I move:
That Dáil Éireann, sharing the serious public concern about the quality of health care, calls for a fundamental reorganisation of the delivery of health services, in order to free resources which could then be used selectively to improve the quality of service and expand the provision for priority needs. The following reforms are required:
1. The establishment of An Bord Sláinte, a semi-State body, to replace the Health Boards and streamline the management and delivery of health services.
2. Cost-cutting reforms in the areas of administration, the purchase of medical and non-medical supplies, certain consultants fees, the rationalisation of laboratory facilities, the greater use of computerisation and better property management.
3. A revision of the method of funding voluntary public hospitals by the introduction of clinical budgeting and separate ear-marked allocations for National Tertiary Services.
4. The appointment in each hospital of a general manager.
5. Hospital managers and An Bord Sláinte should be specifically charged with ensuring much greater co-ordination between hospitals and Community and Primary Care Services.
6. An Bord Sláinte should draw up and implement a National Hospital Plan for acute services, including the concentration of the most modern equipment and advanced skills in regional centres of excellence, where they can be fully utilised to the benefit of the community. These centres should be backed up by the complementary provision of local hospitals with specified levels of care.
7. Improved medical management through greater development of General Practitioner Services including improved access to Hospital Diagnostic Services and Consultant opinion.
8. The re-examination of methods of payment for health care on the basis of giving incentives to preventative medicine and positive health activities.
Throughout the summer we have all witnessed a litany of individual cases of hardship throughout the health service, children unable to gain admission to hospitals such as Temple Street, the growing waiting list for an ever-increasing number of hospital treatments including cardiac surgery, orthopaedic operations, ENT and ophthalmic care. It has been estimated that, in total, some 23,000 people are awaiting different kinds of orthopaedic hospital treatment. Specifically, 8,000 people are on a three year waiting list for those requiring hip replacement. In recent weeks there has been a recurring incidence in Crumlin Hospital and in St. James's Hospital of elective admissions with particularly serious consequences for vascular treatment.
Wrongly, the public impression has been created that most of the difficulties in the health services at present arise solely in hospitals. There are, however, huge gaps in other elements of the service. The elderly, especially those living alone in the community, find little or no comprehensive community care to deal with their specialised needs. The dental service is in a shambles with the effective abolition of the 1979ad hoc scheme, resulting in a situation where medical card holders can get virtually no treatment and, in a majority of health board areas, cannot even get a pair of dentures after teeth extractions. They are advised that they would have to pay £200 or £300 privately for them.
There has been an increase in discharges from psychiatric hospitals without proper, adequate community responses to meet their needs. Public health nurses cannot operate effectively due to the curtailment of travelling expenses and lack of proper super-intendent posts to direct their work effectively. We have seen no sign of a positive commitment of resources to meet the obvious needs arising now and in future from the child care legislation to be completed in this session. Each day columns of our newspapers are taken up with the individual cases concerned with specifically national specialities within the health services. I refer to the oncology unit in Crumlin Hospital which I have visited and where I have seen at first hand the parents filling in for the lack of an adequate number of nursing staff.
We must examine the Minister's response to this crisis. To exacerbate the problem, the public are totally bemused by the indifference of the Minister for Health in responding to the crisis. He is always one report or one committee away from making a decision to rectify the situation. On the other hand, he is publicly attacking the consultants or the hospital authorities. This resulted in a situation last month whereby one public voluntary hospital — the Meath — felt obliged to place advertisements in national newspapers to clarify their position. Is it any wonder, in the circumstances, that 1,800 nurses are applying to An Bord Altranais for certification to emigrate this year? Is it any wonder that morale among the 56,000 people working in the health service has never been lower? The Minister continually complains about having to grapple with the problem he inherited from the Coalition Government of cumulative health board deficits of £55 million. These protestations from the Minister ring somewhat hollow when one reflects on his role as Fianna Fáil health spokesman in Opposition for four years.
In 1985, Fianna Fáil, subsequent to the local elections, took control of most of the health boards and obstructed the cost-cutting reforms of the last Minister for Health. Moreover, one must question his role in the last election knowing the financial situation in relation to these deficits in the health service when his party erected hoardings right across the country proclaiming that health cuts hurt the old, the sick and the handicapped.
Fine Gael's clear view is that the current chaos in the health service could and should have been avoided in the context of financial savings if the prior necessary reorganisation and restructuring of the health service had taken place. The Minister's policy, in so far as there had been any health policy, has been one of cash limitation to health boards and hospitals, coupled with an embargo on staff. These two instruments bear no relationship to efficiency or health needs and that point above all needs to be emphasised. The Minister's policy has been to close the hospitals or to tell them that they will have so much cash and no more. He has said they will have to operate a crude embargo and that bears no relation to efficiency or to the needs of the patients.
The fundamental flaw in the Minister's approach to the health service has been that he has failed to manage the massive resources of a complex service to improve the quality of care to the public. There has been little or no planning with all allocations on a year to year, hand to mouth basis; all health workers are frustrated by the lack of direction and purpose by the ad hoc nature of decisions now taking place. We must ask ourselves, in this limited debate, if more money is the answer. Given some of the amendments put forward by some of the leftwing parties, I wish to spend some time analysing health figures. Health expenditure in 1972-73 was £108 million according to the Dáil Estimates of that year. It should be pointed out that the reason for it being 1972-73 was that we were not on a calendar year financing at that time.
The health budget is now, approximately, £1,200 million, comparing like with like, with capital and current budgets. This represents, over a 15 year period, an elevenfold increase in State health expenditure. If we divide that amount of money into the number of households in the country, some 970,000 in total, we will find that the annual cost of the public health service is some £1,230 per household. When we take into account that at least one-third — and it is nearer to 40 per cent — of the households are at a minimum level of income and have free medical care through medical cards, the minimum cost per household, for those who have to pay for the service, is something in the order of £3,400. If the answer to the problems of the health service is based solely on spending more money and if we repeat the growth of expenditure on our health services over the next 15 years, between now and the year 2003, we are faced with some frightening cost consequences with those parties advocating throwing more money at the system. Those parties need to study the matter.
By the turn of the century the cost of the public health services run by the State would be of the order of £13 billion if we were to repeat the growth we have shown over the last 15 years. If we allow for an increase in the total number of households to a million then the cost per household will at that time be £13,000. If at that stage we still have one-third of the households eligible for free medical care through medical cards, then for the households who would have to pay for it the cost would be £34,000 per household at the turn of the century. Those figures are simply unsustainable.
Therefore, the basic arithmetic of throwing more money into the health services in the short, medium and long terms leads to a situation which is simply unaffordable when one looks at the figures for an average industrial wage somewhere between £6,500 and £7,000 per annum at present applying. Those who argue for unlimited resources to be spent on health have to address this issue. Moreover, I must ask whether our health service now has greater equality in terms of access than the health service of 15 years ago and whether our health service is more caring and efficient. I fear there are the same if not greater levels of inequity adhering to health care now. I must also question whether health service employee numbers can be greatly increased when the current ratio is of the order of one health worker for every three people employed in manufacturing industry. The simple fact is, and this is one of the few points on which I agree with the Minister, that there is no limit to the possible expenditure on the health services.
Therefore, what are the solutions? Fine Gael believe a fundamental reorganisation of the delivery of health services can no longer be postponed and that such a reorganisation would free resources within the health services to meet the areas of priority needs and improve the quality of certain services.
Let us first look at the area of potential savings. Approximately 70 per cent of health expenditure is on pay and 30 per cent on the purchase of medical and non-medical supplies. In the pay area I feel the level of expenditure on administration at 6 per cent is high by international standards. I have seen figures for administration and the level spent on administration questioned. I think those who are administrators tend to look at the figure for management expenditure and say it is a great deal less than 6 per cent. I would say a 1 per cent figure for management expenditure at health board level would be acceptable, and it varies between one and three, I notice, between the Midland and other health boards, but overall administration is too high compared to the GMS. Because Deputy Desmond said in the House if you sacked everyone in administration you would not save a small fraction of St. Vincent's Hospital budget. I think he is not looking at what really is administration. Many of long experience have told me that a whole new layer of bureaucracy was inserted when the health boards were created in 1972.
However, I accept the need for a regional management structure. We should set ourselves a target figure of 3 per cent expenditure on administration. To meet this we need to rationalise certain labour-intensive areas in the health services that do not affect the quality of health care to the patient. I am referring specifically to the need to rationalise the number of laboratories, principally in the Dublin area, within hospitals. After 5 p.m. each hospital maintains a laboratory and is paying dearly for the on-call charges and after midnight charges. There is no reason why these cannot be curtailed and rationalised. Similarly, medical records represent high administrative costs. Given international expenditure, there is no doubt that major savings can be obtained through computerisation in this area.
On a broader level, I am not satisfied or convinced that many elements of the community welfare programme rightly belong in the health services. I question seriously why there is a need in nearly every provincial town and — and I quote Enniscorthy where Deputy Browne and I come from — for an employment office, a social welfare office and a health centre, all issuing income maintenance. Why is this necessary? Why can people not go to one welfare office where their comprehensive income maintenance needs are found? The payments of disabled person's maintenance allowance, infectious diseases maintenance allowance and so on could be carried out very competently by reorganising the role of staff of the Department of Social Welfare incorporating some of the work of community welfare officers. Similarly, much of the work of CWOs in terms of income assessment for medical cards and other eligibility should be rationalised in a more clear cut system of entitlement. Also in the pay area I must confess to being deeply disturbed about certain information I have concerning the incomes of some — I emphasise only some — radiologists and pathologists. While the arrangements of some of these machinerelated consultants vis-à-vis the common contract in 1981 are not uniform between hospitals, it is obvious that some pathologists specifically are earning an income in excess of £250,000 per annum each. More disturbing is that with the developments of technology much of this work is not carried out by themselves but by assistants who approve of the various tests, which is the case in blood tests. I am not speaking about biopsies or other specific good work being done by pathologists, but for the run of the mill, bread and butter work we are seeing the State and the VHI paying ten times the cost of a blood test. In my view it is a scandal and should be stopped as soon as possible. I call on the Minister urgently to investigate why the State is paying ten times over the cost of some of these services and immediately renegotiate to alter the present situation regarding the income of pathologists.
In the area of purchases of supplies for the health services I have a number of serious concerns about needless costs because of a poor commercial approach to the health service as a major if not almost monopoly consumer. The first area of concern is in the most expensive item of drugs. Total expenditure on drugs has risen from some £85 million in 1983 to a present level of £120 million per annum. Alarmingly, I note next week on 1 November there will be a price increase across the board on drugs somewhere between 6 and 15 per cent. My concern about drug costs firstly relates to the fact that we are tied to a percentage increase over and above the price of drugs in the UK. This is unbelievable when we now find that British drugs are among the dearest in Europe, when we should be allied to prices in France, Belgium and Italy. This alone would represent a major saving.
My second area of concern relates to the cost of drugs to hospitals. In this area hospitals do not benefit from the 5 per cent rebate paid back by drug companies to the GMS, and the 104 per cent weighted average price over and above UK prices does not apply to the cost of hospital drugs. Given the level of bulk purchases in hospitals this is simply inexplicable.
The other area of drug saving lies in the prescription and greater use of generic drugs. I fear there may be over-promotion by the chemical companies to general practitioners with various inducements from free samples to post-graduate training to other areas to prescribe freely different and more expensive drugs. I understand chemical companies in this country have some 300 people selling their wares to GPs in this regard. There is conclusive evidence to show that generic drugs within their range are simply cheaper because of the lesser research and development costs, there being no patent involved, with no inferior quality to the patient. I am not satisfied with the present details of the revised GMS contract for general practitioners in this regard in terms of the obligation to use a formulary of generic drugs where possible, and I emphasise the word "obligation".
In overall terms in the drug area I do not accept the argument that the chemical industry in Ireland would be excessively adversely affected by a further renegotiation of the present FICI-Department of Health agreement in view of the fact that only 5 per cent of drugs purchased by the Department of Health are made in Ireland. Moreover, I believe the industry representatives I have met are only too well aware of the current market forces imposing difficulties in the areas of public expenditure and health care.
In the area of medical equipment I am not satisfied with the present purchasing arrangements. Greater utilisation of technical as opposed to medical expertise is required first. This seems to be a major flaw in current purchasing in so far as we have no equivalent to the British Institute of Technicians in this field. Secondly, a small purchasing unit could negotiate directly with British manufacturers and elsewhere supplies of medical equipment at much reduced prices. I note with interest the current report being commissioned by the Oireachtas Committee of Public Accounts on the cost of catering in the health services. This is a very large budgetary item under our hospital programme. I note the interim conclusions of this report which point to areas of major saving through rationalisation of the number of kitchens and tightening up on food wastage and over-production. I await the final report with interest and would direct the Minister to follow up on it immediately once it is published.
I turn now to reorganisation as opposed to direct savings in the health services. The savings I have referred to so far would, in my view, amount to something in the region of £30 million. However, the area of huge cost control lies in the way we organise our diagnosis and treatment of patients. There is a great deal of documentary evidence not only in such reports as Dale Tussing and others but an endless supply of information in relation to the NHS in Britain. It is obvious from these data that a clear direction of health policy can reorientate the health services. I am referring initially to preventative medicine. A simple example that would cost nothing would be a ruthless get tough policy on the wearing of seat belts, an area in which we only have a 50 per cent observance at present. All that is required in this regard is a change in public attitudes. Proper observance of this law would bring about a major saving in certain health costs. I note that in Sweden for example, the concept of all dental decay being preventable is actually applying because of the steps that have been taken to improve oral health and which have resulted in the major rationalisation of dental schools there.
One out of every two people in this country die from heart disease. We have no overall preventative policy in terms of regular compulsory check-ups for blood pressure and cholesterol levels. In fact our screening level for early diagnosis and treatment for umpteen different forms of sickness is either non-existent or pathetic. At a time when all the statistics show that early action is cheaper and better for the patient we are not taking such action. Smoking and other substance abuse is the subject of a clear Irish double think and yet it imposes massive cost burdens on the Irish health service. It must be acknowledged that in the medium to long term these are the areas that must be the ones of priority policy development as the most cost effective response to the current dilemma.
I wish to turn now to the biggest item of expenditure in the health service, our hospitals, which account for in 1988 terms, £715 million, something like 53 per cent of the budget. The Minister has stated publicly that he is not satisfied with the level of management in some of the hospitals, particularly public voluntary hospitals. What has he done to rectify this? In this motion Fine Gael are calling for a national hospital plan to set out, in an orderly way what regional facilities, including diagnostics and treatments should be made available and on what catchment area general practitioners should be confined to in observing these regional specialities. I am concerned that a GP, for some routine surgical treatments, can refer their patients, privately or publicly, to the most expensive teaching hospital in Dublin — the Minister referred recently to the cost of these teaching hospitals in terms of high quotas of junior doctors and so on — when the same operation could be done at a quarter of the cost in their local general hospital. We must impose catchment areas in this regard if we are to be cost effective. This would be followed by, in this national plan, local hospitals which would provide specified levels of care. These could have GP access, proper accident and emergency facilities, as well as dealing with sudden conditions such as heart attacks and car accidents. I cannot accept that the Minister has been successful in this area. Clearly there is no plan at present as can be seen from the fiasco in his own constituency of the major provision, at a cost of some £26 million, of Cavan hospital. Not to be outdone this present Minister lobbied the last Government to make his high tech in terms of European standards hospital a 336 bed facility. It is shameful to see such a monument to the taxpayers' commitment lying idle without one patient in it and costing, annually, over £.5 million to heat and maintain. We cannot afford this type of self indulgence when there are such pressures in other areas of the health service.
Fine Gael are calling for the appointment of a hospital manager in all hospitals. We believe the present structure, especially in public voluntary hospitals, is unclear, inefficient and ineffective. We have a management board structure which is invariably part-time in its well meaning approach, a secretary manager, perhaps of limited managerial qualifications, a matron in charge of one of the most vital parts of management, nursing and, most important of all, the gatekeepers within the context of hospitals, of cost and demand, the consultants. It is debatable as to who is actually running a lot of our hospitals. We envisage the position of a general manager having a clear responsibility to patient standards care in hospitals with undeniable, clear authority to manage, including greater discipline over consultants' arrangements. I am advised that some of the problems in St. James's Hospital recently could have been avoided if this clear managerial structure had been defined and put in place.
My greatest concern, however, in relation to hospitals lies in the Government's financial approach to the way allocations are made. Some hospitals get their allocations through health boards and others directly through the Department. When one studies the method of allocation to date one sees that it is based on some ad hoc traditional method depending on the overall availability of resources. It has no regard for the number of patients treated. In fact the level of information in hospitals in this regard is very scant. It also has no regard for those hospitals that, in the early eighties, did impose greater savings and efficiencies only to find themselves further penalised for so doing as their subsequent year's allocation was based on the outturn of the previous year. This resulted in a situation where inefficient hospitals that ran over budget were effectively condoned in the way money was allocated to them in the following year. To exacerbate matters it did not help when the Minister, recently in the Seanad, made public comparisons between hospitals as to their bed numbers and their allocations without any regard to their out-patient facilities, activities and expenditure. The Minister knows full well that the comparisons he made in the Seanad vis-à-vis Temple Street Hospital were not fair.
The only way to ensure cost effective hospital services is to put the whole focus on the patients thereby making finance available on the basis of the number of patients treated, the public health requirements for the given catchment area and, most important, standard costings based on comparisons between hospitals for individual types of treatment. In other international experience of trying to grapple with the spiralling costs of health care they have found that unless clinical budgeting and diagnostically related groups are introduced to bring about some level of uniform costings of treatment they will find it impossible to make savings without the type of chaos we have seen. At present some hospitals are being very unfairly treated resulting in massive waiting lists relative to the applications to other hospitals.
Too often in the past, in relation to hospitals the debate is one of whether we should have statutory hospitals versus voluntary hospitals. I believe only two types of hospitals exit, those that are efficient and those that are inefficient, and we should progress the development and financial allocations of these hospitals on the basis of incentives for those that become efficient. Included in this would be a clear earmarking of specific allocations for national tertiary services and I would make a specific appeal to the Minister tonight, as these allocations are currently taking place, to do so in the context of the cancer unit at Crumlin Hospital and the excellent work being done there. It is not right that Crumlin Hospital should be allocated a global figure of £12.25 million and that it be left solely up to the management board of that hospital as to what national tertiary services should get. I would single out the oncology unit and the cardiac unit for a specific allocations so that we could relate money to a national service and a national need.
Once hospital allocations are made on the basis of proper incentives and sound economics coupled with professional, well remunerated, trained management we can then deal perhaps with savings in the hospital budget. To go about it in an unplanned ad hoc, across-the-board manner, without such reorganisation can only lead to the present level of chaos.
This confirms Fine Gael's basic thinking in relation to the current health crisis, that the primary issues are of reorganisation and management rather than simply spending more money.
The most cost effective and cheapest form of treatment is self medication. We should look at the area of limited deregulation to allow pharmacists the discretion of using their qualifications to allow the public access to medicines without reference to a prescription for such minor aliments as sore throats and headaches for which is it not necessary to go to a doctor. I believe that virtually all the medical profession would support such a limited move and thereby reduce costs.
The second area of cheaper medical management obviously involves the maximum level of care at the primary level, that is, through the general practitioner. A far greater role can be played by general practice here. We need to develop general practitioner surgery facilities so that as much diagnostic work as possible can be done in the community. I support the principle of a capitation payment to GPs under the GMS and would specifically call on the Minister to ensure that the £3 million allocated annually for specialised work be targeted in the area of diagnostics to ensure developments at general practitioner level in the realm of diagnostics. I am specifically referring to ECG cardiographs which can be done at one fifth of the cost in a GP surgery, and urine and blood tests which can be done more cheaply outside the hospital environment. This whole area of the GMS contract is somewhat too nebulous at the moment. I am aware that there is a working party examining this at present but in terms of value for money there is a clear need for ministerial direction. Moreover, I am very concerned about the relationship between consultants and GPs. I immediately call for the Department of Health to issue a circular to all hospitals to make available the maximum amount of diagnostic facilities within hospitals to GPs. It is a scandal that certain diagnostic work and consultant opinion has to be carried out on an expensive in patient basis at present, often in beds in teaching hospitals costing over £1,000 per week. This is a vital area of medical management of scarce resources to minimise cost without any less care for the patient.
Similarly, international experience has shown that the evolution and expansion of day hospitals and day treatments can create enormous savings. Up to 40 per cent of all hospital treatments in some areas can be done through such day facilities. At present in Ireland we are only operating some 10 per cent of hospital treatments in such day facilities. We need to convert more beds in our acute hospitals into day wards and day surgeries and I call on the Minister to issue a similar circular to hospitals in this regard.
In this Fine Gael motion we call for the establishment of An Bord Sláinte, a semi-State body to replace the health boards and to streamline the management and delivery of the health services. This is a new concept and like all new concepts invariably there will be a resistance to change, especially among those in the health sector. As can be gathered from what I have already said, I am not in any way satisfied with the effectiveness, efficiency and planning of the delivery of our health care services. This must raise the most fundamental questions about the current structures applying and the attitudes of civil servants to what are basically straightforward commercial matters such as purchasing.
At present I am far from satisfied about the level of co-ordination within our health services. Some brief examples in the Dublin area would highlight this. The authority with responsibility in Dublin for community care have little or no interaction with the vast majority of acute voluntary public hospitals in Dublin. In some instances this has resulted in unnecessary pressure on casualty and accident and emergency facilities in some hospitals due to weaknesses in general practice and general practitioner cover at night. It has also led and will lead to further problems in the area of discharges of patients from hospital if more pressure come on hospitals to reduce the length of bed stays per patient.
I fear that many of our public voluntary hospitals are operating as islands, doing their job on their own regardless of the overall picture of the health services to which the patient requires a comprehensive response and for which the same taxpayer is paying. It is incredible that some hospitals should have such an exclusive arrangement to their local health board. This is simply unworkable and it needs to be co-ordinated. There is only one person who can co-ordinate it and that is the Minister for Health. When I specifically put this question to senior managerial executives in the Eastern Health Board and to people in the public voluntary hospitals they have referred to the need for co-ordination. Quasi committees have been set up but nothing has effectively been done to deal with this issue. The more people that are treated in the community the cheaper it will be done and the better the care for the public.
I am also concerned about the quality of management in some area of the health services. There are some excellent, top class, under-paid managers who are doing a remarkable job but, unfortunately, they may well be lost to the public sector because of their low level of remuneration. Allied to this is some very mediocre management. I believe that new structures would ensure the best people in the most strategic places of the health services with proper levels of remuneration and an upgrading of performance through priority being given to greater management, training and expenditure.
The present allocation of finance within health boards, given the clear division of programmes under different managements such as community care, special hospitals and general hospitals, creates divisive competition which is unhelpful to say the least. What is required is an integration of the health services at local level under an area manager who in turn would be responsible to a regional manager who in turn would be responsible to a well managed national board. I believe the semi-State structure is the only way in which this can be achieved. Past experiences outside the health area, such as the establishment of Telecom Éireann and An Post, show the remarkable transformation which can be achieved in services to the public as well as in financial performance, in comparison with the old lacklustre Department of Posts and Telegraphs which was excessively bureaucratic and outdated. I believe a similar transformation can take place within the health services. This does not involve any principle of ideology or privatisation, simply one of better management of finite resources.
I also have reservations about the present operation of health boards. The composition of boards can often be geographically unbalanced leading to a particular bias which can be unfair within a region in terms of the delivery of health services. Here I would point to the current difficulties in the Western Health Board. Moreover, there could be direct vested interests having an executive role rather than a consultative one. I do not believe you can handcuff chief executives in this way and expect them to perform to high standards of professionalism. Moreover, some of the geographical regions create crazy situations in relation to the catchment areas of individual hospitals and health care services and subsequent transport services.
Only a national body can see through and rectify these expensive and wasteful practices. That is not to say that there should not be consumer and public scrutiny of the health services. There will always be a need for political accountability on the part of the Minister in terms of policy and resources. At local level Fine Gael favour the establishment of advisory committees at county level which can make recommendations in relation to local service needs as well as ensuring accountability on an annual basis on the part of area managers.
What is not important here are the minute details of structures. What is important is the attitude to a national health service which does not allow the individual components of that service to see their role in a blinkered narrow way as the sole function of health service matters. Until such time as we take a radical step in this direction uniform cutbacks by the Minister can only inflict untold hardship on the public, as we have seen. Such a semi-Sate body could quickly observe demographic changes which could require greater resources in orthopaedics versus a declining demand for obstetrics and independently implement such a policy. Such a body could carry out a national review of hospitals to obtain the best performance in terms of energy conservation. They could also ensure that a purchasing officer buying everything from eggs to cotton wool would know what everyone else in the same health service was paying for them. The lack of information about what others are paying for them in the sector appals me.
The cost containment unit of the Department of Health has not tackled these issues to date effectively. Such a semi-State body could clearly get better value in the non-medical aspects such as hotel accommodation in hospitals and the greater utilisation of outside management consultants. Such a body could deal comprehensively with the level of bad feeling and I emphasise to the Minister the deep sense of bad feeling which currently exists between the health boards as to the discrepancies, anomalies and inequities in the different allocations to the regions not being based in any way uniformly, either per capita or otherwise. There has been no basic innovation such as the RAWP system in Britain.
Does it make sense to have one health board responsible for some 40 per cent of the population, catering for 1.2 million people out of a population of 3.5 million while it takes seven health boards to cater for the balance? A lot of experience and knowledge has been accumulated since the 1970 Health Act. It is now almost 17 years since the establishment of the health boards. Surely it is time for a fundamental review of the structures in health. Is it right that in some health board areas one can obtain a drugs refund for monthly expenditure in excess of £28 on medicines per month while in other areas the figure is £33 per month? Is it fair that one health board out of eight charge £10 for an appeal on a medical card refusal and a mortuary charge of £40, while the rest do not? Is it right that only one health board should have a salaried orthodontist while the rest do not? Surely, the public have some rights in regard to a uniform health care service and user charges.
There is one other matter that I wish to refer to and which has received attention lately and which the Minister may refer to tonight and that is the announcement that some 850 full-time temporary nursing posts are going to be made permanent. I want to assure the Minister that nobody in the health services is conned into believing that this will solve their problems. In fact, I cannot understand why it took so long to deal with this. When we look at the cost of PRSI for full-time temporary nurses and the cost of PRSI for permanent staff we will see that there is a discrepancy of over 12 per cent of gross salaries. It is cheaper to make people permanent, except perhaps in the short term. In the long term there is the additional cost in terms of the incremental scale over a nine year period in the career structure of nurses, but nobody in the health services believes that that will provide one extra nurse or better care for patients. Everybody will be very disappointed tonight if the Minister is relying on that as his response to the present crisis.
Finally, Fine Gael seek to set out a constructive resolution to our health crisis that clearly recognises that one could easily spend £2 billion on the health services next year without rectifying the fundamental causes of the present problem. We appeal to all the other Opposition parties to support this motion which, basically, will give the Dáil tomorrow evening, or whenever the vote is taken, two choices — between the Government's cutbacks and mismanagement leading to well-documented hardship for public patients or the choice that my party——
