Dáil Éireann debate -
Tuesday, 28 May 1991

Vol. 409 No. 1

Health (Amendment) Bill, 1991: Second Stage.

Minister for Health (Dr. O'Hanlon)

I move: "That the Bill be now read a Second Time."

The main purpose of the Bill being brought before the House today is to make the legislative changes required for the restructuring of eligibility for health services, as agreed in the Programme for Economic and Social Progress. The Bill also provides for the abolition of the income ceiling for payment of the health contribution, as announced in the budget in order to meet part of the cost of the very substantial development of community health services which will take place under the programme.

Today's Bill arises from the Programme for Economic and Social Progress, which was agreed between the Government and the social partners at the start of the year. It is appropriate, therefore, that I remind the House of the major commitments which it contains in relation to the health services.

The programme commits the Government to investing, over a seven-year period, no less than £100 million of additional capital expenditure to the development of community-based services for the elderly, for persons with a mental or physical disability, for psychiatric patients, for child care, for the improvement of dental services and for the provision of new health centres. We are also committed to significant increases in the level of day-to-day spending on these services, so that we will, by the end of the seven-year period, be spending £90 million more in real terms than the present level of current expenditure. The Government are committed to providing additional funding in each year's budget to achieve these targets, and a significant start was made with the allocation of £8 million in the current year.

It is also very important to stress that the development of community-based services which will be possible as a result of this expenditure is going to take place in a very co-ordinated and planned way. Over the past few years working parties and study groups have carried out detailed reviews of the various services and have identified the necessary direction and priorities for their development. Deputies will be aware of the work of, for example, the Review Group on Health and Welfare Services for the Elderly, the Study Group on Psychiatric Services and the Review Group on Mental Handicap Services. Under the programme, the key recommendations of all these reports will be implemented.

The programme also set out the principles upon which the reorganisation of the health services should be based — again, drawing on the findings of the various expert groups which had studied aspects of this area, such as the Commission on Health Funding, the Dublin Hospital Initiative Group and the Hospital Efficiency Review Group. The detail of the Government's proposals for the reorganisation of the management of the health services will be announced in the coming months.

The programme also reiterates and develops the Government's commitment to improvements in areas such as the quality of patient services, health promotion and women's health services.

It would be very easy to provide health services to everyone's satisfaction if money were no object. Unfortunately, the costs of providing health care are so high and the potential demands on the service so limitless that we will always face resource constraints and the difficult choices that go with them. This will be true no matter what level of funding is provided. It is crucial, therefore, that our decisions on the development of services and the way in which we make them available are based on the most thorough and expert analysis of the needs to be met and the best way of meeting them.

The Programme for Economic and Social Progress involves a radical overhaul of the health services, and I believe that one of its greatest strengths is that the various proposals are backed up by the research and analysis of the expert groups I have mentioned. Indeed, I reject the amendment in the name of Deputy Bruton that states we have our priorities wrong. The Commission on Health Funding recommended this change in eligibility. It was recommended by NESC. It was sought by the Congress of Trade Unions. It was agreed by the Government and the social partners. I cannot imagine any greater consensus than the Government and the social partners agreeing that this change is worthwhile in the interests of the people. I have no difficulty in supporting it.

Mr. R. Bruton

You dropped huge chunks of their recommendations, Minister.

Dr. O'Hanlon

The programme's commitments in relation to eligibility provide further examples of the Government's approach to taking careful account of expert research and analysis in adapting the health services to meet changing circumstances in our society. The Commission on Health Funding was established shortly after I came to office in 1987. Their report, which has been generally acknowledged as an exhaustive and most valuable examination of the funding and administration of the health services, was published towards the end of 1989. The Government then embarked on a comprehensive consultation process on the commission's recommendations to ensure that we had the firmest possible basis for our decisions on their implementation. The commission made a number of recommendations in relation to eligibility. These were subsequently endorsed by the National Economic and Social Council in their important report —A Strategy for the Nineties— which provided a significant backdrop to the discussions with the social partners on the new economic and social programme. The Irish Congress of Trade Unions, in particular, pressed for the inclusion of the measures in the programme, and this was agreed between the Government and the social partners.

One of these measures, which did not require any amending legislation, was to have the chief executive officers of the health boards carry out an early review of the methods of assessment used throughout the country for determining eligibility for the medical card. There is a need for these procedures to be flexible to ensure that a person in genuine need of a medical card does not suffer hardship through inability to obtain one. However, the commission had also highlighted the need for uniformity and consistency in the assessment procedures so that persons in similar circumstances are assessed similarly in all areas.

I am pleased to inform the House that this review has already been completed and that, on foot of it, the chief executives officers have now agreed uniform procedures for assessing eligibility for the medical card, which will operate consistently in all areas. In addition, the chief executive officers have agreed that income from the social employment scheme and the family income supplement will in all cases be excluded when an applicant's income is being assessed. These changes are very welcome.

The removal of the income limit for eligibility for category 2 health services was one of the major recommendations of the Commission on Health Funding. At present there are three categories of eligibility: category 1 are entitled to the medical card and receive all necessary services free of charge; category 2 are entitled to the hospital services card and receive a more limited range of services, which includes free hospitalisation subject only to the £12.50 per day charge up to a maximum of £125 in any 12 months; and category 3 have the same entitlements as category 2 with two exceptions: they cannot avail of consultant care as a public patient and they cannot avail of the free maternity care and infant welfare service which is provided by general practitioners. In both cases, they must arrange to receive these services privately.

It is important to realise, therefore, that the difference between category 2 and category 3 relates only to a person's liability for professional fees. Everyone in either category has the same entitlement to a bed in a public ward, paying only the £12.50 charge where it applies. The removal of the income limit for category 2 — in other words, the abolition of category 3 — does not have any effect whatsoever on the number of people entitled to public ward services. Every person is now entitled to a free bed subject to the changes I have mentioned in a public ward in a public hospital. That will not change. The change which comes about is for liability for professional fees.

The commission put forward a number of arguments for removing the income limit — arguments subsequently endorsed by the National Economic and Social Council. These arguments can be summarised in two sentences: first it is impossible to operate the income limit fairly; and, secondly, the existence of category 3 can in practice work against equitable access to public beds.

As regards the first of these arguments, there are several well-known difficulties in the operation of the income limit. Ostensibly, the purpose of the income limit is to identify a cut-off point beyond which a person should be able to afford to pay for any necessary consultant care for his or her self and for any dependants. In practice, the level of income alone is far too crude a measure to identify who can or cannot afford these services, since it takes no account of differing circumstances such as the size of the family, whether anyone in the family needs regular medical care and so on.

Furthermore, the only way to operate the income limit without having a very complex administrative system is to rely on the one document which most people can produce as evidence of their income, the form P60 or similar documentation from the Revenue Commissioners. Given that half the population are entitled to category 2 services, the House will appreciate the need for a simple method of determining eligibility, and the use of the P60 is ideal in that respect. However, it gives rise to certain anomalies. Each person in the family who has independent income, below the income limit, can obtain category 2 eligibility in their own right. Since the income limit is £16,700 at present, a family with two salaries of £16,500 is in category 2 despite having a total income of £33,000 — yet a family with a total income of £17,000, from one salary only, is in category 3 and must pay for professional services. A single person earning £16,500 is in category 2 while a large family with a single income of £17,000 is in category 3. A spouse taking up employment, and thus increasing family income, can actually move from category 3 to category 2. This occurs when the spouse of a person in category 3, who, as a dependant, would also have been in category 3, takes up employment at an income below the limit and is thus separately assessed as eligible for category 2.

The second argument relates to the way in which the very existence of category 3 can, in the view of the Commission, of NESC and of the Irish Congress of Trade Unions, work against equity of access to public beds. The fact that patients are simultaneously public patients of the hospital but private patients of the consultant, in other words, where a category 3 patient exercises his entitlement to a public bed, involves a danger that consultants may, all other things being equal, admit the fee-paying patient ahead of others, resulting in "queue-jumping" into public beds. There is no administrative device that can overcome this difficulty, since the decision as to which patient is admitted first is a clinical one which can only be made by the consultant concerned. The only solution is to move away from the concept of having fee-paying patients in public beds at all. There are two possible ways of doing this. The first way would be to remove the entitlement to a public bed from those in category 3. Looking at Deputy Bruton's amendment, it appears that that is the way he wishes to go. This would mean that the difference between the costs faced by those in category 2 and those in category 3 would greatly increase. Since we have already seen the difficulties associated with the method of identifying those in category 3, the House will appreciate that this approach would only serve to increase the unfairness of the system.

The second way is to give everyone the entitlement to avail of a public bed, as the public patient of the consultant, but to require fee-paying patients to avail of private or semi-private accommodation. This was the option recommended by all the groups I have mentioned, and it is the approach which is embodied in the Bill before the House today.

The new arrangements will be as follows: everyone, regardless of income, will continue to be entitled to a public bed as a public patient; those who wish to be public patients will not be liable for consultant's fees; where a person opts to be the private patient of a consultant he or she will, of course, continue to be liable for professional fees; and modifications in the access to beds will be phased in so that, in general, public patients will be accommodated in public beds and private patients in private or semi-private beds. However, emergency cases will always be accommodated even if the appropriate bed is not available.

The Bill gives effect to these arrangements as follows: sections 3 and 10 deal with the removal of the income limit; section 5 withdraws the entitlement to a public bed from a patient who is not availing of public consultant care, and vice versa; and section 6 deals with the manner in which services are to be provided to patients who are not exercising their entitlement to be a public patient, and empowers the Minister to make regulations governing this.

When the Bill has been enacted, I will immediately make the regulations in question. My intention is to provide for the designation of public hospital beds as public and private, and the public patients must be accommodated in public beds and private patients in private beds. There will be provision for emergency cases to be accommodated even when the appropriate bed is not available. The regulations will provide for the gradual phasing in of the restrictions in access to beds over the next three years, to enable me to ensure that the new arrangements are operating fairly and effectively.

In preparation for the new system, my Department have been involved in detailed discussions with every health board and public voluntary hospital, who have been asked to draw up proposals for the designation of public and private beds and for a three year phased implementation of the modified system of access to these beds. These proposals are being examined by the Department of Health, which are responsible for co-ordinating the overall phasing and for monitoring the new arrangements as required under the terms of the Programme for Economic and Social Progress. It is important to get the balance right in the designation of beds to fairly reflect the patterns of public and private practice. Hospitals have been asked to ensure that their consultants are fully involved in drawing up their proposals.

The clear identification of the status of every patient, as either the public or private patient of the consultant, will be implemented in every hospital, for every patient, from next Saturday, 1 June. Also from 1 June, subject to the enactment of the Bill by that date, the income limit for category 2 services will be removed, so that those who wish to avail of public consultant care may do so, regardless of income. The system of requiring public and private patients to avail of the appropriate designated beds will then begin to be implemented, carefully and gradually, to make sure that the transition works smoothly and effectively in the interests of all patients.

The new identification system will also apply to outpatient hospital services. Section 7 of the Bill provides that, in relation to outpatient services also, I will be able to specify by regulation that where a person is the private patient of a consultant he may, as with in-patient services, forego his entitlement to treatment as a public patient. It also empowers me to specify outpatient hospital charges for private patients. This is consistent with the general approach now being taken, i.e. that private patients of consultants should be regarded as private patients of the hospital as well.

I can best summarise the purpose of the new system by saying that it is intended to benefit public patients without disimproving the position of private patients.

Public patients will benefit by having greater access to public beds, as private non-emergency patients cease to occupy these beds. My Department will be ensuring, through their monitoring of the bed designation process, that there is no fall in the number of what would have been regarded as public beds up to now. In certain hospitals, there have been beds which are nominally regarded as semi-private but which have up to now been largely occupied by public patients. The appropriate proportion of such beds, based on a detailed examination of their usage, will be designated as public beds to ensure that there is no reduction in the number of beds effectively available to public patients.

The private patients who were occupying public beds will gradually be absorbed in private and semi-private beds. To some extent, this will be possible by better management of these beds but, where necessary, hospitals will be able to increase the number of private and semi-private beds to cater for the level of private activity. Any increases in the number of these beds will not be at the expense of public beds and will be introduced on a self-funding basis.

I do not expect the changes in eligibility to cause any significant reduction in the proportion of the population who are already insured for private and semi-private care. This view is shared by the Voluntary Health Insurance Board and is borne out by independent research by the Economic and Social Research Institute. There is, therefore, absolutely no basis for the suggestion which has been made by some Deputies in recent months that the new measures will lead to substantially increased pressures on public wards. All the indications are that the benefits to public patients arising from the measures can be achieved without having to increase the number of public beds or to incur additional costs in the public hospital system.

However, the programme contains a commitment to monitor the operation of the new arrangements. If there are teething problems I am satisifed that they will be overcome and I will take whatever action proves necessary to ensure that the fundamental objective of equity of access is achieved to the greatest extent possible.

The Commission on Health Funding placed great emphasis on the complementary roles of public and private health care. When those who can afford to do so decide to take financial responsibility for their own hospital expenses — for example, by taking out voluntary health insurance — those who rely on the statutory services benefit also since there are more resources available to meet their needs. It is also unquestionable that public patients, and the public hospital system in general, benefit from the availability in that system of the highest calibre of consultant, which is encouraged by the existence of private practice in the public hospital. The Commission on Health Funding, whose primary concern was so much related to ensuring equity of access to services, argued clearly that there was nothing wrong with people being able to get hospital care more quickly by going privately at their own expense, provided that the public patient has a reasonable service and is not disadvantaged as a result of the private patient's access. It is the scope for such a disadvantage, through the possible queue-jumping of private patients into public beds, which is being specifically addresed in the new measures.

Mr. Allen

What happens if the public patients do not have a reasonable service?

Dr. O'Hanlon

The public patients have a reasonable service, £1,543 million has been spent this year — the largest amount ever — and there are 59,000 people working in the public service, 2,000 more than two years ago and they provide a reasonable service.

The balanced mix of public and private health care will continue — the programme contains a commitment to ensure that the public hospital system continues to cater adequately for the needs of private patients and that the important role and contribution of voluntary health insurance is not diminished in any way. The announcement by the Minister for Finance in this year's budget that income tax relief on voluntary health insurance subscriptions will be maintained is a practical and positive demonstration of this commitment.

The recent negotiations with the Irish Medical Organisation and the Irish Hospital Consultants' Assocation on a revision of the hospital consultants' contract, in the context of the report of the Review Body on Higher Remuneration in the Public Sector, took place in the light of the possible effects of the change in eligibility on the income of consultants from private practice. the medical organisations are currently considering substantive proposals from management on both remuneration and conditions attaching to consultant appointments.

The Bill also deals with one aspect of eligibility which did not arise from the Programme for Economic and Social Progress. The opportunity presented by the need to amend the eligibility provisions in the Health Act is being taken to provide a statutory basis for operating a residency qualification for access to services under the Act. For reasons which I will now explain, it is necessary to do this in order to ensure that groups such as young Irish emigrants and persons working temporarily abroad are catered for fairly and on the basis of standard guidelines.

It has long been the practice to operate a residency qualification for entitlement to health services in Ireland and, indeed, this is the practice in most of other countries also. A person is regarded as "belonging" to the health care system of the country of residence. If he needs health care while in another country he is subject to whatever arrangements that country makes for non-residents. This would never, of course, mean being denied necessary treatment, but it can mean being liable for the cost of providing it.

In the absence of a statutory basis for the residency qualification, it has not been possible to have any statutory or uniform criteria for determining when a person should be regarded as qualifying. The Commission on Health Funding pointed that this can lead to uncertainty, and the operation of different criteria in different areas. Under the Bill's provisions, the sections of the Health Act dealing with the two categories of eligibility will both be amended to insert "ordinary residence" as a qualification. There is also a provision to empower me to issue guidelines on uniform criteria for regrading a person as "ordinarily resident" for this purpose. These guidelines will be for the use of the health boards in deciding on eligibility, and also for appeals officers under the new appeals system on health eligibility maters which is currently being established.

The Bill provides certain safeguards in relation to this issue. Section 9 specifies that the new provision will not in any way affect the arrangements under which residents of European Community member states may obtain necessary services, while temporarily in another European Community country, on the same basis as if they were living there. The Bill also provides that the powers of a chief executive officer of a health board to award full eligibility on hardship grounds to someone who would not normally qualify, will extend to giving eligibility, where it is warranted, to persons who do not meet the criteria for "ordinary residence".

Before formulating guidelines on the criteria for being regarded as "ordinarily resident", I propose to arrange for discussions between my Department and the health boards on the common problems which arise at present in the interpretation of residence. My intention is to ensure that anyone with a reasonable case for being regarded as eligible for health services here is able to avail of them. In particular, persons temporarily abroad must be catered for. I am thinking here, for example, of recent emigrants who may not yet have established permanent residence elsewhere, and of people who go abroad to work on short term assignments but would still be regarded as maintaining their permanent residence here. The case of foreign students in Ireland is also one which has given rise to differences in interpretation, and I have in mind to specify, following the relevant consultations, that registration for courses of study beyond a specified duration can be taken as qualifying the student as "ordinarily resident".

Section 8 provides for the amendment of the Health Contributions Act, 1979, to abolish the income ceiling for payment of health contributions. In the budget speech, the Minister for Finance announced that this contribution would, from the 1991-92 tax year, apply to all income, as is already the case with the employment and training levy. As the income ceiling was £16,700, the effect of its abolition is that 1.25 per cent of all gross income over that amount will now be payable, in addition, of course, to 1.25 per cent of the first £16,700. A person earning £20,000 per annum, for instance, will pay an additional £41.25, or approximately 80p per week. Persons earning less than £16,700 will not be affected in any way.

There is no direct relationship between the income limit for category 3 health services and the income ceiling for health contributions. They have differed from time to time and, although they have usually been the same, there is no legal or technical reason why this should have been the case. It is certainly not the case that the income ceiling on health contributions is being abolished as any kind of a quid pro quo for the removal of the category 3 income limit. The purpose of the measure is to provide some of the very substantial cost of the development of community-based services under the Programme for Economic and Social Progress. As I outlined earlier, this will involve capital investment of £100 million over the next seven years, and will also involve yearly incremental increases in the level of current expenditure so that annual current spending on these services will be £90 million higher in real terms in seven years' time than would have been the case in the absence of the programme.

The total amount of additional spending over the seven years will thus cumulate to several hundred million pounds, and this will enable us to transform our community-based services along the lines recommended by the various working parties and study groups in recent years. In this context, I believe that the decision to draw a greater yield from the health contribution, without in any way affecting those earning under £16,700, is more than justified. This income will also enable any costs to be met which arise from the eligibility extension, although I should stress that it is by no means certain at this stage that the eligibility measures should give rise to any significant extra costs, for the reasons which I discussed earlier.

In conclusion, I would like to return to the primary purpose of the Bill, which is to provide for the new eligibility arrangements which were agreed with the social partners as part of the Programme for Economic and Social Progress. These measures address the difficulties with the present system which were highlighted by the Commission on Health Funding and by the National Economic and Social Council, both of whom recommended changes along the lines now being introduced. They will work in the interests of equity and of the public patient, while at the same time maintaining the important balance of public and private care in our public hospital system. Deputies opposite have said that we have a two-tier system and suggested that this is a new development but it is not. That has been the position since the foundation of the State and this system, with its integrated mix of public and private care, has served the nation well.

Since the announcement of the programme in January, my Department have had very extensive discussions with the health boards, the voluntary hospitals and the medical organisations, in order to devise detailed arrangements for the implementation of the new measures. I feel that this approach was most justified in view of the importance of getting the new system right. The operation of the new arrangements will be continuously monitored to ensure that they work fairly, and are seen to work fairly. In the light of the analysis of the commission and of the NESC, and particularly in the light of the discussions with the social partners, I am satisfied that there is a wide measure of support for the course of action being taken.

I commend the Bill the House.

Mr. R. Bruton

I move amendment No. 1:

To delete all words after "That" and substitute the following:

Dáil Éireann declines to give the Health (Amendment) Bill, 1991 a second reading for the following reasons:

(1) it represents a totally wrong set of priorities, when those already eligible for hospital services cannot get an acceptable level of care;

(2) it will worsen existing services, because no extra money has been allocated to match the further eligible patients; and

(3) it accepts and reinforces the two-speed health services by abandoning the fundamental principle of a common waiting list for core services where priority in access to services is decided on the basis of greatest medical need.

The Minister has made a serious error in this move. It is clear he has the wrong set of medical priorities. He is proposing in this measure that we extend eligibility for free consultant care to those earning between £500 to £700 a week, including top business executives who have not asked that this change be made. We should have a different set of priorities in the health services given that there are many on public waiting lists for operations. For example, 1,700 people are awaiting hip replacement operations, 2,400 for tonsillectomy operations, 3,000 for cataract operations and 1,000 for heart by-pass surgery. They are but a few of the people who are not being adequately served under the present system of care. The Minister should concentrate his resources on dealing with their problems and then, by all means, extend eligibility for free consultant care under category 3 to the top 15 per cent of income earners.

The reality is that those who depend on public health care have to wait in line without adequate services being provided. The Minister, and Deputies sitting behind him, must be aware of the plight of 66,000 carers who are not being provided with the resources they need, who cannot obtain any respite and who are trying to cope in silence under fierce pressure. That is the reality. He must also be aware that there are 103 haemophiliacs who have been waiting two years for a crumb of compensation as a result of having been infected by the HIV virus. People are not being properly served and I believe the Minister is wrong to extend this entitlement to the top category of income earners.

The Minister quoted selectively from the report of the Commission on Health Funding and the views of the Irish Congress of Trade Unions. He grossly distorted their position. Both congress and the commission have strongly endorsed the fundamental principle that access to our hospitals must be on the basis of priority medical need — those with the greatest need must get first call. That is a fundamental principle of health care. It is what people on all sides of this House, I believe, regard as necessary from our health services, but the Minister has turned his back on that recommendation. We have had a golden opportunity in the past 12 months to deal with the problem of the common waiting list. That is what Gleeson addressed himself to in this report, No. 32. The reason the taxpayer is being asked to pay an extra £35 million to hospital consultants is so that we would have a service we could stand over and where we knew that the consultants would be delivering care to public patients. This is stated in one of the fundamental recommendations of the Gleeson review body report. It states there should be a contractual provision for a review of the actual mix of public and private patients treated, based on the principle that medical need should be the overall criterion for health services. That was the fundamental principle underpinning Gleeson and also the report of the Commission on Health Funding.

Paragraph 2.61 of the report of the Commission on Health Funding states:

An objective system of assessment for access to public hospitals should be introduced for all planned (as opposed to emergency) admissions, involving a common waiting list for both public and private patients, from which cases would be taken in order of medically-established priority.

That is the fundamental principle underlying these two very valuable reports which the Minister had commissioned. He is turning his back on them although he is attempting to claim their endorsement for what he is doing.

The reality is very different. The Minister is extending cover to a new category of people although he is not providing any extra money this year. There will be fewer hospital admissions this year because the Minister while preserving the number of hospital beds has endorsed health board moves to extend closures for the summer months. Ultimately we will have fewer admissions to our hospitals. What the Minister is doing, by segregating for all time the public and private sections is institutionalising a two speed health service where those seeking public care will be on hopelessly long waiting lists while there will be quick access for those seeking private care and that is completely contrary to the principle underlying these reports. We had decided to pay extra money to the consultants and to deal with the problems with the common waiting list, because we all knew it was not working, although, the Minister until very recently insisted that access was solely on medical need. We were provided with a vehicle to deal with this problem but the Minister did not take it up.

Mr. Allen

The Minister caved in to the consultants.

Mr. R. Bruton

This move in the long run will have very damaging effects on our public health service because it condemns it to permanent inferior status. The Minister is at pains to insist that this new service will not be taken up, that there will be no diminution of private care and that people who are now being offered something for nothing, according to him, would not dream of taking it up. There is only one reason that these people would not dream of taking it up and that is because the service will not be there for them and they are not willing to join the long queues for service which are a feature of public health care at present. The Minister seems determined to have ordinary workers scrimp and scrounge to try to get the cost of VHI cover together so that they can get care when they need it. That is the system he is going to perpetuate. Furthermore what the Minister is saying, in effect is that not only is he not content that they should scrimp and save for VHI cover but he is insisting they will have to pay another £20 million in health levies to the Exchequer which works out at £120 for the average earner. They will have to pay this levy in addition to the VHI, their only option being to abandon VHI cover in favour of this new cover which in reality is not there for them.

The Minister spoke about how the health levy would be applied to developing community services. Anyone who recalls the last budget will recall grimly that this year the extra £4 million to be raised by the health levy was clawed back by the Exchequer in extra savings. That is what has happened to the health levy and that is what is likely to happen in the future. The Minister for Finance sees this as a new cash cow and I believe that is the real hidden agenda behind this move. It has nothing to do with solving the problem of unfair access to our health services or of providing equity in our system, the real agenda is that the Minister wants cover for abandoning hospital admission on the basis of need and wants to cover himself for the claim on extra revenue insisted on by the Minister for Finance. The extension of cover which the Minister time and again insists will be taken up is only a smokescreen which fools no one as to the real agenda he is pursuing. Indeed the Minister had not the sense to abolish the health levy at this stage. The health levy is meaningless in the system the Minister is proposing and is one of the most iniquitious forms of taxation because there is no threshold such as we have in income tax and people are paying on the very first pound. The Minister is retaining a cumbersome assessment system where people will have to pay regardless of income. I think that was a bad day's work.

I was amused to hear the Minister suggest that to deal with queue jumping he would withdraw private rights to use of public beds. This is what the Minister has talked about all the time.

Dr. O'Hanlon

The Deputy is condemning people to queues.

Mr. R. Bruton

The whole policy the Minister is pursuing is to create separate queues. There will not be queue jumping because there will be no need for it as the Minister is enshrining in our system a permanent separation, a fast lane for those who can afford and a slow lane for those who cannot. The only way the Minister will be able to keep this new category out of the public service will be by maintaining that inferior service. If there was a decent public service the Minister knows right well that the 30 per cent at present in the VHI would be availing of that service. The way he is going to keep the 30 per cent who dip into their pockets to pay the VHI is by maintaining an inferior public health service. The way to deal with the problem of an inferior public service is not to extend cover but to channel the moneys into the areas we could have dealt with so as to provide a decent level of care to those who have to avail of public care and have nowhere else to turn to.

Anyone who considers the issue of queue-jumping — that is what the Minister was describing — realises that the only way people jump the queue is that they have the money in their pockets to pay for the service and not what ward they are in. That is what is determining the differnce. Making people eligible for a service that will not be available to them will not change that. People who have the money to pay will still get priority access under the Minister's proposals whereas the commission are going out of their way to say that core services must be available on the basis of medical need. That recommendation has been abandoned.

Another big deficiency of the Bill we are considering today is the complete silence on another issue mentioned in the Programme for Economic and Social Progress but which did not receive any mention here today, that is the question of a patients' charter. That was one good proposal in the Programme for Economic and Social Progress, a proposal which we, on this side of the House would have endorsed. We would have been very pleased to see a patients' charter enshrined in our health Acts. We had hoped that the charter would not be a pious aspiration but a legal underpinning so that we would know that people could demand legal redress if the terms of the charter were not being honoured. It is very sad that we do not see a proposal in this regard.

It is sad that the Minister made no mention of any such move. A proper charter would go well beyond what the Minister has listed in the PESP. The fundamental issue for a patients' charter is the one mentioned in the health commission report, that is, a fair system of access to health care when people need it. The fundamental proposal to back the common waiting list was that there would be regular publication of criteria for hospital admission and there would be a maximum waiting time that people would be expected to wait. That would give a patient in the public sector something real to look forward to. If we had in this Bill a guaranteed level of public service, a guarantee that they would not have to wait unacceptable lengths of time, then we would have a Bill that we could start talking about, giving guarantees to our public patients and providing a better service for them, not this proposal we have here today to extend care to people who are not a priority at the moment, who could not by any measure be considered as people who are in need of our health services.

The reasons offered by the Minister for this change are remarkably weak. One of those reasons is an anomaly in the income limit. The Minister seems to have some sort of problem with conducting a means test for access to free hospital care. That is not an adequate reason for abandoning the idea that we should concentrate our resources on the people who need it. The Minister also mentioned queue-jumping. Queue-jumping enables people with money in their pockets to gain preferential access. The Minister has endorsed that principle by having a completely separate private waiting list. We will now have private waiting lists and public waiting lists. The Minister is institutionalising queue-jumping. We will live to regret this move.

The Minister should have made an effort to concentrate resources on public patients. I would have warmly supported one of the elements in the Minister's programme, namely that people who are getting private care cannot occupy a public bed. We on this side of the House would have no problems with that whatsoever. It is a sound principle. If it had the beneficial effect of freeing beds, that would be great. However, that is not what we have today, and that could have been done without all this smokescreen of extending cover. That is just an administrative rule the Minister could have provided for. It was envisaged in the Gleeson report that it would be there. One of the principles in the Gleeson report was that consultants would declare patient eligibility status. Gleeson was at pains to make that system work so that private patients would not be able to jump queues, and the Minister has sold that.

Mr. B. Allen

Expensively.

Mr. R. Bruton

We have to go back to fundamentals and decide where we will devote the scarce money at our disposal. There are priorities the Minister should be addressing. I mentioned the haemophiliacs already. Once again I want to take this opportunity to say it is high time we had a decent settlement for those people. Already 18 have died and those left are facing a grim future. The Minister should have the good grace to have a settlement for them. They had to have another public meeting last week which was pathetic in the extreme, and there was no representative from the Department at that meeting. It was depressing, and it is not acceptable.

Another issue which disturbs me enormously at the moment is the future of the Tallaght Hospital in the constituency the Minister of State represents. I have heard — and I would like to hear the Minister's confirmation — that that project has not only been delayed but has been scrapped. It is not just on the back burner, it is off the burner altogether. That proposal was fundamental to the reform of the hospital services in Dublin. The Minister makes great play with the various commissions and managerial manuals he has on his desk. However, this is an area of the city which is larger than Limerick which has no hospital and has been waiting for years for action to build a hospital. There has been a hospital board in operation since 1980 but nothing else. This is one of the priority needs that is being asked to wait in the queue, and that is not acceptable.

On the question of priority cases, once again the nursing home problem is raising its head. The Eastern Health Board are running into difficulties paying subventions to people in nursing homes, people who can no longer be cared for at home and for whom the subvention on which they were depending has not come through. The Minister was to have had, by April of this year, a new system of subventions giving high, medium and low levels of subvention to different categories of care. The Minister has been silent on that but he comes into the House with this Bill which is, by no stretch of the imagination, a health priority at present.

The Minister must address much more fundamental reforms if he wants to see our health services develop and bring equity into the system. There are many people who are marginally above the medical card limit and they do not have access to primary care. They have to dip into their pocket for every penny needed for primary care. If the Minister was to extend cover, here was the very worthy case of people on very low incomes who had to dip into their pockets for the first £32 per month for drugs and for all their hospital costs. There was the place to concentrate money and set about giving people a chance to avail of primary care and keep them out of the hospitals. The Minister has always publicly endorsed the idea of developing care for people in the community and giving them a chance, but that has not come about.

I do not want to delay the House. Our views on this side of the House have been quite clearly spelled out. The Minister has fluffed what was a real opportunity to provide decent levels of care for the many people dependent on the public service who have nowhere else to turn. We would have endorsed moves such as taking private patients out of public beds or giving public patients a charter that would be legally underpinned but that is not what came up. This is only an effort to raise extra finances and to extend cover to people who have not even asked for it and who, the Minister is insisting, will not take it up; and people will not take up a free scheme because it will not be there for them. People will not be able to get access and we will have a permanent second class public service under this legislation.

Mr. Ferris

I am disappointed with this legislation and when the Minister announced it earlier in the year I intimated this. I felt it did not really address issues of access to public beds in public hospitals for those who are entitled under the existing medical card system. If beds, consultants, doctors and nurses were available to provide the service, those long waiting lists would not exist. The only reason we have waiting lists for beds is people's inability to gain admission. I may give further details during the afternoon of what we are talking about. It is obvious the Minister is unaware yet of some of the difficulties in relation to health, health care and particularly acute hospital care. We told him so in the election campaign in 1987. Shortly after that there were slight improvements. In 1989 we continued the message and we continue it now on the eve of local elections.

This legislation means we are asking more people to pay more money for services which are not available. That is categoric, true. Any Member who is a member of a health board will be aware that those who are entitled to the service cannot get it but this Bill purports to make beds available to other categories who up to now were considered to be private patients. Beds are being promised to everybody in spite of the fact that no additional beds are made available in any hospital and no funding is being provided. It is as if somebody driving down the road in a small car with four seats offers four people a drive because he has four seats available and suddenly tells ten people on the road that they are all entitled to a drive in the small car with the four seats, but it is not possible to accommodate them. Any acute public hospital that can say it has not a waiting list for acute beds is concealing that fact. On a weekly basis we receive information about their difficulties in trying to live within their allocations identified by the Minister at budget time. That is coming to light each week from the Southern Health Board, the South-Eastern Health Board, the Eastern Health Board and other boards.

Recently the Labour Party introduced the Ethics in Government and Public Office Bill which provided that people should declare publicly their interests. We suggest today there ought to be a new law for cynical politicians which we would call the O'Hanlon law. It could take its place alongside Murphy's law or the Peter principle and it would work on the following lines: whenever the essential social services for which a Minister has responsibility are going through a deep crisis everybody's attention should be diverted by unveiling a gimmick. Irrespective of the support the Minister says he has from the various organs, trade unions, negotiators, NESC or anybody else, this legislation, and its implications, are a gimmick.

Before I deal with the Bill in detail I would like to mention related matters when I talk about gimmicks because we hear many of them nowadays. Deputy Bruton referred to a matter which I was the first to announce in this House, the postponement of the new Tallaght hospital project. I said then and I say now that the decision to postpone that was a disgrace considering the urgent need for this acute facility for the people of Tallaght. The site development was initiated in the mid-eighties to provide essential hospital services for up to 150,000 Dublin citizens living in Tallaght and the surrounding district. The 1991 health capital programme showed no provision for the hospital in Tallaght. As a result all the work, planning and development suddenly came to a halt.

Yet another public scandal arises from this and Deputy Bruton has asked the Minister to reply to it. I understand the Minister is about to compound this scandal with yet another cynical stroke by calling the hospital board together next week for their first meeting in over a year. I have no doubt that on that occasion the Minister will suggest that, although no provision has been made for it and even though all the planning and development has been halted, the hospital has got the go ahead from the Government. There is no doubt that the local elections on 27 June are a magic wand. If we had a local election every year we would have magic cosmetic local government reform as we had last week. We would have other promises like that about the river crossing in Cork which I am sure Deputy Allen will confirm is another gimmick. Next week we will hear promises about the new hospital in Tallaght to suit the local government election candidates of the Minister's party in that area.

I am suggesting that, in spite of the difficulties of canvassing in the constituencies and attending at the House, we should have elections more often because they would help solve some of the problems confronting all of us, including the Minister. However, we will solve no problems with this gimmicky Bill. It is not even a three card trick. On occasions in the three card trick game one can see two of the three cards. In spite of the best gloss the Minister puts on it, this Bill will create major administrative problems in all hospitals and health board areas. Hospital administrators throughout the country——

Mr. Allen

They do not know how to implement its provisions.

Mr. Ferris

——have said there will be major difficulties in putting this Bill into operation. Even the Minister identified the difficulties in his speech. On numerous occasions he said he will review it after it is in operation for a number of years. He said he will continuously monitor the operation of the new arrangements to ensure they work fairly and are seen to work fairly. There should be no reason to review the operation of the Bill if it is as easy as the Minister implied when he said that everybody is entitled to a hospital bed and public consultant services.

In all this smooth talk the Government are now claiming to enshrine in the Bill an important and fundamental principle, that of universal access to health care. I would support the Minister if that was the case but this Bill does not do that and we do not want to create the impression in peoples' minds that it does. The Government are making a mockery of the principle of the fundamental right of access to health care. They are introducing legislation against a background of health services that are in deep crisis. The end result of the extension of this access will be that fewer rather than more people will receive proper care when they need it.

Of course, the Bill will act as a useful fund raiser for the Exchequer. Although the Minister admitted that there will be an increased take as a result, he did not identify what the take will be. We will not hear much about that from the Fianna Fáil or Progressive Democrats activists on the doorsteps in the next weeks. According to the calculations we have made, and the figures published by the Minister for Finance, the net effect is that this Bill will raise an additional £19 million in taxation through PRSI contributions next year. That amounts to additional taxation and is achieved by removing the present income limit.

What will people get for this £19 million extra taxation? What are they being offered under this Bill? It is not an extension of a free consultant service as we understand it. What they are being offered is a choice, to stay in the VHI or join the queue of medical card holders and others. At present those entitled to free consultancy service are not entitled to access to the consultant of their choice just as they are not entitled to a hospital bed when they need one. They are only entitled to access to whatever consultant is available in the hospital to which they are referred and to a bed when it becomes free. Our free system of health care now means that if you have an income you jump the queue, but if you do not have an income you join the queue. The Bill we are now debating is offering people in the VHI a chance of joining the queue. Technically speaking, a large number of people in the VHI do not need to be in it but they will have to remain in it if they want to jump the queue. Why should they opt out of the VHI if no public health care system is available at present? When one thinks about it, this is a bizarre offer by the Government. It is even more bizarre when one considers that Fianna Fáil have described this as progress.

In order to understand why this Bill is little more than a gimmick, it is necessary to consider part of the background to it. We in the Labour Party have always been totally committed to a comprehensive health care system, free at the point of access to all our people, and funded by general taxation. For the last number of years, particularly over the past four years, we have fought against the principles brought in by the Minister for Health in this Government and in the preceding Government. The Minister has presided over the destruction of many of the health services which had been put in place.

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

Rubbish.

Mr. Ferris

The Minister of State was not in the House at the time most of the damage was done but I will itemise the decisions taken by the Minister so that he will be aware of them. It was by no means a perfect service, and we never said it was, but at least it had been protected from the worst cutbacks implemented during the previous years. During the four years the Minister's predecessor, Barry Desmond was in office — when he was much maligned by the present Minister and his colleagues — he kept spending on our health services as constant a proportion of our national wealth as possible. Whenever the Government talk about borrowing, on the Exchequer borrowing requirement, or the current budget deficit or any other excuse they want to make, they always point out how they are reducing these factors as a proportion of the national wealth or GNP. However, when one applies the same measure to the health services, then the root cause of the crisis becomes abundantly and immediately clear. When Barry Desmond left office £7 out of every £100 of our wealth was being spent on our national health service. In 1987 this amount was reduced by the present Minister to £6.60 and to £6.30 in 1988.

Dr. O'Hanlon

What about the £55 million?

Mr. Ferris

By the end of 1990 this had been reduced to £5.80. Those are the facts——

Mr. Flood

He was overspending.

Mr. Ferris

Is that an admission that the Minister is not spending enough?

Dr. O'Hanlon

He was overspending.

Mr. Ferris

If we were overspending then the obvious conclusion is that the present Minister is not spending enough. No wonder our health service is in crisis.

Mr. Allen

That is a serious admission by the Minister.

Mr. Ferris

The crisis in our health service is reflected in the following statistics.

Mr. Allen

People are dying in the streets——

Dr. O'Hanlon

Your leader was Minister for Finance at that time.

An Ceann Comhairle

Let the interruptions cease.

Mr. Ferris

I appreciate your protection, a Cheann Comhairle, as it is very difficult for Ministers to accept these statistics. As I have done many time before, I want to put it on the record that 4,000 health workers have been made redundant, sacked or otherwise in our health services since the Minister came into office. Charges were introduced in a range of essential services. Yet the Minister talks about free consultant services and free hospital beds. In 1987 the Minister introduced charges for these beds of £10 per day for the first ten days. However, like Scrooge, the Minister increased this charge to £12.50 during Christmas week last year. Yet the Minister says that these beds are free. They are not free; they cost £125 for ten days. Two thousand beds have been removed from the acute hospital services while 300 geriatric beds and 700 psychiatric beds have been removed. The Minister says that there are no patients for these beds as they are all now living in the community. What funds has the Minister allocated to the community for these patients? Twenty four hospitals have been closed by the Minister. Some of them have been reopened under the guise of day care centres, etc but they have been closed as hospitals. The threat of further closures still hangs over us. As a result of pressure, some of these acute beds were restored in recent years. The Taoiseach told the Minister that he would have to do something about this matter as the Government of the day were running into difficulties. Even though some beds have been restored, there are still 1,000 fewer beds in our hospital services since Deputy Rory O'Hanlon was appointed as Minister for Health. That is some statistic for the Minister to preside over. I acknowledge that the Minister has had to work within his budget and argue with the Minister for Finance at the Cabinet table for more funds. Yet 1,000 beds have been lost in our hospital services since he came into office. If his Minister of State believes that that is overspending, then God help us.

Mr. Flood

Fifty five million pounds——

Mr. Ferris

We have repeated those statistics in virtually every debate we have had in this House on our health services and the destruction of health care. As we have emphasied, statistics convey only a cold impression of the human suffering caused by these cutbacks. People who suffer from any abnormaly or disease, for example, spina bifida, hydrocephalus, mental handicap, physical disability, psychiatric illness, asthma, AIDS or haemophilia, are particularly vulnerable in a host of ways and they have to depend on the Minister and the Government for help. It is those people and their families who have been the victims of the health cutbacks.

Fianna Fáil put up posters at election time saying that cuts would hurt the old, the sick and the underprivileged. They would not dare to publish such posters for the forthcoming local elections as they know they have hurt those people more than they were ever hurt previously. The Minister is shaking his head but he cannot deny that this is what has happened. I told the Minister that during the run-up to the 1989 general election we would have to bring home to people on their doorsteps the reality of the situation in regard to the health service. Politicians are accused of causing this suffering. We in the Labour Party consistently opposed the Health Estimates. Even when other parties supported the Fianna Fáil miniority Government, we opposed them on the basis that we believed we were doing a service to the people we represented. At least we had the courage to bring this matter to the floor of the House. We have been unequivocal in adhering to the fundamental principle that health care is a basic human right. Everybody, bishops, priests, Catholic associations and so on believe that this basic human right puts an explicit obligation on the community to discriminate positively in favour of the poor. The Minister of State is shaking his head. Obviously he does not believe that health cuts discriminate against the poor. However, the Minister of State probably does not know what it is like to be poor.

Mr. Flood

I know the financial destruction the Deputy's party left behind them in 1987. They should be ashamed of themselves.

Mr. Ferris

The policy adopted by the Government has discriminated against the less well off in our community and has made it increasingly difficult for people on low incomes to secure any access, not to mention equal access, to our health service. We will never be able to describe health care as a basic human right until such time as all of us in this House, particularly the Government, face up to the need for an adequate level of resources for this service. One needs to have priorities in allocating resources. If you say there is not sufficient money in the kitty, let us come back to the House on this issue so that we can decide with you on the priorities, of which health care is certainly one.

Mr. Flood

The Labour Party Minister for Health borrowed——

Mr. Ferris

Who borrowed £18 million for the refurbishment of offices?

Mr. Flood

You doubled the national debt.

Mr. Ferris

We did not borrow that money, you borrowed it.

Mr. Flood

When the Deputy's party were in Government they doubled the national debt.

Mr. Ferris

If you are satisfied to borrow money for the refurbishment of offices, for the purchase of jets——

Mr. Flood

You doubled the national debt in four years.

Mr. Ferris

Why do you refurbish offices and buy Government jets if you do not want to have borrowings? You are selective about what you want to borrow for. You are selective because the poor have been——

An Ceann Comhairle

If Deputy Ferris would address his remarks to the Chair we would avoid many of these interruptions.

Mr. Ferris

I will try to do that. We will never be able to describe this health care as a basic human right until this Government face up to their responsibility in relation to resources. They have had access to a wide range of reports which have been commissioned by the Minister. These include the Commission on Health Funding report, the Kennedy report and the Fox report. This Government and this Minister have had more reports than the number of hospitals that have been closed and that is 24. At the end of the day the decision must be made as one of principle. No final decision can be made on how much is to be spent on our health services until we decide whether health care is a basic human right. If we decide that it is a basic human right, we must take the necessary steps to give effect to the principle. Instead, the effects of the cutbacks are visible all around us. After the 1989 general election the Minister for Health charged the health boards with providing the same level of service as they had been providing. The current budget provision will not allow any of the health boards to maintain that level of service and will result in their being forced to cut back severely on services, and that will result in further waiting lists for our people.

Last week I attempted to raise in the House the problems faced by the Southern Health Board where there is £7 million in unpaid debts, where travelling expenses to workers, public health nurses and community care workers remain unpaid. This was not denied by either the Minister or the chief executive of the Southern Health Board. While people supplying the health board have to suffer delays in payment as have people providing a service to the health board, the boards are told that they must maintain the level of service at the same rate as applied in 1989. In the South Eastern Health Board area, though the allocation was increased only by a fraction to take account of inflation, services were not only maintained but increased. Nurses at Waterford Regional Hospital have been parading on the streets to demonstrate the problems there because of reduced numbers. Activity at that hospital during 1990 increased by 5 per cent, patient days increased by 12 per cent and day-care cases increased by 33 per cent.

Dr. O'Hanlon

That speaks for itself.

Mr. Ferris

During the same year the number of patients treated at Wexford General Hospital increased by 3.5 per cent, and there was a 5.4 per cent increase in patient days. There was an increase in St. Luke's Hospital of 5 per cent in patient numbers. In St. Joseph's, Clonmel, the corresponding increase was 2 per cent. The number being treated at Clonmel General Hospital was about 6,500 with the same number or even fewer nurses than was the case previously. In Our Lady's Hospital, Cashel, surgical operation numbers increased by 8 per cent in 1990 where no additional staffing or funding was made available and in Kilcreene Orthopaedic Hospital there was an increase of 31 per cent. These figures are published by the health boards themselves. I will quote from the South Eastern Health Board Annual Report 1989 which reported on 8 March 1990 as follows:

The allocation of funds from the Department of Health to health boards and health agencies continues to be mainly historically based adjusted for the revenue consequences of capital schemes rather than on any objective or equitable basis. However in 1989 the report of the Commission on Funding was published. The Commission was established to advise on the very complicated issue of how health services should be funded in Ireland. Much of the board's criticism of the allocation procedure was echoed in that report.

This was a health board elected by the people, nominated by the professions, telling the Minister at the end of the year that they agreed with the report of the Commission on Funding. The report continued:

The Commission was given the additional task of advising on the type of organisation required to deliver health services in future. The Board, at a special meeting welcomed this report with certain important reservations, especially in relation to the recommendations on organisation. There are many recommendations which should, if implemented, effect marked improvement in both the system and the services.

Following the emergency introduction of the Health Estimate in the House on 18 December — Official Report, column 15 — the Minister said:

While there are many needs for capital to enable the existing services 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.

Yet at the same time he is telling us he will make more beds available to more people at the same hospital without additional capital. It cannot be done unless the Minister is a magician. We will give him the opportunity to prove whether he is a magician. I have a problem because all the health boards have been in constant contact with us. We appreciate being told exactly what is happening on the ground. Only today we read in the newspapers that health boards are planning to close down beds during the summer.

Dr. O'Hanlon

Yes.

Mr. Ferris

The Minister has described this as a tradition.

Dr. O'Hanlon

It happens every year.

Mr. Ferris

It may have been a tradition in the Minister's constituency but beds were never closed down by tradition in the South-Eastern Health Board or in the Southern Health Board areas until Deputy O'Hanlon became Minister for Health.

Mr. Allen

People get sick in the summer, too, as Deputy Wallace will tell you.

Mr. Ferris

They closed because the Minister did not give them sufficient funding to remain open. It is nonsense for the Minister to attempt to tell us that bed numbers will be maintained at the same level as last year. How can the level of service be maintained at last year's rate? Who will provide the nursing, the medical care and round the clock service even in the summertime when the beds are closed and when people need them? The majority of health boards are over-budgeted at present and are unable to meet their obligations. The Minister is presiding over deficits of £20 million to health boards all over the country. With the cutbacks on the way this year, the crisis in our health service has once again become a major political talking point. The Minister was able to bring such matters to the fore when he was in Opposition. Now he should take the consequences of what is happening in the area of health.

Other areas have also been drastically affected including community care services which in some cases have been damaged beyond repair. Action must be taken to allocate new resources to the community care area. The £8 million allocation to which the Minister referred in his contribution is a joke. It represents about £1 million, on average, for each health board. Such money will go nowhere towards alleviating the crisis that exists. It is very difficult to understand how he can accept that a sum of £8 million is sufficient. Women in particular will bear the burden.

Services for people with mental or physical disability have deteriorated in recent years. The individuals and groups caring for such people have occupied the Minister's offices to protest. They have held public meetings at the Mansion House. The report of the Minister's review group, published in the past couple of weeks, graphically demonstrated that there has been a standstill in this area in real budget terms. In the meantime the handicapped and their families have grown older and their demands are more pressing every day. The crisis in the area of mental handicap covers many aspects but the most worrying feature is that there appears to be little or no planning for the future. A great deal of lip service is paid by the Government to the concept of planning. The reality is that the agencies and their staff in the field are so busy dealing with the crisis in our current services and worrying about next year's financial allocations that they cannot even look ahead to plan. The human hardship involved in mental handicap and physical disability will take a great deal more planning, and the planning would need to start now. It must take place in the knowledge that resources will be made available. If these resources are not made available the Minister will be reneging on his responsibilities. That is the reason we believe it is imperative that the Minister for Finance and the Government commit themselves for a period of years to improving the funding available in the areas for mental handicap at least to the amounts recommended by the review group. This would go some way towards alleviating stress and anxiety for thousands of families.

The current crisis in our health service is inexcusable. Whatever Government came into office after the 1989 election, the one thing they could not claim was that the people had failed to give them a mandate in the area of health. The message from the electorate was clear and unequivocal but it has been totally ignored by this Government. The health service has been pared to the bone in the past three years and I wish I had the words to convey to the Government the anger in the community at the scale and extent of these cutbacks. The anger arises not just from the inconvenience of queueing or the hardship of pain and suffering while on a waiting list or the frustration of having to pay, often from very small incomes, for essential services to which we have all become accustomed as a right. My colleague, Deputy Kavanagh, tells me there is a waiting list of eight years for varicose vein treatment in Dublin. It can take years to get a hip operation. There are also waiting lists for ENT services.

Dr. O'Hanlon

Regarding the eight years, the Deputy's party were in Government for four of those years.

Mr. Ferris

The Minister has been long enough in Government to do something about it instead of referring back to his predecessor in the previous Government. The Minister is unable to take this criticism at a time when he is responsible.

In a real sense the anger in our community springs from the loss of dignity involved in seeking access to services to which people no longer feel they are entitled. In Victorian times charity was inflicted on the poor. People who had nothing were made to feel they belonged to a lower order by the way in which charity was doled out to them. There was no concept of rights and no feeling that decent shelter, a good education and basic health care were part of the citizen's entitlement and the community's obligation. We are rapidly approaching that concept again under this Government and we have already reached it where health care is concerned. I never thought that in my time in politics I would see a day when I would have to argue for the right of access to health care, but as I work in my constituency I come in contact every day with people who are hoping for their turn to get some basic treatment. People are becoming resigned to the fact that they do not have a right to treatment because their income does not warrant it. Other Members can also see this happening if they care to look. There is growing anger at a Government who have chosen to undermine the right of every citizen.

The bottom line after this year's budget is that there is £2.3 million less in the Health Estimate in real terms than before the budget. That is the background against which this Bill is being debated and guillotined. The changes in health care eligibility announced in the Programme for Economic and Social Progress are enshrined in this Bill but they must be regarded as a sick joke. How we will cure the sick joke I do not know, except by voting. These changes were announced on the basis that they would be broadly welcomed in principle but in practice they cannot be delivered. To expect things to happen without negotiation and without resources makes nonsense of the principle. The Minister has had meetings with the consultants and it is obvious that they have a problem about this. Let us hope that there may be some light at the end of the tunnel.

The number of people entitled to a free hospital bed will be exactly the same after this extension as before. The shortage of beds will still exist and will be at least as acute as in recent years. The measures proposed have been decided upon without any meaningful consultation. The consultants were perfectly entitled to object on such a fundamental issue which affects their conditions of employment. A group on remuneration sat down to deal with this problem. They have made their objections known to all of us. They are, after all, essential public servants and we have no way of knowing whether they will ballot in favour of this. Let us hope they do. If they do not, that is the potential for chaos. We are legislating for something which we are not certain can be carried out.

What difference will it make to people who are already entitled to services and cannot get them? Doctors who believe in treating all their patients to the highest possible standards, fully backed by their junior doctors in training, have effectively been told that they are no longer to be encouraged to see patients who pay in a public facility. This will drive many consultants who now see private patients in public hospitals to do more and more work in private hospitals.

Dr. O'Hanlon

The Deputy is contradicting himself.

Mr. Ferris

If that does not happen, the only possibility is that more private beds will be allocated to consultants within public hospitals. On 27 February this year we discussed this matter in the House and I suggested that the Minister intended to open up beds in public hospitals to private patients. This would mean that health boards would be forced to redesignate public beds as private beds. The Minister replied that this was not necessarily so. I went on to say that this would be one of the actions taken to ensure a continuing income from VHI. Today the Minister said that when the Bill is enacted he will immediately make regulations to provide for the redesignation of public beds as public and private. The Minister is contradicting himself. He will do it within a matter of months.

Mr. Allen

Fewer public beds.

Mr. Ferris

How can the Minister designate beds in public hospitals as private without reducing the number of public beds, unless he intends to open up some of the thousands of beds which have been closed?

Mr. Allen

No, he is closing more.

Mr. Ferris

If the Minister were to open up some of the closed beds as private beds at least he would be meeting some of the needs of the Bill. I warn the Minister that he will have to staff the hospital wards properly. This year he is already on record as saying on the airwaves that he does not intend to increase staff.

Dr. O'Hanlon

I did not say that.

Mr. Ferris

I could name the programme in question. The Minister said he intends to designate private beds in public hospitals. This is already happening. Officers of health boards are going around to see which beds they can cordon off in order to call them private beds. Of course that will interfere with the rights of people who are currently entitled to a public bed. I believe there will be trouble, but I hope I am wrong.

Dr. O'Hanlon

You are.

Mr. Ferris

The net result will be the separation of medicine into private and public and this will be enshrined in law as a permanent feature of our health service. This is the classic two-tier system. If the top echelon of income earners take up the entitlement extended to them, for which they are paying an extra health levy, without any extra resources being put into the system, the only possible result will be longer queues. If, on the other hand, the top income earners maintain their VHI cover in addition to paying the extra health levy which will amount to £19 million or £20 million per year, it simply means that they want the capacity to jump the queue. If this happens the Government will be formally sanctioning and subsidising the practice of queue-jumping. That would be the net effect of section 5 of this Bill. It would undermine the morale of the providers of a service and reduce the quality of that service. The position with medicine is no different. The net effect of these measures is that the Government are further underwriting private health care in private hospitals and discriminating in favour of the owners of these buildings and the professionals who work in them. Quite clearly this plan will fail, but if it does not I will be pleased.

We have tried to be as constructive as possible in studying this plan which was supported by the Irish Congress of Trade Unions. We have tried to find out what it would mean in reality, and quite clearly we are concerned that it will fail. When that happens, the Minister will come back to the House, some time in the near future, and make a scapegoat of somebody, probably the consultants. As a person who carries no brief for any interest group, I believe that the consultants are not the problem in this legislation; the problem is the Minister. He is living in a world where nobody suffers, nobody has to wait for treatment, nobody seems to get sick and charity is a substitute for rights. In other words, the Minister is living in a world the rest of us have left behind. He has ceased to represent the people who elected him. I have heard the Minister speak at demonstration marches, but I am not sure how long ago it is since he knocked on doors and learned of some of the difficulties people have to face.

The principle of separating private beds and private hospitals from public beds and public hospitals is a good one, but here we are proposing to redesignate private beds in public hospitals, thereby depriving public patients of their right to those beds. This redesignation is being carried out to suit the Minister, the consultants and the VHI, at the expense of the poor who have medical cards, who have a right to hospital beds, who are on waiting lists and cannot jump the queue because they cannot afford to do so. Some people have waited years for acute hospital services but the beds are not available. We are proposing by this measure to remove the beds which up to now have been available to those on an income below £16,700. We are now removing that income limit and with it we are removing the beds. This is a gimmick. I am disappointed in the Minister for introducing this type of legislation because it does not address the real problem. We are not providing a health service to the people who need it and are entitled to it.

Mr. Sherlock

The principle of this Bill is a good one but the reality is that unless the decision to extend eligibility is accompanied by the provision of extra finance, resources and personnel, the Bill's aims will not only be rendered meaningless but will also contribute to chaos and to waiting lists for our health services. For a long time I have recognised the anomalies that existed in that part of the service which provided for category 3 patients. At present the people in that category are eligible for all hospital services except consultant services which they must provide for themselves. In practice the vast majority of these people insure themselves against this liability with the Voluntary Health Insurance Board. However, in recent times, VHI cover, especially for certain consultant fees, has not been sufficient and in many instances there has been a very substantial shortfall. There is insufficient cover for children of people in category 3 if the income of the parent exceeds the threshold and, unlike the position for people in category 1, no account is taken of differing circumstances, such as family size or the exceptional costs involved.

In 1989 the Minister and the Department decided to make additional funds available when the Taoiseach discovered there was a great shortfall in the health services. In the Southern Health Board area an extra £1,090,000 was made available. A letter issued at that time stating very clearly that there would have to be an assessment of the spending of this money as between public and private health services. Many times since I have asked what is the ratio of spending in that regard but I have never received an answer for the simple reason that no co-operation has been forthcoming from the consultants.

I welcome the statement that it will be an essential element of the new arrangements that the status of the patient must be specified on admission to hospital and that a patient identified as a private patient will be liable for the fees of all consultants involved in his or her care. The fact that private patients have been treated in public hospitals, especially in orthopaedic hospitals, has been a matter of contention over the years.

We have to consider the background against which this Bill is being introduced. Events over the winter have shown that the crisis in the health services, especially in hospitals, is as acute as ever. Last year the flu epidemic was blamed for the chaos in our hospitals. This year there is no epidemic but the health boards and patients face a crisis every bit as serious as that of a year ago, and it is clear that the cutbacks will continue throughout the summer.

A letter to the Southern Health Board outlined some of the measures that are required to contain expenditure, such as a reduction in the level of activity in acute hospitals to end-1989 level; longer holiday and seasonal closure of beds; an increase in the range of surgical and medical procedures to be performed on a daily basis and substitution of more day beds for seven day beds. Health boards simply cannot maintain the services on the funds provided by the Government. The inevitable outcome has been longer waiting lists, more beds in corridors, the early discharge of patients, a longer closure of beds and wards during the holiday period, a worsening of the plight of the physically and mentally handicapped and less money for child care services and facilities for the elderly. The Minister is totally ignoring the problems experienced every day in the health services by doctors, nurses and administrators who have to cope with the chaos resulting from the Minister's disastrous policies, and especially from his refusal to acknowledge the need for increased funding.

Let us look at the reality of the situation. As I said, at the end of January the members of the health board in my area were informed that following a meeting with the Department it was proposed to reduce the level of activity to that operating at the end of 1989. This is in clear conflict with the commitment given by the Minister in the Dáil before Christmas that all health board services would be maintained at their 1990 level. Other proposals included, as I have said, a longer holiday closure period, the elimination of what were described as unnecessary tests, the temporary deferment of filling some vacancies and there would be no additional money for the physically handicapped or for child services.

The same problems are being experienced all over the country. The Irish Times of 19 February carried a report signed by the chairman of the Mater Hospital's medical council which gave a graphic account of the problems facing that hospital. One section of the report stated:

In recent weeks, the number of patients awaiting admission and remaining overnight in the accident and emergency department has increased. This in turn has given rise to inadequate supervision of patients who are left unattended on trollies in various cubicles whilst the nurses and medical staff attend to other patients.

Arising from this, staff numbers in the department are unable to monitor patients appropriately. It is not unusual to find two patients per cubicle, either being assessed for admission or awaiting admission. This practice is humiliating for the patient, the patient's relatives and is an extreme embarrassment for all the staff concerned.

How far removed all this is from the comfort and convenience available to those who can afford places like the Blackrock Clinic. No person in need of medical care and attention should be asked to endure those conditions, and we have no right to call ourselves a civilised society, while we continue to systematically inflict those conditions on the bill. What a great contrast there is between the reality of those conditions and the myth of the "comprehensive, equitable and efficient health care system" promised in the Programme for Economic and Social Progress.

The indisputable fact is that the health services have never recovered from the severe cutbacks imposed by the Fianna Fáil Government in 1987-88 — with the active support of Fine Gael — and will require significant additional funding to be even restored to the levels operating in mid-1980. We must certainly look for the most efficient and effective use of taxpayers' money spent on health, but we have to accept that a decent health service cannot be provided on the cheap. When we see a Government who can allocate more than £17 million to provide a presidential palace for the Taoiseach but can come up with only an extra £1 million for services for the mentally handicapped then serious questions must be asked about our values and our priorities as a society.

Recently I read the auditor's report for the year ending 31 December 1988 for the Southern Health Board and I should like to remind the House of a comment made by the auditor. He said that because of the serious shortage of funds the board had to meet £280,162 in interest and bank charges.

Mr. Allen

The banks win again.

Mr. Sherlock

I understand that on present-day figures that would equate to £400,000 being spent on interest and bank charges.

The Workers' Party have never suggested that additional spending on its own would create better health services. Combined with a restructuring of the health services, additional funding can give the Irish people the quality and range of the services they need. The fact is that the proportion of gross national product we have been spending on public health has been declining steadily, and unless there is a commitment to bring the level of spending back up in a planned and phased way the problems will continue.

Public 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 declined to 6.6 per cent in 1987 and to 6.24 per cent in 1988. By 1989 it was down to less than 6 per cent.

The average spending on health in OECD countries is about 8 per cent of GNP. We believe that spending on health here must be brought up in a steady but phased way to that level. Even with that increase, there must, of course, be the need to control expenditure and plan the most efficient use of our resources, not least because demands for health services will change and grow as the age structure of our population changes, with the proportion of elderly people increasing.

Successive Governments have also preached the virtues of community care as an alternative to institutional treatment, but they have failed to provide the resources to allow this become a reality. Running down institutional care without providing the additional resources to develop community care is a recipe for chaos and for suffering and distress for patients.

This was to be of particular value in the reorganisation of the psychiatric services and the care of people with mental handicaps. Yet five years after the publication of Planning for the Future the alternative community care services are nowhere near as developed as they should be. And this is almost entirely a question of resources, especially capital resources, to open up new community-based facilities.

The same principles apply in relation to general hospital services. If we want to ease the strain on hospital services, community care facilities must be developed. It is no good wishing for them: resources must be allocated to provide them. We need a substantial increase in the number of district health nurses, home helps, health visitors, domiciliary physiotherapists and occupational therapists.

The health services have been an issue that Fianna Fáil have shamlessly exploited when in Opposition and tried to ignore when in Government. Back in 1984, when the health cuts introduced by the Fine Gael-Labour Government were still at a relatively minor level, the Fianna Fáil leader, Deputy Haughey, gave an interview to the Irish Press in which he said: “the health services have been reduced to dangerously inadequate levels, and I think that, if it has not happened already, people will die because of the unavailability of particular services in certain areas”. The Taoiseach says little enough about the health services these days, but perhaps at some stage he might come into the House and let us know how many people he believes have died as a result of the health cuts introduced by his Government.

Fianna Fáil should remember that public concern at the health cuts may well have denied them an overall majority in the 1989 general election. Health cuts, and the quality of our health services, are still very major political issues. Fianna Fáil and Progressive Democrats candidates in the local elections will face the wrath of the electorate unless urgent remedial action is taken and the health boards are provided with the funds required to put the health services on a satisfactory footing.

I should like to turn now in more detail to the provisions of the Bill. As I said, we welcome the decision to extend eligibility for hospital services to the entire population. That is something we have sought for many years. However, against the background of the chaos in the health services, what is going to happen if eligibility is extended to an additional 15 per cent of the population without the provision of additional resources? We must provide additional doctors, nurses, ancillary staff, beds, medical equipment, catering facilities and so on or else we will have longer waiting lists.

There is no reference in the PESP, the budget or in the Estimates to a plan to provide money to pay for the extra numbers who will now be eligible. Perhaps the Minister has made a calculated decision not to provide additional resources in the expectation that if waiting lists are not reduced those who qualify for eligibility will continue to be private patients. If this is the case an outrageous confidence trick is being played on the public — on those who will now pay extra contributions and on those who cannot afford the private service. The only people in the health sector who will get anything extra from this will once again be the consultants. Nurses, junior doctors and hospital administrators will be expected to administer the new eligible 15 per cent without a penny compensation. Such a commitment was not expected from consultants. Consultants have been awarded generous new contracts which include once-off payment of between £13,000 and £17,000 as well as salary increases of between 30 per cent and 50 per cent. This apparently was the consultants' price for agreeing to allow extended eligibility to go ahead from 1 June. As usual the consultants flexed their muscles and have been allowed to get away with it.

We welcome the fact that private patients will no longer be able to use public beds. The Minister for Health has claimed that this will mean an end to queue jumping. It remains to be seen whether or not it will. However, it is worth asking why the Minister has decided not to introduce the common waiting lists for public and private patients as recommended by the Commission on Health Funding. We believe very strongly that a common waiting list should be introduced, and that consultants with public appointments should be obliged to see and treat all patients, whether public or private, in the same manner, that is, in the same room or outpatients' department under the same conditions and from the same waiting lists. It should be a breach of contract to do otherwise. GPs in the General Medical Service are obliged to do this.

I note that under section 5 patients will, effectively have to opt for either public or private status. This needs clarification. Will a patient have to opt for public or private status for a particular period of time? Will it be for a specific illness? Will it be possible to transfer from one status to another while in hospital? These matters need clarification.

The Bill also restricts the right to hospital services to what are described "as those ordinarily resident in the State". What does this mean? Does it mean that a person who has emigrated for a number of years and then returned home will not qualify for services for a certain number of years? How long will a person have to reside here to be considered ordinarily resident in the State?

The enactment of this Bill also has serious implications for the future role of the VHI. If everyone is entitled to free hospital services, what is the point in having a State-owned company which helps provide private services? Certainly there is now no justification for providing tax relief on contributions to the VHI, when everyone is entitled to public cover.

Despite our serious reservations about the willingness of the Government to provide the resources necessary to implement their provisions, the extension of the principle of eligibility for hospital cover is something that we have sought for a long time, and we will therefore not vote against the Bill.

Miss de Valera

The Government recently provided £1.5 billion for health. We have more money in the health system than we have ever had yet there are many problems in the system. It seems to be unable to deal with the pressures. There is particular pressure on acute beds. Too many people are still waiting for beds and we are all aware of overcrowding in the hospitals. It is the purpose of the Bill to deal with the problems.

We are all well aware of the two-tier medical system. Perhaps it is unofficial but it is certainly there. There has been a positive relationship between ability to pay and the time spent on waiting list, so I welcome this Bill in its approach to public patients being given access to consultants free of charge. This is worthy of the support of all Members.

Every Member of the House would agree with the point made by the Opposition with regard to medically established priority. The Minister was accused of trying to underpin the two-tier system rather than underlining that it will be medical assessment that will establish priority. The Minister in this Bill is trying to ensure that public patients have free access to consultants in order to establish the principle that medical assessment establishes the priority. That should be welcomed.

I am worried about one aspect of the Bill. It has been argued that the fact that there will be more public beds available will mean smaller queues for those who wish to make use of public beds. This may be true in the larger hospitals but I find it hard to see how it will affect local hospitals and smaller general hospitals, such as Ennis General Hospital. Out of 78 beds in Ennis General Hospital, excluding day beds, 63 are public. The highest demand in that hospital is for public beds and the vast majority of those who wish to use that hospital are public patients. Will the Minister tell us how he would see the positive effects of this Bill as regards hospitals such as Ennis General Hospital? It is important to point out that a large number of the patients in Ennis General Hospital are geriatric. There are rumours that 50 geriatric beds in St. Joseph's Hospital, Ennis are to be given over to psychiatric patients. The percentage of geriatric patients in Clare is far higher than in many other areas, the effect of reducing the number of beds for geriatrics in St. Joseph's will have a knock-on effect on Ennis General Hospital and will slow down the turnover of beds available for acute patients.

The intention of the Bill is to expand the system, which poses a number of questions. With the options now available to patients, will we be able to cope? Will it mean more demands on public beds? It has been said that the number of public beds will not be decreased; if so, how will the private patient fare under this system? Will the Minister clarify whether there will be a common waiting list? Will the Minister also clarify section 6? I should like to know the implications for medical card holders and public patients.

I am also very pleased that there will be a monitoring system because the point of the Bill is to prevent queue-jumping and eliminate the two-tier system in our medical services which has been the case over a number of years now. I understand that the Minister wants to break with that system, which is what the Bill is intended to do. The monitoring system is very important because it will give an opportunity to the Minister to see whether it works. I should like to see — as I believe every Member in the House would like to see — universal access to health care. I hope the Bill will clarify this and put us on the right road to access to health care for everyone; anything less would be reprehensible.

Mr. Allen

The taxpayers are being taken for another ride by the Minister because, essentially, this is a mini-budget. The removal of the ceiling on health contributions means that the person earning £21,000 per annum will pay £60 more in health contributions; the person on £25,000 will pay £120 more and the person on £30,000 will pay £160 more per annum. What will these people get for their increased contributions? They will get a health service which is at present a shambles; they will have to wait their turn and there is a two year waiting list for many of the specialist treatments.

The individual paying substantially more for health care will remain in the VHI, it will be the passport to private medicine on which he will remain very dependent. I am not here to defend the man earning £25,000 but I am pointing out that he will be paying much more and getting nothing for it. The person with a medical or hospital services card will be in a worse position. The Minister has not answered a simple algebra question: if he has X amount of beds in the public service and he takes Y of it he is left with a decreased amount of X minus Y. The Minister tried to tell us today that the person on a medical or hospital services card will get a better service and that the same applied to the person paying more. The Minister is trying to cod us, he is shaking his head but he should be ashamed of himself. I know it is election time but he should not——

An Leas-Cheann Comhairle

Address the Chair, Deputy.

Mr. Allen

I am addressing the Chair.

An Leas-Cheann Comhairle

You are not.

Mr. Allen

Although it is election time the Minister should not be practising such cold callous tricks on the taxpayers. Of course, in his speech, the Minister did not quantify the percentage of beds which will now be earmarked private in public hospitals and, therefore, we cannot judge the real effect on the health services. We are still unaware of the level of private practice which existed in the health services up to now because the Minister did not have the political will to quantify it. A Southern Health Board report of recent vintage showed that, in certain specialist treatments, up to 40 per cent of private practice was in public wards, utilising public resources, staff and equipment. In other specialist areas it was zero; there are many honourable and hard working consultants in our public hospitals but a few need to be weeded out and the Minister has not done it.

Dr. O'Hanlon

This will do it.

Mr. Allen

It will not do it, the Minister is conning the people; the Minister confronted the consultants and blinked, an expensive blink for the taxpayers in the years ahead. It is worse than the deal the Taoiseach made in 1979 when he gave them a free hand. The Minister is doing the same and giving them a bonus to go with it. The result of the Minister's eyeball to eyeball confrontation with the consultants will cost the taxpayers about £35 million straight away.

Recently debt collectors were knocking at the doors of medical card holders and hospital service card holders but now the tax collector will be pounding on the doors of taxpayers to ensure that they pay the extra money. There is no extra money for what the Minister termed "extended cover" and I cannot see how he will give an improved service. The people who will now pay £100 more annually will see a service in which there are waiting lists for almost every operation, two years for a tonsillectomy or a simple operation for adenoids. Of course, if one has the resources the operation will be done by the same consultant in two or three weeks. The Minister failed to deal with that issue. The same problem exists in relation to hip replacements, a fact which was brought home to me recently. I saw a person in agony because of the lack of membership of the VHI. The Minister has not addressed that problem either and he need not tell us that the proposals in the Bill will rectify it. The coldest con job of all is to give hope to people who think there will be an improvement. The Minister is merely joining the Minister for Finance in taking more money from the people.

What about cancer patients in hospitals? The Minister has been warned time and again that equipment in the Cork Regional Hospital is obsolete. Patients in the throes of cancer are being taken by bus to Dublin for treatment because the Minister failed to deal with the problem of capital resources for our hospitals. He has allowed hospital equipment to run down to a dangerously low level and now he is trying to tell us that everyone will have free hospital treatment and that everybody will be able to avail of free consultant care, but I would remind him that when the holder of a medical card or a hospital services card visits an out-patient clinic in a regional hospital, say, the Cork Regional Hospital, he will see a registrar or a junior doctor — only rarely will he see the same doctor twice — and not the consultant. Is the Minister seriously trying to suggest that by extending this entitlement to an extra 200,000 people that they will suddenly get to see the consultant and that he will have time to see all of them? It is a shame that the Minister has tried to use this con trick.

We face the prospect that the number of beds available in Cork city will be reduced. For instance, the Mercy Hospital which was supposed to fill the gap created following the closure of the North Infirmary may have to close 40 beds during the summer months because an inadequate allocation has been provided. For a long number of years the staff of that hospital have tried admirably to resolve the crisis being faced on the north side of Cork city but now they find themselves under even greater pressure as adequate resources have not been made available which would allow them to deal with the problem. The hospital is bursting at the seams but the Minister is unwilling to provide it with the resources it needs. I hope the Minister will give it the necessary resources——

Mr. Creed

Deputy Dennehy told him all he needs to know.

Mr. Allen

The Minister's backbenchers made him aware of this problem at a parliamentary meeting and also made sure that the press became aware of it. I hope the Minister will take action. Last week in reply to questions put by me the Minister pointed out that 10 per cent of the staff in Southern Health Board hospitals are temporary nurses and doctors, who do not know from one month to the next if they will be retained, and trainee nurses. In addition, haemophialiacs are being treated in a disgraceful, uncharitable and pathetic way but the Minister has washed his hands of the matter and has said he is not in a position to reply to questions because the matter is sub judice. These people are suffering and are dying but the Minister has been callous and ignored their rights.

Given the pressures on the health service, I would have thought the Minister would have won his battle at the Cabinet table to have extra resources made available, but I have constantly made the point that this is not the complete answer. The Minister should have tried to introduce reforms in the health services during the past few years. A number of groups suggested ways in which this could be done but the Minister had not the political will to act. In his contribution earlier today he promised to make changes in the management structures and I await hearing what these will be. I hope he will not play around with the system but rather will introduce changes which will enable us to tackle the problems.

In the run-up to the local elections, Government Deputies are going around the country announcing, for cheap political gain that sums of £500, £750 or £1,000 will be allocated for particular ventures, at a time when no attempt is being made to address the real issues. The philosophy seems to keep the people happy: give them a few bob and they will stay quiet or even vote for them, but that is not the answer to our major problems.

During the past few years our people have suffered heartbreak and tragedy. I have already referred to the suffering being endured by those awaiting hip replacement operations and by those who have to travel to Dublin for cancer treatment. In addition, many parents are heartbroken because they do not have the money to send their children to hospital to have a serious defect rectified, and lives have been lost because of the cutbacks of recent years. The Minister should not pretend otherwise. Indeed, the position is getting worse. Millions of words have been spoken about the issue and horror story after horror story has been told. The position is frightening but what is even more frightening is the Minister's insensitivity to those who are suffering and his pretence that today everybody will get something for nothing, when it is clear they will not.

The Minister is remote from the problem and is insulated by statistics, strategies and the many reports on his desk. Things are bad but they could be far better if the Minister tried to remedy the problems. As I said, there has been a callous and calculating attempt to con the people of the country by claiming to extend eligibility for free consultant care to 200,000 people when the system is already overloaded. He has promised that there will be more reports but what we need is a plan and more resources.

In conclusion, I would remind the Minister that he is dealing with people's lives——

Dr. O'Hanlon

I am glad the Deputy has realised that.

Mr. Allen

——and he should not try to tell them that everything will be all right at a time when people are suffering. Indeed, relations of mine are suffering. I come from an area where the people depend on their medical card or hospital services card and they are suffering. The only thing that will be of help to them is the will to bring about change. However, in his latest test with the consultants during the past few days he let down the people of the country once again because he did not address the issues.

Dr. McDaid

I get a feeling of déjà vu each time we come to discuss health issues in the House. We have heard it all before.

Mr. Allen

The Deputy will hear it again.

Dr. McDaid

When we discussed this issue on 6 February 1990 Deputies Yates, Sherlock and Ferris were present in the House. When the issue was further discussed on 20 February 1991 Deputies Bruton, Sherlock and Ferris were present. The Deputies have tried in the debate on what is a commendable Bill another run down on the health services such as we have heard already.

Mr. Allen

No changes have been made.

Dr. McDaid

I would respectfully suggest to the Deputies that they hold on to their speeches as I have no doubt they will have an opportunity to use them again in February 1992.

Mr. Allen

Is the Deputy admitting that no changes will be made?

Dr. McDaid

At the outset I wish to express the hope that this Bill marks the beginning of a process which will eventually remove the worst aspects of a two-tier health service. We are only too aware of the simple fact that patients who are listed for what are described as elective hospital procedures can be accommodated at much greater speed if they can present themselves as private patients. This is the case also in Britain, a country which boasts of having the finest health service in the world. In virtually every country there are waiting lists and we all have the same problems. Even as matters stand, and in spite of our deficiencies our general population are very much better served than those in the United States, where the very thought of hospitalisation causes nightmares, and hospitalisation may even lead to bankruptcy.

In an ideal situation everybody would be a member of the VHI. This prompts an idea which may or may not be practical in the long run. The VHI Board have been advertising for several years in an effort to enrol as many people as possible, and they have succeeded to a considerable degree. A question that occurs to me is, what would happen if the VHI found themselves with a membership composed of the entire population? I have a picture in my mind of a scenario where those who could afford it would pay their VHI premium and those who could not afford it would have their premium paid by the State with perhaps a partial payment for those people caught in between. This would, of course, highlight the necessity for sufficient hospital accommodation and medical and other personnel to service that demand. The market would indicate the need and the VHI could use their undoubted skills in controlling the day-to-day expenditure involved.

In recent years we have seen the development of a third tier, in my opinion a sort of super-tier, led by the Blackrock Clinic and others. Indeed, it has been suggested that the introduction of an insurance category to cater for this tier was largely responsible for the financial difficulties within the VHI which they had never experienced before, and the lower groups were called upon to subsidise those in the higher groups as a result. I suggest that these higher groups designed to give cover for the super clinics should be financed out of a single fund and the premium should be adjusted accordingly, if necessary. The people who opt for this type of treatment are not the people about whom the Minister or the rest of us are too concerned.

We, on this side of the House, have been accused of ignoring or not being aware of the problems in the health service. Nothing could be further from the truth. The record of Fianna Fáil in this area is there for all to see. The present Bill is about eligibility for treatment in hospitals and one must immediately recall that many of the fine modern hospitals we are talking about would not be there were it not for the building programme initiated by our present Taoiseach, Deputy Haughey, when he was Minister for Health. Since he came into office in 1987 the present Minister, Deputy O'Hanlon, has engaged in the most comprehensive examination of the entire service ever undertaken.

Mr. Allen

That is all he has done.

Dr. McDaid

He has outlined in his speech many of the improvements brought in as a result of extensive consultation with medical and administrative personnel as well as the social partners. This Bill has resulted from similar consultation. The Minister is a patient man, as he should be when dealing with such farreaching and complex proposals. Prior to 1987 many of those on the opposite benches were silent on those matters when they were in a position to do something about them. Of course, even if they had had the ideas it would have been impossible to activate them for the simple reason that they had brought the country to bankruptcy. I have very little patience with the criticisms of Deputy Bruton or anyone else from the parties which formed either of those two Governments.

There are one or two points arising from the Minister's speech which I would like to have clarified. First, let me refer to the present system where private patients who opt or find themselves in public beds are not charged for such beds, apart from the restricted daily fee of £12.50. Should such a situation arise after the enactment of this Bill what would the position be? From my reading of the Minister's speech, it would appear that such a patient would be charged for accommodation. I am aware there will be a phasing in period of three years to take account of needs and deciding what proportion of the beds can be designated as public or private. If a private patient, through no fault of his own, finds himself in a public bed will he be charged, or, to be more precise, will the VHI be charged? At present the VHI premiums are adjusted to take account of the fact that there is no charge for public beds regardless of the circumstances, but what I am concerned about is whether the VHI will seek an immediate increase in premiums to take account of the extra costs that would be involved. I know the Minister has consulted with the VHI Board on matters concerning the Bill and I would be interested to know whether this aspect had been discussed with them. I am aware that the board do not anticipate a head-long rush of people out of the VHI and into public beds as Deputy Bruton seems to expect. I do not believe for a moment that it will worsen existing services, as he suggested also.

In conclusion, some Opposition Members treated the Minister's efforts with their usual contempt but before they go too far they should remember that this Bill is not the work of the Minister alone but derives from the combined submissions of the health authorities, medical personnel, the ERSI, the VHI, the trade unions and all those who took part in the negotiations leading to the Programme for Economic and Social Progress. If they seek to ridicule the Minister they do likewise to the representatives of a broad spectrum of society.

An Leas-Cheann Comhairle

I regret that Deputy Creed's patience has not been rewarded, but the Order of the House requires that I call the Minister to conclude.

Minister for Health (Dr. O'Hanlon)

First, I thank the Deputies for their contributions. Despite the fact that we have explained the rationale behind the change in eligibility over a number of months, it appears, from listening to the Deputies opposite, that they do not seem to have grasped the simple facts.

Mr. Allen

We know the facts.

Dr. O'Hanlon

The position at present is that there are three groups of people: people in public hospitals, private patients who pay for private beds and public patients who are treated as public patients or patients in a public bed who pay their consultant's fees. This last group will no longer exist because patients in public beds who pay their consultants can in future opt for a full public service or for a private service. Indeed, it was Deputy Allen himself who said — I am quoting him because I do not have the evidence — that in some hospitals 40 per cent of the patients in public beds were private patients. That is the very situation this Bill will eliminate, and I am sure Deputy Allen would agree with me on that. This Bill will eliminate that problem because no longer will it be possible for a patient to get a public bed and pay a consultant.

Mr. Allen

They will, it was an irregularity but it will be official now.

Dr. O'Hanlon

That is not an irregularity under the existing rules. That is allowed.

Mr. Allen

Is there no objection to that?

Dr. O'Hanlon

I did not like it and no Deputy liked it. It was within the rules while Fine Gael and Labour were in Government.

A Deputy

I did not argue with you on that.

Dr. O'Hanlon

We have faced that issue. It was Deputy Allen who said the figure was as high as 40 per cent, but I never had evidence that it was that high.

Mr. Allen

Shame on you Minister for admitting that. The evidence is there in the Southern Health Board report.

Acting Chairman (Mr. Wyse)

The Minister to continue without interruption. Since the Minister's time is limited, I would ask Deputy Allen not to interrupt.

Mr. Allen

He is misquoting.

Dr. O'Hanlon

Deputy Bruton's amendment refers to "further eligible patients" as a result of the new measure and to the absence of extra money to match these further eligible patients. The simple fact is that the entire population are already entitled to public accommodation and the change in eligibility relates only to one's liability for professional fees——

Mr. R. Bruton

Where is the extra money?

Dr. O'Hanlon

——and does not of itself do anything to increase the demand for public beds or the cost of providing public hospital services.

Mr. Allen

Will the consultants be on overtime?

Dr. O'Hanlon

Deputy Allen referred to the consultants and to the recent negotiations with the consultants. I would like to assure him that we referred the consultants' claim for higher remuneration to the Review Body on Higher Remuneration in the Public Sector, the appropriate body to refer this matter because they are very highly salaried public servants. We referred this matter to Mr. Gleeson who made the recommendations and we negotiated with consultants within the recommendations. The Deputy need not come into this House and say we ran away, because we did not.

Mr. Allen

You cannot find a consultant in a public hospital.

Mr. R. Bruton

The common waiting list was fundamental to what they were negotiating.

Dr. O'Hanlon

I want to pay tribute to the management side who negotiated for the past six months. Indeed, I am puzzled at Deputy Bruton's suggestion that his party would have supported moves to keep private patients out of public beds without taking the other steps covered in the Bill. Surely, Deputy Bruton can see that you cannot have it both ways, you cannot have a common waiting list and keep private patients out of public beds. A common waiting list means that the next patient goes into the next available bed. The Deputy would keep them out of it if it was another public bed, but still he would tell the people that there was a common waiting list.

Mr. Allen

What we are supposed to be trying to achieve is access to hospital on the basis of medical need.

Dr. O'Hanlon

It would be very unfair to keep private patients out of public beds. We would also have to abolish category 3. As long as category 3 exists, 15 per cent of the patients must be private patients.

Mr. Allen

The Minister is abolishing the notion of a common waiting list and he will not face up to that.

Dr. O'Hanlon

Deputy Bruton questioned my reference to the Irish Congress of Trade Unions. He appeared to suggest that I was incorrect in mentioning their support for the full detail of the new measures. Let me remind the Deputy that the entire Programme for Economic and Social Progress was agreed and endorsed by the ICTU and the other social partners. I would draw the Deputy's attention to paragraph 48, on page 28 of the programme, which refers explicitly to the new arrangements for accommodating private non-emergency patients in private or semi-private beds only.

Deputy Allen referred to politicians going around the country currying favour. I listened last week while Fine Gael's spokesman in the Seanad said there were two ways we could run the health services. One was to balance the books at the end of the year and make sure to only spend the money one gets. The other was to provide a good education service with no reference to money, and good health services. That was his choice. Does that represent Fine Gael policy? It appears from what Deputies Allen and Bruton said this evening that it does. One has to mix the two. One has to provide good health services and a good education service and do so within the limits of the money available.

Mr. Allen

We want to know the policy.

Acting Chairman

I will not tolerate any more interruptions. I have warned Deputy Allen on a number of occasions. I will have to ask him to leave the House.

Dr. O'Hanlon

I consider it was a slur on 59,000 dedicated and committed people, nurses, doctors, paramedical people, administrative staff, catering staff and so on for Deputies to suggest this evening that there were no health services for people unless they paid. People are getting a good service.

Mr. Allen

There is evidence to the contrary. The Minister is codding himself.

Dr. O'Hanlon

I am realistic enough to know that there are and there have been deficiencies in the service.

Mr. Allen

There is a three year waiting list.

Dr. O'Hanlon

Deputy Ferris was able to lay the figures before this House of the increases in the number of people treated in our health services. I admire Deputy Ferris for giving us facts and figures and identifying the increase in the level of services and the number of people in the South Eastern Health Board region. Deputy Allen should know that something similar is happening in his own area. The waiting list for cataracts was reduced by 12 per cent last year. There has been a 14 per cent increase in the number of hip operations performed and an increase of 40 per cent in Cappagh Hospital for hip operations.

Mr. Allen

There is a two year waiting list still; two weeks if one can pay.

Dr. O'Hanlon

The ear, nose and throat service in the Deputy's own city has improved and the Deputy has not the grace to do what Deputy Ferris did and tell us about it.

Mr. Allen

The Minister is misrepresenting the situation.

Acting Chairman

I am giving Deputy Allen a last warning. If he interrupts the Minister again I will ask him to leave.

Mr. Allen

I will not listen to that rubbish.

Dr. O'Hanlon

It is the truth.

Mr. Allen

I will not listen to untruths.

Acting Chairman

Deputy Allen, if you are not prepared to listen to the Minister, leave the House. Otherwise I will have to ask you to leave the House. I want to hear no more interruptions.

Mr. Allen

The Minister should be accurate.

Dr. O'Hanlon

I want to assure Deputy de Valera that we are in discussion with the Mid-Western Health Board about hospitals such as Ennis. The number of public beds will be maintained at their present level and the number of private beds in the smaller hospitals, as in the larger ones, will reflect the existing demand for private beds. I would add, because the Deputy raised the point about geriatrics, that a new post of geriatrician was advertised recently for Ennis Hospital. This will make a big difference to bed needs and the use of beds because it is important when talking about beds to look at the use they are put to.

We have increased considerably the amount of day surgery which has brought us into line with other developed countries. We were very far behind in that regard.

Mr. Ferris

The Minister opened the 20 beds that were closed in Ennis.

Dr. O'Hanlon

It is how the beds are used that is important, not the number of beds. Indeed, it is no harm to point out again in regard to allocations to health boards that we have provided £1,543 million, the largest amount ever provided by an Irish Government for the health services in this State, in the current year. It is important to recognise that there has been an increase of 21 per cent in our allocation to the health boards since 1988. Deputy Allen did not tell us that. Allocations to voluntary hospitals have increased by 36.9 per cent since 1988.

Mr. Allen

Their debts have increased too.

Dr. O'Hanlon

That reflects the increasing demand for high technology in our hospitals. It is the hospital element of the services that results in the demand for more and more money. Reference was made to those suffering from mental handicap. There was a 40 per cent increase in the amount of money allocated to voluntary organisations who are the main providers of service for those with mental handicap here.

I want to refute entirely the suggestion that the extension of eligibility is a cover for seeking extra resources. That is an outrageous suggestion. This change in eligibility arises directly from the Programme for Economic and Social Progress which was agreed between the Government and the social partners at the start of the year. It was recommended initially by the Commission on Health Funding and was supported by the National Economic and Social Council.

Mr. Allen

Only in the context of a common waiting list.

Dr. O'Hanlon

The health contribution has often been criticised as being a regressive tax. It bears proportionately more heavily on people earning lower incomes. Because of the income ceiling a person earning, say, £30,000 has been paying the health contribution at an effective rate of 0.7 per cent, dropping to only 0.4 per cent for someone earning £50,000.

Mr. Allen

He will be paying £160 a year more.

Dr. O'Hanlon

The income from the abolition of the health contribution income ceiling will be put towards the very significant extra expenditure which the Government are committed to in the Programme for Economic and Social Progress.

Deputy Ferris asked what amount would be brought in by the change. In a full year it will be £19 million. Reference was made to hospitals closing. I do not know whether Deputy Ferris would suggest that Beaumont Hospital should remain closed as it did for four years.

Mr. Allen

What about Tallaght?

Dr. O'Hanlon

We closed Jervis Street and the Richmond hospitals. Every time Deputy Ferris speaks on a health motion here he refers to the fact that we closed those two hospitals. It appears that he objects to that. If anybody wants an example of trying to drive a wedge into our health services and separate public and private health care, Beaumont was a classical example. The Minister for Health at the time, former Deputy Barry Desmond, refused to allow the consultants to have a private facility on the campus of Beaumont Hospital. Now Deputy Ferris complains that we will drive the consultants out to private hospitals which is what the then Minister wanted. What we are doing is providing the facility and we will keep the consultants on campus because that is in the best interests of the public patients.

Mr. Allen

Will they still be allowed their private practice?

Dr. O'Hanlon

What we will ensure is that if one wants to be a public patient in a public hospital that facility will be there. If one wants to be a private patient one can be a private patient in a private bed. Again, I come back to the point Deputy Allen made. He knows that in some instances 40 per cent of the beds were used by patients who took their maintenance as a public patient and paid the consultant. That will be eliminated.

Mr. Allen

One never sees the same consultant twice in a public hospital.

Question put: "That the words proposed to be deleted stand".

The Dáil divided: Tá, 81; Níl, 46.

Tá

• Ahern, Bertie.
• Ahern, Dermot.
• Ahern, Michael.
• Andrews, David.
• Aylward, Liam.
• Barrett, Michael.
• Brady, Gerard.
• Brady, Vincent.
• Brennan, Mattie.
• Brennan, Séamus.
• Browne, John (Wexford).
• Burke, Raphael P.
• Byrne, Eric.
• de Valera, Síle.
• Ellis, John.
• Fahey, Frank.
• Fahey, Jackie.
• Fitzgerald, Liam Joseph.
• Fitzpatrick, Dermot.
• Flood, Chris.
• Flynn, Pádraig.
• Foxe, Tom.
• Garland, Roger.
• Geoghegan-Quinn, Máire.
• Harney, Mary.
• Haughey, Charles J.
• Hillery, Brian.
• Hilliard, Colm.
• Hyland, Liam.
• Jacob, Joe.
• Kelly, Laurence.
• Kenneally, Brendan.
• Kirk, Séamus.
• Kitt, Michael P.
• Kitt, Tom.
• Lawlor, Liam.
• Lenihan, Brian.
• Leonard, Jimmy.
• Lyons, Denis.
• Martin, Micheál.
• McCartan, Pat.
• Calleary, Seán.
• Callely, Ivor.
• Clohessy, Peadar.
• Collins, Gerard.
• Connolly, Ger.
• Coughlan, Mary Theresa.
• Cowen, Brian.
• Cullimore, Séamus.
• Daly, Brendan.
• Davern, Noel.
• Dempsey, Noel.
• Dennehy, John.
• De Rossa, Proinsias.
• McDaid, Jim.
• Mac Giolla, Tomás.
• Molloy, Robert.
• Morley, P. J.
• Nolan, M. J.
• Noonan, Michael J.
• (Limerick West).
• O'Connell, John.
• O'Hanlon, Rory.
• O'Kennedy, Michael.
• O'Leary, John.
• O'Rourke, Mary.
• O'Toole, Martin Joe.
• Power, Seán.
• Quill, Máirín.
• Rabbitte, Pat.
• Reynolds, Albert.
• Sherlock, Joe.
• Smith, Michael.
• Stafford, John.
• Treacy, Noel.
• Tunney, Jim.
• Wallace, Dan.
• Wallace, Mary.
• Walsh, Joe.
• Wilson, John P.
• Woods, Michael.
• Wyse, Pearse.

Níl

• Allen, Bernard.
• Barnes, Monica.
• Barrett, Seán.
• Barry, Peter.
• Belton, Louis J.
• Boylan, Andrew.
• Bradford, Paul.
• Browne, John (Carlow-Kilkenny).
• Bruton, Richard.
• Connaughton, Paul.
• Connor, John.
• Cosgrave, Michael Joe.
• Cotter, Bill.
• Creed, Michael.
• Crowley, Frank.
• Currie, Austin.
• D'Arcy, Michael.
• Deenihan, Jimmy.
• Doyle, Joe.
• Dukes, Alan.
• Durkan, Bernard.
• Enright, Thomas W.
• Farrelly, John V.
• Fennell, Nuala.
• Ferris, Michael.
• Finucane, Michael.
• Flaherty, Mary.
• Gregory, Tony.
• Higgins, Jim.
• Hogan, Philip.
• Howlin, Brendan.
• Kavanagh, Liam.
• Kenny, Enda.
• McGahon, Brendan.
• McGinley, Dinny.
• Mitchell, Gay.
• Mitchell, Jim.
• O'Shea, Brian.
• O'Sullivan, Gerry.
• Quinn, Ruairí.
• Ryan, Seán.
• Sheehan, Patrick J.
• Spring, Dick.
• Taylor-Quinn, Madeleine.
• Timmins, Godfrey.
• Yates, Ivan.

Tellers: Tá, Deputies V. Brady and Clohessy; Níl, Deputies Boylan and Durkan.

Question declared carried.

Amendment declared lost.

An Ceann Comhairle

I declare the Bill to have been read a Second Time in accordance with Standing Order 93(2).

When is it proposed to take Committee Stage?

Dr. O'Hanlon

It has already been agreed between the Whips to take Committee Stage tomorrow morning.

Committee Stage ordered for Wednesday, 29 May 1991.