Dáil Éireann debate -
Tuesday, 18 Dec 1990

Vol. 404 No. 1

Supplementary Estimates 1990. - Vote 42: Health.

Minister for Health (Dr. O'Hanlon)

I move:

That a supplementary sum not exceeding £37,550,000 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.

Deputies will have available to them details of this Supplementary Estimate and I do not propose to outline the provisions in detail. In the time available to me, I propose to highlight the four main aspects of this additional provision, namely, the additional provision £23.05 million in respect of acute hospital services; the provision of £13.251 million in respect of the general medical services scheme; an extra capital provision of £7 million and an injection of £9.749 million to improve the cash provision of the health agencies in 1990.

Deputies will recall that, in February last, I gave an understanding to meet the additional costs incurred by health boards and hospitals in dealing with the `flu epidemic, which occurred at the end of 1989 and the beginning of this year. I also gave an assurance that acute bed levels would be maintained at around 12,000 as compared to a figure of 11,200 in mid-1989, and that activity levels would be held at those prevailing in the latter half of 1989. I am glad I have been able to honour these commitments in full, and the provision included in this Estimate reflects the costs involved.

During 1988 and early 1989, the Government were severely criticised about waiting lists. Indeed, it became so pervasive that, at times, one would think that the health services had ceased to function. I made a particular point of tackling waiting lists as part of the programme of work undertaken with the additional funds which were made available to acute hospitals in 1989.

Waiting lists are a feature of all health systems throughout the world. Among the factors influencing waiting lists are the increasing demands from an ageing population and the development of new forms of treatment such as hip replacements. To some extent, they are a problem of success. In this country, the waiting lists for most specialities are not excessive but I accept that there are some areas which needed to be addressed, particularly orthopaedic and ENT.

I am satisfied that the additional £15 million which was provided for the health services in 1989 enabled a substantial increase in activity on the previous year's levels and, consequently, a significant reduction in long waiting times.

Steady progress has been made in a number of key areas and I am committed to building on that work. For example, the number of hip replacement operations performed nationally has increased from 1,624 in 1987 to 1,904 in 1989 and I am confident that the figure for 1990 will reflect a continued substantial increase in performance.

In relation to ENT, very satisfactory results are being achieved. The waiting list and waiting time for Temple Street Children's Hospital has shown very dramatic reductions over a short period. On 1 November 1989 the list was 1,228. On 1 November 1990 it was 550 — a reduction of 55 per cent. The throughput for the period 1 January 1990 to 30 September 1990 was 1,310 as against 913 for the same period last year — an increase in activity of 44 per cent.

The waiting time for ear procedures at the hospital at present is a standard four weeks. With the present rate of progress in relation to tonsillectomies, the waiting period will have been reduced to under two months by mid-1991. Another example of where significant improvement has been achieved is in the South Infirmary — Victoria Hospital, Cork. The ENT waitiing list there has been reduced by over 60 per cent in the period October 1989 to May 1990.

I have been particularly concerned by the problems of child deafness and I specifically targeted additional funds to alleviate this problem. I am pleased to report that as a result of these measures children needing grommets are attended to within a period of six months. These are specific tangible results which are being achieved as a result of initiatives taken last year and continued throughout 1990. They are part of an ongoing programme for reducing waiting times and I propose to continue to build on this progress.

There is a particular challenge to those who manage the considerble resources of acute hospitals to strive for efficiency in their use. It is my intention to pursue with all agencies a vigorous value-for-money programme throughout the system to ensure that the maximum benefit is achieved for every pound of public funds invested in the system. The reports furnished to me by Mr. David Kennedy and Mr. Noel Fox will be particularly helpful in achieving the results which are necessary and desirable. I would like to take this opportunity to thank them and their teams for the splendid work they have done during this year.

I look forward to working with health boards and hospitals in 1991 to achieve savings in those areas which have been identified as likely to yield results. I am committed to supporting agencies and their managements in this vital task and I am very pleased that all savings achieved in 1991 will be used in the system for the good of those who rely on it for services.

The additional provision of £13.251 million is required to meet the additional cash requirement of the general medical services (payments) board which will arise in the current year. While the revised remuneration package for participating general practitioners, introduced in 1989, has operated very satisfactorily, I remain concerned at the increasing cost of drugs. The increase in costs in 1990 has arisen not so much from the level of prescriptions written, although this is a contributory factor. Rather the increase is a function of the type of drug prescribed. While I accept that the ever increasing complexity of treatment and the fact that new drugs are available for the management of previously untreatable conditions, I feel that we can still obtain better value in the purchase and usage of drugs.

The new price agreement with the Federation of Irish Chemical Industries is working satisfactorily and a new drugs formulary will be issued shortly. The general practitioner will remain the key determiner in the control of drug costs, and this role will receive prominence in the ongoing review discussions with the doctors. I hope there can be early agreement on an effective arrangement for the containment of expenditure on drugs and medicines, consistent with the overriding need to provide appropriate therapy to each patient.

A total provision of £7 million has been made in this Estimate in respect of capital expenditure — £6.2 million for building and equipping and £0.8 million for the development of information systems. This will enable my Department to meet binding commitments which have arisen during 1990.

While there are many needs for capital to enable the existing service to be maintained and to allow for very desirable developments, it is not possible for the Government in the current financial climate to provide other than for contractual obligations and essential works, such as fire precautions. During 1990, I have conducted a very thorough review of the capital needs of the health services and I remain committed to introducing a five year programme for capital expenditure.

My priority is to ensure that the fabric of the existing service is maintained so that services can continue to be delivered in an effective and efficient manner. We must also ensure that each capital development is planned so that the revenue cost will be tolerable and that we strike a wise balance between what is desirable and what is affordable.

I am very pleased to provide some additional funding for the development of information systems. This investment is essential if we are to improve the management of acute hospitals, which are difficult and complex entities.

The Supplementary Estimate provides for an additional £9.749 million in respect of balances of grants for years prior to 1990. These balances represent a cash injection which have a permanent beneficial effect on the liquidity of health agencies. This injection will allow the agencies to improve their efficiency in the disbursement of cash and will result in more timely payment to creditors. The taking of credit from suppliers is often seen as "free goods", but this is far from the truth. Suppliers who are made to wait for payment inevitably reflect this in their prices.

Continuity and regularity of supplies is also critical in the health services and these can be threatened if suppliers can transfer to customers who can pay more promptly. The provision of an adequate level of cash in health agencies is essential, if progress is to be made in maximising efficiency from purchasing and the management of supplies.

The Supplementary Estimate also provides for a bonus payment of certain health cash allowances this month in line with the long term social welfare allowances. Provision has been made for an additional £1.45 million to be allocated to a range of minor subheads in the Health Vote. The increases are due to a variety of factors such as additional consultancy contracts, changes in exchange rates affecting contributions to international organisations and additional costs associated with the EC Presidency.

The original Estimates for appropriations-in-aid have been exceeded by £18 million and this sum can now be offset against the additional gross provision now sought. An additional £14.5 million is available from health contributions and this is a reflection of the buoyancy in incomes generally.

This country is a net beneficiary under EC regulations applying to migrant workers and additional receipts in this area will be £3.5 million. The buoyancy arises as a result of a number of factors including currency fluctuations.

Mr. Yates

This is the first opportunity we have had to review the performance of the health services in 1990. I regret that while there has been some modest improvements in some areas such as ENT, the overriding position is one of inequality of access, long waiting lists, gaps in our services and people having to wait for intolerable periods for basic health services.

The Minister referred to hospital waiting lists but he omitted to mention cardiac surgery or neuro-surgery. I will return to orthopaedic surgery later. In relation to cardiac surgery, we have over 1,000 public patients on the waiting list at the national centre for such surgery. The waiting period is too long and the lives of people on the waiting list are at risk because of the length of time waiting for operations. This was discussed previously in the House and I understand that the consultants have now issued an open letter to the Minister arising from his last comments on the matter, refuting what the Minister said. I ask the Minister to reflect on the position whereby people who can pay privately for treatment can walk into an operating theatre in the Blackrock Clinic or the Mater Private for cardiac open heart surgery whereas public patients have to wait at least a year, and maybe two and a half years, for treatment. There are only two operations per day and people cannot gain access in good time.

There is also a waiting list for neuro-surgery at Beaumont. There has been a reorganisation of the neurosurgical services whereby the unit in St. Vincent's has closed and moved to Beaumont. There are only six consultants there and there should be eight. There is a delay of up to a year for those waiting for neuro-surgery relating to the spine. I have spoken to consultants about this. There are people with acute back pain who cannot get back to work and they have to wait a year or more for treatment. Priority relates to brain tumours, other head related cases and the trauma cases arising out of car accidents. This means the elective procedures have to wait too long.

The Minister congratulated himself on the position in relation to orthopaedic surgery and said the number of treatments increased by a modest 300 but this bears no relationship to the need or demand. In the south eastern health board region constituents at Kilcreene Hospital are waiting up to three years for hip replacements. Some of them have been classified by their GPs as priority cases. The position is the same in regard to other joint replacements. That is unacceptable. I have been advised by the orthopaedic surgeons that because of the number of trauma cases they do not have sufficient capacity to make any inroad into the waiting list. The waiting list position as regards hospitals is still totally inadequate.

I regret very much moving outside the direct hospital area but I wish to point out that the Minister made no reference in his speech to some of the major problems in the health services at present. I refer initially to the area of mental handicap. We have had street protests, Dáil debates and budget submissions seeking additional resources for residential and day care centres for adult mentally handicapped people whose parents are no longer able to cope in the home. The situation is that there is not adequate money to guarantee these people, whose parents may pass on, a place. They are facing a crisis and their pleas have been ignored.

Another area which the Minister failed to mention was that of speech therapy. A report was produced a little over a year ago which stated we need an additional 331 speech therapists. The waiting lists for speech therapy are so long that children, in some cases, cannot properly fulfil their obligations to go to primary school due to speech deficiencies. Parents have written to me pointing out that their child is not sufficiently advanced at five or six years of age because of speech impediments to take up a place in national school. It is because of the shortage of speech therapists that the waiting lists are so long. Children cannot be treated on time. A similar position applies in relation to dental care by the health boards. More than 15,000 children are waiting for orthodontic care. No changes have been put in place to facilitate the children requiring urgent treatment.

Last week we debated legislation dealing with child care. We now have international figures to show that child abuse is at a minimum of around 7 per cent or 8 per cent.

Mr. N. Treacy

That is grossly exaggerated.

Mr. Yates

That is not my figure, it is an international figure that was well publicised last week. With the new legislative measures there will have to be additional resources for social workers, there will have to be local referral centres and proper family counselling and back-up support services for deprived families where children are at risk. I see no intent on behalf of the Minister to cater for this area and, therefore, I must express deep concern.

I would like also to refer to the last part of the Minister's contribution where he said:

An additional £14.5 million is available from health contributions and this is a reflection of the buoyancy in incomes generally.

I was advised by officials in the public sector — not in the Minister's Department — that in relation to 1989 an extra amount of £7 million in health contributions came in during the post-tax amnesty period. This year the figure will be £14.5 million. There is an excellent case for the Minister to say to Cabinet that this money should go to the beleagured health service. People are paying this money on the understanding that it is a contribution towards the health service, without being an entitlement. It should be clearly established Government practice now, and in the future, that any surplus money from health contributions, be they on an arrears basis or on a current year basis, should go to the net benefit of the Department of Health. The icy hand of the Exchequer will always grab any loose revenue which is available. This does not reflect the demand and need in the health services for extra resources.

There is one aspect of cost overruns I am very concerned about in relation to the Supplementary Estimate; it relates to the overrun in the GMS. I am referring to expenditure on drugs for medical card holders through the GMS payments board which shows an overrun of £13.25 million. This is very serious. The Minister has congratulated himself on the deal he negotiated with the Federation of Irish Chemical Industries, leaving aside the fact that he said such a renegotiation was not possible during the last election but I am still most dissatisfied with the position in regard to drugs. I would draw to the Minister's attention the position in Sweden whereby, in a very simple way, millions of pounds have been saved. On the doctors prescription form there is a blank square and unless the doctor puts a tick in that square a generic drug is used by the pharmacists in dispensing that prescription.

An Ceann Comhairle

I am sorry to interrupt the Deputy but I want to remind him that less than one minute now remains.

Mr. Yates

I would like to conclude by saying that unless the doctors feel strongly that a branded drug should be used, otherwise a generic drug should apply. This simple measure would save money as generic drugs cost up to half the price of branded products. I realise this is a very limited debate and looks only retrospectively at 1990. I will be contributing to the 1991 Book of Estimates and my party will be opposing this grouping of Estimates because of our continued dissatisfaction with the state of the health services.

Mr. Ferris

In speaking to these Supplementary Estimates I assure the Minister that while I have no objection to additional spending on Health one is forced to ask questions on the planning of the health spending which at this time of the year shows a shortfall of some £37.5 million. This shortfall is in a very sensitive social spending area which is still experiencing the effects of previous drastic cutbacks. The Minister chided the Opposition in his contribution when saying that the demands on the services almost indicated that they were not in operation at all. The reality in the delivery of the service is that if one needs an urgent service or tries to contact a consultant or a hospital one is led to believe that the health services have ceased to operate. We are unable to respond to the legitimate demands of people who are in need of urgent attention.

When one looks at the overall spending on Health which is still suffering from cutbacks, one notes that we still have closed wards, understaffed hospitals and long waiting lists for acute procedures, some of which have been identified by Deputy Yates, including cardiac procedures and hip replacements in all our orthopaedic hospitals. There are long waiting lists and many people in pain. Consultants admit that they cannot fit these people onto an already overloaded waiting list. There are unusually long waiting lists up to six, seven or eight months, for ENT and many other surgical procedures. These essential operations should be carried out as quickly as possible in the interests of the patients concerned.

Deputy Yates also referred to the services for the handicapped. These have been the subject of representations made to us by the many organisations dealing with the handicapped. Only last week I raised on the Adjournment the need for up to 2,000 places for adult handicapped people. In spite of the provision of an additional £2 million in this year's Estimate, there is still a crying need for improvements in this area. The Government will have to give serious consideration to the problems in this area.

There is also a need for the services for old people to be improved. People in my constituency, the south east and many other areas were privileged to have had access to sub-acute hospitals after acute treatment but because of a lack of sub-acute or district hospitals such patients are now being forced to live with their relatives who in many cases cannot look after them. The State is unable to provide adequate geriatric accommodation or welfare home type accommodation for old people. Major progress was made in this area in the past but this has now been stopped and old people are being forced to live with their families or go into private nursing homes which have not yet benefited from the provisions in the new Nursing Homes Bill. Old age pensioners have to pay up to £60 or £70 per week for accommodation which should be provided for them by the State. These people are entitled to this service under the 1970 Act. Even though they have made contributions throughout their working life the Government still cannot meet the demand for this type of service. We cannot rest on our laurels and say that major improvements have taken place in the services for the old and the handicapped if further improvements are needed in these areas.

The problem of AIDs has not been seriously addressed. In spite of the Minister's efforts in this area there is still a perception in the minds of those dealing with AIDs patients that the £7 million which the Department let slip through their fingers could have been directed into this tragic area.

I want to refer to the lack of transport for people in rural Ireland who live far away from acute hospitals and who have to pay up to £25 for transport to a hospital or clinic. These services were available to people up to 1987 but the new system of medical card allocation has resulted in many cards being withdrawn from people who were on the borderline. Even people with serious illnesses, for example, those with major heart defects and people on kidney dialysis machines, have had their medical cards withdrawn from them. There seems to be a belief among health board officials that if a patient is on the borderline his medical card must be withdrawn from him because the system of payment to doctors under the GMS scheme has been changed. There is a need for us to look at the new guidelines and re-evaluate the needs of patients before we create hardship for them. We should also look at the freedom of chief executive officers to make a decision on hardship grounds. People with serious illnesses who need special care and attention and continuous medication should be given special consideration, even to the extent of disregarding the income guidelines.

I am also concerned at the extraordinary cost of drugs in the health service. Some improvements have been made in this area and the Minister has promoted — I was with him when he did this — a generic system of prescription. Many companies in my constituency and elsewhere can produce adequate drugs, properly priced without profits being creamed off by manufacturers in the UK and elsewhere.

The Minister referred to the additional cost for the influenza vaccine. Is the Minister not aware that at present there is practically no influenza vaccine available for people in the south east? According to information given to me by doctors, neither the health boards, health board clinics, GPs nor chemists have this vaccine. If the flu vaccine is to be of any value to old people it should be made available to them at this time of the year. The Minister should address this issue as a matter of urgency. I have been forced to put down a parliamentary question to the Minister asking him if he is aware of the problems in this area.

The cutbacks in the health service have also meant a diminution in the opportunities available for nurses. The large-scale closure of hospitals created many redundancies in the nursing area and nurses were forced to emigrate to Iraq and elsewhere. Up until recently the lives of those working in Kuwait were put at risk. If the Government provided jobs at home for these nurses they would not have to emigrate to Iraq and other parts of the world to get work. They should be able to find work in this country which needs better health care and hospital services.

We will have an opportunity during the debate on the 1991 Estimate to consider how health funding can be better managed. We on this side of the House will highlight deficiencies in this area in a constructive way in the hope that by working together with the funds available or additional funds we will be able to improve the service given to people who have paid for it under the VHI scheme when they were working. It is our duty to ensure that our health services cannot be criticised as they have been rightly criticised in the past. There should be no question marks about this sensitive area of care. I hope any efforts we make to remedy the needs we see in this area will be met by a proper response from the Minister.

Mr. Sherlock

The Workers' Party will be opposing this Estimate because we believe the amount allocated is inadequate to meet the health needs of our people. The structural and financial problems in our health service which led to such chaos in our hospitals last winter, and which were never really addressed, are likely to be repeated if there is another outbreak of flu this winter. The Minister said he had made good to the health boards the amount of excess expenditure involved. There was no evidence at the most recent meeting of the Southern Health Board which I attended to suggest that that money had come into the coffers of the health board. There will be a shortfall of about £2.5 million in that health board this year.

The only way in which the Government can address the problems in health policy and funding is to increase the level of funding to what it was in the early eighties. In 1983 health spending amounted to 7.61 per cent of gross national product and was gradually brought down to 7.1 per cent by 1986. It fell to 6.6 per cent in 1987, to 6.24 per cent in 1988 and was reduced further in 1989. Therein lies the problem. In other OECD countries health funding accounts for 8 per cent of gross national product.

As has been pointed out, there is a shortage of beds and staff in our acute hospitals. The severance or redunancy package which was operated in 1987 left the health boards short of staff. As a result, a reduced number of beds was available. If we wish to increase the number of beds available in acute hospitals we will first have to increase the number of staff. The embargo should be lifted straightaway and the only way to do this is to increase the funding available to the health boards to enable them to employ the nursing and general staff required.

I would now like to deal with the area of mental handicap where one has to take account of the knowledge and experience of professional groups. We have received a submission from a group of social workers representing the Irish Wheelchair Association, the Spastic Clinic, the Multiple Sclerosis Society and others, in which they state:

We are becoming increasingly aware of the discrepancy between the demand for and the availability of services to meet the growing number of young chronic, sick and disabled people. There are two groups about whom we are concerned. One group consists of 110 people living at home and potentially at serious risk and the other group consists of only seven people whose families can no longer cope.

I have also been advised that people with little babies who are mentally handicapped have been told within the past week by the Irish Wheelchair Association who provide them with a home help service that the number of hours they will be able to give them in 1991 will be greatly reduced because they cannot raise the money to provide the service and the health board are not in a position to provide the shortfall. The recipients of this service, the caring relative, are afforded the opportunity of a daily or weekly break from the continuous demands in caring for handicapped persons at home — such demands include the washing, dressing, toileting, feeding and a wide variety of other tasks. This little bit of relief being provided by a small number of social workers to so many families is also being withdrawn and this is very serious.

In relation to the care of the elderly, the cruel face of monetarism is now being turned on the patient in need of full-time care and attention. It now seems to be the policy to tell these people, having occupied a respite bed for a fortnight, they have to go home because they need the bed for some other patient. I am aware of three people living in a small area who are in need of full-time care and attention. It is clear that we are not adequately looking after our elderly who have many fears and experience trauma.

Reference has been made to the increased cost of running the GMS scheme. There appears to be a determined policy to reduce the number of medical card holders, even though it will cost far more to run the scheme as a result. Let me give one example. Let us take the case of a husband and wife with three children with an income of £150 per week. Under this scheme the maximum such a family are allowed earn is £144 — £108 for the husband and wife and £12 for each of the children. Therefore, this family find themselves £6 above the limit. Bearing in mind that out of this income the family have to pay £10 in rent and many other expenses, can this family afford to provide a medical service for themselves and their children? The answer is no. As a consequence, they will find themselves in a very serious position. I can assure the Minister that this is happening and ask him not to shake his head. Unless the Minister makes provision for tax and PRSI to be deductible in assessing eligibility for a medical card this will continue to be the case. It is a disgrace that it cost more to run this scheme with a reduced number of people being provided for. It is obvious that there is something radically wrong with the scheme.

In addition to dental treatment, time and again the Minister has outlined the amount available for orthodontic treatment but I would remind him at this point in time an umpteen number of patients are being turned away from local clinics as the people concerned are deemed ineligible under the guidelines laid down by the Department for orthodontic treatment. These guidelines, which were introduced many years ago, should now be withdrawn as they are completely out of date and many young children who are in need of such treatment are not receiving it.

The Minister referred to both the Fox and Kennedy reports but I have not seen either. Even though the Fox report dealt with the regional hospital in the Southern Health Board area I have not seen it. The Minister also stated that he would introduce a patients' charter of rights but we have seen no sign of this. He also stated that he would put an appeals system in place to allow those, whose applications for full eligibility were disallowed, to appeal the decision but, again, there was no sign of this in the past year. I should also mention that the recommendations in the report of the commission on health funding have not been implemented. We have now reached the stage where people do not know what lies in store for them if they get sick.

There is an insufficient number of acute beds in our general hospitals while insufficient finance is being provided for hip replacement operations, for orthodontic treatment, for mentally handicapped services, for the care of the elderly and a whole range of other services, with the result that an inadequate service is being provided and this has to be rectified. The only way to do this is to increase the amount of funding available for the health services. The sum being provided is not adequate.

An Ceann Comhairle

I call on the Minister to reply. As the House is aware, the debate on Vote 42 on Health concludes at 11.30 p.m. The Minister has a little over two minutes.

Dr. O'Hanlon

It will not be possible in the space of two minutes to deal with all the issues raised but a number of trends run through this and other debates. The first thing I should say is that I am not surprised Deputy Yates decided to run against his colleague, Deputy Bruton, for the leadership of the Fine Gael Party as their ideologies lie at both ends of the spectrum. Deputy Bruton has spoken about the need to save and conserve money and the need not to spend money one does not have, while Deputy Yates has, week after week, come into the House and spoken about the need to spend not just £500,000 but £7 million, £8 million and £10 million on various services. Therefore I am not surprised he opposed his colleague.

At all times I have said that I would negotiate with FICI and I am glad to say I have negotiated with them on two occasions very successfully — much more successfully than my predecessor in office. Deputy Yates always seems to distort — Deputy Ferris was at this again this morning — the amount of money available under appropriations-in-aid. They alleged that £6 million of the amount available in 1989 was not spent. I should make it clear that every penny voted by the Dáil for the health services in 1989 was spent by us.

Mr. Yates

That was a windfall.

Dr. O'Hanlon

The Deputy should know at this stage — perhaps he is being mischievous — that we introduced an Estimate last year and every penny under the heading of appropriations-in-aid was spent. This Estimate is for a sum £55 million greater, yet the Deputy has repeated the allegation today that there is money available which we could spend if we had a wish to do so. I should make it clear that every penny that this House votes for the health services is spent. I deplore the consultants who have told Deputy Ferris that an urgent medical service is not available to those who need it as such a service is available. I have always admitted that there are waiting lists for certain procedures. Indeed, I dealt with a number of them this morning, including the waiting lists for hip replacement and ear, nose and throat operations.

Reference was made to the question of the lack of opportunities for nurses. The number of people working in the health service today is 2,000 greater than the number in 1989. An extra £3 million has been provided for the dental service in the current year. We have a substantial record.