After four years of management of the health services by this Minister, we are once again in 1991 back to a health crisis. The health boards have been left short of funds necessary to just maintain their level of services of last year. They are an estimated £20 million short. The result of this thoroughout the country will be fewer admissions to hospitals for elective-surgery with the inevitable lengthening of waiting lists. In one health board, for example, there will be up to 7,500 fewer admissions this year, there will be fewer residential places for those who can no longer cope at home, there will be extra strain on nursing care and there will be fewer support services for those in the community.
Similarly in the voluntary hospitals we are facing a crisis once again as exhibited by the recent situation in the Dublin hospitals where the accident and emergency admissions system has run into complete chaos. We have as a result — it has been documented — inadequate supervision of patients who are being left unattended on trolleys, often overnight in humiliating circumstances, and many are forced to stay for very long periods.
We are looking at the position in 1991 where the existing chronic waiting lists for services for mentally handicapped persons will worsen. Hundreds are already without service and thousands are facing inadequate service levels for their needs. The reality is that the cuts which the Minister for Health is imposing this year are unplanned and poorly thought out. They are a stab in the dark and a hope that the consequences will not be too bad, when the reality is that they have scant regard for the families who will have to cope with the consequences of longer waiting times and the early discharge which is an essential consequence of these budgets.
There are very notable examples in the various health boards of what will happen. The South-Eastern Health Board report that they will be reducing admissions by 7,500 patients this year compared to the levels which the Minister is forcing them to cut back to. This will result in their waiting lists growing again after a short period when there was a slight decline.
In the Southern Health Board two hospitals will see 1,700 fewer admissions. In the Midland Health Board 70 long-stay geriatric places will be closed and 20 staff will be let go, although the chief executive officer told the board there is a very strong case against this loss of staff. Again in the South-Eastern Health Board we are told of the release of psychiatric patients into the community, although they admit there is not the required development of back-up services to cope with these admissions in the community. Every board reported that they will not be able to develop any new community care services. This comes at a time when the Minister has declared his priority for the development of community care. No improvements will occur in 1991, outside the small number of areas where the Minister has offered special budget provisions.
There is a supreme political irony that this Minister for Health who, in 1989, shielded the Taoiseach from the reality of the health crisis should again, in 1991, a local election year, choose to squeeze out of the service the small improvements he has allowed since the last election which were wrung out of him by the political reality of what was facing patients. Perhaps later this year we will see a drawing realisation about the health crisis.
Some of us looked to budget day as a day we thought there would be some breakthrough in the health allocation. I know many social partners who looked to the health budget to see of very substantial sums made available, were treated to what I would regard as a complete sleight of hand on the part of the Minister that fooled no one. He announced on budget day, and sought applause, for an extra £8 million for dental care, care for the elderly and care for the handicapped. However, when you read the small print of this year's Budget Statement you discovered he was actually taking £4.5 million out of the health services, he was taking £2.5 million in economies which he refused to specify, he was taking £5 million in unspecified restructuring of borrowing — which again he refused to specify — and he was taking £5 million in extra public contributions for health that were being pocketed by the Exchequer.
We are really back to the old days of creative accounting, phantom efficiencies, putting off the evil day where debts are paid, and taxation by stealth. That was the essence of this year's budget announcement in the health area. Even some of the announcements were fraudulent. We heard that another £3 million for dental services was being allocated but the reality is that that was only restoring an equivalent cut that was built into the Estimates given to the health boards.
Since budget day the Minister has shrugged off the reports from the health professionals and contemptuously dismissed their appeals for a reassessment of their funding requirements. Only last week we thought we saw a chink in his armour, that perhaps he was having a change of heart, we heard that maybe he was going to restore £10 million to the health boards. I am extremely sceptical about the reality of this because from what we have heard the Minister's plan is that the money is to be found elsewhere in the health budgets. I cannot look to any year in the health service and see where the Minister will find these savings.
The voluntary hospitals, the other major area of spending, are in deep trouble. In the last few weeks we have seen total chaos in the accident and emergency departments of those hospitals. We have seen detailed reports from professionals in the Mater Hospital of the inadequate supervision, of the inability to monitor patients appropriately and of the chronic overcrowding in cubicles — of more than one to a cubicle — and where patients have to remain overnight on trolleys. As that report indicated this is humiliating treatment for patients at a time when they are at their most vulnerable.
Last year the Minister commissioned a special committee under David Kennedy to report on this. They reported urgently in the middle of the year on what needed to be done. They indicated the lack of adequate observation wards, the need for a greater allocation of experienced staff, the delays in the turn around of results from diagnostic tests, the cumbersome assessment procedures, etc. All the problems were listed. The Minister was to see that the necessary changes were in place by 1 October 1990 at the latest. Clearly the Minister failed to deliver on this as in so many other areas.
Catering for the accident and emergency departments is not marginal in the business of a hospital, that is the essence of their job. Almost half of all admissions to hospital are coming through the accident and emergency departments. This is the time when people are at their most vulnerable. It is not acceptable that the Minister permits a situation where a short cold spell can throw the system into complete chaos, as we have seen in recent weeks.
The tragedy is the way this Minister has presided over our health services where sacrifices have been squeezed from patients, but these sacrifices have been in vain. We have had four years of persistent savings, but in that period the Minister has failed to undertake any fundamental reform that could hold out the vision for people of a better health service. In every area the Minister has refused to act. He refuses to specify health service targets which the health agencies could aim for and against which we could judge their performance. He still uses crude cash controls that fall most heavily on the front line services, and have the consequent effect on patients.
Budgeting for our hospitals and other health agencies remains entirely divorced from their actual achievements in the provision of service. We have seen the two speed health system become more entrenched in the period of this Minister's care for the service. The Minister has even failed to get to grips with the efficiencies that can be achieved easily from the system, in areas like energy, management and the use of drugs.
It is depressing to see that this Minister consistently refuses to put forward plans for the restructuring of our health services. He persists with the cumbersome system of administration from eight health boards which has resulted in a system that is over-administered but under-managed. This failure could be forgiven if the need for action was unknown, but the reality is that the Minister's own Department signalled the direction of reform quite clearly in a document published in 1986, Health, The Wider Dimensions. The Minister inherited a charted course on his desk as to the reforms that were needed. In every area that document indicated the reform in the system needed but the Minister has not moved in any of these areas. Instead of taking action he has piled up more and more consultancy reports. The names of Fox, Kennedy and the Review Group on Mental Handicap trip from his lips as if the mere mention of their names meant that there was reform, change and a better service. These are just more in a long string of reports and the only thing which extinguishes them is that they have not yet had the opportunity to gather dust on shelves.
The Minister expects a gullible public to believe a new display of rhetoric, the pledge in the Programme for Economic and Social Progress that he will develop community care services. The reality is that there are very shallow foundations to the Minister's declared priority for the development of such services. A promise was made in that document that a sum of £100 million would be invested in community care facilities over seven years. However, none emerged in 1991. On the contrary, several requests by health boards for urgent new community care developments were turned down.
On day-to-day spending, the Minister imposed cuts on the budgets of community care providers which were much tighter than those imposed on hospitals. The major hospitals got an increase of over 10 per cent in their allocation, whereas most of the community care services have to make do with virtually unchanged budgets in 1991, despite escalating costs. This makes a nonsense of the Minister's often made claim that he will make extra moneys available to community care rather than to hospitals.
The cruellest cut of all has been reserved for the parents of mentally handicapped children where the Minister halved the allocation in the budget for their needs. The parents of mentally handicapped children have had to take to the streets to highlight the crisis they are facing. As I said earlier, hundreds of mentally handicapped children are without any service and thousands of them are inappropriately placed. Nationally there is an immediate need for 800 extra residential places and 1,000 extra day places. The cost of this runs to about £23 million. It is against this background that we must judge the Minister's allocation of £1 million in 1991, the first year of the much vaunted seven year programme. This sum is an insult. Waiting lists will get far longer for the mentally handicapped and their carers this year. The treatment being meted out to the carers of the handicapped is shameful and a major blot on a society that regards itself as caring.
Many aging parents who have to care for their handicapped children are driving themselves into the ground trying to cope, with far too little help. Many have not had a break in years and they face huge uncertainties in the future. Even the basic support services which one would expect should be provided for people caring in the community are not available to them. For example, only 155 respite places are available, as documented in the recent report by the NRB. This means that fewer than half of the parents of mentally handicapped children can get a break from caring. A similar situation exists for those parents caring for physically handicapped children.
The carers' allowance is a sick joke. It is only paid to parents who are on the bread line, that is, if they earn less than £100 per week, below the minimum income level dictated by the Commission on Social Welfare as constituting a subsistence level. The mentally handicapped do not have automatic eligibility for free doctors' care and they face rationing on essential items such as nappies. Specialist services like speech therapy, occupational therapy and physiotherapy are hopelessly overstrained and the Minister does not have any long term plan in this area. He did not indicate in the PESP any service targets which would be achieved and gave no commitment as to how the service would develop over the years.
That document also raised a new issue, the change in eligibility for hospital services. The Minister proposed that the top 15 per cent of income earners in our community should now be eligible for so-called free services in the hospitals. The reality is that the cost of these services has been significantly increased for those who depend on them. I am very sceptical that this change will bring any improvement to the lot of public patients.
This action is not in accord with what the Health Commission recommended, despite the misleading impression given by the Minister. The commission favoured the abolition of restricted hospital entitlements for the top 15 per cent of earners, but their key recommendation was that all necessary services should be available on the basis of medical need and not ability to pay. This recommendation was to be implemented by a "commmon waiting list for both public and private patients from which cases would be taken on the basis of medically established priority." This, in turn, was to be backed up by regular publication of criteria for admission to hospital and of maximum waiting periods for access to specific procedures. None of these fundamental recommendations made by the commission have been implemented by the Minister. He has ignored the notion of a common waiting list.
On the face of it, it seems absurd to answer the chronic waiting times for public patients by the extension of the service to a further 15 per cent of patients, especially when not a red cent is being provided by the Minister to meet the extra demands which might emerge. The Minister argues that public beds will be freed by excluding private patients from them. Many dispute this but what is most extraordinary is that the Minister does not know how many private patients have been using public beds. He is engaging in what seems to be a major social experiment about which no one knows the outcome, least of all himself. Yet, the Minister confidently announced to hospital consultants that he sees no reduction in private practice resulting from his changes. There can be only one reason why this will be so — the Minister will continue to ensure that the public system is sufficiently starved of resources, that waiting times will continue to be unacceptably long and people will not opt to take up their entitlements. The Minister has steadfastly refused to offer any guarantees about maximum waiting times for treatment in public care. This is why people have been willing to join the VHI.
The abandonment of the idea of a common waiting list held out by the health commission bodes ill for those who have to depend on public provision. The Minister is institutionalising the two speed health service for the first time instead of tackling its causes which were the essence of the Gleeson approach to setting consultants' remuneration. It is sad that we have to come into this House after repeated debates on the issue of the health service and refer again to the failure of the Minister to deal with his responsibilities. This is the reality and the Minister and his party will sadly discover this later during the year.