Dáil Éireann debate -
Wednesday, 19 Nov 1997

Vol. 483 No. 1

Supplementary Estimates, 1997. - Vote 41: Health and Children.

Minister for Health and Children (Mr. Cowen)

I move:

That a supplementary sum not exceeding £40,505,000 be granted to defray the charge which will come in course of payment in the year ending 31 December l997 for the salaries and expenses of the Office of the Minister for Health and Children (including Oifig an ArdChláraitheora), and certain services administered by that Office, including grants to health boards and miscellaneous grants.

I am pleased to have this opportunity to bring this Supplementary Estimate before the House.

The gross additional requirement is for just over £65 million, the precise sum being £65,505,000. This figure is partially offset by additional Appropriations-in-Aid of £25 million, giving a net figure of £40.505 million. This Supplementary Estimate takes account of the fact that £30 million of the total level of funding originally provided in respect of the Hepatitis C Compensation Tribunal will not be required in the current year.

I should explain that some £26 million of the requirement is of a once-off, non-capital nature, £46 million being recurring non-capital and £23 million related to capital expenditure. When account is taken of the £30 million non-capital provision for hepatitis C which will not be required in the current year and additional Appropriations-in-Aid, the net sum required is £40.505 million.

The additional moneys sought are necessary to adequately fund a number of items within the health service which have given rise to additional expenditure not foreseen or which could not be accurately computed when the original Estimate was passed. The document circulated to Members gives the background to this Supplementary Estimate. I intend to cover a number of the main areas but, within the time at my disposal, I cannot go through all the issues.

Broadly, the items contained in this Supplementary Estimate fall into two categories. The first relates to items where there is an inevitable degree of uncertainty in forecasting the actual costs in any one year resulting in the original Estimates not providing fully for these costs. The agreed practice has been to seek supplementary funding in these areas when the actual amount needed becomes apparent during the year. The items recognised by the Department of Finance as falling within this category are medical indemnity insurance, superannuation costs, PRSI costs and demand-led schemes which consist of the community drugs schemes and certain capitation payments such as the domiciliary care allowance.

Expenditure on these items is influenced by a number of factors difficult to predict in advance. Increases in medical indemnity costs are related to growth in claims experience. As Members will be aware, in common with all developed countries, ours has experienced a significant growth in the number and average cost of civil claims throughout our health services, leading to an additional funding of £3.2 million being required for this purpose.

The additional superannuation costs for which funding is sought are occasioned by the age profile of personnel in the health sector. Agencies are experiencing an increasing number of retirements, including those opting for early retirement, leading to an increase in the annual budgetary requirement. A sum of £5 million additional funding is required for this purpose.

In relation to PRSI, modified social insurance status does not apply to workers recruited into the public service after 6 April l995. This means that health agencies experience increased costs in respect of employers' PRSI contributions when recruiting such employees to replace existing staff. This item requires additional funding of £4 million.

Expenditure on the community drugs schemes is a factor of the number and cost of claims under these schemes, again difficult to predict in advance. As the House will be aware, there is a statutory right to relief for expenditure on prescribed drugs and medicines in excess of the expenditure thresholds laid down. There is an additional requirement of £10.9 million in respect of these schemes.

The second broad category of expenditure arises from the need to meet special service needs and genuine once-off expenditure of a pressing nature. In dealing with special service needs, it must be recognised that the health services, particularly in the acute hospitals sector, are influenced increasingly by technological advances and more expensive drugs regimes. In this regard, some £3 million is sought to cover expenditure on high cost drugs, many of which are of a life-saving nature, when the cost associated with even one patient can be very significant. Similar expense is being experienced in relation to blood products for haemophiliac patients, including paediatric haemophilia treatments. Overall some £2 million additional funding is required for this purpose.

Another important matter being addressed in this Supplementary Estimate is child care, in particular the problem of homeless children and those with emotional and behavioural difficulties who require special care and education. Provision is being made for an additional £1.5 million for health boards, on a once-off basis, to cover unanticipated legal costs arising from court cases involving these children. In addition, a total of £4.5 million is being provided on a continuous basis to cover the additional costs incurred by health boards in dealing with these children. It will clearly be seen that we are providing more funding to deal with the problem rather than simply paying legal costs and are introducing specific measures intended to alleviate the problem itself. There is an urgent requirement for funding of £6.9 million to allow health boards to meet the increasing demand for subventions toward the cost of care of older people in private nursing homes. This sum will fully fund the changes in nursing home regulations introduced in l996.

The Government has also agreed to provide a package of funding, on a once-off basis, to meet pressing needs in relation to the disabled and the elderly. A sum of £4.825 million is being provided for the purchase of equipment, technical aids and appliances by voluntary organisations working with people with physical and sensory disabilities and with older people. A further sum of £4.5 million is being made available for services for people with physical and sensory disability. Most of this funding will be provided to allow voluntary organisations to eliminate historical funding deficits built up over the years.

In response to the major problem of drug abuse, the Eastern Health Board has drawn up a comprehensive service development plan to meet the objectives of the ministerial task force on measures to reduce the demand for drugs. This plan allows for the expansion of services in the areas of drug prevention and education, treatment and rehabilitation at a cost of £5 million included in this Supplementary Estimate. This funding will assist in discouraging young people from turning to drugs in the first instance and in addressing the needs of drug misusers presenting for treatment.

I mentioned earlier that expenditure in the current year in respect of the Hepatitis C Compensation Tribunal is likely to be lower than originally anticipated. A sum of £72 million was made available this year to cover the costs of claims made by the compensation tribunal, associated legal costs and those of administering the tribunal itself. The volume of cases dealt with so far this year was not sufficient to use up the approved level of funding. In order to expedite claims before the statutory tribunal which I established by order on 1 November I have made arrangements to facilitate the settlement of claims. In addition, I shall be appointing four additional members to the tribunal in the very near future. A total of £42 million is available for the remainder of this year to cover the payment of claims and associated costs, including £15 million to cover payment of outstanding reparation fund claims where payment is requested this year.

The Supplementary Estimate also provides for an additional £23 million for my Department's capital programme. The original capital allocation for l997 was £108.743 million. The need for an increased provision must be seen in the context of the serious under-investment in the past, particularly when account is taken of the considerable asset base requiring to be serviced which had been estimated at in excess of £4 billion for the health boards alone.

One of the consequences of this under-funding over the years has been that health services providers have not been in a position to invest in the replacement of hospital equipment. The demands for priority capital projects this year resulted in a further postponement of expenditure on urgently required equipment. The point has now been reached at which it is just not possible to further postpone the purchase of essential equipment without damaging the fabric of these services.

Provision is also included in the Supplementary Estimate to allow agencies undertake essential works to address the serious backlog of fire prevention and maintenance works. These are necessary to allow health agencies meet their legal obligations with regard to health and safety regulations. The proper provision for equipment replacement and maintenance works were two issues I was particularly concerned to address. I also intend making provision for these areas from the l998 capital budget.

The original capital programme did not provide for the purchase by the North Eastern Health Board of Our Lady of Lourdes Hospital, Drogheda because of uncertainty in relation to the timing of this funding requirement. In the event, the transaction was completed this year and provision must be made for the necessary funding.

Provision is also included in this Supplementary Estimate for the relocation of the Blood Transfusion Service Board to the St. James's Hospital site as a matter of the utmost urgency. Funding will be required also for the board's requirements in relation to information technology and vehicle replacement.

Since assuming office I have been conscious of the challenges with which we are faced in managing a system as complex and dynamic as that involved in the administration of our health services. Perhaps more than any other sector of the public services, health is influenced by constant technological innovation and new methods of service delivery. While there are undoubted attendant benefits to such developments, almost invariably they are very costly. This Supplementary Estimate clearly illustrates that point. I am also conscious of the genuine pressures with regard to the needs of groups such as the mentally handicapped, physically handicapped and the elderly. I am in discussion with the Minister for Finance with a view to addressing such issues in the context of the forthcoming budget and the multiannual budgetary framework for the health services.

This Supplementary Estimate will greatly assist health agencies in meeting their additional costs and in addressing the need for immediate investment in key service areas. The funding being sought demonstrates the Government's real commitment to adequately fund our health services. Accordingly, I recommend the Supplementary Estimate to the House for its approval.

Mr. Shatter

I listened with interest to the Minister's contribution and have carefully examined the Estimates he has presented to the House. To some extent, I am more engaged about what the Minister is failing to do in the announcements he is making today. One issue that needs to be comprehensively addressed is the additional provision of £1.5 million to health boards to cover unanticipated legal costs arising from court cases involving what the courts have legally described as unruly children — children with a variety of problems. A small number of parents who cannot care for their children due to their conditions are spending substantial sums of money sending them to England for the special facilities they require. That issue must be addressed on a more fundamental basis. There has been a plethora of court cases, both against the State and against health boards, to require that the constitutional rights of these children to have their welfare protected be upheld. It is extremely depressing that £1.5 million has to be allocated to meet the legal costs of health boards in being represented in these proceedings, which is what I presume the Minister is telling us. It would be far more satisfactory if that £1.5 million were put into meeting, or partially contributing towards meeting, the cost of the new facilities and services required in this State to cope with children who have specific problems which currently fall outside the network of our health service. Until the Minister comprehensively addresses that issue, further substantial costs will go to legal services instead of to making provision for these children. I hope the Minister will have something of a more comprehensive nature to say about this issue in either the Estimates debate next week or in the context of the budget. It is not satisfactory that the current approach in this area continues to be maintained.

I said I would comment on what the Minister has not referred to rather than on what he has in this Estimate. To date the Minister has failed, in a way that is unacceptable, to address an issue that was addressed by the last Government and which he is now putting on the long finger. The cardiology and cardiac surgery waiting lists are growing. It is outrageous that some individuals have waited for more than three years for cardiac surgery and, as the Sunday Tribune so well highlighted last Sunday, others have been waiting five or six years. That is completely unacceptable in a modern western democracy as affluent as this State. We are told people on cardiac surgery waiting lists are dying. The figure for the numbers dying is disputed to some degree but it is clear that a number of people who have been assessed as requiring cardiac surgery are dying. If they had a private health service available to them and the financial capacity to cope with that, some of these people would not die.

Last May the previous Government decided, as a result of an objective report by a departmental appraisal group, to establish a new additional cardiac unit in St. James's Hospital. That unit was to provide 500 additional beds for cardiac surgery. It is outrageous and unacceptable that the Minister cancelled that decision, that he continues to prevaricate on the issue as the cardiac surgery lists grow and that he has still not made any final decision on it. It is outrageous because, when in Opposition, the Minister suggested his predecessor's decision to sanction the construction of this unit derived from some sort of short-term political gain relating to a general election. Since entering office, the Minister has discovered his predecessor implemented a decision recommended by an objective departmental appraisal group. Deputy Michael Noonan, when Minister for Health, made that decision because of the urgency of addressing the cardiac surgery waiting lists.

As he now enters his sixth month in office, the Minister has been reviewing, considering, appraising and reconsidering this proposal. While he prevaricates, patients die and the cardiac surgery waiting list grows. People who would have had cardiac surgery at an earlier stage as a result of the previous Government's decision have had it further delayed and their lives have been further endangered. The Minister should not wait until budget day to announce, as if distributing sweets or lolly pops, that he has finally made a decision on a cardiac unit of this nature. This issue is too serious to be dealt with in that way in the context of looking for plaudits at budget time about political announcements. This is a life and death issue for many people. It is also about the type of life they can currently lead because of the delays in surgery.

The Minister told us he will reappraise the issue and may make some general announcement in the future. To cover up the manner in which the Minister has reneged on his duty as Minister for Health in dealing with this issue, I have no doubt that when the announcement is finally made it will be dressed up with a number of other announcements about upgrades in other hospitals or other cardiac services. There is a case to be made for upgrading facilities in Galway Regional Hospital, for example, but there is nothing to stop the Minister sanctioning the construction of the cardiac unit in St. James's Hospital allowing progress to be made — he has delayed progress by six months — and making whatever additional announcements are required to ensure there is a comprehensive service necessary to meet the need in this area. It is scandalous and unacceptable that for no reasons other than party political jousting, the Minister cancelled the decision to construct the unit in St. James's. He is conducting a review of an objective report from his own Department on this issue and, by so doing, delaying essential surgery.

I am concerned about another matter. In fairness to this Minister, successive Ministers for Health have had to wrestle with the waiting list problems in each of our hospitals. As medical advances occur, illnesses that could not be dealt with in the past can now be addressed successfully. The previous Government took substantial steps to reduce the waiting lists and also ensured that we knew the position of waiting lists on different aspects of medical care, particularly surgery in a number of areas. I tabled a question to the Minister for Health last week that was answered yesterday to ask him to state the up to date position with regard to the waiting lists. I know, as the Minister said in his reply, that waiting lists are updated on a quarterly basis. The Minister should have available to him in his Department, and should have had available for reply to me yesterday, the state of the waiting lists as at 30 September 1997. For reasons of which I am unaware, the waiting list table made available to me, which was widely published over the weekend in advance of the answer to my question, stops at the end of June 1997. Is the Minister trying to suppress knowledge of the manner in which the waiting lists have grown under his Ministry? This House is entitled to know the latest quarterly figures. If I seek an updated position on the waiting lists, which are assessed on a quarterly basis, it is unsatisfactory that that information is not made available when it is or should be available to the Minister. I insist it be made available to me prior to the Estimates debate next week. I would like an explanation as to why I have been given figures for June rather than the end of September. My suspicion is that the Minister is not willing to reveal the state of the waiting list during the first three months of his occupancy of the Department of Health and Children. I hope I am wrong in that and, if I am, I will apologise to him.

We will return to many of the issues in the health area in the debates on the Estimates for next year over the next three to four weeks. It is important we address the issues in a sensible way and on an informed basis. However, Members, including the Minister, have a duty to ensure that we do not continue to develop a two tier health service, where those on public hospital waiting lists are denied treatment which those who can afford to pay for it or who are in the VHI can readily obtain. We must ensure people's lives are not placed at risk where essential surgery is required. It is the duty of the Minister for Health and Children to implement policies to ensure that. In so far as the Minister does that he will have support from this side of the House, but if he reneges on his duty and fails to establish necessary facilities for which there is finance and fails to deal with those who are on waiting lists for far longer than the charter for patients' rights envisages, we will put him under considerable pressure in the coming months.

Mr. McDowell

I listened, with some awe, to the indignation of Deputies Sheehan and Ring on the preceding Supplementary Estimate. I am not sure I could ever reach that level of indignation.

I want to comment on the abridged Estimates published last week, to pose some questions and comment on today's detailed Supplementary Estimate. I do not mean this frivolously, but having listened to Deputies Sheehan and Ring on the preceding Supplementary Estimate it struck me that the total transfers of EU funds to farmers last year slightly exceeds the total payments to health boards in this year's health Estimates. That puts things in perspective. I do not mean that in a begrudging way, but we should be aware of those facts before we get as indignant as some colleagues did earlier.

The 1998 Estimates are placed by the Government within a particular political and financial context. Minister McCreevy, with the full support of the Taoiseach, has chosen, at least in principle, to impose a 4 per cent limit—

An Ceann Comhairle

I remind the Deputy that this discussion must be confined to the items constituting this Supplementary Estimate.

Mr. McDowell

That is my intention, but I merely want to make some general comments about their context which is important. We are working within the context of a general increase of 4 per cent for the 1998 Estimates, one imposed for ideological reasons which make no sense. I do not believe that any sensible household would calculate its budget according to a particular target which was not related in some sense to their income, but that is what we, as an economy, are being required to do. Inevitably, as a result health, education and other services will suffer. I recall some months ago the then Minister, Deputy Noonan, told us that an increase of between 6 and 8 per cent would be required in the health service Estimates to maintain the current position but the abridged Estimates provide for a 5 per cent increase in GMS payments and an increase of 6 per cent to the health boards. I understand the Supplementary Estimate, for which we are providing today, is included in the abridged Estimates and perhaps the Minister will confirm that.

The Minister made the point that this Supplementary Estimate is required partly because of the requirements of the Health (Amendment) No. 3 Act, 1996, which received all party support and will come into play very shortly. It should lead to greater accountability and transparency in the funding of health boards. Perhaps the Minister will confirm that, with the benefit of this Supplementary Estimate, all the health boards will be in a position to implement the Act and that as of now all the health boards are operating in surplus and do not have the type of deficits that were run up over many years in previous times.

Under this Supplementary Estimate the Minister is looking for an increase as part of the Partnership 2000 agreement. I am unclear as to the amount of money being provided in 1998 for improvements in the health services. I am conscious of what the Chair said about the Supplementary Estimate and I do not want to range too far from it, but it would be extremely helpful if the Minister could indicate how much money is available for improvements in services in the coming year and how much of it is taken up by payments in 1998 of the full year cost of the improvements in pay made earlier this year. Perhaps the Minister will also give a figure of the cost in 1997 of the special increases which took place earlier this year.

My colleague, Deputy Shatter, referred to the waiting list initiative. The Minister during the summer made some remarks about waiting lists when he essentially questioned whether they reflected the numbers of people waiting for particular procedures. The Minister owes it to the House to clarify that he is committed to the waiting list initiative and intends to pursue it in the year to come. Deputy Shatter rightly said that we do not have up to date figures, but it seems fairly clear that waiting lists are increasing rather than decreasing. We were all struck by the coverage in a Sunday newspaper of the problem related to cardiac surgery financing and Deputy Shatter also made that point. The Minister's delay on that is inexplicable. On a number of occasions he told the House he has commissioned a report for reasons that were unspecified. The previous Minister made a decision to increase the number of cardiac surgery procedures which would be available in any given year by 500. The Minister must make a decision on this or tell the House why he is not in a position to do so.

There are other examples of waiting lists which are in a sense being dealt with by sleight of hand. The numbers on the orthodontic waiting list, particularly in one category, seem to be miraculously disappearing but concern has been expressed that they are disappearing by sleight of hand and not because the procedures are being carried out, and I asked the Minister to address that this morning. Children are being told when they reach the age of 14 and 15 that even though they have been on a waiting list for several years for a diagnosed problem that the procedure will not be carried out under the GMS and they must have it done privately. That is one way of dealing with waiting lists, but hardly the right way.

I want to ask the Minister about details on some of the provisions in the Supplementary Estimate. I notice a figure of £220,000 is provided for freedom of information in 1997. Will the Minister confirm that he has appointed an information officer in the Department and give an update on what provision has been made in the Department for the provision of information when the Act will come into play next April? Will he indicate if the Department is involved in the extension of the Act to the health boards in years to come? There is a provision of £4.5 million for legal fees. I gather that does not include the hepatitis C tribunal and perhaps the Minister will give some more details of what is entailed in that figure.

A once off figure of £1.5 million is provided for Tallaght Hospital. The Minister will be well aware that there is still concern about the opening date of the hospital. Perhaps the Minister could confirm that Tallaght Hospital will open early in the new year. I notice a once off payment of £200,000 has been provided for an equalisation group during the course of 1997. I would be obliged if the Minister would explain what that entails.

On the BTSB, we were faced in October with a bizarre and unacceptable position in Cork where the Irish Medicines Board effectively told the BTSB that it would not license it to continue the production of blood products in Cork unless agreement was reached on the provision of a proper facility in Cork. Will the Minister confirm that agreement has now been reached? Will he indicate whether the cost of upgrading the existing facility and providing a new facility is included in the Supplementary Estimate, or whether it will be included in next year's Estimates? I welcome the provision for the upgrading of the BTSB facility in St. James's Hospital.

At this stage, I confess, I am at a total loss to understand exactly how much money has been paid out in relation to the hepatitis C tribunal and how much money will be spent. I can recall that moneys for hepatitis C payments were brought forward from the 1997 Estimate into the 1996 one. The abridged Estimates refer to an outturn in 1997 of £27 million. Does this take into account the £30 million underspend the Minister comments on in the Supplementary Estimate?

The Minister is still seeking additional funds from the Minister for Finance in relation to budget day spending. I hope he will be successful in getting that and I am sure he will receive support from all elements of this House if he does. I hope in doing that, however, he will not be hamstrung by the Government's needless ideological commitment to targets that make no sense.

I support the Supplementary Estimate, but I would be obliged if the Minister would answer the questions I have raised.

Mr. Neville

I reiterate what Deputy Shatter said with regard to homeless children and those with emotional behaviour problems. There is a need to assist, educate and take care of them. It is totally unacceptable that we must go outside the State to treat such children, who constitute a small number nationally. They account for four or five in the Western Health Board's region.

On the specific issue of a register for child sex offenders about which the Minister has made some statements recently, I understand the Minister has not made a decision to establish such a register but is planning to have consultations about the matter over a period. There is an urgency to set up such a register to protect our children and ensure that paedophiles and serious child sex offenders do not have freedom to move throughout the country posing a danger to children. One of the Minister's backbenchers, Deputy Batt O'Keeffe, highlighted the fact that with a register now in place in the United Kingdom, paedophiles are travelling to Ireland. We must be concerned about this issue.

According to studies conducted in Britain, repeat offences by paedophiles run at an estimated 90 to 95 per cent, which makes a curative approach totally unrealistic. In the circumstances, containment and control constitute the only policy to be pursued. This needs to be combined with more effective co-operation among agencies concerned and a long-term preventative effort directed against child abuse, which is so often the root of such behaviour. The rate of recidivism among sex offenders is less pronounced than with paedophiles, nevertheless it is disturbingly common.

Among the criminal fraternity, paedophiles are in a special category. We can distinguish their sexual activity from that of violent people, muggers and other criminals because, as research appears to show, paedophiles are usually highly manipulative and clever. Their offending behaviour often intensifies as they become older. They are a peculiarly dangerous category and some form of register or identification should be available after they have been convicted and released from prison.

One of the difficulties in dealing with paedophiles is that they do not consider their activities to be wrong. Hardened paedophiles believe the rest of us set unfair parameters on their sexual activity. They do not believe that having sex with children is wrong. Many of them believe that it is the right thing to do and that we are wrong to try to restrain their activity. The fact that some of them are so clever and manipulative makes them especially dangerous.

The requirement to register convicted paedophiles, recently introduced in the United Kingdom, applies indefinitely to those convicted of the most serious offences, that is, those sentenced to more than 30 months' imprisonment. Those sentenced to shorter periods are required to be registered for a period of up to ten years if the sentence is more than six months, and seven years if it is below six months. A non-custodial penalty and caution attracts a registration period of five years.

While such a register is necessary here, it can only form a limited part of a much more comprehensive approach we need to take towards child sex abuse. The majority of children are not abused by convicted offenders. In a minority of cases where prosecution follows the disclosure of abuse, the rate of conviction remains disturbingly low.

Paedophilia is perhaps the most deep-seated of all perverse emotions and feelings with which people can be inculcated. It is a pathetic fallacy to think that paedophilia can be cured; I do not believe it can be. It is an inherent problem rather than one that people acquire and, therefore, we must consider how it can be controlled. It is a problem which devastates affected families whose children have been abused and it also destroys the lives of children. Paedophiles are evil people who take away childhood and innocence. They should be registered. While I recognise there will be much discussion about who needs to know the information available on such a register, the overall issue is so extreme and perverse that a special approach must be taken for the reasons I have stated.

The Minister has failed to release the report of the task force on suicide. Next week, it will be two years since the former Minister for Health, Deputy Noonan, set up the suicide task force. It completed its work before Easter this year, yet we have not seen the publication of the report. I do not know why the report is being delayed.

There is an urgent need to introduce suicide prevention programmes. The Minister has a responsibility to tackle the problem. When it is released, the report will herald an important debate on suicide, including the approach we must take towards reducing suicide levels and the services required to do so.

On 7 October the Minister informed me that 378 suicides had been recorded in 1996. There has been an upward trend in suicides over the past 20 years but there has been very little serious discussion of the problem. Suicide is still part of the hidden Ireland. Society is not equipped to deal with it or to shake off the stigma attached to it. Until 1993 suicide was a criminal act which was dealt with by the Department of Justice. It is now a public health issue which must be tackled by the Department of Health and Children. We must initiate public debate by publishing the task force's deliberations and discussing them in a compassionate and informed way.

Society has a responsibility to respond to people who feel suicidal. Counselling services must be available to those who feel suicidal and to those bereaved as a result of suicide because it is a different type of bereavement. I recently heard someone from Aware on "The Gay Byrne Show" discussing her attempted suicide from an overdose. She said she was appalled at the hospital's response to her problem. We have still not accepted mental health problems and attempted suicide as diseases or in the same light as someone who breaks an arm or a leg.

Mr. Barrett

I want to bring to the Minister's attention the care of the elderly and the cost of private nursing homes, particularly in the Dublin region, relative to the subvention available. The maximum subvention at present is £120 per week. If the old age pension is added to this figure, the amount available to meet such costs is less than £200 per week. The average nursing home in the Dublin area costs between £350 and £400 per week. This means there is a shortfall of £150 to £200 per week.

People in receipt of old age pensions who do not have any other income are queuing up for the limited facilities provided directly by the health board. It costs the health board between £450 and £500 per week to provide suitable accommodation for the elderly. This means someone can be looked after in a publicly owned nursing home run by the Eastern Health Board at a cost of £450 or £500 per week or a subvention of £120 per week can be paid in a private nursing home. It is crazy to force the health board to build more units at a higher cost than what could be provided by adequate subvention in the private sector.

There is also a social aspect to this problem. It is often better for the patient or elderly person to go to a nursing home in their own community where friends and relatives can visit them on a regular basis than to a health board nursing home which could be far away from where they lived originally. For that reason, I ask the Minister to take into account the facts I have outlined when considering the Estimates for the care of the elderly, particularly in relation to nursing homes.

The Eastern Health Board is now taking into account the income of other family members when assessing the maximum subvention limit of £120 per week. This can cause untold problems, particularly if there are divisions in a family or if a son or daughter fail to co-operate because they are married and do not believe it is anyone's business what their partner earns.

We cannot live in a false world by believing that a person can afford to stay in a private nursing home if they have £120 subvention and an old age pension. If a person cannot get private nursing home care, they will either take a bed in a hospital longer than they should or they will ask the health board to provide them with a public nursing home at a higher cost. I ask the Minister to treat this problem seriously and to give us some indication as to whether there is any hope for persons who are in dire need of nursing home care.

Minister for Health and Children (Mr. Cowen)

I accept Deputy Barrett's point and I am aware this is a problem which must be addressed. We are making a further £6.9 million available in the Supplementary Estimates to allow health boards to meet the increasing demand for subventions. Since the change in nursing home regulations in 1996, the Department has increased the number of subventions paid at the higher rate of dependency and provided more funds for extra beds. Some £2.7 million has been made available in this Supplementary Estimate to cover the cost of increasing the numbers on the maximum scale and of providing new subventions. Some £1.5 million of the figure is represented in the provision of extra beds.

The chief executive of the Eastern Health Board informed me recently that the number of elderly in its area is due to increase by 75,000 between now and 2007 as a result of the success of our health services, people living longer and the various degrees of dependency given their age, state of mind, etc. One can imagine the critical service pressures in trying to provide for those extra numbers. The Deputy outlined an issue I have come across in my constituency but, unfortunately, it is not open to immediate correction. Extra funds will be made available to deal with the recommendation that there should be a higher rate of dependency and for the provision of extra beds. I acknowledge this critical service pressure for which we must try to plan in the years ahead.

Health boards must take into account household income when assessing a person's real needs. Difficulties may arise if certain family members feel they are not obliged or are not in a position to contribute towards the cost of maintaining a spouse or parent in a private nursing home. Given the demands on health boards and their attempts to prioritise needs, they must take these matters into account. Subvention by its nature is not meant to meet the full cost; it is a subvention of the total cost.

Thankfully, we have enacted regulations for standardisation and proper care facilities in nursing homes. There is an argument to be made about the cost effectiveness of private vis-a-vis public nursing home care. However, there will always be a requirement for public nursing home care and we must find the proper mix which will give the greatest level of cost effectiveness. The Deputy's point is well made; it is not amenable to an immediate solution. The Supplementary Estimate contains an extra £7 million to deal with that issue.

I thank the Deputies for the contributions. I will try to deal with some of the issues raised.

Acting Chairman (Mr. Briscoe)

The Minister has one minute remaining.

Mr. Barrett

This item is not due to finish until 1 o'clock so if the Minister needs extra time we have no problem with that.

Acting Chairman

The Deputy will be aware as a former Whip of the order of the House on time.

Mr. Cowen

Clearly, a broad range of issues has been raised by the spokespersons. To do justice to the debate, my Department will check the record of the House and deal specifically with the questions raised. Given the time constraint, that is the only satisfactory way I can deal with the situation.

In relation to the cardiac services, I intend going to Government in the next week or two with a full programme for cardiac care services which will be more comprehensive. Deputies referred to a specific initiative regarding 500 people who are on waiting lists for operations.

It is my intention to give out the moneys for the waiting list initiative at the beginning of the year. In recent years the waiting list initiatives have not been as effective as in previous years because the money is going out far too late to the health boards and we are not achieving the level of throughput which I am advised is possible. If the initiative money is available over a 12-month period, the health boards can deal with the waiting lists far more comprehensively rather than being asked to deal with this initiative in the last three months of the year, which is not satisfactory.

As Opposition spokesperson, I was critical of the validation procedures introduced by my predecessor but I am insisting on concentrating on waiting times. It is true that there are people waiting longer for a range of specialties than we would regard as acceptable in the modern day. We must work our way through those significant lists. As far as the individual is concerned, it is not the number waiting that is of concern but the length of time it takes each patient to gain access to the procedures. One of the ways of doing it is to have a liaison officer at health board level who is specifically responsible to the Department for keeping these lists so that we have up to date information. These lists should be validated to make sure that there are no other procedures with which clinicians at hospital level can deal and to do everything possible to make sure we reduce these waiting times as quickly as possible. Waiting lists are an unpalatable feature of every modern health service but I will do what I can to work more effectively in dealing with these waiting list initiatives in a more comprehensive way.

On the other issues which were properly raised, I will check the record and deal with the spokespersons by way of correspondence in the next few days.

Vote put and agreed to.