Health Services: Statements.

Minister for Health and Children (Mr. Cowen)

I welcome this debate as an opportunity to consider in a constructive way how the health services are being developed and how the main problems are being addressed. The Government is very clear about what it is trying to achieve through the health services. It has adopted and is seeking to implement the 1994 health strategy statement, as updated this year in my Department's statement of strategy. It has also set out its specific priority objectives in the programme for Government and is making steady progress in achieving these. Contrary to what is sometimes claimed, there is a clear and coherent programme in place for the improvement of the health services.

The Government has committed significant additional resources for the improvement of health services in areas of greatest need and I shall be describing these in more detail later. It is devoting more resources to the non-capital and capital areas; the latter has enjoyed a significant increase and further large increases can be anticipated.

Planning, management and control are essential in implementing the longer-term strategy. The Government will use the 1996 legislation to control non-capital expenditure within the limits agreed by Government and approved by the Dáil. It will ensure that available resources are distributed as objectively as possible, consistent with real needs, and it will not allow the agenda to be dominated by those who are best placed to make the loudest noises about their needs. It is not an unplanned or rudderless service. It is far better integrated than many health systems and is acknowledged by the OECD as an efficient, well organised service.

In regard to the statements made by the Opposition last week and yesterday in the Dáil on the infamous £32 million, I do not intend to return to this matter in any great detail. For the record I will say one more time, there is no reduction in spending on the health services this year. There is an increase in overall expenditure. The allocations to the agencies have not been reduced and will be increased by the Supplementary Estimate when it is taken soon. The Opposition appears to be demanding that I effectively ignore the accountability legislation which it brought before the House two years ago. I can only say that its principles were quickly overturned by the first real choice it had to make as an Opposition in supporting its own legislation. It should know — I have no doubt it does — that the health services must have genuine planning for the future and that playing politics will destroy the foundations of accountability, planning and management set down by the legislation of 1996.

This Government has, since it took office, shown its determination to invest in the health services so that key areas will benefit from the continuing and welcome growth in the economy. The Health Vote has increased by over 9 per cent this year over the outturn for 1997. The increase for 1999 over the expected outturn for 1998 will represent a figure of 9.5 per cent. Given the Government's commitment to holding public expenditure at an average increase of 4 per cent per annum, it can be seen that the Government is funding the health services as a top priority.

In regard to capital, I have negotiated a three year programme. This is the first time any Minister for Health has been in a position to work with such assurance in relation to capital developments. This will be of immense benefit to the system as my Department and the agencies can plan on a much more orderly basis. The actual amounts for each year of that programme are: £147 million in 1998, £155 million in 1999 and £165 million in 2000. Over that three year period the total amount of extra investment over the original 1997 figure of £108 million will be a total of £143 million. Indeed, the figure for the year 2000 represents an increase of 53 per cent over the 1997 original figure introduced to the Oireachtas by former Minister Deputy Noonan.

All of this reflects the Government's recognition that the health capital programme has not been adequately resourced in the past. The 1999 letters of determination from my Department to the agencies will set out budgets for the replacement of priority equipment, maintenance backlogs and fire precaution works, and it is my intention to continue this process in the years ahead so that the agencies will be in a position to plan for the medium term in regard to better maintaining their infrastructure. It has been a matter of great satisfaction to me that I have been able to greatly increase the capital investment in services for the mentally handicapped, the elderly and those requiring psychiatric care. I am confident that I will, in due course, be able to announce for 2001 a further greatly enhanced level of funding for capital.

The acute hospital sector consumes about 50 per cent of total expenditure. This sector is getting its fair share of resources having regard to the need to meet other priorities, many of which have been relatively neglected until recent years. The hospital system continues to expand with more patients being treated every year. This year alone has seen an increase of 9 per cent in day work with a 1 per cent growth in in-patient activity and with an overall average increase of over 3 per cent.

While the acute hospital sector continues to receive the largest single share of the funding devoted to the health service, the benefits of this funding are clear. In recent years, the acute hospital system has treated a steadily increasing number of patients. A recent study by the OECD has shown that the Irish hospital system has become more productive and efficient. The average length of a hospital stay has declined. Better management of hospitals has resulted in increased occupancy levels. Hospitals have taken advantage of developments in medical practice to increase the level of day care in Irish hospitals almost four-fold since 1986. The impact of these improvements can be seen in the fact that the number of patients treated in acute hospitals has risen by 3 per cent a year since 1987. In the 12 months to the end of August 1998, 539,900 patients had been discharged from our acute hospitals, almost 17,000 more than in the same period last year.

The continuing improvement in output in the acute hospital sector is underpinned by a commitment by this Government to provide additional funding, facilities, equipment and staff to the acute hospitals. In this year alone, the Government has provided an additional £44 million to improve acute hospital services. As a result of this funding, new hospital developments are being brought onstream, including those at Temple Street children's hospital, Longford-Westmeath General Hospital and the Mercy Hospital in Cork. Additional medical and nursing staff are being employed to improve services for patients in important areas such as the accident and emergency service. The cancer strategy provides for the appointment of additional consultants in the specialties of oncology, haematology and palliative care and the development of services for cancer patients in regions where the need for such services has been clear for a long time. The funding and services which have been put in place this year have gone some way to addressing the problems in acute hospitals which the Government faced on coming into office. The recently published Estimates for 1999 again provide evidence of our concern to provide for the development of the health services. I will continue to work throughout 1999 to further improve the acute hospital service.

I announced yesterday an increase in charges for private rooms in public hospitals. Let me make it absolutely clear again that I have no apologies to make for this increase. The increase still leaves a gap between the charges and the cost of providing services to private patients in public hospitals. As Minister for Health and Children, am I expected to allow these charges to be frozen and thereby continue with subsidies for private practice or should those charges not reflect the realistic cost of providing services? There are already considerable subsidies in place for the private sector, including tax breaks, and I will not allow a situation to continue whereby the taxpayer must pick up an ever increasing proportion of hospital costs while the private sector does not meet its fair share.

The total amount earned by the State from private patients in 1997, in respect of private accommodation in public hospitals, is estimated at about £68 million. It is also estimated that the cost to the Exchequer in 1997-98 was £64.5 million in respect of income tax relief on private health insurance premiums and about £20 million in respect of unreimbursed medical expenses. There is massive investment in public hospitals by the Exchequer, including building, equipment and staff training. Public hospitals also provide the accident and emergency services. Health insurance companies avail of these facilities and they must make a contribution towards those services. There are many reasons for cost increases for insurance premia, including the charges made by private hospitals and medical consultants. It is estimated that the last increase of 9 per cent in January 1998 in private accommodation charges contributed only 2 per cent of the 9 per cent increase in private health insurance premia introduced by VHI in September 1998.

On taking up office as Minister for Health and Children, one of the priorities I set was to tackle the problem of unduly long waiting lists and waiting times, as pledged by the Government in An Action Programme for the Millennium. I immediately examined the situation and saw the need for organisational changes in the way the waiting list initiative was being implemented. I took a number of initiatives in 1997 aimed at improving the efficiency and effectiveness of the waiting list investment. These were the much earlier notification to each hospital of the level of funding to be made available to them under the waiting list initiative — hospitals received details of their waiting lists funding in December 1997, whereas in previous years the funding for waiting lists tended not to be allocated until around July; an increased focus on waiting times as well as on waiting lists, so that we would not lose sight of our major concern — that is to reduce the length of time patients must await treatment on a public waiting list.

As regards the waiting list initiative, I allocated £12 million for waiting list work this year, which represents an increase of 50 per cent over the funding made available by the previous Government in 1997. The additional funding will result in an extra 15,000 procedures being carried out during the current year. I took these initiatives against the background of a significant increase in waiting lists during the period 1995 to 1997.

When the Fine Gael-Labour-Democratic Left Government took office in December 1994, waiting lists stood at 24,000. When that Government left office in June 1997 waiting lists had increased to over 30,000. They rose to 32,000 by December 1997 due in part to the allocation by that Government of just £8 million for waiting list work in 1997. This represents an increase of 33.3 per cent during the lifetime of the previous Government. With the reduced funding provided by the rainbow Government waiting lists rose by one-third. This suggests that for the foreseeable future we need more significant funding to address the problem of waiting lists and waiting times and I am addressing the question of additional funding requirements as part of the budget process for 1999.

I caution against adopting a simplistic approach to dealing with unduly long waiting lists and waiting times. Ireland is not unique in having long waiting lists and waiting times for acute hospital procedures. They are a problem for the health services in many countries and no country has yet managed to wipe them out or to have them reduced very quickly. The quick-fix solution of simply throwing money at the problem is not the answer. What is required is a structured, co-ordinated and multi-disciplinary approach to dealing with waiting lists and times. Fundamental to this is the establishment of the underlying causes of unduly long waiting lists and waiting times. Towards establishing these causes and, by extension, a strategy to deal with them in a planned way, I established the expert review group in April 1998 to look at the problem.

The report of the review group sets out a logical and structured means of addressing waiting lists and waiting times. It has recommended that efficient and effective action to tackle waiting lists and waiting times will require developments at each level of the health care system, in particular in relation to care of the elderly. By their very nature, the measures recommended by the review group will take time to put in place to yield their full potential.

As a first step, I am making the organisational arrangements necessary to ensure a structured and planned programme to deal with the waiting lists and waiting times is implemented in each acute hospital as a matter of urgency. In addition to increasing the number of elective procedures during 1999 and achieving an overall reduction in waiting lists and waiting times, I will be putting in place arrangements necessary to manage the waiting list initiative, at national and hospital level, in a more efficient, effective and consistent manner than heretofore. This will involve shared responsibility between management and consultants for the management of waiting lists in a manner which respects the relative roles and responsibilities of both and which has, as its ultimate objective, the implementation of waiting list programmes in each acute hospital, where every person who requires an inpatient surgical procedure receives that procedure within the target times specified.

There has been much recent debate and criticism about the levels of funding for services for persons with a mental handicap. I am pleased to have another opportunity to reiterate my record in this area. Since my appointment as Minister and despite the many competing demands on the resources available to my Department, I have consistently identified as one of my top priorities the provision of the additional residential, respite and day services outlined in Services to Persons with a Mental Handicap — An Assessment of Need 1997-2001. In the past 12 months or so, I have allocated an additional £25 million to these services. This is more than double the additional funding allocated by the previous Government in 1997.

I have also put in place a £30 million national capital programme, to run over four years in tandem with the assessment of need, to provide the infrastructure necessary to support these services. This is the first time such a programme has been provided and it allows for multi-annual planning in developing services.

My recent announcement of a £13 million capital project for St. Ita's Hospital, Portrane, funded jointly by my Department and the Eastern Health Board, is of particular satisfaction to me. I am proud to be part of a Government that is not only the first to fully appreciate the need for this development but is also providing the necessary funding to ensure this development becomes a reality.

The level of additional funding provided to date has given clear and concrete evidence of this Government's commitment to meeting the needs identified in the assessment of need. This commitment, together with the multi-annual budgeting framework, will facilitate a significant development of services for those with a mental handicap in a well-planned and orderly way. This will represent a huge improvement on the ad hoc“stop-go” approach to such development in the past. I have clearly demonstrated my commitment and that of the Government to meeting the identified needs in this area and this will remain a top priority.

The rights of our older citizens to appropriate support in their homes and easily accessible services, when these are required, is also a major issue which needs to be addressed. The need for action is clear from the demographic changes taking place, which will result in significant increases in the number of older people over the next 15 years.

The National Council on Ageing and Older People, in a recent report, highlighted a number of key service areas which need urgent attention. These include the home help service, respite care, support for carers, day care, paramedical services, social work services and services for older people with mental health problems. Having examined the report and discussed the issues with various groups who represent the interests of older people, it is clear the greatest need lies in the provision of better community-based services, particularly care in the home, including support for family carers.

In 1998, we provided an additional £7 million to provide new services for older people and to improve existing services such as specialist departments of medicine of old age attached to general hospitals, together with community nursing units which provide a wide range of services for older people, including respite and day care, day hospitals and day centres. The additional money has also allowed staffing in existing extended care hospitals and in the community services to be improved. An additional £1 million has been provided this year to develop a specialist mental health service for older people, while over £6.5 million was provided in late 1997 to enable health boards to provide greater support to older people in private nursing homes. On the capital side, I have more than doubled the level of capital resources previously made available for health facilities for older people by bringing that figure to £14 million in the current year.

The areas of child care and food safety are key priorities on the Government's agenda. The importance of these areas was underlined with the appointment of Ministers of State, Deputy Moffatt and Deputy Fahey, to take day to day responsibility for making progress on the Government programme. Both Ministers of State will speak later in the debate and outline developments in these areas.

I have set out some of the key policies receiving attention at national level. However, for those policies to impact at ground level they must be built upon by local management. The health strategy and the accountability legislation have placed a key emphasis on the delegation of authority to local levels. In return for such delegation, it is reasonable to expect that best practice should apply uniformly across agencies.

I now turn to the key tasks of governance and management and set out the level of performance I want to see achieved throughout our services. Everyone accepts that health management is a complex and difficult task. It has perhaps been the focus of most public debate in the acute hospital sector. One area which has received insufficient attention to date is that of governance. No manager, however skilled and well supported by clinicians, can deliver appropriate and effective services without clear directions from his or her board. There is an absolute need for every health agency to be explicit about the values and principles which underpin the service it delivers and by which it will measure itself and those it employs.

The accountability legislation brought a sharper focus than ever before to the issue of governance as it now affects health board members and management. This year my Department has embarked on a general programme of governance development with a number of the major voluntary hospitals. This is long haul work but I am certain it will be a vital part of our future success and our continuing ability to deliver quality services within defined budgets.

As we all know from managing our personal finances, budgeting is not easy but it must be done. A failure to live within one's means may be possible for a short period, provided the degree of deviation is modest. However, this cannot be sustained for long without serious consequences.

The managers of health service agencies must also live within their budgets. I accept that the management of acute hospital services poses significant and difficult challenges. The activities to be managed are largescale and complex. The acute demands that may be made on the system are unpredictable. However, none of these demands are new. We have been here before and we have managed these problems.

There is a degree of predictability in what faces each acute hospital every year. The surge in demand for acute services in January and February of each year is a well observed phenomenon. The drop off in demand for elective services in the summer is also well known. The fact that facilities have to be taken out of commission for maintenance or refurbishing is known. At the beginning of each year it should be possible to devise a plan which matches known available resources to these demands. However, a plan drawn up in December or January cannot simply be put on a wall or a shelf and left there to gather dust.

What is the role of clinicians in this process?

We know that clinical decisions and clinical activity drives the vast bulk of spending in the acute hospital sector. We also know and appreciate that expenditure driven decisions have clinical implications. It is, therefore, obvious that clinicians should be involved in the management process in our hospitals. They already are in many hospitals and I will launch an initiative on 27 November to roll this process out to the entire hospital system. I do not claim now, and I will not claim then, that this alone is an answer to some of the difficulties we have seen in recent weeks. The process of implementing this will not be easy and it will pose major challenges to doctors and managers. It will not lead to easier decisions, but it should lead to better ones.

There is a need for partnership in the health services. This partnership lies not just in delivering services but in working together to resolve problems. Two of the most pressing problems requiring attention are medical and nursing manpower. Frameworks are in place for both but if partnership is to work, it cannot work on the basis of Department or management proposing solutions which are then examined or criticised, perhaps rejected, because they represent a change in how things get done, even if doing them differently would represent a better deal for the patient.

We must put the patient at the centre of the system, even if that means changing the type of contracts people have, the hours they are required to cover, the ways in which they interact with other service providers and the processes through which work is done. Those responsible for governance must assure themselves that the service is good and safe and is seen as such by the patient. Management must provide the environment and the infrastructure through which people are likely to give of their best, as well as complying with their statutory obligations and those delivering the service must show flexibility and responsiveness in a dynamic and necessarily rapidly changing service.

Whether in governance, management or delivery, in every part of the service, we must identify and spread best practice. Whether one is receiving or seeking a service in Donegal, Dublin or Kerry, the response should be equally good. I am making this a matter of the utmost priority and I will return to this theme regularly in my discussions and contacts with all parts of the service.

I thank the House for its attention and invite Deputies who may wish to do so to contribute to this debate. I will try to respond comprehensively and constructively either today or subsequently in writing.

I have tried to set out the principles which I, as Minister for Health and Children, must work from and the performance we should work towards achieving throughout our health services. I have secured significant extra funding for hospital services, the mentally handicapped, the elderly and other services. For 1999 the increase in the gross health vote will be about 9.5 per cent or £356 million. This, by any standards, must be regarded as a large increase. I have obtained significant extra resources for the capital programme for the hospital and non-hospital areas and ensured that the programme will be well resourced over the 1998-2000 period. I am confident I will soon be able to announce further significantly enhanced capital funding in the year 2001.

It cannot be denied that this level of increased investment must be balanced by a commitment to govern and manage in a planned way through efficient and effective application of resources. There is a clear responsibility on all of us, whether in this House or involved in service provision outside, to ensure that the principles set out in the legislation two years ago are accepted by everyone and implemented. I appreciate that Deputies are impatient to see early progress in a number of areas and I am equally anxious to advance as quickly as possible. The overall strategy I have set out here builds on the work of previous Governments in the health strategy and the accountability legislation. If the signals we send out to health agencies and the public are to be consistent, it is imperative that all sides of this House support this overall strategy.

Mr. Shatter

We must understand the reason for today's debate which can be explained simply. In the Eastern Health Board area as of June 1998, Beaumont Hospital had 2,497 patients on its waiting list and it will close 96 beds in December, Holles Street Hospital had 64 patients on its waiting list and it will close 32 beds in December, the Mater Hospital had 3,212 patients on its waiting list and it will close 35 beds in December, the Rotunda Hospital had 246 patients on its waiting list and it will close 17 beds in December, St. James's Hospital had 2,129 patients on its waiting list and it will close 113 beds in December, St. Michael's Hospital had 168 on its waiting list and it will close eight beds in December, St. Vincent's Hospital had 1,891 patients on its waiting list and it will close 60 beds in December, and Temple Street Children's Hospital had 1,095 children on its waiting list and it will close seven beds in December.

In the Midland Health Board area as of June 1998, Mullingar hospital had 142 patients on its waiting list and 40 beds will close in December, and Tullamore hospital had 1,737 patients on its waiting list and 40 beds will close in December.

In the Mid-Western Health Board region as of June 1998, Croom hospital had 468 patients on its waiting list and 27 beds will close in December, and Limerick Regional Hospital had 1,455 patients on its waiting list and 45 beds will close in December.

In the North-Western Health Board area as of June 1998, Letterkenny hospital had 632 patients on its waiting list and 19 beds will close in December, and Sligo hospital had 1,544 patients on its waiting list in June and 40 beds will close in December.

In the South-Eastern Health Board area as of June 1998, Cashel hospital had 59 patients on its waiting list and 25 beds will close in December, Kilkenny hospital had 535 patients on its waiting list and four beds will close in December, Waterford hospital had 1,617 patients on its waiting list and 31 beds will close in December, and Wexford hospital had 335 patients on its waiting list and 32 beds will close in December.

In the Southern Health Board area as of June 1998, Mercy Hospital, Cork had 701 patients on its waiting list and nine beds will close in December, South Victoria Hospital had 945 patients on its waiting list and 89 beds will close in December, Tralee hospital had 602 patients on its waiting list and 30 beds will close in December.

In the Western Health Board area as of June 1998, University College Hospital, Galway had 2,891 patients on its waiting list and 58 beds will close in December, and Portinuncula Hospital had 53 patients on its waiting list and 36 beds will close in December.

As of June 1998, there were 25,018 patients awaiting in-patient treatment and 912 beds will close in December. Some 12 of those hospital beds will be closed for almost the entire month of December and the remainder will be closed for an average period of two weeks. According to the Minister's figures yesterday, bed closures to date in 1998 have accounted for a total of 74,379 bed days nationally. The total projected number of bed days associated with temporary bed closures for 1998 will be 90,398. Consequently, in the remaining weeks of this year 16,019 bed days will be lost as a result of bed closures.

We must have a more patient-centred medical service which puts patients first. We must ensure equality of access for all to essential medical care and take the initiatives required to address the inadequacies in our public hospital service. Access to in-patient hospital treatment or surgery must occur within a reasonable designated time-frame for those who require it. To achieve this, demographic and population changes, which economic prosperity has brought about, need to be reflected in our health policy and planning. Resources must be allocated, which guarantee a health service of a standard to which our people are entitled and of which we can be proud. Speedy access to essential health care should not be dependent on personal wealth.

Over an 18 month period the Government has presided over one of the most dramatic increases in hospital waiting lists to have occurred in modern times. By the end of June 1998 there were 34,331 patients on the public hospital waiting list. It is conservatively estimated this figure had grown to 36,500 by 30 September and it is reasonable to assume that by the end of the year it will have reached 38,500. During the Minister's term of office the numbers on the waiting lists will have increased by 10,000. That has occurred not in a time of economic difficulty but in a time of unprecedented economic prosperity never previously experienced in the State. It has occurred at a time when Exchequer income has substantially surpassed the best expectations of the Minister for Finance and his Department and in a year in which it is anticipated the national debt will be reduced by £1 billion.

Incredibly our hospital waiting lists have spiralled in a year when the Department of Health and Children received, through health levy receipts, approximately £65 million in excess of the sum originally anticipated at the start of the year and in a year when, according to the Minister for Finance on Wednesday last week, savings of £32.5 million were expected in the outturn of the Department of Health and Children compared with the original estimated outturn in January 1998.

Throughout the second half of this year hospitals throughout the State have been closing beds and wards for fear they would exceed their allocated budget. Those bed closures have resulted in patients' appointments for elective surgery being cancelled and have contributed to the dramatic increase in hospital waiting lists. Last week I conservatively estimated that 800 beds would close in the month of December, but we now know the number to be 912, with an additional 16,000 bed days lost in the past six weeks of this year. The loss of so many bed days will further add to the waiting lists and prolong the waiting time for essential surgery for thousands of people who require hospital admission. In December 1998 there will be a substantially scaled down public hospital service throughout the length and breadth of the country. In the Ireland of 1998 one becomes ill at one's peril in the month of December.

It is appropriate we are having this debate today as members of SIPTU and the Irish Nurses' Organisation are protesting against proposed bed closures at Tullamore General Hospital, which is the Minister's local hospital. A total of 14 beds are due to close on 5 December for one month with the consequent loss of 1,240 bed days. The Midland Health Board proposes to lay off 17 nurses and five non-nursing staff and essentially place the hospital on emergency status. That hospital has a substantial public waiting list for ear, nose and throat procedures and for orthopaedic procedures, including hip and knee replacements.

As at 30 June there were 559 adults and 533 children on the in-patient waiting list for ENT procedures, 580 patients awaiting orthopaedic care, 119 awaiting total hip replacement operations and 24 awaiting total knee replacement operations. As at 30 June Tullamore General Hospital had in total 1,737 patients on its waiting list, an increase of almost 200 during the Minister's first year in office. The Minister might tell the House if he intends to hold a public meeting in his constituency to explain why he believes it is acceptable that hospital beds will close in Tullamore General Hospital, that essential elective surgery will be further delayed and that his constituents will continue to suffer pain and ill-health.

Mrs. Owen

It is obvious the Minister does not care about the position in Tullamore General Hospital.

Mr. Fahey

He cannot be accused of favouritism.

Mr. Shatter

His obvious lack of concern is shown by the behaviour displayed on the opposite benches and the grins and laughs being exchanged between him and his junior Ministers.

Yesterday the Labour Relations Commission talks commenced in Galway on a dispute which has arisen over the threatened hospital ward and theatre closures in the University College Hospital, Galway. It was reported this morning that those talks were unsuccessful in resolving the problem. That hospital, which is in the backyard of the Minister of State at the Department of Health and Children, Deputy Fahey, proposes the closure in December of two wards and one theatre and the lay-off of 45 nurses. A consultant plastic surgeon at the hospital, Mr. Jack McCann, has offered to loan the hospital half his salary for the month of December to facilitate keeping the theatre open. Galway FM local radio has supported a public appeal for donations to provide the hospital with the additional funding it requires to avoid bed and theatre closures.

In recent days the Minister of State, Deputy Fahey, who unjustifiably and viciously attacked the management of the Western Health Board and the management of the hospital for the current crisis, has gone strangely silent. Mr. McCann estimated that if the closures can be avoided 400 more patients will receive essential treatment by the end of the year and instead of the waiting list at the hospital continuing to escalate it will be contained. As of 30 June that hospital had 2,891 patients on its waiting list for in-patient care. Those included 130 cardiology patients, 484 adults and 179 children requiring ENT procedures, 682 adults requiring ophthalmology procedures, including 536 adults requiring cataract operations, and 539 requiring urological procedures.

No one in this State understands the need to close so many hospital beds and to lose thousands of hospital days at a time when the Department has benefited from an extra windfall of £65 million raised through the health levy, over half of which last week the Minister for Health and Children and the Minister for Finance intended should be withheld from the health service. Those Ministers appear to be mentally locked into a 1980s budgetary time warp and incapable of coming to terms with the economic realities of this State and the health needs of our people as we enter a new millennium. On Thursday last week the Minister and his officials stated that the existence of the unspent £32 million was illusory and that sum would be spent by the end of the year on demand-led services such as the free drugs scheme. Confusion was deliberately sown and a political smokescreen created to cover up the Minister's embarrassment and failure to use these moneys to keep hospital beds open and the embarrassment of his Department, which yet again presents itself as being incompetent and out of touch with the needs of the people.

From the Estimates published it was clear that half of this additional sum of £65 million obtained on the health levy was to be used for such schemes and the remaining half, as of Wednesday night last week, was regarded by the Minister for Finance and stated by him to be retained by the Exchequer as part of the Government's savings in the year. On Tuesday this week the Minister for Finance, to protect his colleague, the Minister for Health and Children, added to the confusion. He stated the sum spent on health at the end of the year would exceed the sum originally estimated to be spent at the beginning of the year. In that he is correct. In so far as the Department has been required to meet the additional expenditure over and above the sum originally envisaged in January, a portion of the windfall from the health levy was to be made available to the Department. However, no portion of that money has been made available to acute hospitals to facilitate them to provide for the extra demands made on them for in-patient hospital care. It remained the position until last night that £32.5 million of the health levy windfall was to be retained by the Exchequer.

As a result of the embarrassment caused to the Government and the Minister for Health and Children, the new Health Supplementary Estimate has been circulated. Contrary to what was contained in the Government's Estimates published one week ago, instead of envisaging a saving of £32.5 million on the end of the year health outturn, it now makes provision for a £5.5 million overrun. Essentially, it provides for the expenditure of the £65 million windfall received through the health levy together with an additional Exchequer payment of £5.5 million. Within one week of its publication, the Minister for Finance and the Minister for Health and Children have undermined the credibility of the Government's published Estimates and have contrived a Supplementary Estimate designed to ensure that the Government cannot be accused of withholding available funds from the health services.

Mr. Cowen

That is nonsense.

Mrs. Owen

The facts are there.

Mr. Cowen

The Deputy would not know how to read them if they were before her for a week.

Mr. Hogan

The Minister should not make such personal remarks.

Mr. Shatter

Tragically none of the additional moneys provided for the Supplementary Estimate will impact on patient care or prevent unnecessary bed closures. A large portion of this Supplementary Estimate is an accounting exercise.

Approximately £30 million of the Supplementary Estimate being proposed by the Government is to top up superannuation and pension funds, issues that could easily have been addressed in next year's budget and issues which would have been concluded in the original published Estimates if the Government had intended to address them.

The Minister and his officials in briefings in recent days referred, as the Minister did this morning, to the 1996 legislation passed by the pervious Government, which prevents health boards exceeding their budgets allocated at the beginning of the year and prevents them from raising overdrafts. This legislation was rightly put in place to enable central Government to determine financial allocations for the health services and to prevent health boards arbitrarily running up overdrafts which they could not discharge out of their own resources. The Minister and his officials talked of not rewarding health boards which had overspent by giving them extra resources raised by the health levy as this, they contend, would be an incentive for those who remained within their budget this year to over-spend next year in the expectation that they would be bailed out. However, the Minister has at no time suggested that any of our health boards are operating inefficiently or misusing the funds allocated to them.

In response to a Dáil question as recently as 3 November and again today, the Minister emphasised that overall acute hospital in-patient activity for the first six months of this year includes an increase of 1.1 per cent over the same period in 1997, while the corresponding increase in day activity was 9.7 per cent. Hospitals have experienced a substantial increase in the number of patients requiring essential surgery and medical procedures. That is partly due to changes in demographic and population patterns. It is also due to the increasing sophistication of medical technology, unavailable years ago, which provides new procedures from which people may benefit. The health boards and hospitals are confronted by a need for medical treatment and surgery for real people whose lives in some cases are at risk and, in other cases, whose quality of life is substantially diminished by pain and suffering.

The 1996 legislation does not act as a barrier to a Minister for Health providing additional financial allocations to hospitals forced to close beds in the month of December for budgetary reasons. It does not prevent the Minister in the middle of the year from reviewing the state of the hospital waiting lists and considering, in the context of unexpected financial inflows to his Department, whether additional funding should be made available to facilitate the undertaking of additional procedures at a time when waiting lists are growing. An efficient and competent Minister would have conducted such a review and would, given health levy buoyancy, have allocated additional funds to tackle the waiting list crisis earlier this year.

Five weeks ago in the Dáil and on behalf of the Fine Gael Party, I proposed a broad range of measures which are essential to tackle the in-patient and out-patient waiting lists in a systematic and practical way and to make our acute hospitals more patient centred. In the Fine Gael policy document, Patients First, reference is also made to the need for new information systems and technology in the Department of Health and Children. This is essential to enable the Department to have available to it up-to-date statistics and information to monitor and analyse the manner in which our medical service is functioning within each health board area and within each hospital. It is a scandal that, in the second half of November 1998, neither the Minister nor his Department can make available complete and up-to-date data on the current state of the hospital waiting lists in the context of each hospital and each specialty.

The Department collates quarterly figures but yesterday the Minister was unable to supply the waiting list figures as at 30 September 1998. It appears the Department and the Minister are relying on figures collated in June 1998. The Minister, therefore, is defending bed closures in December without knowing the full extent of the waiting list crisis by which he is confronted and having done nothing in his term of office to ensure that the data are collected and collated by his Department on an efficient and up-to-date basis so he will be in a position to act when unanticipated difficulties arise.

In recent weeks the Minister has displayed extraordinary incompetence and lack of insight. While defending bed closures and refusing to make additional funds available to acute hospitals, on Monday this week in Waterford he admitted that the waiting lists had increased — without knowing the extent of the increase — and stated that next year additional funding would be made available to the waiting list initiative. If additional funding is required next year, the Minister should explain his justification for closing beds in December and, by so doing, exacerbating the extent of the problem and adding to the suffering of those on the burgeoning lists.

The Minister appears to be incapable of putting people first and regarding those on hospital waiting lists as people with real needs as opposed to mere statistics. The slogan adopted for Fianna Fáil's forthcoming Árd Fheis, "Partnership with People", rings hollow in the context of the December hospital bed closures and the escalating hospital waiting lists. It deserves as little credibility as the election slogan which falsely promised additional health resources and was used by Fianna Fáil in its election campaign of 1987, "Health cuts hurt the old, the sick and the handicapped".

The reality is that major structural reforms, such as those proposed by Fine Gael in its document, Patients First, are required if we are to resolve the problem posed by waiting lists and provide the type of modern, responsive medical service to which people are entitled. It is also clear that additional resources must be provided for both capital and current expenditure. It is the duty of Members of the House to ensure that no person resident in this State is deprived of speedy access to essential medical services owing to their inability to pay for such services.

When discussing the allocation of State funding to the health service, we should also not lose sight of the fact that the State, which has the fastest growing economy in Europe, ranks among the lowest spending European Union countries on health care, according to a recent report on the Irish health system for the 21st century. The report details that the only countries to spend a smaller proportion of GDP on health than Ireland's 7 per cent are the UK, Luxembourg and Greece.

When the Government required additional funding to meet Garda pay and prison officers' overtime, the Minister for Justice, Equality and Law Reform had no difficulty securing sanction from the Department of Finance for a Supplementary Estimate. It makes a mockery of the Árd Fheis slogan "Partnership with People" that the Minister for Health and Children neither sought nor publicly expressed a wish to secure Department of Finance sanction for a Supplementary Estimate to provide additional funds to our acute hospitals to prevent unnecessary bed closures in December.

The complacency of the Minister and the Government parties and their lack of commitment to the public health service is astounding. The closure of hospital beds in December, taken together with the escalating hospital waiting lists, has not stirred the consciences of the Progressive Democrat members of Government or attracted the interest of the Independents who support the Government.

The indifference of the Fianna Fáil Parliamentary Party was well described by a Fianna Fáil spokesperson who briefed The Irish Times on the parliamentary party meeting last week. The newspaper reported the spokesperson as saying that there was surprisingly little clamour from members of the party for extra health funding. Presumably even the Minister was surprised at this. Moreover, the party's chairman, Deputy O'Hanlon, on behalf of the party washed his hands of the issue saying “the united view was that it does not seem to make any difference how much money goes into the area”.

Clearly, that party, which will pretend to the nation this coming weekend that it is in partnership with the people, does not care about the fears of those awaiting life saving cardiac surgery or the pain and suffering being experienced by the escalating number of adults and children on the in-patient hospital waiting lists, many of whom are waiting for up to two years for essential surgery. The party's members also apparently do not care that the content of the report of the review group on waiting lists, which has been on the Minister's desk since August, has been drip fed to journalists and concealed from Members of the House and that the Minister and his Department regard it as "not in the public interest" that it be published and made available for constructive debate.

To date, the Fine Gael Party document, Patients First, is the only comprehensive document in the public domain which describes the measures necessary to tackle the waiting list crisis. This Minister could make a start by allocating a portion of the health levy windfall to prevent hospital beds closing in the month of December.

No major public hospital, such as University College Hospital, Galway, should be placed in a position in which it must publicly seek funding through a local radio station to keep beds and a theatre open. Citizens are entitled, as of right, to an accessible in-patient public health service. This Minister appears to be intent on bringing us back to the era of the workhouse, an era when the poorest sections of the community had no right to medical care and when such care was provided on a grace and favour basis. Apparently in Galway it will be provided from charitable donations made through a local radio station.

Mr. Fahey

It collected a total of £800.

Mrs. Owen

The Government has £32 million on hand and it should spend it.

Ms Shortall

This debate takes place against a backdrop of soaring hospital waiting lists for a number of health services. In addition, there are lengthy hidden waiting lists for all such services. I am referring to the people who are on waiting lists to get on to waiting lists, people who have been given out-patient appointments for 12 or 15 months hence and people who had such appointments but whose appointments have been cancelled. We are not only talking about the waiting list numbers which are already in the public domain but vast numbers of other people on hidden waiting lists for the health services.

The programme for Government contains a commitment to tackle the crisis in hospital waiting lists. If there was a crisis in the waiting lists when the Minister, Deputy Cowen, was appointed to office in June 1996, what words can be used to describe the current situation? The latest figures available show that over 34,000 people are awaiting treatment in hospital. By the end of the year this number will have undoubtedly increased to almost 40,000. At year end, it is likely that the Minister and the Government will have presided over an increase of 10,000 people on hospital waiting lists.

There are many areas of our health services which are extremely problematic. Nobody is suggesting the Minister should have solved all of those problems after almost a year and a half in office, but clear attempts should be made to tackle underlying problems. To date there is no evidence that he has any inclination to take on that tough agenda, to grasp the nettle of sorting out the difficulties in the health services. His approach seems to be more about keeping the lid on things, hoping the problems will not get too out of hand and that he will manage to get out of the Department of Health and Children sooner rather than later.

Mr. Cowen

That is unworthy of the Deputy.

An Leas-Cheann Comhairle

Allow the Deputy to continue.

Ms Shortall

The indications are that there are serious problems with the way our health services are managed. There is a lack of accountability. I welcome the indication that the accountability legislation is to be extended to the voluntary hospital sector. There are serious problems with the manner in which our health services are consultant-led, where consultants seem to be kings in our hospital services with no serious attempt to involve them actively in the management and accountability systems within hospitals.

There is a serious shortage of hospital doctors. Currently there are 121 unfilled consultant posts across all hospitals. I cannot understand that. If we were to bring our hospital doctor numbers up to a level comparable with Scotland or Wales, we would need to employ another 720 consultants.

Most patients attending accident and emergency departments in hospitals expect to be seen by a senior doctor, but because most of our big hospitals have only one accident and emergency consultant, four out of five times a patient attends, he or she will be seen by a junior hospital doctor. Further, the likelihood is that the junior hospital doctor will not have had sleep for more than 40 hours. I cannot understand how this or any Minister can stand over a situation where people are attending accident and emergency departments, sometimes very critically ill, and there are no senior personnel available to take critical decisions about the management of their problems. That is unacceptable in this day and age.

In out-patient departments people wait for 12 or 15 months for an appointment and when their appointment date comes, the likelihood is they will be seen by a junior hospital doctor who may have no expertise in the specialty. I have spoken to junior hospital doctors who have grave concerns about being expected to take decisions about people, sometimes life threatening, for which they have no expertise. That is intolerable. As a matter of urgency the Minister has to apply his energy to dealing with that problem.

Dr. Moffatt

There is always backup.

Ms Shortall

There is always backup, but sometimes it is hard to contact people on the golf course, as the Minister of State well knows.

Dr. Moffatt

I do not accept that.

Ms Shortall

I call on the Minister to take urgent action to deal with that very serious situation.

I welcome the fact that the EU is moving towards extending working time legislation to hospital doctors. I am in the process of preparing legislation in that regard to ensure we extend the working time rule at an early date and not have long-fingered promises. I call on the Minister to take urgent action to review the manpower requirements that will result from the 48-hour working week for hospital doctors, but also as a result of the serious shortages of senior doctors throughout our hospital services.

The other serious manpower problem relates to student nurses and overall nurse numbers. Because of the manner in which nurses have been treated over the years, which has not been improved by the Minister's reaction to the commission's report, many nurses are opting out of nursing. There are other opportunities opening up in the paramedical area, in the area of beauty therapy and so on. There are more attractive jobs which are less stressful and better paid. Nurses are voting with their feet and leaving. Recently in a certain hospital in Dublin where beds had been closed during the summer to save money, it was found that they could not be opened up again in September because nurses could not be recruited.

There is a dire shortage of nurses in the Dublin area. There is a lack of interest among young people in the profession. Again the Minister has failed to take action to address this urgent problem. We should have learned from the experiences in the United States in particular where many hospitals have had to close down because of a lack of nursing staff. That same thing will happen here over the coming years unless drastic action is taken to deal with it.

The same problem of manpower shortages arises in relation to all the therapies — occupational therapy, speech therapy and physiotherapy. There are long waiting lists in all health boards for those services and difficulties in recruiting people in those specialties. The Minister seems to have taken a hands-off approach in dealing with manpower problems in his Department. On several parliamentary questions I tabled in relation to specific shortages, the Minister was not in a position to provide information. What is the Department doing? Is any forward planning taking place?

Child care is another area on which I could speak for another 40 minutes. The same is true of mental and physical handicap. There is a crisis throughout our health service. The Minister is giving the impression that he is not particularly interested.

Mr. Cowen

That is the impression the Deputy wants to take.

Ms Shortall

He has been particularly inactive in relation to all of this. At this time of crisis the money is there. The Minister for Finance put £1,000 million into the bank recently.

Mr. Cowen

More money has been spent on health this year than in the Deputy's time in Government.

Ms Shortall

The money is there to solve the problem, unlike at any time before. What is lacking is the political will to tackle the problem and to sort it out once and for all. If we do not do it now in time of plenty, we will never do it.

There are many problems in our health services but our biggest one is that nobody in this Government cares.

Mr. Cowen

That is nuts.

Ms McManus

That is unparliamentary language from the Minister to use. If I said it, the Chair would have a different attitude.

An Leas-Cheann Comhairle

The Minister made a general statement.

Ms McManus

That is a very polite way of putting it.

An Leas-Cheann Comhairle

He did not make an unparliamentary comment against an individual.

Mr. Hogan

He referred to a medical condition.

An Leas-Cheann Comhairle

We would be in very serious difficulty if we pulled up Members for making general observations.

Ms McManus

Everyone in this State should be entitled to the best quality health care when it is needed, and it should not depend on their ability to pay. The Department of Health and Children's own health strategy outlines this principle very simply when it says:

Access to health care should be determined by actual need for services rather than the ability to pay or geographic location. It is a principle fully established at primary care level where general practitioners operate.

That is not something that was established by accident. A predecessor of this Minister was responsible for transforming primary health care. Dr. Erskine Childers abolished the old dispensary system and prevented general practitioners, by contract, from ever again discriminating between rich and poor, between public and private patients. It was a major step, a revolutionary step towards equality.

In contrast this Minister, his successor, is overseeing an acute hospital service based on a profound inequality. The divide is widening between those who can afford to pay and those, who in the main suffer greater ill-health, who cannot. It is a service in crisis which is not delivering care efficiently and which can only do so if the challenge of fairness and the fair deployment of resources is tackled. The Minister is known for being pugnacious, yet his record has been to side-step rather than confront the issues which need addressing. It is not just a matter of money but of having the same vision as Erskine Childers when he created the GMS at primary care level.

Hospital waiting lists are essentially a question of inequality of access and care. There is a world of difference between the service afforded the private patient and that provided to the public patient. If one can afford to pay, one can buy fast track access and better quality care upon arrival. This is no reflection on the dedicated and professional doctors, nurses and staff experiencing work overload, deteriorating morale and deepening anomalies in the acute hospital services. There is no waiting time in the casualty department of the Blackrock Clinic, yet in public hospitals patients are waiting for life saving operations in ever increasing numbers while beds are being closed in ever increasing numbers. This is an untenable position. The private sector is growing and the numbers joining VHI and BUPA are increasing and will continue to do so, the Minister's announcement of financial increases not-withstanding. Hospital waiting lists are also growing — by roughly 10,000 per year since the Minister took office.

Unfortunately, we do not receive the information we should to prepare for statements of this nature. A lamentable hallmark of the Minister's is that he is secretive, defensive and has an instinct to withhold information and not publish reports paid for by taxpayers who are entitled to see them. I remind him that these reports are not his property, they belong to the people.

His about turn on the argument about the £32 million has been the subject of much anger and is another case in point. We now know that £70 million in buoyancy will be spent on housekeeping and on demand led schemes. It is interesting that his hard line on hospital budgets does not apply when it comes to overrunning his Department's budget. There is one law for the Minister and another for the unfortunate people waiting for hip replacement or cardiac operations. The legislation to which he constantly refers should be revisited and should be either used or amended. I am not afraid to say that. That does not mean I do not believe in accountability, good management and seeking controls in hospitals. However, if legislation leads to unbearable injustice, as it has done, and harms patients, then it should be revisited. No legislation is sacrosanct. The Minister is using it as a form of protection rather than a form of progress.

The Government was elected on its promise in its programme that hospital waiting lists would be tackled. It is a prime commitment in its programme, yet it is its greatest failure to date. Until recently, there was a refusal to face the facts. The Minister, Deputy Cowen, adopted his usual entrenched position. When I raised the alarm with the Taoiseach a while ago, I was told I was being emotive and that there was no noticeable increase in waiting lists. I was shocked to hear a Taoiseach so out of touch with reality. Hospital consultants are now hammering home the message in a way never witnessed before. It is unacceptable to find consultants addressing protesting hospital staff or offering to loan money to a health board to keep things going, yet that is what is happening.

Deputy McManus has only one minute remaining.

Ms McManus

There are the same number of consultants in the public acute hospital service and in private care, 1,250 in each case. In the public service, there are 2,500 junior doctors with approximately 40 in the private health care area. That speaks for itself. That is what the Minister must address and he knows it. He has no argument on it. What he is considering is whether he has the nerve to deal with it.

I welcome the Minister's reference to the issue of manpower but he must establish a fast track training system programme to deliver the level of specialists which will ensure efficiencies. That is how the service will be made efficient. It is not just a matter of money but how it is spent. Specialists must be trained to a wide level and range. Without that change, no amount of hectoring by the Minister or Minister of State will change the problem. It has been the experience in Britain and the US. I understand the difficulties because there are major vested interests. Unless those interests are confronted, consulted and included in the process of change, the necessary progress will not be made.

Mr. Gormley

I wish to share my time with Deputy Hogan.

An Leas-Cheann Comhairle

Agreed? Agreed.

Mr. Gormley

It is undoubtedly true that we are facing a health crisis. This is perhaps best exemplified in my own constituency of Dublin South-East which has seen the closure of three hospitals — the Adelaide, Harcourt Street and the Meath. This is despite the fact that we are seeing an increase in the number of inner city residents and an increase in the number of children living in the area. My constituents are left without adequate hospital services due to bad planning and a lack of strategy in the Department of Health and Children. The Minister must take the blame for that.

Elsewhere in Dublin, the picture is not any brighter. In St. Vincent's Hospital, four out of ten theatres have shut down due to a shortage of nursing staff. The hospital is operating with up to 50 vacant nursing posts. Because of budgetary restrictions the Mater Hospital has closed 57 acute beds which cannot be reopened due to the nursing shortage crisis. The Mater has also closed one theatre and four intensive care beds. Neurology surgery has been cut by 25 per cent in Beaumont Hospital. A combination of budgetary restrictions and nursing shortages is being blamed for theatre cutbacks.

Tallaght Hospital has been unable to open all of its 12 theatres because of staff shortages. Consultants at Tallaght Hospital have complained that elective work at the hospital has been severely curtailed due to the unexpected extra demand for accident and emergency services.

What we have here is a catalogue of instances of mismanagement. The Minister deserves a new title. He should not be called the Minister for Health and Children but the Minister for illness and ward closures. The situation is getting more bleak. It is estimated that A&E admissions at Tallaght are running 30 per cent ahead of the aggregate of the three hospitals Tallaght was intended to replace.

I want to ask the Minister a number of questions. Will he publish, without further delay, the Deloitte & Touche report on Tallaght Hospital? Why is he sitting on that report? Will the Minister confirm that A&E over-runs at Tallaght have caused significant cutbacks in the capacity of that hospital to offer elective surgery, despite the fact that my constituency in the south-east inner city is not adequately served by A&E services?

When replying to the debate, will the Minister deal with the conditions for staff and patients at St. Loman's Hospital in Dublin? Is it the case that conditions there are bad and getting worse? I hope the Minister is taking note of these questions.

Will the Minister provide a breakdown of money allocated to acute hospital services in the Western Health Board, particularly in regard to University College Hospital, Galway? Is it the case that the acute services budget allocated for UCHG was reallocated to capital development? Is the Western Health Board owed money by the Department of Health and Children?

Is Tullamore General Hospital next in line for the UCHG treatment? Have the budgetary constraints being policed by Minister Cowen already led to staff cutbacks and ward closures in Tullamore? Would that have happened if Tullamore General Hospital was located in Kerry South?

Why is Portiuncula Hospital in Galway, an independent voluntary hospital, offering a consultant paediatric service once a month from a hotel room in Athlone when Athlone is the administrative area of the Midland Health Board? Is the Minister satisfied with the consultant paediatric services available throughout the administrative area of the Midland Health Board? Finally, what does the Minister have to say about waiting lists?

It is unfortunate the Minister has left the House because all of us on the Opposition benches would press him to answer these questions. Clearly there is a lack of strategy and bad planning on the part of the Department. Because of the Celtic tiger we have seen a baby boom and people are living longer. As a result there will be enormous strains on our health services but the Minister has not planned for that. I ask him to return to the House and answer the questions I have put to him.

Mr. Hogan

I thank Deputy Gormley for allowing me to participate in the debate. The management of our health services is a shambles at many levels. The Minister seems to be unable or unwilling to take a hands-on approach in dealing with the blockages in the health system that are allowing the public to lose confidence in the ability of the State to properly fund and manage our health services.

We hear various complaints from the general public about waiting lists and ward closures as if these problems only arose in the past week or two. Unfortunately, the Minister has brought much trouble on himself politically because he was very vocal in Opposition. In his first year in office, however, he kept his head down and many members of the public wondered if we had a Minister for Health and Children. Some people suggested there should be a reward offered to the person who could find him. That is in stark contrast to his high profile performances when he did not have any responsibilities.

There are certain matters of which the Minister for Health and Children should be ashamed. In my constituency of Carlow-Kilkenny, where I have the most experience regarding these matters, the problems of ward closures and waiting lists go hand in hand. Up to the end of June there were 2,500 people in the South-Eastern Health Board area on various waiting lists, but 92 beds were closed during the summer and the same number of beds will close during the Christmas period. How can that happen at a time when we know there is some latitude in the allocation the Minister for Health and Children can make to the health board, particularly in view of the £32 million available to him from the health levy?

Home helps, who care for the elderly in particular, are paid £2 per hour; I know the Minister of State has a particular responsibility in this regard. The disabled are involved in more voluntary fund-raising than ever just to meet their costs.

I refer the Minister to an article this week in my local paper, the Kilkenny People, in which one of his colleagues, Councillor Brett, highlighted the fact that there is no toilet and inadequate sewerage and water services in a health centre in Kilmanagh, County Kilkenny, which has been the subject of investigation by the South-Eastern Health Board for a considerable time. Not one extra penny was given to the South-Eastern Health Board in 1988 for capital investment. That must be a first.

Approximately 286 women have been waiting 12 months for cervical smear tests in Carlow-Kilkenny. I must conclude that the Minister for Health and Children does not have any interest in women's health. If he had, he would alleviate the anxiety being experienced by those women and their families.

In relation to the elderly, I recently met the representatives of the community homes in Kilkenny. There are five homes at Freshford, Kilmoganny, Ballyragget, Callan and Kilmacow. Under the section 65 grants the health board gives these homes £68,550 per annum. If the South-Eastern Health Board were to operate the homes, it would cost £823,000. That should give a clear indication of the enormous amount of work being done on a voluntary basis in each community home in Kilkenny. Local groups are engaged in fund-raising to help with the running costs. Freshford, for example, raised £9,000 in local fund-raising this year but they do not know how they can keep going because they are competing with other organisations. The nuns in the area have supplemented the labour costs of all these homes for too long. I am sure the Minister realises that it is a cause of concern that the nuns are not being replaced when they retire and the labour costs will increase substantially.

The cost of caring for a patient in the district hospital in Castlecomer is £345 per week while the cost of staying in a community home is £951 per resident per annum, which is the subvention given by the South-Eastern Health Board.

If everyone in need of care was put in the charge of the health board the cost would be £4,643 per patient per year. A small subvention to community homes would cost £951.60. Much can be done within the overall management of the health service but I am forced to conclude that the Minister, through indifference, has allowed waiting lists to grow, wards to close and a silver circle approach to the funding of our health service in local communities to develop. The Minister is out of touch with people.

Minister of State at the Department of Health and Children (Dr. Moffatt)

What we have heard from the Opposition amounts to words to the heat of deeds. We saw very little action from the Opposition parties when they were in Government.

The year 1999 has been designated by the United Nations as International Year of Older Persons and the Government has placed importance on the development of services for older people. Since my appointment as Minister of State with special responsibility for older people, I have focused attention on identifying service shortcomings and preparing a development plan to meet these shortcomings, which I hope to progress during the lifetime of the Government.

Economic and social progress and improved health services have combined to reduce premature mortality. The population projections prepared by the National Council on Ageing and Older People indicate that the older population may grow by almost 108,000 persons in the period 1996-2011. These projections also indicate that the proportion of the older population aged over 80 years will increase by more than 35,000 in the same period. It is clear therefore, that this country has a growing population of older people and that appropriate strategies need to be put in place to ensure that older citizens lead active and fulfilling lives for as long as possible. In this connection a health promotion strategy for older people has been published and is being acted upon at health board level. When it is no longer possible for people to live at home or be cared for at home, an accessible treatment and caring service must be available.

Last year, the National Council on Ageing and Older People, the statutory advisory body on issues affecting older people published a major review of progress being made in the development of services for older people. This comprehensive report highlighted a number of key areas where services require to be significantly enhanced. It will be no surprise to Deputies, from their experience of meeting and discussing issues with older people or their representatives, that the council has identified support for older people in the home as well as support for carers as fundamental to improving the quality of life for older people generally. Specifically, the council has identified the home help service, respite service for carers, day care centres, paramedical services, a dedicated social work service for older people, the development of the community hospital sector and services for older people with mental disorders as services requiring immediate attention.

Having examined this report and discussed the issues with the various groups which represent the interests of older people, it is clear that the greatest need lies in the provision of better community-based services, particularly in the home and including support for carers. I intend to bring about improvements in these areas on a phased basis in line with available resources.

We have already commenced this process in the current year by allocating an additional £7 million to provide new services for older people or to improve existing services. In the acute hospital sector a new specialist department of medicine of old age has been commissioned which will enable older people to have more intensive treatment and rehabilitation. Funding has been provided to enable community nursing units to be opened. These units provide a wide range of services for older people, including respite and day care, day hospitals and day care centres. The staffing of existing extended care hospitals and community services has also been improved in the current year.

The need to develop mental health services for older people has been identified as a priority requirement by the National Council on Ageing and Older People in its review of services for older people. Up to now, a specialist psychiatry of old age service was only available in Dublin and Limerick. This year, an additional £1 million was provided to develop specialist psychiatry of old age services in other parts of the country and I intend to continue the development of this very important service next year and beyond.

The private and voluntary nursing home sector has a very important role in the provision of extended care for older people. Towards the end of 1997, the Government allocated a further £6.5 million to enable health boards to provide greater support for older people in private nursing homes. The private nursing home sector will continue to be supported in the provision of services for older people.

Since becoming Minister of State, I have been very conscious of the unsatisfactory physical condition of a number of extended care hospitals around the country. I was delighted, therefore, that the Minister for Health and Children significantly increased the capital programme for older people to £14 million in 1998. This is more than twice the corresponding figure for last year. The Minister is not merely talking about these issues; he is acting on them. This investment will enable older, workhouse-type accommodation to be replaced and new facilities to be provided which will include rehabilitation, respite care and day care facilities. For example, this new capital programme will enable 200 additional day care places to be provided throughout the country over the course of the coming year. Day care centres make an invaluable contribution to maintaining older people in the community. They provide social contact, relieve loneliness and isolation and enable the health status of people to be monitored and appropriate services provided. Day care centres also offer respite for carers.

It is my intention to continue with the development of services for older people as I have outlined. I recognise that much remains to be done but given the commitment of the Government which has already been clearly demonstrated I have no doubt that it will be possible, with the greatly increased capital programme for older people announced this year, to improve the network of specialist units, community nursing units and day care centres throughout the country. The task now facing me, as Minister of State with responsibilty for older people, will be to develop the necessary community support services so that older people and their carers will have better facilities and services closer to where they live. I intend to implement a development plan for these services on a phased basis over the next few years in line with available resources.

As Minister of State with responsibility for food safety, I am delighted with the progress that has been made in honouring our commitment on food safety as set out in An Action Programme for the Millennium. We promised to deliver an independent, science-based authority which would ensure farm-to-fork traceability in order to reassure the consumer and we have gone a long way towards meeting this promise.

The Food Safety Authority was established on an interim basis last January using existing health legislation. This was to allow the authority to begin recruiting staff and to put the appropriate structures in place in advance of the primary legislation being enacted. This legislation, in the form of the Food Safety Authority of Ireland Act, 1998, became law in July and the authority will formally begin its work in January 1999.

In the initial stages the authority will have service contracts with the official agencies who currently have responsibilities for food controls and I know that work is well advanced on the drafting of these contracts. As a result of these contracts we will have, for the first time, one central authority which is directly responsible for all aspects of food safety.

It is not a question of throwing a few pounds at it this year, it is a planned programme. The Deputy will see progress being made on it. More money has gone into the health system this year than ever before. This phantom about the £32 million is another falsity raised by the Opposition.

Mr. Neville

The Minister of State should talk to people about hip replacements.

Dr. Moffatt

If the Opposition looked at the figures and knew a little bit about accountancy they will find out that not alone have we used up the moneys that were there, but we will need a Supplementary Estimate for the health system this year.

Mr. Neville

I want to deal with the area of children, in particular the appointment of a children's ombudsman. I am pleased that the Minister of State, Deputy Fahey, who has responsibility for children, is in the House. The Government has totally failed to honour its commitment to establish a children's ombudsman. We urgently need such an office to promote children's rights. It should have a role in relation to the implementation of the Convention on the Rights of the Child. Article 4 of that Convention provides that: "States Parties shall undertake all appropriate legislative, administrative and other measures for the implementation of the rights recognised in the present Convention." In addition, Article 42 of the convention provides that: "States Parties undertake to make the principles and provisions of the Convention widely known, by appropriate and active means, to adults and children alike." Accordingly, having ratified the convention, there is an obligation on Governments to take steps to ensure compliance with these provisions to promote and protect children's rights. One mechanism for doing this is the establishment of an independent body for the promotion and protection of children's rights such as an office of ombudsman for children.

There are three reasons it is necessary to have an office of ombudsman for children in Ireland. First, a significant number of children are in situations of considerable disadvantage. These include children in care and in legal custody, children who are subject to abuse or neglect, homeless children and children with disabilities. In addition, households with children, especially lone parent families and families with three or more children, have a higher than average risk of living in poverty. Research has indicated that situations of disadvantage tend to be cumulative. In other words, children from poorer households are more likely to be in care or in trouble with the law.

Second, although the provisions of the Child Care Act, 1991, have the potential to promote the rights of children in situations of disadvantage, there is no overall mechanism for the promotion of rights of children generally. Third, there are no structural mechanisms to protect children's rights in relation to many public bodies and services, for example, education and health systems. Thus, in many areas there is an absence of a structured complaint and appeals system in relation to children's rights.

At its first annual general meeting in March 1995, the Children's Rights Alliance decided that one of its main concerns would be the establishment of an office of the ombudsman for children, which it felt could play a significant role in implementing the convention and ensuring that children's rights were respected. A report published by Children's Rights Alliance in September 1996, under the title "Seen and Heard — Promoting and Protecting Children's Rights", outlined detailed information on the mechanisms which have existed in a number of different countries to promote and protect children's rights. It examined various options which might be considered for Ireland. It concluded that the setting up of an independent office of ombudsman for children established on a statutory basis "would be the most effective and appropriate mechanism to meet the circumstances of the Irish situation".

I commend the former Minister of State, Deputy Currie, who, in December 1996, announced a commitment to the establishment of an office of ombudsman for children. This was also part of the present Government's programme for Government. However, on the numerous occasions I have asked the Taoiseach to respond on the Order of Business as to when the Government will introduce this measure, he has always been evasive. It is obvious there is no commitment by the present Government to do so.

Following its examination of the first national report on the implementation of the convention, the UN Committee on the Rights of the Child expressed concern about: "The lack of an independent monitoring mechanism such as an Ombudsman or a child's rights commissioner accessible to children for dealing with complaints of violations of their rights, and to provide remedies for such violations." The committee recommended that the Government should positively reconsider the establishment of an office of ombudsman for children to further the implementation of the convention in Ireland. The Minister of State should respond clearly as to whether, or if, an office of ombudsman for children will be established in the lifetime of this Government.

Public discourse with children has been minimalist in nature and is shown by the presence of all the principal education players in the 1994 National Education Convention, with the notable exception of children.

The Constitutional Review Group, the Kilkenny incest team investigation and the report of the 1995 Kelly inquiry have all stated that the Constitution's strong emphasis on the rights of the family may consciously or unconsciously be interpreted as giving a higher value to the rights of parents than to children. A constitutional clarification of children's rights would assist in the creation of a positive environment for a newly created statutory office of ombudsman for children. Consequently, serious consideration should be given to inserting a specific and overt declaration on the rights of children in the Constitution. This would involve the amendment of Articles 41 and 42 of the Constitution.

An ombudsman for children should be allowed to sit and monitor child protection standards, promote examples of good practice and inquire into serious failures of practice. It is essential, in this context, that the ombudsman enjoys locus standi to take legal action in the event of a public body acting in serious breach of its obligations to children. The ombudsman for children, however, should not become involved in legal proceedings until internal complaints or appeals procedures have been exhausted. Otherwise, there is a real danger that this office could become overloaded with individual cases. An ombudsman for children should have a role in encouraging and monitoring local complaints procedures. The primary objectives of the office should be to make the public at all levels aware of the rights and obligations created under the United Nations Convention on the Rights of the Child, ratified by Ireland in 1992.

If the ombudsman for children is to genuinely promote children's rights, the office must engage in meaningful dialogue with children. This could be facilitated through the use of representative surveys or free hot-lines, as are used by the Norwegian and Swedish ombudsmen's offices.

I envisage the children's ombudsman playing an active role in shaping and influencing public opinion, primarily through the dissemination of opinions in the media. Alternatively, the ombudsman could lobby for amendments to legislation, such as the recognition of children's needs in environmental planning.

The ombudsman for children should also act in a consultative capacity in the drafting of legislation by issuing legal advice and information at the request of other public bodies. He or she should also be able to request Government permission to take initiatives on issues pertaining to children's rights with the corollary that the Government could also allocate such responsibility to the ombudsman where it sees fit. The

Swedish ombudsman requested permission from the Swedish Government to tackle the issue of bullying.

It appears the Government has abandoned its pledge to introduce an ombudsman for children in favour of a social services inspectorate. I disagree with this development as the independence of such a body would be open to question. The ombudsman for children should be subject to presidential appointment acting on the recommendations of the Oireachtas. The expenses incurred by the new office in administering its statutory responsibilities should be met from moneys provided by the Oireachtas.

Frank Martin, lecturer in family law in UCC, recently wrote in the Irish Journal of Family Law that children are defenceless in society and should have additional protection. He stated that children are a voiceless and vulnerable minority in society and claims that Irish children have inadequate political and legal power. I am pleased the Minister of State with responsibility for children, Deputy Fahey, is in the House and I look forward to his response.

Mr. C. Lenihan

The Deputy voted against that some months ago.

Mr. C. Lenihan

There may be an argument for this but it would have to be thought out in advance. We should not move to such a system until we have an efficient system in operation. To introduce such a measure at present would only add to the inefficiencies. There is no point pretending these inefficiencies do not exist.

We are all painfully aware that 50 per cent of spending in the public sector goes on staff pay. This figure is higher in the heath sector. This is a worrying development which has to be addressed. People are worried about waiting lists and the manner in which health care is delivered, which they pay for through their taxes. The issue is how we make the system more efficient in a period when huge demands are being made on it. It is important that we get the health care system in order, not just because the economy is forging ahead, but because the profile of the population is predominantly young and of working age which does not place a huge demand on the system. However, when the population begins to age after 2010, we will have greater pressures on the system and we should prepare ourselves for that demand.

The payroll cost must be addressed. People are not satisfied that they are getting an efficient service and this must be examined. Recently, there have been a number of spectacular protest marches to Leinster House. Members will remember the march organised by the farmers and in the past week the mentally handicapped have conducted a protest. Yesterday, the physically handicapped protested outside the House. People believe that Ireland is now a land of plenty and while we should not be irresponsible with taxpayers' money, the Minister should do something for the physically and mentally handicapped. There is cross-party agreement that these people should be better looked after and I appeal to the Minister to take some action in that regard.

I do not wish to make any special pleas on behalf of my constituency. However, I hope the Minister will take a balanced view of the situation in Tallaght hospital. It was established on a stringent timetable and since it came into operation it has provided an excellent service. When the Minister sees the consultants' report I hope he will balance its findings against the stringent deadlines to which the hospital was required to adhere. I appeal to him to bear in mind the extraordinary difficulties any management committee or executive would encounter when merging in a single site a number of distinct hospitals with different aspects to their care provision function. I hope he will be cautious, even lenient, in relation to the overspending which might or might not have occurred.

However, it is important not to send the wrong signal. Hospitals and health boards which go overboard in their spending should not be permitted to gamble with taxpayers' money in the manner which appears to have occurred in the Western Health Board. Such a practice should be deplored and strongly discouraged. It is not healthy for a responsible and accountable budgeting system that health boards can break their spending limits and land the taxpayer and the Government with a large bill.

The Minister, correctly, is making it clear that he will not be browbeaten or emotionally blackmailed by hospitals, consultants or other care providers when waiting lists develop due to their inefficiency in planning the health services under their control. If Deputy Shatter has any further questions, I will be happy to answer them later.

Mr. Shatter

Is this instead of the Minister answering questions?

Mrs. T. Ahearn

I wish to share my time with Deputy Clune.

Acting Chairman

Is that agreed? Agreed.

Mrs. T. Ahearn

I regret that the content, tone and delivery of the Minister's contribution to this debate bore none of the seriousness, urgency and gravity the subject of hospital waiting lists deserves. As I watched the Minister gallop through his speech, checking the clock to see if he would complete it on time, I realised that he had no understanding that people are living in fear that they will not get the surgery they need. People are living in pain and distress and some are living in fear of dying.

The Minister spoke with the luxury of good health. It is a pity he does not have an awareness of what it is like not be able to secure the health service one needs. There are 36,500 people on the hospital waiting lists and there have been 1,400 bed closures in the latter months of this year. These statistics have been quoted many times in the House over recent weeks.

However, the numbers are not just statistics; they represent people. There are 36,500 people who are sick, in pain and distress but who have no medical service. They have no choices. There are also 1,400 people for whom there are beds available in the hospitals but which they are not allowed to occupy. The sooner we stop talking about statistics and begin talking about people, the sooner the reality of the problem will dawn on the Government.

Last Wednesday, the Irish Wheelchair Association marched to Leinster House to demand their rights. What would be the response of the Government if the 36,500 people on the waiting lists took their case to the streets, provided, of course, they were well enough to so do? I guarantee that money would be found from all directions, just as the pleadings of an Independent Deputy were answered by the same Government.

Why must the management and financial problems of health boards be shouldered by patients? I accept that every Minister must manage finances. However, this Minister is totally cost focused, not patient focused. He has one priority, that health boards should live within their budgets rather than deliver an optimum service. A good health board in the eyes of this Minister is the one that does not exceed the budget, irrespective of the resulting cutbacks in patient care.

Has he ever seriously assessed the situation of a person who is on a hospital waiting list, is out of work and is in pain while awaiting surgery? Does he realise that if the person is out of work for six months, he or she has their salary reduced by 50 per cent? If because of the waiting lists and the lack of a health service the person is out of work for one year, their salary ceases. Imagine the trauma confronting a family in such circumstances. Not only is one of its members sick but it is also a family without financial means. The Minister does not have enough personal understanding of the crises in which people can find themselves.

My constituency is also suffering due to the Minister's lack of awareness. Our Lady's Hospital in Cashel is facing the closure of 25 beds. It already has a waiting list of 90 patients. I urge the Minister to get his priorities right. He must contact the health board and ensure that south Tipperary, which has suffered a reduced health service over the years, does not suffer further.

The pain of waiting is only known to those who wait. We have the resources to end that pain and I urge the Minister to listen to our pleas in this debate.

Ms Clune

People cannot understand why the health service is in its current state. Why must there be bed closures while hospital waiting lists continue to increase? At a time of economic plenty we should work to reduce the waiting lists and to keep hospital wards open.

These beds were originally provided to meet the needs of the population. Given the current growth in our population it makes sense to provide more hospital beds, not close existing ones. It is estimated that our population will grow to 4.5 million by 2006. That population will require the facilities of the health services. Given the existing situation, there will be an annual growth in the hospital waiting lists and not an annual decrease, as should be the case.

In the past year the waiting list of public patients in the Southern Health Board area increased by 11 per cent. Of these, almost 800 are on the waiting list of Cork University Hospital. Many have been on the list for more than 12 months. These public patients are dependent on assistance over which they have no control. They live each day knowing that their health is deteriorating, in many cases to a state beyond repair. They see this happening in a country which is going through the so-called "good times". The people on waiting lists are not numbers. They are people with families, who are also suffering, who cannot live ordinary lives because they do not enjoy good health.

A person waiting for a cataract operation suffers vision that deteriorates by the day as they wait for the call to the hospital. When they hear of ward closures, they know that call will be greatly delayed. For what have the people on the waiting lists worked and paid their taxes and health levies? To wait for more than 12 months on a waiting list? The trauma of this situation cannot be overestimated.

What about the 2,487 women waiting for gynaecological services? Over 150 of those in the Southern Health Board region have been on the list for more than 12 months.

These women could be waiting for hysterectomies. A decision to have a hysterectomy is not taken lightly and is probably taken following years of suffering, discomfort, pain, time off work and so on. The decision to perform a hysterectomy having now been made, the woman must suffer for longer and all those around her share her suffering.

In Cork 3,174 people are on the waiting list, many of whom are children. Many of them have been waiting for more than 12 months. Children waiting for tonsillectomies must undergo unnecessary courses of antibiotics and lose vital days in school. Who can measure the economic effect of that?

A measure of our concern about the health services and for the health of citizens is the way in which we fund the hospitals. In Cork the teaching hospital, Cork University Hospital, is grossly under funded This is a major hospital with the busiest throughput of patients in the country, far in excess of most Dublin hospitals. The capital budget for this hospital is much lower than that of any of the Dublin hospitals to the tune of £20 million in some cases. I make no apology for being parochial in this because the facts speak for themselves. I am looking for equality in the health services. The range of services in this hospital is far greater than in any of the Dublin hospitals. It is the major hospital in the Munster region providing a range and complexity of services second to none in the State. In Dublin the various services are spread over a range of speciality hospitals. In Cork no matter what the speciality it is provided at Cork University Hospital, whether it be ENT, cardiology, gynaecology, ophthalmology, plastic surgery or urology. The funding for this hospital is way below that of any Dublin hospital. This is borne out by the figures.

I will make one point to underline the lack of investment in the Southern Health Board region. I made an inquiry as to the appointment of a paediatric cardiologist. It is the view of the Southern Health Board that there should be a Cork based service for the Munster province provided by a cardiologist with specific training in congenital and hereditary heart disease for both adults and children. At present there is no such person in the Cork region but the health board is under the impression that a paediatrician in the region is necessary to ensure that children's needs could be prioritised on the basis of their medical condition. This should be initiated at the earliest opportunity. This is the reality. These are children suffering from heart problems who must come to Dublin. This is a further measure of the Minister's commitment to the health services.

Mr. B. O'Keeffe

I listened to Members talking about caring for people. In dealing with the care of people, we must understand that unfortunately health has an insatiable appetite for funding and, irrespective of the amount of money put into it, there will never be enough funding to meet all the needs of people who want to avail of either community, hospital or other services. Therein lies the dilemma.

Former Minister, Deputy Noonan, and his predecessor, Deputy Howlin, saw clearly that unless we introduced accountability legislation, the health services would not develop. Every year it had been possible for every health board to exceed its budget and expect someone else to pick up the tab. Generally the health boards and Members of the Dáil welcomed the fact that at long last some structure was being developed whereby health boards had to manage the budgets given to them. Every year there is a significant increase in the budget given to each health board. Obviously it will never be enough and we must accept that fact. However, we must learn how to manage budgets efficiently and effectively. One must have cost controls while at the same time delivering the type of service which patients need, desire and deserve.

In most instances this is happening. There is a great danger in this ongoing debate about health boards, under the new accountability legislation by which a health board is cited as having exceeded its budget provision. Compare the Galway situation with the other health board regions. Other health boards managed their budgets and managed to ensure they stayed within them while providing a commendable level of service. We should consider what would happen if, for instance, the Minister for Health and Children succumbed to the demands in Galway to provide additional funding at the end of the year, when it is quite obvious that the health board's budget has not been managed like those of other health boards. It would be a licence for the other health boards to spend over and above the provision given to them for next year. If that happened, the type of accountability which that side of the House demanded when they were in Government would go out the window. There must be some consistency in this area in ensuring that accountability is retained and is seen as important in the overall strategic planning for health services.

I referred to the huge demand for health services. One of the obligations of the Minister's office under the accountability legislation is that there should be an ongoing review of the budget provision and the operations within the health boards to ensure they are living with their budgets. If there was a monthly report from each of the health boards, how come the Galway health board overspent? It is important from the Minister's perspective that his Department be even handed in ensuring that each of the health boards remains within its budget. The early warning signs would be the indicator to departmental officials that the health board would be in trouble at the end of the year. Within the health boards' estimates everybody knows the pattern. They know there will be a major demand on the services in the early part of the year and another major demand on the services in the latter part of the year. However, during the summer period that demand levels off. One can always close beds without any great disruption to the overall system and we have always done so.

It is important I refer to the acute hospital sector. Over the years there has been a significant increase in the amount of money provided to the acute hospitals. Budget demands continue to rise and the amount of money given continues to rise on an annual basis. With regard to the waiting lists, what level of accountability exists? I am not making a political point, I want to ensure that we get value for money. I want to establish that there are norms within the acute hospital sector. Can anybody in any hospital or in the Department state the normal number of procedures which would be carried out by a consultant in the orthopaedic sector or cardiac services, for example? Should a consultant be in a position to carry out 100 procedures per year on public patients? Does it differ from one acute hospital to another? Is there a consultant in Dublin carrying out 150 procedures on public patients and another in Cork carrying out 50 procedures? Are statistical data available to us on the relativities between various hospitals and various consultants as to the number of procedures carried out?

A couple of years ago we had a major waiting list initiative in the orthopaedic sector. Patients from Cork were flown to Belfast to have operations carried out. However, I note the waiting list for orthopaedic surgery has increased dramatically. What impact did the previous provision of funds have on this sector? Obviously there is an increased demand in the number of people seeking orthopaedic services. How often are reviews carried out in orthopaedics? Does a person who has had a hip replacement return after three, five or seven years?

There has to be accountability on all sides. That is why the report of the expert review group on the waiting list initiative is important. In the event of any future review of waiting lists and the provision of additional funds, I urge the Minister to ensure there is productivity and that it will have a long-term impact on the waiting list.

It is believed that 10 per cent of those attending accident and emergency departments need never be there. Does that mean that people are referred to accident and emergency departments by general practitioners who could be adequately dealt with in the surgeries of these general practitioners? University Hospital Cork has a 60 per cent throughput in accident and emergency. That means 6,000 patients have gone through the system who would never have been there, thus clogging the system. Perhaps the time has come when the Minister should seek the co-operation of the College of General Practitioners, the accident and emergency departments, hospital managers and consumers. One can imagine the frustration of the patient in the accident and emergency waiting room, who often has to wait many hours. Much of this frustration could be avoided if there was a greater level of co-operation between accident and emergency departments, GPs and the patient and we might have a better and more effective system in accident and emergency departments.

Mr. McCormack

I note the Minister of State, Deputy Fahey, who was to take the last slot, has disappeared from the Chamber and is turning his back on the Oireachtas——

Dr. Moffatt

Beidh sé ar ais.

Mr. McCormack

——in the same way as he is turning his back on the patients in Galway. It is obvious he did not want to speak in advance of me because it would not take long for me to refute the misinformation he is putting out about this matter. During the question and answer session I will question him.

I welcome the concession to have this delayed debate on the health services. I regret the Taoiseach did not concede this debate when we raised this matter on the Order of Business last week. Following several Adjournment debates he gradually conceded there should be statements by the leaders. When I insisted on speaking on the matter, I was ejected from the Dáil, which I very much regret. I welcome the fact that we are having a debate on this matter. I appeal to the Minister of State, Deputy Moffatt, and the Minister of State from my constituency to listen to the debate with an open mind and not say they can do nothing about the problem when clearly they can.

In University College Hospital, Galway, the health board management has decided to close a theatre, two wards and to lay off 45 nurses. This has reduced the theatre capacity by 20 per cent. There is now the extraordinary situation where the four remaining theatres are working on a 24-hour basis. What could be more crazy than to close one theatre and make the others work around the clock, without adequate time in which to prepare for the next procedure?

The ward closures are causing concern in Galway to patients, families of patients on waiting lists, those on waiting lists and to doctors, nurses and staff who are working in a chaotic situation trying to fight the case. I welcome some of the nurses from Galway to the Public Gallery today. They are trying to fight against closing wards and yet continue to do their legitimate duty providing nursing care in the hospital. How can we allow this situation to continue? The laying off of 45 nurses means that those competent, experienced nurses will be lost to Galway because they will get jobs elsewhere. I have experience of this, given that one of my daughters is a nurse and she can get a nursing post anywhere in Ireland or in the world because of the demand for nurses. Yet in Galway we are sending 45 nurses elsewhere. They will not be in situ next year, if and when we get the waiting list initiative.

I cannot understand the reason the Minister of State, Deputy Fahey, is turning his back on the situation developing in his own constituency. The closing of theatre wards in University College Hospital, Galway, until 1 January will add an estimated 800 patients to the waiting list. Already the waiting list in Galway has increased from 2,079 in June 1997 to 2,891 in June 1998 — a 38 per cent increase, one of the largest increases in any health board hospital. Some 1,386 who were on the waiting list when this Government took office were still on the waiting list 12 months later. Perhaps the Minister of State, Deputy Fahey, will refer to this when replying.

The money promised for the waiting list initiative next year will be required to deal with the backlog of patients not being dealt with now. How short-sighted can the Government be and what bad value for money that will be? Despite what Deputy O'Keeffe has been sent in to say, the problem arises simply because an adequate budget has not been provided by the Minister to run the health services in our region.

The additional increase in the Western Health Board budget this year — excluding non-pay increases and development funds, which are ring-fenced — was £835,000, an increase of 1.5 per cent. With inflation running at 3 per cent and medical inflation running at more than 20 per cent, how in the name of God can we run our health services with that inadequate funding? That is the key to the problem.

If the Minister were to properly fund the health service, he would have a case for asking health boards to remain within their budgets. The simple fact is we are not getting enough money to run a proper health service at University College Hospital, Galway. This is typical of the discrimination by this Government against the west. For example, the University College Hospital, Galway, budget at £45 million can compare to that of a similar hospital, St. Vincent's in Dublin, which provides the same procedures on a budget of £70 million. This is evidence of the Government's discrimination. In the first instance the blame for the crisis in Galway rests with the Minister in not providing the necessary funds.

I am amazed the Minister of State, Deputy Fahey, is turning his back on the situation in Galway. During the last general election, Senator Fahey, as he was then, conducted his campaign from the hospital. Headlines in newspapers at the time read: "Politics is all About People — Vote Frank Fahey of Fianna Fáil, the Republican Party"— it did not say anything about the patients' party; "Bertie Ahern Committed to the Highest Standards at Galway Hospital"; "Ten Thousand Leaflets on Trolley to Make UCHG an Election Issue".

Mr. Shatter

He obviously fell off the trolley.

Dr. Moffatt

Has the Deputy nothing positive to say about Galway? He should say something about capital expenditure.

Mr. McCormack

At that time he laid the blame at the then Minister's door. However, he has changed his tune since becoming Minister of State and he has embarked on an attack on management. He said in the local media that the hospital is not being run as it should be, there is bad bed and patient management, there are fundamental management problems and that new management structures are not working. I do not know if there is any foundation to these accusations, but if there is evidence of bad management, he should set up an investigation. I will support him if he provides funding to keep the theatres and wards open.

Credence is being given to the Minister's statement because the hospital and health board management have not publicly refuted it. These are serious allegations and I am surprised they have not been refuted. Perhaps the hospital management is afraid the Minister in his vindictiveness will reduce the promised capital budget if his remarks are refuted.

Mr. Shatter

Waiting lists have been a problem for many years. I was unfortunate to have to visit the casualty department of Beaumont Hospital in January 1997 where I had to wait 12 hours. I noted on that night that approximately 50 per cent of the people did not need to be there as they had cut fingers and minor injuries. Only one doctor and nurse attended on that occasion, so this problem is not new. The Minister recognises this and is taking the necessary action to resolve it. Some £12 million was allocated this year for waiting lists, which is an increase of 50 per cent on the amount provided by the previous Government.

The Minister provided £750,000 to extend the angiogram unit at Beaumont Hospital in my constituency. One would get the impression from listening to this debate that the Minister for Health and Children is playing bingo or is sitting on his laurels. However, that is not the case. There has been an increase, not a decrease, in overall general expenditure this year.

When the Minister took office last year he made it a priority to tackle the long waiting lists and times. He undertook a number of initiatives aimed at improving the efficiency and effectiveness of waiting lists. As Deputy Batt O'Keeffe said, accountability for performance related activities must be the norm. It is not good enough to throw money at something which is breaking down as that will not solve the problem. There must be accountability, proper structures and a means of measuring performance.

Deputy Cowen is a caring Minister. He has given special attention to services for older people.

Mr. U. Burke

He leaves them waiting for 24 hours on trolleys.

Mr. M. Brady

We must tackle the issue of the rights of our older citizens who require home support and easily accessible services. The number of older people will increase significantly over the next 15 years. I am pleased the Minister proposes to allocate substantial funding to provide the necessary services for them.

A number of key areas need urgent attention, including home help, respite support, support for carers who often experience stress and hardship and services for older people with mental health problems. There is also a need for better community-based services, particularly care in the home. Due recognition should be given to family carers who, in many cases, are prisoners in their homes and find shopping trips too difficult to contemplate. I have highlighted these problems to the Minister and he will make the necessary funding available to improve services.

It is wrong for any public representative to make political capital out of the health services or people who are sick. This Minister has done more for the health services, the elderly and the deprived people in our society than any other Minister for Health.

During my discussions with the Minister he recognised, as did the Minister for Social, Community and Family Affairs, Deputy Ahern, the need to increase the level of support for voluntary organisations which care for the elderly in their homes and in senior citizen complexes. I pay tribute to the great work done by those who work in voluntary organisations in my constituency of Dublin North-East and to those in Dublin Corporation who make life more enjoyable for many of our senior citizens. People give of their time voluntarily to provide meals on wheels for the elderly in St. Anne's Court, Rosedale Court, Rosevale Court, Raheny Court and Greendale Court. The wife of the Minister for the Marine and Natural Resources, Deputy Woods, has done voluntary work in Greendale Court for many years. Fianna Fáil has always been a caring party and has looked after the elderly.

Mr. U. Burke

The Deputy has forgotten about the situation in the west today.

Mr. M. Brady

We recognise much more needs to be done for the mentally handicapped. At present 1,400 mentally handicapped people urgently require a suitable place to live and an additional 1,000 mentally handicapped people require access to a suitable day care facility.

There has been much debate and criticism about the level of funding for services for people with a mental handicap. I am pleased to have this opportunity to spell out what the Minister proposes to do for those people and the programmes that are in place. The provision of additional residential respite and day care services was outlined in Services to Persons with a Mental Handicap. There is also a document entitled An Assessment of Need 1997 to 2001. An additional £25 million will be allocated for services for those people, which is more than double the additional funding allocated by the previous Government.

The Minister has put in place a £30 million national capital programme to run over four years in tandem with the assessment of need programme to provide the necessary infrastructure to support those services. This is the first time such a programme has been provided and it allows for multi-annual planning to develop these services. There is also a need to provide residential care centres. Many parents of children with a mental handicap have told me they are terrified about what will happen to their children when they pass away. They are afraid their children will be put into institutions and forgotten about. I made suggestions to the Minister on how to address the needs of those people and he has taken the necessary steps in that regard.

The recent announcement of a £13 million capital project for St. Ita's Hospital in Portrane, funded jointly by the Department and the Eastern Health Board, is particularly welcome. I am proud to be part of a Government which, for the first time, not only fully appreciates the need for this development but is prepared to provide the necessary funding to ensure it becomes a reality. Those are some of the projects about which I have spoken to the Minister and which he has taken on board. He has also taken on board many of the suggestions made by other Deputies, including Opposition Deputies.

Having listened to the debate, one would get the impression we do not have a Minister for Health and Children and that this is the first time there have been waiting lists, but one cannot argue with the facts. The Opposition can try to make political capital out of this, but that is all it can do.

We do not have time to detail the various categories of hospital and health services that are in need of an overhaul by the Minister and the Ministers of State responsible. It may be fine to assume that in a few years' time we will be able to resolve these problems, but I do not believe that is possible. The Minister has misread the position. When he was in Opposition he failed to properly estimate the full degree of the requirements of the health services and he is now paying the price. To ensure there will no further damage to the health services and that no more vulnerable people on hospital waiting lists suffer, the Minister should move over and allow someone who knows something about the health services to take over from him.

Mr. U. Burke

I thank Deputy Durkan for sharing time. During this debate the Minister and Government backbenchers have stated that this issue will not be resolved by throwing good money after bad. Is that an adequate response to the people lying on hospital trolleys in Galway hospital and other hospitals? Is it an adequate response to those who will be obliged to remain on waiting lists indefinitely? Is it an adequate response to the people who cannot gain access to services they urgently require?

The Government's statement that it will control non-capital expenditure within set limits is understandable. However, if the health service continues to be adversely affected, there will be an obligation on the Minister of the day to intervene to provide adequate funding for basic services when and where the need arises. No one, health boards or individuals, can budget for sickness, which means that there is always a need for flexibility and discretion. The Minister and his Ministers of State have shown that they are not prepared to grant such flexibility or discretion. They have also shown a callous disregard for the people's needs in terms of the provision of health services.

What does the Minister of State intend to do to reduce those numbers?

Mr. Fahey

Despite the fact that a 50 per cent increase in funding has been provided and that waiting lists have finally stabilised, it is important to remember that a fundamental problem remains to be tackled. The Minister for Health and Children has set about tackling it in a fundamental way. As he stated earlier, in the forthcoming budget he will announce the implementation of initiatives based on the work carried out by the review group which will deal with waiting lists in an effective, proper, planned and long-term way.

With regard to the dispute in respect of the proposed closure of 57 beds and a theatre at University College Hospital, Galway, discussions unfortunately broke down yesterday at the Labour Relations Commission. The closures at UCHG have been proposed in response to a serious projected year-end deficit which, if not addressed, will translate into a first charge on the Western Health Board's 1999 allocation——

Mr. U. Burke

What does the Minister of State intend to do to address this problem?

Mr. McCormack

What about the £32 million?

Mr. Fahey

——in line with the provisions of the Health (Amendment) (No. 3) Act, 1996. A first charge of this order would obviously present severe problems for the board in trying to deliver existing levels of service in 1999.

Mr. U. Burke

The Minister of State should make Deputy Healy-Rae aware of that.

Mr. Fahey

Mr. U. Burke

Was the Minister not going to sell Merlin Park to pay for it?

Mr. Fahey

There are a lot of crocodile tears being shed here, but it is important to remind Deputies opposite that they provided only £39 million in the last Estimate before they left Government for UCHG. It has been necessary for us, in the short period during which we have been in Government, to increase that by £5.5 million. Those are the facts.

Mr. Kenny

Consultants tell us that patients will die.

Mr. Fahey

This Government has to ensure that we stop funding acute hospitals on the basis of a demand-led programme. The days are gone when hospitals can simply demand and demand.

Mr. McCormack

The Minister of State has learned a lot in a year and a half.

Mr. Fahey

We are now planning and investing properly. There are major management problems in UCHG which are a contributing factor to the current crisis. The days when a manager could walk into a ward on a Wednesday and announce that it was to be closed by Friday are long gone. We cannot tolerate that.

We are not going to throw good money after bad when there is such mismanagement.

Mr. M. Higgins

I am sharing time with Deputies Connaughton and Kenny.

What the people of Galway want is to have the question of the closure of two wards and an operating theatre taken out of the negotiations currently taking place so that we can get on with addressing every other issue, including those mentioned by the Minister of State. It is disappointing that the Minister of State and other Government speakers have not addressed the specific point made by Deputy Shortall when she spoke this morning.

Reference has been made to the Health (Amendment)(No. 3) Act, 1996, which was passed during the period when I was in Government. There is nothing in that legislation to stop the Minister addressing exceptional circumstances. Specifically, section 5(3) of the main Act states:

The Minister may amend a determination under subsection (1) by varying the maximum amount of net expenditure that a health board may incur for a particular financial year and, if the Minister so varies that amount, he or she shall notify the health board concerned in writing of the extent of the amendment as soon as may be and the determination shall apply and have effect as so amended.

That was put in specifically to allow ministerial discretion. It is a point that should be unemotively discussed because, if the baseline upon which the budget is calculated is inadequate, it will throw up problems like the ones we are experiencing. The issue is a simple one. Why does the Minister of State not take the powers in the Act under section 5(3) and address the issue? This would have the effect of eliminating the principal obstacle to the resolution of the difficulties that arise at present.

It is a complete confusion to suggest that the labour relations consultations which broke down yesterday have any capacity to deal with this problem. It is beyond the capacity of those talks to answer the fundamental problem. We are now faced with a fundamental point. There are 3,494 people on waiting lists at University College Hospital. It has been stated by those who are in charge of administrative decision-making that there was a demand during the summer when demand was expected to fall. It has also been pointed out that there are additional costs associated with capital development. There is ample scope to consider giving, by way of supplementary allocation, such sum as would relieve the current problem. That is what we want.

I do not have the time in three minutes, nor have I the inclination, to start going back over the long history of Deputy Fahey in relation to the hospital. I find it appalling that the hospital, its needs, its patients' needs, the structure of its staff management, are made a political football. If, as has been pointed out by Deputy McCormack and others, there are management difficulties that require intervention, our support is forthcoming for the resolution of these. What the public wants, what the community wants, is the taking of the closure of the wards and the operating theatre out of the equation. It is time for the hypocrisy to end.

I was a member of Government. I have stated what was in the 1996 Act. It does not preclude additional funding. When we were in Government people used to say they wanted the Government to act. Now that we are in Opposition it is suggested that it is a problem for all of us. We accept that but it is the Government that is responsible for decision making. The Minister has the capacity to act under section 5(3) of the 1996 Act.

Mr. Connaughton

The manner in which the Government has sought to tackle the crisis in the health service is scandalous. For years the catch-cry was that there was not enough money available to provide the services required. Although the Minister and the Ministers of State have sought to deny it, a sum of £32 million made available in the 1998 Estimates remains unspent. As a result 70 staff are to lose their jobs in Galway. I agree with Deputy Higgins. There is nothing to prevent the Minister from making additional funds available to resolve the problem.

It is now easier to gain entry to the Connacht final, a livestock mart or to get out of a traffic jam than it is to be admitted to hospital. When on this side of the House a week did not go by without the Minister of State, Deputy Fahey, having some story about University College Hospital, Galway, for The Connacht Tribune. With his ministerial colleague, Deputy Ó Cuív, he had all the answers, but they have made a hash of it.

Mr. Fahey

We are providing the answers. A total of £120 million is being made available.

Mr. McCormack

When?

Mr. Fahey

I am proud of my record.

Mr. Connaughton

The Minister of State should solve the problem and not try to blame anybody else.

I wish to share time with Deputy Crawford.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Mr. Enright

We are all aware of how serious are the problems. There are 34,331 people on hospital waiting lists. At a time of unprecedented growth in the economy and Exchequer returns — there is a budget surplus of £1.3 billion — one would expect a Government to provide the additional funds required to ensure patients receive the care and treatment they require. In what can only be described as a sick joke the Government has decided to close hospital wards and lay off nursing staff. This is cruel and heartless. It is alarming that the Government is showing such callous disregard for patients.

Although there are 1,700 patients on the waiting list at Tullamore General Hospital, it is proposed to lay off 17 nursing and administrative staff. This is scandalous. Something has gone seriously wrong. The Minister, Deputy Cowen, spoke of a quick fix solution by throwing money at the problem. That is reminiscent of what the Minister for Finance, Deputy McCreevy, said. That is not the solution. We are dealing with human beings, people of all age groups, who continue to suffer. Much is said of the economic boom and the Celtic tiger. The manner in which the Government is dealing with people on hospital waiting lists would put Shylock to shame.

I appeal to the Minister to ensure additional funding is provided immediately. We are witnessing uncalled for and wasteful expenditure of Government funding while people are on hospital waiting lists. Something must change and the Government must provide the necessary finance.

Mr. Crawford

I welcome the opportunity to raise a number of issues regarding the health service. The Minister will undoubtedly refer to a new allocation of money to the health service next week but he must live with the fact his colleague, the Minister for Justice, Equality and Law Reform, obtained an additional £91.5 million for his Department. Those on hospital waiting lists for hip replacements and other operations are asking if the Minister for Health and Children is aware of the crisis, if he is hiding behind the legislation he claims he is bound by, or if he is prepared to obtain the necessary funds at this time of the so-called Celtic tiger to ensure people do not continue to suffer as they do at present.

I appreciate that the former Minister, Deputy Noonan, was and the current Minister, Deputy Cowen, is committed to the programme for the North-Eastern Health Board region, especially the proposal to upgrade Monaghan General Hospital. That is an absolute necessity and the Minister should make clear in his next proposal that it will be funded. I realise it cannot be upgraded in one year. Since there is a three year programme for the health service, I have no doubt he can find the necessary funding to provide the extra theatre and beds for the hospital. There are excellent consultants there but that has created its own problem. When they are on duty, there is complete chaos in terms of car parking. It is urgent that it be tackled if a serious crisis is to be averted. Ambulances and other urgent and necessary services cannot get through. Security is also an issue. A number of us met senior executives of the North-Eastern Health Board who assured us the problem will be rectified.

Navan Orthopaedic Hospital is another serious matter. It has given a great service to our constituency over the years. Unfortunately, it seems the beds are not available to provide the level of service specialists working there wish to provide. A pensioner, who is required to stay in a home in Northern Ireland paid for by the health board, has been on a waiting list for ages to enter Navan hospital although there is a bed for him in a health board facility in Monaghan town were he able to use it. However, he cannot do so because of a serious orthopaedic problem. A handicapped 25 year old has been on a waiting list for a year and this has caused enormous problems for his family. A 90 year old needs a small operation but cannot get a date. The surgeon wishes to carry it out but does not have the facilities available to him. Another person requires an operation on a joint.

I received a letter the other day from a lady in Monaghan town who asked why her appointment had been cancelled. She had been on a waiting list for two years to receive treatment in Omagh hospital when she received the following letter:

Dear Patient

I am sorry to inform you that your admission for Monday, 26th October 1998 has been postponed.

We have been instructed by the North-Eastern Health Board in association with Sperrin Lakeland Health & Social Care Trust that no further operations will be undertaken until further notice for patients from the Cavan/Monaghan area. You will be given a new date as soon as [possible]

It is possible in conjunction with our friends across the Border, both in Omagh and Belfast, to reduce waiting lists. The Minister has an opportunity to provide the funds to give people their rights. As his party said some years ago, the poor, sick and handicapped should not be discriminated against at this time.

Mr. Higgins

(Dublin West): It was a nauseating spectacle to witness the trading of insults in the Dáil a half hour ago between senior Deputies in Fine Gael representing the west and Fianna Fáil Ministers of State also representing the west. It was particularly so when one considers it happened on the backs of people in Galway and throughout the country who face serious problems. The policies of both parties and their actions in recent years have been equally culpable for the current crisis. It is extreme cynicism for both parties to pretend they have fundamentally different policies in the area of health services and the provision of proper health care for all people.

Both parties underpin the philosophy which dominates this society in its economic choices and structures, where the profits of individuals, corporations and powerful vested interests come strictly before the desperate needs of people on hospital waiting lists. The scandals revealed over past years show the priorities of those who form the establishment in this society. There was the revelation of the massive rip off of taxation by powerful interests such as the banks. We do not know the full amount involved, but it would, had it been properly investigated, undoubtedly have amounted to hundreds of millions of pounds of taxpayers' money. Imagine the difference that would have made if, instead of going into private pockets and offshore accounts, it was invested in health services to relieve the suffering so obvious at present. Similarly, there was a huge tax amnesty introduced by a previous Government which wiped out hundreds of millions of pounds which could and should have been invested in the health of our people rather than going into the pockets of the super rich.

It is nauseating to see the health service and the health needs of our people used as a source of profiteering by private interests. I find it objectionable to see private insurance medical companies muscling in to the health service. I also find objectionable the advertisements they use to try to do this in which health care becomes a product to be marketed in the same way as soap powder and patients become clients to be exploited rather than human beings to be treated and cared for. We need a comprehensive public health care policy to meet the needs of our people and to end the two tier structure that currently exists in our health care system.

Private consultants take a disproportionate share of resources. Pharmaceutical companies, powerful multinationals, make enormous profits from health care products, medicines, etc. Resources, which should be put towards the provision of better care, are being soaked up by these vested interests. Those resources could be and used to eliminate hospital waiting lists.

The controversies of recent weeks have again highlighted the suffering of those on the hospital waiting lists. Senior medical physicians are now speaking out. One doctor, in an article on the Mater Hospital in the Evening Herald, said that the shortage of space meant he had been virtually unable to admit any patients, many of whom require urgent attention. He went on to outline the case of a man from Ballymun who is suffering severely from a prostate gland problem. The would-be patient, who is racked with pain, urgently requires surgery but there is nothing he can do to admit him to hospital.

This crisis has come about as a result of the false priorities of the main political parties that have dominated Government for decades. As a result of political decisions taken we are now experiencing this crisis. In an article in The Irish Times on 16 November, Dr. Miriam Wiley, head of the Health Policy Research Centre at the ESRI, states:

The proportion of GDP devoted to health in Ireland ranked joint fifth relative to other member-states in 1985, and 11th in 1990. Since 1993, the only EU member-states to spend a smaller proportion of GDP on health are the UK, Luxembourg and Greece.

That is a categoric indication of what was allowed to happen.

The Minister of State, Deputy Moffatt, referred to food safety in his contribution. Many people are concerned that the Fianna Fáil-Progressive Democrats Government has utterly failed to move on one aspect of food safety. In Opposition, Fianna Fáil had a clear position on food safety. It stated that current scientific knowledge is inadequate to protect the consumer and the environment from the unpredictable and potentially disastrous effects which may appear immediately or at any time in the future. Fianna Fáil said it will not support what amounts to the largest nutritional experiment in human history with the consumer as guinea pig.

Unfortunately, the Minister of State, Deputy Fahey, has already spoken and probably will not get an opportunity to respond, but it is shameful that a Fianna Fáil dominated Government continues to sit on the sidelines while these products are sold to consumers as part of what it referred to as the largest nutritional experiment in human history.

I pay tribute to voluntary groups like Genetic Concern, two members of which — Clare Watson and Quentin Gargan — have been on a vigil outside Leinster House for the past 24 hours to draw attention to the negligence of the Government in this regard. Pressure must come from ordinary people because it is obvious the Government will not move on its own. We must have legislation on these dangerous products and prevent the powerful vested interests and multinational companies turning our people into guinea pigs for the sake of their profits, as they have done with the health service as a whole.

Mr. Finucane

I wish to share time with Deputy Gerry Reynolds. I welcome the debate. I am a member of the Mid-Western Health Board which has focused on the waiting list issue at many of its meetings.

Another area of major concern is the ophthalmology waiting list in the Mid-Western Health Board area which increased by 17 per cent from December last year to the end of September this year. A total of 766 people are now waiting for ophthalmology services. Many of those on the list are elderly people who need cataract operations. I raised this issue recently with my health board because it is important for older people to be able to read a newspaper, but there is a considerable waiting time before a person is called for a cataract operation.

The Mid-Western Health Board, in its budgetary submission, will signal its concern in this area and seek additional funding for associated theatre costs. I hope those concerns are reflected in an increased budget for that area because if resources are provided, results are achieved. That was highlighted by the success of the Orthopaedic Hospital in Croom where there has been a dramatic reduction in the number of people waiting for hip and knee operations. A fifth orthopaedic surgeon was recruited and an extra operating theatre opened. More needs to be done, but I wanted to highlight the positive action that has been taken in that area.

The ear, nose and throat waiting list is increasing and is a major cause of concern because young people cannot attend school if they have a hearing impairment. That problem must be addressed.

We must also address the problem of what has been called the invisible waiting list, the people waiting to get an appointment with a consultant. We all know constituents who require serious operations. It is interesting that the health boards do not have statistics in this regard. I would have liked to say more on this topic, but I will pass over to my colleague, Deputy Reynolds.

Mr. G. Reynolds

A person to whom I spoke last week told me that in 1970 there were 95 administrators in the Eastern Health Board area. The figure for 1998 is 7,500, which represents an enormous increase. How much of the total health Estimate is spent on administration in all the health board areas? The crisis we are currently experiencing in the health area is due to the fact that much of the money is being spent on administration, not at the coal-face.

I come from the North-Western Health Board area which has been held up as an example for other health board areas. In Sligo General Hospital, however, waiting lists have increased by 47 per cent in the past year and a half. If that is the most efficient health board area, I would not like to know what the least efficient one is doing. How much money is being provided for the administration of the health service rather than the provision of services? If the Minister and Ministers of State are courageous they will try to resolve this problem and spend money where it is most needed, on the people waiting for operations.

Dáil Éireann debate - Thursday, 19 Nov 1998