Vol. 2 No. 2
I welcome the Minister for Health and Children, Deputy Cowen and his officials. The purpose of this meeting is to consider Vote 33 of the Revised Estimates. Our timetable allows for opening statements by the Minister and Opposition spokespersons followed by questions and answers.
Is that agreed? Agreed.
The Estimate before the Committee provides a gross sum of £3,549,777,000 (three billion five hundred and forty nine million seven hundred and seventy thousand pounds). The figure shows a 9 per cent increase, over £300 million, on the outturn for last year. This is a record increase in the original provision for health.
In the Dáil Chamber, I set out in detail the progress being made with these additional funds. Today, I will give further details on a number of priority areas. I also wish to discuss some broader issues which influence the framing of this year's Estimate. The key issues which I will outline remain relevant and will influence the development of services over the next few years.
During the 1980s we succeeded in developing a national consensus on the key issues facing the economy and the contribution different sectors could make. The current economic performance in large measure flows from the achievement of this consensus. The ESRI pointed out recently that the challenges we now face are substantially different from those which pertained a decade ago. The imperative to reduce expenditure and taxation levels is now of much less importance than identifying priorities for investment in social and economic infrastructure. A modern and comprehensive health care infrastructure must constitute a key element of these priorities.
In setting out the issues which will guide the framing of Estimates for health by this and subsequent Governments, I make a number of propositions.
First, I propose that significant further spending is required to continue the orderly development of services. Real increase in health spending, having allowed for inflation, averaged just under 7 per cent per annum during the 1990s. We are not at a point where this trend might be expected to reduce in the years immediately ahead. There are significant increases in the cost of maintaining current services. In addition, across a broad range of services, including those for the mentally handicapped, the physically disabled and the elderly, child care, and cancer and cardiovascular services, the comprehensiveness and quality of existing services needs to be improved.
This year's increase of 9 per cent allows a considerable advance to be made in improving services. The total increase in funding since this Government came into office is just under £800 million. With exactly the same opportunities and within the same timescale, the previous Government provided just over £400 million or only half that level of increased funding. This Government has prioritised the health service as never before and accelerated the development of services. In the future there is every chance that these years will be looked back on as a turning point in the development of the services.
Since June 1997, for example, mental handicap services have been allocated an additional £53 million, with a full year cost of £59 million next year. In the three year period 1995-97, the previous Government allocated a total of £36.2 million in capital and revenue funding or, on average, just over £12 million per year to these services. This compares with an average of £25 million per year allocated by me to these services to date. I have also put in place a £30 million national capital programme to run over four years. This will provide the infrastructure necessary to support the services. This is the first time such a programme has been provided and it allows for a much more co-ordinated approach to be taken in the planning of these services as opposed to the haphazard approach taken in the past. My objective is to ensure that everyone identified as needing a service will have their needs met within the next three years.
In relation to services for people with physical and sensory disabilities, the report, Towards an Independent Future, was published in December 1996. This report sets out the requirements for the development of services. Following the publication of the review group report, the previous Government provided a total of £3.7 million in 1997. Before the end of that year, my Government invested an extra £10 million in this sector. Last year a further £12.4 million was provided and this year £13.4 million is being made available. This makes a grand total of £35.8 million for physical disability services since this Government took office.
My predecessor, Deputy Michael Noonan, set up a review of cancer services. This review led to the development and publication of a national cancer strategy which sets out the improvements required in this area. I have made some £19.5 million available to implement the provisions of the national cancer strategy since coming into office. This substantial funding is, in particular, addressing regional imbalances in the availability of cancer treatment services outside Dublin. Preparations are also under way for the introduction of national breast screening and cervical screening programmes, and the national breast screening programme will get under way in the autumn. Phase 1 of the national cervical screening programme is under way in the Mid-Western Health Board area and a full national programme will be rolled out using the lessons learned from this pilot programme.
I have taken a particular initiative on the improvement of cardiovascular health. As an immediate step, additional adult cardiac surgeryfacilities are being developed at St. James's Hospital and University College Hospital, Galway. Children's services are being developed at Our Lady's Hospital for Sick Children in Crumlin. Target activity levels are in the region of 450 procedures annually at St. James's Hospital and 300 procedures at Galway. This additional activity will increase existing adult cardiac surgery capacity by over 50 per cent. Developments at Crumlin, which are taking place in association with the national cardiac unit at the Mater Hospital, will provide up to 100 additional cardiac procedures for children. This will increase existing paediatric cardiac surgery capacity by up to 40 per cent. At the same time, a medium-term strategy for the improvement of cardiovascular health is being developed. This strategy will address the preventative, medical and rehabilitation services needed to reduce the incidence of the disease and improve the services available to those who develop cardiovascular problems.
A total of £20 million has been made available to address hospital waiting lists in the current year. In line with the recommendations of the Review Group on the Waiting List Initiative, a further £9 million was allocated in the 1999 budget to services for older people, and £2 million to accident and emergency services in areas that will help to address the underlying causes of waiting lists. On the basis of performance in previous years, it is estimated that a further 20,000 procedures will be carried out under the waiting list initiative in the current year.
There has been much ill-informed comment on waiting lists. We are already making in-roads in this area, a fact which has received insufficient notice. The figure of 34,996 for those waiting at the end of March of this year is 1,887 down on the previous quarter. This is the first fall in waiting lists since December 1996. Waiting times for both adults and children are also being reduced. I have provided two and a half times more funding this year than was provided by the previous Government in 1997 in relation to this initiative. That Government provided £8 million for waiting list funding in our hospitals in 1997. It was increased to £12 million in 1998, an increase of 50 per cent, and to £20 million in the current year. Not only have I provided substantially more funding for waiting lists but I have also begun to address the underlying causes of the problem. I set up the first comprehensive review of the area and the review group's report has offered a comprehensive blueprint for the way forward. I will not be found wanting in implementing the review group's recommendations.
On the capital side, the provision in this year's Estimate is £46 million or over 40 per cent higher than the provision when I took up office. Capital spending, in particular, has been entirely inadequate in the past. A modern, efficient and quality service cannot be delivered to the public with inadequate infrastructure. We cannot hope to promote good morale and motivation among staffif the conditions they are asked to work in are run down. In the past, when funding was tight, the capital programme was the first area to suffer. In particular, inadequate provision was made for maintenance of the existing infrastructure and replacing equipment. This is a false economy and cannot be sustained without doing considerable damage to the quality of services. We have a considerable capital asset base in terms of infrastructure and equipment, and to maintain this base at a reasonable level there must be a continuous programme of investment.
Over the three year period from 1999-2001, the total amount of capital investment by this Government will be £525 million. This compares with only £309 million spent by the previous Government during the period from 1995 to 1997. I am also the first Minister to set up special funding of £10 million per year for the replacement of equipment. The funding being provided across a broad range of services proves the Government's commitment to properly resource the health services. Significant additional funding is required to continue these improvements. For its part, this Government is committed to providing these funds.
That brings me to my second proposition. Funding is only part of the answer since continued improvement in management and delivery systems is also required. Funding, while necessary, will not be sufficient to meet the health care needs of the public. The scope for increased investment in services which is opening up as a result of our economic performance will not, on its own, be sufficient to bridge the gap between what we would like to spend and what we can afford. As far back as 1948, when the British national health service was being set up, Nye Bevan said:
We shall never have all we need. Expectation will always exceed capacity. The service must always appear inadequate.
That remains true today and it makes it all the more important that we use what we have wisely. Reform, therefore, must proceed alongside the provision of additional funding. The way the service is organised, managed and delivered has undergone considerable change in recent years. These improvements have to be continued.
The legislation providing for the establishment of the Eastern Regional Health Authority has been enacted. This will improve considerably the co-ordination of services in the Eastern Health Board area. In particular, it will provide for a smoother interface between acute and community services. The enactment of this legislation is a notable milestone in the programme to improve the organisation and management of the health services.
The introduction and development of service planning is another positive development. Service plans allow for a full evaluation of current services and detailed planning of activity for the coming year. Once adopted by agencies they are the benchmark against which expenditure, output and progress are assessed during the course of that year.
Improvements in planning and evaluation are being supported by the development of information systems. The investment of time and money in this area is yielding better measures of service needs, outputs and outcomes. For example, the input of directors of public health into the service planning process is being greatly facilitated by the public health information system. The development of this information tool is being led by the Department of Health and Children. In the acute hospital system, the use of casemix analysis in the planning and funding of services puts us to the fore internationally. The development of mental handicap services around the country is based on the sophisticated information on service needs and current placements available in the intellectual disability database. This model is being extended to the physical disability area where a similar database is being developed.
The health service is composed of a broad range of areas. The standard of information available to support the planning and management of service delivery is not even across the whole service. This is being addressed so that the best standards which exist in some areas will, in the future, apply throughout the service. Improvement is not just about more of the same. Last year there was a 3 per cent increase in in-patient and day-case activity levels. However at the same time as activity levels are being increased the quality of care is also being improved. The development of clinical audit, quality assurance, risk management and continuing professional education is improving quality within hospitals. An accreditation framework is being introduced into the major academic teaching hospitals. Each of these initiatives will improve technical effectiveness, but of equal importance are the perceptions of patients. There is significant scope to improve standards of customer service, and health agencies must put this concern at the centre of all their operations.
My third proposition to the committee is that services must be developed in a planned, sustainable and orderly manner. I have been criticised for not solving all problems within the service overnight. I do not consider this to be justified since it is unrealistic and counter-productive to try to change everything at once. The only thing worse than no plan is an unrealistic plan. I have tried to come up with realistic, costed plans based on all the evidence.
There are constraints on the pace with which developments can be introduced which have as much to do with the availability of physical infrastructure and trained staff as they do with funding. For improvements to be sustained into the future they must be built on solid foundations. The easy way out for any Minister is to just throw money at problems. It is more important in the long-term that the right decisions are made from the start. If we get decisions on infrastructure and staffing wrong, it will be very difficult to rectify them at a later date. Therefore, plans must be effective and must offer value for money.
Our services have grown in times when available funding was sometimes very scarce. With less prosperity, many very urgent priorities were Iong delayed. Lack of funds acted as a brake on the implementation of many very worthwhile plans. The challenges we now face are different. We need to ensure that systems for evaluating proposals are rigorous and evidence based. We need to ensure the implementation of proposals is monitored to ensure maximum benefit is achieved from the investment. Where necessary, we need to be more flexible in developing technologies and modes of delivery that overcome constraints imposed by physical infrastructure or staffing availability.
My fourth proposition to the committee is that continued economic prosperity will be the key in facilitating the development of the health services. If there is one lesson from the contrasting experience of the 1980s and 1990s it is that it is much easier to make progress in the health area when the overall Exchequer position is favourable. We have every reason to be optimistic about the economic outlook. Nevertheless, it would be naive to think there will not be hiccups along the way. Health must operate within an overall economic strategy which takes account of all factors. In particular, once budgets are agreed we must live within our means. To do otherwise would put at risk a continuation of present favourable circumstances.
My fifth point, which is also related to the economy, is less often considered. It is that the contribution of health and health care to economic development must be recognised. The role of education and other factors in laying the foundations of the current boom is often mentioned. The contribution of health has been almost totally overlooked. Fifty years ago Irish life expectancy was approximately 60 years, there was significant mortality from infectious diseases such as tuberculoses, influenza and measles and the infant death rate was high. Life expectancy is now approximately 76 years and infant mortality has fallen from a rate of 66 per 1,000 to less than 6 per 1,000. There are clearly many factors at work here and the health sector cannot claim all the credit. However, the contribution has been significant.
Investment in health is sometimes portrayed as a burden on the economy. On the contrary, investment in effective health care has a very important contribution to make to the development of the economic and social infrastructure of the country. The priorities for investment in economic and social infrastructure are currently being considered by the Government in the context of the national development plan. Investment in health infrastructure should be an essential component of the next phase of national development.
I advance a sixth proposition that there should be a phased increase in health spending to a level more in line with our EU partners. Irish health spending as a proportion of gross domestic product is at the lower end of the range among EU countries. Wealthier countries tend to devote proportionately more income to health. Therefore, our low ranking reflects the fact that for a long time we lagged considerably behind other EU countries in terms of national income. As we know from the debate on EU Structural Funds, we are now rapidly approaching the EU average national income. However, total resources, both public and private, spent on health are markedly below that of the EU average.
Having adjusted for purchasing power parity, in 1995 we spent $1,100 per head of population on public and private health services while the EU average was $1,475. Greece is the only country within the EU spending significantly less per capita on health while our spending is at or around the level of that in Spain and Portugal. Having regard to the extent of unmet needs and our increasing wealth, we should now plan a phased, targeted increase in the real level of health expenditure to bring us more in line with our EU partners.
Additional funding must be carefully targeted at key areas such as acute hospitals, mental and physical handicap, child care and the elderly, where there are recognised service deficiencies. We should also seek to reduce the incidence of disease through the promotion of healthier lifestyles as is already under way in relation to cancer and cardiovascular disease.
The recent OECD report on our health service found that: "The Irish system is based on a mixture of public and private care which has resulted in good provision of health care at a relatively low cost to the taxpayer." In 1998 over four million cases were treated in hospitals as in-patients, day cases, outpatients or in accident and emergency departments. The service is by no means perfect but by international standards these people received quality care delivered in an efficient manner by well trained staff. This is not to be complacent since the service can always be improved. The Estimate before the committee today will allow us to build on existing achievements and considerably improve services in areas where there are recognised deficiencies.
There is nothing particularly remarkable about the Minister's propositions in his opening statement. We could not disagree with the content of these propositions. However, the final proposition is an indictment of his term of office in the Department of Health and Children. It gives the lie to his opening comments which seek to laud the level of Government expenditure on our health service. His final proposition was that "there should be a phased increase in health spending to a level more in line with that of our EU partners". He stated:
Irish health spending as a proportion of gross domestic product is at the lower end of the range among EU countries. . . Having adjusted for purchasing power parity, in 1995 we spent $1,100 per head of population on public and private health services while the EU average was $1,475. Greece is the only country within the EU spending significantly less per capita on health while our spending is at or around the level of that in Spain and Portugal.
As Fine Gael spokesperson on health, I have been making that point for two years. The Government's expenditure on health is not in line with that of our European Union partners. It falls substantially below the levels of expenditure to which the Government should have committed itself from day one in the context of the very substantial economic boom from which this country is benefiting and the substantial additional sums being received annually by Government through the tax system. These amount to many millions of pounds more than the Minister for Finance predicted in each budget he introduced.
Our expenditure on health is substantially out of kilter with that of other EU countries. Given Ireland's boom economy, the level of expenditure on health services is a national disgrace. Under this Government, at a time of unprecedented economic wealth, we have a two-tier health service. Those who are insured through the VHI and who have the funds to pay for health care can get immediate access to excellent health care when they require it. Nobody in the private health sector is on a waiting list for hip replacement or cardiac surgery. During the lifetime of this Government, contrary to what the Minister has portrayed, the waiting lists have continued to escalate. The Minister berates reportage of the more recent waiting lists information published. Between 31 December 1998 and 31 March 1999, based on the published figures, there was a drop in the waiting list figures from 36,500 to just under 34,996. The record of this Government is that at the end of March 1997 there were 29,000 people on the in-patient hospital waiting lists. Under the Minister's term of office in the Department of Health and Children, hospital waiting lists have increased by 20 per cent, at a time when the economy is booming.
If the principles the Minister enunciates were put into practice when he became Minister for Health and Children, we would not have had a series of crises within the health service, many engendered by funding shortages. It is an indictment of the Minister that it has taken two years for him to come to terms with the reality that our health spending falls substantially below the line of other European Union countries.
People should not be on waiting lists for hip replacement operations, cardiac operations and tonsillectomies. An opportunity has been lost during the past two years. I am not sure that the Minister has the time to implement the principles he articulates. The allocation for this year will not be sufficient to reduce the waiting lists to the level when the Minister took office. It is unacceptable that this situation continues to pertain.
There are regular crises in the accident and emergency wings of hospitals that are unable to cope with pressure points when they arise. Last year there were closures of wards and lack of beds through financial shortfalls. The Minister should have ensured that spending was increased to European Union levels, that the facilities in our hospitals were used to the maximum degree and that a more efficient system was used for the recruitment of consultants. It takes too long to replace consultants at a time when there is recognition of the need to appoint additional consultants to particular hospitals. It can take from six to 12 months to fill posts even when the Minister or the health boards are given permission. We need new, streamlined procedures.
The Minister referred to the fight against cancer. There are two major programmes that should have been implemented on a national rather than a pilot basis. In Ireland most cancer deaths are caused by breast cancer. The mortality rate can be reduced by 25 per cent through screening of high risk groups. We were supposed to have a pilot screening programme in operation since September 1998, but this will not come into effect until January 2000 at the earliest. Why is it taking so long for the cervical screening pilot projects to be implemented?
The Department of Health and Children is complacent about health problems. Such is the bureaucratic perception about the lack of urgency to get announced projects up and running that a project announced in 1997 is set to be put in place in 2000. There is a need for a new sense of urgency and concern about the health difficulties experienced by people, especially women. The concern has not been reflected by the responsive action that is necessary. As regards cancer, the Department of Health and Children has not set up a pilot prostate screening programme formen.
Recently there has been the scandal of a 13 year lead-in period for junior hospital doctors to assume a 48 hour week, in line with those of the European Union. It is no longer acceptable for junior hospital doctors to work for 60 to 80 hours per week with few breaks for lunch or sleep. It is not conducive to them or their patients' health. Although there is a hint of Government commitment to introducing the 48 hour week for junior hospital doctors within a shorter period than that provided by the European directive, the Minister for Health and Children did not press for it in his report this morning. We should have a lead-in period of no more than five years because we have the facility to do so. The working conditions of doctors should improve and patients should receive the medical care to which they are entitled, particularly in the case of publicpatients and those in the accident and emergency areas.
I am disappointed with the Minister's statement. Any increase in funding is welcome, but in light of the improved economic circumstances, this is expected. His message is that the services are the same but there is a little extra to pay for them. The paucity of his approach is unacceptable considering the requirements of the health services. His propositions are managerial in tone and content, they are not about policy, change or tackling the fundamental issues.
We must deal with the inequality inherent in our health service, particularly in acute hospital services whose waiting lists serve as an example. Poor and sick people must wait for treatment to which, in theory, they are entitled but in reality are unable to access because of low income. At a time of unprecedented wealth people aredying.
The Minister should also examine the inequality in health status as a result of lifestyle and socio-economic factors. There is the usual reference to how we should all live better and more responsibly when it comes to health promotion and different lifestyles. There is no clear intention in the Minister's statement that he will introduce significant measures to tackle the inequality that is creating sickness and ill health in society. The position is becoming increasingly acute when one looks at the differences, whether in terms of smoking, alcohol abuse or the issues covered in the excellent first time survey on lifestyles. Socio-economic factors are the key to our health status, yet the Minister is disregarding this central fact.
I take issue with the Minister in his statement that with exactly the same opportunities and within the same timescale the last Government provided a certain amount. I am not arguing about the figures but with his contention that the circumstances and conditions are exactly the same. They are not. We are getting richer, there is greater tax buoyancy and more people are at work. That should and does offer greater opportunities for dealing with what are significant failings in the health service. The Minister is dealing with different economic circumstances and he should not pretend otherwise to try to make his record look good. It is not convincing and it leaves him open to challenge.
On the issue of the percentage of GDP, in his proposition he states that things should be better sometime in the future. Nobody will argue with that, but what will the Minister do to achieve the goal of a greater percentage of GDP? He does not tell us the current state of play. Usually when we look at Estimates we want to know what is not spelled out rather than what is spelled out. We all know about creative accounting and that Estimates are designed to look good. Is the percentage of GDP that is spent on health care higher than it was three or four years ago?
Yes.
I would like to hear that figure because it is important to know by how much it is higher. If it is not significantly higher, there is a failing on the part of the Minister. I am interested to note the Minister's claim that there is a 9 per cent increase in resourcing and funding. As I read the Estimates, the increase is 8 per cent. The Minister has included in the figure appropriations-in-aid, largely health levies which are increased significantly - to 23 per cent - because of tax buoyancy and more people are at work and, therefore, contributing. I always find Estimates difficult to follow but it appears that, because there is a significantly greater contribution being made there, it comes to 1 per cent in overall terms. It has to be acknowledged that that does not mean great management by the Government, it is just that more money is coming in as a result of buoyancy.
I am curious as to why the lottery is no longer used as a resource, as in the past. When it was set up a commitment was given that it would not be used to replace Exchequer funding. Clearly there is a reduction in lottery funding. It is curious that national lottery funding to health agencies and other similar organisations has decreased from £19 million to £7 million, a huge drop. The grant to research bodies has hardly been increased. We need to know what is going on in relation to funding. It is important to know the precise position in terms of health care funding and how it is being allocated.
An interesting point is emerging in the Estimates about the GMS. Payments to general practitioners are lower than previously. Presumably that is because more people are outside the GMS net than before because more people are at work. If that is the case, in terms of inequality we should be looking at people who are not eligible for the GMS but are still on relatively low incomes, who are in an impossible position particularly when children are sick. They can barely afford to pay the doctor to come out and treat their children. The Minister has made some effort in terms of elderly people caught in this poverty trap, but nothing has been done for parents of children who fail to qualify for the GMS. At a time when presumably the numbers are falling - certainly the cost to GPs is reducing - the Minister should improve access to the GMS, open it up to more people, if necessary, target children under a certain age and guarantee that primary health care will be available to them. That would be a modest but significant improvement for families at a time when the Minister can afford it.
We do not have a sufficient number of hospital beds across the country. I am concerned about bed closures. I realise statements have been made by hospitals that there will not be the same number of bed closures as in the past. What is the precise position of the Department in relation to summer bed closures? Will the Department guarantee that St. Michael's Hospital will be retained as a step down facility or a full hospital facility? Will the Minister please guarantee today that that will happen?
What is the position regarding junior hospital doctors? Considerable pressure has been put on the Minister and he has had to do a U-turn. Will he spell out what is being done to deal with this scandal in the health service?
Before beginning the general discussion of the Estimates I suggest we complete each subhead before proceeding to another, commencing with subhead A, the administrative budget.
On IT consultancy services, what is the position regarding year 2000 compliance in the Minister's Department? Is he satisfied that each health board has done what is necessary? What is the position with regard to the various hospitals throughout the country? Concerns have been expressed that within particular health board areas hospitals have not kept up with the designated timeframe to ensure year 2000 compliance. What work has been done by the Department with regard to computer difficulties that could arise on 9 September 1999? This date is known to be one that can give rise to particular computer difficulties. To what extent have health boards and hospitals been alerted to that difficulty and to what extent have they addressed it? Will the Minister give a categorical assurance that on 9 September 1999, or when we reach 2000, we will not suffer serious computer failures which will place at risk health services or the health of patients?
Will the Minister clarify the nature of the contracts given to Drury consultants? It seems that since he took up office Drury consultants have had a regular public relations consultancy with the Department. What contracts have been entered into with them for 1999? Was there a public tendering process or advertising of the consultancy they are now operating? I want to know the sum agreed by the Minister that will be paid to Drury consultants this year. I would like him to spell out precisely the services being provided by Drury's to his Department.
I am a little concerned that there would be a reduction in regard to technology in the Department. Is the Minister satisfied that the Department's computerisation capability is satisfactory? I appreciate that health boards are the bodies responsible in terms of statistical information on waiting lists etc., but it is extraordinary that one has to wait four or six months to get information on hospital waiting lists, for example, and that the consultants' lists are not easily accessible by GPs. We do not know enough about the effectiveness of the health promotion activities of the Department. We do not know the impact of these health promotion activities because it appears there is not the capacity for data collection, assessment and analysis in the Department. There is always a tendency to use outside bodies to carry out research. That is probably a good idea, but it appears that the normal checks and balances and the knowledge gathering capacity of a Department is absolutely central to wise decisions. The managerial approach the Minister is talking about is his key priority when it comes to managing his Department, but is he satisfied that everything is running smoothly in terms of the possibilities that technology can offer? Reducing that capability now, as it would appear in these Estimates, seems strange.
We are not reducing the capability for technology. We are spending more on technology this year than we ever spent - £14 million this year as against £9 million last year - so I do not know where the idea is coming from that we are spending less on technology. As I outlined in my address to the committee, the reason we are spending more money is that there is a need to introduce best practice into the whole system. That is good in some areas but not in others. We are updating the technology requirements of the agencies all the time and putting more money into them.
I know that, but I am talking about the Department.
The position is similar in the Department in the whole case mix criteria I use for the allocation of funding for hospitals. Last year, for the first time, we introduced a new system where allocations were made at the beginning of the year and we were able to come back, having spent £3 billion, with an overrun of approximately £4 million or £5 million on revenue expenditure. That indicates that management systems are fairly good. While it is a nice line and the media might pick it up, the idea that there is something Dickensian about the system in the Department is simply not true. Enormous amounts of money are being spent on technology because we want to get back the information flows to improve outcomes, evaluate, monitor and ensure we are getting value for money because we are spending a great deal of money. Any suggestion that there is a reduction in technology is simply untrue and can be discarded. We attach a great deal of importance to technology. When I came into the Department I was bemused by how little money had been spent to update modern management systems in the health service, despite the many policy-driven people in the previous Government. Perhaps a little management expertise might not go astray. A little managerial ethos might not be out of place. We have a sufficient number of visionaries. If we try to run the service on a day to day basis the patients might be better off.
Deputy Shatter spoke about Y2K compliance. A committee is dealing with that, under an assistant secretary general, on an ongoing basis. We have had a number of meetings with the committee members. I have met them and the chief executive officers and they are aware we are giving this matter priority. Replies to parliamentary questions would detail the procedure to date in terms of finding out what they needed, the audits that were done etc. That work is well advanced. We have provided money to the agencies. We are having discussions with the Department of Finance about additional moneys sought, for which I understand contingency funds will be available.
The 1999 issue is being dealt with by the committee which is not unaware of the glitches that may occur as a result of the technology in place. One of the problems with the health service in terms of Y2K compliance is that one part of a piece of equipment may have been made in Taiwan, another in Japan and another in the United States. Difficulty has been experienced in trying to bring all that together and ensure that the equipment works on 1 January 2000. Much progress has been made on that and the committee can be assured it is being accorded the priority it deserves. As regards giving categorical assurances, I am advised that progress has been made on this. Obviously the work we are doing is to avoid disastrous consequences. This is a challenge for everybody in the private as well as the public sector. I know from my discussions with the secretary general and the assistant secretary general involved that progress is being made to the extent that we are happy that we are on target for the compliance criteria we have set down for the agencies to ensure they are on time. We expect all this work to be done by August or September.
Is any particular hospital or health board giving cause for concern because they are behind time in their work? I understand that is the case. I do not want to be alarmist about this but we are entitled to know where matters stand in that regard. What is being done to tackle that problem?
That is being brought into line. Some were making less speedy progress than we would have liked. We have now brought them all up to speed and that is no longer a problem.
As regards the consultancy question, Drury's have a five month consultancy, which others applied for, and that began in April. It is based on tender - I understand the figure is £25,000.
Perhaps the Minister will clarify when this tender was received and the number of groups that applied. Will the Minister outline the reason Drury's were given preference? It seems Drury's have been the regular advisers since the Minister came into office. I am not saying there is anything untoward in that but there should be an openness about this. It appears that no matter what public relations work is required personally or for the Department, Drury's are given this work. I would like the Minister to clarify who they are working for. What is the specific work they have been contracted to do for £25,000 for five months of this year? When does that contract end and what arrangements are proposed after the five month period?
All the requirements for consultancies were adhered to in relation to this contract as in relation to any other contract awarded for consultancies - there is no difference in respect of this contract. I understand at least two other agencies made an offer for this contract. As the Deputy knows, we are making a rearrangement to improve communications in the Department and an assistant secretary general is working on that. The contract was awarded for five months because at the end of that time we will be in a position to evaluate the further consultancy work we require as a result of the reorganisation taking place in the Department in terms of improving communications.
What is the difference in terms of what Drury consultants are doing? In what way does it differ from what they did previously? Last year they had a contract to facilitate the Department making whatever changes were necessary to ensure that internal communications were more efficient.
That is now in process. They are providing advice to the Department on a range of issues including cardiovascular health policy and the presentation of a White Paper on Voluntary Health Insurance. They are working with the Department on a range of major policy issues and their brief is to the Department, not simply to the Minister.
Is their brief essentially concerned with the presentation of the departmental policy, publication of departmental documents and advising the Minister on how to deal with public relations issues? What date does their brief end? Why did Drury consultants get the contract rather than one of the other two? Was there a price differential between them? What criteria applied?
There is no mystery about the criteria that applied, it was the normal requirements for consultancy. It was not dealt with in my office but at administrative level. Drury consultants have an expertise and experience in this matter. The fact that they were incumbents, so to speak, would have put them at an advantage over others. They enjoyed the confidence of the Department in respect of the work they had been doing. There was satisfaction in the Department with the work they had done. Renewal of a contract came up and they and others applied for it, but they got it.
The Minister is saying the tendering process was merely for the sake of optics, that Drury consultants were there already, they were preferred and they would have been given the contract.
No, that is not the case.
When does the contract end and what procedures will be in place for a new contract thereafter?
Obviously, we have very few difficulties in the health service if we are going to spend half an hour on this matter. There is no need to misrepresent my position or what I am saying. It is very simple. It is similar to what I am sure happens in the Deputy's legal practice. I am sure that if a larger number of people come to Deputy Shatter's legal practice or Deputy McManus's clinic or attend Deputy O'Keeffe's lectures, the members of the committee would attribute that to their expertise and competence. It is very basic. Drury consultants and others applied for a consultancy and Drury got it. It was dealt with in the normal fashion at administrative level and there it lies. Drury consultants have done work for the Department and they will work for it over the next five months.
Will the Minister tell the committee the total amount paid to Drury consultants for the consultancy work contracted for the Department or the Minister since he took up his term of office as Minister for Health and Children?
I do not have that figure but I will get it for the Deputy. Off the top of my head, it is approximately £125,000. I will advise the Deputy of the exact amount.
I suggest it might be at least £150,000.
If it is, the Deputy should not hold me to the figure of £125,000. I will get the figure for him.
We will move on to subhead B.
Under B7 the figures for national lottery funding range from £19 million to £7 million. Those figures are reflected in the Estimates. Will the Minister elaborate on them?
Some Departments work through the agencies or the health boards. The Department of Social, Community and Family Affairs would give much more direct funding to individual projects. We channel moneys within the core funding of the health boards. There is that difference. There is less direct departmental funding to projects in our Department than is the case in other Departments.
I am talking about this year and last year. I refer to funding the Minister directed, which was itemised as lottery funding. It has been a bone of contention that lottery money has been used in effect to replace Exchequer funding. That has been a long-standing issue. The Minister has now done something different and I am not very clear on what that is, but he appears to have reduced considerably, in this instance by way more than half, the money from that source. How is that money being made up or have we lost that source of income?
The subhead covers the cost of services funded from the national lottery, including services provided or funded by health boards. The reduction in this subhead results from the recommendations of the review group on the national lottery. It recommended that certain services previously in receipt of national lottery funding should instead receive Exchequer support. Accordingly, these services are now being funded from subheads B1, B4, B6 and H.
That deals with why it is reduced, but what has happened to the money that was allocated for health expenditure? To where is it being allocated? Presumably it is recorded somewhere else in the Estimates.
No.
Does the Minister mean we have lost the money that was allocated to the health services?
No, we have an Exchequer commitment for more money that was otherwise discretionary under lottery funding. We have, therefore, improved our position.
We have also lost money that we could have had in addition to that money.
That was lottery funding which was discretionary. The Deputy remarked earlier on the idea that lottery funding should not to be used instead of Exchequer funding. We now have more Exchequer funding for that purpose and that is lodged in as core funding.
My difficulty is that we are now using Exchequer funding to replace lottery funding. Presumably there is still some lottery money that has been transferred somewhere else. Is that money within the health budget or somewhere else, or has it been taken out altogether?
The funding I have now for payments to health boards and miscellaneous bodies is £7.169 million. What was previously lottery funding, which I have now made Exchequer funding, includes services for the elderly, £5.68 million; child care services, £2.15 million; mental and physical handicap, £1.93 million; and public health and health promotion £1.34 million. That is core health funding. Moneys from the lottery are being directed to the Department of Social, Community and Family Affairs.
So the Department has lost that money?
The Department is spending the same amount of money on the same services, but we have only changed the source of funding.
I know that. The Minister claimed he has increased the funding, but what he is saying is that funding has replaced the lottery funding which has gone elsewhere.
I never said that I had increased the funding, I said I succeeded in getting Exchequer funding for what was previously lottery funding which was used for this purpose. That is a better position for the Department than was the case heretofore. Lottery funding is decreasing as a result of competition from charities. If I was told by the Department of Finance that because the lottery has increased its prize winning money and wants to maintain its output and volumes etc. the Department is allocating only £5.2 lottery funding for services for the elderly, Deputy McManus would be the first in the Dáil to ask where is the other £418,000. She would demand that I get it from the Exchequer. I decided to get the £5.68 million from the Exchequer, which means I will not have to worry about securing lottery funding.
I wish to ask the Minister a number of questions that I understand fall under this subhead - if they do not, that can be clarified. This subhead is largely concerned with funding to health boards. It relates to services provided by health boards and a number of issues arise under all these subheads. I referred, as did the Minister, to hospital waiting lists. As highlighted by the Minister's report and by a report I published on behalf of Fine Gael, one of the difficulties we have within our hospitals is inappropriately occupied beds. Some elderly patients who require long-term care do not have an alternative to hospital care and they are occupying beds. Elderly and young people, who require some type of step down care facility but not an acute hospital bed, are occupying hospital beds. What progress will be made this year in tackling that problem in terms of funding to health boards? What additional facilities are being put in place or will be funded to free up hospital beds that are inappropriately occupied and to provide more appropriate, and what would be in effect less costly, facilities for the elderly and young people concerned who fall into this category? My second question——
I will reply to the Deputy's first question. As a result of the improved management information system, we know that as at the week ending last week, there were about 240 people inappropriately placed in the Eastern Health Board area, including elderly and young chronic sick people with head injuries, for example. There has been a reduction from 140 this time last year to 110 in the number of elderly in the inappropriate placement category. The follow through on the review group's recommendation of investing in services for the elderly as well as trying to solve the waiting list problem in hospitals is starting to give results. We have been in discussion with the health boards, in particular the Eastern Health Board, on coming forward with proposals on how we address this issues, particularly the young chronic sick. There are long-term patients who are in the wrong place, and others such as the elderly and the young chronic sick who need rehabilitation but are not getting it. In the past week or two the health boards submitted proposals on how we might improve the situation. We are examining that to see how we might be able to assist. We expect the additional £9 million allocation for the elderly this year will improve the situation. We have asked for a comprehensive overview as to how we might solve the problem as distinct from moving people around.
On a related issue, many families with an elderly member in nursing home care find that the State subvention to which they are entitled falls very dramatically short of the real weekly costs and as a result they are experiencing great difficulties. Does the Minister have proposals to deal with this issue? Does he accept that financial difficulty has contributed to elderly people occupying acute hospital beds, for example, where persons cannot get a bed in a health board nursing home and the family does not have the funds to provide for such care, they are being left in acute beds because there is nowhere else to go? Has the Minister plans to increase the subvention for nursing home care or to fund health boards' capital expenditure for the provision of nursing home care?
In response to the Deputy's second point, it is important to point out that in respect of units recently completed, those under construction and those in planning that have been approved and will be proceeding, we will be investing £60 million from the capital programme in units for the elderly. That is a significant increase.
They are not actually open.
They will be opened as soon as they are built.
In the context of that expenditure how many beds will be provided?
The board members have made care of the elderly the priority issue whereas it is the acute hospital sector that gets all the publicity. We are making this level of investment in the provision of places for the elderly because it is the stated priority of the public representatives. As regards the nursing home subvention, there is a trade off between increasing the subvention rates for fewer numbers or having the maximum number possible avail of it. The issue raised by Deputy Shatter is in the background and we are in discussions with the Department of Finance on it for next year's Estimates. I took a conscious decision at the beginning of the year not to proceed with an increase in subvention rates on the basis that the demand was such that an increase in the rate would have been an injustice to the many people who would then be ineligible altogether.
About 650 beds in nursing homes are being bought by the health boards in addition to those provided by the capital investment. The Eastern Health Board has to buy beds from the private sector and we have provided more money for it to do that. We will discuss the underlying problem which the Deputy raises with the Department of Finance for next year. I have made a judgment not to proceed the way I proceeded this year for the reasons I have given.
I am pleased the Minister is looking at this area, but we have not responded to the very real and growing need of the elderly who are not capable of caring for themselves and whose families do not have the capacity to care for them. The extent of the problem is to some degree a consequence of the success of our health service because people are living longer. There is a need for a dramatic increase in expenditure in this area and to recognise that we must provide additional nursing home facilities run by our health boards. Ultimately, it would be financially better that the health boards provide their own facilities rather than hire beds from private nursing homes. This is an ever-growing problem which will continue to impact on our acute hospitals if we do not address it. There is a new poor developing, married couples with teenage children who are fighting to make ends meet and find the final straw is when their elderly parent needs nursing care in a nursing home and may find themselves having to pay £200 to £300 a week to keep their parent in that type of facility with very little help from the State. They are living under great strain. Others who do not have the expertise are trying to care for the elderly at home and find that the strain is impacting on their quality of life.
We need a radically new approach to addressing the needs of the elderly. I agree it is a particular problem in the Eastern Health Board area because of the population concentration in the region, but it is not confined to that area. I have no doubt there is a need for a dramatic new initiative to provide additional facilities.
The Minister said he had to make a decision to increase the subvention or leave it as it was and use the money for other purposes. This comes back to what he said in his speech today on expenditure on health services. He did not need to make that distinction in the year 1999 as there is sufficient additional money flowing into the State coffers to allow the Government to substantially increase the subvention this year and not wait until the next budget. I suggest there should be a policy change in this area and the subvention should be increased. We should not have to wait until the next budget.
There are difficulties with child care services, particularly in the Eastern Health Board area. What is the current capacity of the health board to carry out assessments of children alleged to be at risk? What plans are there to provide any additional funding the health board requires? The Minister now accepts, although he did not some months ago, that there have been difficulties within the Eastern Health Board with the manner in which it runs its adoption services, particularly its assessment services in respect of foreign adoptions. Could the Minister advise the committee when the report on the adoption assessment procedures, which he now has in draft form, will be published, and when steps will be taken to rectify the problems caused by the procedures, and in particular by the approach by Eastern Health Board personnel in assessing the suitability of couples seeking to adopt abroad?
Deputy Gormley, do you want to put related questions?
They do not relate to child care.
On the issue of subventions, it is important to point out that we have moved from £4 million in 1993 to £33 million in the current year, which is significant. We are also building up our day services and trying to improve community care so that people will be able to look after their relations in their own homes for as long as possible, where that is feasible and clinically advisable.
On child care, the Minister of State, Deputy Fahey, commissioned a consultancy on intercountry adoption, the question of delays, assessments and so on. There are backlogs, particularly in the Eastern Health Board, Southern Health Board and North-Eastern Health Board areas. I went to Government yesterday to publish the report. We require an extra £500,000, including an extra £300,000 Exchequer money, agreed yesterday, and £200,000 from the Department's resources to try to address the backlog. In the past people have had to wait between one and three years for decisions, assessments and so on. We got a Government decision yesterday which will put money in. We are also setting up an implementation group on the recommendation to make improvements on a phased basis. Money is being allocated to deal immediately with about 480 cases.
What are the guidelines regarding uniformity of approach to carrying out assessments so that people are not treated in an unnecessarily intrusive or difficult way?
The report will be published. It is a very comprehensive report which covers all the issues. Its recommendations will be adopted. An implementation group has to be set up. The point is that we are providing extra resources to deal with couples who have been waiting as an immediate measure.
When might we expect the report to be published?
I just got a decision yesterday. I expect the report to be published in the next week or so.
I apologise for not being here earlier. I had to go over to the House. On the waiting lists, the Minister announced a "get tough" policy of financial incentives or penalties in December 1998, following the recommendations of the review group on the waiting list initiative. In that context, what is the total financial allocation set aside by the Minister as an incentive package to hospitals and health boards which have met their service plan targets under the waiting list initiative, the additional funding to be allocated to each health board or hospital under the waiting list initiative plan, and the level of funding to be withheld from each health board or hospital under the same plan?
A sum of £20 million pounds has been provided this year to the various hospitals and agencies for the waiting list initiative. I allocated £16 million and withheld £4 million which will be allocated on the basis of performance. It was mentioned that money was taken back. What I said in the Dáil was that if the boards did not send me the figures they need not bother applying for the money. They have been sending the figures.
I am also trying to make known the waiting times per specialty and per consultant so that patients might know why they are being referred to one consultant rather than another and will be somewhat empowered in deciding that they do not care whether Dr. X or Dr. Y does the operation, that they just want to get it done. It is that sort of basic informational change that we are bringing about. The remaining £4 million has not yet been allocated. We have only gone through our first quarter. I will know, when the next figures come in, who has performed well. Some hospitals have better capacity than others. We want to identify those rather than allocate money based on waiting lists, because lists are an indication that the work cannot be done anyway.
Is the Minister saying that additional funding could be allocated to hospitals based on their performance——
Yes.
——and that hospitals which are performing well can expect to get extra money from the Minister?
If they are doing the business they can expect more money.
The Minister talks about underlying causes in relation to funding. Are we looking at the underlying causes of ill health? We know, from WHO figures, that 80 per cent of cancers are related to environmental problems. Are we looking at that in detail?. The Minister has allocated more money to the health service, but is that one of the areas that the Minister would be interested in examining? Cancer rates are higher in Dublin, presumably because of the quality of the air. Is that something we need to look at and that the Minister would like to invest more heavily in?
Health status is made up a number of issues. Deputy McManus referred to socio-economic conditions. That certainly is a factor in one's health status. Environmental issues are another factor. What the public system has been doing in appointing directors of public health to health boards and having them involved in the service planning process is giving greater status to such issues in deciding how the health services are run. That area of the service is in its infancy. The question of pollution as a cause of health problems is really a matter for the Department of the Environment and Local Government.
Does it not require an interdepartmental approach, a more holistic approach?
It does. However, the Irish Road Hauliers Association might listen to the Minister for the Environment and Local Government where it would not listen to the Minister for Health and Children. If smoke is spewing out of an exhaust pipe the person to do something about it is the Minister for the Environment and Local Government, Deputy Dempsey. I take the Deputy's point on the need for preventative strategies, but my job is to provide for those who unfortunately have cancer a treatment regime that is uniform, that uses best practice and has the necessary multidisciplinary teams in place at area health board level. Deputy Noonan's policy on that, which is probably his legacy to the Department, is in its implementation phase. Significant improvements are taking place in the delivery of cancer services as a result.
Although it is not the first time the Department has done this, rolling out a programme which is realistic, recognising the funding issues and the need to get the personnel and to build up the hospital expertise over a multi-annual period of five or six years, is proving the best way of qualitatively improving the services for people who have such a killer disease as cancer. We will have a similar programme for cardiovascular health moving on from the success of the cancer strategy. The causal factors are issues which concern Government generally and other Ministers, in particular, in terms of how they stop the environmental problem impacting on health status subsequently.
I tabled a number of parliamentary questions on home births. Does the Minister believe we could make a substantial saving if there were more home births? I understand it costs far more to have a baby in hospital than at home. Is this something the Minister would encourage?
I am informed a pilot scheme is starting in Holles Street on this issue, from which we can learn how this might form part of our maternity services generally. There is a commitment to set up a pilot scheme in Holles Street.
Will the Minister outline what he plans to do about St. Michael's Hospital? On subhead B2, the drugs refund scheme, I note there is only a slight increase. People on that scheme are being forced to pay more before they buy into it. Is it governed by the drugs budgeting approach which applies in the GMS? People are being hit badly by these increases, and maybe we should adopt a different approach. Is the drugs budgeting approach applied in this case? Will the Minister explain the major drop in the Estimates for the homes for mentally handicap persons administered by voluntary bodies? I presume there is not a major drop, although there is in the Estimates.
Nye Bevan's dictum does not apply in the GMS when it comes to payments to GPs. Why can the Minister not expand the GMS, improve it and ensure more people are protected, particularly people with young children? What is his reason for not going down that road?
I am pleased he said the Department is well equipped as regards information technology.
After the visionaries.
The story is already changing. He did so much good work; he was the manager after the visionaries and worked for the betterment of the patient. If that is the case and in terms of the Minister's commitment to value for money, can the Department work out a comparative cost of the same procedure in different hospitals? Does the Minister have that basic information?
Yes.
That is an improvement.
I thank the Deputy for agreeing with me on something.
Does that go into all procedures?
Yes.
Well done.
On St. Michael's Hospital, the Eastern Health Board is considering possible uses for the facility. We will consider the results of its appraisal when it is completed. It will include an assessment of the physical structure as well as the possible service uses for the facility.
Is there a commitment to buy it?
There will be no commitment to do anything until we appraise the situation to see if it fits into its future network. We await that appraisal. On the mentally handicapped, moneys have gone to the agencies. There has not been a drop in the amount but a different funding mechanism applies.
The drugs payment scheme has far more advantages than disadvantages. It requires expenditure of £42 per family per month with no need to wait up to four months for a refund based on expenditure in excess of £90 over three months. From a cash flow point of view for low income families, it has many advantages, most of which have been acknowledged by everybody.
The purpose of the scheme is to ensure families are not put under financial strain for a period of four months while they apply for and await a refund. Clearly, from a cash flow point of view, in terms of what it costs low income families to get medicine on a monthly basis, this will be a better scheme.
It is possible to point out a disadvantage for some people as regards the drugs cost subsidisation scheme, but this scheme requires expenditure of £42 per month per family. When trying to reform and improve the situation, the Deputy would probably be able to show me the 4 per cent or 5 per cent of cases in which there is a difficulty. Overall, there is no question but that the drugs payment scheme will be a far better scheme for low income families than the present one, which is administratively cumbersome. I am aware of people who had to get loans from credit unions over the four month period while they waited for their refunds because they did not have the money in the first place. This scheme will require expenditure of £42 per month and everyone will know the situation. It is much simpler and the pharmacist rather than the patient will deal with the problem. For that reason, I hope it will be well received.
I understand the drugs budgeting approach currently used applies to drugs prescribed under the GMS. Does it also apply under the drugs refund scheme?
No.
I am curious about that. If this is being lauded, as it has been by the Department, as being value for money and good control over the spiralling cost of drugs, will we have a system where if one is poor and on the GMS, the drugs one receives will be of a different standard from those received by people on the drugs refund scheme? If it is a good system - I am open to persuasion - and a good way to get value for money and maintain quality care, why does the Minister not extend it to the drugs refund scheme?
There is also the issue of equity. If one looks at the common list, which has been overlooked, people on medical cards had to pay for certain drugs because they were not on the GMS list but on the drugs cost subsidisation list. People on higher incomes were able to get a subsidy back in respect of some medicines which were not available on the GMS. We are trying to bring in a uniform scheme with the GMS list for the person on the medical card and another scheme, a drugs payment scheme, whereby the same medicines will be available. We cannot have a system under which those on higher incomes are able to get refunds for drugs which were not available under the GMS scheme.
The Minister is missing my point. I am not arguing that point, but I accept that equity is important. The drugs budgeting approach encourages GPs to control costs when treating GMS patients. The GMS is not being circumscribed in that way in terms of treating people on the drugs refund scheme. There is an inequity.
Dr. Michael Murphy in Cork undertook a report on whether there was evidence of poorer quality being available. The report stated strongly that there was no evidence of poorer quality in the other approach. That is why the drug budgeting on the GMS is not being extended.
If it is a good idea, why does the Minister not extend it?
The report of Dr. Murphy, who was asked to look into whether there was evidence that there was a problem in that area in terms of the quality which were being applied, stated firmly that there was no such evidence. Therefore, we accepted that recommendation. We took Dr. Murphy's word for it.
I am not arguing that point. I am saying that if it is good, fair and maintains quality, why does the Minister not extend it into the drugs refund scheme since he is arguing that his role, as Minister, is to get value for money and that this is his skill?
The drug budgeting scheme which we use in the GMS is for the purpose of encouraging doctors to have prescribing patterns which will enable us to meet one objective, which is the control of costs, but which also provides an incentive to the GP because some of that money goes back into the development of the GP's practice. That is what that is about, it is a separate issue.
Under the health board section with which we are dealing, I tabled a parliamentary question to the Minister and we have been in correspondence about the following matter. This committee produced, through the good offices of Senator Jackman, a good report on children who suffer from attention deficit disorder. A difficulty arose in the context of Our Lady's Hospital for Sick Children, Crumlin, which for a six month period only had the services of a psychologist who specialised in attention deficit disorder and who was available to assist not just the child but also parents coping with children who suffer from this disorder. That psychologist provided important additional support to parents who were under pressure. I understand that the position terminated in December 1998, it has now been re-advertised and the hospital will be recruiting another psychologist to do this work at least for another six month period.
I suggest that both the Children's Hospital, Temple Street, and Our Lady's Hospital for Sick Children, Crumlin, should have at least one full-time psychologist specialising in attention deficit disorder who can provide assistance to both the child and the family of the child in coping with the difficulties which arise. Similar facilities should be provided in appropriate hospitals outside the Eastern Health Board area. It is my understanding that there is not provision for this. In so far as the Minister may say to me that other health boards have not, through their service plans, sought financial applications for a post of this nature, I suggest that his Department should raise this issue with other health boards with a view to seeing whether we can ensure for the year 2000 that at least within every health board area there is an appropriate number of psychologists recruited who specialise in this area.
The report of this committee shows a wide variety of needs across a range of areas dealing with children who suffer from this difficulty. Here is an area in which Our Lady's Hospital for Sick Children, Crumlin, ran a pilot service in a sense and it was found to be of great use. Indeed, a single psychologist doing this work in that hospital is not sufficient as I understand the psychologist only had time to deal with parents who had the most difficult and most disruptive children. There were parents, who sought assistance from this psychologist and who hope to get assistance from the new psychologist, who have been told they will be no access to such a psychologist until well into next year.
There is a great need for us to recognise the extent of the difficulties caused by attention deficit disorder and to put in place new facilities and additional assistance to deal with them. I do not know whether the Minister or his officials have yet had an opportunity to read the report, which was published by this committee, on that issue. If they have done so, will the Minister indicate his views on that report and the action he proposes to take to implement its recommendations?
I am aware of Senator Jackman's keen interest in this area. It is a matter which she has raised on a number of occasions in the Seanad and privately. I am also aware of the confidence which the parents had in that psychologist. I received a few telephone calls directly to my home about it when there was an indication that she was moving on. Obviously in a situation like this, where people have not had help in the past and where a person comes and does such work and he or she moves on, people are hugely upset and hope there are ways in which the person can be kept. That simply was not possible in this case.
As the Deputy said, Our Lady's Hospital for Sick Children, Crumlin, is seeking a replacement. I am not aware that the Children's Hospital, Temple Street, has ever come forward to us with it as a priority issue. If that hospital was to do so we would have a look at it and see whether it could be incorporated in the service planning for next year if it was deemed appropriate and needed.
This is an area which has taken health boards a long time to recognise as one of specific and identifiable difficulty. I suggest the Department prompts each health board to indicate the numbers of children who suffer from this difficulty and the families affected so that an assessment might be made about the countrywide needs in this area. It has taken a long time for recognition to be given to this particular difficulty and that one is not simply dealing with stubborn, disruptive children. There is a need for an even approach to the provision of services in this regard in health boards. I am genuinely concerned that some of the other health boards have not yet come to terms with the needs in this regard. As a result, the Minister will not receive a request in service plans for the provision of someone who can provide the service which the psychologist apparently provided in Crumlin which was of such great value to parents last year.
It is always a question of priorities. I will get briefed on the committee's report and then we can discuss it at Question Time.
I suggest we now take subheads C to H, inclusive.
Over the past ten years I raised an issue, which needs to be addressed and which arises under subhead E, with a succession of Ministers for Health from every party, including my own. I am appalled that this matter, which relates to adoption, has not been addressed. The Minister may be familiar with the fact that regularly through the court system a number of cases take place each year in camera. Few are ever reported. Occasionally the odd court judgment is reported and gets some publicity. These are cases in which perhaps many months after a child has been placed for adoption the natural parent changes her mind about continuing with the adoption process or when the Adoption Board asks for final consent it is not forthcoming. In can result in a High Court case in which on occasions two, three or four years after the child has been placed the natural parent seeks to have the child returned to her and the adopters seek to complete the adoption process. Adopters, through no fault of their own, find themselves involved in extremely distressing and expensive High Court proceedings. The reality is that most of the adopters who find themselves in that position do not qualify for free legal aid and must foot the bill for a court case which will always take a minimum of two days but which on occasions takes three, four or five days.
I do not wish to make a political point of this because successive Governments have not addressed it. Until 1987 the fees of adopters caught in this position were normally discharged through the Attorney General's Office under the Attorney General's scheme. Those fees were so discharged when, on completion of a case, the court recommended that the scheme apply and the effect was that a substantial portion of the costs incurred by adopters - the scheme did not cover some aspect of the work which on occasions have to be done for adopters - were discharged through the Attorney General's Office. In the context of the various financial cutbacks that occurred across a broad range of areas in 1987, the payment of the fees of adopters through the Attorney General's scheme was abolished. That remains the position.
Let us consider a case where my wife and I had a child placed with us for adoption. The child lived with us for 12 months but when the natural mother was asked to consent to the adoption she refused. Matters were allowed to remain static for a period before I decided to bring the adoption to a conclusion, perhaps in the second or third year. The only way I could do so is by bringing High Court proceedings which the natural mother might defend. In most instances, natural parents are not liable for costs and, even if they were, the courts would not make an order for costs against them because there is a great deal of concern about their plight. In reality, nearly all natural parents are represented by law centres. A number of the cases to which I refer find their way not only to the High Court but also to the Supreme Court because the natural parents have no financial inhibition in appealing to the latter. As it stands, even when the adoptive parents win their case, are awarded custody of the child and the court allows the adoption order to be made, the adopters are obliged to foot the Bill for legal costs. These may and in most instances do include the costs of child psychiatrists charged with carrying out family assessments, attending in court and giving evidence. The legal costs in cases of this nature may amount to between £10,000 and £20,000, including outlays.
How many such cases are brought each year?
I do not believe that more than ten are brought each year. However, perhaps I will obtain the precise statistic by tabling a parliamentary question.
There is an odd aspect to this matter. In 1988 a new Adoption Act was passed. Under that Act, a child abandoned by its parents and placed in foster care can ultimately be adopted. There is a procedure provided in the 1988 Act where a couple who have had a child living with them for 12 months or more can apply to adopt that child if he or she has been abandoned by its parents and the courts are of the view that there is no reasonable possibility of the parents caring for the child. People who have had children placed with them in such circumstances can apply to the court to have the child freed for adoption. There is the possibility, however, that a court contest may occur at the end of which it may be decided that a child should be freed for adoption. A Supreme Court case of this nature was reported on in the newspapers last Saturday.
Where it is decided that a child should be freed for adoption, the couple involved can proceed to adopt the child. If the adopters decide to take this course of action, the health board will pay their costs. Either a lawyer appointed by the health board will represent the adopters concerned or if they obtain private legal representation the health board is obliged to pay their costs under the 1988 Act. This affects a small number of people. It is a gross discrimination that if a child is placed with couple and they follow the 1988 Act procedure, they will be indemnified against legal expenses where they are involved in a court case with the sole objective is to protect the welfare of a child, whereas if a child is placed with that couple under the general adoption laws they can be obliged to pay legal costs.
In the past ten years, the Minister's predecessors have taken no action on this matter. In my profession as a lawyer, I have witnessed the difficulties which arise because of this discrimination. I ask the Minister to consider this matter in the context of any review that takes place in respect of adoption law. If a child is properly placed with a couple for adoption and if, in the context of that child's welfare, the couple refuses to return a child when its return is requested - particularly in circumstances where the professional view is that it is in the child's interests to remain with the adopters - those people may, through no fault of their own find themselves caught up in court proceedings to protect the welfare of the child and allow them to complete the adoption, and they should not be obliged to incur the level of legal costs to which I referred earlier.
I ask the Minister to consider ensuring that a financial allocation will be made next year by the Department to meet the needs of the small number of people who are affected by this issue annually. I suggest that a similar provision to that which applies under the 1988 Act should be put in place and that we should not revert to the old Attorney General's scheme, which was of assistance but which created particular difficulties.
I was going to refer to that scheme as my escape clause.
The Attorney General's scheme created problems for various people although their fees were eventually paid. The main difficulty which arose was that it took the Attorney General's Office approximately four years to issue payment. The lawyers involved did not mind waiting but on occasion child psychiatrists were not excited about waiting three or four years to be paid for carrying out assessments and attending in court.
Child psychiatrists are more materialistic than lawyers. I will take this matter up with the Adoption Board in the preparation of the Estimates for next year.
The board should be able to indicate the number of cases involved because it is usually a part defendant in the proceedings to which I referred. I should state that judges have constantly requested that this matter be addressed. On a number of occasions they tried to make orders for costs against the Adoption Board in order to protect the adoption applicants. It is not the board's fault that these cases have arisen and it cannot be held liable for costs.
I have a number of questions on this section. Why has the figure relating to payments to people with injuries caused by thalidomide increased? I would have thought that this figure would be on the decline.
With regard to statutory inquiries, what will be the cost incurred this year in respect of the inquiry we recently debated in the House into people with haemophilia who were infected with hepatitis C and HIV? Where in the Estimates is provision made for this cost? I notice that payments under the hepatitis C compensation tribunal have not been increased. I presume the Minister has not taken action in respect of the High Court decision which substantially increased the payment offered to a particular victim. I know he indicated that the State would not contest or appeal that decision but should it not be taken into account to prevent a raft of cases coming before the High Court?
What is the Minister's position in relation to vaccinations? I ask this in the context of payments to people who were damaged by vaccinations. I have tackled previous Ministers for Health about the fact that although Ireland is a developed country children are not being vaccinated to the extent they should be. Is the Minister putting in place resources to ensure that vaccinations become accepted as part of the health care system? I recall investigating this matter and discovering that the level of vaccination against measles in Bangladesh is 90 per cent while in inner city areas of Dublin the figure is 30 per cent. There have been measles epidemics in the past and I do not doubt that they will happen again. Will the Minister outline his approach to vaccination?
Will a serious effort be made to target health promotion? I am aware that the Secretary General of the Department met the committee and discussed the possibility of targeting. What action does the Department intend to take in this regard? Is the Minister determined to ensure that health promotion is properly targeted? We cannot afford to take a scatter-gun approach where people who already know how to look after themselves will obtain information while those who need it will not.
I will answer the Deputy's last question first. The Slán survey carried out by Dr. Kelleher points out the need for targeting. It could be argued to a certain extent that the broad message is getting through. However, it is clear that we need to target certain sectors of those who smoke, for example, young women. That approach will be adopted; that is what the survey indicates. The health promotion unit will devise its programmes on that basis in future.
There is an initial provision of £900,000 for the setting of a tribunal for haemophiliacs. If more than that amount is spent this year, provision will be made in the Supplementary Estimate. Similarly, if the payments in the hepatitis C tribunal exceed the provision in the Estimate, the Department of Finance obviously will have to cover that in a Supplementary Estimate because there is a commitment to pay the amounts awarded.
The Deputy mentioned the thalidomide issue and the subhead that she referred to covers the payment of monthly allowances to 31 adults who suffered from severe congenital deformities as a result of their mothers taking the drug during the early stages of pregnancy. The allowances have been increased in line with health cash grants generally.
Some improvements should be seen on the vaccination issue because the dispute relating to public health nurses has been resolved. We are still hitting approximately 84 per cent and need to improve on that. We need to hit 95 per cent and we expect that to improve as a result of the resolution of this dispute.
There is only a 9 per cent increase in the capital investment for building and equipping of hospitals, which I thought would be more because the Minister has spoken about this and there is obviously a need for capital investment. However, it is in line broadly with the overall increase in the Estimate. How does the cost relate to building inflation? Has the Minister worked out the amount of the increase? For example, inflation costs in residential areas have gone through the roof. Such costs must be deducted from the amount allocated by the Minister before the real increase can be given.
Obviously, there are inflation costs in respect of building, but I have a multi-annual programme. It is not static or a two year programme which would not allow me to know what I would get next year. We will spend this year's moneys on the basis of those multi-annual projects. The overall figure is £525 million and we will spend and allocate as we go through that phase because there has been little capital investment in the past.
I was waiting for it.
It is because of that. It is difficult for me to get enough builders and "brickies" to do what needs to be done and I do not know what I am getting because they are very busy people. Thankfully, there are builders interested in building hospitals, otherwise, I do not know what I would do.
How much are they charging in terms of their costs increasing?
The building inflation cost is approximately 8 per cent.
Therefore, that is a real increase of 1 per cent.
I better let that remark pass because there is no point in discussing multi-annual programmes with the Deputy.
That is unworthy of the Minister.
I do not mean it in that sense. The Deputy will take it on the basis of a 1 per cent increase in building costs. That is so far off the mark.
I was only joking.
Does anything arise from subhead J - appropriation in aid?
I note the extraordinary 23 per cent increase in this subhead, which is beneficial to the Minister in terms of drawing up an Estimate.
I thank the Minister for providing a great deal of information. He has answered questions knowledgeably and I appreciate that. I am aware of the help he has received from his civil servants.
I hope the Minister will constructively take up some of the issues raised, which have nothing to do with party political battles, in the hope that we contribute to improving the health services.
I appreciate that and the fact that, but for the Deputies opposite, I do not know what type of debate we would have had.
The Minister could have had an easy ride.
I thank both Deputies, the Minister and his officials for the expeditious manner in which the Estimate was dealt with.
