Dáil Éireann debate -
Wednesday, 11 Jul 1990

Vol. 401 No. 5

Estimates 1990. - Vote 42: Health (Revised Estimate.)

Minister for Health (Dr. O'Hanlon)

I move:

That a sum not exceeding £1,254,664,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1990, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.

The gross non-capital provision in the estimates amounts to £1,389.214 million. Allowing for Appropriations-in-Aid at £163.75 million, the net non-capital grant provision is £1,225.464 million, of which £7.6 million is national lottery funded. The net non-capital provision represents over 21 per cent of total Government expenditure on supply services as compared with under 20 per cent in 1989.

The net non-capital grant provision represents an increase of £82.332 million on the corresponding out-turn figure for 1989.

This year sees a signficant improvement for those in receipt of health cash allowances. Increases of between 5 per cent and 10 per cent in these allowances have been provided for. The provision takes account of certain special pay awards and phase III of the general pay increase under the 1987 agreement on pay in the public service.

The level of non-capital expenditure approvable on the basis of the subhead provisions in the Estimate is £1,391.975 million. It comprises £873.154 million in respect of pay, £441.601 million in respect of non-pay, and £77.220 million in respect of cash allowances. When account is taken of the directly generated income of health agencies the total expenditure in 1990 will be £1,502.975 million.

The capital provision for 1990 is £37.7 million. Of this, £22.7 million is being provided from the Exchequer, £12 million by extra-Exchequer receipts comprised of £11 million equipment loans for new facilities, £1 million from sales of properties, and £3 million is being made available from the lottery. In addition, a provision of £3.5 million was made for systems development and related services in the health agencies. Funds will be spent on priority projects which are designed to maintain and improve the infrastructure of the health services.

The 1990 capital programme makes provision for expenditure on all the major components of the health services, including general hospitals, psychiatric services, services for the handicapped and community health and welfare services.

My Department are at present in the process of drawing up a comprehensive five year capital programme covering all the major components of the health services and I expect to have decisions made on this programme in the context of the 1991 Estimates.

I believe that when the health services in 1990 are reviewed it will be seen as a year of consolidation and renewal. It will also be seen to be year in which a number of very important initiatives were taken to shape the services for the future.

When I made a statement to the House on 6 February 1990, I outlined a detailed action plan for the year. I set out in considerable detail a range of initiatives which would be taken this year. I am very pleased to confirm that very good progress has been made on this action programme. In the short time available to me this evening, I would like to report to the House on those aspects of the programme which have been priorities during the first half of this year.

First, I made a firm commitment that overall hospital activity throughout 1990 would be maintained at the latter half of 1989 levels. I also gave an undertaking that the agreed cost of the additional activity arising from the 'flu epidemic would be met in such a way that it would not intrude on the services to be provided this year. I am glad to report that both these commitments have been honoured in full and that health boards and hospitals have been enabled to maintain acute hospital activity at the agreed levels.

In my February statement, I indicated that a number of initiatives would be taken to improve efficiency in the health services. In particular, I mentioned that studies would be undertaken by Professor David Kennedy on the acute hospital services in Dublin and that Mr. Noel Fox would conduct an efficiency review of acute hospital services.

In regard to the efficiency review, I expect to receive a report on the first phase of Mr. Fox's assignment around the end of August. I will, in due course, make a full statement on the action which will be taken on foot of the report.

Professor Kennedy has submitted an interim report. He has made recommendations on steps which can be readily taken to streamline acute hospital services in Dublin. He has identified a number of areas which need urgent attention, including the development of improved diagnostic, treatment and rehabilitation services for the elderly. He has also strongly recommended the development of new structures for the planning and delivery of health services in the Dublin area.

Professor Kennedy has identified the best practices in use in hospitals and has recommended that these be quickly extended to all acute hospitals in the Dublin area. The measures to be taken by the acute hospitals in Dublin include:

—the adoption of an admissions policy in each hospital, supported by an intensive bed management policy;

—the introduction of one-day and five-day wards, specifically to deal with planned admissions;

—senior medical staff to become more involved in decision making in accident and emergency departments when decisions are being taken on further hospital treatment; priority to be given by medical staff to their accident and emergency commitments on the days when they are on take;

—more effective diagnostic support for accident and emergency departments and improved liaison with general practitioners;

—a more systematic approach to planning of discharge for patients in need of follow-up care; and

—improved public education on the use of hospital services.

I accept these recommendations and have already asked each of the acute hospitals in Dublin to produce a plan to implement them in advance of the seasonal increase in emergency admissions during the winter. The implementation and impact of these measures will be closely monitored by my Department, working with a term drawn from the membership of the Kennedy Group.

I am particularly anxious to act on the recommendations made by Professor Kennedy in relation to the improvement of services for the elderly. While there will be some additional resources required to implement fully what is necessary, I believe that we can make considerable progress on a number of fronts without further delay.

Earlier this year, I made available £4.5 million additional funds to health boards to develop home and community-based services for the elderly. Important improvements in services are taking place throughout the country, such as expansion of day care places, appointment of additional public health nurses, extension of home nursing and improvement of staffing ratios in existing homes for the elderly.

Because of the extent and rate of expansion of the population of elderly people in the greater Dublin area, a substantial share of the additional funds has been allocated to the Eastern Health Board. Further funds will be made available to provide additional places in nursing homes, which will help to relieve pressure on the acute hospital services in Dublin as advocated by Professor Kennedy.

My Department have already had discussions with a number of the major Dublin hospitals about the provision of a comprehensive specialist medical service for the elderly. I have been encouraged by the positive response of the hospitals and their commitment to finding ways and means of developing such a service within their existing resources. My Department are developing proposals for a pilot project in rehabilitation of the elderly and I am having discussions with the National Medical Rehabilitation Centre to explore the contribution which they can make in this field.

I also accept the conclusions drawn by the group as to the unsatisfactory nature of the organisational structures in Dublin, and changes to bring about significant improvements to deal with this are under active consideration at the moment.

Medical consultants are one of the key groups in the delivery of hospital care. The recent report on the pay and conditions of medical consultants by the Review Body on Higher Remuneration in the Public Sector, under the chairmanship of Mr. Dermot Gleeson, presented a clear analysis of many of the problems associated with the provisions of services at consultant level. It looked at the question of pay and conditions for consultants in a comprehensive way and clearly points to the need to consider the issues together rather than in isolation. I do not wish to pre-empt the discussions with the medical profession, which now are being arranged, but I believe that these recommendations provide a satisfactory basis on which to structure the future relationships between patients, consultants and management.

Last year I announced the introduction of a new drug cost subsidisation scheme to alleviate the position of people with limited eligibility and a requirement for long-term prescription medication. I am very pleased to announce that my Department have now reached agreement with the contractors' committee of the Irish Pharmaceutical Union on the introduction of this scheme, and that acceptances has been recommended to the members. I hope to make a full announcement, giving details of the scheme, when balloting is completed later this month. The implementation of this scheme will be of particular benefit to those with chronic conditions, such as asthma.

A new three year agreement was negotiated between my Department and the Federation of Irish Chemical Industries on the price of drugs. This agreement provides a satisfactory basis for the control of drug prices on the Irish market, and will have immediate benefits for both the Exchequer and the private purchaser.

Our presidency of the EC was very successful from a health perspective, and I am confident future Presidencies will build on the positive and constructive work that we achieved: Tobacco — A directive harmonising reduced tar levels in cigarettes was adopted; Cancer — A 50 million ECU Europe Against Cancer Programme for 1990-94 was agreed which will focus on cancer prevention, health information and education, training of health professionals and research; Drug Abuse and AIDS — The EC Council of Health Ministers agreed programmes to develop plans and strategies in these areas: and completion of the internal market where considerable progress was achieved relating to foodstuffs and medicinal products.

I adopted Youth and Positive Health as the theme to run through our Presidency. I put a special emphasis on health education and the promotion of positive lifestyles among our young people. This initiative was widely supported by all the EC Health Ministers and will now form the basis for future policy programmes.

In conclusion, I have outlined briefly the initiatives which are being taken to get the maximum return from the investment by the State in the health services and to improve those services in a number of key areas. The action programme has already brought beneficial results in the hospital and community care sectors, and when fully implemented, will have created a significantly improved environment for a first class health service.

I believe that with the resources made available by the Government, and the policy initiatives detailed in this statement, the right standards of health care which our society rightly expects will continue to be provided.

An Ceann Comhairle

Deputy Ivan Yates. We were a little late commencing this debate on health. It was due to commence at 8.45 p.m. but I want the agreement of the House to ensure that we conform to the Order of the House proper and that it concludes as stipulated at 9.45 p.m.

Mr. Yates

We still have ten minutes. I must deplore the short time given for this very important debate but now I will proceed as fast as I can. The last major debate we had on health in this House was in June. Many of the health issues which generated so much public concern over the last year still remain unresolved. There remains a two-tier health service which means public patients dependent on the State service still have to wait unacceptably long periods for hospital treatments and are denied access to other services. None of the underlying problems in the health service requiring reform have been dealt with.

It is disgraceful that we now have 730 adults awaiting cardiac surgery in the Mater Hospital and these queues are being lengthened due to the fact that there are only 25 public beds there. Despite promises, the reduction in the level of surgery there has put lives seriously at risk and the Minister must immediately make available extra resources to ensure the maximum throughput of patients. Similarly, the waiting period for total hip replacements is still a matter of years. Many elderly people right across the country are mobile only by virtue of walking aids and are in severe pain. The Minister's promises to resolve this problem have barely touched the surface and in no way resolved it. Again this summer we are facing the prospect of summer ward closures which will result in further delays in access to hospital for selective patients.

Last December we saw thousands of the friends and relatives of the mentally handicapped on the streets demanding justice for the mentally handicapped. National studies now show there is an inevitable demand for an additional 800 residential places for adult mentally handicapped persons and a further 1,000 similar day care places. The onus is on the Minister to organise planned capital allocations of finance over the next five years to ensure that the families of the handicapped are not expected to cope alone. Repeatedly I am advised of cases of elderly parents who are fearful of the lack of care to be provided for their handicapped son or daughter after their own lifetime. Platitudes are no substitute for proper hostel, day care and rehabilitation facilities.

In regard to dental services, the Government have failed utterly to provide an adult dental service for routine treatments. In the mid-eighties adult medical card holders and their dependants could go to their local clinics and obtain approval for referral to a local dentist for treatment. Despite many protestations inside and outside the Dáil there is now only an emergency extraction service. Old age pensioners are being asked to pay over £300 for a set of dentures privately. The Minister for Health in conjunction with the Dental Council has still not established the auxiliary post of denturist to sell dentures to the public more cheaply. An approved training course and qualification procedure should be established to allow for a proper career structure for this specialist group. The Government have also failed to recruit full-time orthodontists to the health boards. Through a change in the contract of employment to allow some level of private practice this problem could be overcome. Many children face real anxiety and depression from badly formed teeth and cannot get enough priority points to be treated. There is no national dental prevention programme involving water flouridation, fissure sealants and dental maintenance for school children.

I turn to AIDS, a most serious public health issue facing this country and the world in the nineties. It is reckoned conservatively that some 20,000 people will be HIV positive by the end of this decade. It is vital that we now put in place the best possible AIDS prevention programme to attempt to control the spread of the disease and to meet the care requirements of these patients. We need the immediate appointment of a second consultant to the gum clinic to treat patients. We need proper continuous funding from the Department of Health for the unit in St. James's, not the British Medical Council for research grants or ad hoc lottery funding. We need proper counselling services, and supplementary welfare allowance payments to meet the specialist needs of heating, dietary and mobility expenses of AIDS patients. We need a code of practice to outlaw discrimination against AIDS patients in the workplace. Sheltered housing and home care nursing are required for AIDS patients. We need a national advertising campaign to promote a greater understanding and to provide information on the prevalence of the disease, as is the case in Britain. I regret that despite the best efforts of the national AIDS co-ordinator, all the Government have done is to try to sweep this disease under the carpet because of its stigmatised nature. There are no guilty or innocent victims of AIDS. They all deserve our care and compassion. This is a policy of serious neglect that will lead to tragic and fatal consequences in the future.

Over the past 18 months the Minister for Health constantly rejected my claims that huge savings could be made in the cost of drugs. Yet, the drug industry volunteered a saving of £14 million, or 10 per cent, in order to obtain another purchasing agreement. They were desperate to get any agreement to avoid a free-for-all. We could have made a further £10 million savings with the substitution of off-patent branded medicines by generic drugs of equivalent composition. In Sweden there is a very simple technique. On the prescription form there is a blank square and unless the doctor puts an X in that square, the chemist must use a generic drug. If the doctor wants a branded product to be used he can put an X in the square. This would save millions of pounds because generic drugs are 25 per cent to 30 per cent cheaper than branded drugs. I call on the Minister to make this simple change for obvious cost benefits.

The biggest practical problem facing many hospitals is the lack of availability of specialist nursing staff to recruit, and our over-dependence on non-EC foreign doctors at non-consultant hospital level is very worrying. The root cause of both of these problems is the massive level of emigration by our nurses and doctors, which in total runs into tens of thousands over recent years. This is turn is due to a crisis in morale of health workers because of the high level of stress, the poor level of pay and conditions, and the lack of planning in the health service. The Minister must immediately tackle this by first improving the incremental payments for specialist nursing posts. The pay difference between an ordinary staff nurse and a nurse in an operating theatre or working in intensive care is only £226 a year. These are the people who are going abroad. We need to increase the increments for those nurses. We need to relax the embargo and recruit a further 1,000 nurses so that we will not have the scandal of people working full time in temporary positions. We should also implement the Gleeson report to revise the circumstances for our consultant doctors. All of these measures will show that we appreciate the work of the health staff and will restore morale.

In relation to the elderly we need to immediately improve our community care services. We should implement a central recommendation of the care of the aged report "The Years Ahead", whereby panels of district nurses would be available on a part-time basis under the guidance of district nurses and public health nurses to provide the same nursing care that is available in hospital.

I hope the Minister will state, when replying, what the new levels of subvention will be in the nursing homes arising from the Nursing Homes Bill. We need to know that elderly people will be looked after in nursing homes during the coming winter when other beds are not available. We need the appointment of more geriatricians.

Through the work of the special Dáil committee the Child Care Bill has passed Committee Stage. Before this is enacted child care services will have to be improved in order to implement the proposed changes. New facilities such as supervision orders will require extra care and social workers. We need localised referral centres for abused children. We need a larger panel of foster parents, children's courts and a national children's council. We also need sheltered accommodation for homeless children. The Bill will be meaningless when enacted unless these other services are put in place.

In relation to community care there are two appalling difficulties at present. There was a report saying that a further 300 speech therapists are required. We also need occupational therapists. The waiting lists for speech therapy are so long now that children will not get a service within their formative years.

The Minister should carry out an immediate study in relation to the health costs between North and South. According to figures given by the Minister in reply to a Dáil question it takes a little over £1 billion to provide a health service for 1.5 million people in Northern Ireland whereas in the Republic it costs £1.39 billion to provide a health service for 3.5 million people. This means that it costs £395per capita to run a health service in the Republic and £632 per capita in the North. What are the reasons for these huge discrepancies? Either we are under-funded here or they have a much better service in the North.

I regret that the Minister has still not announced major reforms necessary in the structures of the health service. The Minister is still sticking with the health boards when no later than today in the Kennedy report they have been proved not to have been the answer for the future. The report clearly recommends new structures for liaison between hospitals and community care. The current ad hoc approach is short-sighted and will not succeed in obtaining greater efficiency. We need the radical reform that this House is demanding.

I regret that despite the preparation of two more reports under the chairmanship of Fox and Kennedy, the basic inequality between the private and public patients, which led to the motion of no confidence in the Minister earlier this year still remains. Morale amongst health workers has never been lower. The vital services, particularly for children, are non-existent in many parts of the country. The waiting lists for hospital operations are still unacceptably long and in some cases the lists are lengthening. A comprehensive plan has not been put in place to meet the future crisis of AIDS and structural reforms have not been implemented in the delivery of health care. Unless the Minister acts decisively immediately, the next winter will see another crisis in the health services.

Mr. Howlin

I feel a certain weariness in rising to speak on what for many is an annual ritual. Since I was appointed Labour Party spokesperson on health in 1987 I sought to evaluate the effect of Government health policy and financial allocations on the quality of the health service that had been built up to be the pride of Ireland. All of us shared pride in our health service. The year 1987 when I was appointed to this portfolio turned out to be a significant year. The year was characterised by health cuts and savagery which has since shaped all our discussions and arguments on health issues. The shock waves of that cruel year still reverberate around this country. I get no satisfaction in July 1990 from saying "I told you so". I predicted as far back as 1987 the consequences of a policy which had a fiscal core and no health strategy, one that was devised not in the Department of Health but in the Department of Finance and implemented by a Minister who decided that he need not have a health policy at all. All of Ireland saw my predictions become a reality.

We are a caring people. It is part of our uniqueness that we care for one another and particularly for the weak and the sick. It is a tribute commented upon by people who visit this country. If we have a national consensus about anything it is that health care above all else is a basic human right.

The hospitals which this Minister closed in 1987 remain closed and the beds he closed remain shut and out of service. The staff that were available then are no longer at the service of the Irish people. However, I still have a duty and a responsibility to continually highlight the facts whenever I have an opportunity to do so in this House in the hope that the situation will be redressed. We have had some success in the last few years in highlighting the most glaring defects and deficiencies in the health services so that the Minister can try to redress them. We have had many debates on specific issues that have been touched on since.

One of the earliest decisions of the Minister was to establish a Commission on Health Funding and this important group presented a detailed and valuable report to him towards the end of last summer. The long promised response from the Government to this report is still awaited. The Minister, instead, saw fit to respond to a no confidence motion in February of this year by establishing two more working groups to give him yet more time. One group is chaired by Mr. Noel Fox and it will look into the efficiencies of acute hospitals. The second group, chaired by Mr. David Kennedy, will examine admission policies, out-patient arrangements and discharge arrangements in the Dublin area.

The Minister told the House last February that these initiatives would produce results within that Dáil session and allow him to bring more detailed and specific plans to the Government before the summer recess. Where are the plans? Where are the legislative proposals that must follow the detailed survey and analysis that the working groups carried out? When we hear from the Minister we hear about plans to establish committees or set up review groups. He has been in office for three-and-a-half years, a period longer than many of his predecessors, and he continues to try to avoid responsibility for his actions and to refer to previous administrations. He continues to avoid making clear policy decisions. Tonight the Minister told us about Professor Kennedy's review but I should like to known when we can expect to get the Minister's view, or the view of the Government, on the legislative proposals they have, if any, to address the crisis that has existed for years in the health service. The Minister should remember that he has had statutory and legal responsibility for more than three years.

The Minister's main legacy to date has been his axe-wielding. I finally received at the end of May a reply to my parliamentary question of January 30 concerning hospital bed closures. In conjunction with that I received a letter from the Minister outlining the number of beds closed from 31 December 1986 to January 1990. The Minister told me that the number of hospital acute beds closed was 2,331, that 323 geriatric beds were closed and that 221 district hospital beds were closed. It was not surprising that the Minister in the covering letter urged me to exercise caution in dealing with those figures. The result of those closures is evident to all Members and citizens.

Today I asked the Minister to indicate the number of people on the waiting lists in each health board area for hip replacements or other orthopaedic procedures, and he told me that the waiting list for hip replacement in the Eastern Health Board area was 840 and that there are 2,700 on the waiting list for other elective procedures in that health board area. There are hundreds in each health board area awaiting hip replacement and other elective procedures. The Minister cannot deny that; he supplied me with the list today. Among the thousands of people on the waiting lists are people who are suffering. I wrote to a constituent of mine this week who has been waiting for some time for a hip replacement. After contacting the orthopaedic surgeon in my area I had to tell that person that the chances of getting a hip replacement were virtually nil. I told that person that she had been on a routine waiting list since 21 April 1988 and that the list included patients who had been waiting since October 1986. I told that constituent that until her doctor certified her as an absolute priority there was no hope of her obtaining a hip replacement. I know that that person is suffering. Doctors, in trying to determine priority cases, must test one person's suffering against that of another.

At Question Time today the Minister acknowledged that there are 20,000 children waiting for orthodontic care and he had the neck to boast that fewer than 600 cases are being dealt with annually because of his extra allocation. That is a big deal.

Mr. N. Treacy

I beg the Deputy's pardon; he is out of order.

Mr. Howlin

I have said in the past that health cuts adversely affect women in particular, and they are the cares in our society. I am not asking the House to take my word for that but to consider the contents of a letter I received from the secretary of the midwives section of the Irish Nurses Organisation who could not be described as a militant with an axe to grind. The secretary asked me to bring the contents of her letter to the attention of the Dáil and to the notice of Dr. O'Hanlon. The letter states:

The midwives section of the Irish Nurses Organisation deplore the downgrading of health services for women. As a nation we value motherhood so highly that we have enshrined the contribution women make as mothers in our Constitution.

The letter lists the services that have been savaged and continues:

Women are now expected to travel long distances to avail of essential antenatal care. Prior to the health cutbacks maternity hospitals and units funded "satellite clinics" where the maternity team rendered appropriate antenatal care.

The latter is no longer available. The letter referred to the lack of follow-up after a birth and pointed out that it was now common practice to discharge women after 48 hours into the ill-equipped community services. It pointed to the lack of trained and experienced neonatal nurses, the lack of advice in relation to fertility and the ever-extending waiting lists for gynaecological operations. In fact, I received three pages of complaints from the INO in relation to the services for women. I have files upon files on the Minister's failures.

I referred to the need for services for the mentally handicapped at length in the course of a debate earlier this year, but the residential places I called for have not been provided and we need respite care for those who shared 24 hours of every day looking after mentally handicapped people. What does the Minister intend to do about them? AIDS has virtually disappeared from the agenda and we only had a passing reference to it tonight by the Minister.

I will end my contribution on health policy with a quotation from the Council for Social Welfare of the Catholic Bishops' Conference. They said:

Health policy in Ireland is at a critical point: either firm decisions are taken now about the kind of health care system we want or the drift of recent years towards a markedly two-tiered system will continue and, indeed, accelerate. The council's submission to the Commission drew attention to the fact that the trend towards a greatly expanded private system and the widening gap between it and the public system, had emerged without any public or political debate signifying that the community actually wanted it.

The people want a public health service, the Minister has failed to provide it and I demand that he respond to the real crisis that exists and not delude himself any further.

Mr. Sherlock

At the outset I should like to say that I will be opposing the Estimate as The Workers' Party consider that the amount allocated is inadequate to meet the health needs of our people. The structural and financial problems of the health services, which led to such chaos in our hospitals last winter, have not been addressed. Another outbreak of 'flu next winter will almost certainly mean a repeat of that problem with beds in corridors and patients in need being turned away. The Workers' Party have never suggested that additional money on its own would bring about a better health service. However, combined with I a restructuring of the service, additional funding could give the Irish people a health service that would be among the best in Europe. The reality is, however, that the proportion of gross national product we spend on our health service has been steadily falling and unless there is a decision to bring the level of spending back up in a planned and phased way the problems will remain.

Health spending in 1983 accounted for 7.61 per cent of GNP and was gradually brought down to 7.1 per cent by 1986. It fell to 6.6 per cent in 1987 and 6.24 per cent in 1988. By 1989 it was down to 5.72 per cent and this year it will be around the same figure. The average spending on health in OECD countries is about 8 per cent of GNP. We believe that spending on health in this country must be raised in a planned and phased way to this level. Even with this increase there would still be a need to control expenditure and to plan the most efficient possible use of our resources especially as the demand for health services is likely to grow with the changes in our population structure and the increase in the proportion of elderly people.

One of the major failings of our national health policy over the years has been its lack of long-term planning. It has been expanded where necessary on an ad hoc basis and has been cut back on an ad hoc basis when the pressure came on for cutbacks in Government spending. We need a proper long-term plan and strategy both in regard to the provision of services and how they should be financed. It is not as if we are short of studies or reports. There are any amount of them, but what has been lacking on the part of successive Governments has been the will to make the decision on long-term strategies and stick to them. The most recent example is the report of the Commission on Health Funding. This report which was the culmination of almost two years of work by the members of the commission amounted to more than 400 pages. It was published last September, but since then seems to have totally disappeared off the Government agenda.

During the debate on the noconfidence motion in February, the Minister for Health announced the appointment of two further committees or initiatives, as he described them — one headed by Mr. Noel Fox and another by Mr. David Kennedy. Six months later nothing else has been heard of these initiatives. The time is gone for committees or examinations, what is required now are decisions and commitments. I hope that as contained in the Minister's statement here tonight there will be action in this regard.

Another promise made by the Minister during the no confidence debate, was the establishment of a national patients charter. Again, nothing further has been heard of this. The Workers' Party has long sought a Charter of Patients Rights which would guarantee the right to equality of treatment on the basis of need, equality of access and care when in hospital, and information and access to personal medical records. The health services are there to serve the needs of the patients, and the Department of Health, the medical and nursing professions and the administrators must never lose sight of this important principle.

One sector, which very often seems to lose sight of this principle is the consultants. When the Gleeson Committee recommended last month huge increases in the salaries paid to consultants — providing in some cases for salaries of up to £50,000 per year — I was prepared to support them given that the other changes recommended in their contracts might lead to an improved service for the members of the public. Now we find that the consultants have rejected the proposed new contract as they consider that it might interfere with their right to earn more from private practice.

I believe that the time has now come to take a strong stand with the consultants. There must be no question of paying the increased salaries unless the consultants are also prepared to accept fully the other recommendations regarding the new contract. Consultants with public appointments should be required to treat all patients, whether public or private, on the same basis and in the same manner, that is in the same room or out-patients department, under the same conditions and from the same waiting lists. GPs in the GMS are obliged to see patients on this basis, and consultants should be subjected to the same requirements. Consultants have had a vested interest in ensuring that services for public patients were inferior to those for private patients, so that more people would be encouraged to take out private insurance and thus boost their incomes from private practice.

An Leas-Cheann Comhairle

I have allowed you be your own time-keeper. I think the time is almost up.

Mr. Sherlock

Níl, a Leas-Cheann Comhairle, Tá beagnach cúig nóiméad agam fós.

An Leas-Cheann Comhairle

Gabh mo leithscéal. Shíl mé nach raibh an oiréad sin ama agat. Is trua liom faoi sin.

Mr. Sherlock

Go raibh maith agat. The consultants must no longer be allowed to exercise a veto over improved health services for our people.

I appeal to the Minister at this time to look again at the eligibility level for medical cards. Many people who badly need medical cards are being excluded on income grounds — especially when the tax on PRSI is not deductible in assessing eligibility. Consequently many young couples rearing small children, and who are marginally over the limit, are not in a position to pay their general practitioner or to pay for drugs.

Recently I welcomed the new agreement between the Department of Health and the Federation of Irish Chemical Industries, which will lead to a 10 per cent decrease in the price of drugs supplied under the GMS to hospitals and health boards. I described the price reduction then as long overdue, as Irish drug prices have been among the highest in Europe. Drug costs constitute the biggest single item of expenditure in the GMS and hopefully the money saved will allow for improvements of services in other areas.

Many patients, however, will not benefit from the reduction in price which, it appears, will only apply to drugs supplied through the GMS. Those who have not got medical cards and who buy prescribed drugs in the normal way from their chemist shops will, apparently, have to pay the existing prices. I would ask the Minister for Health to pressurise the drug companies who have been allowed profiteer for too long at the expense of the sick and the taxpayer, to reduce drug prices for all patients.

I should like to refer to the child care case that arose in the Supreme Court. The Chief Justice in the Supreme Court criticised the absence of legal aid in cases concerning the care and custody of children.

During the debate on the Committee Stage of the Child Care Bill, The Workers' Party representative sought to introduce an amendment to provide a comprehensive scheme of separate legal aid and advice for both parents and children in such cases. The amendment was ruled out of order on the basis that an Opposition party was not entitled to propose an amendment which constituted a potential charge on the Exchequer. I am now advising the Minister that there is no restriction on him and there is a clear obligation on him to act in that regard.

An Leas-Cheann Comhairle

I am glad, Deputy Sherlock, that I did not knock you off your stride. Tá athás orm nár chuir mé as duit nuair a chuir mé isteach ort. The Minister of State has three minutes.

Mr. N. Treacy

Tá athás orm cúpla focal a rá. We are at the half way stage of 1990——

Mr. Howlin

I thought the order of the House was that the Minister would have five minutes to conclude. We have until 9.45——

Mr. N. Treacy

I can take an hour if I get the hour.

An Leas-Cheann Comhairle

The Minister will be called in about three minutes time. I am calling the Minister of State.

Mr. N. Treacy

We are at the half way stage of 1990. Progress had been made by the Minister for Health and by certain other Departments in managing our health services. Progress was made on important legislation including the Child Care Bill, which has passed the Committee Stage, the Nursing Homes Bill, which is currently being considered by the Seanad and the passing of the Control of Clinical Trials Bill, which passed all Stages in both Houses.

The Minister for Health announced additional allocations totalling £10 million to improve services for the elderly, the mentally handicapped and dental services.

The £5 million allocated to services for the elderly is being used to strengthen home nursing and home help support services, to provide increased day care, short-stay and long-stay care for the elderly and to provide additional home nursing places for the relief of families caring for dependent elderly people at home. Of the £3 million allocated to dental services, health boards have received £1 million to date in respect of the period March to June. Each health board has been asked to supply details of the use to which the additional funding was put. The focus was on treating urgent orthodontic cases and improving the services available to eligible adults and children.

A sum of £2 million of the £10 million was allocated to services for the mentally handicapped. The emphasis has been on providing additional places in residential care, respite care, day care and family support services.

The regional co-ordination committees are drawing up five-year plans in accordance with criteria provided by the Department of Health. It is expected that these plans will be available in the autumn.

The special allocation provided in the 1990 budget has already made a significant improvement in dental services. More than 5,000 adults have begun courses of routine dental treatment through the new arrangements put in place by the health boards. It is hoped that at least an additional 15,000 will benefit from the improved services during the current year, bringing to at least 20,000 the number who will benefit from the special allocation during this year.

Part of that special budget allocation was used to begin the orthodontic treatment of a further 1,300 top priority cases from the orthodontic waiting lists, in addition to the 600 we initiated earlier, bringing the total to 1,900 and not 600 to which Deputy Howlin referred earlier. That is the number for whom treatment has commenced due to special allocations made by the Minister for Health in the past six months.

The health boards have also adopted a planned strategy for the delivery of dental services for children based on the routine assessment of children in specific school classes. This approach will help to provide a better routine service for children, with early diagnosis of problems, and should eliminate differences in the delivery of services identified in various parts of the country.

The provision of orthodontic treatment is expensive. It is only possible to provide the most expensive fixed, appliance-type therapy where the orthodontic problem is of sufficient gravity to warrant the treatment. All children who apply for treatment will be assessed in accordance with guidelines drawn up by my Department with priority given to those children with the most serious conditions.

The conditions attached to the posts of consultant orthodontists are at present under review to render them more attractive to suitable candidates.

An Leas-Cheann Comhairle

I am sorry, Minister of State, the order of the House requires me to call on the Minister. I will have to get the House to agree if we are going to alter that arrangement.

Mr. N. Treacy

I am replying on behalf of the Minister.

An Leas-Cheann Comhairle

Is the Minister of State making a complete reply?

Mr. N. Treacy

Yes, I am.

An Leas-Cheann Comhairle

I took it that the Minister of State was coming in until such time as I called on the Minister to reply.

Mr. Yates

Is the Minister going to speak in the debate again?

An Leas-Cheann Comhairle

The House must agree. The order of the House is that the Minister would be called on to reply and would have five minutes in which to do so. Three minutes ago I called on the Minister of State. I thought he was going to speak until I would then call on the Minister to reply. What is the position?

Mr. N. Treacy

The Minister to reply, of course, a Leas-Cheann Comhairle.

Dr. O'Hanlon

I might deal very briefly with some of the points raised. Deputy Howlin implied that I do not have a health policy. He also accused me of buying time by establishing groups such as those led by Professor David Kennedy and Mr. Noel Fox. I resent these assertions; they are untrue and distorted. Indeed if the Deputy could bring some objectivity to bear on the issue he would accept that, after a period of particular and unavoidable difficulty, I might add, caused by the Coalition Government in office before us——

(Interruptions.)

Dr. O'Hanlon

We have now entered a period of steady renewal perhaps not sufficiently dramatic for the Deputy but acknowledged by those who have no particular axe to grind. I have a very close idea of where I want the health service to go and I am not going to be deterred——

(Interruptions.)

An Leas-Cheann Comhairle

We talked about Standing Orders giving the Minister five minutes in which to reply. Is he going to have them? I can advise the House that I will be asking anybody who is not disposed to listen to leave. I am not going to repeat that.

Mr. Howlin

I would suggest to you that if any other Member of the House was being argumentative you would have pointed that out, too.

An Leas-Cheann Comhairle

The Chair needs no such reminder from the Deputy or anybody else. I shall do that. The Deputy reminding me will not exclude him from whatever action I might take. The Minister without interruption.

Dr. O'Hanlon

Certainly I will not be argumentative but I have to point out the facts.

One thing I would like Deputy Howlin to do is give me the name of the patient he maintains has been waiting since 1988 for treatment because I will be glad to investigate that. It has not been my experience that people now wait that long on the orthophaedic lists. Indeed in this House a member of Deputy Howlin's party came in here one morning and spoke about a patient having travelled 40-miles, fasting to hospital, and having sat there all day, returning home without having anything done for him. When my secretary telephoned the Deputy in question asking for the name of the patient, he said there was no such patient but that was the sort of thing that might happen.

Mr. Howlin

The Minister should not ascribe to others——

Dr. O'Hanlon

We would want to be careful that that does not recur. I have worked to a policy since assuming office. I rationalised the hospitals. We have built up the larger hospitals with those no longer needed being closed. The Deputy is wrong in saying that all the hospitals that were to be closed have been closed. A number of them, such as Kilrush, Ennistymon, Brownswood in the Deputy's own county, are all open at present.

Mr. Howlin

Brownswood is a private hospital.

Mr. N. Treacy

It is a hospital.

Dr. O'Hanlon

Community services were developed, with more money for the elderly and for the dental services. On drugs we reached an agreement with the Federation of Irish Chemical Industries. It is all right for Deputy Yates to come in here and cry crocodile tears about that might have been done.

Mr. Yates

The Minister said there were no savings to be made.

Dr. O'Hanlon

What did his Government do when they introduced the first agreement? His Government introduced the agreement that obtained until this year——

Mr. N. Treacy

They did nothing about it.

Dr. O'Hanlon

——when we improved the agreement. As I have already said, the drugs refund scheme will be of particular value to all patients with chronic illness including asthmatics.

The psychiatric services have been developed on a community base over the years despite the restraints on finance. My colleague, the Minister of State, has already referred to mental handicap. While there has been a 13 per cent increase in inflation there has been a 25 per cent increase in the allocation to the voluntary organisations dealing with mental handicap.

With regard to AIDS, when I assumed office there was a mass media programme which had been ready for a number of months beforehand. The then Government were afraid to introduce it; the two parties in Government could not agree on it——

Mr. Yates

The Minister had pamphlets published and they were held back at the last minute.

Dr. O'Hanlon

Within two months of assuming office I introduced that mass media programme. I am glad to say that our methods of prevention, diagnosis, treatment and management of AIDS compare favourably with those adopted worldwide. Deputy Yates went on radio about three weeks ago and called for compulsory anonymous testing in this country, the only country in the world——

Mr. Yates

No, I called for anonymous testing.

Dr. O'Hanlon

The Deputy did; it is on the records of RTE.

The Gleeson report has been referred to already. Because of the time constraint on me all I can say is that I intend to persevere with what is a most rewarding if difficult task.