I welcome the opportunity to come into the House to debate the issues raised in the motion and the amendment tabled by the Government. It is time we had an intelligent debate on health. Emotive pleas and the painting of a monopoly of virtue on one side of the House as a cogent argument for more action on the health services, without any systematic analysis of the problems in this dynamic sector, does not add to the debate and only becomes an exercise in futility.
I am happy to have the opportunity to outline my strategy in the health area and to identify what needs to be done. The slightest perusal of the development of the health services in this country in the past couple of decades, quite apart from the 50 years since the Department was founded, reveals that tremendous strides have been made in the country's health services. Successive Governments can take credit for various aspects of those developments. I do not intend engaging in a petty political battle this evening as that would not serve anyone well.
I want to address the issue of waiting lists. An initiative was introduced in 1993 under the Fianna Fáil/Labour Government which saw £20 million being invested in the health services in the first year of the Programme for Government and £10 million in the second. There was a change of Government in 1995 and resources were reduced. Waiting lists increased by one-third under the Rainbow Coalition; the last amount allocated to the waiting list initiative by the Rainbow Government was £8 million in an election year in 1997. The money did not become available until the month of August and the waiting lists continued to increase. No review was carried out nor was there any management of the system to see what the problems were and what could be done about them.
Arising from the review I undertook during my first year in office, I was not satisfied that the matter was simply a resource issue. However, in the budget Estimates for 1998, I increased funding for the waiting list initiative by 50 per cent up to £12 million. Those are the facts. A further 14,000 people received procedures on the public patients' waiting lists. There are no private patient waiting lists. If people have money, they will gain access to surgical procedures without too much difficulty. It is time we started calling a spade a spade. I want to square a deal for public patients but many people involved in the health sector will have to play their part in making that happen. I want to engage in a partnership approach. I recognise the matter cannot be solved within the acute hospital system alone but it is a fact that no private patient has to wait as long as a public one. Some 36,000 public patients are awaiting procedures; 42 per cent of those have been waiting more than 12 months.
There is a spectrum of pain between some cosmetic operation which has to be carried out to remove a scar from a cheekbone and a life threatening operation for a public patient awaiting a cardiac procedure. The first thing I did on taking office was to identify life threatening problems. In regard to cardiac services for public patients, I engaged in a process to analyse the situation and increased capacity in St. James's Hospital and University College Hospital, Galway. Waiting lists are reducing as a result. In regard to paediatric waiting lists, the list in Our Lady's Hospital for Sick Children in Crumlin, which did not receive any investment for many years, has reduced by almost 40 per cent. Waiting lists for adult cardiac by-passes have reduced by 200 and currently stand at approximately 1,000. We have further to go but apart from providing resources to deal with the immediate problems, we must identify where capacity limits exist and create greater capacity where necessary.
In regard to the health strategy implementation and the provision of regional self-sufficiency, no proposal was received to provide cardiac by-pass services for the west until I made a political decision to ensure that the capital development proceeded and that cardiac surgery was available to people in the west in a location near to them.
We are now seeking to replicate initiatives undertaken in the cardiac area in seven cardiac specialties whereby 70 per cent of the waiting list will be identified. In regard to the extra resources I intend applying when I announce a waiting list initiative when the Government has concluded its deliberations, I am going to draft a memorandum to the Government seeking to carry out the recommendations of the review group to deal with the short, medium and long-term problems associated with waiting lists. We will insist on a structured response being received from everyone in the system. The review group has certainly identified a big problem in regard to inappropriate placement in public hospitals with up to 150,000 bed days per year being technically wasted because people are in hospital when they should be receiving different type of care elsewhere, be it post-operative, recuperative or whatever. We must deal with resource issues on the capital side to provide for alternative accommodation other than hospital beds and we must educate the public that hospitals are simply part of a continuum of care in our health services. They are not places to which one goes to prepare for operations, have operations and undergo post-operative care.
There is a need to increase throughput in our hospitals. The day care situation has quadrupled in the past four or five years. When one considers the total in-patient activity of 535,000 in-patient cases per year and 250,000 day cases, it puts the 36,000 people awaiting individual procedures in context; they represent approximately 4 per cent of total activity. That is higher than we would like but we must endeavour to reduce waiting times, not lists. The individual person does not care whether he or she is 10,000th or 34,000th on the list — he or she wants to know how long it will take before the procedure can be done. The notion of lists is a simplistic one which does not deal with the issue.
As a result of the increased resources, the level of those waiting beyond 12 months, which is the target we set ourselves for public patients, is now at 42 per cent. This figure has only reduced by 1 per cent this year but, importantly, it has stopped rising.
One issue is putting greater resources into the services but the other is to provide the capital requirements in hospitals to deal with the throughput needed to bring down the lists. In 1993 when we started because of the changes and cutbacks that occurred in the late 1980s there was surplus capacity in the system which could tackle the problem fairly immediately and there were dramatic improvements in the first year.
Those who propose this motion were in Government — a so-called left wing Government with a left wing Minister for Finance. He said to me in the Dáil last week that this is the first time that action can be taken for the disabled and those with mental handicap. He was in charge of three Book of Estimates totalling conservatively £40 billion of public expenditure and he did nothing about these matters.
Illogical arguments were put forward in the other House and were made this evening by Senator Gallagher questioning why, if capital gains tax deductions can be made, something cannot be done for public patients. The fact is that the reduction in rates of capital gains tax has brought a greater tax take so that there is more money available as a result of the capital gains that have emerged from property dealings and transactions on the stock markets.
People would like to suggest an ideological position in which capital gains tax would be pitched at 90 per cent and that would prove support for the "small people". The fact that there would be no transactions and no revenue seems irrelevant. It is the same ideological issue they put forward with the residential property tax and it was removed when they realised the ideological nonsense.
Let us present the left wing persuasion on Government with what it did about bringing up the economic cost of private patients using public beds in hospitals. What happened from 1995 to 1997? There was no increase on private patients using public beds in that period although public hospital costs were going up by 13 per cent. Here was a socially progressive Government which was prepared to subsidise private patients in public hospitals. Nothing happened under the Rainbow Coalition Government on this issue.
I increased costs to them by 9 per cent last year and I announce today that I will increase them again by 9 per cent in 1 January next because there is still a cross subsidy in favour of private patients using public hospital beds. The total income from private patients in this regard is £63 million, the tax rebate on the tax allowance for VHI premiums is £64 million and the amount from reimbursed medical expenses is £20 million. The taxpayer is thus down £20 million.
Some Members claim that they want to cry loudly for the public patients, yet when in office they did nothing for them. They reduced the waiting list initiative which was particularly geared to public patients yet this was the socially progressive Government we had from 1995-7. Its rhetoric was great.
It did nothing for those with mental handicap. I have spent £25 million on mental handicap in my first 12 months in office which is double that which my predecessor spent in an election year, 1997. In addition, for the first time, there will be £30 million four year capital programme for mental handicap. We cannot deal with the problems Senator Gallagher raises to the extent that he wants more residential care, more respite care and more day care places unless we build the places. Is he succumbing to the trend of putting more money into the system because of an editorial which does not see the full picture and blithely criticises the Government? That is not a solution.
Before we can put in the revenue we must put in the capital. When the capital is in place there are additional revenue implications year on year as a result of that capital investment. I have done a deal with the Minister for Finance, for which I make no apologies, because we have an asset base in the health system of £4.5 billion. We have not had a public capital programme worth the name. In 1997, £103 million was provided on a capital base of £4.5 billion — that would not be regarded as a maintenance budget let alone a capital budget. There is a refusal by some to stand up and be counted on this issue.
I have got gross non-capital expenditure this year for the first time ever over the £3 billion mark. The budget for health has increased by 100 per cent in five years. However, the capital programme was not developing at the same rate. As a result we need to reinvest in the infrastructure. There was never even an equipment grant. There were operating beds in hospitals which had not been changed for 30 years.
I am indicating to the health boards and voluntary hospitals that they must be disciplined in relation to their revenue allocations because I am getting an expanded capital programme in return for that. The Supplementary Estimate I am providing relates to technical adjustments with regard to demand led schemes, PRSI, superannuation, etc. That is the deal and I am prepared to stand over it. I am not prepared to have the hospital system, which takes up over 52 per cent of total resources and where the vested interests preside, question whether it should have to stick to a budget.
One can always make an argument for more money, there was never a Health Estimate under which one could not argue for more money. However, we must agree on the theoretical point that whatever the financial resources they are finite year on year, that we have a finite budget. If 52 per cent of the budget is going to the hospitals and they maintain that they will not be subject to the same budgetary disciplines as the community based services, mental handicap services and the physically disabled services, who pays? If the hospitals seek more money because they have exceeded their budgets, who pays? If we accept that that the sum is finite those who pay are the mentally handicapped, the physically disabled, the poor and those relying on the public health nurses. Do not let anyone suggest otherwise.
Now that we have a statutory framework, sponsored by the Government led by Deputy John Bruton and supported by me, it is time to tell the hospitals that they will get their budget at the beginning of the year. I brought in a change in relation to the waiting list initiative and they get the increased waiting list initiative at the beginning of the year. They know exactly where they stand on 1 January because they do not get their estimates in mid-March. However, they may not come back in October and November and play the game that has been played for years, saying on an emotional basis that they need more money because they have exceeded their budgets. We must try to plan our health services based on service plans agreed at the beginning of the year and based on the allocations that have been given.
Let nobody suggest we are not putting more money into the health services. With the support of my colleagues in Government I am able to get far more money than any other Department working off a higher base. The bottom line is whether we allow one part of the health sector to dictate to everybody else. Will it decide what the level of progress is for everybody else? It is time to stand up and be counted.
I want a squarer deal for the public patient and I will insist on going forward with a proposal which will not address the acute hospitals sector alone. We need more beds for the elderly and more community nursing units. That will only come from increased capital programme money. It cannot and could not be done with a £103 million capital allocation. However, a sum of £147 million this year, £155 million for the coming year and £165 million for the following year — from the three year budget profile next year it will be seen what I have agreed for 2001 — will provide the wherewithal to address the structural problems.
It is clear that pumping more revenue into the system without renovating the system will not solve the health sector's problems. The experience of the last five years has shown this to be so. If we want a square deal for public patients we need more money in the waiting lists initiative and I will do that. I will insist on managing the waiting lists. I will respect clinicians' autonomy in determining when people are called for operations but medical secretaries alone will not decide who is on waiting lists. We will have to manage waiting lists and ensure people who are waiting longer than necessary are called for appointments far more quickly. The only way to do this is to manage from the centre while ensuring those who show efficiency and throughputs and are prepared to do the extra work to give public patients a square deal are rewarded. This is my formula for dealing with the problem and what I am arguing for at Government. When the Government undertakes its final deliberations I am confident we will return with a structured approach to the problem and that we will replicate the success we have seen in cardiac services right across the seven target specialities which represent 70 per cent of waiting lists.
I am not here to say everything is rosy in the garden. However, neither am I here to listen to the same old arguments and emotive pleas which are not addressing or answering the problem. The only way to address the problem is to objectively stand back and analyse where there are deficiencies. Within months of becoming Minister for Health and Children I came to the conclusion that I cannot solve the problems in the health sector unless I get capital investment into the sector. We are already seeing the benefits.
Senator Gallagher spoke of the problems in Tullamore General Hospital which has a regional specialty for orthopaedics and ENT. There are long waiting lists because we do not have the capacity or perhaps adequate personnel to get the necessary throughput. Also, we have not invested the resources into the public patient waiting lists initiative to do the job. It is a multi-pronged process and one of the ways we will improve the health service in the midlands is by continuing what we have been doing in terms of capital development.
We commissioned phase 2A in Mullingar General Hospital which was opened last week and ensured a paediatric unit for Portlaoise General Hospital worthy of the name given that it is responsible for maternity services in Laois-Offaly. We will bring forward a capital development programme for Tullamore General Hospital of which we will all be proud. We have done this in the Mercy hospital and my predecessor did it in Limerick Regional Hospital.
I visited Galway city and could not believe that we did not have the capacity to put in place capital investment for a hospital worthy of the city. I put forward a proposal for a £120 million capital investment programme, beginning with an investment of £60 million. In the meantime there will be inconveniences and problems and every other hospital and health board is prepared to submit themselves to the budgetary disciplines on the basis that I am doubling capital investment for the elderly and am for the first time ever providing a budget for mental handicap and respite and residential places. I doubled the allocation for the physically disabled. I remember representatives of the Independent Centre for Living coming to meet me and I cleared their deficit because they were at their wits end, as Senator Gallagher is aware, due to the problems which were arising. We provided £4 million for aids and appliances thereby helping 11,000 families. The money went towards hearing aids, people in the Irish Wheelchair Association and many other disability groups. Much can be done with small amounts of money. Not all expenditure has to be in the hi-tech area. People come to me looking for millions of pounds, but should this be to the exclusion of other groups which are not quite so organised or vehement and which are too busy trying to deal with their day to day family problems? I am not prepared, and I do not care what it costs me, to allow that continue.
The accountability legislation will only be effective if it works in its first year. Having sponsored the legislation we cannot now decide to forget about it and do something else this year. There are problems, but as a result of the good financial management of the Government, we have moneys prepared for 1999 which will bring service improvements totalling £154 million including, but not exclusively, improvements for hospitals.
Seventy per cent of my budget is pay related, including pension payments. This means that £200 million from the opening Estimate of £354 million for next year, an 11.3 per cent increase on this year on, is pay related. It is always a case of how much tar one can get on the road.
I wish to make it very clear that temporary bed closures are a symptom of the problem. We are losing 90,000 bed days as part of trying to manage a system which involves ward refurbishment, reorganisation in hospitals and bringing on stream new developments in hospital services. However, it represents just 2.5 per cent of the total bed complement in the hospital system. This is the equivalent of 200 beds temporarily closed per month out of a total complement of 12,600. We should put the issues in perspective and have an intelligent debate. Of course there is room for improvement, but I am not prepared to accept the historical deficits of the past when we were not prepared to renew our infrastructure. If the health system was a house it would have crumbled long ago because we did not invest, replenish or — to develop the metaphor — provide the necessary extensions.
Last December I told the health boards to manage their budgets, that the Oireachtas had given them statutory responsibility to do so. I also told them that where overruns emerged they had statutory responsibility to bring forward proposals to reduce them and to come in on budget at the end of the year. Is anybody seriously suggesting we can plan a future improved health service without reference or adherence to budgets? It is impossible and cannot be done. The ad hoc system has destroyed our attempts to build incrementally, year on year, a better health system and, more importantly, a better deal for public patients.
