Dáil Éireann debate -
Tuesday, 13 Dec 1988

Vol. 385 No. 6

Supplementary Estimates 1988. - Vote 43: Health.

Minister for Health (Dr. O'Hanlon)

I move:

That a supplementary sum not exceeding £1,000 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 original net Vote for health for 1988 was £1.109,944, including a capital provision of £41,030,000. This excludes an amount of £20.1 million which is being drawn from Vote 46 in respect of the general increase and other special increases under the 1987 agreement on pay in the public service.

The movement of a Supplementary Estimate for a token sum is to allow the use of additional Appropriations-in-Aid accruing in the current year. The additional receipts amount to £14.1 million in total and arise under the headings of health contributions receipts under EC regulations and the proceeds of property sales.

Apart from the additional Appropriations-in-Aid there are unexpected funds in the existing Vote provision which, with the appropriate subhead adjustments, will allow for the bonus payment of certain health cash allowances. The unexpended funds arise mainly in respect of the cost of special pay increases provided for in the original Vote which will not now arise until 1989. The total cost of the bonus payment is £0.9 million.

The Supplementary Estimate is made up as follows:

	£m
To meet the additional cash requirements of the GMS (Payments) Board	13.501
To meet the 1988 costs associated with the refurbishment of Hawkins House, to be transferred to Office of Public Works, for work carried out on behalf of Department of Health	0.636
Total	14.137
Less:
Additional Appropriations-in-Aid	14.136
Net Supplementary Estimate	0.001

The increased Appropriations-in-Aid arises as follows:

	£m
Additional yield from health contributions	9.8
Additional EC regulations receipts	3.7
Proceeds of the sale of the Health Education Bureau premises	0.636
	14.136

The additional yield of £9.8 million from this source has arisen in line with the 1988 general trend in income-related revenue. The effects of the tax amnesty and the introduction of self assessment for the self-employed are reflected in the extra yield.

A sum of £3.7 million over and above the original receipts forecast under EC regulations has arisen. These receipts are subject to currency variations and the original forecast cannot, therefore, be precise. Under the regulations in question each member state is, subject to agreement, required to meet the health care costs incurred by another member state in respect of its migrant workers, which includes pensioners, as well as the dependants of such workers.

The receipts shown in the Health Vote under this heading represent the net payment due to this country from the UK authorities. In the case of other EC States, we operate on a reciprocal non-reimbursement basis, due to the relatively small number of migrants involved. The methodology and costings on which the receipts are based are approved by the EC Audit Board in Brussels.

The sale of the premises formerly occupied by the Health Education Bureau realised £636,000. The health promotion unit which assumed the responsibilities of the bureau will now be located at Hawkins House.

It is intended to use £13.5 million of the additional Appropriations-in-Aid to meet the grant requirements of the General Medical Services (Payments) Board for 1988. As Deputies will be aware the GMS scheme or choice-of-doctor scheme is demand led. The increased user demand evident in 1988, requires that the resources made available to fund the scheme be now adjusted.

The continuing increased demand in the choice-of-doctor scheme undoubtedly demonstrates the key role which those in general practice play in the provision of health services. The importance of this role has been one of the principal factors in the drawing up of the revised remuneration package for doctors participating in the scheme.

My Department are completing the necessary arrangements to ensure that the new contract is issued to the participating contractors during next week. The new arrangements were accepted by the Government and by a large majority in the IMO's July ballot. It was clearly understood by all parties to these negotiations that the arrangements would apply to all participating doctors. I am satisfied that the new arrangements represent a satisfactory balance between the legitimate interests of doctors, management and patients alike.

Deputies will be aware of an extraordinary general meeting of the Irish Medical Organisation which took place over the weekend. In that regard the IMO have not formally communicated to me that there is any change in their position regarding the agreed introduction of the new arrangements from 1 January next.

The allocation to the GMS (Payments) Board for 1989 provides for the implementation of the new contract. The terms of the new contract will ensure a better quality and a more comprehensive and cost-effective general practitioner service. Indeed the position of the role of practitioner within the primary health care area remains pivotal. The new contract will assist, I am confident, in the delineation of the role primary care staff in general and a clear understanding of their unique role and contribution.

The revised package does not only cover remuneration for current services. It also provides for a contribution towards a superannuation scheme as well as enhanced training opportunities and nursing and secretarial support. This package is fundamental to the continued evolution of general practice as the cornerstone of an appropriate primary health care delivery system.

While the framework of the new contract is in my view most valuable, the clear provision for a comprehensive review at the end of next year and regularly thereafter provides an opportunity to take account of experiences in operating the new contract.

The purchase price of Hawkins House paid by the Office of Public Works was based on the capitalised value of the floor space previously let to the OPW and already occupied by Government Departments. This in effect meant that the additional floors previously occupied and later vacated by private tenants were obtained free of charge. The total refurbishment costs which fall due for payment in 1988 amount to £636,000.

I should point out, however, that the refurbishment costs are offset by the proceeds of property sales, both realised and anticipated, and by a reduction in the requirement for rented accommodation. As I have already said, the former Health Education Bureau premises have already been sold and the premises currently occupied by the Adoption Board will be offered for sale when the board move to Hawkins House. There will be a continuing benefit to the Exchequer commencing in 1990 due to a reduced need for office space which is currently rented. Based on present rates the letable value of the vacated rented space is about £250,000 per annum. Apart altogether from this economic benefit there will be the increased efficiency inherent in operating from a centralised location.

Adjustments between subheads of the Health Vote and within the overall level of grant available will provide for the cost of meeting the bonus payment of certain health cash allowances, in line with other long term social welfare benefits. The bonus payment, which amounts on average to 65 per cent of the normal weekly payment, will benefit some 33,000 disabled recipients and their dependants. In addition the bonus payment will also benefit those in long term care who have no means of their own and who are in receipt of the weekly spending allowance. This is an indication of the Governments commitment to giving priority to those who are financially the least well off in our society. As Deputies will see, this is a technical Estimate and I recommend it to the House.

Mr. Yates

The detail of this Supplementary Estimate is minor. I would describe it as technical housekeeping. Unfortunately, the Minister did not refer to many of the topical issues in the health service that are preoccupying the minds of so many people who are not only serviced by the health sector but also working in it. At the end of 1988 we can now review the disastrous effects of the failure of the Minister for Health to respond adequately to the growing crisis in the health service. There have been real cutbacks in finance to the health service, without the necessary policy adjustments to protect public patients from hardship.

In this short debate I wish to outline the aspects which I consider to be most unsatisfactory. The first of these, as I have repeated many times, is that of waiting lists. Last week at Question Time in the Dáil the Minister failed — I fear, deliberately — to give precise information on the numbers on out-patient and in-patients waiting lists. From my information on different hospitals, from consultants, management, general practitioners and others, I estimate that there are at least 50,000 people awaiting appointments on an out-patient or inpatient basis. Short waiting lists for periods of weeks or even months are not unreasonable. However, the current chronic position where patients have to wait two or three years for operations is simply unacceptable. I am specifically referring to the appalling situation whereby 8,000 public patients, most notably old age pensioners, are waiting for orthopaedic hip replacements. Similar waiting lists apply to ENT treatment and ophthalmic surgery. Even routine general surgery and vascular work on an elective basis has ceased in some hospitals for the last three months of this year on account of their budgetary restrictions. The Minister has failed not only to introduce an effective response to these needs but has allowed the position to deteriorate without acknowledging the problem.

Because of the specific problems in the short term I contend the Minister should introduce, as a short term measure, contract allocations to those hospitals with specialties on a unit cost basis to clear the backlog of cases. In the long term the answer must be to allocate finance to hospitals on the basis of clinical budgeting and harnessing consultants in the exercise of cost control.

I wish to turn briefly to the psychiatric services. I have visited different health boards in recent times. There have been one or two recent cases of concern. I am becoming increasingly concerned about the accelerated programme of discharges of psychiatric patients into inadequate or often non-existent community care facilities. It appears that the period of rehabilitation of such patients in certain parts of the country has been cut short. In some cases this has been counter-productive, with patients regressing and not being discharged. Also for voluntary patients I fear there may be indequate community nursing arrangements to oversee patient needs beyond the straightforward requirements of day care centres and night hostels. I want the Minister to ensure that a reasonable degree of caution is shown in this area so that the overall policy principle which we support, of de-institutionalising the psychiatric services, is not brought into disrepute.

I wish to turn now to the dental services. The Minister has often referred to the working party chaired by his Minister of State, Deputy Leyden, on the dental services. Having read their report I know now why he has not seen fit to publish it. It clearly states that the obligations on health boards to provide a dental service to the 1.96 million people eligible for free dental care under section 67 of the 1970 Health Act are not being met. The whole of our dental service is in a state of utter chaos. The Irish Dental Association clearly are not operating the PRSI dental benefit treatment scheme effectively. Since 1985-86 the poorest people in the community, in varying degrees have had no routine, adult dental service such as the provision of dentures and rectifying tooth decay.

There are some 24,000 people awaiting orthodontic care. In some cases they are being obliged to pay privately over double the rate applicable in Northern Ireland, up to £1,800 for a service. There is urgent need for a national strategy on dental care, resolving the anomalies between the Departments of Social Welfare and Health schemes, providing for a comprehensive preventive programme on tooth decay and gum disease. That should be an absolute urgent priority. I welcome the recommendations of the report of the Working Party and would hope they would be implemented immediately.

I might turn now briefly to the Voluntary Health Insurance. I have requested a public debate on this matter many times in this House which has been denied. The VHI have lost over £30,000 for every day this Minister has held office in the Department of Health. For example, over the two financial years covering March 1987 to the end of February next the VHI will have lost, in net terms, £22 million, unprecedented in their 30-year history. Under the provisions of the 1957 Act establishing the Voluntary Health Insurance the Government have clear responsibility for the finances and policies of that State body. The fact that the Minister did not initiate a recovery programme this time last year will cost VHI subscribers £10 million. Even to this day I cannot understand the inordinate delay and neglect of this extremely grave matter. I note that only last month the VHI issued a public statement saying they hoped to have their recovery programme in place by 1 December, which date has now lapsed.

What is required is a reorganisation of VHI plans into three categories of cover to facilitate the three types of private hospital care, which are: pay beds in public hospitals and low technology private hospitals. Cross-subsidisation will have to cease from the cheaper plans to the more luxurious cover. In future hospitals should be paid by the VHI on a cost-per-treatment basis, based on average bed stays and competitive costings between hospitals. Other formulae allow exploitation of scarce VHI funds.

Another report commissioned by the present Minister, an excellent one, related to care of the elderly. One of the most important demographic changes occurring in this country is the increase in our elderly population. It is estimated that there will be a 20 per cent increase in the total number of those over 75 years of age by the year 2006. I wish to commend the report of the Working Party on Services for the Elderly published last October which clearly pointed out the need for reorganisation of the health services to meet the needs of the elderly. At present there is a limbo obtaining between the geriatric, psychiatric and community care services for the elderly. Unfortunately, the Minister has not yet given any clear commitment to the implementation of the recommendations of that report with regard to the provision of day care centres, day hospitals, the development of geriatric medicine in general hospitals, the provision of sheltered accommodation, the establishment of back-up nursing panels on a part time basis for home nursing services and the need to meet the individual health care needs of the elderly such as chiropody, hearing aids and dentures.

It seems pointless for the Minister to commission such reports if he is not prepared to act on their recommendations. Surely the Minister must now give some unequivocal commitment of even a gradual response to these recommendations. Some of the changes recommended, such as district nursing teams, clearly are matters of reorganisation rather than of extra resources. If the Minister is to deny adequate geriatric beds he must provide proper community care facilities.

In the course of his remarks the Minister referred to the current review and new GMS contract to be implemented from 1 January next. Recent events in relation to the revised GMS contract for general practitioners have raised questions as to the implementation of the negotiated memorandum between the Irish Medical Organisation and the Department of Health. I have stated publicly that I favour a system of capitation payments to doctors. I note that this Supplementary Estimate allows for an additional £13.5 million of GMS expenditure. It appears to me that the current row is not about patient care but rather about money. It would be unacceptable for taxpayers to get the worst of both worlds after 1 January next. By that I mean a fee-per-item system of payment for some and a capitation-type payment for others — with all the bonuses of holiday pay, pensions, locums and so on — which could only result in an increased cost for the same service or, in some cases, perhaps even a lesser service. It is not possible to devise a scheme that will suit every circumstance of general practice ideally. Therefore I favour the introduction of the new scheme provided a national formulary on drugs is included and a proper incentive scheme for more diagnostic work to be done at general practitioner level.

The 1988 Child Care Bill has had its Second Reading in this House. It is now time to make financial provisions for the statutory responsibilities in relation to child care services which will devolve on health boards under the provisions of that Bill. Such will include referral centres for cases of suspected abuse adequately staffed; residential facilities and foster resource groups to provide alternative care for children at risk, as deemed by the courts and deprived families will require back-up social worker support and counselling. All of these specific needs render it necessary for there to be, from 1989 onwards, a child welfare budget within each health board. To date the Minister had declined to give such a commitment. I call on him, in replying to this debate, to specify what resources he feels the provisions of this Bill will entail and what arrangements he is making therefor.

As long as I have been spokesman on Health for my party it has always been necessary for Fine Gael to spell out their alternative strategy. We accept that there are budgetary restraints on all spending Departments given the current fiscal position. However, I wish to make it quite clear that, while we will not oppose this Supplementary Estimate, we shall reserve our position in relation to next year's Health Estimate Vote. My strongest criticism of this Government's health policy is the fact that they have allowed little or no planning or any coherent health policy to develop in tandem with financial restraint. This has led to much hardship and yawning gaps in our health and welfare services.

I believe savings can be effected in the purchase of drugs on the basis of renegotiation of the present agreement with the Federation of Irish Chemical Industries based on European prices for the same drugs. It is my belief that a saving of £8 million out of a total budget of £120 million would be eminently reasonable. Similarly, non-medical supplies could be purchased more economically, thus yielding even further savings. In terms of staffing I do not accept the need for eight individual health board finance and personnel departments given the capacity of modern computerisation. I would specifically instance the Department of Education and the way salaries are dealt with for the many different grades of teachers. In the Dublin area we are getting bad value for money also in relation to the management and lack or rationalisation of our laboratory services.

Some health boards have achieved major savings in the areas of catering and energy conservation in hospitals. If the lessons learned in some hospitals were applied nationally substantial savings could be made without having any negative effects on patient care.

The Minister has placed health boards and hospital managements in an impossible position in trying to operate his cuts without policy directions as to how to implement them without further hardship. Year to year financial allocations virtually make planning impossible. The Minister should get Government approval for three year financing for the health services. If this can be done for TB eradication I cannot see why it should not apply to health care.

Many people who have given a life-time's service to health feel that this is the best time to reorganise our health services to achieve lasting reform that would focus resources on patient services and preventive medicine. I regret that this Government, despite their pre-election promises are simply giving us more of the same, have failed to implement any radical reform initiated by their predecessor and have allowed the health service to deteriorate to an unacceptable level.

Miss Harney

The way we deal with Estimates in this House is very unsatisfactory. This applies to the way we deal with the general debate on the Estimates and it applies equally to the debate on a Supplementary Estimate. If one were to glance quickly at this Estimate one would assume that we are just talking about giving the Department an extra £1,000 and one would wonder what all the fuss was about. Behind that £1,000 and the housekeeping mechanism engaged in here lies a very sorry story indeed, because the GMS payments board are running out of money. If this Estimate were not to go through, salaries perhaps for last month and for this month could not be paid.

Since the essential largest sum of money being provided is for the GMS payments board, it is appropriate to dwell for a few moments on the new proposed payments scheme for doctors participating in the GMS. Over the last few days I expressed a number of reservations about the manner in which the scheme has been handled. From the Department and the IMO point of view, a lot of lessons need to be learnt. The Minister referred to the fact that a majority of doctors voted in favour of the proposals last July but only 58 per cent of doctors participating in the GMS participated in that vote. We are within three weeks of the implementation of this new proposed method of paying the doctors in the GMS and all that the Minister can say is that within the next week he will be able to send out the new contracts. That is not good enough.

The Minister should postpone the implementation date for this new payments scheme. It will not be feasible, in less than three weeks time, to move to this new scheme. What will happen is that one set of doctors will be paid under the new system if it suits them, and another will be paid under the old system if it suits them. I am reliably told that because the State is in a legal contract with all the doctors in the GMS, the State cannot unilaterally break that contract. If that is the case, and the Minister continues with this proposed implementation date, after 1 January, there will be two methods of paying doctors. It will create more confusion than we have already. I regret that this has led to a lot of bitterness and division between GPs. At the end of the day it is the patients who will suffer.

I am not happy with the new system, I favour some movement towards capitation. Many in this House have said that one of the difficulties in relation to the way consultants are paid for public patients is that they get a fixed salary regardless of the number of hours worked or the number of public patients they see. That is not satisfactory. We are proposing to move to that system to pay doctors under the GMS. That will lead to a two-tier service at GP level, the one area of the health service about which I never hear a complaint. Although the GP service is costly it is not by any means the major cost to the health services and the doctors' salaries proportion of it is only about one-third or less of the overall cost. Patients whether private or public, whether medical card holders or not have easy access to their GP. After the implementation of this new proposed method of paying doctors, I fear that that will not be the case. I agree with the Irish College of General Practitioners, the body responsible for professional standards in the area of general medicine when they say that there are not enough incentives for doctors to visit the terminally ill, the elderly and the handicapped in their own homes. They said that they would like to see a performance sensitive contract. I always favour, if possible public servants and doctors being paid in relation to some kind of incentive mechanism. All of us perform better if that is the case. I appeal to the Minister to postpone the implementation date beyond 1 January in the interests of unity among doctors and patients. The patients and the 1.3 million medical card holders are the real sufferers if this continues as proposed. I appeal to the Minister to consider organising an independent ballot of all the doctors participating in the GMS. Doctors will not buy a pig in a poke, and it is no wonder that last Sunday's meeting ended in such confusion with both sides taking a different view as to what did or did not transpire. It is not good enough and it is a pity that this whole issue has led to this bitterness and confusion. That will continue if the Minister persists with implementing this scheme in less than three weeks time.

The cost of drugs relates to the more expensive side of the GMS. Reference was made to the new drug formulae. Unless it is compulsory for people to prescribe from those new formulae there is no point in having them. Having it on a voluntary basis will not work. Will the Minister reconsider this?

In relation to the issuing of prescriptions and so on it is crazy that private patients can get prescriptions for up to six months in the case of the pill for instance, whereas a public patient has to return every month. Many women object to that. That is another area where money can be saved and I hope it forms part of any new proposals to be introduced.

Last week in the Dáil the Leader of my party raised a question in relation to the number of committees established by the Minister for Health since he took up office in March 1987. I was aware of quite a number of committees but I was surprised at the two-page answer which indicated that 21 committees had been appointed by the Minister. The Minister also said that that list of 21 did not include departmental ad hoc groups which the Minister had also set up to perform administrative functions. If there is anything that characterises this Minister's term of office so far, it is the fact that he makes few decisions himself. Anything that is difficult, contentious, controversial or requires thought and imagination is passed on to a committee and then, as Deputy Yates indicated, the committee's report is shelved to gather dust.

In relation to one of those committees, the group who considered Temple Street Hospital, is the Minister now in a position to tell the House what he intends to do about this hospital? I understand that a decision was to be taken this week. It is not fair to people working in Temple Street or anywhere else to have to continue operating under a cloud of such uncertainty. It is bad for the morale of the patients, the doctors the nurses and anybody with anything to do with the hospital. The Minister has all of the reports and has had a lot of time to consider them, so there is no reason why the Minister should not make very clear what he intends to do about Temple Street Hospital.

If the Minister intends to divide Temple Street between Beaumont and the Mater Hospital that would be most regrettable. It would divide up the expertise built up over a long number of years in Temple Street Hospital. It will not be possible for the one paediatrician operating in the casualty unit there to give the same level of service between the two hospitals. The same applies to the other staff. That would be an appalling decision for the children particularly in the north inner city of Dublin.

The Estimate also refers to the cost of refurbishing Hawkins House. The initial sum allocated is £663,000. Last week a question was raised by my party in the House as to the cost to the Department of Health of transferring their administration from the Custom House, Apollo House, Joyce House and Upper Merrion Street and so on, to Hawkins House. The answer was that they did not yet know what the cost would be. I understand that the Department have entered into considerable cost in moving their administration to Hawkins House. Perhaps the Minister will indicate the cost because I am told it is not an economic one and, if not, why did they transfer their administration to Hawkins House?

I should also like to refer to the sale of buildings which the Minister said was bringing in some revenue to the State. I recently raised a question about the sale of many of the buildings owned by the voluntary hospitals. When hospitals are amalgamated or moved to new, de luxe buildings, the State should have some way of recouping a certain amount of money from the sale of their old assets. After all, the State has spent an enormous amount of money on these buildings, inflated their cost and value and, therefore, should gain some revenue when the buildings are sold. I was sorry to hear that only in relation to two Limerick institutions any money was forthcoming to the State although the amount in question was very small. The State should look again at the question of ploughing in resources with no strings attached.

The health services have, for some time, been in crisis. When people say that, they are accused of being irresponsible but one could not live with one's eyes open and not see the appalling things going on in the health services, the long list of public patients waiting to get into hospitals for essential operations. Our health service is expensive and bureaucratic. There have been many cuts in relation to the provision of care at the professional end and very little in relation to administration. The Minister for Health is not taking charge of his portfolio. He seems to be happy to pass on responsibility to health boards or committees of one kind or another. That is not good enough. In a small country like ours, £1.3 billion should be more than enough to provide a fairly decent standard of health care for all our citizens. It is time the Minister looked at the way public hospitals are funded to ensure that moneys given to them are not simply given in advance each year as a block grant with no strings attached. He should ensure that they are required, in return for that money, to take a particular number of patients in each of the different categories. That is extremely important because too much discretion is being left to the hospitals. As a result, when we get to the middle of the year, some of the more emotive areas are cut back because they will get more publicity. The Minister for Health needs to take charge and to ensure that any public moneys given to health institutions are for specific tasks and not at the discretion of CEOs, consultants or matrons.

Mr. Howlin

I should like to comment briefly on the way Estimates and Supplementary Estimates are taken in the House. I wish to add my voice to the dissatisfaction at the way they are presented, that spokespersons are given the Estimates a matter of days in advance and that there is a formal statement by the Minister and a response by Opposition spokespersons. I have raised the question of a change at meetings of the Whips and I hope it can be implemented next year. It will mean that there will be dialogue across the Floor, where Members may ask questions which will elicit responses from the Minister. It will be like a Committee Stage debate which will help us all in this regard. It will make for a more constructive session than simply a formal statement.

Those of us who handle health portfolios are almost weary of the type of Estimates presented. We dealt with the Estimate proper on 23 June last and I predicted that the provision of £1.109 billion would cause havoc in the health services. That prediction has come true. By every objective measure of service, the system over which the Minister presides is breaking down and falling apart. We have heard the litany of hospital closures, the list of bed closures, the lengthening waiting list for elective surgery in every health board region and cutbacks in ambulance services. In my own health board area, a private enterprise tried to step into the breach to provide an ambulance service to replace the one that had been withdrawn but it has also collapsed so people have been doubly hit. The unfortunates who had their service withdrawn in the South Eastern Health Board area invested money and lost it when the private enterprise system, which was supposed to provide them with cover and some measure of security in case they became ill, also collapsed. There was no help from the Minister, his Department or the South Eastern Health Board, whom I hold responsible for their loss.

In relation to community care provision, there is a list of hardship. The same applies to dentistry and orthodontics. Virtually every day in the House, Members from every county seek to raise urgent cases of children who require orthodontic or emergency dental work. In many health board areas, all that is available is extractions. A proper service is not available to the vast number of people.

The Minister for Social Welfare introduced a scheme for spouses. He might be interested to know that not a single dentist in County Wexford operates that scheme. If a spouse wishes to avail of treatment under the scheme, she is referred outside the county but she must go on a waiting list as only a handful of dentists operate in the South Eastern health board region.

In relation to opthalmic surgery, many are waiting for cataract and other operations. Their sight is steadily disimproving as the wait goes on month after month. The Minister's cold and calm response to all the crises that have been outlined — not just by me and other politicians — but, more pointedly and objectively, by health service workers who are trying to operate the system, is to present a Supplementary Estimate that amounts, in net terms, to a token.

The Labour Party have fought health cutbacks tooth and nail. In every Estimate which the Minister presented, we pointed out the consequences of forcing them through, aided and abetted by other conservative parties. We have obviously lost that battle in 1988. We failed to move the Minister and the Government from their cold and uncaring path of cuts. However, even the Minister must be aware, from his political clinics, of the myriad of tragedies which are represented by the cold statistics we talk about in the rarefied atmosphere of Leinster House.

During the Estimate debate proper in June, I spoke of the experience of one hospital by way of anecdote. I referred to the Meath Hospital, Dublin. This evening, because I am firmly of the view — and maybe it is part of my national school training — that illustration is far more forceful than talking in blunt global terms of millions of pounds, I want to mention one case history to the Minister which might spark his conscience, and that is to talk about another Dublin hospital, St. Vincent's. By way of anecdote I will tell of an experience I had last Thursday. I received a phone call from a patient in Waterford who is suffering from an abcess on the liver. He is a very sick man, as was attested to me by his friends and his GP, and he required urgent medical attention. His local hospital, Ardkeen in Waterford, was unable to provide the required treatment and he was referred to a specialist in St. Laurence's Ward, St. Vincent's Hospital, Dublin, one of the largest and most important of our national hospitals. He was anxious to get this treatment and asked if there was anything I could do to facilitate his early admission to this hospital.

I telephoned the ward sister. I spoke to a very caring woman who told me that they had been instructed by the hospital administrator that there were to be no elective admissions into St. Vincent's Hospital until 2 January next at the earliest. The only admissions were coming through the casualty ward, on stretchers, and they were the only cases they had the authority to deal with. She told me there were "stretchers everywhere and we cannot deal with the congestion"— her words. When I asked her what were the prospects of admission for this very ill man from Waterford she pulled out his file and said he was listed as an urgent case, but that he was one of 100 urgent cases listed for admission and that he would have to take his place in the queue. That is a scandal. For us to be talking in global terms about a health service when there are seriously ill people who cannot get the medical treatment they require is a scandal. I call on the Minister to address himself to that scandal.

Next year's provision offers only more of the same, further pressure on the health boards and further pressure on voluntary hospitals which will close more beds, reduce services further and further divided the type of health service available to our people. There will be a quality and immediate health service for those who can pay. I am sure my friend from Waterford could have his operation immediately if he had the money, but what do we offer those who do not have money, who are dependent on the public health service? We offer them a waiting list with a hope and a prayer that they will avail themselves of the facilities before their condition worsens to such an extent that they will be beyond help from the medical services.

The other Deputies referred to the single largest item in this Supplementary Estimate — £13.5 million to the GMS Payments Board, an overrun of a magnitude which alarmed us all. But more to the point, I am disappointed, even alarmed, at the remarks in the Minister's speech which do nothing to allay the concern and confusion among the general public on the future of the GMS from January 1 next.

I understand there is an emergency meeting of the IMO tonight. The Minister should address urgently what type of services will be available through the GMS to medical card holders and the general public in the New Year. As Deputy Harney suggested, the one element in the health service that seems to be providing support to the general public, and in particular to medical card holders, is the GMS. They know if they fall ill they can call on their GP, but there is an element of doubt creeping in whether a comprehensive service will be available to them. I ask the Minister to address that point more forcefully than he has done already when he responds to this debate.

I endorse the comments of the Fine Gael spokesman on Health in relation to the Child Care Bill. One of my most strident comments in my Second Stage contribution on that Bill was the requirement for a specific, clear and defined allocation of moneys to the health boards if the goods intentions of the Bill are to be realised. It is clear from every submission from every caring agency that all the good intentions in the world are not worth a bag of beans if the resources are not provided to enable those good intentions to be realised, if the staff, training, and facilities are not provided in each health board area. I would ask the Minister to clarify that point, although it will be probably more appropriate to next year's Estimate debate because a long and protracted Committee Stage debate will lead this legislation to be enacted through both Houses of the Oireachtas hopefully before next summer.

Deputy Yates said it was the practice of Fine Gael to spell out the alternatives. I would remind him that on one occasion when we were discussing an Estimate, his immediate predecessor, Deputy Allen stated, in what I describe as Ramboesque fashion, that Fine Gael were totally dissatisfied with the Estimate provision and pledged — and got considerable media coverage — on Friday that Fine Gael would oppose the Estimate. Needless to say, that decision was changed between Friday and Tuesday when the vote took place.

Temple Street Children's Hospital is an issue which has caused great public disquiet in recent weeks and months. I understand that today the Minister had a meeting with the chairman of that board. If he has given this information to the board and the chairman, he might now tell the House the exact allocation to Temple Street Children's Hospital for next year and what his intentions are for the future in relation to the provision of specialist children's hospital facilities in the capital.

This Estimate offers no hope to all those people who are dependent on a public comprehensive health service to meet their needs in times of crisis. At a dinner attended by affluent, well-heeled individuals in recent days, the Taoiseach got great cheers and support when he suggested the Government were on course and would follow through with more cuts in public expenditure programmes. I can assure the Minister and the House that the cheers of the affluent will not drown the cries of the poor and the weak who depend on a public health service in their time of distress. No service and no sector of public expenditure fits more acutely into that category than the health services.

This Minister has presided over the dismantling of a proper public health service. For that reason the Labour Party will oppose this token Estimate and demand that a proper health service is provided for all.

Proinsias De Rossa

It gives me no pleasure to comment on the last speaker's statement that it was this Minister who started to dismantle the health services. It is a regrettable fact that the former Minister for Health, a member of the Labour Party, started to move away from the provision of a comprehensive health service. The fact that the Government are continuing in that direction is to be deplored and we shall oppose it at every opportunity.

However, tonight I wish to speak on the major row between the Department of Health and the IMO on the changes in the GMS service, which affect more than one third of the population and which have not been debated in this House. We have an opportunity to refer to it today. However, there has been no major debate in this House on the fundamental provision of health services for the people of this State for as long as I can remember. There is as much need for an Oireachtas joint committee on the health services as there is for a committee on Foreign Affairs which I have argued for. We are spending over £1,000 million on our health services, much of which, it has to be said, is wasted. Nevertheless, I would argue that the present direction and strategy being employed by the current administration is not improving matters. Attempting to save money by simply forcing more and more people into the private health sector is not going to provide a comprehensive health care service for the people. It simply results in the creation of a two-tier health care system, whereby those who have the money to gain access to the best health care, will get it and those who do not will take their place in the queue which gets longer and longer as the days go by.

The recent decision by the Minister for Health to freeze the allocation to health boards for 1989 at the 1988 level is an effective cut of 3 per cent in real terms. That again can only mean greater cuts in the provision of health care services — in areas such as the services for the mentally handicapped, the disabled and indeed in some hospital services as well. It is really deplorable that this House has not got down to debating the direction in which we want the health services to evolve and develop. We are in the process of creating a new health care system by sleight of hand. This is a disgraceful way of dealing with a major element of the quality of life enjoyed by citizens of this State.

There is a squabble between the IMO and the Department of Health on the capitation fee system of payments. I am not in favour of the proposed system, not because I am opposed to a capitation fee system — I believe that is the best way of paying for the service — but it will only work if a capitation fee system is applied to the population as a whole. The only way in which a capitation system will operate properly is that a free GP service is available to all citizens. If the proposed system, as it stands, is introduced for GMS patients, there will be an inbuilt incentive for general practitioners to see their GMS patients less frequently, to give them less attention and instead to concentrate on the private patients in order to boost their income. So far as I am concerned that will follow, as automatically as night follows day.

It is unfortunate that the sole intention of the new system is to save money and cut back on the services available to the one-third of the population who qualify for the GP service under the GMS scheme. Effectively we are planning to cut back the services for the poorest in our society simply to save money and without considering the knock-on effects that will have on the care available to those people. It has to be acknowledged that because they are part and parcel of the one million poor in our society, they need more care and attention than those who are better off. I do not support the current system.

Professor Dale Tussing did most of the pioneering work on health economics and he advocated very strongly that there should be a shift from hospital care to primary health care, leading to a reduction in costly hospital beds and a consequent shift to community services. He also advocated a shift in community services so that non-physicians would deal with the minor ailments that people normally go to GPs with. However, he argued that if that system were to work, we would have to introduce a free general practitioner care for all, otherwise a two-tier health service would continue to evolve at the expense of those who most need medical care.

The draft agreement between the IMO and the Department of Health changes the method of payment to general practitioners from a fee per item to a capitation fee. The scheme will allow for pensions for general practitioners and for study and annual leave and will help pay for back-up staff. On the face of it, it looks like the system Professor Dale Tussing was proposing. However, when you consider that it will apply to only one-third of the population, it is clear that this is not what he had in mind. So as far as I am concerned, there is a need to argue for a comprehensive medical system that is available to all citizens. No doubt, others will argue that that simply means providing free medical care for those who are well off, and that is so, but if we have an equitable and fair taxation system, there is not reason that the cost would not be clawed back from those who can afford to pay directly. In other areas such as education the experience has been that those who can afford to pay choose to pay, and there are quite a number of people who pay VHI premiums at present who are fully entitled to avail of hospital care and the GMS service — 15 per cent of those paying the VHI subscriptions do not have to. However, they see it as a means of avoiding the queue to see a consultant or to get into hospital. If we addressed that problem, the service might be more productive.

The position with regard to consultants needs to be seriously examined. We need to introduce a new contract for consultants that will ensure that hospital consultants, in particular, would see their public patients under the same conditions that they see their private patients and that they would be given exactly the same care and attention as private patients. I have some minor experience of dealing with consultants in public hospital wards and it is like being in a cattle yard, with dozens of people in the one room and half a dozen consultants talking to their patients about their ailments, examining them and so on in a way which lacks dignity for the patient who goes to see them. In no way will a consultant deal with his private patients in this fashion. I argue that, just as GPs have to sign a contract that they will treat their GMS patients in the same way exactly in terms of waiting rooms, consulting rooms etc., as they treat their private patients, consultants must be obliged to do the same thing.

I want to refer to Temple Street and Crumlin hospitals. I put a parliamentary question to the Minister last week for written reply in regard to the number of children waiting for ear, nose and throat operations. The reply I got was that 780 children are waiting for such operations in Temple Street and 250 in the Crumlin hospital. That is more than 1,000 in those two hospitals alone. I indicated last week that I knew a child who needed an operation urgently because the child was losing its hearing, yet a consultant in Temple Street told the parents of that child that at least 200 children were waiting for operations which were more urgent than this child's. If this child loses its hearing it will not recover it. Fortunately, due to the determination and tenacity of the parents concerned, they have managed to get the child into another hospital.

The reality is that 780 children are waiting to get into Temple Street and 200 children are waiting to get into Crumlin hospital for serious operations. Their condition may not be life-threatening but the children need the operations particularly in relation to hearing. I understand from those in the medical profession to whom I have spoken that if a child's hearing is not adequate in the first two to three years of its life, then its capacity to learn how to speak is impaired and the probability is that it will never recover fully the capacity to speak properly. I put it to the Minister that, while technically the 1,000 children waiting for ENT operations in these two hospitals in Dublin may not be at risk of their lives, other factors should be taken into account when deciding whether an operation is urgent. I appeal to the Minister to provide the resources necessary at those two hospitals to clear the backlog of children waiting for these operations. Temple Street say their waiting list is two and a half years long. Clearly, something is radically wrong with our system when 1,000 children can be waiting for operations of this kind. I appeal to the Minister to provide the resources even in this one area.

Minister of State at the Department of Health (Mr. Leyden)

I am pleased to get an opportunity to speak on the Supplementary Estimate for the Department of Health. Since coming into office in 1987 we have had to deal with a massive overrun in the Department of £50 million.

Mr. Howlin

They are your health boards. Your majority elected them.

Mr. Leyden

I say particularly to the Labour Opposition spokesperson that his colleague, Deputy Barry Desmond, when Minister for Health from 1982-87 was responsible for this irresponsible action——

Mr. Howlin

Every Wednesday your Minister said he was not getting enough.

Mr. Leyden

——in allowing an over-expenditure of £50 million. We have to deal with the restrictions in public expenditure but along with that we had to deal with this difficult problem. We had to cope with it and we are coping with it.

I compliment the Minister and the Department on the efficiency with which the allocations are now made to the health boards and the hospitals in advance of the commencement of the financial year. This allows the private hospitals and the eight health boards to prepare their estimates well in advance of the commencement of the year so they know the situation exactly and can plan ahead.

Mr. Howlin

No, they are bunched before they start.

Mr. Leyden

How we have a more efficient, streamlined, caring and effective health service since the change of Government. I compliment the health boards on their work and the way they have co-operated with the Department and the Minister since we took office in 1987.

In relation to the report on the dental services, I thank Deputy Yates and other Deputies for their kind comments on it. I had the honour of chairing the group who produced this report at the request of the Minister. The Minister decided he was not satisfied with the general dental service. We have inherited the situation here from previous administrations.

Mr. Howlin

Is the Minister of State satisfied now?

Mr. Leyden

We are not going to start this business of accusing anybody.

Mr. Howlin

Is he satisfied now?

Mr. Leyden

This is serious. The Minister decided in March 1988 to appoint me chairman of this group to review the dental service and we met on many occasions to discuss this, and the report is here. The report is available so nobody needs to obtain it through any unofficial source. It can be obtained from the Department of Health at any time.

Mr. Yates

That is progress.

Mr. Leyden

It is available and will be circulated and available to the health boards.

(Interruptions.)

Mr. Yates

Read page 27.

Mr. Leyden

The Minister, Deputy O'Hanlon, in his meeting with the health boards' chairmen and chief executive officers and advising them of their allocations for 1989, laid particular emphasis on the dental services. He expressed his concern at the level of dental services provided throughout the country and particularly at the waiting lists of adults awaiting dental treatment, the absence of concentration upon children's dental services and, indeed, in a number of areas the numbers of children awaiting orthodontic treatment. Health boards at his instigation are currently preparing proposals which will address over a given time span the difficulties I have referred to.

I am convinced that a phased programme throughout health boards generally must take place during next year to ensure that appropriate levels of development take place in the dental area. Provision has been made in the health capital programme for further planned development in the area of water fluorination, which is very important as has been mentioned already by Deputy Yates. The Department's deputy chief dental officer is currently engaged, at the request of and with the co-operation of the management, in the preparation of a plan of systemically addressing the deficiencies in dental services provisions. Indeed, I will be meeting with the Irish Dental Association tomorrow to discuss the report with a view to bringing about a major improvement in these services.

I heard a comment made by Deputy Harney of the Progressive Democrats in relation to the number of committees the Minister has established to review certain aspects of the health services. I believe this is a proper and planned approach to the health services.

Mr. Howlin

It keeps you off the streets.

Mr. Leyden

To have the advice of experts in a particular field I believe is the proper approach. I have the responsibility and honour of working with a very high level committee who are experts in the field. I am merely chairman of that committee.

Mr. Yates

I heard that the Minister of State pushed Roscommon's case pretty well.

Mr. Leyden

We had discussions with the chief dental officer of the Department of Health, the deputy chief dental officer of the Department, a programme manager of the North-Eastern Health Board, the Dean of Dental Affairs of the University of Dublin, a finance officer from the Eastern Health Board, a HEO from the Department of Health and an assistant secretary of the Department of Health, Mr. Joe O'Rourke, who has since retired from the Department, and I take this opportunity of expressing publicly in the Dáil my thanks for his work and the contribution he made in the preparation of the report we submitted to the Minister in June.

I want to make it clear that the Minister's approach in appointing committees in particular areas to obtain the best possible advice and then to act in due course on the advice is a very proper approach to the health services, because this is a very complex area of development.

In relation to the Supplementary Estimate, the move by the Department to Hawkins House is a very worthwhile exercise. It brings all the different sections of the Department together. We are a very efficient, hardworking, streamlined Department. The fact that we will be together in one building means that we will be more efficient. I look forward to that move which is taking place at the moment and which will be completed early in 1989. I would like once again to compliment the Minister on the excellent work he has undertaken since he became Minister in 1987. The fact that he has expertise as a medical practitioner himself has contributed greatly to this success as Minister.

Dr. D. Fitzpatrick

I am hoping to cover some points raised in this debate. I would like to start by congratulating the Minister and I hope that on 1 January the new capitation scheme will come in. In the longterm it will bring a better quality of general medical service directly to the patient and increase the facilities where they are needed, where the patients live, rather than having them trek for very minor procedures and for tests into a large high cost, high technology medical centre.

I would like to deal for a moment with the dental services. As we have heard, there has been a review committee considering this area for the past year and a half. They have come up with a very comprehensive review and with some proposals for the restructuring of the dental services. The dental services are unique among the medical services provided in that they deal mainly with people in need, people in pain. People do not normally think about dentists until they are suddenly stricken with a toothache. In the Dublin area generally if a toothache comes on after normal surgery hours or at the weekend or on a long weekend, one finds there is very little chance of the pain being relieved until the next working day. One of the areas I believe was not looked at by any study of dental services is the provision of emergency dental services out of hours or on long weekends. An emergency service could be provided, with the co-operation of the health boards, the dental hospital and dentists in general practice. I am not talking about a great service dealing with major facial injuries or anything else. I am speaking about the person who looks for and cannot find treatment for a toothache out of hours. For approximately £40,000 a year there could be set up in the Dublin area an emergency service. This relatively small amount of money would go a long way towards alleviating much distress.

Other problems in the dental services are the lack of orthodontic treatment available under the medical card system to people in need. The main problem here is lack of manpower. We do not have enough orthodontists who are willing to work in the health board services or in the public services. One way around this would be to create in the health board areas non-consultant hospital dental training posts. One does not have to go to a dental hospital to train as an orthodontist; one can train outside in clinics under supervision. We should look at this and create these posts for some years to see if they work and if we can alleviate the long waiting lists for orthodontic treatment.

We produce every year approximately 60 dental surgeons. Their training course is as long as that of doctors. Yet when they are qualified, at great expense to the State, most of them leave the country to seek work abroad. Over the years they come back into the system but, before they leave, we should consider the introduction of an intern year for dentists. If, these 60 dentists, before they got their qualifications or their licence to practice, had to do a year in the public dental service, we would be going a long way to alleviating the manpower shortage.

Another area I would like to deal with is the accident services in the greater Dublin area. This service is putting great pressure on hospital beds. The accident services are working well, probably too well. The voluntary hospitals on the accident rota in Dublin admit approximately 600 patients a week. This means there are 600 beds taken up. The problem arises when a patient who is booked in for an ear, nose or throat operation, a gallbladder operation or whatever, is contacted by the hospital either on arrival or before they arrive to inform them that the bed has been taken by a patient brought in as a very urgent case. We will have to look at this problem. I know there is a subcommittee dealing with this. I would reiterate that the accident services are working well but it is the pressure they are putting on what we would call the cold cases, the routine admissions to hospitals, that is causing disruption. We should look at the possibility of opening a hospital to deal purely with accidents in the Dublin area. This will eventually come and we might as well start looking in a serious way at the idea now, at the implications and the cost.

In regard to the hospital services in Dublin generally, complaints arise about people not being treated or not being admitted to the hospital when they felt they should be. Great play was made here about the ear, nose and throat services in the Dublin area and about the waiting lists for admissions to them. We could start making savings in the hospitals and recycling the money into the clinical area. I am talking about making savings in the non-clinical area — pathology, radiology, biochemistry, administration etc. In most hospitals in the Dublin area there is not just duplication but triplication. In any given area where there are one, two or three hospitals, they all have full blown pathology departments when one pathology department could service two or three hospitals. We could look carefully at this to see how savings could be made; but there is no point in making savings if the money is going to be taken out of the service. It must be put back into the clinical area where it is needed.

To come back to dentistry again, there seems to be a groundswell of opinion in favour of closing the Dublin Dental Hospital. This would be a backward step not just for Dublin but for dentistry in general. The Dublin Dental Hospital has served not just Dublin but the whole of Ireland for the last 100 years or more and it has given a good service. In the last two years it has managed to increase its services at no extra cost to the State. Through streamlining and savings in administration they have managed to increase the service to the people in this area. They also provide a teaching service. This is an area that is not entirely in the bailiwick of the Minister for Health. It falls between Education and Health and this House and the people outside it should be aware of the great service this hospital has given over the years. It is a community-orientated service which tries to give the people what they need. For this they should be applauded.

I look upon our medical and dental schools, whether they are in Cork or in Dublin, as national assets. They should be developed and there is no reason why we should not look upon them in the same way that we look upon the international services offered by the ESB, Dublin Gas, Bord na Móna and so on. We should be selling the services offered by those colleges throughout the world and we should encourage foreigners to train at them. It would not mean any cost to the Irish taxpayer and the graduates would be good ambassadors for those schools and for this country.

Minister for Health (Dr. O'Hanlon)

I thank those who contributed to the debate. Deputy Yates complained that I did not deal with topical issues in my opening statement and he was correct because I confined my remarks to the Supplementary Estimate. I reject his allegation that there is a crisis in the service. We have a first-class quality service thanks to the dedication of the staff working in it and the commitment of administrators in health boards and voluntary hospitals. The service in our hospitals and at community level is first class. I have always accepted that there have been problems in regard to waiting lists, particularly for certain high tech procedures such as orthopaedics and hip replacements. It is only in the last 12 years that hip replacement has become a popular procedure and the demand for that service has grown at a rate faster than any of us expected. However, we have had waiting lists for hip replacements for the last five or six years. They did not come about since we took office and I am glad to say that we have done something about them. With the Arthritis Foundation of Ireland we have provided two new operating theatres in the only stand alone orthopaedic hospital in the country, Cappagh, and that is an indication of the Government's commitment to alleviating that problem.

Deputy Yates expressed concern about the discharge of patients from psychiatric hospitals to the community. I would be concerned if there were specific cases and I should like him to bring them to my attention. It should be remembered that the decision to discharge a patient to the community is a clinical one. There is no particular cost saving involved because it is just as expensive to provide a community service as it is to provide a hospital service for a long-stay psychiatric patient. I have assured the House, and the public, that we do not intend to follow what occurred in Italy and in parts of the US. In those countries patients were discharged from hospital at a time when hospital facilities were not available for them. We are not going to allow that to happen.

My colleague, Deputy Leyden, chaired a committee on the dental services. In that regard Deputy Fitzpatrick made a constructive contribution to this debate. I agree with his comments about the integration of the dental services and the need to use the available facilities to provide an improved dental service, including the use of the Dublin Dental Hospital.

Mr. Yates

Will the ad hoc scheme be coming back?

Dr. O'Hanlon

The House will be aware that as soon as I became aware that a problem existed in the VHI I asked consultants to investigate and report back to me. The consultants reported to me in October and within one week I had given the report to the chairman of the VHI. The board asked the consultant to take over as recovery manager and, in order to facilitate that, I appointed him a member of the board of the Voluntary Health Insurance. We should look back to the term of office of the Coalition because during that time they refused a request by the VHI for an increase in premiums. That request was made in respect of the end of 1986 and the early part of 1987. The two major hospitals in the service were built and came on stream during the term of office of the Coalition. It would be no harm if Deputies, when debating the difficulties of the board, considered what happened during the term of office of the Coalition.

Deputy Harney referred to the GMS negotiations and Deputy De Rossa spoke of what he called a row and a squabble between the IMO and the Department of Health. I should like to assure the Deputy that there is not a row between the IMO and the Department. The difficulty is within the Irish Medical Organisation. The Department of Health negotiated with the IMO — John Horgan chaired the meetings — and a proposal was voted on by that organisation. It was accepted 2:1.

Mr. Yates

Will it be compulsory.

Dr. O'Hanlon

The present difficulties are within the medical organisation and are not between the Department and that organisation. Deputy Harney raised a point about the contract and I should like to point out to her that it did not contain anything that was not in the eight-page explanatory document that was sent to each doctor in advance of the ballot taking place in the autumn.

Mr. Howlin

Will it apply across the board from January?

Dr. O'Hanlon

I should like to tell Deputy Harney, who raised a point about the number of committees I set up, that I make no apology to anybody for establishing committees to look at specific areas of my responsibility. I do not have the facility that Deputy Yates has, of having a simplistic answer for every question in regard to health. Those questions have been addressed by health administrators for 20 years and they were not able to find an answer to them.

Mr. Carey

Everything is simplistic as far as the Minister is concerned.

Mr. Yates

The Minister will have to be decisive.

Dr. O'Hanlon

Deputy Yates has the answer to questions that have been considered by professional people for 20 years.

An Leas-Cheann Comhairle

I should like to advise the Members that, whether they find the Minister's comments argumentative, irritating or unwelcome, they must contain themselves while he endeavours to conclude in four minutes.

Dr. O'Hanlon

I am pleased to be able to say that most of the committees I set up reported within four to six weeks and gave me some very useful information. For example, I established a committee to deal with computerisation of the health services. I admit to the House that I am not an expert on computerisation but I was glad to have experts in that field advise me. The advisory council on health promotion will make a very valuable contribution to the improvement of the quality of health for all our people. I set up a committee to look at the question of hearing aids and I do not make any apology for not being an expert on hearing aids or the technology of them. I am not concerned if Deputies feel we should not have committees or that we should pick an answer off the top of our heads and implement it. It is possible to do that in Opposition but not in Government.

I agree with Deputy Harney that it is not fair to have people in Temple Street Hospital working under a cloud but I should like to ask her, who is responsible for that? A consultant of Temple Street Hospital was the first person to reflect on the quality of the service at that hospital. Some of his colleagues agreed with him and the Opposition jumped on the band wagon. A "Today Tonight" programme followed and people were asking me not if I was going to close Temple Street but why I was allowing it to remain open. I was left with no option but to ask a person to have a look at the hospital. I am glad to say that the report endorsed my view on the matter. A similar view was expressed by the matron and the nurses of the hospital, that there is a high quality of service for children at Temple Street.

Mr. Yates

Will it continue?

Dr. O'Hanlon

I should like to tell the House that while I only received the report on Friday, and am studying the implications of it, there is no threat of a closure of paediatric services provided by Temple Street Hospital.

Mr. McCartan

What about the hospital itself?

Dr. O'Hanlon

Deputy Howlin referred to a Committee Stage debate. I would have no objection to that because I would answer with confidence every single question that was raised in this House. In relation to all the various points raised there is an answer to each one of them.

In the minute that is left to me I would like to mention a few of the various areas where there has been progress over the last 12 months. Beaumont Hospital was opened, a health promotion unit was set up, Cavan, Mullingar, Castlebar, St. James's and the Mater Hospitals were either completed in terms of building or of equipment so that they would be ready for service in 1989.

Mr. Howlin

What about the closure list?

Dr. O'Hanlon

Services for child sexual abuse were provided in two hospitals. Temple Street and Crumlin and money was allocated to each of the eight health boards. Legislation in the areas of adoption, of tobacco products and of clinical trials was brought through this House and the Child Care Bill is before the House. The GMS negotiations were brought to the stage where they were balloted on by the IMO. We anticipated the danger in the Voluntary Health Insurance and took the appropriate action to ensure that the VHI would continue to provide a high level of service to the people.

In conclusion I would repeat something I have said before to those who say that the health service are in a state of crisis. Last year 500,000 people were treated as in-patients in hospital and 1,500,000 people were treated in hospital as outpatients. That does not include the number of people who were treated by their own general practitioners. Nor does it include people who attended private hospitals or who attended consultants in their private clinics. That, for a nation of 3,500,000 people, is proof enough that there is a proper level of good quality service available.

Mr. Yates

Some of those are repeat visits.

Question put.

The Dáil divided: Tá, 69; Níl, 13.

Tá

• Abbott, Henry.
• Ahern, Bertie.
• Ahern, Dermot.
• Ahern, Michael.
• Andrews, David.
• Aylward, Liam.
• Burke, Ray.
• Byrne, Hugh.
• Calleary, Seán.
• Collins, Gerard.
• Conaghan, Hugh.
• Connolly, Ger.
• Coughlan, Mary T.
• Cowen, Brian.
• Daly, Brendan.
• Davern, Noel.
• Dempsey, Noel.
• Dennehy, John.
• de Valera, Síle.
• Doherty, Seán.
• Ellis, John.
• Fahey, Frank.
• Fahey, Jackie.
• Fitzgerald, Liam.
• Fitzpatrick, Dermot.
• Flood, Chris.
• Flynn, Pádraig.
• Foley, Denis.
• Gallagher, Denis.
• Gallagher, Pat the Cope.
• Geoghegan-Quinn, Máire.
• Hilliard, Colm Michael.
• Jacob, Joe.
• Kitt, Michael P.
• Kitt, Tom.
• Barrett, Michael.
• Brady, Gerard.
• Brady, Vincent.
• Brennan, Matthew.
• Brennan, Séamus.
• Browne, John.
• Lawlor, Liam.
• Lenihan, Brian.
• Leonard, Jimmy.
• Leyden, Terry.
• Lynch, Michael.
• Lyons, Denis.
• Mooney, Mary.
• Morley, P.J.
• Moynihan, Donal.
• Nolan, M. J.
• Noonan, Michael J. (Limerick West).
• O'Dea, William Gerard.
• O'Donoghue, John.
• O'Hanlon, Rory.
• O'Keeffe, Batt.
• O'Leary, John.
• O'Rourke, Mary.
• Reynolds, Albert.
• Smith, Michael.
• Stafford, John.
• Swift, Brian.
• Treacy, Noel.
• Tunney, Jim.
• Wallace, Dan.
• Walsh, Joe.
• Walsh, Seán.
• Woods, Michael.
• Wright, G.V.

Níl

• De Rossa, Proinsias.
• Desmond, Barry.
• Gregory, Tony.
• Higgins, Micheal D.
• Howlin, Brendan.
• Kavanagh, Liam.
• Kemmy, Jim.
• McCartan, Pat.
• O'Sullivan, Toddy.
• Pattison, Séamus.
• Sherlock, Joe.
• Spring, Dick.
• Stagg, Emmet.

Tellers: Tá, Deputies V. Brady and Browne; Níl, Deputies Howlin and Pattison.

Question declared carried.