Estimates 1991 (Resumed).

Debate resumed on the following Estimates which were moved by the Minister for Finance (Mr. A. Reynolds) on Friday, 5 July 1991. Votes 1 to 3, inclusive, 5 to 44, inclusive; and Supplementary Estimates, Votes 2 and 39.

Last night I dealt specifically with an area that concerns all of us, the area of mental handicap. The human hardship involved in mental handicap and physical disability will get a good deal worse unless planning starts now. This planning must take place in the knowledge that resources will become available. I am asking the Minister for Health, Deputy O'Hanlon, whom I complimented last night in his absence, to fight at Cabinet for these resources. It is imperative that the Minister for Finance and the Government should, instead of considering further cutbacks, commit themselves now for a period of years to improving the funding available in the area of mental handicap. The amounts recommended by the review group would go some way towards alleviating the stress and anxiety of thousands of families.

In South Tipperary we have a very active association for mentally handicapped children funded by voluntary organisations and public charities, social employment schemes, FÁS schemes and so on. In the last number of days they have issued documentation to all Members of the Oireachtas in South Tipperary. Putting their case in context, they said:

In the absence of a multi-disciplinary early intervention service as recommended in the Review Group Report, parents of infants with delayed development in South Tipperary are left to fend almost entirely for themselves with the voluntary assistance of members of the Association and other helpers.

In the absence of supported pre-school services for children with delayed development, parents are left to cope alone and children are losing crucial opportunity for the development that will not come again.

The single development centre for children in the country is dependent on temporary appointments from FÁS Schemes and on volunteers from the County Association who have to beg on the roads and streets of Tipperary to support the Head of the Centre in her heroic struggles to keep up standards and to meet the needs of two-year-olds and young adults in the same premises.

We are aware that this is not the case in other counties. Why can fully staffed early intervention teams be available in County Galway and not in South Tipperary.

Is it that the Minister is complacent and depending on voluntary organisations to do the work of his Department? The association continued:

Why can pre-school locations be available in Dublin, Cork and Kerry and not in South Tipperary?

The Tipperary Association wishes to draw the attention of the people of South Tipperary to the situation of two schools at Cashel which are providing for a large number of pupils with a multiplicity of other handicaps in addition to their mental handicap.

In many other counties, such schools have access to a support service team which has a multiplicity of professionals including psychiatrists, psychologists, social workers, speech therapists, physiotherapists and so forth. Why is it then that these facilities in South Tipperary have to attempt to cope with only token support.

There is almost a total absence of educational opportunity for children of school going age with a severe or profound degree of mental handicap and when they are accepted in schools or in the developmental centre no additional provision is made by statutory authorities to meet their needs.

In South Tipperary, there are no places, either day or residential, for adolescents and young adults with a severe or profound degree of mental handicap with the exception of the inappropriate placement of a few adolescents in the development centre at Cashel.

In the whole of South Tipperary, there is virtually no crisis or respite accommodation for either children or adults of any degree of mental handicap.

In the whole of South Tipperary, there are not more than twenty residential places for adults with a mental handicap outside of the psychiatric hospital and there are no services whatsoever for elderly mentally handicapped persons except within the psychiatric hospital.

In South Tipperary there is not a single day or residential facility for adult mentally handicapped persons with seriously challenging behaviour outside of the psychiatric hospital.

In South Tipperary, there is not a single day place for an adult person with a severe to profound degree of mental handicap.

In South Tipperary, there are not more than half a dozen residential places for adults with a severe or profound degree of mental handicap outside of the psychiatric hospital.

We are fully aware that South Tipperary is being grossly neglected and unfairly treated and we call on politicians of all parties to address the issue as a matter of extreme urgency. We also demand that the Department of Health, the South-Eastern Health Board and the Service Providers in South Tipperary treat this as a matter of grave crisis and set about the implementation of a concrete plan to rectify the situation.

That is just an example of one county's efforts to deal with a major problem. Something like 2,000 places are required in this area and the funding from the Minister in the last year and in this year has provided only about 150. That certainly does not attempt to address the real problems in the area of funding for the mentally handicapped. The Minister has often repeated his personal commitment and that of his Department in the House, and we have accepted that commitment but we find, in the middle of this year, that there are problems in the area of funding in all Departments and that the Minister for Finance and his colleagues are expecting further cutbacks in health because that Department happen to be big spenders, and because they are big spenders they are the first to suffer when there is talk of cutbacks.

The Minister should stand up and fight his case in the Department of Health and at Cabinet to ensure that there will be no further peeling back of funding for services, and he will have the total support of the Labour Party in this House. We now want to make sure that the trimmed down and cut back services since 1987 will not suffer further and that the Government's priority will be to ensure that the health services, which are in serious crisis in some areas, will not be further curtailed for lack of finance. We do not want what is now only an apology for a service to be further run down. A move by other Departments to encroach on the minimal budget for this year of the Department of Health would have political and other consequences.

I am glad the Minister is here. I hope he will respond positively and reassure us that he will stand up and fight for his Department, which has an impact on all the problems of the country. The Minister should consider health services to be a basic human right and should act accordingly and the Cabinet would have to accede to his requests.

I am glad to reassure Deputy Ferris that we will continue to develop our health services. Deputy Ferris expressed concern in relation to the area of mental handicap. Since I came to office we increased by 40 per cent the allocation to organisations catering for mental handicap. That is a substantial increase, well ahead of inflation, and it allowed for substantial development in services in that area. In 1987 and in 1988 there were some savings in various areas of the health services, but savings were not made in the area of mental handicap services.

Deputy Ferris referred to the need for planning and I agree that we should have planning. For that reason I re-established the co-ordinating committees in the health boards, with representatives from the area health boards, the voluntary organisations who deliver some of the services and from the Department, to plan for local needs. With regard to south Tipperary, to which Deputy Ferris referred, it is a matter for the South Eastern Health Board to plan their services to suit their area. Even if I could, it would not be appropriate for me to dictate their priorities.

You could give them money.

Substantial funding has been provided and not just the 40 per cent increase in the ordinary allocation to the agencies catering for mental handicap. A sum of £2 million was provided in the budget in 1990 which provided 179 new residential places, 442 day places and respite care for 200 persons with mental handicap. Not alone was that £2 million repeated this year but a further £2 million was provided to allow further development in the services, particularly in Cheeverstown House and in Áras Attracta in Swinford.

With regard to planning, not alone did we re-establish the co-ordinating committees in the health boards but we produced the report of the working party Needs and Abilities. That outlines the needs, and within the Programme for Economic and Social Progress we will provide the new services necessary. We all accept that it is necessary to develop services for people with mental handicap.

With regard to cutbacks, it is time we stopped talking about cutbacks in the health services in this House and faced reality. Over the last two years there has been in increase of 3,000 people working in the health services. There are now just 60,000 people working in the health services. That is an indication of the development that is taking place. There are also 1,000 more hospital beds open now than there were two years ago. There has been quite substantial development in the health services.

With regard to waiting lists, I inquired today with regard to Cappagh Hospital and I was told that there are 11 consultants in Cappagh Hospital and nine of them have waiting lists of less than four months for hip replacements at the moment. I asked if we had sufficient facilities to eradicate waiting lists. I am told that that is possible in regard to hip replacements, but I hasten to add that when we have all the hips replaced and repaired we then, as one hospital did last year using the increased allocation which they got, get into knee joint replacements and elbow replacements. It is very encouraging that we are up with the very best and most modern technology in the world and that we are moving into other new joint replacement operations.

However, my main purpose in the House this evening is to discuss the Estimate for my Department. The gross non-capital provision in the Estimate amounts to £1,510.366 million. Allowing for appropriations-in-aid at £194.053 million, the net non-capital grant provision is £1,316.313 million, of which £11.8 million is national lottery funded. The net non-capital provision represents over one-fifth of total Government expenditure on supply services and represents an increase of £40.247 million over the corresponding out-turn figure for 1990.

Health cash allowances have again been increased at a rate significantly in excess of inflation. The rate of disabled person's maintenance allowance has, for example, been increased by almost 6 per cent. The Estimate also provides for the cost of certain special pay awards which fall to be paid in 1991.

On the basis of the subhead provisions in the Estimate, the level of non-capital expenditure approvable amounts to £1,511.100 million, of which £1,045.527 million is in respect of pay, £377.684 million is in respect of non-pay and £87.916 million is in respect of cash allowances. When account is taken of the income generated directly by health agencies, the total projected expenditure for 1991 amounts to £1,630.500 million, which is a substantial sum of money.

The House will be aware of the very valuable contribution the national lottery has made to the development of community health services in recent years. Last year more than £10.5 million lottery money was spent on providing a wide range of services, including services for the elderly, child services and services for the mentally and physically handicapped. In 1991 the lottery allocation will be £16.89 million, of which more than £5 million is for the hospital building programme and £5 million is to assist with the implementation of the recommendations of the working party report The Care of the Elderly — The Years Ahead. The balance will be used to assist projects similar to projects in previous years and includes special allocations for the mentally handicapped and for child services.

From 1990 the procedure for the distribution of national lottery funds was changed. While the Department continue to retain control of funding for national based projects such as child services and services for the elderly, grants to local voluntary agencies are now a matter for the relevant health boards. The amount allocated to the health boards for this purpose in 1991 is £1.5 million.

The total capital provision for 1991 is £41.330 million. Of this, £27.240 million is being provided by the Exchequer, £5.090 million by the lottery, and a further £9 million is being provided from external sources. Despite the difficult financial situation which has obtained in recent years, considerable progress has been made in improving the physical infrastructure of the health services. Major improvements in the acute hospital sector have been made, particularly at Beaumont, the Mater, St. James's Hospital, Cavan Hospital, the International Missionary Training Hospital, Drogheda, Castlebar and Mullingar. This year, I am making funds available to complete the commissioning of the developments at St. James's Hospital and funding is also being provided to continue work at Sligo, Wexford and Ardkeen. Provision has also been made in 1991 for construction work on important hospital improvement schemes at the Rotunda, Monaghan and Kilkenny. Progress continues to be made in the improvement of the capital stock of the psychiatric service, services for the elderly, services for the physically and mentally handicapped and child care services.

Significant capital developments have taken place in recent years, despite limitations on capital funds, and I recognise that much remains to be done. In relation to capital, I am endeavouring to take a view of what must be done over the next five years or so. We already have significant contractual commitments which will dominate the next few years. Beyond that, we must try to ensure that the existing system is maintained at the right level of efficiency, safety and effectiveness. We cannot contemplate embarking on further developments unless we are satisfied that this additional draw on resources will not hinder our ability to maintain existing services at a high level of efficiency. I am particularly conscious of the demands which must be met in relation to fire precautions, maintenance and the replacement of equipment.

The programme of information technology of the health services made good progress over the last year. Increased funding has been provided and over the two years 1990-91. Almost £9 million in special capital grants is being made available. Every health board, and many of the large hospitals and other health agencies, have received grants in support of a wide range of projects. The programme is concentrating on the provision of information in support of the management of patient care and of resources. Modern hardware, software and networking technologies are being installed. Particular attention is being given to ensuring that the agencies have the capacities to extract full benefit from these developments through involvement of users of the systems in their selection, training, the development of systems expertise locally, and so on.

Despite the continuing tight budgetary position, some of the most important developments in the health services in recent years have taken place in 1991.

The conclusion of the Programme for Economic and Social Progress represents a significant milestone in the development of community based services. As the House is aware, there was a debate in the eighties about where new moneys coming on stream should be spent in the health services. There is now a consensus that new moneys should be spent in the main in the community for the development of community services. This is not the view just in this country; it is also the view in other countries in the developed world. I am very pleased that that is recognised in the Programme for Economic and Social Progress and that a very comprehensive programme spells out in clear detail where developments will take place within the next seven years.

Subject to the overriding consideration that we continue to live within the fiscal parameters set out in the programme, substantial capital funding will over the seven year period be allocated to services for the elderly, the physically and intellectually disabled, the psychiatricially ill, child care, dental services and health centres. In addition, the Government will significantly increase current expenditure on these services.

We have already made progress in this regard. This year's budget included additional funding for specified community-based services. I emphasise to the House that the Government will not be prepared to allocate these additional resources without ensuring that value-for-money is achieved and that the planned developments in services actually take place. Indeed, the monitoring arrangements for the programme will ensure that resources are used for the specific purposes for which they were allocated and that their impact will be assessed.

The recent enactment of the Health (Amendment) Act, 1991, represents yet further progress in our efforts to simplify and streamline the operation of the health services by establishing just two categories of eligibility. The Act will ensure a much fairer system of access to public hospitals. Under the new admission arrangements which are being introduced on a phased basis, all non-emergency patients will be obliged to make an explicit choice between public and private care, including accommodation and consultant treatment. This will result in improved access to public beds for public patients, since public beds will no longer be occupied by consultants' private patients. I believe that, in adopting this approach, we will greatly improve the services available to all persons in public hospitals, whether they choose public or private care.

This year I have placed a major emphasis on the health service as a whole achieving greater value for money throughout each area of activity. I am pleased to report that the service has responded very positively to this initiative. My Department are providing agencies with every support possible in the pursuit of this objective.

The concept of value for money has now been firmly established within the structures of health boards and major hospitals. Particular emphasis has been given to the promotion of greater co-operation among health agencies. I am glad to say that there has been a ready and rewarding response.

Late last year I received the report of the Hospital Efficiency Review Group who examined in detail the efficiency of seven major hospitals under a wide range of operational headings. We are currently implementing the main recommendations of that report.

I have established a top level steering group to work closely with the chief executive officers of the participating hospitals on the implementation of those efficiency recommendations contained in the report which are amenable to immediate action. Particular attention is currently being focused on savings which can be achieved on the pay side; public utility contracts; materials management, including purchasing, and pathology costs. I am confident that as the year progresses, this initiative will continue to show very positive returns. This is being done in the context of an incentive-based policy which provides for the agencies concerned to retain the benefits of the economies generated.

Conscious of the need to maximise performance the chief executive officers of the health boards, as well as taking the initiative of assigning a senior officer to the development and co-ordination of value-for-money programmes at board level, have also at national level established a value-for-money co-ordinating committee under the chairmanship of the chief executive officer of the Eastern Health Board.

In addition to these measures a number of very important initiatives have been pursued directly by my Department this year. Examples include the introduction of a computerised price index system on a pilot basis in seven sites to provide monthly comparisons of prices, brands and usage on a range of over 900 products. The system has the added benefit of providing valuable comparisons with the United Kingdom health authorities. I may say in that context that when I came into office I established a cost containment unit. We discovered that in some instances the hospitals which were using the largest number of certain items, say, disposable gloves, were paying a higher price than hospitals which were using a lower amount. By keeping an eye on the prices paid by the various agencies and keeping in touch with the supply officers of the hospitals and agencies we were able to achieve substantial savings through the cost containment unit. We have developed this further through our value-for-money programme.

The area of income generation has been reviewed and agencies have been advised to pursue more vigorous collection methods in, for example, the collection of road traffic accident income. A number of improved income generation schemes are also in the process of being established at present to ensure that agencies maximise the use of all available assets and resources.

Arrangements are being put in place to ensure a more co-ordinated approach to the procurement of equipment. We are in contact with our colleagues in Northern Ireland concerning the purchase of an expensive piece of equipment, a magnetic resonance machine. They are purchasing a similar piece of equipment and we have adopted a joint approach in the tendering process to obtain a better price.

A detailed examination of professional indemnity insurance costs has been undertaken. Arrangements have been put in place to facilitate increased take up of European Community intervention schemes by health agencies. Greater co-operation between the Dublin children's and maternity hospitals is being promoted. A series of initiatives have been pursued with our colleagues in Northern Ireland in the non-pay and equipment purchasing areas. I have referred to one such initiative already.

In recent years there has been growing public awareness of the scandal of child sexual abuse. The growth in the number of reports of child sexual abuse and the number of cases in which abuse has been confirmed has been most disturbing. As recently as 1982 there were only 37 confirmed cases of child sexual abuse known to the health boards. In 1989 the total number of confirmed cases of all sorts of child abuse known to the health boards was about 1,300, of which the number of confirmed cases of sexual abuse, was about 500. These figures represent a four-fold increase in five years. The Department have not yet completed the collection from health boards of statistics in respect of 1990, but on the basis of the returns that have been made to date all the indications are that the total number of cases in 1990, including child sexual abuse, will show a further increase. In response to this appalling development. I have approved the establishment of specialised units for the investigation, management and treatment of children suspected or being victims of child sexual abuse. These units are at Temple Street and Crumlin Children's Hospitals and are composed of multi-disciplinary teams, including a paediatrician, psychologists and social workers, with psychiatric support where necessary. Outside of Dublin, services for the investigation and treatment of the victims of child sexaul abuse have been set up by each of the health boards.

The growth in child sexual abuse clearly illustrates the need for effective legislation to protect children who are at risk. This is the major objective of the Child Care Bill. The Bill has recently completed its passage through the Dáil and Seanad. The purpose of the Bill is to update the law in relation to the care of children, particularly children who have been assaulted, ill-treated, seriously neglected or sexually abused or who are at risk. The Bill aims to achieve these objectives through the strengthening of the powers of the health boards to provide child care and family support services; to allow immediate intervention by health boards and Garda where children are in serious danger; and other measures designed to promote and preserve the welfare of children.

Implementation of the Bill will necessitate major expansion and new investment in our child care services. In the Programme for Economic and Social Progress the Government have given a commitment to making the necessary resources available to enable the Bill to be fully implemented over the seven years of the programme. Already a good start is being made this year in preparing to implement the provisions of the Bill.

In developing our service, special regard will be had to the most vulnerable groups — to children who are unloved and unwanted, to children whose parents are unable to care for them, to the plight of young Traveller children living in Third World conditions and to the tragedy of the homeless children. The plight of young homeless people and the dangers which they face is an issue which the Government take very seriously. As the House is aware, the Taoiseach recently gave the Minister of State at my Department, Deputy Flood, special responsibility for the co-ordination of child centred services. One of his first tasks is to expedite a number of projects which will provide additional accommodation for homeless young people. A number of initiatives in this area have recently begun to come on stream in Ballymun and Tallaght and negotiations concerning a number of other projects are at an advanced stage. I have asked the parties concerned to make every effort to expedite this process and would hope that most of the additional places would become available during the summer. A number of other longer term projects are also planned, some of which should come on stream towards the end of the year. I will be keeping the situation under close review and can assure the House that the Government are committed to doing all that they can to bring an end to the plight of young people sleeping rough on our streets.

I am delighted that the legislation dealing with the recognition of foreign adoptions has been enacted as the Adoption Act, 1991. This legislation sets out new statutory procedures for the recognition in the State of adoptions effected abroad. While the legislation was framed primarily with the Romanian adoptions in mind, the provisions will apply to adoptions granted in countries throughout the world.

Given the scale on which Irish people are travelling abroad to adopt children, it is clearly desirable that the law here should be clear and explicit with regard to the circumstances in which such adoptions are entitled to recognition. It is equally important in the interests of the children concerned that there should be proper procedures to regulate the adoption of foreign children by Irish residents. Children involved in inter-country adoptions are particularly vulnerable and those countries where the adopting parents reside have a special responsibility to protect the welfare of the children by ensuring the suitability of the proposed adopters is properly assessed beforehand. I believe that the new legislation achieves these objectives and that it provides a secure legal framework for the adoption of foreign children by Irish residents.

The problem of drug abuse is one which is a matter of deep concern to all of us. I am determined that every effort should be made to ensure that this problem is controlled in as effective a manner as possible. Past responses to drug misuse problems have tended to concentrate on supply reduction through a range of legislation provisions and stricter enforcement measures. While these efforts have to a large extent been successful in limiting supply and frustrating the efforts of organised suppliers of illicit drugs, they can only be fully effective if operated in tandem with comprehensive demand reduction policies based on education, treatment and occupational rehabilitation.

When I reconstituted the National Co-Ordinating Committee on Drug Abuse in May last year I asked them, as a matter of urgency, to develop a set of recommendations which would form the basis of a national strategy to prevent drug misuse, covering all aspects of the problem and in particular demand reduction. The recommendations of the committee formed the basis for the Government strategy to prevent drug misuse. The strategy recognises that there are no easy or instant solutions available to us in our struggle against drug misuse, and recognises existing deficiences. It sets out realistic and achievable targets in relation to data collection, demand and supply reduction, including education and increased access to treatment and rehabilitation programmes, underpinned by a co-ordinated structure, at both national and regional levels, geared towards their effective implementation. It involves much greater emphasis on community-based services and introduces, for the first time in Ireland, the concept of community drug teams, drawing on the expertise of general practitioners and other health and social services professionals working in the targeted communities with serious drug misuse problems, in addition to proposals on strengthening the legal provisions available in the area of supply reduction.

The health status of this country leaves much to be desired. The folowing examples provide graphic illustration of this point: 12,000 deaths annually are as a result of coronary heart disease or stroke. Many of these deaths are premature and preventable. The number of deaths from coronary heart disease and stroke for males in the age bracket 30-69 is 336 per 100,000 — the corresponding figure for Italy, Spain, Belgium and France is under 150; 63 per cent of adult male and 48 per cent of the adult female population are overweight and 5,000 deaths annually are attributable to smoking.

The Irish lifestyle is implicated in many of the poor status indicators to which I have just referred. A major focus of health promotion policy is the development of pilot health promotion projects which form part of a national plan for health promotion intended to ensure that the Irish population has a quality and quantity of life on a par with the best health status in Europe.

Significant funds have been invested in the development of the lifewise programme. This programme is a health education programme for adults aimed at promoting healthy behaviour and providing individuals with the skills, information and motivation to develop a healthy lifestyle. The programme has been piloted in the Mid-Western Health Board area, and because of its success to date, a number of other boards, along with the Irish Countrywomen's Association, have asked to be party to the programme. A national structure to oversee the development of the lifewise programme and to ensure its quality is being developed.

Alcohol abuse, particularly among young people, continues to be a major source of concern. The recent report of the psychiatric hospital services indicates that 25 per cent of admissions are due to the abuse of alcohol. Unfortunately many of the people admitted to hospital because of the abuse of alcohol are young people. I was pleased last year to launch a drink awareness programme for young people. This programme is a joint initiative between my Department and the National Youth Council of Ireland and it aims to provide young people with personal and social skills necessary to make responsible decisions regarding their use of alcohol. A nationwide training programme for youth leaders and other persons involved with youth is now under way and 350 people have been trained to date.

A number of other initiatives in alcohol education are also being pursued. However, a broader focus is required to tackle the problem of alcohol abuse. Measures necessary to address the problem are multi-factorial and are encompassed within the remit of a number of Government Departments and statutory and voluntary agencies. In pursuance of a broadly based policy on alcohol, the Government decided that the Advisory Council on Health Promotion should develop a policy which will address broader economic, social, educational, cultural, and health factors which impinge on alcohol use, including the problem of underage drinking. The council have recently commenced a major consultative exercise in pursuance of the formulation of the policy. I hope to receive a draft national alcohol policy by the end of the year.

Reducing the number of people who smoke and especially preventing younger people from taking up the habit remains a priority in my Department. On Shrove Tuesday I launched the 1991 anti-smoking campaign. The campaign includes a multi-media advertising campaign which highlights the dangerous and disgusting nature of the smoking habit, particularly in relation to young people, a schoolbased information campaign, and a general practitioner-public health nurse pack which will be developed during 1991 to assist such professionals in their practice to adopt a more focused anti-smoking approach. In addition, I am confident that the Government decision to increase the price of a pack of 20 cigarettes by 10 pence in the January budget will help significantly in reducing the number of people who smoke.

The recovery plan introduced in January 1989 by the Voluntary Health Insurance Board has been a success and reserves are now moving back towards an appropriate level. The principal nature in the recovery plan were subscription increases; some reductions and restrictions in benefits and cost containment measures, particularly hospital cash limits. From 1 March 1991 the VHI introduced their new full cover system under which, in return for increased fees, participating consultants agree not to charge additional amounts to patients.

The present position in regard to participation in the scheme by the different consultants is as follows:

radiologists — 78 per cent are participating

physicians — more than 50 per cent are participating

pathologists — 99 per cent are participating

anaesthetists — negotiations are not yet concluded

surgeons — 15 per cent are participating.

The VHI expect that the numbers of participating consultants will continue to rise and they will persevere with their efforts to boost participation.

I am confident that following the positive trends inherent in VHI's affairs in the past 18 months, VHI, with my support, will continue to offer at reasonable cost and on equitable terms, health insurance to all those who wish to avail of it. Private health insurers in other countries, in contrast, do not offer health insurance cover on equitable terms but rather, operate on a principle of charging older and more vulnerable subscribers higher premia than the young and healthy low risk categories.

The proposed liberalisation of the insurance market, including health insurance, in the move towards the EC Single Market by January 1993 could have implications for VHI operations. In view of the serious consequences for Irish health services generally, my Department have made a submission to the EC outlining the particular circumstances of the Irish health services and seeking to maintain community rated health insurance, that is the type of schemes operated by VHI, as the only type of health insurance available on the Irish market. I am hopeful that we will be successful in this regard.

I made reference last year to the commencement of the first review of this contract for GMS doctors and to the unique opportunity it provided for an assessment of its operation. The review has been completed, under the chairmanship of Mr. John Horgan, former Chairman of the Labour Court and his report has been considered by both the Irish Medical Organisation and the management side. The report contains a number of recommendations both in relation to the interpretation of specific clauses within the contract and to the operational aspects of others, as they affect the overall effective and efficient operation of the scheme. I am satisfied that the review recommendations are a fair interpretation of the manner in which the contract was originally intended to operate and, taken as a package, will serve to strengthen the commitment of all those involved in its operation to develop the full potential of general practice.

I am particularly pleased that a satisfactory arrangement has been agreed on the matter of establishing a tax effective GMS pension plan. It is expected that the scheme will be in operation very shortly. The resolution of this matter has allowed the Irish Medical Organisation to complete their consideration of the review report.

I have previously mentioned in the House my concern regarding the need to control costs within the GMS scheme and, in particular, my disappointment with the growth pattern in the volume of prescribing medicines.

The total expenditure on drugs in 1989 was £107, million, an increase of 15.9 per cent on the previous year. The total ingredient cost of drugs rose by 18 per cent, of which approximately 6.5 per cent was due to price rises and 11 per cent was due to volume increases and substitution of dearer drugs. When analysing previous years' figures it was found that a similar rate of volume and substitution increase has been a constant feature of the scheme.

The total expenditure on drugs in 1990 was £114 million, approximately an increase of 6.1 per cent on the previous year. The total ingredient cost of drugs rose 6.3 per cent over the 1989 figure. The latest figures available for 1991 indicate a continuance of this upward pattern in prescribing.

Having regard to the very serious position now reached in relation to prescribing patterns within the GMS scheme, I have recommended to Government that the drug strategy outlined in the GMS review report be implemented without delay.

I am conscious that the strategy involved close co-operation between general practitioners and the health boards. I am confident that this co-operation will be forthcoming from both parties.

The strategy proposed is designed to produce significant drug savings in 1992. I have already introduced some elements of this strategy including the launch of the National Drugs Formulary and the introduction of a repeat prescription facility to the GMS scheme to help curb this growth in the prescription of drugs.

The strategy envisages the establishment of a national therapeutic advisory committee, which will give independent authoritive advice in relation to prescribing both in hospitals and the community. The aim is to encourage the highest standards of treatment through appropriate, safe, efficient and cost-effective prescribing. Other elements of this strategy which I intend to implement with the co-operation of the Irish Medical Organisation and the profession include: enhanced educational measures on drug use and prescribing focused on the general public and on doctors; greater co-ordinating between hospital and community prescribers; improved analysis of prescribing data; better information flows, including those to general practitioners in relation to their own prescribing patterns and costs; better support structures and greater involvement of health boards in the management of prescribing.

Another element of the Government's strategy in this area relates to drug prices. In this regard I am glad to report that the agreement between the Government and the Federation of Irish Chemical Industries completed last August led to a decrease in drug prices of approximately 10 per cent on average in the first year. The significant feature of this agreement is the breaking of the link between Irish and UK pharmaceutical prices. In future price movements in Ireland will be linked to movements in prices in certain EC countries and this will result in a significantly lower price adjustment in August 1991 than would otherwise have been the case.

In 1990 a special allocation of £3 million was made available in the budget for the development of dental and orthodontic services. A similar amount was made available as a special allocation in the 1991 budget. This additional funding has brought about much needed improvements in the adult dental services provided by the health boards and has also enabled improvements to be effected in the orthodontic services. About 24,000 adults benefited from the improvement availability of routine dental treatments in 1990, bringing to nearly 42,000 the number of adults who received routine courses of dental treatment during 1990, while a further 34,000 adults received emergency treatments. The accumulated backlog has been greatly reduced especially for people waiting for dentures.

Two and half thousand children began their courses of secondary orthodontic care in 1990. It is estimated that health boards will be able to provide up to 2,000 new starts in orthodontic treatment in 1991. Priority in orthodontic treatment is being given to children in the most handicapped categories in accordance with guidelines issued by my Department in 1985. Recently the conditions and salary attached to the post of consultant orthodontist with the health boards have been revised by my Department to make the post much more attractive. Vacancies in the health boards were recently advertised by the Local Appointments Commission and I am very hopeful that a number of suitable candidates will come forward. Appointments to those vacancies will enable further improvements in the orthodontic services to be carried out. As well as the recruitment of consultants, a number of dentists in health boards are being trained to treat the less serious orthodontic patients under supervision. This will also help considerably in reducing waiting lists.

The increased level of funding for dental and orthodontic services provided in 1990 and 1991 has brought about significant improvements in the dental services. Dental care provision for handicapped persons is a priority area. The creation of the new full-time post of consultant in dentistry for handicapped children and young adults — centred in the Dublin area, but which will provide a national service — will result in great improvements by making specialist level treatment more widely available and by training other dentists and dental students to treat these special patients. The newly created grade of dental hygienist will make a significant improvement to the amount of dental care available for eligible children and adults. I am also engaged in discussions with the Dental Council concerning the creation by the council of a grade of denturist who may legally supply dentures to members of the public.

Good dental health requires that there be a combination of preventive and treatment programmes available to the community, the mix depending on the amount of dental disease already present. Where effective and efficient preventive programmes are in place there is less reliance on expensive treatment programmes. I might mention here that a number of studies show that across a wide range of parameters there has been a steady improvement in levels of oral health. Goals set in 1984 for the year 2000 will have to be revised as a number of these goals have already been exceeded for some age groups. Nevertheless, much remains to be done. Careful planning is required to maximise the resources available. My Department are currently preparing a dental plan which will set goals for oral health for each age group in the population to be achieved over the next decade.

The fluoridation programme continues to be a cornerstone of our preventive programme. This programme is carefully monitored at health board and at Department level. About 65 per cent of the population are served by water supplies which are flouridated. While there has generally been a significant decrease in the level of dental caries in children, surveys show that this decrease has been most significant in children who had been lifetime residents of fluoridated areas. Some of the plant dates from the setting up of the fluoridation programme over 25 years ago and the need for replacement is constant. A sum of £200,000 was provided in the 1991 Budget for the provision of new plant and for the replacement, as necessary, of existing plant.

I have already referred to the services for mental handicap and the very substantial improvements that have taken place. When Deputy Ferris raised the issue I responded to it. I have referred to the fact that we now have in place a very good programme and I referred to the report of the working party and the provisions in the Programme for Economic and Social Progress.

Our psychiatic services have continued to develop along the lines recommended in the report Planning for the Future. This report recommended a service which was comprehensive, community oriented, sector based and integrated with other health services. The implementation of the policy outlined in Planning for the Future has involved a fundamental reorganisation of our psychiatric services from the traditional institutional approach to one where the emphasis is placed on treating people to the greatest extent possible in local community settings without the disruptive effects of hospital admission. It is encouraging that the hospital population has reduced from 30,000 in 1958 to fewer than 8,000 at present and there has been a very substantial reduction in the last five years of 4,000, from 12,000 down now to 8,000.

I am glad to be able to report that health boards are continuing to make progress in providing community psychiatric facilities. Since Planning for the Future was published in 1984 the number of day hospitals and day centre places has tripled and the number of hostel places more than doubled.

In the past year substantial progress has been made in integrating acute psychiatry with the general hospital system. Acute psychiatric units have been opened at Cavan and Tralee general hospitals and it is intended to open similar units at Naas and Roscommon hospitals later this year. A new community based psychiatric service is being developed by the Eastern Health Board at the Mater Hospital for north Dublin city and as part of this service it is intended to open a new psychiatric unit in the Mater in 1992. Other significant service developments this year include the development of a community psychiatric service in Roscommon, Kildare and north Tipperary and the improvement of facilities at the Central Mental Hospital.

As I indicated to the House on 26 February last, the Government are committed to assisting health boards and agencies to continue to maintain bed availability of 12,000 beds in 1991.

While special earmarked funds were allocated at the end of 1989 to effect improvements in the average waiting times for identified "blockspot" areas, for example, orthopaedics, children ENT services, open heart surgery, the overall strategy of the Department is to concentrate on getting the maximum return from every pound invested and rigorously seek efficiencies where they can be found. Only when this has been achieved should the question of additional funding be considered to finance needs and not demands.

The third report of the Kennedy Group which I have recently received contains a number of very important recommendations regarding in-patient waiting lists and out-patient services. It does not accept that it is merely a question of allocating more resources in an undirected manner to either or both of these problems. Rather it makes a series of detailed recommendations on a lengthy number of steps which should be taken by each hospital before it is in a position to demonstrate that it cannot provide an adequate service with the resources already available to it.

In relation to waiting lists, the report recommends that initially all waiting lists be validated. Each hospital should maintain comprehensive, standardised information concerning the numbers and types of patients awaiting admission. Validation to establish reliable waiting list data should be adopted as a firm policy in each hospital and such policies should ensure that appropriate management and clinical action is taken on foot of such reviews.

Hospitals should also immediately carry out a bulk postal review of patients who have been on a waiting list for more than an agreed period of time. On completion of this comprehensive review and validation of current waiting lists, formalised regular arrangements should be made by each hospital for the ongoing review and validation of lists. This approach is not standard practice in all hospitals at present and until it is, data relating to waiting lists should be treated with great caution.

The report further recommends better scheduling of activity to reduce waiting times, analyses by hospitals to establish whether their activity levels, having regard to case mix, are broadly comparable with the productivity levels of similar services in other locations, a systematic review of the scope for increasing levels of day surgery for appropriate conditions, development of appropriate information technology and better information to general practitioners with regard to the average waiting times for admission. While the Kennedy Group's recommendations were based on their analysis of the hospital services in Dublin, they have equal validity for other areas of the country.

The third report of the Kennedy Group also makes a number of important recommendations with regard to the organisation of out-patient services. It highlights the need for better appointment systems for out-patient clinics, for a policy for dealing with non-attenders, and for reducing the level of unnecessary return attendances. It makes recommendations on better patient information and it highlights the need to match staff to the particular demands of providing a high quality out-patient service.

These recommendations do not come from a group representative of any single discipline. The group which was chaired by David Kennedy was a broadly based group drawn from all the major agencies in Dublin, including representatives of the managements of the hospitals, their consultant staffs and the general practitioners. The Department will be working closely with hospital managements and staff to implement the recommendations made. Many of these will be applicable in all hospitals.

The Department remain committed to the delivery of a high quality service to patients. Following a detailed analysis of the problems which arise in the delivery of care, the report of the Commission on Health Funding in 1989 recommended greater responsiveness to patients' needs, including an appeals system and the specification of maximum waiting periods. A "patients' charter" specifying a hospital code of conduct covering the information to be given to patients before, during and after treatment is being developed, with a patient feedback mechanism within each hospital with the aim of improving communication and the quality of services within hospitals.

A considerable amount of work has been undertaken on these issues within individual hospitals and it is hoped to progress these matters further, building on the specific range of detailed recommendations made recently by the Kennedy Group.

This will link in with the measures announced in the Government's Programme for Economic and Social Progress to minimise waiting times for patients, to provide comfortable waiting areas with appropriate amenities and to provide patient information leaflets. The programme also refers to the development of the “patients' charter”; based upon the following principles: the right of access to services in accordance with need; the right to considerate and respectful care; the right to privacy; the right to information; the right to confidentiality of all medical records; the right to refuse to participate in research projects; the right to respect for religious and philosophical beliefs; and the right to make a complaint.

In recent months, an extra ten beds were opened in the Mater Hospital so as to bring back heart by-pass activity rates in line with previously agreed target levels. My Department are examining as a matter of urgency ways and means in which to increase this activity further.

My Department entered into a formal agreement with Camberwell Health Authority in March 1991 which provides that all patients referred from public hospitals in this country requiring liver transplantation will be operated on at King's College Hospital, London. Under this agreement, Irish medical staff will be seconded to King's College Hospital to receive appropriate training and experience to enable a liver transplant service to be re-established in Ireland as soon as circumstances allow. The circumstances are not related to funding but to the fact that it is necessary that a certain number of patients need transplantation — approximately 50 patients per year — in order to have a viable transplant programme. As soon as the numbers who need transplantation — unfortunately the numbers are increasing all the time — are sufficient, a programme will be re-established in this country.

A working group representative of the Department, the Southern Health Board and the voluntary hospitals in Cork have been established to draw up a plan for the development of hospital services in Cork city and county for the next decade.

The function of the working group is to seek a consensus on the role of acute hospitals and on the priorities for development. The terms of reference of the group are as follows: 1. to examine the present organisation of acute hospital services in Cork city and county and assess the existing services; 2. to draw up a plan for the development of acute hospital services to include: a definition of the role of each of the acute hospitals in relation to national, regional and local specialties as appropriate; recommendations for changes in the organisation of services to provide a more efficient and effective service for patients; maximum co-operation and sharing of facilities where appropriate between Cork hospitals; identification of priorities for service development; a management development programme for each hospital and the hospitals collectively.

The provision for the health services in this year's Estimate reflects this Government's continued commitment to the provision of a first-class service for our people. Inevitably, while the level of service provided has increased over the past number of years, demand will always outstrip the level of service which we are in a position to provide. This has been the experience in health services in all parts of the world, and Ireland is no exception. This Government's prudent economic policies have played a vital part in the progress which we have made over the past number of years. In the current economic climate it is more vital than ever that this prudent approach be maintained. In such circumstances it is unlikely that it will be possible to meet the all but insatiable demands on the health services — indeed it would be irresponsible to attempt to do so.

As I have said, there are problems not alone in our own country but also in all developed countries in the world, including Britain, France and the United States. I want to assure the House that this Government are committed to a continuing policy of achieving maximum return from the public funds invested in the health services and of measured progress in the development of our health services. There has been very substantial improvement and development in our health services in the last couple of years, and I have already referred to that. We want to continue to provide a high quality service that will respond to the needs of our people.

These Estimates are being discussed at a time when the Government and economists are warning that public expenditure for 1991 is way off course and that collective action is needed and indeed contemplated. I have no doubt, given the general nature of the debate yesterday, today and over the next few days, during which no specific Minister will reply to charges or questions asked, we will have to wait as usual and rely on the national media to convey to us decisions taken by this Coalition Government behind closed doors during the summer recess. We will have to rely on the media to tell us exactly where the sledgehammer blows will fall. No doubt they will fall on the heads of the poor and on low income families because usually that section of society suffer when there are cutbacks. Clearly, with no political will to broaden the tax base in regard to company or capital taxes the only strategy being adopted by the Coalition Government is to achieve savings by cutbacks in vital services.

It is a scandal that although extra time was squeezed out of the Government to allow the Opposition time to air their views, we will be breaking next Friday for the summer recess not any wiser about Government policies or being able to use this Chamber to challenge the Government on their cutbacks. It is scandalous that we will be no wiser as to how the £200 million or £300 million overrun on expenditure will be resolved. With a backdrop of ever increasing numbers of people joining the dole queues and emigrants returning from as far afield as Australia, America, mainland Europe and Britain it is clear that not only has public expenditure lost direction but the Government have lost their way and the will and ability to stop the avalanche in employment numbers. For the last four consecutive months more people have been dumped on the dole queues.

The Government arrogantly declared that job creation was not the role of Government but rather their role was to create the environment conductive to job creation for business. I suggest the Minister tell the 250,000 people unemployed loud and clear that Fianna Fáil on their road to conservative fiscal rectitude, tailing the Progressive Democrats, do not give a damn about them, that job creation is the role of private enterprise and that the Government can sit back on their presumed laurels, beat themselves on the chest and say how great a job they have done: they have created this wonderful Alice in Wonderland type of environment for business with low labour costs, inflation running at three per cent and companies making huge and record profits. Expatriation of profits is running at approximately £2 billion per annum. In this Alice in Wonderland environment exports are up and the balance of payments is under control but unemployment rises relentlessly each month.

I remind the Government, and particularly the Progressive Democrats Minister for Industry and Commerce, Deputy O'Malley, who has responsibility for the Department most concerned with job creation, that the general public demand an active and participative role by Government in creating jobs by themselves, in joint venture schemes or by creating commercial public enterprises. The policy of total reliance on private enterprise to provide sufficient jobs has failed. The Government have failed the people. This is a message they will be reminded of at the next general election.

I wish to concentrate, in the short time available to me, on the Department of Social Welfare and their Estimates. I wish to speak in general terms about the carer's allowance and the Cotter and McDermott case. The Programme for Economic and Social Progress has been targeted by a well-known Trinity College economist. He feels it has been too generous in its commitments. The Workers' Party have long supported the concept of centralised collective bargaining but opposed the PESP primarily because of the absence of any specific commitment to genuine tax reform and because it effectively facilitated the privatisation of a number of commercial semi-State companies. We felt that public sector workers, and their families should not be asked to forego badly needed pay increases simply because the Government got their sums wrong.

If the Government renege on their commitments, solemnly entered into, how could workers or trade unions accept the word of any Government of the future? Public sector workers have, once again, become the focus of attack from a group of highly paid right-wing economists and commentators. Contrary to widespread public perception many public sector workers are poorly paid and earn well below the average industrial wage. Any attempt to deprive them of the agreed increases would provoke an angry response and could lead to serious industrial relations problems. A number of pending special pay awards have been singled out for particular attention. However, the validity of these claims has been accepted by the Government and in many cases workers have already made considerable sacrifices by agreeing to defer implementation dates. I congratulate the workforce in Aer Lingus who have made tremendous sacrifices by deferring implementation dates and incremental increases in the interests of Aer Lingus.

Workers in the public and private sectors have, since 1987, shown a considerable degree of moderation in wage claims and demands. They were assured by the Government that this would contribute to reducing unemployment levels — that was the basis of their commitment — but instead the unemployment figures are the highest ever recorded and the public sector workers are once again being asked to make more sacrifices, while other sectors are not being asked to exercise similar restraint. There is no limit on the fees that may be charged by professionals, profits or dividends earned. Senior executives of newly privatised State companies have in some cases trebled their salary levels. Public sector workers are not the cause of the current budgetary over-run and they should not be asked to carry the can.

The Workers' Party — and this is on record — voted against the Programme for Economic and Social Progress because it was inadequate in its commitment and not, as certain economists are arguing, far too liberal in its commitment. However, we are determined to defend the programme now that it has been agreed and particularly since the Trinity College economist — who very often is listened to by Fianna Fáil and Progressive Democrats Ministers — has started his campaign to have it renegotiated. How dare he, or anyone else for that matter, say that this programme is too generous when one considers the economic climate for business in Ireland today and the benefits accruing to business from that climate? Section IV of the programme under the heading “Social Reform” states:

Social welfare expenditure is exceptionally high in the Irish economy because of our high unemployment and our high dependency ratio.

If a Government ever got their figures wrong this Government did when the Minister for Finance, Deputy Reynolds, estimated the numbers who would be unemployed and for whom allowances would have to be made in his budget. The Government estimated 238,000 people would be on the dole. However, the figure now stands at an all time high of 258,000, 20,000 higher than the projected figure. What standard of living will these unfortunate unemployed workers have? How long will they have to suffer the indignity of unemployment, the queueing in often squalid conditions at the so-called and misnamed employment exchanges?

Section IV of the Programme for Economic and Social Progress at least recognised the squalid and often dehumanising conditions prevailing in many employment exchanges. It states that “the ongoing programme of modernising and improving accomodation and facilities for social welfare clients around the country will be continued with a view to providing an accessible and dignified service with due regard to adequate facilities for transacting private and confidential bussiness”. Is that section of the programme to be hampered by cutbacks in the Department of Social Welfare? Will the modernisation be put on ice? We do not know because no Minister will answer my questions or those of other Deputies. Will the minimum conditions, such as the provision of a ladies' toilet in Werburgh Street employment exchange be provided, as the commitment in the programme seems to imply? Can one imagine in 1991, the Department of Social Welfare forcing women, many of whom are pregnant or have children in tow, to queue in Werburgh Street which does not have ladies' toilet although there is one for men? So much for the provision of “dignified services with due regard to adequate facilities”. So much for the social welfare clients.

I was refused permission during the passage of the Social Welfare Bill to refer to two women — Cotter and McDermott — because of the ridiculous sub judice rule. I want to address this issue which has immediate relevance for 40,000 Irish-women. What will the Government do about discrimination against women? It has been going on for so long one must presume that the Government are trying to wish it away. I assure the Minister and the Government that the women affected — and their families — will not allow him to forget that the Government owe them money.

Why are the Government treating these women so despicably? Is the Minister trying to force each and every one of those 40,000 women to go down the same road as Mrs. Cotter and Mrs. McDermott? Does he intend to drag them through the High Court, the Supreme Court and the European Court of Justice before he will agree to a settlement? This case has been running for so long that it is no harm to remind the House of its history; 22 December 1984 was set as the deadline for the elimination of discrimination on the grounds of sex, either directly or indirectly, by reference in particular to marital or family status in statutory schemes which provide protection against sickness, invalidity, old age, unemployment, accidents at work and occupational diseases.

Despite the fact that the deadline for implementing EC Directive 79/7 was 22 December 1984 no action was taken by the Irish authorities until the enactment of the Social Welfare (No. 2) Act, 1985. Even then the Act was not brought into effect until various dates in 1986. What should have been law in 1984 was not introduced until various dates in 1986. We had many reservations on the manner of implementation of the Directive to Irish law; we submit that there are many areas where the Directive has not yet been properly implemented. Our complaints at the time concentrated on the proposed elimination of discrimination in two specific areas: (1) on the duration of payment of unemployment benefit, which is that the maximum duration of entitlement of a married woman to unemployment benefit was 312 days, which is 52 weeks. The duration of entitlement for men, married or single or for single women, was 390 days, a difference of 13 weeks.

The second issue was the low rate of payment. A married woman living with her husband or a woman living apart from her husband but being maintained by him received a lower rate of benefit than a man, married or single, or other women receiving disability benefit, unemployment and disablement benefit, invalidity pension and occupational injuries benefit.

The Social Welfare Act, 1985, was passed on 16 July. Section 6 of the Act which standardised the duration of payment of unemployment benefit for men and married women by extending the duration of payment in the case of married women living with their husbands from 312 days to 390 days, was activated only in May 1986 when the Social Welfare Act abolished the reduced rates of disability, disablement, unemployment and injury benefit, invalidity pension and unemployment supplement payable to married women living with their husbands. Furthermore, the effect of the 1985 Act was very limited in that only those married women who had received unemployment benefit within the period of 75 days prior to 16 May 1986 were entitled to benefit under the amended legislation. Consequently, all those married women, who ceased to receive unemployment benefit between the period from 22 December 1984, the deadline for the implementation of the Directive, and 15 February 1986 were unable to avail of its provisions.

Similarly, married women who were in receipt of reduced rates of disability benefit, disablement benefit, injury benefit, invalidity pension and unemployment supplement from 23 December 1984 to 15 May 1986 — or the date of the expiration of entitlement if this occurred prior to 15 May 1985 — had no remedy or relief in relation to the discrimination they had suffered unless they could rely on the provisions of the Directive as and from 23 December 1984.

I appreciate that this is all very complicated but when one demystifies it and looks at the figures, dates and the Directive and what this and previous Governments were supposed to do by a certain date one understands why 40,000 — mainly married — women are demanding to be given a fair crack of the whip. The European Court of Justice held in the McDermott and Cotter judgement, No. 286/85 that Article 4 of the Directive was sufficiently precise and unconditional to be relied upon in national proceedings and applied by a national court. It followed, therefore, that individuals such as Mrs. McDermott and Mrs. Cotter could directly rely on Article 4 of the Directive in the absence of implementing measures before the Irish courts as and from 23 December 1984, thereby precluding the application of any national provision inconsistent with that article.

The European Court held that, in the absence of implementing measures, women have the right to be treated in the same manner and to have the same system applied to them as men in the same situation. This ruling meant that Mrs. McDermott and Mrs. Cotter were entitled to receive unemployment and pay related benefit for a further period of 78 days and it also meant that they were entitled to receive a higher rate of unemployment benefit from 23 December 1984 until their right to receive the unemployment benefit expired. That issue was conceded by the Government following the judgment of the Court of the European Communities when the case came before the Irish Supreme Court on 27 July 1989. The Government, however, did not make that concession in relation to any of the other women's claims. In fact, the Government failed to notify potential claimants of their rights pursuant to Article 4 once 22 December 1984 had passed. The Employment Equality Agency was established under the Employment Equality Act, 1977, and its function includes the provision of information and advice concerning equal pay and equal treatment in employment and vocational training. However, it has no function in social welfare matters. There is no equivalent to the Employment Equality Agency in relation to social welfare entitlements. In addition, there were no administrative procedures set up to enable married women to apply for the full rate of the appropriate payments or for the payment of the unemployment benefit for the full duration applicable to married men in similar circumstances. The Government did everything to frustrate and keep people in ignorance of their entitlements. Right through to this very day they attempt to continue their ostrich-like, head-in-the-sand approach to those famous cases, which have gone through the whole court procedure from the High Court to the Supreme Court to the European Court of Justice.

The State scheme of civil legal aid and advice does not allow for the provision of general information to the public in relation to rights such as these effected by the directive. Therefore, the inadequate funding of the State's civil legal aid scheme and the exclusion of tribunal representation from its ambit means that in social welfare matters there is no comprehensive scheme of legal aid. The rights of married women who are affected by the directive therefore cannot be effectively enforced by recourse to law.

There goes the sad and sorry history and the torture through the European Court of Justice. But here we are in Dáil Éireann on 10 July 1991 and here I am making the case that I was not allowed to make when the European Court of Justice found in favour of Mrs. Cotter and Mrs. McDermott. I was shut up because the case was reputedly sub judice. Every element of the news media was carrying statements and all forums were talking openly about the issue, but here in Dáil Éireann we were gagged. I am now delighted to be able to take the opportunity to remind the Minister and the Government of the long history of the Cotter and McDermott case. I also remind them that it is not as yet final. We have a long way to go before the women of Ireland who are entitled to those payments stop demanding their rights. It follows from the judgment of the European Court of Justice in the case of Cotter and McDermott that all married women who after 23 December 1984 received a lower rate of disability benefit, unemployment benefit, disablement benefit, invalidity pension or occupational injuries benefit for a shorter period of time than were actually received by similarly situated men have been discriminated against contrary to Article 4 of the directive and as such they are entitled by right and by law to be compensated for such unlawful discrimination.

At the height of that debate a Government press statement, issued on 3 October 1984, calculated that more than 40,000 women would be affected by the implementation of the directive. Only a small number of the 40,000 women have attempted to have their rights guaranteed by the institution of proceedings. It is my contention and my party's contention that the Government should consult its own records in the matter and should compensate for the discrimination suffered by all married women who received the lower rate of the appropriate payment after 23 December 1984 or who received the unemployment benefit for the reduced period. The Government should not be allowed to rely on its own inactivity or its failure to establish a comprehensive scheme of civil legal aid to escape its liability in this matter.

It is clear that in this modern age of computers and technology there are sitting in the offices of the Minister for Social Welfare computer printouts that name every individual woman who is involved and who is owed arrears by the Government. If ever the Minister for Social Welfare has the opportunity to come back to reply to the case, then he will have to quantify what he believes to be the total sum outstanding and he will have to make the proper arrangements for the payment of that money.

What are the Government going to do now that the European Court of Justice has found in favour of those women? Although the Government arrived at an out of court settlement in the Cotter and McDermott case very recently, it is just not good enough for the Minister for Social Welfare to sit back and do nothing; they must make a financial offer sooner or later. They cannot get away with trying to face down those women, their rights and their entitlements, which courts both here and in Europe have decided they should have.

What kind of a farce are Estimates debates to be that there is no ministerial reply to be given to me on this matter, with its direct relationship to public expenditure? The Minister has absolutely no alternative — the courts have already decided and he must pay those women. I look forward to hearing that he is taking the steps to ensure that the entitlements of those women will be met in full in the immediate future.

I wish to move to another issue covered under the Social Welfare Estimate. Yet again it has a direct bearing on and affects mainly women. I wish to examine the issue of the carer's allowance. The way in which the Government treats women is quite incredible. When the Minister introduced that allowance into the House in November 1990 everyone applauded it as an allowance that was well and truly overdue. Unfortunately, it was not until we were given the details of the scheme's workings that its relative worthlessness to the vast bulk of carers became clear.

The Minister had promised that in the first year 8,000 carers would benefit from the scheme, which would replace the previous prescribed relative's allowance scheme. We must now examine the position more closely. We must consider who has in fact benefited. As and from 5 June 1991, eight months after the introduction of the scheme, the figures show that instead of the promised number of 8,000 beneficiaries only 1,400 carers received the maximum allowance of £45, which is to be increased to £50, and that a further 1,784 carers are in receipt of a reduced payment. Imagine carers being reduced in their payment from £45 downwards. To say that only 3,154 people out of the 65,000 carers in this country are on some form of benefit clearly shows the scheme to be completely inadequate. The mean means-testing in action under the scheme deducts for every pound of earnings in excess of £2. Given the value to the State of the carers doing what would otherwise have to be done by the State at an incredible cost, I would argue that, as the first stage in reform of the carer's allowance, this unacceptable means test should be abolished.

The narrow range of carers who are eligible must be extended drastically to allow far more carers to benefit from the scheme. As people will remember, the present allowance is only paid to people who are providing full-time care and attention to social welfare pensioners aged 66 years or over or to recipients of invalidity pensions or blind person's pensions regardless of their age. Is it any wonder that such small numbers benefit? When one combines both the miserable means testing and the narrow definition of carer, we should not be surprised that only 1,400 people are eligible.

There can be no reason why the scheme is only made available to those carers of people classified as pensioners aged 66 years or over. Has the Minister forgotten the realities of life in Ireland today? Does he not know that in Ireland most people over 65 years of age are lucky enough to enjoy good health and are active and independent? We have a long tradition of caring for our older relatives who, through ill health or misfortune, do not enjoy the same degree of independence as the majority. Yet we are making the miserable £45, soon to be increased to £50, payable to carers so restricted that they have to be dealing with 66 year old pensioners. What about the vast number of people younger than 66 who are being cared for? What about the mentally handicapped and those suffering from a huge range of ailments who are in need of constant care and attention? What about the sacrifices being made by those who are devoting very often a lifetime of care to these categories? Yet this carer's allowance restricts eligibility to those with an income of £2 or less and who are caring only for 66 year old persons in need of full time care and attention.

Many severely disabled or dependent elderly people were cared for by statutory services and institutions when they could not be looked after at home. The level of care in some of these institutions left much to be desired and therefore they became a last resort, in many cases a resort of desperation. Now, in the enlightened eighties and nineties, Government policy gives a new direction to services for the elderly, emphasising care within the community. The elderly person, of course, should be assisted in every way possible, with family and voluntary and statutory supports, to stay in his or her home. If full-time professional care is needed it should be as local as possible and fulsome in its response. It should not erode the person's rights or disregard their individuality. The implementation of this policy in regard to keeping people in the community began in the seventies and has galloped through the eighties. Sad to say, though, the necessary services in the community have only crawled forward compared to the needs of the people.

It is all very fine to present ourselves to the public and say what a caring society Fianna Fáil is creating. How are they going to de-institutionalise people? How are they going to keep the elderly out of homes? How are they going to keep them in the community when they provide such meagre, insufficient resources and viciously exploit the people who end up spending many years of their lives caring for elderly people?

The result of this process is that the carers of our older relatives carry the full brunt of responsibility and yet they are not accorded recognition in practical and necessary ways. Their needs, working under such strains, are unrecognised and ignored. There is an urgent need to educate professional staff, including those controlling finance, to the reality of these people's lives. Research indicates that there are 65,000 elderly people in this country who due to declining health depend on a caring relative for daily help and that approximately 25,000 of these elderly people require a high level of daily help — in other words, full-time care. Think of those figures. There are 65,000, 25,000 of whom require full-time care, and remember the figure for those eligible for the carer's allowance at 1,400. To qualify for the full rate of carer's allowance one needs to be living with one's relative and be destitute. Yet it is Government philosophy and policy that elderly people have a right to remain at home and be cared for by their families, as if care was something that could be plucked out of the air.

Now we have moved away from poor institutionalised care to the quiet and hidden desperation of home care. Women carers repeatedly say that in many situations, even where the carer is married with a husband and children and brothers and sisters of their own, they are left, 99 per cent of the time, to bear the responsibilities and to do the necessary day-to-day tasks. Imagine the emotional and psychological loneliness, the hard around the clock work, the meagreness of the services provided by overstretched staff. These all reinforce the reality that the carer is fully responsible and alone and forgotten by this Government.

The family continues to be the strongest and most reliable source of care for the elderly, the handicapped, the disabled, the chronically ill. In the family women are the main care givers. The majority of people in need of care continue to be cared for at home rather than in institutions. Families show a high degree of adaptability to the needs of dependants. There is in fact an impressive body of evidence which indicates the variety of ways in which family members, mainly women again, seek to maintain independence at home despite having to simultaneously discharge other family duties and work responsibilities.

There is a huge number of carers in Ireland, mainly women, who look after a relative who is elderly, ill or disabled. Many spend long hours doing the practical work of caring. Some experience considerable stress and undertake caring at a personal and financial cost to themselves and their families. Some are elderly themselves and in poor health and often they receive little or no help. This army of carers is the key to community care, providing an informal infrastructure and network of care. Their contribution is enormous both socially and economically. Without them the State would have to bear greatly increased costs in health and social and personal and family support services.

I was delighted to hear the Minister for Health list a patients' charter. Now I would ask the Minister to recognise that there is a need for a carers' charter that would provide a clear statement of the rights of carers. They have, of course, a right to lead full and independent lives and continue to provide care without undue cost to their own way of life. A community of caring implies that the carer does not find herself or himself caring for a person in isolation. A central element in a community of caring is the provision of services, from formal to informal and voluntary services, which will address the different needs of carers and the people for whom they care at each stage in the caring process.

This Government have a role to play and this role will require a financial commitment but we cannot ignore the rights and the plight of carers and of those being cared for. Will the Minister for Social Welfare wake up and take note of the case being made by carers? Will he cooperate with them in making the necessary resources available for them to carry out their caring role in a humane and sympathetic way? Will the Minister support a carers' charter in which he would recognise that carers have the right to be recognised for the central role they play in community care, that carers have the right to address their needs for personal fulfilment and in relation to their contribution to their families and to the community, that they have the right to practical help in carrying out the task of caring, including domestic help, home adaptions, incontinence services and help with transport? Will the Minister be prepared to support a carers' charter that would recognise, too, that carers have the right to such support services as for example, public health nurses, day care centres and homehelps to provide medical, personal and domestic care, a carers' charter that would recognise that carers have the right to respite care both for short spells as in day hospitals and for long periods to enable them to have time for themselves, that carers have the right to emotional and moral support, the right to financial support, a recompense which does not preclude carers from taking employment or sharing care with other people, that carers have the right to regular assessment and review of their needs and those of the people for whom they care? We must recognise, too, that carers have the right to easy access to information and advice, to expect the involvement of all family members and to have counselling made available to them at different stages of the caring process, including bereavement counselling. The Minister should also acknowledge the right of carers to skills training and to development of their potential. Carers seek a charter whereby public authorities and community members would provide a plan for services and support for carers, taking into account the unique demographic developments up to and beyond the year 2000. Carers are also demanding the right to involvement in all levels of policy planning, and to participate and contribute in the planning of an integrated and co-ordinated service for carers. Carers want the right to have an infrastructure of care, a supportive network to which they can relate when they need to.

Will the Minister now agree that however well intentioned the carer's allowance may have been it is grossly inadequate and too narrow in its application and goes nowhere near satisfying the very legitimate and dignified requests for recognition by carers associations?

I am delighted to have had the opportunity to highlight the demands of carers and the rightful demands of approximately 40,000 married women who have been discriminated against by this Government and to whom there are outstanding payments due. As this is the Estimates debate, the two demands I placed before the House today have some financial implications. I would ask the Minister to relay to the Cabinet the very genuine and sincere claims of the 40,000 women who have been discriminated against plus the 65,000 or the 25,000 carers, depending on what way one looks at the figures, who are not being recognised and who are certainly not being financially assisted by this Government seeing that only 1,400 carers are getting the £45 or £50 carer's allowance.

I thank the Chair for being so tolerant with me and for assisting me in whatever way he could. I will listen with great interest to what the Minister for the Environment has to say on behalf of the Government about the carer's allowance and about some of the points I have made.