Health Services: Motion.

Mrs. Fennell

I move:

That Seanad Éireann calls on the Government to reconsider their budgetary proposals in relation to Health Services because of their serious implications for the well-being of the general public.

In moving this motion I wish first just to make the point that Fine Gael in principle do not oppose public expenditure cuts in Departments in line with our policy to reduce public expenditure and borrowing, but what we do oppose is the cruel and uncaring manner in which these cuts are being imposed by this Government. Never before, I suggest, has there been such a sense of desolation and fear over a political decision. Daily and hourly we have reports of loss of vital services, close down of hospitals, staff dismissals, and overall a confusion about where it is all going to end or what kind of health service will this country have when the cutting agenda is achieved. People have cause to be concerned. Fianna Fáil back in office are using a sledgehammer approach without, I suggest, a full knowledge of the immediate effects of their policies or indeed, what lies down the road two or three years ahead. It is an unbalanced, disorganised health service that will penalise not at all the better off but the lowly paid worker.

It is regrettable that Fianna Fáil had to take such an approach to the health cuts. Not for them the already costed and thought through programme of Fine Gael with our proposed charges for out-patient treatment and prescriptions charges.

No one who seriously examines the figures for health spending at £1,315 million this year, two-thirds of it going on staff pay, could turn a blind eye to the need for serious reform measures and root and branch pruning. But this has to be done in a professional way working towards better public enlightenment and education about the use of the services offered under heading of health and an attempt to get consensus on changes.

What have we now? A revolution up and down the country with health boards in chaos with several Fianna Fáil councillors distancing themselves from Fianna Fáil policy at health board meetings and turning their backs on party policy that does not suit them, as of the moment. Who said that only a single party Government could make decisions that would be binding? Are we now seeing a coalition Fianna Fáil — and, I suggest, not only over the health cuts.

I have to concede that some of the public outrage is the normal knee jerk reaction coming from professional sections who may not always have patient interest primarily at heart, or from members of political parties who themselves know well that the Dáil has no licence to print money for endless spending — it either comes from the hard-pressed taxpayer or is borrowed at enormous cost — but who continue to put over that simplistic concept to their followers for party popularity.

That apart, I find present Government behaviour on these cuts quite extraordinary and I have constant flash-backs to Dáil health debates and Question Times when the present Minister, and some members of his party who would like to have been the present Minister, used extreme language to the then Minister for Health for his reasonable efforts to bring greater economies into the system and effect cutbacks. He was castigated, condemned, labelled as a sinister influence, almost a harbinger of death, all by people who even then had high aspirations to govern but who choose to ignore the greater need for phased cutbacks in favour of political whingeing and scaremongering. Well, I suggest they are paying the price now. I know Opposition parties must oppose but there is a responsibile way to do that, not the destructive, counter-productive way in which Fianna Fáil did it when the statistics and figures were so obvious and demanded honest appraisal, not destructive hypocrisy.

Let us look at what we mean when we talk about the health area: there are the health boards, the hospital care in general, psychiatric hospitals and hostels, the general medical service, dental care, free drugs, medical cards, childcare, health centres, health education, care of the aged, the Blood Transfusion Service, nursing training, community nursing and care of the handicapped.

While one could not begin to prioritise these different areas in terms of importance for cutbacks or otherwise, they show what a diverse and comprehensive subject we are talking about. The health area in all its spending must be scruplously examined and a cohesive policy that takes account of public needs and public spending should be drawn up. For instance, I note the concern of my party colleague, spokesman on Health, Deputy Allen, regarding the resistance of the IMO, to the review of their contract with the Department and suggest that if consultants are to play a real and meaningful role in public medicine external interests should be restricted.

We are spending astronomical amounts on health care. Costs have increased dramatically at a time when demographic changes are in favour of teenagers and young people who are the least demanding in the area of health care and we have not got value for money. The economist, Dale Tussing who examined and recommended changes for a National Economic and Social Council report said: "Had the rise in costs been accompanied by widely perceived improvements in the range, extent and quality of medical care there would be substantially less concern. Cost increases have occurred with no corresponding gains". He points out that preventive care, primary care and community care are sections which have been sacrificed in over-spending hospitals. This is absolutely the case in capital spending in hospital building within the recent past with overruns on original estimates, as with Beaumont Hospital, where the original tender of £16.77 million was exceeded by £6.4 million: a similar situation was allowed in Tralee Hospital.

Of course, it is important that we in Ireland should have the benefits of modern medical technology, treatment and techniques and we can be proud of the pioneering work being done in the area of transplant surgery in our main Dublin hospitals like the Mater and St. Vincent's. But nothing excuses the apparent sloppy attitude to runaway building costs, as highlighted by the Committee on Public Expenditure, and in direct contravention of the regulations set out for capital projects by the Department of Health and the Department of Finance.

We now have a considerable focus of attention on all areas of health care and the public anger will not disappear. I suggest that in making all the services, both hospital and community care, more effective and responsive to the consumer we should look at the cost effectiveness of greater use of day wards for minor surgery and treatment. I know this is happening in some areas at the moment. As an example of effectiveness we need only look at Hume Street Hospital which has a most efficient treatment centre for psoriasis, and enables sufferers to come in for treatment in the morning and then go to work. That hospital also no longer keeps patients over the weekend and all of this gives greater saving with no greater inconvenience to patients. When giving a full service three years ago and open over a Christmas period, I was told that it would have been cheaper for Hume Street to transfer the handful of patients there over to the Shelbourne for a week than cater for them in the hospital complex as was the case. Yet the rigidities and resistances in the system held up important changes, which saved money but gave an equally good service.

I have long believed that we should be developing community care to enable a reduction in institutionalising people as happens in other countries which per capita spend less on health care. For instance, in Holland many mothers spend only two days in maternity hospital for normal deliveries and have community back-up care at home for both mother and baby, but this system, of course, requires prior planning.

The present health budgetary approach means that funding on important programmes for women are being either held up or scrapped. The free Hume Street cancer screening clinic now has to close or charge fees. It is inconceivable that the child sexual assault unit at the Rotunda is, according to reports, due to close in June. The team of nurses and doctors at the Rotunda unit have done invaluable pioneering work over the past few years, taken initiatives in this essential area of child sex abuse and highlighted social problems in a very special way that I believe would not have been done in any other hospital.

For a long time many concerned people have been stressing the need for developing mamography, breast screening units, here but without much success. Research findings in the US, Sweden, Holland and England are most encouraging — where screening is carried out and monitored, early cancers are detected and lives saved but equally of relevance is the fact that these detection programmes not only save lives but in the high risk age group also save public money through less spending on terminal care units.

Finally, someone has to take responsibility for a comprehensive plan for our health services to ensure that a balance is maintained and that the low paid worker, the old and the handicapped are not put at risk because they cannot afford to pay the price. The Government must engage in a major reconsideration, a major review of their proposals and they must do it soon.

Mrs. Bulbulia

I formally second this motion and reserve the right to speak.

Dr. O'Connell

I am rather interested in what Senator Fennell had to say. I am not surprised at the Fine Gael motion calling on the Government to reconsider the budgetary proposals in relation to the health services as essentially the cutbacks are in line with the Fine Gael election manifesto. I can understand Fine Gael getting alarmed because of the public outcry. They must be seen to be doing something, hence this motion. At heart they know that cutbacks are vitally necessary if we are to bring the State's finances under control.

In my opinion the Minister for Health has very courageously grasped the nettle and Fine Gael themselves, knowing the perilous state of the nation's finances, were very courageous in putting their budgetary proposals before the public in the election campaign, but I do not think Fine Gael are being a responsible Opposition party in now attempting to exploit the situation or in expecting a Minister a few months in office to come in and, miracle working, bring in a plan that was streamlined and professionally operated, as Senator Fennell said. To think that anyone in this world could do such a thing is beyond my comprehension and that of any sensible person. The Minister has granted the health boards the 1 per cent increase over 1986; he reduced the voluntary hospital budget by 7 per cent, but he did not dictate to the health boards how they should effect their cutbacks. He left it to the members.

In the health boards there are some chief executive officers who are rather dictatorial in their approach, who have unilaterally — I mention in particular the South Eastern Health Board and the Western Health Board — brought in cutbacks without consulting the members and that is very dangerous. Senator Fennell talked about dissidents in Fianna Fáil; this is a lie and I want to nail that lie. What the members and TDs are saying is: "We agree in principle with the cutbacks but we do not agree with the way they were enforced or implemented by the health boards or the CEOs", and quite rightly because they were not consulted. We should settle that once and for all. As I said, these CEOs came in, presented the cuts as a fait accompli and without consultation with the members. This was regrettable.

Health is a very emotive issue and the marches of the various groups added to the public fears. The health service is a very big industry rather than a caring, healing service. I would go so far as to say that the interests of the patient assume a very low priority. The marches, with their hyped-up hysteria, were not about patients; they were about job losses; closure of hospitals and career opportunities which were gone. Slogans such as "Dr. Death", "Patients will Die", etc., were literally hysterical nonsense deliberately produced to frighten people. I am a medical doctor as is the Minister for Health——

Mr. Ferris

You said these things yourselves.

Dr. O'Connell

Anyone may read my speeches in the Dáil. Never once did I say this. I said you could have a very good health service without necessarily spending extra money. That is exactly what I said and I will say that again. You can have a good health service without necessarily spending extra money, but it would call for co-operation from the people working in the service. This is what you need but extra money need not be spent. I will explain this now.

As I said, I am a medical doctor, as is the Minister for Health, and we know the implications of the health cuts. Lives are not being put in jeopardy. Every country in Europe has had health cutbacks because health spending has got out of control. I spoke with a professor yesterday in Britain and he said that our health cuts in Ireland are minimal compared with theirs and he was astonished that there is such an outcry. He said they have much worse health cuts.

A Senator

Blame the Tory Government.

(Interruptions.)

An Cathaoirleach

Order. The Senator in possession should not be interrupted.

Dr. O'Connell

I think we should put health into proper perspective and, as I said, more money does not necessarily mean more health. A little more attention paid to healthy life styles, proper diets, elimination of smoking, reduction of weight, moderate alcohol intake and proper exercise will achieve more than all the major breakthroughs in medicine. It will mean more in eliminating heart attacks, strokes and lung diseases if we exercise a little more care and spend a little more money on health education. This is what we must do, but we are sometimes mesmerised by all the newfangled medical breakthroughs. Yes, we have achieved much in medicine. The advances have been phenomenal but the advances and their application have been and still are very expensive and, what is more, the advances are taking place at such a pace that we are not able to afford them; we cannot afford the cost of these medical breakthroughs.

We have hailed these advances with a paean of praise but they are costly. Open heart surgery costs a minimum of £4,300 per patient, plus the cost of the loss of that person's earnings. If we take the 873 open heart operations which were carried out in the Mater Hospital last year, we will see that the operations for those patients cost £3,750,000. Sometimes we do not realise this when we talk about the major breakthroughs. We see kidney transplants and renal dialysis as routine procedures now, something which not too long ago was considered very rare. Now these are seen as daily occurrences, but they are very costly. They are worthy operations; in many cases they are life savers but it costs thousands of pounds to keep a kidney patient on a dialysis machine. We forget the cost of this.

We often forget that medical breakthroughs are taking place faster than we can provide the money for them. The trouble is that when a great, new, worth-while procedure becomes available we want to avail of it, and to hell with the cost. The surgeon or physician tells the patient that the treatment can be given, and there is a demand for a unit. That is the next thing which follows, the demand for a unit. This escalates the cost to the health services. Have we the right to make these services available without asking the taxpayer if he will pay for them? Have we the right to redistribute the budgetary allocations so that they get the money, perhaps at the expense of the psychiatric patient, the geriatric patient or the mentally handicapped patient? This is what is happening. More money cannot be given because the taxpayer will not give more money. The advances are there, the breakthroughs are there and people are availing of them. There are hip operations, kidney transplants, bone marrow transplants, by-pass surgery and cardiac transplants.

Mr. Ferris

And rightly so.

Dr. O'Connell

But who is going to pay? Will the public pay?

Mr. Ferris

What about the lives?

Dr. O'Connell

Senator Ferris poses a very interesting question. We need to initiate a public debate on this because there is a very big, moral, ethical issue involved here. Which is more important? Is it saving the life of a mother with a young family by providing a new expensive procedure costing thousands of pounds at the expense of services for the old, the mentally handicapped? This question has become very relevant and will become much more so in the years ahead.

Medicine is a science undergoing change and advances all the time. What is impossible today becomes a reality tomorrow, but not without cost. We should appeal to all groups in the health service to consider the financial crisis. The Government and the Minister do not like what is happening. They do not take any sadistic pleasure in implementing these cuts. The Minister for Health is a caring individual who knows patients better than anyone in this country. He has worked with patients as a family doctor. Therefore, more than administrators, politicians or legislators he knows the situation; he understands it very well. It is not a very nice task for him.

Indeed, I took exception to colleagues of his in the medical profession for daring to challenge him, to ridicule him or to condemn him on this when they knew he was carrying out what the public asked for. They asked that the public finances be brought under control. He has endeavoured to do that with a caring concern for the patients and the public. It is regrettable that any political party should try to exploit this situation. They asked for the cutbacks. They said we must have fiscal rectitude. It is being provided now and they say it must not happen.

They are seeing the outcome of what they called for themselves. It is not pleasant. Perhaps Fine Gael might have been in power and might have had to do this. They know the consequences. They were in power; they knew the financial situation in the Exchequer. They knew all of this and they called for those measures. Now they are condemning them. This is hypocritical. The sooner we have an Opposition who say, "Where there is a crisis, we stand by you" the better. We need political maturity. When we see this we can say that it is a good country and the public will respond. But when a politcal party say at one stage that this must be done and then stand up and condemn it out of hand — not one person saying it is necessary — I say that is pure political hypocrisy.

Mr. G. Reynolds

If we indulged in hypocrisy you would not be over on that side of the House.

Dr. O'Connell

A five year budget might have been a better solution. If we had time perhaps that would have been the best answer, because to effect the economies in the health service in such a short time can be very traumatic. I accept that but there was no alternative. If the Opposition were prepared to co-operate in a five year budget for the health service we could have had a more gradual approach to the cuts and there would be a less traumatic effect on the public. This would have been the answer in my opinion.

The previous Minister for Health, from what I understand, allowed the health boards to overrun to the tune of £55 million. I understand he did this without the consent of the Minister for Finance or the Government.

Mr. Ferris

Without the consent of?

Dr. O'Connell

Without the consent——

An Cathaoirleach

Senator O'Connell and Senator Ferris, you cannot address each other across the House.

Dr. O'Connell

I am speaking through the Chair. The previous Minister for Health allowed an overrun of £55 million without the consent of the Minister for Finance or of the Government. This has added to the seriousness of the situation. I am not trying to make political capital. I am just trying to emphasise one point. I am objective about this. This £55 million overrun has created a serious situation. In those circumstances, that in itself, without any other measures, had a very deleterious effect on the health services and that has to be borne in mind. The sooner we are prepared to look at this in a proper statesmanlike way and not try to make political capital out of it, the sooner we will put this country into proper shape.

It is not good enough to take advantage of the situation and exploit it for purely party political reasons; it is very regrettable and I am rather surprised because I never thought Senator Fennell would resort to that. Indeed, listening to her many speeches in the Dáil that was not typical of Senator Fennell. I appeal to her to let us look at this a little more dispassionately. Let us consider the interests of the patient. This is what is wrong: among the various interest groups the patient's priority is very low. We now have an industry which has produced this situation. We are not talking about patient care; we are talking about job losses and things like that which do not really matter. The dedication is gone from the health services, the healing is gone. We are now talking about career structures.

I remember something similar happening with the youth service, Comhairle le Leas Óige. They were not interested in youth clubs. These so-called youth officers were interested in career prospects for themselves. I was so disgusted with the whole situation that I resigned from it. This is what is happening here and it is a great shame. If we paid a little more attention to the needs of the patients and considered them we would not be out marching, as I see happening, in the streets.

Minister for Health (Dr. O'Hanlon)

Senators will be aware that the Dáil is at present debating a motion on the health services financing for 1987, which the Progressive Democrats put down and to which the Fine Gael Party moved an amendment which commences as follows: Dáil Éireann "wishing to remain within the 1987 Revised Estimates for Health...". That is the start of the motion put down by the Progressive Democrats and is also the beginning of the amendment in the name of the Fine Gael Party.

In this House, at the instance of the Fine Gael Party, we are debating a motion which reads:

That Seanad Éireann calls on the Government to reconsider their budgetary proposals in relation to Health Services because of their serious implications for the wellbeing of the general public.

While Senator Fennell referred to the fact that we should live within our allocation for 1987 — the Revised Estimate for 1987 — it does not appear in the motion. Indeed, it is difficult to be sure of where Fine Gael — or for that matter the Progressive Democrats — stand, because last night in the Dáil the spokes-persons for both parties, while on the one hand supporting that view, kept demanding the addition of more and more expenditure to support various elements of the services, largely in the particular Deputies' own constituencies.

This is, of course, all very fine but it fails to accept that when you add a facility to one service, if the global sum is restricted, you must take from another area of the service. The track record of Fine Gael in office shows the same inconsistencies of approach which ultimately led to the split with the Labour Party. In this respect I remind the House that I am the third Minister for Health to hold office this year. First, up to 20 January last there was Deputy Barry Desmond. He left office because he could not stay in there with Fine Gael because of the inconsistencies in measures proposed by that party. In particular, he could not tolerate the prescription charges at £1 per item prescribed for these people who are deemed eligible to hold a medical card and who by that definition are the very poorest in our community. He could not accept the provision for the general medical services scheme which left it short to the extent of £25 million in the ridiculous belief that £16 million could be raised from prescription charges in the remainder of this year 1987. He knew the Health Act had to be amended and that it would take time before the charges could be implemented. Indeed his estimate was that the maximum that would be received from such charges would be £4 million and he suggested that if you were to implement such charges — because of the increased number of drugs that would be prescribed on a visit to a family doctor — there might be no saving by imposing a prescription charge.

Deputy John Boland as Minister imposed the ban on dispensing in rural areas but, significantly, although his own party in Government were pursuing a policy of financial rectitude, he did not issue the letters of allocation to the health agencies which were consistent with that approach and for which they were seeking approval. I am sure everybody here will agree that the allocations to the health boards should have been sent out as early as possible in the year. They were available on 20 January when the Estimates were published by the Fine Gael Government because Labour had left Government and they were not sent out. It is a fair question to ask why they were not sent out. I believe they were not sent out because the Government did not want to be embarrassed in the run up to the general election and the then Minister for Health accepted that there should be a prescription charge on the very poorest people in the land.

Senator Fennell referred to the chaos in the health services. I accept that there is chaos in the health services but it is caused, first of all, by the fact that the allocation for 1987 was not sent out until April. I met the CEOs and chairmen of the health boards on 2 April, gave them their allocations and discussed those allocations with them. Indeed, I might add that that was the first time the chairmen and the CEOs of the health boards were met as a group since November 1983 which again in my view is part of the problem: the total lack of consultation. The other reason there is chaos in the health services and, indeed, the reason we now are having the difficulties is the overrun of £55 million over the past two years, £36 million overrun in 1986 and £19 million overrun in 1985. In trying to effect the savings that should have been made in 1986 and 1985 problems have arisen for the health boards and for the various voluntary hospitals around the country. That is the cause of the chaos.

I assumed office on 10 March 1987 and, as I said last night in Dáil Éireann, I and my Cabinet colleagues were, to put it at its mildest, shocked to discover the real extent of the financial problems facing the country. We had to face the inherent threat that, if we did not get public expenditure under control, external agencies would step in and do it for us in a most unpalatable and clinical way. Despite those underlying financial problems, with my colleagues in Cabinet I examined the allocations proposed for the health services, added to them in certain respects, providing, for example, an extra £25 million for the general medical services which had been left £25 million short by the Fine Gael Government in their Estimate of 20 January which would have meant that the general medical services would have collapsed in the autumn of this year. I rescinded the decision to impose prescription charges and provided for out-patient and in-patient charges supported by a voluntary health insurance scheme, moderately priced. In this respect I made absolutely sure, by the list of exemptions which I included, that there would be no hardship imposed on anyone. I also restored the right of doctors working in remote rural areas to dispense medicines for those living at a distance from pharmacies.

A great deal of agitation and disturbance in the health services has been caused by the sensationalism of certain elements in society which to a significant extent has been added to by a degree of immoderate and unsubstantiable statements by people within the health services who should know better. I would be the last, as I have said on a number of occasions recently, to deny any group or individual person the right to make known their concern or to protest in a reasonable way. I do, however, find it very disturbing when there is a deliberate attempt to cause widespread public unease by suggesting that health services are being underfunded to such an extent that we cannot provide the services necessary to meet the essential needs of the people. Indeed, I think everybody here will agree that with an allocation of £1,300 million and over 55,000 people working in the services, we are well equipped to provide the necessary level of service for the people.

Senator Fennell referred to the rape crisis centre. It is important to point out that it was never the intention of the Government that the rape crisis centre should close. It was not the Government who made the decision to close it; it was not the Minister for Health who made the decision to close it; the decision was made by the board of the Rotunda Hospital. The board of the Rotunda Hospital must have seen it as low in their priorities when they decided that they would close it as an option. Indeed, it is fair to say that the Master of the Rotunda and Dr. Woods knew at the time they were criticising the Government for its closure that they themselves were a party to the view that the centre, as far as child assault was concerned, should be moved out of the Rotunda because the Rotunda is for adults and they believed the centre would be better in a child hospital location.

We are spending over £1.3 million on the services this year — in fact, £16 million more than was spent last year. In sending out the 1987 letters of allocation to health boards and voluntary hospitals I gave clear and specific guidelines to the agencies on how they should frame their budgets. I was concerned to ensure that the basic fabric of our health care system should be preserved while, at the same time, ensuring that the best possible service should be delivered within the amounts available.

The instructions to agencies required them to make necessary spending reductions in the institutional area, and in particular in the acute hospital sector. The overall bed provision in our acute general hospitals is widely accepted as more than adequate by reference to international norms. I directed agencies that community care services should be protected to the greatest extent possible and I laid a particular emphasis upon key services for the old and housebound, such as community nursing services, services for the mentally handicapped, home help services and meals-on-wheels, child care services, particularly day care and pre-schools services for deprived and disadvantaged communities and after care programmes for children leaving long term residential care.

I asked that adequate provision should also be made for boarding out payments to reflect the trend towards increased numbers in foster care and that the health boards should maintain their expenditure on these services at least at the 1986 approved levels in real terms. This approach is in keeping with the modern view about the nature of health care and with expressed governmental policy to protect primary care within community rather than hospital-based treatment. The guidelines I have referred to had regard to the overriding need to maintain frontline staff, who provide a service directly to the sick in our community, at an acceptable level.

I did not think it unreasonable that the letter of allocation should require the health boards and the voluntary general hospitals directly funded from the Department to face up to the harsh reality of the need to bring their expenditure into line with what their allocations could realistically support instead of, as in previous years, incurring overruns which essentially went unchecked. These overruns are, in fact, the root cause of our present difficulties. As I have already pointed out, the overruns of £55 million in the last two years are causing the difficulty at present.

An examination of public services generally by the Government led immediately to the conclusion that, to a very significant extent, the problem of the numbers employed in the public sector has not in reality been tackled in recent years. For instance, when I took office there were 62,000 people employed in health boards and other agencies to provide health services. Ten years ago there were 51,000. I find it difficult to accept that this increase in numbers has produced a corresponding improvement during that time in the quality of the service delivered to the patient. Given the financial difficulties facing the economy at the present time this clearly is a situation which could not be allowed to continue.

In introducing the budget the Minister for Finance announced that no public service vacancy could be filled without the express approval of the Minister for Health with the consent of the Minister for Finance. After consultation with the Department of Finance it was decided that, because of the late stage in the financial year and the random effect on services by closing down all vacancies as they occurred and having particular regard to the sensitivity of health services it was agreed that a package of (i) non-filling of some vacancies; (ii) reduction in current temporary employees and (iii) reduced scale of locum cover, to achieve an overall reduction of 2,000 posts by 31 December 1987 was agreed.

There has been considerable inaccurate public comment of late, and it was repeated last night in the Dáil, to the effect that clerical and administrative staff in the health services have been dealt with more leniently than other categories of staff as a result of the economy measures being taken by health agencies and that these grades have been spared at the expense of nursing and medical posts. I want to nail these false statements.

The factual position is that health agencies were instructed to reduce overall staff numbers by a number of means and that these reductions were as far as possible to be spread evenly across the grades. Clerical and administrative grades account for about 10 per cent of all staff employed in the health services. Less than 2 per cent of the total staff of health boards are engaged in central administration.

So far as the remainder are concerned, they are involved in delivering vital services directly to the public. They include community welfare officers, staff involved in determining eligibility for medical cards and those involved in the making of payments under the drugs refund scheme and the payment of cash allowances to the disabled and the handicapped. They pay salaries, wages and pensions; they order goods and supplies, maintain medical records and schedule out-patient clinic appointments. Senators will also be aware that the task of collecting the new out-patient and in-patient charges which are of such vital importance to the financing of the services this year will also fall on the administrators. It is clear, therefore, that the scope for widespread reductions in the administrative grades employed in the health service has been considerably exaggerated.

I am satisfied on the basis of the most recent information available that the numbers in clerical-administrative grades will be reduced proportionately consistent with the many important functions which they have to carry out.

My task now is to shape a health service which is affordable and sustainable. It seems to me that there are two critical areas to be addressed. We must have an acute hospital system which is geared to our ability to pay, which is effective and caring, and which is efficient. Alongside it and linked to all vital points, we must have a primary health care system which is capable of doing many of the things now done in hospitals. I want to elaborate on these two points.

In adapting the acute hospital system to our present circumstances, we must take a number of important decisions.

We must decide on the level of funding we are prepared to devote to this sector of the service. In making this decision, we must ensure that there are adequate funds for other services including primary health care. We must organise the system so that each hospital within it is medically viable and gives a quality service in a businesslike manner.

We must also quickly develop a form of primary health care which provides a real and viable alternative to hospital care. Such evidence as is available to me does not suggest that this is now the case. It can hardly be, as long as the general practitioner services remain divorced from other services.

I am satisfied from my own experience, from the many reports which have been completed on this subject and from the information available to my Department that there is scope for a significant reduction in the number of acute beds. However, we will only get the real benefits from such a reduction if the beds are distributed in viable hospitals, each with a clear role and part of an integrated system. The proposals for reductions which have now been put before the Department do not, in a number of cases, fit with what will be our requirements in the medium and the long term.

In my recent address to the Association of Health Boards, I made it clear that I do not believe there is any particular merit now in reducing the number of health boards. That does not mean there is not room for change, for innovation and for adaptation within the existing framework.

We can now move quickly to streamline our acute hospital system. Starting next week, as I announced last night, officers of the hospital services division of my Department, with assistance from Comhairle na nOspidéal, will commence consultations in each health board area. As Senators are aware, a team of senior officials of my Department have already been to each health board area and, indeed, to each voluntary hospital and have brought back a profile of how each of these agencies intends to effect the savings necessary this year. At present, we are studying the findings and we will be looking at them to ensure that there will be a rationalised health service in place.

Next week they are going again to meet with health board officials. They will meet with the management of health boards with the voluntary hospitals and the staff interests involved to devise a plan for each area. When that is done, the results will be considered globally in the Department to ensure they are integrated at regional and national levels. I believe there should be a consultative process in the health board areas where the health boards, the voluntary hospitals and those interested would be able to come together and would also provide an opportunity for the people working in the services to have an input into how they believe funding should be allocated within their own area to the various disciplines within the service.

Following the receipt of information from our own officials and the results of the study within the health boards between the various agencies involved we then convene a national conference of the various interests affected before finally deciding upon the definitive national plan. Because of the implications, not least in the making of allocations in respect of 1988 and subsequent years, this plan will have to be settled by the end of July.

We do not start from scratch. First of all, I must make it clear that in a number of health board areas there is no great attention required to bring them into line with what is essentially needed. They have set their own houses in order. Secondly, we have available from Comhairle na nOspidéal a great many helpful reports and recommendations. Thirdly, my Department have already undertaken a considerable amount of work in analysing the implications of the general course which I am advocating.

There are, as Senators will know, special problems in the urban areas of Dublin, Cork, Limerick and Waterford. There is, particularly in Dublin and Cork, an urgent need for better co-ordination between the voluntary hospitals and between those hospitals and the health boards. As Senators are aware, each voluntary hospital in Dublin, for example, received their allocation and then decided within their allocation how they would effect the savings this year and the services they would provide. It is very important that there should be a rationalised service and we are looking at that. For example in St. James's Hospital the board decided to close the bone marrow unit. It was not the intention of the Government that that unit should be closed. That decision was made by the board. They believed that was the decision they should make. We will be looking at the profiles presented by the various voluntary hospitals in Dublin and ensuring that there will be a proper and rational service in the city of Dublin.

I have asked the Department to proceed immediately with consultations with the various authorities in the health board areas to work out suitable arrangements for co-ordination of existing services and appropriate involvement in the future rationalisation of the acute hospital system. I am studying work which has been carried out on the adequacy of the primary health care elements of community care services. I envisage that in one or two areas, we will get some pilot schemes under way as soon as possible.

The purpose of the schemes will be to test, in practice, the extent to which alternatives to hospital care can be developed and to work out the best working relationships between hospitals and community based services. I will be asking for the wholehearted support of all concerned in the implementation of these pilot schemes. I believe that to have pilot schemes, community care and primary health care is the right way to proceed. It is important that, when we put a major comprehensive primary health care scheme in place, it should be one suited to the needs of the Irish people. We do not want to import one from another country. We also want to ensure that it will conform to the needs of people in the inner city areas, in remote rural areas and in rural towns. For that reason, I believe we should have pilot schemes in operation and then evaluate how they are working before finally putting a major primary health care scheme in place.

Finally, I am preparing a statement on our priority needs in the institutional care of the chronically sick and the terminally ill. We need this quickly so that we can properly explore all reasonable options in the rationalisation of the acute services. It has been very apparent to me over the years as a health board member and as Opposition spokesman on health matters that the funding of the health services needs to be given a detailed examination. The two months I have spent as Minister for Health deepened that conviction. I have, therefore, with the Government's approval, made arrangements to establish a broadly based review group to examine the appropriate level and sources of funding consistent with the maintenance of an equitable, adequate and comprehensive health service. I will be announcing the names of this group within two weeks. I will be asking the group to report as soon as possible.

In the two months I have spent in office I have worked very hard and I think, with all due modesty, that I can reasonably say I have got a grip on the situation — a situation which, particularly in the area of financing, has become very confused because of the wrangling in Government between the Fine Gael and Labour Parties leading to their ultimate break up. I think I know with some definition where I am going. In that period I have introduced an amendment to the Health Act and debated the regulations made to impose the out-patient and in-patient charges, and other motions including Adjournment debates relating to the so-called health cutbacks.

I have had to devote time to preparing very necessary and delayed childrens legislation and I have introduced the AIDS information campaign which I am glad to say is going extremely well. I might say in this regard that I was heartened to learn at an EC Council of Health Ministers meeting last Friday how well this country's campaign measures up to those being undertaken elsewhere.

I would, therefore, urge that when this week's debates and discussion in both Houses of the Oireachtas are finished, I should be allowed without further distraction to proceed in a rational and sensible way to tackle the problem of the health services.

It is my intention now to give intensive study to the ways and means through which we can come to grips with the problems which must be tackled. I will do so in the full knowledge that overall financial parameters must, for the benefit of the country, remain as they have now been set. I believe I can meet the challenge and that, given reasonable co-operation on all sides, we can emerge out of the present phase with a leaner, fitter and more effective health service.

An Cathaoirleach

Senator Bulbulia is graciously giving way to Senator Robb.

Mr. Robb

I should like to thank Senator Bulbulia for her generous gesture. I could not be absolutely certain that I will be here next week.

I should like, as a practising doctor in a small hospital that has been under threat for 15 years, to say, first of all, that I appreciate the way in which the Minister for Health has shown courage. It takes a lot of courage to work against the grain and that is what the Minister is doing at the moment. I do not agree with many of the things he is doing, but he has started a whole new debate throughout the country about how we need to re-look at what we mean by a health service, redefine what we are trying to achieve and try to engage both the people and the health employees in that debate.

I should like, therefore, to develop some ideas about the politics of health which may be helpful to the Minister as he goes forward in the next few months to develop a national plan. It is the function of the Department of Health to set out guidelines, but it is also the function of any Government to trust the people. There are far too many Governments today in countries throughout western Europe in which the people are not trusted and in which they are ruled by diktat and very often a rather unaccountable diktat at that.

Before moving into the thrust of what I have to say in the short period available to me and before I forget it, the Minister asked for ideas towards the end of his speech. I am sure he has heard of the wonderful word "audit" which has struck fear into the hearts of all practising physicians and surgeons in the North of Ireland. Northern Ireland fares rather badly, when it come to audit, with the rest of the United Kingdom. The northern area does not do too well in relation to the whole of Northern Ireland and Ballymoney comes out worst of all, i.e., we are the most inefficient unit but perhaps that is because the surgeon comes to the Seanad too often. We have had to look at our operation as a result of audit.

We have a national cake and the Government decide how it is to be distributed in terms of various Departments. I would like to ask how should it be distributed. How do we determine our priorities? How do we create a balance between the need for expensive specialised care on the one hand which has already been alluded to and general health care on the other? I will give a few ideas about distribution. About ten years ago a consultant surgeon in Guy's Hospital, London, writing in the prestigious journal, The Annals of the Royal College of Surgeons, under the heading "Long Live the Small Hospital", said that only 10 per cent to 15 per cent of all hospitalised ill health required super-specialist, super-technology attention and that also went for accidents and emergencies. By extension with some figures drawn up in Trinity College by Professor James McCormack, when he was the first GP Dean of a faculty in these islands, we could argue that 1 per cent to 2 per cent of ill health require specialised super-specialist treatment and 10 per cent to 15 per cent of hospitalised ill health require this treatment.

Unfortunately, the people inside our profession who have all the power to determine under-graduate attitudes to health service requirements and to postgraduate training needs, tend to come from that area of the spectrum of health care delivery inside the medical profession which deals with the super-specialist 10 per cent to 15 per cent. That is not to say it is not a very important aspect of health care delivery but it is to say that those who practise it have far too much power which brings me on to Ivan Illich.

The medical establishment has become a major threat to health. What do we mean by health? When we talk about the health service, we are talking about a disease service. We go to disease centres; we do not go to health centres. We must start by making a distinction between curing and preventing disease on the one hand and promoting health on the other. The promotion of health is a radical concept. It involves people; it involves the client; it involves the operatives.

How do we determine priorities? Having established how we will distribute our finances in relation to hospitals in accordance with the 10 per cent to 15 per cent that require this super-specialist super-technology, we then go on to say that a big central hospital is in the middle of a city, deals with its local district and it will also have a commitment to 10 per cent or 15 per cent of the hospital requirements of the rest of the region or the rest of the nation. Once we allocate our funds we have to ask ourselves what does the patient think who wants an extra nurse at night and hears there is a case being made for an extra gardener outside. What does the surgeon who wants a gastroscope think when he hears of the thousands of pounds being spent on a new car park? What do the trade union movement think when they are worried about the implications of unemployment in relation to health and they have to be convinced that the surgeons, if you please, need a percentage rise in income while the outside labour force is being reduced? Who determines the priorities? Is it right that the Department of Health should determine these priorities or, to reiterate my first point, is it not high time that in health matters, as in all other matters, we develop a new political concept whereby the people are much more readily involved and we have their confidence, and confidence as employees and as consumers, in the determination of health?

I will put forward a thought for the Minister to tease over. It is something we are putting into action next week in Ballymoney and I responded in this way to Professor John A. Murphy in a recent debate. We hope to have a first annual election of all employees in our local hospital and then we hope to set out to get the client, the ex-patients guild, set up and to have them to elect representatives and we will have equal numbers of consumers and hospital staff. When we have got that set up we will then co-opt essential key figures who have not been elected in the first place. We will, therefore, have a balance between the institutions, the employees and the client or the consumer — the patient — and they will be able to debate matters in the context of the budget given to them as a result of figures in relation to the audit which I have mentioned. They will be able to determine what the priorities are in the institution.

However, we go further — we go into the community. Why cannot we have a concept of the community health guild? To that you would bring the various organisations to which Senator Nuala Fennell and the Minister of Health have already alluded, the representatives of all the voluntary and statutory agencies in that particular community dealing with matters of health. The first thing they will learn, as I have emphasised before, is about each other's existence. They will learn about the fantastic resource which already exists in the community in which they live and that if you create a network that resource can be mobilised to try to bring about de-institutionalisation of health care in a sensible way, adequately funded with proper training and proper support. The danger at the moment throughout these islands is that we are trying to de-institutionalise health care, throw the people back into the community where those who receive them have not the training, the confidence, the back-up, the finance or anything else to deal with the problems. The theory is excellent but the practice is not and the way it has been brought about in many cases is disastrous.

There is a need for community health education. I also think that in health, as in many other areas in Ireland, it is high time we started at community level to develop the concept of the community forum, a forum in which we can discuss matters of importance to that community, be it health at a time like this, be it agriculture at a time when the European Parliament is going to drag money away from agriculture, be it use or ownership of resources or whatever, I emphasise the importance of the committee inside the institutions, the guild in the community and the forum for the people. We need to mobilise the talents of the people of good will for the well-being of the community, with guidelines provided by the Minister and he can certainly provide those guidelines if he backs them up with audit.

There is nothing more chastening than to suddenly look at the histograms which show that you are the bottom of the league, because you know you are going to go out of existence if you do not improve. Having said that, let me give a warning: do not be seduced by statistics. I had erosion by stealth in the seventies and I am now being eroded by statistics. You can have the greatest amount of gobbledegook presented to you by well-meant, highly ambitious civil servants with data processing machinery and all the power that accrues from them; you are totally defenceless and you find when you ask for the figures they do not make sense. When I last got the figures from the Department of Health in Northern Ireland I was told I had done 800 internal fixations of fractures last year, had removed 60 stones from kidneys and a lot of other absolute balderdash. When I got down to it with pen and paper I actually got the figures.

Let me then conclude with another quotation from Ivan Illich. Let us not forget that Illich who said, "The medical establishment has become a major threat to health" also said, "The only certainty in life is death". He asked questions about how much of our money, time, resources and energy were put into preventing the only certainty of life. Having said that, it is the quality of life and the state of well-being that matters. Welfare is part of well-being but it is certainly not the only thing when we come to talk about well-being. Well-being involves the being of the people and to date the people have neither been trusted enough nor involved enough, nor given the power to make their participation effective.

With those thoughts, I wish the Minister the best but I will give a warning — if you throw cuts at the Irish people without trying to rationalise them, if you do it at this speed and you do not have the politic locally to cope with it and to engage the people in dialogue it will be a disaster.

Mr. McGowan

I am sure it is right and proper to bring in the motion and to allow for discussion on this very important subject because it allows for debate and it gives an opportunity to take a rational look at something that has been debated and debased around the country. It gives the Minister an opportunity to speak to the media and to the public and to repeat what he has been explaining in a very reasonable, cool, calm and proper way over the past couple of months. The Minister has been helpful. His attitude has been right and balanced and any reasonable person would understand his language. The organised hysteria in some areas is doing a major disservice. Senator Nuala Fennell is perfectly right to say that it is regrettable that Fianna Fáil have had to be involved in the cutbacks. She said also that somebody has to be responsible, and the Minister for Health of the day and the Government are responsible.

The Minister is acting in a very responsible manner but all of us deplore what is happening in some areas. I want to use this opportunity to deplore what is happening in my county, in Donegal. All kinds of ill-informed people are on a bandwagon trying to upset the health services in my county, organising campaigns and causing disruption. It is being organised from a hospital headquarters in Letterkenny by people who are only concerned to take what political advantage they can to stir up and to cause confusion and misunderstanding. I say to those people that they will not succeed at the end of the day, because this is far too important a subject to mislead people into believing that the present Minister and the Government are responsible for the serious cutbacks and that they have an alternative. A campaign is being organised from St. Conal's Hospital, Letterkenny, a hospital with 298 patients. It is costing £6,500,000 per year or £26,000 per patient, or £500 per week per patient in St. Conals hospital in Letterkenny. I would like to see a close review which, as the Minister has indicated, he will undertake shortly. There are areas of waste to be looked at and there are waste and economies to be effected in St. Conals hospital. The heat and energy costs in that hospital are greater than those for all the other medical institutions in County Donegal. It is an old and out of date building.

The reason I raise the matter here is that I am surprised that the people who organised a campaign of disruption would not first look on their own doorstep to see where economies could be effected. If economies were effected in St. Conals hospital not one nurse would be out of a job in County Donegal. I ask the Minister to contact the health board and to have a hard look at that aspect of the health services in County Donegal. I am certain that if he does that he will find that economies can be effected, that nobody will lose a job, no wards will be closed down and no service withdrawn. I am satisfied that those who are now organising the disruptive campaign in County Donegal would find the solution on their own doorstep if they wanted a solution. They will not go unchallenged and will not blame the present Government and the present Minister for Health for cutbacks. It is upsetting to find restrictions and cutbacks or withdrawal of services and young nurses losing their jobs.

I am very interested in a pre-election brochure which was put out in the north west region. The brochure starts by saying:

Hospital — estimated cost — £43 million, the Government go-ahead for Sligo General Hospital extension came in July 1986. The Minister of State, Deputy Nealon, announced the issue of tender documents in November. The project will give Sligo and the North West a regional hospital equal to the best in the country. At peak periods of construction about 400 people will be employed on site. It is the largest State project ever undertaken in Sligo.

It is no wonder people who read that believe it but they found out within a few short months of the change of Government that wards were closing, that there were restrictions on expenditure. They must have asked themselves what kind of people are in Government and whether they care for anyone. I submit that the present Minister's approach is proper, that time will prove he is a caring conscientious Minister who is prepared to talk, to go on television and so on to explain what he is doing. He should continue to do that. At the end of the day the truth will prevail. Then those who have an unreasonable approach now or who are being misled will clearly understand that the situation is such we have to effect economies to continue to provide a service. The Minister has a thankless job. It will take all the courage and calmness he possesses to deliver on and keep up the health services within the constraints of the economy.

Mrs. Bulbulia

First, I congratulate the Leas-Chathaoirleach on his election.

I have listened with great interest to the contribution of the Minister whose speech I found long on aspirations but I wish him well in the plans he has enunciated here this evening. He stated that he has now got a grip on the situation. I have no doubt that he likes to think he has but that is not the reality which I know obtains and which I believe he knows obtains also. The general public as well as the patients and those working in the health care services have no such perception. They do not feel that the Minister has a grip on things.

Senator John O'Connell's contribution was breathtaking in its audacity. When the Senator was a Member of another House he was one of the most virulent attackers of the previous Minister. His attacks were highly personalised and in many instances objectionable. He now displays the zeal of a convert. I would think it is an obvious cause of a poacher turned gamekeeper and I am interested to see him in that role.

The motion put forward by Fine Gael has been deliberately misinterpreted by Senator O'Connell. The Minister expressed some confusion as to what the motion meant. I would point out to the Minister that the motion does not request any further funding or any greater degree of financing. It asks the Government to reconsider their budgetary proposals in relation to the health services because of their serious implications for the well-being of the general public. In other words, it requests the Minister to go back to the drawingboard because there is no plan, coherence or cohesion about what we all know is happening in the country. In the course of my contribution I do not want to be alarmist or to scaremonger or to worsen a situation we all know to be very bad. I accept the calls and the need for a reduction in health expenditure but I contend that what is happening now is havoc and chaos and is entire mayhem. I will develop that point as I make my contribution.

Senator O'Connell was interesting in that he claimed blithely that there were no dissidents in Fianna Fáil on the health service issue. I would like to advert to the situation in my own constituency where a Fianna Fáil TD, Jackie Fahey, has renounced and denounced——

An Leas-Chathaoirleach

I do not wish to interrupt the Senator but it is unusual to name a person from the other House.

Mrs. Bulbulia

I accept your ruling. It is embarrassing to have to admit to this and to have to go into it but a Fianna Fáil Deputy in my constituency has denounced at public meetings another Fianna Fáil Deputy in my constituency — that latter Fianna Fáil Deputy is a member of the South Eastern Health Board and took part in decisions which affect the vital interests of the first Fianna Fáil Deputy. I would advert to another member of the South Eastern Health Board who was "notorious". I am putting that in inverted commas and not in neon lights.

Mr. Ferris

From South Tipperary.

Mrs. Bulbulia

There is one from South Tipperary as well. The list is endless.

Mr. Ferris

Most notorious.

Mrs. Bulbulia

The long suffering taxpayers of this country were conned at the last election. They voted for a party who promised there was a better way, a party who were saying that health cuts hurt the old, the poor and the handicapped. It is no wonder the people are thrown into absolute confusion and are incensed and particularly angry with the members of that party at Oireachtas and at local authority level in every constituency in the country. It is a most painful time because the hypocrisy of that party has been exposed massively.

I am speaking on this motion because I am gravely concerned at the crisis that has arisen in our health services resulting from the extraordinary U-turn of the Government party who prior to and during the general election campaign kept on insisting that there was a "better way". The posters shouted at us from every gable wall that health cuts hurt the poor, the old and the handicapped. Those people and particularly members of my party who sensibly called for necessary reductions in public health expenditure were reviled and accused of being monetarist and Thatcherite and of lacking compassion and concern. That is why the general public finds themselves bemused at the spectacle of that same party now in Government wielding a cost cutting axe on our health services with, it appears, a certain unbridled enthusiasm, leaving in its wake fear, uncertainty and, indeed, it is not an exaggeration to say near panic, particularly amongst the elderly and the geriatric. There is no overall coherent planning. I am not talking about the Minister's aspirations; I am talking about the situation now. There is no central policy directive. The application of these cuts is clearly seen to be chaotic, unfair and inefficient. The measures decided upon have all the appearances of having been hastily cobbled together and could be described as a disordered rout rather than a planned, phased programme of cost-reduction which was always envisaged by the former Minister and for which he was castigated and reviled every time he attempted to suggest it. Where is the strategy now, not when the Minister's task force has reported? Where is the national health plan? We just cannot pull the plug on our carefully built-up health services, financed by the taxpayers. It is clear that strong action has to be taken, but there is no need for such chaos. One would have expected a firm, consistent and consultative approach. My question is: is random cost cutting without informed evaluation currently Government policy? Certainly all the evidence seems to suggest that, in fact, it is.

Obviously, I want to speak about my own health board region and I am not adopting that tactic employed here this evening by Senator O'Connell who was inclined to blame certain CEOs for a lack of consultation and a lack of involvement with local people. The South Eastern Health Board had two meetings to discuss their planned cuts of £6.3 million. At the first meeting the motion to proceed with the package brought forward by the CEO was lost because of one dissident Fianna Fáil member of the South Eastern Health Board. The second time the motion was passed, and those who passed it talked about it being the lesser of two evils and Hobson's choice. In fact it was a panic decision. Three hundred and seventy three jobs are to go in the region, 170 acute beds and 312 psychiatric beds are to go, dental, ophthalmic and chiropody services are to be discontinued. Just to give and idea of the pettiness of the decisions arrived at, the chiropody service for an entire region costs £65,000 and that is to be completely obliterated. Who will suffer from that? The old, those with diabetes and those most in need of this little, little service which would give them increased mobility. Transport to clinics has been virtually eliminated. The package in relation to Waterford city and county is fundamentally flawed. It hits at mothers, children and the old. I make no apology for talking about Waterford because it is the centre of the regional hospital and it is the hub of the health care services in the south-east region.

The Minister talked about the need to bring about co-ordination between voluntary hospitals and health board hospitals and the light would appear to be dawning. If that is the case I am pleased, because the hospital I am particularly concerned about — one of two in fact — the one I wish to speak about at the outset is the County and City Infirmary in Waterford. I echo what Senator Robb said in his contribution, which was as usual thoughtful and reflective. He said "long live the small hospital" and this applies absolutely to the County and City Infirmary in Waterford which has a long and proud tradition, which has served the people of Waterford and surrounding areas over a long number of years and which is held in great esteem by the general public. It is not going too far to state that it is a beloved institution.

In marked contrast to other voluntary hospitals, many of which have been asked to take cuts of as little as 7 per cent, the Infirmary has been asked to take a swingeing 24 per cent cut amounting to £339,000 in its annual allocation of funds from the Department of Health. In the remaining months of the year it would mean that the infirmary would have to take a cut of £1,000 a day. I want to know — I hope the Minister will reply and I hope he will say he will improve on its allocation — why this hospital has been singled out to take such an inordinate cut compared with the other voluntary hospitals. The Infirmary management committee stated that, unless the allocation is increased, the hospital will be forced to close in September. They made this statement with the greatest of reluctance but also the greatest of concern to ensure that whatever health services are supplied in the Infirmary are efficient, effective and ethically of the highest standard.

Closure of the Infirmary is unthinkable and I am sure my colleague Senator O'Shea will have plenty to say about this when he makes his contribution. Public representatives of all parties in the constituency — and there are no dissidents on this one — have all rejected this concept. They pledged themselves to ensuring that the hospital will be kept open. Waterford City Council at a recent meeting unanimously called on the Minister to restore the infirmary's financial allocation to a realistic level which would allow the hospital to continue to provide the range and quality of service which it has provided for so many years. There is overwhelming public support for the hospital action committee. Thousands of signatures have been collected in support of keeping the Infirmary open and it can only be kept open if it gets a realistic allocation.

The arguments for keeping it open are not based on sentimentality. They are strong, cogent arguments grounded on the very real medical and surgical needs of the area. The closure of this hospital would have most serious repercussions because 1,600 operations are carried out each year in the infirmary. A third of the surgical needs of the entire area are dealt with there. The casualty services deals with 14,000 visits annually and other out-patient visits number 10,000. Ardkeen or Waterford Regional Hospital, as it is now called, would not be able to cope or, indeed, compensate for this huge loss of service as it is already working to capacity.

Something that does not appear to have been countenanced at all when the decision was made about the Infirmary's allocation is the fact that building has commenced on the new Ardkeen Hospital and its services will inevitably be affected. Also overlooked were other significant factors. Waterford is geographically isolated in hospital terms. The nearest general hospital is in Kilkenny, 30 miles away. The SouthEastern Health Board have fewer acute hospital beds per capita than any other region. The Infirmary has had no greater capital portion to the population than any other region. The Infirmary has had no capital allocation for 20 years and any money that was raised on the capital side was raised by voluntary subscription. People were enormously generous. The Ladies Voluntary Aid headed a wonderful committee that brought in thousands of pounds to support the Infirmary.

I should also like to advert to the District Hospital in Lismore which has been affected by these cuts and to point out the extraordinary situation which has arisen in relation to the decision to pull the plug on this one. It is a 21-bed district hospital and the decision is perceived by the people of the area as a brutal assault on the only hospital in the area. It serves the towns of Lismore, Tallow, and Cappoquin, the village of Ballyduff and a vast rural hinterland stretching to the borders of north and east Cork. To leave that area without its only hospital seems an extreme decision. Costs are not great; there is a staff of 12, with an annual expenditure of £140,000 which is peanuts in the context of the total allocation to the South Eastern Health Board. The elderly people in that hospital are frantic at the prospect of being transferred elsewhere, far from their loved ones. As a member of An Bord Altranais I should like to comment on the chaotic nature of the cuts in public expenditure on health for this particular body.

The Minister will be aware of the Central Applications Bureau which was a direct result of The Nurses Bill, 1986, passed in both Houses of the Oireachtas. Within six months of the launch of this badly needed CAB, the number of places for student nurses has been drastically reduced and it was extraordinary to hear the CEO of An Bord Altranais being asked in a radio interview about student nurse places for 1987 and proclaiming that he knew nothing about it; he had no word from the Department of Health; he could not really comment because he did not really know. Such a lack of co-ordination is indefensible and should never be the case. There is no information on student nurse intake. There is total confusion among those who have applied to the CAB and the whole system has been undermined before it has even got off the ground. There are tremendous implications for nurse training. I see a run down of a system very carefully built up over the years. I want to know what will happen to nurse tutors. Indeed they want to know what will happen to themselves. Will students be replaced by staff nurses? To remove the 1,600 student nurses who are taken in each year to our hospitals will have serious implications for patients and for the general workforce. There is no guarantee that existing student nurses will receive their required training and will, therefore, be in contravention of EC legislation.

An Leas-Chathaoirleach

The Senator's time has expired.

Mrs. Bulbulia

There is so much more I could say and I am prepared to have another go on the next occasion. My wish is to see a well financed, lean and tight health service but, above all, with some co-ordination, planning and perceived intelligence at the top.

Debate adjourned.

The Seanad adjourned at 8 p.m. until 10.30 a.m. on Thursday, 21 May 1987.

Seanad Éireann debate - Wednesday, 20 May 1987