I move:
That a sum not exceeding £1,109,944,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1988, 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 £1,207.414 million. Allowing for Appropriations-in Aid at £138.5 million, the net non-capital grant provision is £1,068.914 million.
The net non-capital grant provision represents a decrease of £43.111 million on the corresponding out-turn for 1987 (£1,112.025 million). The decrease is due to additional appropriations-in-aid of over £8.6 million, (which have the effect of reducing the funding requirement from the Exchequer), a reduction of £12.6 million in the requirement for balances of grants due to health agencies, and the additional full year effect of economies achieved during 1987.
An increase of 3 per cent from July in the rates of allowances to disabled persons is provided for. The provision also takes account of the writing off of local loans, as well as the restoration of the community drugs schemes. There is no provision for the cost of pay increases arising under the 1987 pay agreement. This cost will be met from Vote 46 and will add approximately £20 million to the total available for health services.
The level of non-capital expenditure in 1987 which can be approved on the basis of the subhead provisions in the Estimate is £1,297.5 million in gross terms, or £1,190.5 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 year.
The gross estimated expenditure of £1,297.5 million represents a decrease of £22.5 million on the outturn for 1987. It comprises £800 million in respect of pay, £427.5 million in respect of non-pay (excluding cash allowances) and £70 million in respect of cash allowances. About 81 per cent of the gross expenditure will be met from Exchequer funds. The approximate breakdown of estimated gross expenditure of £1,297.5 million in 1988 between programmes is set out in Appendix I.
As can be seen from the data presented, the general hospital programme absorbs almost 49 per cent of the total non-capital budget. I will return later in my statement to developments in this particular programme.
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 or so. In 1973-1974 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 £1,190.5 million, representing about 6.7 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 total health capital allocation for 1988 is £43 million. In the current difficult financial situation, this is a substantial allocation and it will be spent on the priority capital projects that are included in the capital programme in order to improve the infrastructure of the health services.
Construction or equipping work will be continued on all the major general hospital projects that are provided for, including St James's, the Mater, Cavan, Mullingar, Castlebar, Loughlinstown, Waterford Regional Hospital and Our Lady of Lourdes Hospital, Drogheda (a new maternity unit). Provision has also been made for major new schemes where construction has commenced in 1988, such as the Sligo General Hospital and the Wexford General Hospital (Phase 1). The planning of the new Tallaght hospital will be continued.
Equipping work will also commence at the Swinford Mental Handicap Centre and will continue at the new 100 bed replacement geriatric unit at the Sacred Heart Home, Carlow.
Funds will be made available in the current year to fit out and furnish the new city centre drug centre in Pearse Street Dublin.
Funds are also being made available in the current year to deal with high priority fire and structural precautions.
The income ceiling for payment of health contributions has been increased to £15,500 with effect from 6 April 1988. The income limit for a hospital services card was increased to £15,500 with effect from 1 June 1988.
On 31 March 1988, 38.08 per cent of the population were covered by medical cards. The figure for 31 March 1987 was 37.73 per cent.
The guidelines for medical cards were increased from 1 January last.
It is important to acknowledge the major contribution which the national lottery is making to the health services. Six million is being expended largely on services for disadvantaged persons, with a particular emphasis on community-based projects. The lottery is making a very important contribution to the following services in the current year:
services for the mentally and physically handicapped;
services for the elderly; psychiatric services;
community information and development services;
AIDS prevention programmes; and child care services.
I was particularly pleased with the Government's decision last January to establish a new structure for health promotion, a decision which experience has since shown was a very wise one. I had been concerned about the apparent emphasis on illness services and a corresponding lack of attention to the promotion of positive health and preventive strategies generally.
The new health promotion structure operates at three levels and is now in full operation. It comprises a health promotion unit in my Department, an advisory council on health promotion and a committee of Ministers.
The health promotion unit, in addition to taking on responsibility for the development of health education programmes, is also responsible for developing a wider policy of health promotion, acting in concert with the appropriate statutory and voluntary agencies in the health and other relevant sectors.
The unit has been active since its establishment and has already launched a number of significant campaigns both in its own right and in association with a number of voluntary agencies. These include: participation with the Irish Cancer Society in the "Europe Against Cancer Week"; the launch of a "Drugs Question — Local Answers", a community-based approach to combating alcohol and drug abuse; and the launch of a major food hygiene campaign, under the slogan "Clean watch", which succeeded in commanding wide support within the food trade and the relevant professional groups.
Recently the advisory council on health promotion made recommendations to me in relation to a number of other programmes related to alcohol, tobacco and nutrition and I am at present studying these.
I was particularly pleased to be able to report to Government that, among a number of positive results from the review of the drug agreement between my Department and the Federation of Irish Chemical Industries we reached a new agreement, to terminate in 1990, which will put a voluntary price freeze on drugs and medicines in operation up to the end of October, 1988 regardless of currency movements or increases in UK parent prices.
One particularly worrying development which impinges on the public health area is the spread of the AIDS virus. To date, there have been 49 cases of AIDS in Ireland. Nine have been haemophiliacs, one heterosexual, 18 have been homosexuals/bisexuals, 14 IV drug abusers, four homosexuals/IV drug abusers and three babies born to infected mothers.
The emerging pattern from these statistics taken in conjunction with the breakdown of the AIDS cases clearly demonstrates that the future pattern of AIDS in Ireland will be dominated by IV drug abuse. The most serious implication of this epidemiological finding is the risk of spread into the heterosexual community. There is in fact evidence to show that the virus is already spreading into the heterosexual community. As this pattern has emerged, the Government's AIDS strategy has been developed to meet the situation. Recently I answered a question in the House as to what the Government have been doing and will continue to do.
The continuing importance of cancer in all its forms as a major cause of illness and mortality is a fundamental concern. It is widely recognised that one of the most effective ways to monitor the presence of cancer within the community, gain a better understanding of its epidemiology and to devise appropriate preventive measures is by means of a national tumour register. I have therefore set up an expert committee to consider how a national tumour registry should be established and to determine the operational methodology and funding requirements. I expect the committee to report in September. I am also awaiting the report of a group on cervical screening so that we might look at the possibility of implementing a national cervical screening service.
The programme of developing health centres is continuing. Among the new centres completed in the past year are Skerries, Athlone, Shannonbridge and Carlow. New health centres are under construction while other centres are being upgraded and extended.
In addition, part of the recently vacated hospital at Baggot Street, Dublin was refurbished for use as a health centre. I expect that similar developments will take place at other locations. The development of health centres meets a clear need in our primary care service and it is my intention to push ahead with the health centre development programme as resources become available.
Since becoming Minister for Health, I have been increasingly concerned at the rise in the number of cases of alleged child abuse being reported to the health boards. In July last, my Department published a new set of guidelines which incorporate procedures for the identification, investigation and management of child abuse.
I fully accept that there is a need to increase the range of services available, particularly for sexually abused children and I have already allocated special funds to enable the services at Temple Street and Crumlin Children's Hospitals to be significantly expanded. There is, of course, a need also to improve services on a countrywide basis outside the Dublin area and I have, therefore, allocated special funds of £450,000 from the national lottery to different health boards outside of Dublin to enable them to improve their capacity for the assessment and investigation of alleged cases of child abuse including child sexual abuse.
The reorganisation of psychiatric services is continuing along the lines outlined in "Planning for the Future."
At the same time new facilities are being established in community settings. In 1987 alone, 50 hostels with some 300 places were opened throughout the country. Day hospitals are also being opened so that people can receive treatment locally and without admission to the psychiatric hospital.
There is a capital cost involved in setting up new facilities. However I am fully committed to our policy in this area. This is a once-off capital investment and the running costs of community services will be met by redeployment from hospital budgets.
The level of financing of mental handicap services has steadily increased as a percentage of overall health expenditure over the last number of years. In 1979, 7.6 per cent of health expenditure was allocated to mental handicap services while now roughly 11 per cent of health expenditure will be used to provide services for people with a mental handicap. I am glad to say that we were able to protect the mental handicap services during a period of financial constraint in the last two years.
Today I received the working party report on services for the elderly. While I have not had time to study it yet I would like to place on record my appreciation of the people who served on that committee. I look forward to reading it as I believe it will be a blueprint for the direction of those services in the future.
Advances in technology have had a huge impact on hospitals and this has in turn forced hospitals to critically evaluate their methods of operation. There is a greater methods of operation. There is a greater emphasis now than in the past on concentrating resources on out-patient and day facilities. I am greatly heartened to see that practically all hospitals are now adopting this approach with the result that far more patients than heretofore can be treated at a substantially reduced cost. Also, the developing technology and improved management of patients means that the length of time patients spend in hospital has been considerably reduced. I think it is very significant that, while practically all hospitals reduced their bed capacity in 1987, very many of them in fact treated more patients than in 1986.
These developments indicate that the actual bed complement of a hospital is not in itself the critical factor. Other factors such as diagnostic support facilities and improved patient management can be and are of great importance and these are the areas on which our attention should be focused rather than on bed numbers as such. All of these are positive initiatives which occurred in the past year and they are initiatives which I intend to foster and encourage in 1988.
The past year also saw many other positive developments including the opening of the new Beaumont Hospital and the other capital developments to which I've already referred.
One of the results of the acute hospital rationalisation has been the necessity for reorganisation of the accident and emergency service provided on a rota basis by major Dublin hospitals. I am aware that problems have arisen in relation to this service leading to dissatisfaction and concern regarding the continuing ability of the hospitals to discharge their various responsibilities in a satisfactory manner and have initiated a review of the services. I have recently suggested discussions to examine current organisation and delivery of these services. I will be setting up immediately a steering group which will have management and accident and emergency consultant representation from each of the hospitals concerned and it will operate under the chairmanship of the Hospital Programme Manager of the Eastern Health Board which has responsibility for co-ordination of these services.
December 1987 witnessed the enactment of legislation providing for a statutory scheme of control of clinical trials. This will permit the carrying out of legitimate and necessary testing of medicinal products while at the same time guaranteeing that the safety of participants is protected. I am currently drawing up guidelines for the purpose of implementing the provisions of the Act.
As the Deputies will know the Child Care Bill is before the House and we hope to see that progress through both Houses of the Oireachtas.
The new Tobacco Bill passed all Stages in the Dáil last night and will be in the Seanad in the coming weeks and following its passage through the House and becoming law there will be no delay in implementing the necessary regulations to give effect to it.
Reorganisation of health board services is one of my priorities in improving our health delivery system. The question of the abolition of the health boards is not on my agenda. I accept that changes need to be made in relation to the framework of health boards, the relationship between boards and management and the role of boards and improvements in the management of our delivery system. All these need to be addressed. At present we are looking at the structures of the health boards to see whether the formulation of programmes is the most appropriate way to deliver services or whether we should look at geographical areas in the future.
Since taking office I have expressed the need on several occasions to review the overall structuring and direction of health and social policy.
Our ultimate objective should be to determine specific developmental targets for the population as a whole and for groups which require particular attention and whose health status or quality of life requires improvement. Given that limited resources are available for expenditure on health services and that informed and rational choices must be made it is particularly timely to set down the direction, the principles and the emphasis which will underpin how we approach the question of health and deliver services to promote positive health. Equity, equality and efficiency considerations must be central to a planned approach to meeting health and health services needs.
Considerable preparatory work has already taken place. The major national Beaumont conference on my Department's discussion document "Health — The Wider Dimensions" was very successful and focused attention on the future direction of health policy and the factors which should determine how best to proceed. The removal of identified health inequalities in line with the Government's stated objective of protecting the vulnerable and less well off in our community will be a major factor underlining my approach to health policy and resource allocations. It will also be important in this context to have available the findings of the Commission on Health Funding which will concentrate on the central question of health services funding in the future.
The developments I have outlined today across the full range of health and social service programmes, provide clear and expressive evidence of the positive, planned and organised approach which is currently taking place in our health services. I have referred in some details to the developments that are taking place in health promotion in the hospital development programme, in the psychiatric services and in the community care programme. I have informed the House of the reorganisation, planning and funding initiatives which I have taken and which will inform the debate on the future direction, funding and management of services.
It is important that the short-term difficulties which arose because of the urgent necessity to take remedial action in all publicly funded services, including the health services in the public service, is placed in context. Notwithstanding these short-term difficulties we have preserved a quality service which is affordable, which can develop and expand on a firm and sound basis in future years.
In conclusion, I wish to emphasise that the concentration in the last 12 months or so in the health sector has been wrongly focused on the economic and financial constraints which have applied in the health services. While it is so obviously true that we have always had similar constraints in the past it needs to be reiterated to avoid a wrong perception that in some way unlimited resources are available to the health sector. It is a fact of life that the resources we would like to have available on health and social services will fall short of the demands for services which are generated. Ireland is not unique in such a situation. Indeed, most developed countries are similarly placed. Nevertheless it is important to record that our health services are sound, that the commitment of those involved is excellent and that a sense of purpose and direction is evident for the provision of quality services which meet the genuine needs of the population.
