking to free up the resources necessary to strengthen primary care services. Steps have already been taken in this direction in that the general hospital programme accounted for £51.1 per cent of total expenditure in 1985. My Department's letter of allocation for 1987 calls on health agencies to examine institutional costs critically with a view to targeting the greater part of the savings necessary in this area, thus protecting, as far as possible, community services.

In discussing the current provision for health services we need to be conscious of the rapid growth in health expenditure that occurred particularly over the last 15 years. In 1973-74 net expenditure amounted to about £143 million, representing about 5.2 per cent of GNP. In the current year it will be of the order of £1,216 million, representing about 7.1 per cent of GNP. While this percentage is high, it has, in fact, declined from a peak of around 7.9 per cent in 1982.

The factors responsible for the increase in expenditure over the years are pay and price inflation, extension of eligibility for certain services and improvements and developments of services. In recent times the range and sophistication of our services have grown rapidly, embracing many new technological advances as well as considerable expansion in the area of personal social services. Not unexpectedly these improvements gave rise to significant extra costs.

If we are to maintain and improve the quality and scope of our services, we must rationalise, particularly in the institutional area.

Health agencies, including health boards, public voluntary and joint board hospitals and homes for mentally handicapped persons were notified in April of the approved non-capital allocation levels for 1987. On 2 April I met with the Chairmen and chief executive officers of health boards and discussed with them the difficulties and opportunities which face the health services in the current year. I advised the health boards of the need to produce action plans for 1987 spelling out in detail the measures necessary to contain expenditure within the approved allocation levels.

In the series of earlier debates on the health services there have been frequent criticisms by the Opposition of the measures which are required of the agencies to contain expenditure within the targets set for 1987. I would remind Deputies that the previous Government allowed the agencies to exceed the notified allocations consistently over the last few years. As a result overruns of £55 million had accumulated up to the end of 1986. Thus funds which should have been on the treatment and care of patients in 1987 are instead being used to make interest payments on past debts. It is largely this mismanagement of our services over the last number of years which has given rise to the present situation.

Given this situation, I am very aware of the difficulties facing our health service managers and I fully realise that all available skill and expertise will be required to manage our resources throughout the year. I have in general been encouraged by the positive response that has been forthcoming from the agencies and am firmly convinced thet the resources available will be sufficient to enable vital services to be maintained.

An area to which I am paying particular attention is the potential for savings through efficiency improvements in the health services. There must be an emphasis on getting better value for money.

I have established a cost-containment and efficiency unit in the Department of Health to co-ordinate the rapid exchange of information between health boards and hospitals on cost-saving initiatives, good practice, best prices for supplies, evaluation of alternative products — in short, all the support information which manages at local level require in order to achieve greater efficiency.

The Exchequer capital allocation for the health services in 1987 is £57,563 million. In the current difficult financial situation, this is a substantial allocation which will be deployed to improvements in the infrastructure necessary for the efficient delivery of health services.

On the general hospital side, the emphasis will be on the rationalisation of services to ensure that an efficient and effective service is available throughout the country. Construction or equipping work will be continued on a number of major general hospital projects, including St. James's, the Mater, Cavan, Mullingar, Castlebar and Loughlinstown. Provision has also been made for major new schemes where construction has commenced in 1987, such as the provision of a new maternity unit at Our Lady of Lourdes Hospital, Drogheda, and the construction of the new Waterford Regional at Ardkeen.

The planning of the new Tallaght Hospital will be continued and further planning will also be carried out for many other general hospital projects, such as St. Luke's Hospital, Kilkenny and Naas General Hospital. Major hospital developments at Sligo and Wexford are at tender stage.

Apart from the major general hospital schemes which I have mentioned, the policy of improving out-patient and day hospital facilities will be maintained in the current year, to the extent that resources permit.

The recommendations contained in the policy document which was published some time ago on the psychiatric services —Planning for the Future are being implemented as quickly as possible and the diversion of capital resources away from the psychiatric hospitals and into the community psychiatric services is beginning to be reflected in the composition of the psychiatric capital programme. Hostels, day hospitals, day care centres and other community facilities are being planned throughout the country for psychiatric patients. In Dublin, psycho-geriatric units, which will improve standards at St. Brendan's Hospital, are being built at Clonskeagh and similar units are being planned for Ballymun and Dún Laoghaire.

In the case of the mental handicap services, the aim is to develop facilities which will enable mentally handicapped persons to reside in the community and the capital programme includes projects geared to the achievement of this objective. On the physically handicapped side, construction work is well advanced on the provision of new residential accommodation at St. Joseph's school for the deaf at Cabra and a major development scheme is in progress at St. Mary's school for the deaf, Cabra.

Planning will proceed on a number of other important developments including the provision of a new national centre for the blind at Rathmines. Planning has been largely completed for the provision of new children's accommodation at St. Mary's School for the Blind at Merrion.

The provision of facilities for the care of the elderly will continue to be a priority. The construction and furnishing of the new geriatric unit at St. Oliver Plunket Hospital, Dundalk, will be completed and work will continue on the provision of a new 100 bed replacement geriatric unit at the Sacred Heart Home, Carlow. Planning has been completed for the provision of a new geriatric hospital at Dungarvan.

There has been an extensive programme of building health centres and clinics in recent years in line with the policy of bringing the health services into the community. This policy will be continued in 1987 and funds will be made available for various projects in this area. For example, building work commenced in the current year on important health centre developments in Athlone and Gorey, while tenders have been received for a new health centre at Portlaoise. Also, community-based treatment facilities for drug abusers will be developed and provision will be made for a number of community welfare projects.

As a guide to the way in which resources are applied in the health services, I would refer Deputies to my Department's annual statistical publication, the 1986 edition of which was recently published and circulated. I hope the 1987 report will be published before the end of the year, representing an improvement on the normal lead time for such reports.

One of the more notable statistical trends in recent years has been the decline in the birth rate. Since 1980 the birth rate has fallen quite dramatically from 21.8 births per 1,000 population to an historic low of 17.4 births per 1,000 in 1986. This is paralleled by a decline in birth numbers from an historic high of some 74,000 births occurring in 1980 down to approximately 61,500 births for 1986. This is the lowest recorded number of births since 1968.

An additional source of information on activity in the health services is the report on the health services, which was last updated to December 1986. That report covered the period 1983-1986. I intend to continue the practice of producing such a report on an annual basis.

Eligibility for medical cards is normally determined by the chief executive officer of the appropriate health board by reference to agreed income guidelines. The new guidelines with effect from 1 January 1987 compensate fully for changes in the cost of living during 1986.

I have increased the income ceiling for health contribution purposes to £15,000 with effect from 6 April 1987. The Revenue Commissioners are responsible for the collection of current health contributions from all sectors. Health boards remain responsible for the collection of arrears due from farmers for periods up to 6 April 1984 and while £6 million is still owed by farmers to health boards, the health boards have been very successful in collecting arrears of over £2.5 million in the last two years.

One consequence of the limited resources available to the Exchequer for health and other services was the recent introduction of charges for in-patient and out-patient services. Given the general budgetary situation and the dependence on the Exchequer for virtually the entire burden of funding the health services, the Government had no other responsible choice. The only alternative course would have resulted in a serious deterioration in the availability and quality of services.

In advance of the introduction of charges I requested the Voluntary Health Insurance Board to make available a low cost and easily accessible insurance scheme to cover the new charges. The new scheme has gone a long way in allaying people's anxiety over the charges. For less than the cost of the out-patient charge or a single daily charge of £10, an adult in a group scheme is insured for a full year against the in-patient and out-patient charges. This scheme, at my request, applies regardless of age or a person's present state of health.

Structures for the delivery of health care in Ireland are based on a balanced mix of public and private facilities. This arrangement has worked well to date, has enabled us to provide a high standard of health services and is clearly an approach which is very acceptable to the community. The cost of the private element is met largely by insurance cover made available by the Voluntary Health Insurance Board. As the House is aware, the VHI Board were set up in 1957 and they have served us well in the interim. I am looking at the possibility of introducing legislation in the near future to amend the VHI Act and I have asked the VHI Board to prepare a scheme that would provide comprehensive cover for community care services, general practitioner, dental, optical and drug costs etc.

While virtually all of the current debate about the health services has focused on the financial aspects there are many positive policy developments across the entire spectrum of the services. As part of the Government's legislative programme a number of significant pieces of health legislation will be processed.

The Children (Care and Protection) Bill was before this House before the last Dáil was dissolved. Rather than reintroduce that Bill, because as many as 150 amendments were proposed, most of them by the then Minister, I have decided to introduce a new Bill, the Children (Care and Protection) Bill. That Bill will be circulated during the summer recess. Earlier this week the Adoption (No. 2) Bill, 1987 was presented to Seanad Eireann and circulated to Senators. It is hoped that Second Stage of that Bill will be taken within the next week to ten days in the Seanad.

The Control of Clinical Trials Bill, 1986, which provides for a statutory scheme of control of clinical tests, has been passed by the Seanad and is currently at Committee Stage in this House.

While the penal measures provided for persons convicted of drug pushing have been significantly strengthened in recent years, the Government are satisfied that these measures will not be complete until we introduce legislation providing for seizure of the assets of drug pushers. We regard the introduction of such legislation as a priority and, while it gives rise to certain constitutional questions in this country, it is currently the subject of consultations between my Department and the Attorney General's Office.

I propose to bring a new tobacco Bill, to control smoking in public places, before the Dáil in the autumn.

Apart from this range of legislative developments, progress on service development is being made on a number of fronts within the various health care programmes.

In relation to the acute hospital system I have already indicated that change is now needed. We must have an acute hospital system which is geared to our ability to pay, which is effective and caring, and which is efficient. It must be closely and constructively linked with a primary health care system which is capable of doing many of the things now done in hospitals.

Since 1968, we have succeeded in greatly improving the acute hospital sector. I do not think we have done so in the most effective or efficient way. There has been no shortage of proposals and plans. Yet, outside of Dublin, the hospital system, in terms of number, location and size of hospitals, remains largely the same as it was almost 20 years ago. We have now arrived at a situation where we cannot afford to sustain, at an appropriate level of competence and capacity, all the acute beds and hospitals which are in the system. This is obviously a matter of great concern.

As indicated in my address to the House on 19 May, I have set in motion the process of adaptation which is now necessary and likely to be welcomed by those most vitally concerned with the delivery of acute hospital services.

A rationalisation of acute hospitals does not mean that all hospitals no longer providing acute services must close. There are other uses to which some of these facilities can be put. I have particularly in mind the improvement of accommodation and services for the chronic sick and terminally ill. There are areas in which new or additional health clinics are required and, in large urban areas, there may be a need to provide a casualty service where in-patient care is no longer available.

The future management of acute hospitals can be greatly improved. There are many exciting developments taking place in this sector. Work is being done on development of systems to measure the output of hospitals in ways which would be clinically acceptable. This will provide a much improved basis for allocating, budgeting and control. Modern computer systems can help communications within the hospital, can help provide support for clinicians and nurses and can aid all aspects of management. There are many new approaches to hospital management emerging in other countries which we must monitor and assess with a keen eye on own requirements.

It is not sufficient to rationalise the system without improving its management. My Department are at present considering, in association with the relevant training interests, the introduction of a management development programme geared to the complexity of a modern day health service.

In relation to the psychiatric services the detailed planning of the re-organisation of the service is continuing. The intention is to move away from the traditional dependence on the large, old psychiatric hospitals and to base the service for the future firmly in the community. There will, of course, be need for in-patient care but, more and more, this is being provided in units in general hospitals. Further units of this type are in planning at present. A wide range of facilities has already been provided in the community. It is our intention that this will continue. The overall expenditure for 1987 on mental handicap services is estimated at £113.48 million. This compares with a total of £107 million at Estimates stage in 1986, which indicates an increase in line with inflation.

Despite the present critical financial position, in making the allocations between the various agencies, I took steps to protect the mental handicap agencies directly funded by my Department. I recognise that many areas of weakness still exist in our mental handicap services. We are examining those to ensure that proper and adequate services will continue to be provided for the mentally handicapped. Similarly we are examining the possibility of implementing more of the recommendations contained in the Green Paper on Services for Disabled People, Towards a Full Life.

One of the crucial elements in the maintenance of the handicapped in the community is the provision of an adequate community care service. In this regard I have made clear my intention — despite the limited resources available — to protect community care services, particularly in the case of the handicapped. In the development of their budgetary strategy for 1987 I specifically requested health boards to protect community care services for the handicapped as far as possible.

A major challenge to the health services over the coming years will be the provision of an adequate level of services to the increasing number of elderly persons in our society. A comprehensive review of services for the elderly, which commenced in August last, is being undertaken by my Department.

The General Medical Services scheme provides a first rate general practitioner service to some 37 per cent of the population or 1.3 million persons. This service is a vital front line element of primary health care and is the first port of call for many persons needing medical attention. In 1987, £108 million will be spent on the General Medical Services. In so far as the funding of the General Medical Services in the current year is concerned I might remind Deputies that, despite the difficult situation confronting the Government on assuming office, an additional £25 million was made available over and above the allocation of £82.8 million provided originally by the outgoing Government. In this respect I should say that I have been in contact with the Irish Medical Organisation. I expect negotiations on the General Medical Services to resume in the very near future.

In June 1986 the then Minister concluded an agreement with the Federation of Irish Chemical Industries, representing the pharmaceutical industry, governing the terms of supply of drugs to the health services. My officials are at present in negotiation with the Federation of Irish Chemical Industries to try to achieve improved terms. Hopefully we will succeed in the current year.

I am particularly concerned at the level of the dental and ophthalmic services for eligible adults. I am at present actively reviewing those services. In regard to the orthodontic services, one of the difficulties encountered was that, when posts were advertised by five of the health boards, one post only was filled because of a scarcity of orthodontists. The programme of developing health centres is continuing. Many new centres will be opened this year and work will continue on others.

I have already referred to the legislative developments in relation to child welfare. I should like to refer briefly to the widespread public concern about child abuse, particularly child sexual abuse. Some time ago a working group was established under the aegis of my Department to review services and provisions in relation to child abuse. Arising out of that review it has been decided to establish two new units to cater for the victims of child sexual abuse. These units will be located at Our Lady's Hospital, Crumlin and at Temple Street Hospital. I might mention also that my Department will be publishing shortly revised guidelines on the investigation, management and treatment of child abuse.

The most significant development in decades in the public health area has been the spread of the AIDS virus. In the past week I answered questions in the House on the AIDS virus. I will circulate with my script details of what my Department are doing and have been doing in recent years to combat this very serious illness, the most serious threat since tuberculosis 40 years ago.

The health services now form a major component of public health sector employment. Since the health boards were established in 1970 numbers employed in the health services have increased considerably. For example, in January this year, there were some 62,000 people employed while, ten years ago, the corresponding figure was 51,000. I find it difficult to accept that this increase in numbers has produced a corresponding improvement in the quality of service delivered to patients. Given that pay costs comprise 70 per cent approximately of overall costs, and in the light of the general budgetary difficulties, the growth in numbers could not be allowed to continue.

In his Budget Statement the Minister for Finance announced that no public service vacancy could be filled without the express approval of the Minister for Health with the consent of the Minister for Finance. Following discussions with the Department of Finance, it was agreed that, because of the late stage in the financial year and the random effect on services by not filling vacancies as they occurrd, a package of, first, non-filling of some vacancies, second, reduction in current temporary employees and, third, reduced scale of locum cover — to achieve an overall reduction of 2,000 posts by 31 December 1987 — was agreed. Apart from the 2,000 posts, health managements may have to effect further reductions in personnel as part of their overall plans to work within approved limits of expenditure this year.

I am convinced that the future of the health services can best be served on the basis of full consultation and, where possible, consensus among all those involved. I have met the Irish Medical Organisation, the Irish Nurses' Organisation and the Alliance of the Health Unions. I have also met representatives of the Irish Congress of Trade Unions together with my colleagues, the Ministers for Finance and Labour. In the context of industrial relations, I appeal to the Irish Nurses' Organisation, who are members of the alliance, to avail of that forum to pursue their issues and problems and not to take strike action which can only be to the detriment of patients.

Discussion on the reorganisation or rationalisation of health boards in the recent past have concentrated almost entirely on the question of how many boards there should be. This is somewhat peripheral to the more central question of how best to achieve efficient, effective and accountable management and delivery of services. A number of the initiatives to which I have referred elsewhere, particularly on the question of funding of services and hospital rationalisation, may suggest changes in the future organisation of services and the structures required. I am not convinced that a reduction in the number of boards as an end in itself would necessarily be of benefit.

I do accept that the statutory functions and responsibilities of health boards require examination as they have remained virtually unchanged during a period of major development in the services they provide and the general environments in which they operate. It is important that any changes required be brought forward in a constructive manner with due regard to the major contribution already made by health boards and voluntary agencies in the development of health and welfare services over the years. In the development of any new solutions in this regard I see a role for pilot schemes which could be used to evaluate, without commitment, any new arrangements proposed.

In the succession of debates on the health services in this House since I assumed office, including the motion on the hospital service charges, the various Adjournment debates on particular aspects of the services, motions on health expenditure, and the debate on health policy, there have been frequent references to panic measures, a lack of co-ordination and poor planning overall. On all occasions I have refuted such allegations and have provided many examples of the extent to which the adjustments to the health system are planned and co-ordinated and the steps taken to ensure that established priorities are observed in the allocation of resources. My review of developments this morning provides further evidence of a health system which is meeting essential needs and adjusting in an orderly way to the new environment in which it must now operate.

I must in this respect comment on reports of a statement made by Deputy Dukes in Tullamore recently in which he castigated Fianna Fáil for a failure to plan properly for the health services while in opposition. This is an amazing approach from the head of a party whose draconian and abrupt about-face on health policy and funding ended a four year partnership with the Labour Party in Government.

I want at this point to draw a distinction between what is necessary to cope with short-term management of the health services and the macro adjustments that now need to be considered to gear the health system to the needs of the nineties and beyond. Initiatitives are now being taken in relation to various aspects of the system, for example, the various service reviews I have mentioned, the rationalisation of the acute hospital system and the establishment of the Commission on Health Funding which I have set up and which, under the chairmanship of Dr. Miriam Hederman O'Brien, held their first meeting on Wednesday last. The outcome of these exercises will be fundamental to the long-term development of the health system. Some of the modern concepts in health policy being promoted, for example, by the World Health Organisation and being actively pursued in other developed countries, demand fundamental changes in attitudes towards health on the part of the individual, the wider community and the health professions. A change in the balance of responsibility, as between the individual and the health care system, also seem to be indicated, if we are to seriously think in terms of a greater reliance on preventive services with a concentration upon accident prevention, vaccination and immunisation programmes, the development of a nutritional strategy and a broad policy of health promotion in which there will be in current circumstances a concentration about the abuse of drugs and alcohol, responsible sexual behaviour and smoking of tobacco. These issues were raised by the publication of "Health — The Wider Dimensions" last December. I am committed to pushing ahead with them and I would intend to hold a national conference on health policy in the next few months. It is my earnest hope that the culmination of this period of consultation and debate will be some new public consensus on the nature and scope of health policy.

Mr. Allen

I believe that everybody in this House accepts that there must be a close scrutiny on our expenditure on the health services. However, what we are divided on is the fact that many of us in this House believe that the rationalisation should not reduce patient care to an unsafe and unacceptable level and I sincerely believe that patient care has been reduced to an unsafe and unacceptable level.

Many of the front line personnel in the health services, that is, junior doctors, nurses, etc., are probably best equipped to say where cuts might be implemented to a safe degree. To date the decision making has been by health board management who are not always totally familiar with the real situation. There has been an irrational approach to the problems — a panic-stricken and poorly thought out approach by the Minister in his attempt to save money. The Minister has put aside considerations in relation to patient care.

I have spoken to many hospital personnel in recent weeks and it is obvious that there is a veil of silence with regard to exactly where the health cuts are to be implemented in many hospitals. Information on staffing levels in many cases is not available and I believe this is because the people who are making the decisions, the management in the health services, do not deal with patients but rather with budgets and finances.

The cuts are being implemented haphazardly and as a result health care will become a privilege for those who can afford to pay for it.

In recent weeks, the Minister for Health has stated on a number of occasions that the health services are in debt because of overspending by the previous Administration and he repeated that allegation today. It is really about time that the Minister for Health and his party stopped trying to blame somebody else for the devastation in the health services at the present time caused by these savage health cuts. Yes, it is true that health boards overspent in recent years but these health boards were controlled by Fianna Fáil and were encouraged by the party leadership to behave as they did. They were encouraged by the Minister, Deputy O'Hanlon, in this House when he continuously criticised the measures being taken by Deputy Barry Desmond at the time. That campaign was led by the Minister, Deputy O'Hanlon.

The deep crisis in the health service has arisen because the Fianna Fáil Government have reduced the allocation to health boards and voluntary institutions this year by about £35 million. A comparison of the budget put forward in January this year and the cuts made in March shows a reduction in the allocations to the health boards, excluding the GMS, of £7.2 million, a reduction of £12.6 million to other institutions and a reduction of £3 million in the programme for building, equipment and furnishing of hospitals. That amounts to a total reduction of £22.8 million. That came after the directive given by the Minister to the health boards to reduce their deficit over five years. That means at least £10 million per year is being taken out of the health services on top of the £22.8 million. I would put a conservative estimate of £35 million as being taken out of the hospital services this year alone because of this Government's decisions.

Fine Gael published health and other proposals before the last election and our party advocated many well thought out savings in our health expenditure. These proposals in relation to savings were debased against the backdrop of Fianna Fáil posters stating that there is a better way and that health cuts affect the old, the sick and the handicapped, and indeed they do today. Our approach was a better way than the crude hamfisted approach of Fianna Fáil which has now brought the health service to its knees.

It must now be clear to the Taoiseach, the Minister for Health and the Minister for Finance that the health service cannot absorb cuts of this magnitude in one year in the present circumstances. The Minister went ahead with the cuts. He was a lazy Opposition spokesperson as he did not have policies worked out in his four years in Opposition. The Minister, as the evidence suggests, came to office without any ideas in his head and indulged in an orgy of cuts which have now brought the health services into their deepest crisis since the foundation of this State.

Having brought about a major crisis in the health service, the Minister then proceeded to set up a review group, which he should have done in the last four years, which would look at future policy matters within the sector. In other words, the Minister put the cart before the horse. He made cuts and now he is deciding what policies to adopt as regards rationalisation.

As I said in a previous debate, there is a need for a cooling off period before further, permanent damage is done to the health service so that other options can be carefully examined. This in-depth examination must take place at the highest level and must look at the structure of the health boards, the administrative costs within the health service and the many inefficiencies and abuses within the health system.

It is ironic that the Minister, having indulged in cuts, has convened a meeting with An Comhairle na nOspidéal for today or tomorrow. At last he is bringing in the professional people. Officials from his Department have had discussions with representatives of An Comhairle but only at management level. The professionals have been ignored. At the last minute the Minister is bringing in the professionals to put a seal of respectability on the cuts he has indulged in in recent times. The morale in the health services has been shattered. Any attempt to paper over the cracks by holding sessions with representatives of An Comhairle will not put the matter right.

It is Fine Gael's objective to use their parliamentary strength in the national interest to achieve a position in the public finances which will create conditions for increased employment and for a lasting cut in the tax burden without adding to debt service costs in two or three years.

We accept the estimate figure but we cannot accept the decrease in allocation which has arisen in programme G4 of the Estimate, that is the grants to the health board and other health institutions. There has been a drop in this allocation by £22.8 million and this decrease is one of the major factors in the crisis we see in the hospitals services at the present time. We stated very clearly last March that we would use our Dáil strength in the national interest. However, we cannot accept the manner in which matters are being handled at the present time in the health services and there comes a point in time when we have to cry halt. We suggested better ways in this House of creating economies but the Government have pressed ahead and have amputated services without any policy direction.

My party believe that the Government have gone too far and we have no choice but to oppose the Estimate. I wish to make it quite clear that it is not about the amount of money being spent on the health services overall but it is the manner in which this money is being spent. We support financial sanity but in an ordered, well thought-out way. What has been done in the health services has created disorder and chaos.

We believe that the Government have now taken the wrong course in relation to health cuts and I wish to make it quite clear that Fine Gael have told the Government that it is still open to them to take a different course but they have refused to do so. They have embarked on a course of action which seriously damages a basic social service. In the coming months, Fine Gael will put out policy statements in relation to various areas of the health service. We have already set out quite clear proposals to the public which will assist in helping the Government to live within the present financial allocations.

Many Irish people wonder today why the health service is so threatened and so downgraded. Everybody is aware that there are limits on the expenditure of public finances but people now want to know why there is not a planned approach to rationalisation involving full consultation with those associated with the health service.

Instead of Minister and Government bashing, as went on when Fianna Fáil were in Opposition, Fine Gael intend to continue in a realistic manner to debate and propose policies in relation to fundamental issues which must now be tackled. We must decide what the health care needs are for Ireland, we must decide what type of health care system is most suitable for the Irish people. We must decide what funding arrangements are to be made for our health service and what type of management system should be put in place. We must also decide what type of hospitals are needed to develop an efficient service to the public.

We have a responsibility to the old, the sick and the mentally handicapped to design a health care system responsive to their needs and not have policies that have generated fear and unnecessary anxiety in recent times. It is imperative that we initiate a process of consultation, of objective option appraisal and analysis. We can look at the options available to us if we have a planned approach which involves consultation at all levels. If this process is open and honest, acceptance of change within the health system will be assured.

It would be an understatement to say that the cutbacks have caused great frustration and anxiety among those working in hospital and health care services, particularly in view of the way they have been implemented. Those cuts have penalised the most efficient and effective services. I shall give examples later. I have yet to speak to a member of senior management of any health service, health board or hospital who does not believe that his department, his programme or his hospital is efficient. How can we judge efficiency if we do not have any form of evaluation with which to measure the economic factors as well as measure the qualitative factors? The health boards and voluntary hospitals have little choice but to implement the cutbacks across the board in the crudest of ways.

The Minister spent four years in Opposition and in that period he failed to produce a policy for health. The Department must be aware that an efficient management information service will have to be developed to enable decisions to be made and to rationalise them in a responsible manner. We must have more professional management in our health services. From a medical point of view we had an excellent health service but there is a great need for development in the administrative and general management areas. Unfortunately, we do not have the type of professional hospital management that the health service is crying out for. That has been acknowledged by many people down the years. We have failed to strengthen the management role or the planning functions throughout the health services.

The Department of Health must press ahead urgently with a system of budgeting similar to that which has been in operation in other countries. That system had to be implemented in other countries when health costs exploded. I regret that the Minister has a closed mind in regard to health boards. We must look at the number of boards operating here. We have eight and we must carry out an in-depth examination of their role. In my view they are over bureaucratic and often overlap in their functions and services. With modern computer technology we should be considering reducing the number of health boards to a more manageable figure.

The cuts introduced in recent months have affected many centres. The Waterford Infirmary suffered a 25 per cent cut and there have been threats to Roscommon Hospital, hospitals in Clare and in my constituency. The North Infirmary Hospital in my constituency has had to operate under severe cutbacks and is threatened with closure. That hospital had 106 beds and ten day-care-beds with a staff of about 120 but its budget was reduced by 20 per cent this year, from £3.5 million to £2.8 million. That is the only hospital on the north side of Cork city and the Minister is ignoring the serious social implications of its closure. The Lord Mayor of Cork, and 50,000 people in Cork city, signed a petition asking the Minister to reconsider the allocation to the hospital but the Minister, arrogantly, refused to accept the petition. Instead, the Lord Mayor of Cork had to travel to Dublin yesterday to present the petition to the spokespersons of the Opposition parties. I appeal to the Minister to rethink his decision in regard to the North Infirmary and accept the petitions through his officials today.

Mr. Molloy

I have a lot of petitions.

Mr. Howlin

I have many petitions also.

Dr. O'Hanlon

Do the Deputies want me to increase the allocation? They do not want any cuts but they want more money.

Mr. Howlin

Yes, we want more money.

Dr. O'Hanlon

The Deputies cannot have it both ways.

Mr. Allen

We want the Minister to reallocate his budget and introduce better planning. Something that must be examined immediately is the waiting period for patients for operations. Even before the present strike, it was unacceptable that a person had to wait many months for a surgical appointment and possibly many years before that surgery could be carried out. I believe proper management of outpatient departments could be brought about so that waiting lists could be reduced. The present service is not good.

To improve the service family doctors should have access to facilities in hospitals, for example, access to the laboratory and X-ray facilities. The present system whereby up to £50 can be charged if a doctor sends a specimen to a laboratory is totally ridiculous. If that patient by-passes his doctor and goes directly to the outpatient department, he can end up having even more expensive tests carried out completely free of charge. That system must be looked at.

I will deal briefly with a number of issues to which I will be addressing myself in more detail at a more appropriate time. The Minister must look at preventive care and the abuse of alcohol. The Minister said the community care programme would be maintained as far as possible, but I am asking him to reduce in a planned way the moneys being spent on our hospital services and to put more emphasis on community care services. The Minister said he was anxious to do something like this but his statement today is in total contradiction to reality and what has been happening in recent times throughout the health service.

The cutbacks in the area of public health nurses means that the community care programme has been seriously weakened. The care of the elderly is creating a huge challenge to our health services. Within the next five years the number of people over 65 years of age will increase by 10 per cent and those over 75 years by 20 per cent. There is a problem at present in relation to finding suitable residential accommodation for the elderly. Coupled with this is the problem of insufficient community care services. We are now at the stage that people cannot be looked after in their own community and this particularly affects those who are living alone in the community. I ask the Minister, in co-operation with the Department of the Environment, to bring in an imaginative scheme to care for our elderly.

I intended dealing at length with radioactivity and its threat to the health of the community. I am disappointed to learn that since the Chernobyl disaster last year — it is obvious from a reply given to a parliamentary question last week that we have not learned any lessons from that disaster and that if there was another disaster we would still be in a state of chaos — the Minister is leaving it to the health boards to organise emergency services in their areas. That system has proved to be very faulty in recent times. I ask the Minister to have a national emergency plan because of the dangers posed by Sellafield and other nuclear plants thoughout Europe. I also ask him to look at the mentally handicapped and at drug abuse in a reasonable way.

As regards the dental service, the Minister said there was a shortage of orthodontic surgeons. This shortage is there because our dental schools are not providing the necessary training. There should be more emphasis on post-graduate courses for some of our dentists rather than depending on orthodontists who have been trained abroad.

We look on the allocation in the Estimate for Health as being badly apportioned and, therefore, we will be opposing it on Wednesday next.

Mr. Molloy

Since our foundation the Progressive Democrats have consistently identified enormous public spending and borrowing as one of the major factors inhibiting economic recovery in this country. Indeed, in our economic policy document published last October we were the first party to spell out precise reductions in a number of areas of public expenditure, including health. We still believe in this approach and are convinced that it is the country's only hope for restoring our economy and reducing unemployment.

We firmly believe that spending reductions can be made with a limited effect on services and that if done in an appropriate way will be accepted both by the public at large and by those employed in these services as there would now appear to be a reasonable consensus in the country at large about the desirability of reducing public expenditure.

The widespread public concern about perceived cuts in the health service which has now arisen, is in our opinion, due exclusively to sheer mismanagement on the part of the Government. The fact that health spending has actually been increased for 1987 has been virtually ignored as cutbacks are being initiated in an ill-conceived and totally unco-ordinated fashion by the various local bodies concerned, without direction or supervision, to ensure that services on a national basis remain essentially intact. If the Minister is going to confine his activities to simply handling financial allocations to health boards and hospitals without directions as to how that money should be spent, then he is no more than a messenger boy for the Minister for Finance, and a very expensive messenger boy at that.

The Progressive Democrats are particularly disturbed that the Minister's ineptitude with regard to the disposal of the 1987 health budget has seriously jeopardised the long sought for and hard-won acceptance by the Irish people that we cannot continue to live beyond our means with regard to public finances. The opponents of a realistic approach to public spending are seizing on the widespread threats, and rumours of threats, to essential health services as indicative of the catastrophic consequences of any attempt to limit public spending. It is this aspect of the current crisis which would have the most devastating long-term effects.

It is, however, our view that the present crisis rather than demonstrating the undesirability of curbing public spending, indicates far more the absolute necessity for clearly analysing the details of public health spending in order to ensure that we are getting the best value for whatever money we spend. Even the most superficial analysis raises some obvious but nonetheless alarming questions which the Progressive Democrats would like to see addressed at the earliest opportunity.

For instance, why do we spend a higher proportion of our GDP on health care spending than many of our European neighbours? Are we really getting a better service for this money? Why do we need significantly more hospital beds per 1,000 people than the UK or Denmark? Why is it that despite virtual universal agreement that health care spending should be concentrating on community-based services? There has been no appropriate transfer of State resources in this direction over the past decade. Why is it necessary to have eight separate health boards, as one of those boards covers one-third of the population and would not appear to function any better or any worse than the others? Is it not reasonable to propose that the country could get by with, at the very most, three health boards? These questions raise broad issues which are the kernel of the crisis now affecting the service and the position will not greatly improve until these issues are faced up to. The type of cuts imposed by the Minister this year do not confront the real problem. The Progressive Democrats want to emphasise that we are not just interested in appropriate and rational saving; we are much more interested in appropriate and rational spending.

The failure of the Minister to specify to those involved where cuts can and cannot take place has had a devastating effect both on those working within the service and those depending on the service. It has resulted in a frenzy of activity by numerous sectional interests, both professional and political, with the sole aim of jealously guarding their sectional patch regardless of the effect on the overall health system. The resultant panic measures have caused grave and genuine disquiet and distress throughout the community. In our view this could and should have been avoided through adequate consultation, followed by firm and decisive action on the part of the Minister.

To permit local politicians, various sectional interests, bureaucrats and some hospital management boards to engage in an orgy of headline grabbing threats of the direct consequences, was clearly inappropriate. However, not alone do we condemn the Minister's inaction; we also condemn some of his actions and many of the actions proposed by some of the health boards and voluntary hospitals for which the Minister holds ultimate responsibility.

One of the measures announced which has not, in fact, been widely publicised is one to which we take particular objection. I refer to the decision to refuse entry to the general medical services to doctors who have been in private general practice for the past five years. This measure has no direct cost saving consequences. The gradual increase in the number of GMS general practitioners does not of course increase the number of patients entitled to the service. It merely reduces the number of patients per doctor, surely a desirable outcome for both.

In the light of inevitable reductions in hospital services it would be appropriate to spread the resultant increased general practitioner workload among as many qualified general practitioners as possible. We also believe that one of the great advantages of the GMS has been the uniformity of general practice services to the private patient and to the medical card holder. This new measure will gradually lead to emergence of two types of general practitioner — the private GP and the GMS GP. This has to be a retrograde step both socially and economically.

When I raised the question previously of the need for public accountability of voluntary hospitals of the huge sums of taxpayers' money they spent, the Minister replied that every penny was accounted for to his Department. The Minister misses the point. Why do some voluntary hospitals publish an annual report giving an account of their activities and at least some opportunity to see how they spend their allocation of public funds whereas other large voluntary hospitals who may be recovering in excess of £20 million pounds annually give no such public account of their stewardship. The Progressive Democrats adhere strictly to the principle that the public have a right to know how their money is being spent. This requires publicly publishing annual accounts.

The recent hospital allocations contain a range of changes from 1986 figures varying from an increase of 19 per cent to a decrease of 25 per cent. The North Infirmary Cork, for example, suffered a 20 per cent reduction; what was the basis for this figure and for figures applied to these hospitals? On what basis were these variations decided? Equally, variation in health board allocations range from + 0.7 per cent to 3.16 per cent. What is the basis for that allocation?

The £10 hospital charge is proving a severe imposition on low income families. People are now afraid to go to hospital for urgent treatment because of the cost. Out-patient charges may have some disincentive value in relation to casualty attendance and in returning patients to less expensive GP services. Furthermore it is unlikely that substantial sums for any individual will arise in the case of out-patient charges. In-patient charges are quite different. There is no evidence that hospital admissions are patient initiated; they are doctor initiated. Furthermore, any individual or family can be faced with a relatively large bill at very short and unexpected notice.

These charges further differentiate benefit level between the lower one third i.e., medical card holders and the middle third and will undoubtedly act as a disincentive for anyone to show the initiative, ambition and enterprise to move from the dependence of being a medical card holder to the overburdened middle sector. The criteria applied for exemption was absurd; a six weeks old child was exempt and a seven weeks old child liable. Why are infectious diseases exempt while malignant diseases are liable?

We are totally opposed to the idea that hard working, highly taxed citizens should be expected to suffer the indignity of prostrating themselves before CEOs or any other bureaucrats of health boards to beg for exemption from the charges which they cannot afford to pay for, simply because a huge portion of their earned income is already removed from them as tax, PRSI levies etc., to finance an overbloated administrative system, to which they must now appeal for charitable indulgence in a humiliating and, to us, totally unacceptable fashion. Will the Minister provide the House with the projected costings for the additional administrative machine now being created to collect these charges?

I cannot accept the Minister's argument that the health charges will not cause any hardship as everyone can insure themselves with the VHI. This is just a frank admission that these charges are nothing other than another unfair and uneconomic form of taxation which does absolutely nothing to address the issue of controlling and managing health care spending in a wise and equitable way?

The Progressive Democrats wish to protest in the strongest possible way about the earlier moves by hospital management to intimate that junior doctors and nurses should face across the board reductions in their salaries as a quid pro quo for retaining staff numbers at previous levels. It is totally unacceptable that these front line workers, many of whom work long hours for low pay, should face such discriminatory action. If such measures are envisaged they should be shared equally by all employed in the service, managers, administrators, clerical, medical, nursing, paramedical and ancillary staff. There can be no selecting the soft options as attempted in the case of junior hospital doctors and which is now being attempted in relation to nurses.

Indeed the Minister's handling of the junior doctors' case was disgracefully negligent. I said already in last week's debate that there need never have been a junior hospital doctors strike, if the Minister had directed hospital managements to uphold the February 1986 agreement. The Minister sat idly by; the strike went ahead; panic and confusion reigned for over a week, sick people suffered, operations were postponed and, when the dispute was settled, it was based on acceptance of the terms of the February 1986 agreement. The junior hospital doctors won their case. It was irresponsible to have forced them to such extremes to achieve the implementation of something that had previously been agreed after lengthy negotiations.

The junior hospital doctors' strike had to be called to stop hospital managements from reneging on an agreement they themselves had previously freely entered into. The Minister's inaction condoned what was being attempted and it would be fitting at this stage if he were to apologise to them for causing such unecessary distress to staff and patients.

The arbitrary cuts in the health service that we see being applied will lead to an effective dismantling of the hospital health service as we know it, this in a service which has been allowed to grow in an unbalanced and arbitrary way over the past 15 years. Cuts must be made in the health budget. On that there is little contention. However, the cuts that are being applied by the various health authorities will result in job losses among staff groups who will not find any alternative employment since their skills are confined to the providing of health care, e.g. doctors, nurses particularly, and other ancillary paramedical staff.

Unlike other groups in society, these employees are trained specifically to work in the area of health care. The alternative for these workers is, therefore, to accept redundancy or emigrate. The latter choice has already been made by many of our senior nursing staff. As we know, little mention has been made of cuts in administrative staff and other non-medical staff who would be considered to be more mobile and versatile in terms of expertise and job opportunities.

The cuts contrast sharply with the cuts made in the National Health Service in the UK over the past number of years. The NHS is a fully operational scheme, in operation for more than 50 years. The rationalisation programme of Mrs. Thatcher's Conservative Government has resulted in a cut in the bed numbers to the order of 10 per cent in England and 4-5 per cent in Wales and Scotland over an eight year period from 1979 to 1987.

The cuts imposed by the Fianna Fáil Government will result in a similar number of bed losses percentage-wise in one fell swoop. This is surely not acceptable, given the effects of such a decision on our system. The cuts in health board and voluntary hospital budgets will lead inevitably to longer waiting lists for elective surgery for medical card holders and non-VHI members. Many of these people do not have the alternative of being able to afford VHI insurance. They will have to wait. Of those who can afford VHI cover, many will take it out.

This will lead to an increase in demand for private health care with the consequence that those consultants-specialists who operate in this area will have to choose between letting the queues for their private services lengthen or spend more time in their private practice to the detriment of their commitment to their public patients. The situation at present with an increase in the private health sector through the opening of the extended Mater Private Hospital and the Blackrock Clinic has already caused a distinct level of discontentment among NCHDs. This will only get worse.

If we accept the inevitability of an increase in the private health sector we must ensure that it is not totally at the expense of the public health service. The common contract which was agreed with consultants in the late seventies must be examined closely in the light of developments over the past five years. The ability of consultants to engage in private practice within the public sector is causing increasing friction among other health care professionals who carry out work for the benefit of private patients, yet do not see any funds accruing to the hospitals where they work.

Bluntly they see some consultants ripping off the system for their own gain. It would appear that this is allowable under their contracts but the situation has deteriorated in the years since that contract was agreed. In general, non-consultant staff do not wish to share in the gains of private work, nor do they wish to see their jobs being affected adversely while this situation remains.

There is need for the Department of Health to look at the relative efficiency of the various health institutions. Under the present system of cuts the heretofore most efficient institutions will be hardest hit as they have been working closest to the bone over a number of years. Institutions which have been inefficient in the past will now have to become more efficient but their level of services need not suffer.

It is strongly rumoured that the new facility at Beaumont will now have a bed complement of 450-500 compared to the 750 originally proposed. It is also suggested that the budget to be allocated to Beaumont will be no more than that now allocated to the two hospitals due to close, St. Laurence's and Jervis Street despite the fact that it is accepted that Beaumont Hospital, because of its size and planned facilities, will require a larger budget than that of its present constituted hospitals. Beaumont Hospital looks like becoming a white elephant and the proposed hospital in Tallaght will probably suffer similarly.

I understand that the budgets allocated to the three children's hospitals in Dublin will be cut overall by 14.5 per cent. It is clear that private health care will remain the only viable alternative for many parents who may not be able to afford it. Are we to accept an abdication of responsibility to those most vulnerable health-wise in our society, children and the less well-off?

The Irish health care system is in crisis. Successive Governments have continued to ignore the underlying problems participating this crisis while continuing to pay out extraordinarily amounts of taxpayers' money to paper over the cracks. The present national economic crisis has left us without sufficient funds to continue this cover up. The cracks are appearing more and more each year: longer waiting lists, loss of emergency services, under-manning and low morale in community services, public anxiety and confusion about entitlements etc.

People have long since realised that without the availability of unlimited resources that pious aspirations and grandiose political promises mean nothing. It is a truism that where everything is "free" but in short supply, the weaker sectors are the ones who always lose out. If we are to preserve and develop our health services radical systematic change must be undertaken, powerful vested interests must be challenged, and the rights, needs and individual responsibilities of the citizen must once again be made paramount.

Most people remain totally confused about their rights in the area of eligibility for State health services. A confusion shared by patient and staff alike. Indeed confusion concerning entitlement to health services is so endemic in our system that we must seriously consider whether individual sectors in our society are not accruing significant and unfair advantages from it at the expense of the less well off and the taxpayer.

The present system of eligibility for State run health services was set up in 1979. The population is divided into three categories. Category one, medical card holders, are entitled to all services free of charge; public ward hospital services, family doctors, public health nurses, free drugs; indeed any service which a health board chooses to develop.

There is little substantial difference between the remaining two classes. Those over an income limit have to pay a hospital consultant's fees even if admitted as a public patient while those under the limit do not. This, of course, applies only to public ward hospital services. What precisely one is entitled to as a private patient remains a mystery. What many people sadly realise is that if you do not have some private arrangement you will find it very difficult and time consuming to get at the service you need. Who wants to wait six months while his health deteriorates? These two groups must meet their own family doctor fees and receive limited support for expenditure on drugs and no support for any other therapies.

Whole areas of confusion still exist concerning other services, public dental services, community nursing, cervical smear testing, support for elderly parents at home or in nursing homes, home helps, speech therapy, home physiotherapy, chiropody, etc. The underdeveloped nature of these services means that in many areas they are, for all practical purposes, not available. Serious confusion exists also about the correct referral procedures for many of these ancillary services. The questions most often asked are "How do I apply" or "Where do I apply"? The answers are usually vague and unenlightening.

Entitlement to residential care for the handicapped and the chronic sick remains ambivalent and is aggravated by State supported voluntary organisations operating their own equally ambivalent criteria.

The Progressive Democrats believe there are four major defects in the present approach to eligibility for health services. These are, (1), it encourages unlimited use of services by medical card holders regardless of their needs relative to other groups or more importantly regardless of whether any health benefit accrues to them or not; (2), it creates a poverty trap for those lower middle income groups whose income is marginally above the medical card guidelines and without some tapering off system, serious hardship is caused particularly in the areas of GP fees and pharmacy costs; (3), it encourages unlimited use of acute hospitals in the non-medical groups, they do not have to pay for hospital services but do have to pay for GP services: this occurs even where acute interventions may be the least form of care needed and (4), the ambivalence surrounding the entitlements results in the weaker less articulate groups failing to obtain the services needed by them. Usually these groups include the poor, those living alone, particularly the elderly, the mentally handicaped and the mentally ill.

It is clear that the administration of health services in this country has proceeded on an ad hoc basis since the establishment of regional health boards in 1970. Many excellent studies have been carried out, some fine recommendations have been made by various committees and commissions established by successive Ministers for Health. Unfortunately, what has been lacking most of all is not the ideas that were needed to imprive the system but the political clout to implement them. All those who have held the office of Minister for Health since 1971 have not had the foresight or the ability to implement any long term strategy that would deliver a rationalised cost efficient health service adequate for the needs of our people.

Now under this new Administration we again see a continuation of the same lack of planning that has bedevilled the health services for so long. It is extraordinary that a Minister for Health would allocate funds to each health board and voluntary hospital and then set up a departmental examination of the needs of each of these bodies. Surely it was incumbent on the Minister to lay down specific guidelines to each health board and voluntary hospital regarding hospital and medical services and to make financial provision for 1987 to enable them to live within these guidelines. The chaos and confusion that has resulted from the Minister's inept handling of his portfolio to date has led to deep resentment by medical staff and health administrators and has caused fear and panic to thousands of sick people.

It is not possible for the Progressive Democrats to give their support to the Minister's Estimate because of the extraordinarily incompetent way in which he has set about dispursing the £1.3 billion allocated in the Estimates. All about us we have evidence of vital services being withdrawn, front line medical personnel, doctors and nurses being fired; all this despite the fact that the overall allocation for health in 1987 is greater than it was in 1986 under the then Minister, Deputy Desmond.

If the Progressive Democrats were to vote for this Estimate today, it would be tantamount to our condoning the creation of chaos in the health services which has been brought about in such a short time by Minister O'Hanlon and his Government colleagues. I wish to serve notice that at 5 p.m. when the question is put, the Progressive Democrats will oppose this Estimate and call for a vote. In conclusion, let me quote briefly from a letter sent to me, as follows:

I am a victim of Acute Myleoid Leukaemia, and have been attending the haematology unit since 1980. My praise for the dedication of these men and their staff knows no bounds and they, of course, are the reason I'm still surviving.

I understand now that, due to the health cutbacks, there is a real danger that the unit will have to close——

Dr. O'Hanlon

It is not closing.

Mr. Molloy

or at best, have its services severely curtailed. This would be disastrous to myself and many others. My only hope for surviving my disease is to have a bone-marrow transplant carried out and this was scheduled for next August.

If I do not have the transplant, I will die in the foreseeable future.

Mr. Howlin

I rise to speak on this Estimate with a sense of growing frustration. Probably no other Minister has attended the House more frequently than the present Minister has done in the last number of months. The reason for that is stark and clear, that around the country there is a breakdown in the services we spent generations building up. I have listened with growing frustration to the same type of response on a weekly basis from the Minister for Health and also from some of the Opposition benches. To reiterate the support for the overall strategy and yet to preserve the right to oppose the implementation of that strategy on the ground is nothing short of gross hypocrisy. One cannot reconcile those conflicting views.

By the time they are four months in office, Fianna Fáil will have broken every single promise they made to the people of this country during the last election campaign. Among other things they will have abolished the farm tax, sacked nearly 4,000 health workers — not 2,000 as in this morning's script — doubled the waiting list for health care, made the poor pay for being sick, cut the rights of many workers, frozen children's allowances, abolished home purchase and home improvement grants, increased local authority rents and charges, abolished local services, sacked hundreds of workers and so on.

All this, has come from a party campaigning on the slogan, "There is a Better Way". This is a party who have done so many U-turns that they would not know a better way because they have lost their own way. Their supporters and representatives on the ground around the country are totally lost and confused as to why for four years they have received directions from on high that they were to oppose every modicum of savings proposed and now are expected to defend savagery on a scale unprecedented since the foundation of the State.

Many thousands of ordinary people voted for Fianna Fáil in the last election. They were voting for a party who said they cared, for a party who said they were going to make the economy grow, for a party who said they would put people back to work. They were led to these assumptions by speech after speech in the previous Dáil from front bench members, including the present Minister for Health. I have already quoted some of these speeches into the record of the House and shall not embarrass the Minister further or bore the House by quoting them now.

What has happened? Amid all the so-called good news that the Government have been trumpeting about in the media last night and this morning there were two news items that told a different story, a story which sums up the meaningless of Government policy and Government promises. I am referring to the report from the OECD which told us two things, first, that unemployment will continue rising this year and, secondly, that economic growth will be virtually non-existent. The implications of this report are truly horrendous. Why are people being asked to endure the range of vicious cuts they are being forced to endure day by day if the only impact that will have on the economy is further unemployment and no growth? How could any Government, especially a Government who make such a big deal out of stressing their care for people carry out these swingeing cuts when they are achieving nothing except heartbreak and suffering for many thousands of families?

The other implication of the OECD report carried this morning is that there is a great deal worse to come. That is the horrendous picture. As unemployment continues to rise, so will expenditure on unemployment related social welfare even at the paltry rates allowed by this Government, until they are way over the spending estimate by the Minister for Finance. The lack of economic growth, coupled with a very slow rate of decline in interest rates, will throw all the Government targets further off course than they already are. If we can believe the promises made by the Taoiseach and the Minister for Finance — and that is a very big "if"— that means we are in for a further massive round of cuts through the summer months and into the autumn in order to give some semblance of reality to the figures on which the Minister and this Administration have staked their reputations.

Only a month ago, as spokesperson on health for the Labour Party, I endeavoured to place what was happening in the health services in context. In a major public statement I outlined some of the worst features of what was happening. Some of what I said at that time was scoffed at by politicians from the other side of the House and by some media commentators. Sadly if anything the Labour Party understated the impact of the cuts which at that time were being forced through this House in a tacit coalition of Fianna Fáil, Fine Gael and the Progressive Democrats.

There is some satisfaction in observing that at least one of those three parties have now seen the damage that the actions and policies pursued was doing not only to the country but to themselves and have opted out of that coalition in this area at least. Of course, they only saw the damage after it had been done. I guess that the ordinary grassroots members of the party saw the damage long before the party leadership did. Nevertheless there may be some hope in that for the people who have been suffering from the policies of this Government as a result of the petty and short sighted philosophy the Progressive Democrats among others have espoused and which has been embraced by Fianna Fáil and Fine Gael.

In May we said that 3,700 staff would be fired. It is now evident that 4,000 jobs will go. We said that 300 psychiatric beds would go with no planned community alternatives. The figures are still coming in but it is now patently clear that the true figure will be a great deal higher than the estimate we made in May. We said that women would be major victims of the cutbacks. The true extent of that is only now becoming clear. Government Buildings were picketed by women demanding very basic services, for example, that cervical smear tests should be available to them without having to pay £10 before they are allowed to pass the doors of the hospital or clinic. The true extent of the cutbacks and what we outlined is dawning slowly and clearly on the ordinary people of the country. The impact on women should be a particular cause for shame for the Minister and for every Member of this House.

We said in May that the dental and ophthalmic service would be decimated That too turned out to be an under-statement. I listened with some frustration to the Minister's statement this morning that he is particularly concerned at the level of dental and ophthalmic services. He has good reason to be concerned because in the South Eastern Health Board region those services are virtually nonexistent. I ask him in his response to give me an answer for the elderly people who come to my clinics now in Wexford and tell me they have received a letter from the health board simply saying that their services have been discontinued.

Dr. O'Hanlon

Three years ago.

Mr. Howlin

The are told also that if they want their glasses they will have to fork out their money — if not, tough. Similarly in the dental area if you cannot afford to pay for the services and you are on a medical card, it is tough because the services are not there to cope.

We warned that the transport services would virtually disappear but no one could have anticipated the amount of pain, bewilderment and suffering that cutback has caused particularly to the elderly whose normal transport for regular therapy sessions in clinics and hospitals is virtually abolished. Ambulance drivers are now coming to me. One local councillor belonging to the Minister's party said that he was shocked to have to sit in at a session in a hospital where the elderly — some of them in tears — were told they would have to find their own way into hospital in future because the service was not there. It was for emergencies only and that at a cost — you pay for it if you have not got a medical card.

What of the hospitals themselves? We warned of the possible closure of at least 20. With each passing week it looks possible that that figure too will be surpassed. I understand that the Minister is thinking of organising a conference in the not too distant future when the next round of cutbacks and closures will be announced to the hospitals. Within the past few days I have been given information by the Minister for Health in response to a Dáil Question which throws new light on this stark issue. That information showed in the clearest possible way that every single one of the voluntary and joint board hospitals is operating now under the most extreme difficulty. It is worth demonstrating that by example.

The Adelaide Hospital are expected to survive this year on a figure equivalent to their 1983 budget; Baggot Street Hospital must cope with their 1982 allocation; the North Infirmary in Cork, which was alluded to by Deputy Allen, has been given an allocation smaller than they received in 1982; Jervis Street Hospital are operating on their 1985 budget and the Rotunda Hospital are expected to carry on on their 1983 allocation. Temple Street Children's Hospital have been given a figure equivalent to their 1984 budget, James Connolly their 1983 budget and St. Vincent's their 1984 budget.

All these figures provided by the Minister for Health show in reality the pressure being put on the voluntary hospitals. They show that of the 51 voluntary and joint board hospitals, no less than 46 are required to operate this year within smaller financial allocations than they had last year and, in the examples I have just given, on smaller budgets than they received three or four years ago. This list is only the tip of the iceberg. It does not include, for instance, any of the health board hospitals around the country which have all been devastated by cuts of a similar nature. The files of letters and pleadings for information on further cutbacks grow daily. To put on the record the number of cutbacks, the job losses, the wards closed, the services abolished and so on over the past four months would take the entire time allocated to me plus the entire time allocated for this whole debate. Stating the dilemma in this way highlights where the blame belongs. One of the shabbiest sights to which we have been treated in recent weeks was the sight of the Minister for Health whining that he had no control over how hospitals and health boards spend their money. This Pontius Pilate act of the Government washing their hands of the problem has been a particularly nauseating feature of this whole exercise and of this and every other debate we have had on health in the past couple of weeks.

An Ceann Comhairle

I intervene to advise the Deputy that he has five minutes remaining.

Mr. Howlin

It should not be forgotten that the Fianna Fáil Party spent four years promising that they would increase health board spending when back in office. They spent thousands of pounds on advertisements on hoardings and on literature to that effect but now we find that the people who are suffering most under this penny-pinching régime are those whom they promised to defend. The Minister tried to imply in his opening speech today that the problem in the health service was caused by the overspending of the previous Government. Their philosophy is, if in doubt, trot out the same old propaganda. We have answered that propaganda again and again in this House. I will say it again for a Minister who finds it difficult to learn. The theory is that if one repeats something often enough regardless of its truth eventually it will stick.

In 1977 staff employed by health boards totalled 31,682. By 1981 the number had risen by one-third to 39,640. In all that period Deputy Haughey was either Taoiseach or Minister for Health. In 1980 health spending as a proportion of GNP was 8.2 per cent. By the end of 1986 after a period in office of my colleague, Deputy Barry Desmond, as a result of a gradual process of curtailment and rationalisation, the proportion was down to 7 per cent. The root of the present crisis lies not in the actions of the past four years but in the irrational and unplanned expansion orchestrated by the present Taoiseach when he was either Taoiseach or Minister for Health from 1977 to 1981. To attempt to correct that imbalance in one year without regard to the level of services, proper management and deployment of staff has proven to be a recipe for disaster.

In relation to the famous £55 million, the reality is that every year there were supplementary budgets for the health boards' huge overspendings because the health boards felt that they could spend what they liked. Deputy Desmond, as Minister for Health, indicated to them that they could not expect supplementary budgets and there were no supplementary budgets during this time in office. Yet, health boards, on the go-ahead from on high, felt they could overspend to their hearts' content, knowing that the Opposition spokesman on Health, Deputy O'Hanlon, would orchestrate a campaign to embarrass the Minister for Health, Deputy Desmond, at every opportunity.

We have asked who should pay for the crisis? We know Fianna Fáil's answer. It is their approach that the poorest and the weakest must pay. They have virtually abolished capital taxation and they have abolished the land tax. The answers highlight the startling and fundamental hypocrisy of this Government in their approach to the health services. The Minister admitted as much this morning in his opening remarks when he referred to the rapid growth in staffing and spending over the past 15 years, without having the courage to lay the blame where it belongs.

In overall terms, if people sought a glimmer of hope in the speech by the Minister in this debate they were grievously disappointed. It is clear the Minister's only interest is in screwing down costs no matter what the cost in terms of human suffering. A Minister for Health who makes patients the pawns in his policy does not deserve to be in office. That is why we are opposing this Estimate. We have consistently opposed it since the Budget Statement and since we had an indication of the savagery of the cutbacks proposed. We will welcome in the lobby the support and belated conversion of the Fine Gael and Progressive Democrat parties in that opposition.

An Ceann Comhairle

Will the Deputy bring his speech to a conclusion.

Mr. Allen

Not belated.

Mr. Howlin

I hope that if and when this Estimate is rejected by the Dáil the Government will at least realise that the people expect them to live up to the promises that put them into office.

Mr. McCartan

Nothing is so important to a nation as the health of its people. A health service should never depend on the ability of any citizen to pay for it. The Workers' Party believe that all health services should be free and should be paid for out of general taxation. Those who can afford to pay more should do so through taxes while those who cannot should get the same high-quality care and treatment. Proper health services are a right. This is not the case in Ireland today. Those who can afford VHI get an excellent service and those who cannot, get long waiting periods, long queues, and more and more a very inadequate service.

Listening to the Minister's speech today and hearing that in the current year £1.2 billion, representing 7 per cent of GNP, is to be spent on our health services in the current year it is incredible to think just how wrong the Minister has got it and how poorly he is performing in delivering services to the people. So much money could never have been more poorly spent, money which was raised from the hardworking taxpayers. The Minister must take full and personal responsibility for what is a shameful debacle. He must take responsibility for all the pain, anguish, fear and uncertainty which exists throughout the country. People do not know whether they will get the service they need if they are ill. I will quote from some correspondence received by a constituent living in Howth, from Our Lady's Hospital for Sick Children in Crumlin which is probably the finest such facility not alone here but in western Europe dealing with illness among the most vulnerable, the most cherished of our community, our young children. It illustrates the level to which the Government's policy and the legacy of policies or absence of them on the part of previous Governments has brought us.

Due to the reduced funding to Our Lady's Hospital for Sick Children this year, the hospital has felt obliged to restrict the work activity of all units at the hospital including the hospital's Cardiac Surgical Unit. This will undoubtedly prolong the time spent on the waiting list and the waiting list will definitely grow.

If there has been any deterioration or alteration in your child's symptoms or condition please visit your family doctor and ensure that the secretary to the Cardiac Surgical Department is informed. We do not agree with or accept the reduction in operations being performed that has been forced upon the National Cardiac Surgical Unit by the hospital as a result of reduced funding and cannot accept any responsibility for it.

The words "forced upon" highlight the method in which the Minister has gone about seeking to regulate health services in a most vulnerable area. This is what we are reduced to. Children in need of urgent surgical heart treatment are being told about long and lengthy queues, about cutbacks and about the need, if deterioration occurs, to consult family doctors. What does that mean for the mother of the child in question? It means the following:

She has already had major heart surgery on two occasions and has pulled through. She now urgently requires an operation to replace one of her heart valves with an artificial valve. Without this operation she is expected to live less than another year.

The mother goes on to plead:

I would be most grateful if you would ask your Parliamentary colleagues to request that the Minister for Health should find some way to provide extra funding, so that my daughter and other children like her are given the chance to live.

That, a Cheann Comhairle, puts in sharp relief what is at issue — people's right to live and the right to have an adequate and proper health service which they so greatly need and for which they pay so dearly.

The Minister's speech today is regrettable and disappointing in terms of its utter failure to address any fundamental issues surrounding our general medical services. It must be recognised that the health services through successive Governments and over successive years have developed in a most haphazard way. There has always been the total absence of any national devised plan of development. We have, as a result, varying standards of service, no comprehensive overall delivery of service with the result that hospitals, counties and regional boards, deliver different services to different sectors of the community at different standards of delivery.

The Workers' Party have constantly made the point that, with so much money spent on a yearly basis and such a great proportion of our gross national product, we should have no difficulty whatsoever in providing a totally free national health service. It can be done in other countries and it should be done here. A national free health service properly planned, delivering all services required to all people, is the only concrete way in which the haphazard and unsatisfactory level of health services which exists today can be overcome. The Minister failed to address the issue as to whether in the current service, or indeed in any service, doctors and other persons on a professional basis should be paid on a fee per item basis, a fee per visit basis, or whether we should be moving towards a salary basis for these people. It must be recognised that a fee per item, fee per visit basis, is nothing more than an incentive to professional people to abuse the service in their own interest. There is no reason why doctors and other professional people who work in and provide these services under our national health scheme should not be salaried and paid on the same basis as all other public servants.

It is equally regrettable that the Minister did not address the whole area of the control of prices of pharmaceutical wares and drugs which are dispensed on an annual basis through the service. It is signally interesting to note that he does not at any stage in his speech offer any information on the proportion of the overall cost of the service which is paid to the drug companies. The reason for that is simple. It is approaching a scandalous situation, highlighted to a great degree by the recent consumer prices survey and report that indicated that of all the EC countries Ireland pays most for the drugs consumed through the national health service.

The Minister does not appear to be prepared to address, and he has not addressed in his speech today, the question of ending the use of public hospital facilities without charge for private practice. It seems utterly indefensible that consultants, many of whom have been referred to in the press in recent times, can earn so much in private practice. The extent of the money they earn in private practice and in servicing Irish health services has been exposed by figures provided to us by the trade union movement. These consultants, some of the highest paid individuals in the State, are allowed on a daily basis, free of charge to use the facilities of our public hospitals.

The Minister failed to address the question of the so-called voluntary hospitals serving the prime interests, the needs and the demands of the consultant doctors. I say so-called voluntary hospitals, because 97 per cent of their funding comes from central Government funds and out of the taxpayers pockets. That is indefensible. It helps to create two standards of health care, one for the rich and one for those who cannot afford to pay and are thrown back on the general medical service. It is essential that the Minister should address the need for a planned approach to our medical services. It is essential that he looks at the question of providing a 100 per cent national service and that voluntary hospitals are brought in under the control of the Government.

I listened to the contributions from the Labour Party today. It is all very well to stand up and condemn roundly the effects of cutbacks. All of us can do that, but I have not heard one suggestion from the Labour Party of an alternative plan they could offer to the Government or the electorate to the present haphazard approach to the health services. Their performance in Government in the past four years was no better than the performance of this Government of today in terms of a planned approach and avoiding haphazard guerrilla warfare on the medical services and facilities.

A matter in the Minister's speech that is worrying is the total absence of any reference to Beaumont Hospital. If one is to read into what he proposes and what is afoot in the speech in terms of the very careful mention he gave to all other facilities — let us face it, he went right around the country and looked to anything that was happening as a means to paint the picture of progress in the health services — one must ask what has become of Beaumont Hospital? He told us previously in this House that by the end of the year it would be open. There is no mention of any fund allocation in his Estimate for that hospital.

Mr. Carey

He did not say which year.

Mr. McCartan

This Minister still has not brought to book the private consultants and interest groups of private medicine who have single-handedly blocked the opening of Beaumont Hospital since it was built five years ago. It is a national scandal that such a fine facility is standing idle and costs so much money on a weekly basis simply to maintain empty. I would like the Minister in his response to give a clear and detailed account of how he proposes to have that hospital opened by the end of the year, what funds he is making available to it and how he hopes to get over all of the outstanding issues of negotiation that still have to be dealt with in terms of nursing, staffing and other facilities there.

An area of major concern arising out of the Minister's speech is the proposal of a cutback in staff. Again it represents simply a decision taken, or rather forced upon him by his Government and Minister for the Public Service, with no consideration as to how it might be implemented. Whether it is 2,000 or 4,000. I ask the Minister to declare on this as he has been challenged on his figures by another Deputy and we have a right to know what is involved — how does he propose to implement that at all if he is talking about progress in building new hospitals? How is he going to start Beaumont Hospital if by the end of the year he is cutting off 2,000 jobs? In the area of staffing, a question must be directed to and answered by the Minister: why are this Government and this country educating so many of our doctors, nurses and dentists simply to export them because we cannot employ them here? What is the sense in that? When will the Minister address the whole need of planned education built into an overall plan for our services?

I am very disappointed the Minister in his speech did not at any stage seek to address a very good submission made to him by the ICTU. He is not prepared to give any regard to that sector of this society who pay for our medical services and for our hospitals. They have a right to be heard, consulted and listened to. Until the Minister gets his act together, until he learns something of the basic need of industial relations, learns what he needs to do with all the money and until he realises he has to sit down, discuss and negotiate, the demonstrations and campaigns will continue. We all will be out on the streets next Wednesday in support of a major day of protest against the ineptness of his Department and of his performance.

Involved here is not just a question of bookkeeping. It is a question of life and its preservation. Until this Minister can reinstil order into our medical services and confidence in the people that they will get the services they need when they need them, he will be faced with continued opposition from all parties in Opposition in the Dáil. For this reason we as a party tabled our motion of no confidence in him. How can anyone defend such ineptness as we have experienced in the past few months? This Minister has earned for himself the nickname "Doctor Death". It must be repeated time and time again, it is one he has earned——

An Ceann Comhairle

That is the kind of appendage which should not be applied to any Member of this House. I deem it unparliamentary.

Mr. McCartan

I regret it is one that this man has earned and I have to say it.

An Ceann Comhairle

It ought to be withdrawn.

Mr. McCartan

It is one that he will have to carry——

An Ceann Comhairle

I am asking the Deputy to withdraw the remark "Doctor Death".

Mr. McCartan

I am not prepared to do so.

An Ceann Comhairle

If the Deputy does not withdraw the remark he will withdraw from the House.

Mr. McCartan

I will withdraw from the House.

Deputy McCartan withdrew from the Chamber.

Mr. Durkan

The job of the Minister for Health at any time, particularly at a time of financial or economic recession, is difficult. I know the Minister to be a sincere and concerned man and, for that reason, I give him credit for recognising the difficulties he has in front of him, although I do not agree with the manner in which he is going about dealing with them. In fairness to the Minister, I fear that is probably not his fault.

The one thing I have objected to consistently in relation to the cuts we are experiencing now in the health services is not the fact that the cuts have taken place but that the people were led to believe before the last general election that there would be no such thing as cuts. As I have said in this House, only one party spelled out clearly to the public exactly what was going to happen. What did the main Opposition party do then? They behaved in the same fashion as small boys being asked a difficult question by a school inspector. They hopped from one foot to another, fingered their ear and chin coyly and looked around to see if somebody else would answer the question. Unfortunately, that persisted right throughout the election campaign to the extent that the public were hoodwinked about what the then Opposition were going to do or pretended they were going to do.

What happened? Reality dawned on them before the election counts were over. Suddenly they began to think back on all the speeches they had made in this House during the past four years. They began to recall the graphic detail they went into as they counted the patients who allegedly were dying in hospital corridors, patients who were not receiving services, and the old, the sick and the handicapped who were neglected, according to themselves, in the past four years. Suddenly they remembered all those things and then they realised they did not really believe it at the time they said it, that they were only saying those things for the benefit of the public in the hope that they would be gullible enough to accept what they were saying. Amazingly, the public accepted it but the public have now come down to reality with a thump.

We can all recall the speeches that were made in the past four years when, for instance, the members of the main Opposition party who were members of various health boards got up at every single health board meeting and castigated the then Administration for lack of funding, lack of caring, lack of attention to the serious needs of those who were underprivileged and in need of health services. We listened patiently meeting after meeting as hospital after hospital was gone through in minute detail with graphic instances of how people were dying, about to die or had died as a result of alleged non-attention by the then Government and the non-provision of funds for the services. That must sound very hollow to the people sitting on the opposite side of the House when they look now at their own members going to those health board meetings and remaining silent, and in some instances seeing a certain construction and a certain merit in the way the matter is being handled now. What a change, what a transformation in a short time, where a few months ago they were howling and whining like a wounded rhinoceros whenever the question of funding for services came up.

The previous speaker referred to Beaumont Hospital. I happen to be a member of the Eastern Health Board. In the past 12 months of the previous Government's administration not a meeting of that board went by but the matter of Beaumont Hospital was raised and there was a clear indication that, as soon as there was a change of Government, all the difficulties there would be resolved miraculously, that the consultants' problems were all about to be resolved miraculously, the inference being that it would happen overnight. There is not a word about it now; it has all been forgotten. Just how sincere were the people who made those claims at that time? How sincere were the people who populated the various sub-committees and visiting committees of the hospitals over the last four years, when they indicated that they were concerned, that a different administration would put a different complexion on the hospital services as they applied to the public? Just how sincere were they at that time? Hopefully their sincerity ran somewhat deeper than their later commitment.

Most people would not have objected so strongly to the health cuts had they been told beforehand, had somebody somewhere in what is now the Government party, got up and said: look, times are tough, we will have to effect economies, we will do it in this, that, or the other fashion. Then the public would have had the right, opportunity and benefit of judging for themselves as to whose brand they wanted to buy. The public themselves could then have decided where the cuts would be implemented because they would have known beforehand what was going to happen. They were not given that opportunity. Nor will they be given it now because the cuts are being imposed on them arbitrarily.

Even at this late stage the Minister could endeavour to deflect the worst aspects of the cuts from those who will be most seriously affected. I refer to cases of operations of a serious nature requiring urgent attention. I would ask the Minister to ensure personally that where there are patients in need of urgent surgical or medical attention they will receive such attention on the basis of an analysis or examination of their case. Like every other Member of this House I have received letters from constituents indicating that, unless particular attention is devoted to a given patient within a specified time, it will have serious consequences for their life or health. I mean that sincerely and in a non-political way.

I would also ask the Minister to take into account the counselling services provided by, for instance, the social workers in Temple Street Hospital with particular reference to the parents and friends of children who may be terminally ill. I have in mind the leukaemia counselling unit in that hospital. Because of restrictions on travelling expenses and other items applied by the health boards at present some parents may have difficulty in availing of those counselling services as they did heretofore. It is a very important service, giving parents support at a very traumatic time when one of their loved ones is terminally ill when they need all the support and help they can get. If, through lack of funding or for any other reason, they cannot avail of those services it only aggravates their anxiety. I would appeal to the Minister to devote particular attention to that area, to ensure that some tragic or traumatic incident does not happen or, at least where such can be averted, we would so ensure. The same would apply in the case of Our Lady's Hospital for Sick Children in Crumlin in respect of a baby or child who may be ill occasioning great trauma for parents. That is another area in which the cuts are having an effect. I have been in correspondence with the Minister in relation to some of these matters. I hope he will see fit to alleviate them by intervening personally to ensure that the worst effects of the cuts are mitigated for those least able to bear the burden.

There has been much comment in this House in recent years about the cost of drugs. People involved in the pharmaceutical services will advance various arguments as to whether Irish people pay more for drugs than anybody else. The fact of the matter appears to be that they have been and continue to do so. For that reason Fine Gael proposed a prescription charge in an endeavour to introduce an element of consideration for the cost of prescribing drugs and the cost of the drugs themselves. It was felt that it would draw people's attention to the fact that every time they presented a prescription there was a cost involved, in turn alerting them to the fact that there was need for economy. While I agree with much of what Deputy Desmond had to say I do not accept the theory he put forward which was that such would lead to greater prescribing. I do not accept that at all. It was a pity the present Government did not implement that prescription charge because it appears that many more people were in favour of it.

I want to mention briefly community care services which are being hit in a way not many people know about at present. There are many families whose elderly parents or relatives in other circumstances might have been institutionalised or looked after by the State. But because of the latest cuts and the regard in which they are held by their families, those families are now endeavouring to look after them at home. They are experiencing difficulty in so doing on a number of counts. There is first the number of items which have been eliminated and which were available previously to medical card holders. There are also the various medications and attachments which were previously available through the General Medical Services which have also been restricted. As a result some families are experiencing great difficulty in keeping or helping to keep relatives at home. If one compares expenditure on community care services with those of hospital or institutional services then one finds the balance weighs very heavily in favour of the community care services. People have greater access to those services and they are also those to which the public themselves contribute most. I would ask the Minister to impress on the various health boards to ensure that those areas are catered for to a greater extent, that redeployment of funds in those areas should be considered in order to encourage the families of such people to continue to look after their relatives and ensure that the State would be seen to be co-operating with them in so doing.

The Minister, being a member of the medical profession, will recognise the problem to which I am about to refer. I happen to live in a constituency located within 25 minutes travelling distance from the capital city. Since becoming a member of a health board I have always had the feeling that, if you like, the clout of the consultants in the Dublin area is that much more formidable than that obtaining elsewhere. That has been generally recognised. While everybody acknowledges certain economies to be necessary it will be disastrous for the services — both community care and hospital services, but in this case particularly hospital services — if cuts are applied allowing hospitals such as the Naas General Hospital, St. Vincent's Hospital in Athy or any other hospital for that matter, to ramain closed for a protracted period. It must be recognised that the end result will be that somebody somewhere, some guru, will say that there is scarcely any need for the continued existence of such hospitals. It has long been proved and accepted elsewhere, outside this country, that big is not always beautiful, that the smaller cottage-type hospitals are regarded as being more efficient in the delivery of services to people and that, likewise, people find those institutions more accessible. I would ask the Minister to ensure that the effect of the cuts on such hospitals is not such as would allow the kind of scenario I have just described develop. We have expended sufficient time and energy, have generated sufficient heat and discussion in the past ten years trying to establish the case for those hospitals. It would be tragic if that were to be undermined.

I mentioned already that the Minister might monitor the services himself. As a member of the Eastern Health Board, I have listened with interest to a number of the speeches today and during previous debates on this matter. In the Eastern health Board the cuts are applied generally across the board with job losses ranging from 2.8 per cent to about 3.7 per cent. It is generally reasonably fairly distributed from administrators to frontline personnel. As we all know, 2.8 per cent of a very small workforce amounts to a very small number of people whereas 2.8 per cent of a very large workforce amounts to a fairly considerable figure. In the Eastern Health Board approximately 410 to 420 people have lost their jobs so far and that is unfortunate. I am sure the Minister is not making those cuts deliberately and does not enjoy doing so but it is still happening and it will not be to the benefit of the services provided to and for the people.

I hope that in future elections whenever people in the political arena decide to air a particular policy before the public they will do so before the election so that everybody will know who deserves support on the basis of what they put forward. If that was the case I would have not hesitation in accepting the will of the people at any time but I strongly object to what has happened in this case because the people were duped. They were misled along the lines that I and many other speakers have referred to. I hope that in future the Minister will endeavour to ensure that the worst effects of that Uturn will not be borne out in such a way as to cause grevious hardship to the people.

Mr. Desmond

The control issue before the House today is the amount involved in this Estimate. On at least five separate occasions since the general election I have pointed out in this House that the net Exchequer provision of £1,111 million in this Estimate for this year is totally inadequate to run a comprehensive health service. I have tried repeatedly to get that point across but all sorts of side issues are trotted out, particularly by those who have not as yet got the political honesty to admit that the deliberate decision by the outgoing Government and by the incoming Government to reduce the net Exchequer contribution to the health services to £1,111 million or 6.7 per cent of GNP is, for the most part, the cause of the hardship being imposed on the people. It is because of that decision that serious hardships are being imposed on the sick, the elderly and, to a lesser extent, on the handicapped. In the case of the latter group, the programme, to an extent, has been protected.

Time and time again people come into the House and say that everything would be fine if we could bring the consultants into a more rational regime and under greater accountability that if we had greater rationality in the general medical services and reduced our drug expenditure by putting greater controls and impositions on the drug companies and simply rationalised the health boards the problem would be resolved. In simple and blunt terms that would not be so because you cannot reduce health expenditure from 7.2 per cent of GNP to 6.7 per cent of GNP in one fell swoop without causing serious disruption to the health services. By taking that course of action you cannot avoid closing acute hospitals, you cannot avoid not filling 2,000 vacancies, you cannot avoid firing 1,700 temporary staff and you cannot ultimately avoid, as will probably happen this year, firing 200 or 300 permanent staff.

There is no point in blaming just the Department of Health or in their simply having a go at consultants, at drug companies and at all the soft options such as Beaumont and so on. The reality is that the Government made a deliberate decision to reduce the Exchequer contribution to health to a miserable £1,111 for 1987. That has caused real hardship and the closing down of many wards in voluntary hospitals. In St. Vincent's Hospital two wards with 90 beds were closed down. In another hospital the number of beds has been reduced from 500 to 400 and 90 staff have been laid off. There are many areas which urgently need rationalisation in our acute hospital services. Similar substantial reductions have been made in regional and major general hospitals throughout the country.

Why has all this happened? It happened, first, because there is manifest public ignorance as to the way the health services are constituted. It is, unfortunately, endemic in some Government Departments, not in the Department of Health but notably in the Department of Finance and, to an extent, in what was the Department of the Public Service, that we are spending far too much money on our health services but I do not believe we are. Any country which is spending 6.7 per cent of GNP, or £1,111 of its net Exchequer contribution of health is not over-endowing its public health services.

I do not think we are grossly over-endowed with hospital beds. The view has been expressed time and again that our hospital beds have gross over-occupancy and that we have too much specialisation, maladministration and mismanagement in the system. I reject those arguments because they are soft options, cop-out options for the failure of the body politic, including the main political parties here, to say that they will provide sufficient resources and, simultaneously, will ruthlessly rationalise, bring about greater efficiencies and will do it in such a way that they will not destroy the system.

I have treated with some scepticism the call today by ICTU who are supporting demonstrations. They want to have consultants and GPs paid on a salary basis. We have no objection to that but it will not save a big amount of money. I accept that it is an attempt to deal with part of the problem but it is not a solution. They want an end to private practice in public hospitals and to subsidies, including tax reliefs, to private hospitals. That is fair enough but that will not solve the problem of the under funding of the health services. They want voluntary hospitals brought under greater democratic control and I have no great objection to that. They want tougher approaches to controlling drug prices and prescriptions. I do not have any objection to the latter and I think £4 million or £5 million could be saved there in any year.

However, there is not one reference in the ICTU document to the real problem, that the Exchequer provision of the health services is grossly under provided for 1987 and will continue to be if the current political climate obtains in 1988 and 1989. Health is the soft option. Why not the Department of the Environment? One could comfortably reduce the Estimate for that Department and not cause the same type of hardship. We would not visit real hardship on people if we took a home improvement grant from them but the unfortunate woman who is trying desperately to get into a public hospital to have a hip replacement is suffering and will continue to suffer throughout 1987.

The Minister said he wants to reorganise the system and towards this end he has established a commission on health funding. I do not know where the Minister got the members of that commission. I recognise the name of the chairperson, for whom I have a profound regard, and that of one of the CEOs but there is not a health economist in sight. There is not a representative from the Department of Finance, a Department that needs education badly. I do not see a great deal emerging from the deliberations of that commission. I accept that a trade union official has been included but that appointment was made because the individual is a pal of the Taoiseach. Is there a representative of ICTU or the voluntary hospitals of the commission? A representative of the private hospitals has been included but is there a representative of the VHI? I question the thrust of that commission because it does not have health economist expertise or a major input from the Department of Health — I do not mean any disrespect to the person appointed from that Department. I wish the commission well and the chairperson is eminently qualified as she proved when acting as chairperson of the Commission of Taxation.

On the day that we are discussing the Health Estimate and deciding to take 3,500 to 4,000 jobs out of the system the Government paraded themselves through the national media as giving £25 million to a very wealthy international organisation, an Irish meat company to create jobs. It represents a cost of £40,000 per job and by and large those jobs are open to question. That £25 million is being given to a person who, apparently, is very wealthy to help him open up meat plants although we already have a superfluity of meat plants. Apparently, the Department of Finance were given 24 hours to make up their minds on whether they wished to object to that investment. We have paid out £25 million of State funds to create 650 full-time jobs over five years. That amount of money would have kept the Health Estimate intact for 1987 but the answer is to reduce health expenditure because it is good for the soul, good for the body politic. That type of perverse ideological viewpoint must be opposed rigorously as we go along. It merits opposition here.

The Minister should be up front about some of the changes that are taking place. A major change has taken place in relation to eligibility for health services. I was shocked to learn — apparently the Minister acquiesces in this — that in future a person who applies to the Midland Health Board for a hospital services card will have to enclose £10. That decision was made by the chief executive of the health board with the apparent approval of the Minister. In my view it is contrary to section 72 of an earlier Health Act which states that the Minister may make regulations applicable to all health boards or to one or more health boards regarding the manner in which and the extent to which the board or boards shall make available services under that Act and generally in relation to the administration of those services. Under that section the Minister deemed that anybody with £15,500 per year or over would be excluded from category two eligibility. However, if one wants to apply for a hospital services card to the Midland Health Board, to which one has a statutory entitlement, one must pay £10. It is bad enough paying a £10 inpatient or a £10 outpatient charge, but now we have a £10 charge when applying for a hospital services card. I enjoy the benefit of a hospital services card because I am a voluntary contributor but I am damned if I will give the Eastern Health Board £10 when making my application for 1987. I will not because there is no statutory obligation on me to do so. If necessary I will present the Eastern Health Board with a P60, as people in the Midland Health Board region should do, and tell them that I have a statutory entitlement to the card.

I dispute the suggestion that under section 17 of the Health Act, 1970, the CEO of a health board has power to say to a person who wishes to appeal a decision in regard to a medical card that he or she must send in £5 or £10. That is outrageous. If the Minister wants to bring in those regulations he can say that a person has or has not eligibility for category two on the basis of £15,500. The Minister can rest assured that he will face an injunction from ordinary citizens, like health boards members, in regard to those charges unless the necessary regulations are made. To add insult to injury if a person in the Midland Health Board area wants to apply for a £28 drug refund, he has to send in £5. Thus, the drugs refund scheme is being adjusted to £33. The Minister has, in effect, condoned surreptitiously three new charges.

Mr. Naughten

Surely Deputy Desmond cannot be correct. This is horrifying.

Mr. Desmond

It is correct. Apparently the Midland Health Board have introduced these three new charges under the regulations relating to the drugs refund scheme and the Health Act. They have even gone so far as to say that if the person challenges a decision on a supplementary welfare allowance application, £10 must be sent to the health board to have the case reviewed. It is a social scandal that anything of that nature should be brought in, and I challenge the Minister to change his approach to this matter.

We must reform the common contract. We will require a new contract for new appointees because if we try to change the existing contract, the present staff members could take the case to the High Court. We must bring in a capitation system for the GMS. I am completely in favour of that. We must register public voluntary hospitals, despite the Minister's reluctance, and they must be properly controlled. We must end the embargo in the Department of Health if we are to have sufficient staff to run the system. It is impossible for a couple of hundred people to run the health system.

I support the Minister's view on legislation relating to smoking. I am glad we are bringing in the Adoption Bill in the Seanad and that we are going ahead with the Children (Care and Protection) Bill. I warmly welcome the Minister's progress report on the psychiatric services, particularly in Castlerea and Carlow. I am very proud of the work that is being done in that area. We must reorganise the health boards but the Minister will not do that now because within the next ten days he will make 24 political appointments to the eight health boards. The names are already known. That is not reorganisation; that is politicisation once again, as was done five years ago by Fianna Fáil, and it will be carried through again for the next five years. That is appalling in terms of reorganisation.

There is plenty of money for the health services. If one goes to a race meeting or a dog track or even a pub on a Saturday night one will see young people under the age of 25 who will not be availing of the health services. Some of them would begrudge £1 for the elderly although they would spend £20 on three rounds of drinks. If I were to put 4p on a packet of cigarettes and £8 million in return for the health services, I would do it without a blush. The State has money. Yesterday the Government gave £25 million to a wealthy meat baron, without a flutter of an eyelid from the Department of Finance. This money was to provide hypothetical jobs in a country which already has a superabundance of meat processing plants.

We give £30 million tax relief to the better off in the community who join the State-sponsored Voluntary Health Insurance. I pay my VHI contributions and I pay my social insurance too. If we get tax relief at the standard tax of 35 per cent on our VHI contributions, we would have another £10 million for the health services. The closing of local hospitals which provide services for elderly people is wrong, because these people have to go into nursing homes. I will give an example. A family contacted me the other day because an elderly person, 74 years of age, suffering from a stroke, was sent out of a general hospital and into a nursing home in Dún Laoghaire at £195 a week. The family do not have that kind of money. No hospital will take her and there are no acute hospital beds in the area.

I end with this plea. Let us stop this double standard of privatising the health services and building a two tier system. Let the Minister tell the Taoiseach that this House protests in the strongest possible terms at the reduction and destruction of the health services which were built up over the years painfully and with great care. I believe our people are generous, caring and willing to pay for the health services but their politicians must be prepared to tell them that they must pay, although they will not relish paying. Everyone must pay his fair share so that those who are deprived, handicapped, physically or mentally, or old, can live their lives with dignity and proper medical care.

Mr. Carey

I am aware of the public outcry there has been in recent months at the attempted closures of many long established institutions. The difficulty people have is in deciphering what the real position is. A certain amount of responsibility for the recent high drama we have seen on our streets lies with Fianna Fáil because of the deception they practised when in Opposition. They called for improved services, said there was money available and that more could be done. The Fine Gael Party recognised that our financial problems had to be tackled and they produced a budget last January. The people decided that the Fine Gael cuts were too difficult to accept and they opted for the softer option which was Fianna Fáil. They rejected the Labour Party option because, as Deputy Desmond clearly outlined, they would have to increase taxes to provide a health service.

The Progressive Democrats in their taxation document produced in October 1986 said they would reduce overall taxation progressively to 25 per cent over a five year period. I do not believe they would be too concerned about the current budget deficit or anything like that, but they would have a cut of approximately £23.5 million in the Department of Health. At the bottom of page 18 in that document they say that the gross savings in the revised Book of Estimates would be £253 million. If we add to that the 3 per cent inflation costs we would add another £140 million, giving us a gross figure of approximately £400 million. The statistics they produced show that they too would call for cuts in Departments which could bear them. One of the Departments chosen by Fianna Fáil, Fine Gael and the Progressive Democrats was the Department of Health.

For some reason — we were talking about it yesterday — Fianna Fáil have been converted to financial realism. They put the unfortunate Minister for Health in the firing line and told him to implement the cuts. The problem is that these cuts will not be of a temporary nature because the financial difficulties will continue next year. The system implemented leaves a lot to be desired. Fianna Fáil Deputies are noticeable by their absence in any debate on health. They came in here the other night to comfort the Minister for Health in his agony as a result of the attacks by the Opposition parties although they were mild compared to the assaults we experienced in government. I regret that Fianna Fáil — with a few exceptions — do not appreciate what the Minister is doing for the country. None of them has supported his proposals in the Estimate for Health. He is left to plough a lone furrow. The absence of the Minister of State is particularly noticeable as he was very loquacious when he was on this side of the House in relation to his proposals for Castlerea and so on. He criticised Deputy Desmond when he was Minister and said he should be banned from the face of the earth. He has now changed his mind and obviously sees there is a need for financial rectitude. I am sure Deputy Leyden's conversion will be well thought of in County Roscommon when he next goes before the electorate.

There is an idea in the capital that the health cuts will be of short duration. It is thought that trade unions will take to the streets and that the Government will draw back. Perhaps that could be true but it is certainly not the case in my constituency because the Minister has acquiesced to the decision of the Mid-Western Health Board to close the maternity hospital in Ennis. If there was justification for the closure we should have been told what it was. However, neither the Mid-Western Health Board nor the Department of Health have issued a press release as to why Caharcalla Hospital should be closed. Expectant mothers in County Clare have got a very raw deal by the Mid-Western Health Board and the Department of Health. Ultimately, the Minister is responsible for this decision.

I asked the Minister on a previous occasion why he agreed to the closure of Cahercalla. This hospital had been proposed by the Taoiseach in 1980 and accepted by the Department of Health. The hospital has only been in operation for about three years and it is now to be closed. We are reasonable people but we cannot accept that decision without proper justification. We made sacrifices to ensure that the hospital was built and other services were neglected so that the women of Clare could have a maternity hospital. Officials have been dropping hints from time to time that the people of Clare did not fully avail of the services but there was an onus on the Department of Health or the Mid-Western Health Board to draw the attention of the women of Clare to the fact that the facility available should be utilised.

At present there is chaos in the hospital, the consultant does not know whether he is coming or going and the expectant mothers are physically in a poor state. There was a queue of people awaiting a decision last week as to whether the hospital would be open for the end of June and the beginning of July and nobody seems to know the answer. It would be much more sensible to phase out the hospital because at present patients are referred to other consultants whose books are full. Women who are expecting babies in early July have been offered appointments at the end of July. Would the Minister call that a reasonable service? He said the other day he was proud of the service he had given to his profession and indeed I heard him praised in the south as he had practised in Limerick. In the interests of the women of Clare, will the Minister examine the position, particularly in Ennis, where the poorer sections of the community will be affected? Those who have cars will probably be accommodated elsewhere.

People who have a long history of difficulties in pregnancy are being overlooked and this is causing extreme trauma. There has been a haphazard, ill-thought out approach to the health cuts. The problem has been brought about because the health boards are totally unwieldy. The Minister, with reduced administrative staff, could provide a very good service.

In case the Minister thinks I am totally critical of him, I should like to compliment him for being so forthcoming in the matter of health cuts and publicising them. There seems to be a reluctance in the health boards to accept the financial position which the Minister has outlined but that is born out of political expediency practised by members of the Minister's party who, in order to take on the outgoing Minister, overspent their allocation in the previous few years. The Minister must confront his own people in the health boards but I do not think he will be totally successful. There are still people indicating there are excesses in expenditure on the capital side practised in health boards.

Some of these new units being created might well be accommodated in adapting existing buildings. This refers to the community health care programme being drawn up by the Minister. In the interests of the taxpayer, I appeal to the Minister to ask the health boards to review their stock of buildings in particular places and see whether existing units can be utilised more fully, in order to give the progressive services to which the Minister aspires.

Mr. Naughten

It is my pleasure to have the opportunity to say a few words on this Estimate. We are all extremely concerned and recognise the very difficult financial position this country is in. We all appreciate the difficulties of providing an adequate level of service in these difficult times. I suggest to the Minister that on this occasion he and his Government have cut the health services at far too fast a rate. Vast parts of the country are being left without a health service, including parts of my own health board area. In the Western Health Board, of which I am a member, we face a shortfall of £8.4 million. There is absolutely no way in which the board can survive with this drastic cut. If we do not get additional funds, over 530 staff must be laid off by the board. I appeal to the Minister for additional funds, whether it be from the approximately £1,300 million Budget allocation or by way of additional funds from the lottery, to protect the structure of services in the Western Health Board area. We are faced with a complete and total breakdown of services.

As a result of the decision taken at the board meeting, the whole of the eastern side of the health board area will be left without medical or surgical services. The decision taken by the board effectively means the closure of Roscommon Hospital. This is because of the failure of the Minister and his Government to make adequate funds available to the Western Health Board on the one hand and by the Fianna Fáil dominated health board taking a decision to close that hospital. That is not the way hospitals should be closed down. If a service can be terminated in any part of the country it should be done in a planned and structured way. We will have no service whatsoever in Roscommon if that hospital closes. There is nowhere the 55,000 people in that catchment area can get service. We are faced with a reduction in beds in Castlebar Hospital and, I understand, in Portiuncula Hospital in Ballinasloe, where the budget has been severely cut. We are faced with a reduction in beds in Galway, both in Merlin Park Hospital and the regional hospital. There is no way in which people from Roscommon will be able to get beds in those hospitals. That is the situation we are faced with. I sincerely appeal to the Minister to examine the possibility of making additional funding available to the Western Health Board area.

I remember being here last year when we were discussing psychiatric services. I remember very clearly the now Minister of State for the Department of Health saying what he would do if he were in the Government's shoes and giving all sorts of commitments. Deputy Leyden at the time was extremely critical of the policy being pursued by the then Government and promised that on Fianna Fáil's return to office the situation would be rectified. I need hardly remind the Minister of the large posters in the last election campaign stating that health cuts hurt the old, the sick and the handicapped and that there was a better way.

I put it to the Minister that what he and his Government have done by cutting the health services to the present level is criminal. It is totally eliminating health services from parts of this country, particularly my county. We are faced with a unique situation there. Last year, as a result of a ministerial order and of the policy pursued by the health board since 1972, it was decided that the acute unit in Castlerea Pyschiatric Hospital would be resited in Roscommon.

Following much negotiation in which the Department officials were involved, it was decided that a new unit would be provided as an extension to the County Hospital in Roscommon. It was put before the Western Health Board meeting in January that a £750,000 extension be provided. For political reasons, the Minister's own colleagues in the Western Health Board rejected that proposal. They would not accept it unless they got three additional consultant posts in the hospital, one of which was surgical, one medical and one other post. What a change there has been in less than five months. We are now faced with a total withdrawal of services from that hospital. We have a proposal from the Western Health Board that our surgeon should be transferred to Castlebar and our consultant transferred to Galway and the county hospital reduced to a district hospital. These were the proposals put before the Western Health Board.

The only budget that Roscommon Hospital has at present is that of a district hospital because when the board adopted their budget which was railroaded through, we were told that a magic £700,000 had been discovered because the farmers' contribution was going to be collected. We all know what happened with regard to the court case in Youghal which has changed that situation and has effectively meant that the £700,000 which was to be collected in farmers' contributions in the Western Health Board area to provide for surgical and medical services at a greatly reduced rate of a 49 bed unit in Roscommon is no longer available. That is the reality.

The Minister referred to the farmers' contribution but did not refer to amending legislation being introduced so that these levies could be collected, or to a proposal that he and the Department of Health would make up the shortfall to the health boards because the health contributions can no longer be collected due to defective legislation introduced in 1978.

Getting back to the subject of the psychiatric unit and Roscommon County Hospital, the health board accepted in principle the idea of having an acute unit in Roscommon but it was to be an acute unit linked to a general hospital, not to a district hospital. I would like the Minister when replying to inform the Dáil how he sees services developing in Roscommon. Does he see an acute psychiatric unit being transferred from Castlerea to a district hospital in Roscommon? Will he provide the necessary funding to enable surgical and medical services to continue at Roscommon? We must have additional funding. The Minister's colleague, Deputy Morley, who is chairman of the board, refused three members of this House who requested him to call a special health board meeting to discuss this extremely urgent matter which has developed as a result of the decision in the Youghal court case.

I would be very grateful to the Minister if he would clarify precisely what the situation is with regard to the future of surgical, medical and psychiatry services in Roscommon and where we will get the necessary finance to provide those services. Is it his intention not to make additional moneys available to the health board and, if so, where will the people get the service? Is it intended, as with surgical and medical services which it was envisaged would be provided in Castlebar and Galway, that 12 months down the road we will be faced with pressure to have the psychiatric service provided in Galway as well. I would like the Minister to address these points when he is replying.

There is a unique and unprecedented situation because for the first time permanent civil servants are being made redundant in that nursing staff permanently employed by the health boards are being made redundant. They do not enjoy the normal privileges — if one could call them that — people get when they lose their jobs in private employment. Those people enjoy unemployment benefit. I would like to ask the Minister what his proposals are in this regard. Where is the money for redundancy payments going to come from? Are his Department going to make additional funding available to the health boards to meet redundancy payments? This is a major problem which has arisen in all the health boards. The Minister has the opportunity to inform the House and people throughout the country as to what precisely is going to happen. This is a matter of great concern to everybody.

Deputy Desmond referred to the charges for the provision of what I would deem as people's statutory right — a hospital services card and re-examination of their medical card if they are not satisfied with a decision. Now if people are not satisfied with the decision taken, they must now pay a fee to some of the health boards before that application can be reexamined. This is a scandal and I ask the Minister to examine the matter immediately. It is totally illegal and it will be a desperate indictment of the Government if they allow this to happen. People are now being charged for applying for what is their right and this should not be allowed to continue. The Minister for Health must act on this immediately because it is frightening that this type of conduct is allowed.

The Western Health Board are in an impossible position. I would like the Minister to inform the Dáil if he is fully aware of the implications of these cuts for the Western Health Board and, I am sure, for all other health boards. As a member of the Western Health Board I am aware of the desperate impact these cuts are hving on that board. I have already outlined the disastrous situation the board faces with regard to my county hospital as a result of the withdrawal of surgical and medical services. Difficult decisions have to be taken also in relation to psychiatric services.

I would like to refer to the position in the geriatric hospitals. We are faced with a reduction of 50 beds in the Roscommon hospital, 50 beds in Loughrea and 50 beds in Castlebar hospital. The Western Health Board covers a vast geographical area where a high number of elderly people live on their own in remote parts of rural Ireland. If they get sick and wish to get into the Sacred Heart Hospital in Roscommon, St. Brendan's in Loughrea or St. Mary's in Castlebar, they simply will not be able to get in because of the cutbacks in the number of beds in those institutions. The Minister cannot seriously expect this to be tolerated. I am not sure if the Minister is fully aware of the devastating impact this can have on elderly people who are ill and wish to get into any of those institutions.

I wish to refer to community care services. The Minister in his speech referred to people being treated in the community. I wonder if the Minister is fully aware of the implications the budget cutbacks which he announced are having on the community care services, both in the numbers of people employed in the services and on the restrictions in the mileage allowances for district nurses. In the Western Health Board area each district nurse has to look after 3,500 people. This is an increase of 50 per cent but, at the same time, their mileage allowances have been reduced by 25 per cent. It is not possible for district nurses to provide the care their patients require because of the large numbers of people they have to look after. This is another service which is completely overstrained.

No matter where the Minister has to get additional money — whether it is by way of the introduction of charges for perscriptions or whatever — he should consider introducing this rather than dismantling the health services totally. At present we are faced with a total dismantling of the health services. Before the general election both the Minister and his party gave clear commitments that there was a better way. I am calling on the Minister to show us what the better way is because if he continues along the line he is going the health services will be totally wrecked. There is no doubt about this. The Minister of State, Deputy Leyden, gave clear commitments before the general election with regard to Roscommon hospital. He put it on the line that "a vote for Leyden was a vote for the hospital". I am calling on him to honour his commitment to the people of Roscommon. We need our hospital with full services, both surgical and medical. We will co-operate with the Department in providing a new acute unit there but we want the money to do it. The obligation is on the Minister and the Minister of State to provide that additional funding for the Western Health Board, so that they can continue to provide a service for the people of Roscommon. If the hospital in Roscommon closes, the result will be that the rich will live and the poor will die because those people with VHI will be able to get services elsewhere while those with medical cards or the middle income group will not. That is the reality. I appeal to the Minister to make the additional moneys available to the Western Health Board so that full services can continue at Roscommon County Hospital.

Mr. T. Fitzpatrick

I want to avail of the opportunity to say a few words on the Health Estimate. The Department of Health is a very topical one at present. In the Minister's brief today he sets out the type of health service to which we are entitled and which should be provided. The Minister said, amongst other things, that the health service should be caring and efficient and that it should be within our capacity to pay for it.

The Minister then went on to say we are not getting that service and I agree with him. I interpret the Minister's words as an admission that the health boards have been a failure, that they are not doing a good job. I always had reservations about health boards. They were set up on the advice of an American firm of consultants. They would probably have been excellent if they were set up in America or in an economy with the strength of the American economy. When the health boards were being set up I said I regarded them as mini monsters. I often thought since, that I had made a mistake and that I should have omitted the word "mini".

Efforts were made by the last Government, particularly the last Minister for Health, to rationalise the health services, to cut out waste and squandermania, to get them to provide the sort of service the Minister has just recommended — efficient, economic and within our capacity to pay. Under the last Administration efforts made by the Minister, Deputy Desmond, to bring the health boards under control were derided by the Opposition day after day and week after week in this House. Private Members' Motions were put down and when they were being debated the galleries of this House were not as they are today, filled with grand young children, but were filled with the employees of the health boards who were paraded in here for debate after debate and entertained to a denunciation of the cutbacks and efforts that were being made to bring the health services under control.

They were led to believe that all that was needed was a change of Government to see the end of cutbacks, and the end of sackings and redundancies in the health services. They were led to believe that if there was a change of Government there would be full and plenty and that, as a result, there would be no restrictions on the health services. That was a pity. In the long term it will not do the Fianna Fáil Party any good. I wonder what the nurses are thinking now, the temporary nurses who were told a few months ago that a change of Government would ensure that their jobs would no longer be temporary but permanent. It is true that they are no longer temporary, because not even temporary jobs are being provided for. They have lost their jobs altogether.

I read in today's paper that thousands of nurses have threatened to go on strike. That is unthinkable. When we have come to the stage where doctors and nurses, the people of the caring professions, decide to go on strike to attain their objectives, there is something wrong with society. It is bad enough when the ESB employees strike to attain their ends and in doing so cause endless trouble and great loss in the economy, but it is much worse when the medical profession, the doctors, for the first time in the history of the State decide to go on strike, and say they will not work except in the most extreme cases. The GPs throughout the country were threatening to go on strike. Why? Because of the retention tax, because they were asked to pay tax in advance. We have one section of the medical profession going on strike because they are taxed too heavily and another section going on strike because the Minister for Health is not spending enough money. That is an absurdity and cannot be allowed to continue. I do not want to drag this any deeper into politics than is necessary but I have outlined the damage that the performance of the Opposition during the term of the last Dáil has done to the medical profession and to the nursing profession by driving them onto the streets in a strike.

Democracy is the best system of Government available. Any country that enjoys a democracy would be very foolish to lose it. Democracy is under severe strain here at the moment. People have not the respect for politicians they should have and which they have in other countries. Why? How about the nurses who canvassed during the last general election for a change of Government in the honest belief that there would be fewer cutbacks instead of more, that there would be more money spent on the health services than before, and that there would be better working conditions, better hours, and better equipment? What must those nurses think now? What must they think of the politicians, who indirectly in this House, and directly, led them to believe that would happen, whereas things are infinitely worse now than before as far as they are concerned.

Some days before the last general election the medical profession, or a big percentage of it, took to the streets and indeed to the mountains canvassing for a change of Government in the belief they would get better treatment if there was a change of Government, that there would be a more caring Administration in office and they would have better facilities. What must they think of politicians now? Surely they must be sorry and disillusioned. In that regard I could say that the canvassers were bad judges, that they should have thought again before they set out to canvass or they should have got something signed on the dotted line, but they took the promises that were made in this House, when their leaders were brought in here to sit in those seats to see the performance put on during Private Members' time.

I deprecate a system, a policy or an organisation which brings people into this House, people who are vitally concerned and have a vested interest in a subject to see a performance being put on leading them to believe they will get what they want. I believe that such tactics are bad and they are to be deprecated. You could use all sorts of emotive words to describe them but that sort of a performance is not in the interest of democracy or in the interest of the easier government of this country. In fact, when you reach the stage where nurses and doctors are taking to the streets and to placards, you are getting very near to having a country that cannot be governed. The medical and nursing profession are taking to the streets or are being driven to the streets, but they should not take to the streets so easily when they have a system by which they can change Governments. However, they will say we changed Government and we thought Christmas would come every month, but things have become worse rather than better, so what is left, but only the streets and the placards?

I am glad to be able to say to the Minister for Health that the General Hospital in Cavan seems to be proceeding very well.

Dr. O'Hanlon

We are agreed on that.

Mr. T. Fitzpatrick

It was not always so easy for the Minister to agree. It was one of the thorniest problems he had to deal with, including the one he is dealing with now. At any rate, I am glad it seems to be going on very well.

Mr. Naughten

I hope it keeps going that way.

Dr. O'Hanlon

We are agreed on that.

Mr. T. Fitzpatrick

The Minister dealt with it in a few short words. I hope he can assure me that the contract will continue on schedule, that there will be no shortage of funds and that the hospital will be completed next year. I admired the Minister at that time because he took a certain stance in a very difficult situation.

The Minister stated that one of his priorities would be the care of the elderly and attention to the needs of the elderly. There are two matters which I should like to deal with. One concerns hip operations which so many elderly people find necessary and for which the waiting list is unacceptable. The waiting list is far too long and something should be done about it as the amount of money involved is not very large. The other item relates to cataracts. Many elderly people are awaiting attention for eye operations. I was told of a communication the other day from a city hospital saying that the waiting time is now two years. I admit that the present cutbacks may be responsible for that to some extent. The fact that the people are told there is a waiting list of two years may have something to do with the present dispute with the Minister's Department. Two years of a wait in the case of an elderly person is crazy. It is simply saying that the service is not available to that particular person. Those are two matters which should be attended to immediately.

The one bright spot on the horizon in the last election — some people inside and outside the House may consider it funny to hear me say this — was the re-election of the outgoing Minister for Health, Deputy Barry Desmond. One would have expected in most constituencies following the campaign of bombardment and the unfair and scurrilous attacks carried out against him that he would not be re-elected. It reflects the highest credit on the people of Dun Laoghaire-Rathdown that he was not kicked out. I say that notwithstanding the fact that my own very good friend Liam Cosgrave was not re-elected. It just shows that there is still some hope in this country and that people are prepared to admire a man who does the right thing.

Mrs. Barnes

Thank God.

Mr. T. Fitzpatrick

But Dún Laoghaire-Rathdown is Dún Laoghaire-Rathdown.

Mrs. Barnes

They always vote well there.

Mr. T. Fitzpatrick

Perhaps there are many constituencies in the country where he would not have been re-elected. I felt I should pay that tribute to Deputy Barry Desmond because when an unpopular decision had to be taken he took it. He did his best to do what he thought was necessary.

Mrs. Barnes

I welcome the opportunity to contribute to what is probably one of the hottest issues in Ireland today. I should like to start on areas which we can build on together and on which we are all agreed regarding the health service. Having regard to our demographic structure, with a very young population, it is a matter of concern that that population should be healthy. Looking at the young people around today, both children in primary school and at second level, I am constantly impressed by their healthy appearance and outlook.

In health terms we have come a long way from deprivation, from the dispensary mentality and from the community care, which once existed only on a voluntary basis. I am aware of how much taxpayers' money goes into the health service. I am a great believer in building constructively even on adversity and I deplore the fact that we begin to produce results or reviews of the systems and procedures only when we are in crisis, but at least out of this crisis let us examine how the money is spent. Above all let the Fianna Fáil Government even now begin to plan and programme their budget and health services so that they cater for the people who should most benefit from the services and for whom they were set up in the first place, and then the caring staffs will look after them. Those are the people who need hospital and nursing care and they are some of the most vulnerable in our society. We do not want an empire building of health boards, or administration costs which visà-vis the direct cost of patient care are imbalanced. Let us try to set up a health service based on health and embracing preventive medicine. Let us set up a lifestyle programme that will be based on the positive side of health rather than on clinical treatment of the sick.

I would like our medical staffs to look more closely and with less hostility at the area of homeopathic medicine, the replacing of costly drugs which sometimes have debilitating and even dangerous side effects, with what has been used in centuries past and is still used basically even within artificial and chemical drugs. I am referring to herbal remedies. Let us examine our drug programme and the cost of drugs and their prescription and administration with a view to encouraging people to rely less on that area and more on natural remedies and restoratives. There has been a resurgence, even a renaissance, of what is described as the holistic view of health and of medicine. I ask everybody involved in the medical profession to see how we can extend, expand and encourage that type of healthy outlook and initiate programmes for health in that regard.

The Minister has set up a review committee. I hope, as all spokespersons on this side of the House had hoped, that that review committee would have been set up before the swingeing, savage cuts and attacks that are taking place now were introduced. Those cuts hit the most vulnerable, the children, women, the elderly and the poor and, in the long term cost effectiveness then affecting people for whom attention now could obviate more difficult and costly treatment in future. In view of the late institution of the review group we ask the Minister and that group to review as urgently as possible and to report as cogently and as practicably as possible. We cannot allow a health service, that was set up to cater for the vulnerable to be pulled apart at its very foundations rather than dismantled in areas where we can afford to dismantle it. One of the costliest features of that structure that we must examine is the administration and prescription of drugs, particularly costly drugs, within the medical profession. Concentration on generic drugs and the elimination of the use of the more costly drugs which chemical companies find very profitable financially has been the subject of debate for many years. Perhaps administrators of drugs find the latter type more profitable than generic drugs which are less costly. A full review of the drugs area must be a priority with the review committee.

The Minister in his speech on the Estimate today presented us with facts that are of concern to all of us. Every effort must be made to turn the focus and thrust of our health programme around and back into the community and to caring, close relationships rather than institutionalisation and isolation in large, centralised, extraordinarily costly hospitals. However, the cuts that are being introduced now are contrary to that thrust which we all agree is the only one from the human and cost level point of view. For instance, the general hospital programme in the Estimate absorbs some 50 per cent of the total non-capital budget. By that concentration on the general hospital programme we are neglecting positive steps to put back into the community the health and care programmes needed. Indeed, some of the cuts have negated that very objective. The secretary of the INO said this morning on a radio programme that public health nursing was being cut back. This is extraordinary, because that area is the centre of everything we are talking about with regard to community care.

The public health nurses who will be allowed to work still within the community, have been told, according to their secretary, that they will have to increase their number of visits to an increasing number of patients within the community. At the same time their mileage rate is being reduced. The secretary said, and I say, that that does not make sense. First, it does not make sense to cut back on that kind of nursing care within the community. Second, to ask people to work miracles of visiting more patients in outlying areas while using less petrol is preposterous. Either we have made a breakthrough in cost effectiveness in energy terms in the consumption of petrol or the nurses cannot do what is asked of them. That is the trouble with many of the cuts that confront us daily as they come to light. They are impracticable and they are contary to the aims of the health programme we all wish to see.

I and many other women are particularly interested in community care, caring for the aged within their communities without having them moved into more costly institutions which have less concentration on family relationships. I am thinking of geriatric or institutional day hospitals. We should encourage relatives and neighbours to take care of the elderly. I would hope that the review committee would focus their attention on this area in particular. When we talk about reducing costs but still providing adequate health services it should be remembered that one of the ways in which that can be achieved is the acknowledgment of women, particularly, and neighbours, who attempt to keep the elderly within the community and not transfer them into costly institutions. To date they have been given no such acknowledgment by way of their efforts being seen as gainful work carrying some social welfare benefit. I am thinking in particular of women who break their careers and the continuity of their social welfare contributions, particularly as they relate to pension or benefits in later years. Very often the duration of such caring constitutes a short period only in a relative's career. If such relative was encouraged rather than penalised for taking such a break in employment it would mean that the elderly person would have a caring relative looking after them, usually in their last days. If only they were given some acknowledgment for such caring by way of social welfare credits it would mean that they would benefit from such credits before rejoining the labour force. We should show some commitment, ensure some economic independence for such people. I emphasise that this sacrifice — and it is a great one at times — is always asked of women, particularly single women. One only has to look at the pattern of elderly single women living, in some cases, below the breadline, in discreet or open poverty, who have given up their careers — or perhaps never allowed work or avail of the same opportunities as the rest of us — because of the demands made on them of looking after elderly parents or relatives.

Not alone are those women not acknowledged in social welfare terms while they engage in such caring but, in terms of benefit or payment, they must reach the age of 58 to be eligible for the paltry — one of the lowest — payments given any group in the country. Until we change our attitude to such people there is no point in saying we will change the structures with regard to community-based care and nursing. The harsh reality today is that there is no longer an extended family to cushion the elderly aunt or to take in what was called formerly the spinster sister — which was not a very kind description either, but at least it meant she had a roof over her head. There are women today who into their mid forties or fifties have nursed such parents or relatives within the family home. Then, at that crucial time in their lives, married sisters and brothers return demanding the sale of the family home. This means that that middle aged single woman, without any qualifications and practically no employment opportunities available to her, is forced to make a life for herself, perhaps providing accommodation with only one-fifth or one-sixth of the proceeds of the family home. We all know what that would amount to in money terms today. It constitutes one of the great injustices we have endured and have expected women in that category to withstand. Yet there is not even a social acknowledgment of or indulgence for what they have done. When the review committee are making their recommendations about restoring nursing care to the community — as I expect they will — it goes without saying that this is one group of people they will have to take into consideration.

There is another anomaly obtaining within the social welfare system. For example, if one is looking after an elderly relative one may receive some kind of payment but if, say, one is a married daughter of the elderly relative then one does not. In fact an elderly relative can lose their living alone allowance if, say, even a grandson or granddaughter sleeps overnight in the house. Many old people feel vulnerable and are afraid of sleeping alone in a house at night. Yet it can cost them their living alone allowance.

It should be remembered that we are moving into times in society when there will be a high number of elderly people. Statistics already available forecast that, by the year 2000, we will have a higher number of elderly people without the benefit of an extended family or a relative to look after them. We must plan for that time. Indeed it could be said that all of the problems being encountered at present were occasioned by the lack of planning in the establishment and structuring of our present health services programme. Now that we have statistics we must insist on proper planning in regard to housing and services for the elderly, for the numbers who will find themselves without much family support in coming years, particularly in urban areas.

In the course of his remarks the Minister mentioned that hostels, day hospitals, day-care centres and other community facilities are being planned throughout the country for psychiatric patients. This initiative must be welcomed. However, all I have said with regard to financial and other supports for people caring for such people must apply in the case of psychiatric patients as well. We need day care centres. We also need what might be described as rehabilitation centres for people who have not fully recovered to be able to support themselves independently. There is a huge need for that type of nursing care as well.

I also welcome what the Minister had to say in regard to psycho-geriatric units in Dublin, which will improve standards at St. Brendan's Hospital and that units will be built at Clonskeagh and are planned for Ballymun and Dún Laoghaire. Naturally, I welcome — and not just in an insular constituency sense — the introduction of such units in Dún Laoghaire. Statistics show that there are twice the number of elderly people in the Dún Laoghaire constituency as there are, on average, in others.

I am glad to note that the Minister is present for my concluding remarks. I should like the Minister to give the House an assurance in regard to the whole area of women's health, the type of tests needed, particularly in the area of cancer screening, that not alone will those services not be dismantled, curtailed or have to be paid for by people who cannot afford to pay — thereby being denied them — but that they will be extended. I should like the Minister to give the House an assurance that all cancer screen testing will continue, tests such as those carried out at the Well Woman and other health centres, very often on a voluntary basis and which have been of greater support to women's general well being than perhaps many of the services available at more costly units. That kind of smear testing should not be denied to women.

I wish to refer in particular to the fact that the management of St. Luke's Hospital are reported to have said they will no longer carry out such smear testing for agencies or organisations outside their own hospital. I have also been made aware by women throughout the country that there will be drastic cutbacks in community health centres which used to carry out such day-to-day health procedures as smear testing and regular checks on children with regard to their hearing, their teeth and their eyesight.

Our health service is costing a lot of money and a small group of taxpayers are trying to carry the full burden. In a country with three and a half million people, half of whom are under 25 years of age, we should recognise the cost effectiveness of preventive health care. I ask the Minister and his review group, which may be reporting at the end of July, to give urgent consideration to ensure that no cutback is made on screening and testing in the community health centres, the Well Woman centres and the other community care centres. Those services ensure that women will not die from breast cancer, cervical cancer or any of the other cancers that can be treated successfully at present if caught in time. In conclusion, I would appreciate very much if the Minister could give a positive response, particularly in regard to the question I raised about St. Luke's Hospital but also in more general terms.

Mr. Taylor

I do not think the Minister will give too many commitments about what he will do with regard to the health service. The health services of this country have been ravaged. The Taoiseach has written to Departments calling for yet further cutbacks. I did not notice in the letter, which was publicised, that the Department of Health were excluded from that request for cutbacks and I am sure the Minister, who is a loyal member of the Fianna Fáil Party and of the Cabinet, will respond in kind, if he has not already done so, to the Taoiseach's letter calling for these further cutbacks.

It has often been said that the kind of country one lives in and the kind of society one participates in can be judged by the degree of care it shows for the weakest sections in that community, the old, the sick, the handicapped, the young and the disabled. Those are the criteria on which, on an objective test, a country and a society are judged as to the degree to which they have progressed as civilised society in the modern world. Because of the actions of the Government since coming to office, we will fare very badly when that test is applied.

The Fianna Fáil Party used every opportunity when in Opposition to draw attention to the actions of the previous Government when their Minister for Health, Deputy Barry Desmond, was doing his utmost and succeeding in maintaining a reasonably adequate health service. The present Minister came into the House with his colleagues on many occasions and heaped scorn, using hyperbole and flowery language, on what the last Government were doing and thereby inducing the people of the country to believe they could put their reliance and their trust in the Fianna Fáil Party, that they would stand by them and would maintain their basic needs for health services, social welfare and so on. How sad it is that the once great party of Fianna Fáil — they were once a great party — have reached the stage where the weakest sections in the community are attacked and decimated. Those who most need the care of the State are singled out for this savagery that has been imposed upon them by the Minister, the Government and the Fianna Fáil Party.

We remember the big hoardings we saw around the country in the run-up to the last general election. They said the Fianna Fáil Party would look after the sick and the handicapped. It must have cost their party a lot of money to provide these hoardings. They then have the gall to come into this House and introduce these measures. Sometimes I wonder about the hypocrisy of this party and this Government when I think of what they are doing to the poor, the sick and the afflicted.

The Minister imposed charges of £10 for in-patient care and out-patient care and this causes further hardship on the poorest sections of the community. The Fine Gael Party, and it is no great credit to them, were not so great on their health policy either. The Labour Party who were actively engaged in the last Government in maintaining a reasonable modicum of health services pulled out of Government because of the insistence by Fine Gael Ministers on making severe cutbacks in health services. That was what precipitated the last general election.

The Fianna Fáil Party in their wish to remain in power are bending over backwards to show they are even more Fine Gael than the Fine Gael Party. We have seen, on the issue of the economy, of health and of other matters, a coming together of these two parties but the Fianna Fáil Party are setting out to excel even the Fine Gael Party who were content to make charges on in-patients only. But that was not good enough for the Fianna Fáil Party and for this Minister. He had to go one better and bring in charges for out-patients also. The Minister assured us in the House, when we warned him of what might happen, that nobody would be turned away from a hospital. He said if people came to a hospital with a sick child he would see to it that they would not be turned away if they did not have the £10.

Some weeks ago a woman in my constituency contacted me in a state of panic. Her child had a fractured arm and she said when she took the child to a Dublin hospital she was turned away because she did not have £10 to pay them. I immediately made efforts to telephone the hospital in question. There were four telephone numbers listed in the directory for this hospital. I rang each number in turn — it was about 8 p.m. or 9 p.m. — but there was no reply from any of them. Ther phone rang merrily while in the meantime the child was in agony with a fractured arm. So much for the Minister's assurance that this could not and would not happen. That is just a symptom of the malaise that has befallen the Government. They have chosen the health services as the area in which to make the most vicious cutbacks.

In some hospitals haemophiliac units and testing units are being closed down. Other hospitals are closing at 5 p.m. and the out-patient departments of some hospitals have been transferred to other hospitals. It all adds up to an attack on the public health service and the Fianna Fáil Party are the instrument of that measure. Fianna Fáil have abdicated all the interest they had some years ago in the poor and disadvantaged. I accept that our economy is in difficulty but there are many ways a caring Government could deal with that.

In my view, the best way is not the imposition of swingeing cutbacks on those who cannot afford to pay for the services. The best way is to bring in an equitable taxation system. If we have to make attacks on health, they should be introduced at the luxury level and not at the public level. We know that that luxury level of health care, that upper crust element of the Blackrock Clinic type are not experiencing any cutbacks. The VHI class, and the consultants are not experiencing cutbacks. The junior doctors there were not on strike last week and I am sure the nurses will not be going on strike next week.

The Minister has wreaked havoc on the system. Daily we read of marches and protests throughout the country. How many marches are planned for next week? Will we have the spectacle outside Leinster House of Molesworth Street and Dawson Street being crowded with thousands of people assembled in protest? Has the Minister any conception of what he has wrought on the feelings of working class people? Is he aware of the feelings he has engendered by his policies? We have reached the stage where the most dedicated of all the professions, the nurses, of whom we can be so proud, are about to go on strike. We are all aware of the wonderful services our nurses have provided down the years but they have been brought to this pitch by the Government and the Minister, and have, by a two-to-one majority, decided to go on strike. What a sad commentary that is. What an outrage it is to have our nurses declare a strike against our health services.

Does the action of the nurses give the Minister pause for thought? In my view, the Minister is not aware of what the ordinary people are saying or of how frightened they are about the prospect of hospital closures and money demands being made on them. If the Minister thinks he can deal with this problem by organising an insurance scheme through the VHI to cover the £10 per day charge for out-patients he has another think coming. If that is his view, he has lost touch with reality and does not have any idea of the difficulty some families will face. Some people cannot afford to make their way to the VHI and they do not have any idea of how to take out an insurance policy. Most of them do not have insurance policies on the furniture they have in their council houses. We have all had approaches by tenants after fires or a break-in and been told that they had no insurance policy to cover their goods. Those people would find it difficult to organise the VHI annual premium. If the Minister thinks such people can organise themselves to get insurance policies with the VHI it is another example of how far removed he is from reality.

The VHI play an important role for the upper echelons, the upper bracket of medicine. There is no problem there because the subscribers get a tax concession on the premium. It is interesting to note that that concession has not been interfered with by the Government although the Government have cut back on the allowance for mortgage interest. The Minister for Finance did not interfere with the cosy tax arrangements and concessions that the luxury brand of medicine attracts. However, the tax arrangements for the person who buys a basic terraced house have been cut.

The Government, and the Minister, are protecting the upper echelons of society. The Minister has thrown aside the interests of ordinary working people who need a national health service. It is important that those people should be made aware that if they fall on difficult times, if all their money runs out in the middle of the week, they will be cared for in our hospitals. The Government have hit every section of the health service, nurses, doctors, hospital porters and laboratory units. Marches take place daily and more are planned over the next fortnight. This is something that cannot be tolerated in a western society. Is it beyond the ability of the Government to protect the needy and the sick in our community? Can they not organise their taxation policies in such a way that the needs of the poor will be catered for? I am referring to those who cannot afford to go to the Blackrock Clinic, pay consultants, or pay £10 for treatment at an out-patient department of a public hospital. I hope I will not hear of a repeat of what happened in Tallaght. On the last occasion the Minister failed to live up to his commitment. Some people may have to go scraping around to get £10 to have an eight-year-old child who has fractured an arm treated. Has the Minister any idea of how the family budget will suffer if £10 has to be found to get treatment for a child? Has any consideration been given to taxing the friends of the Fianna Fáil Party, the big farmers? Has the Minister considered raising taxes from those people so that those who are at the bottom of the heap in the economic pyramid of our society will not have to suffer a loss of food, clothing or school books when scraping together the £10 needed to have a child treated at the out-patient department of any of our hospitals or to stay in hospital for a few days?

I should like to ask the Minister if the government have given any thought to introducing a realistic capital taxation system. I should like to remind the Minister that his party, with great glee, abolished a wealth tax which the Labour Party were instrumental in having introduced. That was a moderate tax and had it been left intact it would have brought in more than enough money to cover the shortfall in the health services. Fianna Fáil could not wait to get into power to abolish that tax. It is worth recalling that that tax was imposed on those with assets of upwards on £100,000 and incomes in excess of £20,000 but that could not be accepted by Fianna Fáil.

One remembers with sadness the day Fianna Fáil abolished the wealth tax. It should never be forgotten what Fianna Fáil did in that regard and how at the same time they cut back on capital taxation. One remembers the cheers which emanated from the Fianna Fáil backbenchs when the announcement was made by the then Fianna Fáil Minister for Finance that the wealth tax was abolished. I was not a Member of the House at the time but I remember reading in the press that they cheered. Are the Fianna Fáil Party cheering at the health policy of the present Government? Are the cheers resounding from the Fianna Fáil backbenchers when they see the pitch to which the country has been brought, the marches and protests that are taking place? Did the Minister give any consideration in Cabinet to advocating the reintroduction of the wealth tax?

That one, single taxation measure, which would not mean a thing to those at whom it would be directed, I per cent or 2 per cent on the capital of those having upwards of £100,000 capital assets, apart from their dwelling house which might be worth more than £100,000, plus income of £20,000 a year, would have yielded enough to stop the marches. It would have given a sense of security to the poor who could sleep in their beds knowing that, if their children were taken ill, they could go to the hospital, as they had done since the foundation of the State, and be received with sympathy and courtesy, and not turned away because they did not have £10.

Dr. O'Hanlon

That is a desperate reflection on the hospitals.

Mr. Taylor

It is a reflection on the Minister because his measures brought about this situation. Imagine the consternation when a parent brings a sick child to a hospital but before anything can be done for the child the hospital authorities ask if the parent has £10.

An Leas-Cheann Comhairle

I must draw the Deputy's attention to the time——

Mr. Taylor

As the Minister raised this point, I must reply to him. Such a thing never happened when Deputy Barry Desmond was Minister for Health, nor did it happen with any of his predecessors. Such a thing could never have happened. The new concept is that we must pay, money up front. Need no longer counts. That is the new era which has dawned with this health policy. I ask the Minister to think about this once again and also to consider reintroducing capital taxation because that money could be used to restore the health services.

Miss Flaherty

Even at this late stage the Minister should admit to the House that he did not know what he was doing when he proposed cuts of this severity on budget night. At that time we identified that the system could not cope with cuts of such depth without leading to the consequences we have seen in service and chaos in the health services. I gather from some of the newspapers that the Minister is reported to be a hero among the Cabinet but for those working in the health services and those in need, he is very much the villian of the piece. He may have offered the health services to the Minister for Finance, in an unprecedented fashion, adopting an attitude which is out of keeping with the best traditions of those who sought to develop and preserve these services and within the confines of monetarism gone wild in the Fianna Fáil Party, this may be a heroic move but for everybody connected with the health services, he is clearly the villain of the piece.

I wonder why not one Member of the Fianna Fáil Party, except the Minister, came in to argue for the Estimates today. Do they, in their heart of hearts, wish they could do as we are doing, that is, oppose these Estimates? We are opposing the Estimate because we believe a cut of £22 million from the health and hospital services, with the consequences we are seeing every day, is too steep. Despite all that has been said in this House, the Minister decided to play the hard man in monetarist terms and the Government are backing him. The Government and the Minister have failed to respond to the concern everyone has expressed.

As I said, I believe the Minister did not know what he was doing on budget night. I would like him to admit that when his investigating teams came back from the various institutions around the country, they told him they were shocked at the consequences of these severe cuts. We are still awaiting the results of that review although almost half the year has passed.

It was very interesting to read last year's Estimates debate. The present Minister described the morale in the health services as being at an all time low. We could use much of his contribution in today's debate and it would be even more telling that any phrases we could come up with. Today he denied, or tried to discount the repeated claims that these cuts were totally unplanned, that there was no plan and no direction and that he is now trying to bring order into them. That too can be seen by looking at the debate on last year's Estimate.

Last year the then Minister, Deputy Barry Desmond, announced the development of the new maternity services in Cahercalla Hospital. What have we got this year? These services are to go. Over the past six to eight years there was a great deal of investment in the maternity, obstetrics and gynaeological units in St. James's Hospital. What do we have this year? This is the area where the cuts are to be made. The present Minister and his predecessor said that the long term and most desirable objective was to have maternity services based in general hospitals. Where is the only maternity unit in a general hospital in Dublin? It is in St. James's and this unit is to go. It is the smallest unit in Dublin. In terms of rationalising the maternity services in the eastern region it will make only a tiny contribution and will have to be followed by more serious decisions very soon.

I asked the Minister before, but I did not get a reply, if he is satisfied that his stated policy objective and that of his Department, that maternity services should be provided in general hospitals, is to be forgotten and if this unit is to go. St. James' Hospital is unique in offering very specialised back-up services for mothers who in the past have found it impossible to manage full pregnancies and to bring their babies to full term. They have pioneered programmes and because they are a general hospital they can offer specialised back-up in heart and renal care. That service will go because of the proposed axing of the whole service.

There have also been murmurs in relation to some of the other specialised services in St. James's such as the haemophiliac and bone marrow transplant units. The maternity unit is also to be closed. That indicates a total lack of planning evident in a hundred and one areas as a result of the cuts proposed in the budget.

The Minister has good intentions in regard to the psychiatric services but there is very little meat in his proposals. He said he hoped to move away from traditional dependence on large psychiatric hospitals and early on in his speech he referred to his intention to go ahead with plans to implement future planning proposals. All those who work in that field are satisfied that the net effect of the cutbacks this year will mean that the whole process will be slowed down substantially.

There is a contradiction in the area of community care. The Minister said he will continue to protect these services but Deputy Barnes indicated there has been a substantial cutback in the public health area. Public health nurses are not replaced when they go on leave; they are already overstretched and the implications are extremely serious. They give the lie to the belief that there was any planning to replace the cuts in the acute services or those in general hospotals with some sort of development.

The testing services have also been severely hit. Deputy Barnes referred to cervical smear tests and I should like to mention that the total range of diagnostic tests which have been available free to date from GPs will now cost £10 per test. Perhaps people will be able to get around this by attending hospitals but in that case they will be liable for the out-patient charge. If they go to their GPs it will cost £10 for the visit and £10 for the test and if they go as out-patients they will clog the system which is meant to providing a specialised service. Many of these tests are in the venerealogical area which means also clogging the very limited services available in the clinics which deal with sexually transmitted diseases which at present are coping with about 40 to 80 patients per night as a result of the recent publicity campaign launched by the Minister.

To return to St. James's, why is the maternity unit to go? It is to make place for the burns unit in Dr. Steven's Hospital. However, there have been rumours that that hospital will also be closed. It is part of a jigsaw. All this is a contradiction of many things which the Minister and the Department stated in regard to health policy. The Minister had only a few short weeks to prepare a budget and he was unprepared for the level of pressure exerted by the Department of Health and the Department of Finance. He was unable to withstand it and submitted to a whole range of cuts which cannot be sustained without severe damage to the services.

I am very concerned about the area of mental handicap. In his speech in relation to the capital programme, the Minister said that in the case of mental health services the aim is to develop facilities which will enable mentally handicapped persons to reside in the community and that the programme included projects geared to the achievement of this objective. I should like a list of those projects from the minister because from my question to him in this House on 9 June in relation to the Eastern Health Board area, which I know particularly well and in which there is a crisis in terms of services for the mentally handicapped, the Minister said that the health board believe they need to develop services which would cost in the region of £5 million per annum and £8 million in capital expenditure. Clearly, no provision has been made for these sums and the net effect will be that there will be no development for the mentally handicapped this year in Dublin. I cannot speak for anywhere else. Many parents look after their mentally handicapped children at home. What will happen to them? Already the provision of disposable napkins has been cut which is a very real problem and involves major extra cost or children running the risk of infection. That decision is indefensible and should be revoked.

There is a very high number of mentally handicapped children in my constituency — perhaps it is due to the socioeconomic groupings, I do not know — but everybody is very concerned about it and the subject comes up at every meeting which I attend. Those parents are extremely worried at present about hospital charges. Mentally handicapped children are not excluded from the £10 charge although they have to attend hospital regularly with a variety of illnesses. A clear guideline should be issued that if such children attend one week with a chest complaint and the next week with some other ailment that they will not be treated each time as a new case and charged again. Mentally handicapped children are quite often in hospital so in-patient and out-patient charges are a great worry. I ask the Minister to look at this area and to respond in a positive way to his commitment to maintaining mentally handicapped children in the community. We know that parents of mentally handicapped children do trojan work and have pioneered amazing services for them. They will continue to do so, in conjunction with the Department, although it has been a relationship that has not been without its tensions and there are criticisms on both sides. To cut services at this level to the parents and the children is indefensible.

I should like to refer to community services in a more expanded fashion. I mentioned public health nurses, testing and the mentally handicapped. In relation to the latter, there is a crying need for development of the capital services to provide long and short stay units and day units, especially in north Dublin. The Minister should commit himself to regarding this as a priority. Having pressed this matter with the former Minister, I was glad when he announced in his budget speech that there was provision for one day centre. There is no specific proposal here and it is disappointing not to be able to tell the parents of such children that there will be an easing of the problem.

The services which day hospitals provide have also been affected. Blan-chardstown Hospital has cut not only geriatric beds but also the psychiatric day centre which provided support for 20 or 30 people who came there regularly recovering from the effects of alcohol, gambling and general psychiatric illnesses. They have now been released on to their own resources. Deputy Barnes made the point that many of these short term savings will be expensive in the long term. A person who has been involved himself but who has recovered from a depressive problem associated with alcoholism and who has been leading this group, is satisfied that without that support a number of these people will not be able to survive on their own in the community and will end up back in institutional care. There has been no planning with these cuts. There is no coherence in them. They do not implement the kind of laudable objectives referred to by you throughout your speech. There is no beef in what you are saying in many areas.

Another hospital which is near to your heart, a Leas-Cheann Comhairle, is Cappagh.

An Leas-Cheann Comhairle

The Chair is happy that at last he has attracted your attention. You were addressing the Members.

Miss Flaherty

My apologies. The Cappagh Hospital allocation has been cut by £600,000, which means that they will have to reduce by half the number of operations. This is the only orthopaedic unit in the public service doing hip and joint replacements. There are plenty going on in the private sector and there will be lots more as a result of this budget. Cappagh Hospital do the joint and hip replacement for arthritic people as well as for mentally and physically handicapped patients. It is the only hospital that supplies the latter service. Patients requiring operations will now have to wait four years instead of two years. That means that the operation will come too late to be of value in many cases. Many will not be able to stay in the community. At minimum, it means two more years of pain when people could be living a more mobile life. This is one of the arguments that I and others have against the idea that because we are not any healthier for all the expenditure, we should cut expenditure. We may not be staying out of hospital any more, but the quality of the lives of many, such as arthritic sufferers, has been greatly improved. Does that come into the equation at all?

Cappagh Hospital, over the last number of years, never exceeded its budgetary targets. That is another element of the total injustice in the implementation of the cuts. I am sure the Leas-Cheann Comhairle will agree with me there. That hospital, like Hume Street Hospital, took on immense savings programmes and successfully brought back their budgets under the careful pruning attention of the gardener of the health services, Deputy Desmond. These hospitals have been treated similarly to those which overspent substantially; no recognition has been given to places such as Hume Street, or to James's Street maternity unit which managed with the reduced allocation of beds to deal with a similar number of cases effectively and efficiently. It is regrettable that those who have given the lead and been responsible about expenditure have been hit as badly as those who perhaps had spent wildly and developed services in conflict with the Department. I hope the Minister will respond to these points.

Miss Harney

I am delighted to have an opportunity of discussing this Estimate but am surprised to find that the Minister is alone on the Fianna Fáil benches. Having read reports over the last number of weeks about the concern that existed within his party and having regard to the number of times issues relating to the closure or possible closure of hospitals or to the health services generally have been discussed, I am surprised that the Deputies did not see fit to come here today to contribute to the debate. The public, too, will find that a surprise.

It is unsatisfactory to some extent that this is probably one of the few opportunities we have in this House of having any kind of general debate on the health services. I and others in this House have felt for some time that there is a need to have a proper parliamentary structure so that Deputies interested in matters relating to health can have, throughout the year and throughout the lifetime of this Dáil, an opportunity of contributing more fully to the input on health policy. It is a disappointment that in the establishment of committees earlier this week, at a time when we need to look realistically at the task of getting the economics of the country in order on the one hand and at the same time to be able to provide a caring health service for those who need it, a health committee was not established in the Oireachtas, particularly one of this House.

Over the last number of weeks as well many other Deputies, by way of parliamentary questions have sought to establish information in relation to many matters that so many members of the public have been contacting us about. The usual classic reply from the Ceann Comhairle's office — and it is not too easy to establish who is responsible in this matter — is that it is argumentative or that the Minister has no function in the matter, even though it comes directly under the auspices of his Department, or that the Minister has referred to it in his speech on the Adjournment. Some days ago I tabled a question in relation to the bone marrow unit in St. James's Hospital, getting a reply saying that I could not raise the matter because the Minister had referred to it in the Adjournment debate. I remember going through the column quoted and not being able to see anything that reassured me that the Minister had adequately dealt with the question I had tabled.

It is very unsatisfactory that Deputies cannot get ordinary, basic information. So many people are beginning to feel that this House is becoming irrelevant. This is because if they approach a Member of the House for basic information they are told it cannot be given. Whoever is responsible, whether it be the Department or the Minister for Health, or the Ceann Comhairle's office, I can only say that I never experienced anything like such responses from the previous Ceann Comhairle's office. That will have to be rectified as a matter of urgency.

I speak also as a member of a local health committee. I am not a very active member, as I think it is a totally useless and irrelevant body. The meetings, which I rarely attend, are taken up with councillors asking when a clinic will be opened, when a doctor or a dentist will be appointed there, or when a certain building will be built. This is ordinary information that anybody in any civilised, decent society should be able to get by telephoning or writing. We do not seem able to do that in this country, despite the fact that we have such an enormous public service. That is a pity.

It is not just the cost of the local health committees that worries me and they are costly as anybody involved will agree. What concerns me is that they are composed of people like myself who know absolutely nothing about the health services. I am not in a position to be a member of an advisory committee, just as most of my colleagues are not, in relation to health care. It is about time we got our act together in this regard. These committees tie up the time of so many administrators in the Eastern or other health boards and of so many consultants and others who should be involved in the direct provision of care and the administration of the service to the public.

The Progressive Democrats are voting against these Estimates, not because of the provision of approximately £1.3 million not being adequate. It is perfectly adequate. I understood Fine Gael believed that, too. A Private Members' motion tabled by this party some weeks ago was, I believe, supported by the Fine Gael Party. That does not seem now to be the case. We are against this Estimate because it is the only opportunity we have to make our point. Unless the Minister and the Department of Health become accountable and responsible for the provision of health care, we will not be able to achieve what all of us want to achieve and what I believe can be achieved — an appropriate health service for this small country with such a young population.

We should provide that service on the same basis as it is provided in many European countries other countries provide that service at a lower percentage of GNP expenditure than we do despite our very young population. We should be able to do this. However, we will only be able to do it if the Department who are responsible for the allocation of the moneys and the Minister who is responsible for health policy take their roles seriously and do not abdicate and pass on the buck, and blame a local health board if services are not being provided.

In that context I know many members of the public who are deeply annoyed — and I share their concern — at the manner in which some of the vested interests involved in the provision of health care, and I include politicians in that, have tried to stir it up for ordinary members of the public. On a recent television programme I heard a medic announce to the nation that children will die as a result of an allocation to a hospital. I remember watching that programme with other Members of the House and I was appalled at how any professional medic could speak like that and frighten and intimidate people and be so misleading.

I say that to support what the Minister is trying to do but he is not doing it in an appropriate way. I appreciate the difficulty he has because too many vested interests do not want to face reality, do not want to face up to the economic situation and want to use their political muscle including frightening vulnerable people in our society. This has gone on too long. This is appalling and Members of the House who have engaged in that kind of political point scoring are to be blamed. I remember hearing one Member of this House say that people were going to die that day, the next day or whenever. I wish we could have debates in a rational and meaningful way rather than in that hysterical nonsensical way. It does nothing for the politicians who engage in it; it does nothing for the professionals who engage in it, and it does nothing to alleviate the genuine fears I have come across among many members of the public.

When ordinary members of the public have genuine fears and want to get basic information, whether it is in relation to the sexual assault unit in the Rotunda Hospital or the bone marrow unit in James's Hospital, rather than waiting for three or four days to elapse after an announcement is made, or until this House meets and a Deputy puts down a question or gets up on the Order of Business the Minister and his Department should see it as a matter of policy to clarify the points being made and alleviate the fears the public have and not allow these fears to build up. Many of these fears are built on misleading and false information. If the Minister and his Department were to continue to do that it would go a long way towards achieving what he and many Members of the House are trying to achieve.

I feel dishonest in many ways in speaking about health. There was a keep-fit programme in this House about ten years ago. I am probably one of the unhealthiest Members in that regard. Like many others who speak about certain subjects, I do not know as much about this subject as I would wish to know. I have read a number of reports written by people who have examined our health services. I have read a number of the comments from the Dale Tussing report. He described as ad hoc the manner in which our health services are administered. He described as unsatisfactory in the extreme the way in which we set targets for expenditure in the Department of Health.

We need to engage in a zero budgeting process as they do in most large commercial undertakings. Rather than take cuts of 2 per cent here, 3 per cent there, 4 per cent somewhere else, or an even spread across the board, the Minister should examine from scratch every scheme under the auspices of the Department and the health boards and see if they are still necessary, how they can be improved and how they can be delivered more efficiently. If that were done, within the budget provision for this year we would be well able to provide a service that would be a model one for everybody who needs health care. We are a small and thankfully a healthy country. We have a young population, a pleasant environment and a much lower percentage of elderly people than there are in many other countries. We should be able to achieve what most people want to see achieved — the provision of a basic health service to the community at a cost, and not the economic provision made in this year's budget.

There is something that concerns me deeply in relation to the vulnerable or marginal areas and it is a trend I have noticed developing more particularly since the cutbacks were introduced over the past few months. I want to refer to this briefly because Deputy Keating is anxious to contribute. The current strike at the ISPCC offices has resulted in those offices and the facilities of that society not being available to the thousand or so families they work with. These are vulnerable children and families at risk. It is a shame that that strike is under way. I know that it is a voluntary body and that the Minister has not got direct responsibility for it in the same sense as if it were a health board or agency under the auspices of his Department. The Department of Health provide a major proportion of the funding for that society. Given the children and the vulnerable people that society deal with, I ask the Minister and his officials to do whatever they can to ensure that the strike is over as soon as possible.

It will not take very much to settle it. I have examined, in so far as one can examine industrial matters, the grievances of those on strike. I have looked at the salary scale most of the people in that society work for and they must be people of outstanding dedication and commitment to work for under £5,000 a year, as 25 per cent of the staff of that society apparently do. For the sake of the vulnerable people who depend so much on the services of that society I ask the Minister and his officials — and I know the Labour Court are involved — to involve themselves directly in some way to bring the two sides together to thresh out the difficulties. The country should be able to afford the £87,000 it would take to end that strike so that those vulnerable children and families be able to continue to have the services of that society.

Mrs. Barnes

And the staff.

An Leas-Cheann Comhairle

I wish to remind Deputy Keating that he will be obliged to demonstrate that he can say something original, brilliant and relevant to the matter in two minutes.

Mr. Keating

I cannot promise that but I promise not to speak for more than two minutes. As we all know, one in five people will enter hospital in the next year and that figure is rising all the time. During the past 20 years the admission rate has doubled but the population has not doubled during that period. Yet the Irish health service will swallow up some 8 per cent of GNP this year. It is the largest spending Department in this State, employing about 70,000 people. In Britain they spend a little over half of that on their health services. That expenditure of over £1.2 billion is borne by the taxpayer.

This is a truncated discussion on the Estimate for the Department of Health. The essence of that Estimate is to ask this House to approve substantial sums of expenditure. While agreeing that there are adequate funds if used wisely, the manner in which the accountability for that funding is administered is wrong and there is great difficulty in obtaining detailed information from the Department. I have a list of questions some of which I had hoped to ask but they have been ruled out of order because they are allegedly matters for the health boards although they affect how our money is spent. Those reasons force us to a vote against what the Minister seeks to do here.

When the health boards were set up and back as far as 1966 when the White Paper on the health services and their further development proposed the setting up of the regional boards, we were told that the purpose was to allow the Department to take a more detatched and generally more co-ordinating approach to health expenditure. It is fundamentally wrong that the Minister for Health and his Department can say they cannot account for moneys because it is a matter for the health boards. That is an abdication of responsibility and is fundamentally offensive to the standards of public accountability for taxpayers' money.

There are question marks over the way some of that money is used. It is profoundly wrong that some consultants have open-ended use of facilities paid for by taxpayers, facilities such as telephone facilities, when nurses, for example, cannot make a telephone call in some of the hospitals. There is no possibility of us being able to ask why every staff canteen in every hospital subsidises to the tune of 50 per cent the meals for its staff and discriminates between the menu for the staff and for the patients. There are many other questions relating to the way in which the health boards operate. The Minister is the defender of the health boards——

An Leas-Cheann Comhairle

I would remind the Deputy that he is fairly near a resolution of his problems.

Mr. Keating

——but he will be a little less enthusiastic about them when he sees they are a large part of the problem. We have to vote against this Estimate. I am sorry I do not have a little more time to develop some points.

Minister for Health (Dr. O'Hanlon)

I have listened attentively to the debate since 12 o'clock today and I thank Deputies for their contributions. I am puzzled at the Fine Gael Party because while Deputy Allen told us that £1,314 million was adequate to provide services this year and that we should not go outside of that, Deputy Flaherty, the spokesperson for Health, said that it was too deep a chunk to take out of the services this year.

Miss Flaherty

You could raise money in other ways.

Dr. O'Hanlon

The parties opposite would want to decide whether they believe we should live within this allocation or go outside it.

(Interruptions.)

Dr. O'Hanlon

As far as the Government are concerned we will not go outside the allocation for this year.

(Interruptions.)

An Leas-Cheann Comhairle

We cannot have this continuous interruption of the Minister.

Dr. O'Hanlon

Deputy Boland who was Minister for Health on 20 January when the budget was announced by the Minister for Finance, Deputy Bruton, had the allocations ready to send out to the health boards and to the various health agencies but he did not do so. Why? If the allocations had been sent out, the various agencies would not have to deal with the problems in the space of seven months. They would have had 12 months, or at least 11 months, within which to deal with their allocations and to effect the necessary savings. Deputy Allen referred to the £55 million over-expenditure, as did Deputy Howlin. The previous Government allowed £55 million of over-expenditure, £36 million last year and £19 million the previous year. That is the real reason for the problem this year. We have allocated £4 million more than Fine Gael would have allocated to the agencies and indeed we allocated £25 million more to the GMS.

Miss Flaherty

£22 million less.

Dr. O'Hanlon

It is correct that Fianna Fáil control the health boards, but the Minister has the power to implement section 31 of the Health Act which I am implementing this year and which I will see is adhered to. That facility was there for the previous Government but they ran away from their responsibility.

Mr. Desmond

We exercised section 31 repeatedly.

Dr. O'Hanlon

It has been exercised repeatedly but not adhered to because the previous Government did not have the courage to ensure it would be adhered to. It will be adhered to this year. Deputy Allen referred to the number of health boards. I do not see any reason to reduce the number at this stage because it is important to have a local input. In listening to Deputy Molloy who complained I did not make the individual decisions around Ireland, I can assure this House that Deputy Molloy would be the first Deputy to be in here if I were to suggest what should be done in Clifden. He would want to know why I was being dictatorial and why I did not leave it to the Western Health Board who are in the best position to judge. I have no doubt about that nor has any other Member of the House.

Deputy Molloy read a letter about the bone marrow unit in St. James's Hospital. Deputy Flaherty and Deputy Harney also raised questions about what would close and about the lack of information on what is happening. It is important for people to realise that hospital boards of voluntary hospitals are independent but funded by the State and that they have the right to decide in the first instance as to how they will spend their allocation. If hospital boards decide to close the most sensitive unit they are doing it for political blackmail reasons. It would be wrong for a Minister to give in to that sort of blackmail and give them more funds to keep these units open.

Mr. Keating

Why did you not stop them doing it?

Dr. O'Hanlon

We did stop them doing it in the Rotunda, after three weeks of hype by members of the Opposition. The Sexual Assault Unit in the Rotunda will stay open——

Mr. Keating

They should not be in a position to do that in the first place.

Dr. O'Hanlon

——within this year's allocation.

Mr. Keating

The system that allows them to that is wrong. They are putting fear and terror into people.

Dr. O'Hanlon

I dealt in the House previously with the basis on which the allocations were made. They were made on the basis of protecting the community care services, the services for the elderly and for the handicapped and on the basis that any savings that would be made would be made in the acute hospital area. We have an over-provision of acute hospital beds here. We have 9.4 beds per thousand of the population whereas the European average is 9.1 and the UK is 7.9 beds per thousand of the population. It is in that area that we are anxious for savings.

Deputy Howlin referred to the OECD but left out some important facts about the economy. Inflation is at its lowest in 20 years and interest rates are coming down. This is exactly what the Government wanted to do in their policy. It is only by creating the sort of environment in which people will invest that we can have economic growth. It is only through economic growth that we can provide the level of social services we need. Deputy Howlin also referred to a list of hospitals and to reductions but it would be no harm to look at the more positive side. A number of hospitals in this city are receiving over £20 million. Anybody who studies that aspect will realise that it is possible to provide an adequate and proper level of services with that kind of money and that because a hospital has a reduction of 6 per cent, 7 per cent or 8 per cent it does not necessarily mean that it will close down, as Deputies opposite would suggest. Deputy Howlin referred to the £55 million and said that in the past Fianna Fáil Governments had introduced Supplementary Estimates and he lauded Deputy Desmond for not introducing a Supplementary Estimate and for allowing overspending. By introducing a Supplementary Estimate, the Government of the day at least provided money for the services. The reason we have such a problem now is because the money was not provided.

On the question of Beaumont, hopefully, it will be open by the end of this year. There is no problem in relation to Beaumont except that the equipment that should have been ordered four years ago was not ordered. We have now ordered the equipment and as soon as it is installed there is no reason why Beaumont should not open to replace the Jervis Street and Richmond hospitals.

I am satisfied that sufficient funding is being provided to ensure an adequate service. A sum of £1,314 million will be spent on the health services this year. A total of 60,000 people will be working in the health services. If people are frightened, it is people such as Deputy Taylor who are frightening them. I would like the Deputy to give me details of the case where a child was refused service in a hospital. I am aware of a case where a child went to the hospital in the very first days of the charges and was asked for £10. The patient did not produce a medical card or any evidence of exemption. They returned two hours later to the hospital with £10 and got treatment for the child. The next day, when all that was over, the manager of the hospital discovered the error and sent back the £10. When they had the £10 back it came to Deputy Taylor's attention and found its way onto the front page of the Irish Independent. I do not know if that is the case the Deputy is referring to——

Mr. Desmond

That is not true.

Dr. O'Hanlon

——but I would be anxious to hear of any case——

Mr. Desmond

Deputy Taylor had personal——

(Interruptions.)

Dr. O'Hanlon

I am surprised the Deputy did not bring the matter to the attention of myself or officials of my Department.

Mr. Desmond

It relates to Mrs. Nolan and to the Children's Hospital in Crumlin.

Dr. O'Hanlon

As I have gone over my time I am sorry I cannot deal with the points raised by the other Deputies. I assure people we are providing sufficient funding, that there are sufficient people working the services and that there will be a service available to anybody who needs it. This is about people. We are a caring Government. At the end of the day we will have a leaner more efficient service.

An Leas-Cheann Comhairle

Is the motion agreed?

Deputies

No.

An Leas-Cheann Comhairle

I am putting the Question: "That the motion in respect of Vote 47 is hereby agreed to."

Question put, and a division being demanded, it was postponed in accordance with Standing Order of the Dáil No. 127 until 8.30 p.m. on Wednesday, 24 June 1987.

The Dáil adjourned at 5.05 p.m. until 2.30 p.m. on Tuesday, 23 June 1987.