I move:
"That Seanad Éireann notes Shaping a healthier future — A strategy for effective healthcare in the 1990s.”
Health Care Strategy: Motion.
I am pleased to have the opportunity today to address Seanad Éireann on the subject of the national health strategy and to await the response of Senators to what I consider to be the most important document that I have been involved with since I became Minister for Health. I welcome the recognition of its importance which is implicit in the decision of the House to have this debate today.
I believe that the health strategy has the potential to transform the health services of this country. For the first time there is a clear statement of the underlying principles, the key objectives and the strategic direction of the health services. It is clear from the general reaction in the last two weeks since the strategy was launched that there is a widespread recognition, both within the services and without, that a blueprint now exist for a more effective, equitable and accountable health care system.
When I became Minister for Health I was determined that I would build on the existing strengths of the services and implement the reforms needed to overcome the weaknesses. Just over a year ago I announced that, with the assistance of my Department, I would draw up a comprehensive health strategy. In developing the strategy I carried out a comprehensive examination of both the strengths and the weaknesses of the health system.
Foremost among its strengths is the quality and commitment of its staff. Another important asset, the extent of which is perhaps unique in Ireland, is the involvement of the voluntary sector as a substantial and integral part of the public services. I was also conscious of a real enthusiasm within the services for development and change.
The principle weakness in the services is a lack of clarity about the overall focus or direction of the services. In the absence of specific goals or targets, it is very difficult to assess real effectiveness. This situation is unsustainable in a service which is spending over two and a quarter billion pounds of taxpayer's money each year and which could spend much more on undoubtedly worthwhile developments if resources were available.
A second weakness, and one which has long been recognised, is the inadequacy of community services and of appropriate linkages between community and hospital services. This works against the objective of providing appropriate care in the appropriate setting. Finally, it is clear that the organisational and management structures of the health services need to be significantly updated if real progress is to be made in tackling the other weaknesses.
The health strategy addresses all of these weaknesses in a clear and cohesive manner. Its title, Shaping a healthier future — A Strategy for effective healthcare in the 1990s, conveys its main theme, the reshaping of the health services in terms of a clear strategic direction so that improving people's health and qualify of life becomes the primary and unifying focus of all our efforts.
There are three important principles which underpin the entire strategy — equity, quality of service and accountability. The Government's commitment to social justice has been seen in a wide range of policies since we took office, but there are few areas of Government policy which can have a greater impact on social justice than health policy. I am especially pleased that in endorsing the health strategy my colleagues in Government have agreed to the clearest statement yet that our health services should help first and foremost those whose health needs are greatest.
It is now an established fact that factors such as unemployment and poverty are linked with poor health status. We also know, and have known for some time, that certain groups, such as travellers, have a health status far below that of the population as a whole. The health strategy contains a number of measures which will address this inequality, the most innovative of which is the creation of health development sectors. This means that each health board will be required to identify within their region those sectors which need special attention in terms of targeting health services. These sectors may be geographic areas, or they may be specific population groups such as travellers. The strategy explains how the health services will focus especially on improving the health status and quality of life of those sectors.
The second principle is the measurement of quality. This has several dimensions. The formal measurement of the technical quality of the services will become an essential, integral part of their provision, and all health care professionals will be expected to become involved in ongoing clinical audits of their own areas.
However, there are other aspects of quality which can have a marked effect on the patient's satisfaction or otherwise with the services provided, aspects such as dealing efficiently and courteously with patients and showing a sensitivity to their requirements. These aspects will also be evaluated through regular surveys.
The third principle is accountability. The health strategy sets out new arrangements for improved legal and financial accountability, but it also goes beyond that. It sets out a new approach to the provision of health care under which everyone providing a service knows what is required of them and accepts responsibility for the achievement of agreed objectives.
The health strategy sets out the decisions which the Government has made regarding organisational structures and will be followed by the necessary legislation. The principal decisions are as follows. The Eastern Health Board will be replaced by a new authority which will have comprehensive responsibility for all health and personal social services in its region. The remaining seven health boards will also have full responsibility for all services within their regions. There will be a much clearer distinction between the responsibilities of the board and the management in each health board and to emphasise this they will be renamed as health authorities. The Department of Health will no longer be involved in the detailed management or direct funding of individual services. The independent identity of the voluntary agencies will be fully respected and they will benefit from formal agreements with the health authorities which clearly set out their service requirements and the associated funding.
I believe that the basic concept of the regional health board is fundamentally sound — I informed the members of the Association of Health Boards of this when I spoke to them last weekend — and has served the country well since its introduction in 1971. The division of administration into eight regions has provided a strong element of local democracy in the health services. The local populations now identify with the boards for their regions and the planning and delivery of services has evolved effectively in that context over the past 20 years.
However, it would now be widely accepted that the roles and responsibilities of the boards, their managements, and the various agencies with which they interact, all need to be clarified and placed within a stronger framework of accountability. The detailed measures which are necessary to bring this about will, of course, be debated when the necessary legislation is put before the House.
The strategy document is in two parts, as Members will have seen. The first part, printed on white paper, is the strategy proper — five chapters explain how the system will be reshaped to bring about the necessary transformation, in accordance with the principles I have described. The second part, printed on blue paper, is a four year action plan which itemises the detail of what is to be achieved in each individual service. A good example is the dental services, on which we have had a debate for the last two hours. The outlining of what is to be achieved in dentistry is clearly set out. The Health (Amendment) Bill, which has just been passed by the House, is an important element in the strategy on dental services. The first part of the strategy document outlines a clear overview and strategic direction and the second part outlines a developmental strategy, consisting of a four year action plan, for every sector in the services.
The objectives and the targets set out in the strategy and the action plan do not just deal with service developments. They also deal with the importance of focusing our health promotion policies on tackling the main causes of illness and premature death. I was intrigued by the debate on the Order of Business, which showed Senators want to be involved in the enhancement of their own health. I applaud and support this. There are very significant potential reductions in the extent of illness and premature mortality if we can, as a community, adopt the appropriate preventive measures. A cohesive programme to bring this about is included in the strategy.
When I launched the strategy, I said that the most important message I wanted to convey was that the strategy is neither designed nor intended for the library shelf. Our actions today show this is the case. I intended it to be the working agenda for everyone in the health services from now on. The transformation which is required affects everybody — their way of thinking, their approach to the patients or clients for whom they are responsible and the basis on which they take everyday decisions. Their participation in the implementation of the strategy is so crucial that I have arranged for a short summary of the document to be distributed to every single person working in the health services.
I am also arranging that the full document will be widely available and accessible, and that meetings and briefing sessions will be held throughout the services to help explain the new approach. It might be of interest to Senators that the initial print of 10,000 copies of the document has already been distributed. There is huge demand for it, not only from health services workers but from the general population. Some 80,000 copies of the summary have also been distributed. People are concerned about health and are engaged by a new strategy. I am heartened by the responses we have had to date.
I have also made it clear that the implementation of the strategy will take account of the views and ideas which emerge in response to it. It contains an explicit invitation to all interested parties to consider and debate the strategy and its implications. I will read with interest the comments of Members today about it. The strategy sets out broad principles and objectives, but these will have to be translated into detailed plans at national and local level. I want to see the widest possible participation in this process.
I am very pleased to have been the Minister responsible for this landmark document, but I am also conscious that the expectations which it will raise must be delivered on. I know that this strategic plan, framing objectives for the health services to achieve, structures to achieve them and mechanisms to measure progress, will be welcomed by all who work in and depend on the health services.
I am very encouraged by the initial reactions which I have received since the launch. While various individual proposals have been welcomed by the sectors concerned, I am particularly pleased with the general recognition that, above all else, the document provides a clear strategic direction for the services as a whole and that it will enable everyone involved to work together more effectively on "shaping a healthier future".
I congratulate the Minister on drawing up a comprehensive health strategy programme. It is a blueprint for the health services until the end of the century. The first part of the document sets out the principal purpose of shaping a healthier future, so as to give a clear sense of direction to the health services in the way they are planned and delivered. The second part sets out a four year action plan for the implementation of the strategy during the period 1994-97.
The key aspect of the strategy is to redirect the health services towards a health promotion approach, based on encouraging people to take responsibility for their own health and providing the environment and support necessary to achieve this. It sets out a number of targets and outlines how they are to be achieved. I was relieved to note that the recommended sensible limit of alcohol consumption for males is 21 units a week. This is equivalent to 10.5 pints of beer. It is unlikely that I will exceed this limit but I fall short of another of the document's targets, which encourages light physical exercise most days of the week. The action plan also deals with the dental services, which we dealt with this morning, and the health of women, children and travellers.
A chapter deals with drug abuse and I welcome the measures proposed by the Minister to deal with the problem, which include primary prevention programmes in schools, dissemination of information through a public health campaign and the provision of at least four additional primary care clinics to service catchment areas of Dublin. I welcome the involvement of general practitioners in the implementation of the methadone Protocol. I am pleased that the Department of Health will implement a four strand strategy based on surveillance, prevention, care, management and anti-discrimination. Prevention should be given priority and I am glad that the programme will enhance the existing primary education on HIV and AIDS. I welcome the provision of additional satellite clinics for drug abusers. There are drug problems in my area. I appreciate that additional finance is being made available to the Eastern Health Board to create these clinics. If drug addicts are to be treated properly with methadone, there should be no more than 30 or 40 people attending a clinic on any one day.
One of the most extraordinary aspects of the document is the reference to the rapid rise in the number of people in the older age group. This poses a special challenge for the health services over the next four years. The programme states that over this period priority will be given to the strengthening of home, community and hospital services to provide much needed support to elderly people who are ill or dependent and assist those who care for them.
I am pleased to note that substantial progress has been made in recent years in reorganising the mental health services and that this will continue, that people with psychiatric problems will be admitted to general hospitals rather than psychiatric hospitals and that the number of people in psychiatric hospitals will be phased out to live in the community. I compliment the Minister on the money he has made available to the health boards to enable them to carry out this proposal.
The four year action plan is a very challenging one and I wish it every success. However, today I want to address the role of the health authorities. Legislation will be introduced to provide for a new authority in the eastern region. Under what is proposed, the Department of Health will be freed of its involvement in the management of individual services and will be able to concentrate on setting overall health objectives, negotiating health estimates, determining the financial allocation of the new authority and evaluating services and financial performance against the national objective. In other words, it will alleviate the burden of the day to day running of these authorities.
In order for the new authority in the eastern health region to fulfil its role, it is important that the necessary powers and functions are delegated to it by the Minister. It follows that the new authority would allocate a total budget for the region over the total administrative areas envisaged, taking account of the population needs resulting in the provision of an identified range and level of services in each area.
I understand that the new authority will ensure that health services in the region are delivered in an integrated and co-ordinated way. This new integrated approach to health care delivery is very important having regard to the existence of separate large hospitals, the number of isolated smaller specialist hospitals in Dublin and the stand alone maternity and paediatric hospitals which has led to a degree of fragmentation of specialised services on separate geographical sites.
As a member of the Eastern Health Board I am very conscious of the significant role and the high level of services provided by the voluntary hospitals in the Dublin area, both for patients from its own area and from other health board areas. I fully accept that their integration into the wider health and social services is necessary for the planning and delivery of a co-ordinated and effective service. I am pleased to note that the Minister has stated that the board of the new authority will be responsible for articulating community views and will have an input into policy formation. I recognise the importance of ensuring that the views of consumers of the service are fully reflected in their organisation and delivery.
The document states that the legislation will be general in nature and will supply the framework within which the statutory and voluntary agencies will operate. As the Eastern Health Board recognises, given the role of the new authority and the wide range of interests which exist in the health and social services field, the composition of the board of the new authority will not in practical terms be totally representative. The board should, however, be broadly representative and its size and composition should be in line with the proposed role which is strategic rather than operational.
The health board is of the view that at least 51 per cent of the members of the board of the new authority should be locally elected representatives nominated by the local authorities in the region. The remainder of the members should include persons nominated from the voluntary sector or appointed by the Minister for Health and professionals with appropriate expertise elected by the members of their professions. The mix of local elected public representatives and practising health professionals as members of the Eastern Health Board since 1971 has worked well and I would like to see a continuation of this type of representation on the board of the new authority. This would not preclude development and professional input as part of the normal management process.
I would be grateful if the Minister would take these views into consideration when he is bringing in the legislation for the new health authority in the Dublin region. I thank the Minister for this blueprint for our health services over the next years. It is a very challenging document and I congratulate him on producing it.
I wish to share my time with Senator Roche.
An Leas-Chathaoirleach
Is that agreed? Agreed.
I congratulate the Minister on his very positive approach. This document is concerned with health promotion, general practitioner services, dental services, women's health, family planning, children's health, child care and family support services, travellers' health, addressing drug misuse, food and medicine control, acute hospital services, HIV and AIDS patients, ill and dependent elderly, palliative care and people with mental illnesses, mental handicap and physical or sensory handicap. That is a very comprehensive list. It shows the determination of the Minister and the Government to ensure that our health services are on a par with those worldwide.
I am pleased that some of these services have already been implemented by my own health board. We had a public briefing on it the other day and we were very pleased to see that much of what was in the document had already been implemented. I am delighted that voluntary organisations are now playing a greater role and that there is greater communication and co-operation between the voluntary organisations and the health board personnel. When we started to develop community care and putting psychiatric patients into high support hostels there was resistance in the community. We often asked if the community wanted community care. Thank God that has changed. We have now proved and the community has accepted that the community approach is the best one.
It is sad that in this day and age we need to have services to promote health and to explain to people how to take care of their health. Many people are abusing their health by the misuse of various substances, such as alcohol, drugs, overindulgence in smoking and so on. This all costs the country millions of pounds because many of the problems we face today are avoidable. Many accidents are avoidable and should never have happened.
The booklet which accompanies the Shaping a Healthier Future document should be sent to every school. I appeal to every teacher to spend an hour with their students discussing this booklet. I believe that would do a great deal of good. Students are brought to this House — and we are delighted to see them — to the museum, and so on. However, I have been advocating for years that we should bring them to some of our high support hostels, accident units, alcohol units and jails to let them see the other side of life. We show our children all the good things in life but there is, unfortunately, another side which is sold very cleverly and efficiently. Advertisements show the glamour of teenagers drinking but not the abuse. We do not see young people in cardboard boxes or lying along the streets as a result of alcohol abuse. This side is not shown on television.
The two biggest problems in society today are the abuse of drugs and alcohol. For the first time ever a strategy is to be put in place dealing specifically with drugs and alcohol. This is very important. I believe that 60 per cent of our social problems do not result from a lack of money but from the misuse of money. People receive quite a lot of money in social welfare payments and if it was spent in the right way their standard of living could be much higher. Unfortunately, the drug barons are out there and some people are addicted to alcohol. These abuses cause an enormous drain on the health services.
I am pleased that the Minister has adopted a four year plan; this is a very positive approach. The Minister will go down in history as the person who took decisive and positive action to improve the health services. I was pleased last year when extra money was provided to deal with waiting lists. The money did not get lost, as happened so often in the past. Services can be provided in Northern Ireland at a much lower cost than they can be provided here. That should not be the case. I have repeatedly said at estimates meetings of the county council and the health board that we should not ask for more money. Instead, we should be specific and precise regarding how the money will be used. Are we using the money to the best advantage and are we getting value for money? We have lost too much money. We do not know the cost of operations or any unit of health. The strategy will focus on this area.
If one employs somebody to paint one's house, one knows how much it will cost. However, if one goes into hospital, one does not know how much it will cost. It is not good enough nowadays to say that an operation in one hospital will cost £1,700 while the same operation will cost £2,400 in another hospital and £3,500 in another hospital. This type of variation arises in the orthopaedic area. We must get to the fundamentals of getting value for money. I am delighted that this will now happen.
I welcome this strategy. I would have liked to have said more but I wish to share my time with Senator Roche. The Minister will go down in history as the man who played a leading role in improving the health services. I am particularly pleased that the Minister appreciates and values the work of health boards. I have repeatedly made this point. Over the years, many journalists said that one single board, Sláinte na hÉireann, could do the work of health boards. However, they were not in the services and when one asked them questions they could not answer. I am delighted that the Minister realises this point. I assure him that he has the full support and co-operation of every health board in Ireland in the large task facing him. We will ensure that the strategy will be a great success.
Senator Roche, you have approximately 11 minutes.
I thank Senator Farrell for sharing his time. He is most generous. However, 11 hours would be insufficient to deal comprehensively with the health service.
I welcome the Minister to the House and I heartily commend him for this document. It is almost 25 years since the new health service structures were put in place. In that time, there have been vast changes in society. The technology of health services has changed dramatically and incomprehensibly. There are daily changes in the way services are delivered and in what they cost. The entire ethos of the health service has changed from an institution basis to more community based care. The cost of health services has grown dramatically and out of all expectations. In 1970, if one had told former Minister Childers, when he enunciated the new principles for health administration, the type of costs that would be involved, he would have looked at one as if one had lost any sense of reason or rationality.
We have a good health service and I was very pleased when Minister, Deputy Howlin, made that point at the weekend. We do not need to apologise. We need to ensure that our health services are improved. I commend the Minister and his Department and we must ensure that every punt spent on the health services delivers a punt. There has been confusion in the structures and one of the great benefits of this document is that it will put in place a more clear cut set of structures. However, before I deal with the framework, I wish to deal with a number of specific points in the document.
I welcome the Minister's undertaking that there will be better identification of the needs to be addressed. We need to make our health services continuously client oriented. We must recognise that they exist to serve that patient, not to serve the professionals, the consultants or occasional political ambitions. They are there for the people and that message has come across repeatedly in pronouncements from the Minister, Deputy Howlin. He should be commended for this. It is made very clear in the strategy document. The document also calls on the need for more clear cut evaluation. Unless we have research, we will not have development, rather confusion and muddle. The necessity for evaluation, monitoring and establishing objective systems of monitoring is very clear in the strategy document. It is to be commended and we all welcome it.
The Minister's strategy document, as Senator Farrell said, focuses on 16 separate areas of service development. We could spend an hour on each of those areas and I wish to touch on four or five. The general practitioners service is the backbone of the medical services. The Minister correctly recognises this and he undertakes in the document that there will be better organisational support. In the Eastern Health Board area in recent times, for example, we have made additional back up services available to GPs. It is entirely welcome, as Senator Doyle who also serves on that board knows well. By making the laboratory services at Loughlinstown Hospital available to north Wicklow GPs, we have created a situation whereby a much better service is delivered to patients under the GMS and to paying patients of the GP service.
There is a great deal to be commended in the GP services but there are occasional lapses. There is a need for some form of ethical scrutiny of the way some GPs operate. I mention in particular the politicisation of the GP services of the GMS in 1992. I realise that the medical practitioners have an absolute right to lobby for every penny to which they believe they are entitled. However, there was a particularly high profile GP service in Bray and it terrified members. People know of this. There was one unfortunate occasion when a man who suffered a serious nervous breakdown came to my house in such a state of distress that he had to be taken by car to his home. His wife had to be called from her workplace to calm him down. That is unethical and unacceptable. People who operate on that basis do not have a place in the GMS. Sadly, in that case, having beaten the big political drum, that particular GP service did not take the trouble when the dispute was settled to go back to all the patients and say that their medical cards would not be removed as of 17 December 1992. I wish I had more time to deal with this matter but, unfortunately, I do not.
The Minister also mentions the public dental service. There has been a tremendous amount of improvement in this area. We should commend the Minister, the Department and the health boards for what has been done. However, there is still a huge amount to be achieved. In his introduction, the Minister says that neither geographical location nor one's relative wealth should determine the services one receives. We must all accept, particularly in the area of orthodontic care, that wealth and one's geographical location determine the quality of service. This document, the Government, the Minister and all Members of the Oireachtas are determined that this should no longer be the case. I welcome that commitment. There is still a huge amount to be done regarding that service. I call on the dental association to assist the Minister and the health boards in a partnership to resolve the remaining problems. A huge amount has been achieved in the dental services but the task is not endless. If there was a comprehensive partnership approach, the remaining problems could be resolved.
The Minister indicates that a comprehensive plan for women's health will be published. It is astonishing at this stage that we are still talking about a comprehensive women's health service. We talk about services for minorities and correctly so. However, we are dealing here with 51 per cent of the population. As far as I am aware, only one health board has so far adopted a women's health policy. That document, adopted recently by the Eastern Health Board, was marred by a mischievous debate as to the degree of support for Well Woman centres. The practice I mentioned in the case of the GMS played an interesting role in that but less they appear illiberal, they kept their hands well disguised while they did their mischief.
The Minister mentioned specifically care in the community for elderly people. The age profile is changing dramatically in this country. We will all be old some day, if we have the sense to get out of politics and last that long. It is a privilege to service the elderly's needs yet we are not doing it in a comprehensive way at the moment and we will not until we make this a clear strategy objective. This is done in this document. I welcome the commitment to improve services for the mentally ill.
I want to address the issue of the framework for the services. In 1970-1971, when we established the health boards, we put in place a new health framework. I was pleased when at the weekend Minister Howlin identified the health boards as having served this nation well. No human organisation is perfect, but the regional health boards have done a good job. I was particularly pleased when the Minister gave commitments regarding the ongoing composition of those boards. I want to say something about the boards themselves and the proposition that all health care services and personal social services are to be brought under the single new unified health authorities.
That is a very important step. Its importance can be illustrated by reference to the Eastern Health Board. In the EHB area at the moment approximately £600 million per year is spent on personal social services and on health services. Less than half of that is actually controlled by the Eastern Health Board. The balance is doled out in a variety of forms through the Department of Health and the huge amount of voluntary organisations that do such an extraordinary job in this area. It is a fact that the Eastern Health Board — the country's biggest, which deals with one third of the population — does not have any of the major hospitals in its area under its direct control. We have the three hospitals at Blanchardstown, Naas, and St. Columcilles at Loughlinstown, but they are not major hospitals. The major hospitals are voluntary ones and in the development of their services their relationship is not with the body that should co-ordinate their services but is on an individual basis with the Department of Health. Equally, all the voluntary organisations, including the Autism Society and many others, must individually take their supplicant's cup to the Department of Health.
When the new health structures were created under the 1970 Act the belief was put firmly in the minds of most people that we were creating a dichotomy between the person responsible for policy, the Minister, and the administration of policy, which would be at health board level. But because that was never successfully achieved there has been a degree of unnecessary overlap and areas of controversy. I can think of one controversy — though I am tempted to mention it by name, I will not do so — where, because the health board was dealing with a voluntary body at one level and the Department of Health at another, unnecessary controversy prohibited a voluntary organisation from coming on stream for some time. By bringing the voluntary organisations and the health authorities clearly together in a partnership we should avoid that in future.
At the weekend conference in Wexford the Minister mentioned the composition of the health boards. I know it has become fashionable to be cynical in the extreme about the role of elected representatives. For some reason we can all celebrate the collapse of the Berlin Wall, the spread of democracy in Eastern Europe and what has happened over the last ten days in South Africa. However, when it comes to our own nation we continuously undermine, with cynical and frequently ill-supported comment and rhetoric, the role of democratically elected personnel. I make no apology for saying that every single councillor, town commissioner and representative — no matter how lowly or exalted — has something unique that does not exist in any other area — the imprimatur of the people.
I was delighted when the Minister make it absolutely clear that he is not going to dilute the democratic element in the health boards. That is a most important principle which was established by both Houses of the Oireachtas. In the original Health Bill in 1970 that principle was not clear cut. But both Houses of the Oireachtas insisted and the Minister of the day, Deputy Childers, accepted that principle. Minister Howlin is now enshrining it for the future.
I would wish that there was more time because there are many good things that deserve to be said about this strategy document. There are some questions I would wish to ask but I can do that in correspondence. I compliment the Minister and his Department for a very good job.
I welcome the Minister to the House. Before I start I should declare an interest because I am an employee of the Minister's and so, naturally, I will be looking at the question from this point of view as well as being a Senator. I can tell the Minister from my heart that those working in the health service have been greatly cheered by the interest he has taken in the health service since he took up his appointment. This ministry is probably one of the most difficult in the Government because it affects everybody. One does not have to be sick to be affected by the health service; all you need is for a friend or relation to be sick to be affected. So it is a difficult area which the entire population has its eye on, and the Minister is handling it very well.
The strategy document is to be welcomed. It is nice to see the word "philosophy" being used and social gain being mentioned as well as health gain. Far too often we go from one small objective to another, but an overall look at policy like this is well worthwhile. One could look at this document in two parts, the first being the wood and the second the trees. There will be a lot of sprightly conversation going on when we discuss the legislation for the wood, so I will leave that until we get into it during the year. Senator Roche in particular brought up some tingling subjects, including the control of the voluntary hospitals, which I can see will lead to an electrifying autumn.
When we are looking at other health services it is important to look at other small countries — I get the feeling the Minister has done this — and not constantly look at the United Kingdom or the United States just because they are English-speaking. It is interesting to see how often the figures for places like Denmark come up much the same as our own. We are a small country so let us try to compare like with like rather than looking at Britain's national health service, where things are not going at all well. I have an article here entitled "Could our service go the way of the NHS?" I do not think so, and certainly not in the Minister's hands. We have the bones of a good health service although we naturally have many things we can improve on, but every health service has that.
It is important also that money is not stressed the whole time in this document. Spending more money is not always the best thing to do. We must put thought into things. Thought, education and promotion of good lifestyles are often far more difficult than spending more money to placate people and get them to go away. The Minister must be congratulated on avoiding the latter course.
We have to keep a close eye on some of our own health problems because they are not the major health problems in the European Union. The only one I am going to pick out here is cardio-vascular disease which, along with Finland and Scotland, we have an appalling incidence of. I was horrified recently, on reading a document about medical research in the European Union, to find that cardio-vascular disease was not in the top five but was an also ran. If we do not put effort and energy into researching this disease here we can certainly forget about the Italians or Greeks doing it for us. We have to watch priorities like this and not rely on other areas to do work that we need to do ourselves.
I commend the Minister for having given more money to medical research last year but it was at a pitiful level and we are still at a pitiful level. While I do not think, as I said at a meeting in the College of Physicians, that we can have a sprinkler system and fire money out in all directions to try and advance research on everything, the Minister and his Department would be well advised to try to put as much money as possible into those areas of research at which we are very good and where we have a high incidence of the problem. Examples include fibro-cystic disease among children, cardiovascular disease and schizophrenia in the mental health area. I realise that the Minister cannot give money for everything and that occasionally a tough line will have to be taken with the medical profession. We are inclined to simply expect the Minister to forward money. This is not, perhaps, the most desirable approach. The Minister should seek explanations for the requests for money.
He will not always get them.
There are important areas, particularly cardiovascular disease, where we must make an independent effort because nobody else will do it for us.
I also liked this document because it supported the World Health Organisation's philosophy of health for all by the year 2000. It looks on health as being not simply an absence of disease but the presence of physical, mental and social wellbeing. I commend the document in that regard. This is a four year plan. It would probably be a good idea to have progress reports.
Women's health — they constitute 51 per cent of the population — has been regularly discussed. I visited the National Institute for Health and the Health and Human Services Departments in America recently. Both have programmes on this issue, although I do not know why two programmes are necessary. The programmes are monitored, which is a good idea. Perhaps the Minister would have — since half term reviews are "in" at present — a half term review of the strategy.
An early half.
Some issues mentioned in the document require urgent action. The first is the question of North-South co-operation. This is very important and the more the Minister can achieve in that area the better. The IRA has not been of help in this regard. An example of such co-operation would be the appointment of, for example, an orthopaedic consultant to cover Letterkenny and Altnagelvin hospitals. The hospitals are only a short distance — I think it is only 16 miles — apart. Such co-operation would result in great savings on manpower and expertise would be shared by both hospitals. However, the situation on the Border has deterred such co-operation.
The Minister should, in consultation with the Northern authorities, consider not only the possibility of joint purchase of hi-tech machinery but also sharing the use of such machinery. I am told that the Johns Hopkins Hospital in Baltimore, which is one of the most advanced hospitals in America, has more magnetic resonance imaging machines than there are in all of Canada. The average use of the machines is two per day. The ownership of the machine is not what matters, the expertise in its use does. We, too, want state of the art machinery. It would be an extremely good idea if we could, as the Minister suggests, share such machinery with hospitals in Northern Ireland through an arrangement whereby machinery is bought in alternate years by hospitals in the North and the South. I hope the Minister makes progress in that area.
I am delighted with the Minister's strategy for encouraging people to take better care of their health. The section on reducing the incidence of mental and physical handicap in the newborn is extremely important. We did an enormous amount of work on neural tube defects in this country. We had the highest incidence of anencephaly and spina bifida in the world. It is now proven that such defects are associated with folic acid deficiency and it is good that the Minister is promoting awareness of the importance of adequate folic acid content in the diet of women of childbearing age.
It is a great pity that in 1994 we are still getting ready to establish a national database on physical and mental handicap. This issue has been neglected for a long time and I am glad to see that the Minister will address it. I compliment my retired colleague, Dr. Victoria Coffey, who years ago, and with great difficulty, started a register on congenital defects.
According to the section on mental handicap, databases will be introduced. This is important because not all mental handicap cases are the same. The separation of mental handicap and mental illness in this document is of extreme importance and must be commended. People with mental illness have been somewhat neglected. What has happened to the Green Paper on Mental Illness?
This year.
I am delighted because parts of it are particularly important. Legislation on that issue is urgently needed. We have a high level of committals to mental hospitals——
A White Paper will be published this year.
I am delighted. We have a high level of involuntary admissions to mental hospitals and that problem must be tackled. I will not discuss alcoholism and drug abuse, because Senator Farrell discussed them earlier. Suicide is not a problem for the Department of Health alone. Other elements are involved in suicide and, while mental illness is important, it is a more extensive problem which must be carefully examined.
In the area of palliative care it is good that the hospice service will be given more support. The personnel in that area of health care are incredible. It is extremely important that people are given the opportunity and the right to die at home. None of us can ever be sufficiently grateful to the nursing service that operates in association with the hospices. I strongly commend the proposals regarding the elderly and dependent and their carers.
The Minister has, rightly, taken the issue of HIV and AIDS very seriously in this document. I am confused by articles in the press which claim that there is little likelihood of spreading AIDS through heterosexual sex. That is not true. A letter from a colleague of mine who is an expert in that area stated that she did not know where this notion had come from. I have seen such articles in British newspapers and I would not like to see the idea being circulated in this country. In Africa, where AIDS is prevalent, the disease is spread through heterosexual sex. I do not know what we can do to disabuse those who write in this way about the disease. It is a cause for alarm. It appears to single out minority groups such as drug abusers and the gay community. We must keep a close eye on that development.
We also must realise that AIDS and HIV infection are closely associated with drug abuse. Drug abuse, unfortunately, has become more serious in this community. There are differences within the medical professional on the best way to deal with the problem. Some practitioners favour methadone programmes and others do not. However, the clean needle exchange programme which the Minister has promoted has been of great value, because it is bad enough that a person is a drug addict without also being infected with the HIV virus. The Minister should ensure that clinics are available for women who are involved in what is described as "sex work". These women have been very good in their attendance at the clinic in Baggot Street and I hope the number of services available there will be maintained.
Cost effectiveness in the health service is very important. Throwing money at a problem does not necessarily solve it. However, it is most important that the Minister convey to the acute hospital services that while he expects great care to be taken in the area of cost, he also expects great care in the area of quality. The number of operations carried out on a day care basis has greatly increased. We must ensure that such cases are carefully selected, that they are absolutely suitable, that there is ease of access for the patient to return to the hospital if there should be a problem and that there is good out-patient back-up for such patients. That area of medical care is of great value. It is a great improvement in comparison with the length of time people spent in hospital for minor operations 20 years ago.
We must also remember that there has been a great improvement in socio-economic conditions; people who could not have been discharged in the past now can. In the Minister's message to the acute hospitals I hope he stresses that, while he wants them to watch costs, he also is concerned with quality. "Clinical audit" has become a buzzword and the Minister will be looking at that factor as well as the amount of money spent by hospitals.
The Minister intends to introduce further legislation on pharmacy and medicines controls. One area not mentioned in the report is the sale of drugs over the counter. The Department should devote some thought to this area because it can produce savings. However there can also be greater expense involved. If people are prescribed over the counter drugs, they may be given a dearer product because it is covered by their insurance scheme. We must consider not alone the safety of these drugs but also whether people are being given more complicated drugs to save them money, although they might be better off without them.
The Minister has also looked at health remedies. A report was recently published on food and health products and the issue requires careful monitoring. Sometimes there is not enough control over the advertising of these products; the claims being made for some items have not been examined. Perhaps a good deal of legislation would be necessary in this area. Everyone can make herbal tea from ingredients available in the garden but if it is being sold in a shop it should be controlled. This does not come under the Minister's jurisdiction at present but undoubtedly he and his Department will tackle the problem. I would not decry such remedies because some of them may be extremely useful and most of our pharmacological products derive from a natural ingredient. However, they should be analysed because some of these remedies can have serious effects if one takes an overdose; one can even have problems if one overdoses on vitamins. Legislation is certainly necessary in this area and we can rely on the Minister to introduce it.
The emphasis on traveller health services is welcome. They have a much shorter life span and many more illnesses than the settled community. While we say they must be allowed to follow their own lifestyle, it is important to remember that it reduces their life span.
One area where action could be taken soon is adoption. There is only a small paragraph on adoption in the strategy, and it could go further. The Adoption Board has been in contact with the child care unit in the Department within the last few months. The board is anxious to introduce an active list, which would be easier to compile than a stillbirths register. The present list is a passive list which contains women who have given children up for adoption, adoptive children and possibly natural fathers. The people involved put their names on the list themselves and others can seek the name.
An active list contains all names, both mothers and children. If someone decides to look for his or her mother, the name can be found on the list and the woman involved can be contacted to ask whether she wants to make contact with the child. The Minister should introduce an active list which should be kept under the control of the Department. Such sensitive information should not be taken outside a statutory body.
I am pleased with the section of the report on health care. It would be marvellous if the Minister achieved his intentions with regard to breast feeding. The immunisation programme is also good and I spoke to the Minister for Education about this matter. It should be considered desirable that children be immunised before they start going to school, although it should not be made compulsory as in America. One hopes that would not delay attendance at school.
I commend the Minister's strategy and I look forward to his energetic efforts in the autumn.
I congratulate the Minister for this excellent document. Shaping a healthier future is undoubtedly a strategy for effective healthcare in the 1990s. By the year 2000 this package will undoubtedly be seen to have been useful in getting the health services into proper shape.
Most discussion on health in Ireland centres on financial structures and the amounts of money received by doctors and consultants. I sometimes believe we have lost a feel for the people who should be our real concern. I am glad the Minister has decided to leave the health boards as they are currently structured. They were set up in 1970 and are still basically solid. The Minister has only changed the Eastern Health Board and should be complimented for maintaining the others because they perform excellently.
Health boards usually consist of local representatives, local authority members and representatives of the professions who provide the services. The boards are based on service in local communities and members on the boards are the best able to provide the service because they understand problems in the community.
My health board has suffered in the last number of years because it has streamlined its budget to clear its debts. They missed out on the money given to other health boards that had not behaved themselves. The North-Western Health Board is probably the best run in the country. I have not always been complimentary to them and I have pointed out their mistakes in the interests of getting a better health service for the people I represent.
The document says the health boards will now manage and implement the services and provide a budget to be agreed annually with the Minister. This should bring more accountability and provide a higher quality of service, which can only be better for the public. All health boards are under pressure, especially in relation to the staffing of services. Consideration should be given by both the Minister and the Department to the life of the people working in the health services, specifically in nursing.
I worked in nursing for 26 years. We should examine general nursing, psychiatric nursing, mental handicap nursing and public health nursing. People in these areas provide the hands on services and perform admirably within the health sector. They do not receive the consideration or the praise they deserve, although I do not suggest that such consideration is not given by the Minister.
A nurse should not have to work until he or she is 60 or 65 before being allowed retire on a pension. It is a demanding and trying job. One cannot simply come in at 8 a.m. and leave at 5 p.m., or at 1 p.m. and leave at 9 p.m. In general hospitals, if there is an emergency or work is not completed, a nurse simply cannot leave. In a factory one might be able to go home at the end of a shift but in nursing a patient's life is at risk. The demands on nurses mean they have to stay to help and do their duty.
At times nurses receive nothing in return. In some circumstances no consideration is given by way of time off for people who work extra hours. They do not receive extra money. Nursing is their vocation, it is said to be their hard luck if they are in the wrong place at the wrong time.
General nurses should be allowed to retire at 55 years of age. This would be in line with the conditions which apply to psychiatric nurses. Psychiatric nursing is a trying job because they work under stress from early morning until they leave in the evening. These nurses may retire at 55 years of age because of the stress and strain of the job. It is only right that they should be allowed to leave at 55 years of age when one considers the amount of time they must give to the people with whom they work and the amount of listening they must do. I ask the Minister and the Department to consider reducing the age of retirement to 55 for the other nursing professions.
I also ask him to bring the nurses' pay review on stream as soon as possible. This has been talked about for many years. I ask the Minister and the Department, in conjunction with the Local Government Staff Negotiations Board and the unions involved in nursing to bring this situation to an end. These people make a tremendous commitment to the health services but they do not get the same consideration as others.
More funding should be made available to the community services in the psychiatric area. During my time in the trade unions I felt that the document, Planning for the Future, tried to clear the hospitals of people who, it thought, would survive in the community. I worked with these people and I saw those who moved to the community, but no money was provided for backup services. I seek the Minister's support on this issue. I welcome the commitment given by the Minister over the last number of weeks that this issue is being addressed. I have no doubt this will happen given the Minister's commitment to the health services. I will follow this to the bitter end to ensure that money is provided for the mentally handicapped and the mentally ill.
I congratulate the Minister for his commitment to provide an extra £25 million for the mentally handicapped. This is a welcome development. I condemn the reports that enough has been done for the mentally handicapped because they will never have enough money. I would like another £25 million added to the money the Minister is providing. We should never forget these people. The cost of such a service is great, but the Minister can deliver it, if anyone can. I have no doubt the cost will be high, but he will be remembered for his contribution to humanity.
There is a four strand strategy in relation to AIDS — surveillance, prevention, care and management. This is important. The nursing unions recently held a one day seminar on AIDS in Letterkenny, County Donegal, and one amazing fact which emerged was that a 64 year old lady had contracted AIDS. This proves how easy it is to contract the disease and we are at a loss to do anything about it. Senator Henry mentioned North-South co-operation. At present, there is excellent co-operation between Altnagelvin Hospital in Derry, Letterkenny General Hospital and Sligo General Hospital in relation to cat scans, AIDS procedures, etc. This is welcome and I am delighted to see it addressed in this document.
I commend the decision to give all staff an introduction to the health strategy. Staff in the health services have told me this is the most forward-looking document in years. They can get their teeth into it and it has been welcomed on the ground. We must support and educate these people because they work with the patients and they will pass on the information to the public. This will provide a better service in future. I have no doubt that managers in the health services will meet their staff to discuss this document which contains a lot of information and the need for a health strategy.
Throughout the years various reports on health have been issued. People have little concern for their diets and many health problems, such as cancer, smoking and heart disease are caused by inadequate education. The same is true of alcohol-related accidents and teenage drinking, which seems to be the norm. The people are either not properly informed about the dangers or they are choosing to ignore them. This document will make it easier for health managers to identify the problems and to talk to their staff. It is important they should be involved in educating the public.
Public health nurses are in constant contact with the community. They can educate the people and the feedback will be important for the formulation of future health care. Information about the public's needs must be updated. We must strive to provide a quality health service for everyone, regardless of age, class or creed. We must address the problems and try to improve them.
People may ask what is so radical about this document. There is a new focus on improving the health and quality of life of the people. What will the changes mean for health service personnel? It will increase responsibility and give them greater management powers and more opportunity for training and development. This is welcome and I notice it in the nursing area, in particular. What will the health strategy do for the patient who is the number one priority? It will mean a better and longer life expectancy, better health for everyone, support for those depending on care in the community and an opportunity to express their views. The health services should help in this regard, but continuous education is important.
I welcome the document. It will be a tremendous achievement if, by the year 2000, its contents are carried out in the manner outlined by the Minister because it will provide a better health service.
Before I call Senator Honan, I understand there are five speakers who wish to contribute to this debate. However, it was agreed on the Order of Business to conclude at 2 p.m. I would like the Senators to co-operate in this regard.
I will share five minutes of my time with Senator Sherlock.
Acting Chairman
Is that agreed? Agreed.
I welcome the opportunity to discuss this important document and to congratulate the Minister for producing this health strategy. It is the first time such a strategy has been presented to us and it is almost 25 years since the health boards were introduced. It is time to rethink the way we are providing our health care services. The Progressive Democrats welcome the publication of this strategy which we see as a blueprint for major and much needed structural reform of the health services.
Annual expenditure on health care in Ireland has grown to £2.25 billion which, in anyone's terms, is a sizeable sum of money. We must get the best value for money while providing the highest standard of care. In the report the Minister emphasised his priorities in three areas — equity, quality of service and improved legal and financial accountability. By equity he means helping those whose needs are greatest and everyone supports this aspiration.
By European standards we have a good health service, but as in any area there is room for improvement and the Minister has outlined many areas of improvement in his strategy. The Minister has set targets which must be achieved and which must be worked on by those involved in the health services. We must focus our energies on certain aims and ensure that they are reached by the end of this plan.
I welcome the key objectives in the health strategy. Nobody could argue about stricter financial control over the new health authorities and a more focused health promotion policy which would reduce avoidable deaths. The more significant role for general practitioners and the special health initiative for deprived areas and for groups such as travellers and the mentally handicapped are also welcome. I welcome the fact that more attention is being paid to the user of the service — the patient.
I welcome the fact also that the Minister has acknowledged that we do not need any more hospitals after Tallaght has been built and that better and more organised community care and general practice is what is needed. The Progressive Democrats encourage and welcome this redirection of resources to enhance primary care. We will support the Minister's efforts in this regard.
The problem many people have with this strategy is the cost. We spend huge sums of money on the health services and a lot of these aspirations will be costly to implement. If one looks at health promotion, which is desirable, it takes a long time to see its effects; and this may be difficult because people want to see results quickly. Strengthening the role of general practice and community care and providing extra services, including those we spoke about this morning in the dental area concerning private dentists, will be costly. People want action quickly and they want to be able to measure the results.
As the Minister said, the main theme is the reorientation or reshaping of our health services so that improving people's health and quality of life becomes a primary and unifying focus of all our efforts. That is commendable. We spoke about the huge cost of the health services and the Minister said my party may not support him when he looks for additional funding in the Estimates next year.
I look forward to it.
I assure the Minister that if he can demonstrate effectiveness and value for money, we will support him.
I welcome the acknowledgement in the plan that not everything depends on medicine and curing diseases. Preventative medicine is important and it involves a lot of changes in our habits — for example, our smoking, drinking and eating habits and the amount of exercise we take. Many illnesses are not caused by outside factors, they are self-induced. Although we spend a lot of money on the health services, statistics show that Ireland is close to the bottom of the table when it comes to life expectancy. We must find out why that is the case and try to change it.
I welcome the Minister's promise to publish a plan later this year for women's health, which will be implemented over the next four years. I am glad the Minister has said that this plan will take account of the recommendations of the Second Commission on the Status of Women of which I was a member. For too long women's health has been under-funded and neglected. A strategy which has targets must be put in place. For generations women have cared for everyone else except themselves. They now need to be cared for.
My party welcomes the commitment for a national policy to provide refuge accommodation for women and children who are victims of domestics violence. Recently Members saw a video produced by the Adapt refuge in Limerick. It was frightening and it made us realise that we are not providing adequate funding for this service. It has been acknowledged that health boards should provide this service. This is necessary because many areas do not have such facilities. When we discuss incidents such as the Kilkenny incest case, many people will ask how can women stay in these situations of violence. Until now, these women had nowhere to go. I welcome the Minister's commitment to this area.
The Minister's commitment to many other areas relating to women's health is welcome — for example, genetic counselling. There has been a lot of discussion about breast screening programmes for women and this has been debated in this and the other House. While everyone appreciates the cost of providing mammography services, we acknowledge that this might not be the most effective way to provide screening for women under 50 years. Perhaps we should consider self-examination or breast examination by GPs which would cost less than mammography services, which may not be effective. I welcome the Minister's commitment to look at the national screening programme after the results of the Eccles Street programme are finalised.
I am also concerned about counselling and information for women who must deal with crisis pregnancies. This was addressed in the report of the Second Commission on the Status of Women, which recommended that legislation be implemented after the amendment was passed in November 1992. While I understand that legislation is in the pipeline, I would like to know when it will be introduced.
When Senator Henry and I spoke about the breast screening programme on the Adjournment last week, the Acting Chairman inadvertently said we were looking for a breast feeding programme. I am glad the Minister mentioned this in his report. He wants 30 per cent of all four month old babies to be breast fed by the year 2000. I am glad to say that I breast fed my three children at four months. The hepatitis C incident highlighted the importance and the different problems women have in the health services. I welcome this proposed plan and look forward to its publication. Provisions for family planning are also welcome. Sterilisation services for men and women are badly needed throughout the country. Certain urban areas have this service, but many areas do not.
If all the plans outlined in the strategy are brought to fruition, it will mean a better standard of medical care for everyone and will ensure that the vast amount of money we are spending will be spent more efficiently. Nothing is perfect, but this document goes a long way toward addressing the needs of health services in terms of efficiency and accountability and it is the best way to deliver health care to the patient. If at the end of the four year period the action plan is in place, we will have a healthier nation and we will get a better return for the millions of pounds we are investing. We have seen a lot of short term fixes in this area and, therefore, the provision of a plan and a strategy is welcome.
I thank Senator Honan for sharing her time. A national health strategy must target those most in need in order to achieve overall improvements in health standards in an appropriate way. I refer to the GMS. Until 1991 a fee per item system of payment to doctors and pharmacists was in operation. At the time we were told by the programme manager and the executive of the Southern Health Board that if we changed that to a capitation grant there would be great improvements, because we would know what we had to pay and, therefore, savings would be made which could be injected into the health services. However, that did not happen. At that time 39 per cent of the people were eligible, but that figure has been reduced to 33 or 34 per cent. The Minister is being praised for his concern for people. However, women raising children in my area, which is no different to any other, cannot afford to go to the doctor and pay £15. If they go to the Doctor, they cannot afford to go the chemist. That is not an exaggeration, it is a fact. I wonder if the change from the fee per item system to the capitation system was in the interest of the patient. Senator Roche mentioned people coming from a GP's practice when they threatened to withdraw, but that did not apply only to Bray. I hope Senator Roche is listening. It applied to many other areas of this country as well.
The Minister talks about the health boards, about linking the general practitioners to the hospital, setting up hospital boards of management and bringing general practitioners on to the boards of management. I refer to Mallow general hospital.
I will not refer to community care but I make one strong request to the Minister. In 1988, because of the policy of fiscal rectitude adopted by the Government of the day, health advisory committees were withdrawn. There is provision in the 1970 Health Act for health advisory committees and I appeal to the Minister to set these up, even if he limits their meetings to even one every few months. The health advisory committee would provide a forum for the whole spectrum of people involved in health services. The regional health board is too far removed from the people in that regard.
I ask the Minister, even at this late stage, to advise the executive officers of the health board to increase the income limit for full eligibility and make tax paid deductible. I am not exaggerating when I say that this is a serious problem. People cannot afford to pay for health care because the income limit for full eligibility is too low.
I welcome the Minister to the House and compliment him on bringing forward this very important document. It is very thought provoking document which was well researched by his officials and by himself. The Minister then allowed all concerned the opportunity to make a response to it. That is a good basis for any document.
The principles of the document are very important and equity for health care is of vital importance. He has set that as the first priority. The second priority is the quality of service. Accountability is also very important in the provision of a proper health care system in this country. I wish to speak about a number of headings but I will not be able to cover them all.
Accountability comes into the area of budgets. The budget of a health board, indeed the budget of any public body, is of importance. We all have problems with budgets which are structured on a yearly basis. That applies to county councils, health boards and Government. Decisions are often made at the very end of the year which are not part of the proper strategy of the institution. Annual budgets in themselves are not in the best interests of a health care service. This is a four year programme. It is a pity we could not have a four year budget as well so that the strategy would be maintained in planning the annual budgets.
In regard to the development of the health services, over the last number of years some very important Bills were put through both Houses of the Oireachtas. In 1992 we had the Child Care Bill, now the Child Care Act, and the Nursing Homes Homes Bill, now the Nursing Homes Act. Those Acts are now in place and funding is being found for them. They are an important step in the development of our health services.
I have a complaint about the Nursing Homes Act. It is important that we have a subvention system for people who want to go into nursing homes, but we should always be conscious of the fact that some people want to end their days in their own home or with their family. I am not convinced that we are supporting that concept. At present it is not in the financial interest of people to stay at home and be cared for there. We have the carer's allowance, which is administered by the Department of Social Welfare but which impinges on the health and health care of people, and we have the subvention to nursing homes. If we had a subvention to the family that would care for their elderly parent or relative, more people would stay at home and be cared for there.
I also wish to comment on the psychiatric services. The community approach to psychiatric services was welcome and an important step in the breaking down of the large psychiatric hospitals; but I am perturbed that the community approach does not receive adequate financial backup, as is the case from the information that was made available to me. The discharge of people from psychiatric hospitals into hostels and houses in the community is not an end in itself. Back-up and a follow-up service is necessary and the health boards and the Department must take on this responsibility. The responsibility cannot be undertaken by untrained people as is sometimes the case at the moment.
Professional back-up must be provided. The professionals are not being provided. How many health boards are providing training facilities for psychiatric nurses? The Western Health Board from which I come, although I have not been a member for many years, has not trained a psychiatric nurses in ten years. Who is carrying out the psychiatric nursing? I am of the opinion that many untrained people are now carrying out the functions of professionals in the best psychiatric services. That is not in the best interests of provision of psychiatric care in this country and we will pay the price for that in the future. That matter should be addressed. The provision of professional services for the care of the mentally ill is of paramount importance. I would like to see the Minister allow the training of psychiatric nurses in the Western Health Board area this year. I understand that An Bord Altranais, the Nursing Board, have already cleared the way there and the Department should allow the provision of nurse training facilities for the intake of students in 1994.
The other area of vital importance in my own county is the decision by Government recently to locate a high detention prison in Castlerea. That will have an effect on the psychiatric services there. The Western Health Board last week decided to maintain the services for the mentally ill for that area of the county in Castlerea. I call on the Minister to endorse that decision and provide finance for the provision of those services there. We owe this to the mentally ill people in that half of the county and to the staff who have been providing that service there for many years.
I compliment the Minister on the development of services for the mentally handicapped. This is a welcome development and it is important that there is now a realisation that it is not appropriate to place mentally handicapped adults in psychiatric hospitals, which was the case down through the years. The Minister has provided residential places for the mentally handicapped and that is a welcome development.
There has been to some extent a geographical rat race between the health boards as regards the provision of acute services, among others. While I agree with the principle of health boards, there must also be a balance in the provision of services on a county basis. The recent decision of the Western Health Board to seek the extension of the acute services in the county hospital in Roscommon is an important policy step. I ask the Department and the Minister to support this by putting in place a second anaesthetist and a second surgeon in the county hospital in Roscommon. This is necessary to relieve the pressure in Galway and Castlebar. It is not now appropriate to have a single anaesthetist and a single surgeon working in a hospital and I hope that in the near future the Department and the Minister can see fit to support the Western Health Board in this matter.
I thank Senator Finneran for sharing his time with me and I compliment the Minister and his Department for bringing forward this thought provoking document. Five minutes will not do it justice, but I will highlight some of its aspects. The last review of the child health services was made in 1967. It is an oversight that no attention has been paid to child health services since then, and I am glad that the Minister has undertaken to review the services. If we have healthy children they will grow up to be healthy adults. Many problems which would require more expensive treatment in later life can be sorted out in childhood.
I am glad that the document focuses not on buildings and fancy, shiny equipment, but on the services we can provide for everyone. The emphasis on primary health care is important and I hope that in all aspects of the health services — GPs, public health nurses and hospital staff — the public is given the best possible treatment and gets the best possible value out of the 8 or 9 per cent of GNP spent on health care each year.
I join with other speakers in paying tribute to the Minister for his dedication to the mentally handicapped. I would remind people in the Mid-Western Health Board area that there has been an increase of funds from the Government to the mentally handicapped. Despite newspaper editorials to the contrary, this Government is committed to helping the mentally handicapped, particularly in the mid west area. Scare-mongering by individuals telling people that money is not being made available is little short of lying.
The strategy includes a section on travellers' health. As a member of the task force on the travelling community, I appreciate that the Minister has undertaken a joint study with the task force on the general health of travellers and how it can be improved. A health service can only be judged on how effectively it delivers to every section of society. One section which seems to suffer from a greater degree of ill health is the travelling community and any study which will help improve its general health is to be welcomed. Travellers present greater problems for the delivery of health services than the settled community, as they are highly mobile, live in poor sanitary conditions and, by virtue of intermarriage, are at higher risk of hereditary diseases than others. I welcome the emphasis on the care that must be delivered to travellers.
I also welcome the emphasis on palliative care. We have not been as diligent about it as we might have been and those who are terminally ill should get the best possible care in the last years of their lives. I hope that when the Minister, Deputy Howlin, leaves office he will be known not as the Minister for sickness but for health.
I would like to share five minutes of my time with Senator O'Kennedy.
Acting Chairman
Is that agreed? Agreed.
I welcome the opportunity to speak on the programme published by the Minister for Health and to compliment him and his Department for putting together such a fine programme in a short time covering the many aspects of the health service. We recognise that it is one of the most expansive Government Departments, which affects everybody directly or indirectly. This plan puts matters into focus. I am glad the Minister has set a target date for implementation, because if time targets are put in place an effort will be made to reach them. That is important if something effective is to be done.
This document is the starting point of an action plan and further development plans in different areas will have to be put in place subsequent to it. One of these is the dental development plan. Although I did not have an opportunity to speak on this matter this morning, it is one which must be addressed. It is important to recognise that there is a cost factor involved and a plan cannot be put in place without financial support. In order to widen its remit and extend the numbers catered for by the dental service, there will be a cost involved. The dentists who will implement this plan must be provided with the necessary resources.
This programme also includes the presentation of a plan for women's health. A serious issue which has arisen in recent times is that the incidence of breast cancer in women in Ireland has increased rapidly. There must be a reason for this and there is a need for research in this matter to find the cause. It must be addressed urgently and I hope that when the Minister is considering this matter he will give it priority. It is unacceptable that the rate of breast cancer among women in Ireland should increase so rapidly compared to other member states of the European Union.
This programme also suggests there should be a special health programme for the cares and needs of travellers. Other Senators have spoken about this important issue. Travellers have not been given any special consideration in the health care area up to now, although they have been given special treatment by local government and local authorities in regard to housing. There has not been a specific and conscious follow up on this issue and their case warrants special attention. It is good that it has been recognised by the Minister in this plan.
The role of acute hospitals in the health service has also been addressed here. I am interested to see how its role will emerge within the various communities. As somebody who comes from a peripheral area, I would be concerned that the efficiency and cost effectiveness of the acute hospital may take priority over the health requirements and needs of those working on the ground. Accessibility of health service is also important.
In the County Clare area, the Limerick and Galway Regional Hospitals are now becoming the focus of attention and the role of the local county hospital is diminishing. This is unacceptable. Accessibility of the health care service on a geographic basis will have to be examined. There must be a balance between cost effectiveness and accessibility. This applies especially to rural and isolated area and should not be lost sight of in the restructuring of the health service as proposed in this document.
The Minister's three underlying principles are equity, quality of service and accountability. He refers to the participants and says that greater recognition will be given to the key role of these who provide the service and the importance of enabling them to do their fullest potential.
I would like to raise an issue relating to the district nurses who provide these services on the ground. Last night the district nurses in Kilrush voted to take strike action in County Clare because of an unsatisfactory situation that has developed with the Mid-Western Health Board. What the Minister has said here is fundamental. The role of the professional health care person of the ground should be given key priority and their voices should be heard and recognised. There has been a tendency for the administrator and the bureaucracy to supersede the voice of the professional. It is not good that the opinions of the person on the ground are not deeded. I ask the Minister to contact the Mid-Western Health Board this afternoon and find out why such a situation was allowed to develop. It is incredible that such action should have come about. These nurses are professionals who have been providing an excellent service across the county for many years. They have always given not only what is required by the board but a service to the local community. They are forced to take strike action because of bureaucracy not facilitating or recognising their specific needs. I ask the Minister to address this matter directly with the Mid-Western Health Board this evening to ensure that this strike does not go ahead.
There has been much discussion of the mental handicap services. A group of parents in Kilrush raised over £70,000 to build a workshop there and were assured by the Mid-Western Health Board that the necessary money would be provided if they provided a certain amount themselves. However, they have been told by the board that the additional money provided by the Minister this year for the mentally handicapped can only go towards existing services and not to a new facility. The people propose to provide a service that is required in an isolated area. They were initially given assurances from the board that money would be provided, now they have been told it is not available. I ask the Minister to address this matter.
I would love to address many other issues in this document but I do not have the time because I agreed to share the remainder of my time with Senator O'Kennedy.
I thank Senator Taylor-Quinn for sharing her time. Obviously, the Senator had more to contribute to the debate.
The AIDS epidemic is the single greatest problem of our period. I want to read a letter, which is of great significance to this debate, from a distinguished public servant who was a county physician in north Tipperary for many years. Having retired from service he went to work in Zambia on a voluntary basis.
Greetings from Zambia. ... this is not the main purpose of this letter, which is to give you a personal experience of the AIDS epidemic today. The reality of this disease and the destruction and suffering it is bringing to the people here is far worse than anything I had imagined...
If your patient is in the age group 15-45, weighs under 40 kg., has a history of chronic diarrhoea and oral monilia, there is not much doubt about the diagnosis. I believe that a survey in Lusaka, the capital, reveals that one in three adults test HIV positive, and most of these will be dead in five years. Infants with AIDS are quite common and pathetic and most of them will die before the age of three. Of those who survive, many are AIDS orphans where both parents have died.... It does not need much imagination to see the personal and social tragedy that this involves — what kind of adults will these children grow up to be?
My colleague, Dr. John Hartley, an Englishman and Medical Director of the hospital, has supplied me with some statistics of this hospital which bear on all of this.
(1) 65% of persons admitted to the hospital for various complaints in the 25 to 40 year old age group tested positive for HIV in 1991.
(2) 80% of all TB cases test positive for HIV.
(3) 18.2% of 900 fit blood donors tested positive for HIV in 1993.
This means that almost 20% of apparently healthy adults in this area are carrying the HIV virus and will come down with the disease AIDS within the next five years.
Dr. Hartley, in his report for 1993, states "Work as a physician is dominated by HIV related disease and it leads to a strain and a sense of helplessness induced by the unrelenting nature of the epidemic and the pitiful state of many of the sufferers".
Proof of the escalating figures for AIDS in this hospital may be given by the fact that in 1992, we had 500 patients with TB, whereas last year, 1993, the number had risen to 800, and most of these were HIV related.
His conclusions were as follows:
To what may one attribute this modern epidemic? It is generally accepted that "sleeping around" is the main cause, and this applies both to teenagers and to young adults. Now it is widespread — it was not always thus, but seems to have come about in the past thirty years or so. Traditional Zambian marriage was monogamous and for life, e.g., the Bemba tribe. True, the Tonga tribe, which whom I work, are polygamous, but there is a whale of a difference between polygamy and promiscuity as we have now.
The health authorities in Zambia seem to be overwhelmed by the problem. For some time, they may have failed to realise the extent of the disaster. However, there has been an extensive publicity campaign to inform people of the risks of casual sex and condoms have been freely available from 1985. If you are driving to Lusaka today you will see big placards warning people of the dangers of casual sex, both as to STDs in general and to AIDS in particular. Information is there in plenty, but neither this nor the fear of contracting AIDS, nor the availability of condoms has succeeded in stemming the tide. It's realised here now that awareness of facts alone does not alter behaviour. Dr. Hartley says "A condom is better than no condom" but I wonder if even this is true.
However, in the Ireland in which I grew up, the example of home, school and society in general helped me and my generation to acquire control in matters sexual — a necessary step on the road to development of the human person.
He goes on:
Now, if you offer the youth of today mere information and freely available condoms, are you helping him to gain that control of his sexuality. I think not, and suggest the Zambian experience supports this contention.
You may say to me that Zambian and Ireland are very different countries. Maybe so, but I see a lot of similarity between the Zambian and Irish characters. Both are bright and basically happy people. They both like company and are good talkers, both have a good sense of humour, both are easy going but both can be fiery or even violent if aroused. If what has happened here in Zambia with AIDS should be replicated, even in a small way in Ireland, we would have on our hands a major disaster that would make the Famine of '47 or the present unemployment crisis seem small beer. Furthermore, as is happening here, the resources for medical care are being gobbled up by AIDS patients, and we are short of almost everything that would be taken for granted in the First World, drugs, needles, syringes, gloves etc. Sophisticated medical techniques like heart surgery, kidney transplant or joint replacement surgery simply do not exist here. Thus, the good health service built up over several years in Ireland could, itself, be put at risk if AIDS got a hold on our people, as it has got a hold on the people in Zambia.
Dr. Hartley comments further: "If you have a society which has a `natural' system which gives protection against spread of HIV it is an enviable situation, and to erode it by promotion of condoms and liberalisation of sexual morals would be a backward step." My plea, therefore, is that the greatest bulwark we have against AIDS is traditional sexual morality. The State must do all it can to support this, not to undermine it.
This letter was written by Dr. Brian Lemass of Nenagh, retired county physician who gave a lifetime of service to the people of north County Tipperary. He wrote the letter to a senior figure in the Department of Health to indicate, from the experience he had, the need to have responsibility in sexual matters as the first priority, and not the programme of "If you must have sex have a condom".
I put extracts from this letter on the record of the House because I hope that in all things we do we will learn that if we follow that latter road, "have a condom, use a condom", we may face the consequences that the poor people of Zambia are facing now where normal health care is impossible.
Question put and agreed to.
Acting Chairman
When is it proposed to sit again?
It is proposed to sit at 2.30 p.m. on Wednesday, 11 May 1994.