On behalf of the Select Committee I would like to welcome the Minister for Health and Children, Deputy Cowen, and his officials. The purpose of the meeting is to consider the Supplementary Estimate falling within the remit of the Department of Health and Children, Vote 33. A proposed timetable has been circulated for today's meeting. It allows for opening statements by the Minister and Opposition spokespersons followed by an open discussion on the Supplementary Estimate by way of a question and answer session. Is that agreed?
Estimates for Public Services, 1999.
Vote 33: Department of Health and Children (Supplementary).
It is but before we proceed I wish to raise a matter of some importance. This meeting was arranged in circumstances where, as I understood it, the Dáil had to first decide this evening whether the Estimate would be taken at this meeting, but it is highly unsatisfactory that members of the committee only received the final details of the Minister's proposed Estimate approximately five minutes ago. We received a draft, but we had no way of knowing whether the Estimate as it is now presented would be in a similar form to the draft or whether additional matters might be included in it. That is not the correct way for this committee to do its business and, in the context of future Estimates meetings, I would hope that the final version of a Supplementary Estimate to be determined and voted on by members of this committee would be submitted to the committee at least a week prior to the meeting being held to determine the Estimate.
I find this unsatisfactory, if not impossible, and I raised it in the House a short time ago. Bad habits probably developed over the years in relation to voting through Supplementary Estimates but it is impossible for us to do our work if we are presented with an Estimate three minutes before we attend a meeting. I received a draft Estimate, and it was made clear to me, by way of a fax, that it was only a draft. I do not even know if the draft Estimate I received is the one we are now about to debate. I appreciate that coming to the end of the year the Department wants to get extra money, and it may not even be the fault of the Department - it is probably as much the fault of the Department of Finance - but that is immaterial to the point Deputy Shatter and I are making. This committee has a job to do and if there is to be accountability in the system we have to have procedures that allow us to protect that accountability. I ask the Minister not to come before us with a Supplementary Estimate unless he is satisfied - I would like to hear his opinion on this - that the proper procedures have been carried out and that this committee can do its work, whether we are in Government or in Opposition.
I appreciate the position the spokespersons find themselves in. We are on a tight schedule this year to pass Supplementary Estimates for the purpose of having the Appropriation Bill in the House before the end of the year. The signing off of the Supplementary Estimate took place on Friday in the Department of Finance and we immediately provided the draft to the Whips office. It was called a draft because it had to be put to a plenary session of the House before it could be released. The draft is the same as the one before us now which has been officially adopted by the House for discussion in committee. That is as a result of the time issue and also the procedures in the House generally. The best I could do was ensure that the Whips had the Estimate as soon as it had been agreed by me and the Department of Finance, which was last Friday. I wish to inform members that there have been no additions or deletions carried out between then and now. The procedural reason for the Estimate being provided to the Opposition spokespersons is that the House had to adopt it. As members know, some procedural issues have been raised in the House since 4.20 this afternoon and we have only just received them in the past five minutes. Had we not done so we would probably be adjourning now for half an hour until the Dáil had formally adopted the Estimate for the purposes of discussion in committee.
I have been in this position before and I can understand the Deputies opposite being frustrated by the procedures but it is not totally within my remit. The earliest the Dáil could meet since Friday was this afternoon after the Order of Business, and there was a lot happening on the Order of Business. That is position. I work with Finance all the time to make sure I am not open to criticism from Opposition Members for not making adequate provisions where there are issues to be addressed. I take the point, but I wanted to explain the position from my side of the fence.
On a point of information, I received a fax dated 2 December, the day before it was agreed by Finance. As I recall, the 2nd was a Thursday.
The service is even better than I thought. I thought it would not have got there until Friday, but clearly——
I do not mean to cut across the Minister, but at that point it was not clear whether that would be the final Estimate. I do not want to dwell on this, but if we are at this level of brinkmanship, mistakes will be made and it will be impossible for us to have a reasonable and informed debate. The date on this fax is 2 December which was a Thursday.
It was agreed by Finance at official level on Thursday. Different situations have arisen in recent years. Budgets are being brought forward at this time of the year rather than Supplementary Estimates. I take the point, but I am explaining the circumstances of the issue.
Point taken. I invite the Minister to make his opening statement.
I am pleased to have this opportunity to bring the Supplementary Health Estimate before the committee. I thank the committee for making itself available at what I appreciate is a busy time of the year for everyone.
I also appreciate the arrangements put in place to allow for a speedy discussion of the Estimate once it was referred by the Dáil. There is a very tight schedule for Supplementary Estimates this year to allow the Appropriation Bill to be taken before the House rises. My Department would have wished to have placed this Estimate before the House sooner but, unfortunately, with the pressure of business in the Department of Finance leading up to the budget it did not prove possible to get the necessary approval any earlier.
The past five weeks have seen major announcements regarding the increased investment to be made in the health services by the Government. The record provision in the Abridged Estimates, which has been further built on in the budget with the largest ever budget package for Health, marks a major opportunity to put in place the kind of service that has long been sought by the public. The provision of £2 billion in capital funding over the course of the national development plan provides us with an historic opportunity to fundamentally address the weaknesses within the system. There will be other opportunities to debate these issues since today we are concerned with the Supplementary Estimate.
Since I took office I have striven, in so far as is possible, to provide the necessary resources upfront in the original Estimates. That gives agencies a proper indication of funding for the year and allows them to plan the services to be delivered with that funding. Obviously, there are issues that will arise during the year that cannot be planned for and a number of these are provided in today's Estimate. Nevertheless, as a general rule in my dealings with agencies throughout the year, I have been careful to impress upon them that, while service issues raised by them can be addressed in the context of future allocations, in respect of the current year they must plan within the resources already provided.
The gross additional requirement in this Estimate is for just under £244 million; the precise sum is £243,798 million. This figure is partially offset by additional Appropriations-in-aid of £64,712 million, which gives a net figure of £179,086 million. Some £15 million of the total requirement is for capital spending and the remainder is non-capital.
The Supplementary Estimate also takes account of the fact that £35 million of the total level of funding originally provided in respect of the Hepatitis C Compensation Tribunal will not now be required in the current year.
The additional money sought is necessary to fund adequately a number of items within thehealth service that have given rise to additional expenditure. A number of the items for which funding is sought relate to areas where there is an inevitable degree of uncertainty in forecasting the actual costs in any one year and consequently the original Estimates may not provide fully for these costs. The agreed practice has been to seek supplementary funding in these areas when the actual amount needed becomes apparent during the year. The items recognised by the Department of Finance as falling within this category are medical indemnity insurance, superannuation costs, PRSI costs and the demand-led schemes, which consist of the community drugs schemes and certain capitation payments such as the domiciliary care allowance. The agreement that these items will be finalised in the Supplementary Estimate in the context of expenditure trends in the year to date is of significant benefit to health agencies in managing the remainder of expenditure within the level agreed at the start of the year.
Expenditure on these items is influenced by a number of factors that are difficult to predict in advance. Increases in medical indemnity costs are related to growth in claims experience and, as Deputies will be aware, this country, in common with all developed countries, has experienced a significant growth in the number and in the average cost of civil claims throughout the health service. As a result of these developments there continues to be significant upward pressure on the premiums health agencies have to meet. For example, the major maternity hospitals have seen substantial increases in premiums this year in respect of obstetric and gynaecology activity. Additional funding of £2 million is required for this area.
The additional superannuation costs for which funding is sought are due to the age profile of personnel in the health sector. Agencies are experiencing an increasing number of retirements, including those opting for early retirements, and a consequent increase in the yearly budget provision is required. A sum of £8.4 million in additional funding is required for this purpose.
In relation to PRSI, modified social insurance status does not apply to workers recruited into the public service after 6 April 1995. This means that health agencies experience increased costs in respect of employers' PRSI contributions when recruiting such employees to replace existing staff. The increase in the income ceiling under which employers' PRSI is payable has also led to increased costs in the current year. This item requires additional funding of £4.4 million.
Expenditure on the community drugs schemes is a factor of the number and cost of claims under these schemes which, again, is difficult to predict in advance. As Deputies will be aware, there is a statutory right to relief for expenditure on prescribed drugs and medicines in excess of the expenditure thresholds that are laid down. There is an additional requirement of £24 million in respect of these schemes.
An additional £90 million is sought to meet the costs of the general medical services, GMS. The costs of the GMS, and in particular the costs of providing prescription drugs and medicines, have increased considerably in recent years. The increase in these costs proved to be greater than that provided in the annual Estimates. This meant that at the end of last year there was an accumulated debt in the GMS of £53 million. There was a recognition at the time that this position would have to be addressed. It was agreed with the Department of Finance that the opportunity should be taken to conduct a thorough review of the increase in costs in order that an assessment could be made of the ongoing implications for the finances of the GMS Board.
As a result of this review £90 million is sought in the Supplementary Estimate. Some £50 million of this provision is required on a once-off basis to eliminate the accumulated shortfall that has built up in the last couple of years. A sum of £40 million is required on an ongoing basis to bring the annual provision for the GMS into line with the board's ongoing requirements.
A sum of £7 million is sought in respect of recombinant blood products. These are synthetic based products used in the treatment of haemophiliac patients, including paediatric patients. Expenditure in this area can be particularly unpredictable since in certain circumstances very intensive treatment of a patient is required involving the administration of high doses of what are very expensive products. The introduction of these products in recent years has been based on expert clinical opinion as to their greater efficacy over alternative treatments. The increase in expenditure during this year arises from an increase in usage and an increase in the price of these products.
The Government has also agreed to provide a package of funding on a once-off basis to meet the pressing needs of the disabled. A sum of £5 million is being made available for the provision of equipment, aids and appliances for people with physical and sensory disabilities. I thank my colleague, the Minister for Social, Community and Family Affairs, Deputy Ahern, for his co-operation as it is intended to finance this £5 million provision from savings emerging on the Social Welfare Vote to the end of this year.
A total of £102.5 million is provided for the increased costs of nurses' pay. There have been four Labour Court findings covering issues such as specialist allowances, pay, incremental credit, new posts and upgradings. The costs of these findings in the current year, including the payment of lump sums, is covered in the funding sought. Also covered in this costing is £5 million in respect of nurses' overtime.
A sum of £1.5 million is included in respect of Springboard pilot projects to intervene in supporting children and families in need of assistance. This funding is being transferred from the Vote of the Department of Education and Science, which has lead responsibility for the young persons services and facilities fund under which these projects are being funded. A sum of £2 million is being made available for counselling services for victims of childhood abuse. This follows a Government initiative earlier this year. The Estimates for next year provide for the full year cost of this initiative which is £4 million.
In June this year I brought a memorandum before Government setting out proposals to improve procedures applying to inter-country adoptions. The proposals were based on the recommendations of the review of the inter-country adoption assessment procedures. A sum of £300,000 is provided in the Supplementary Estimate to assist in implementing these recommendations. A further sum of £500,000 has already been provided in the Estimates for next year.
A sum of £3 million is sought for the costs borne by three health boards in catering for refugees from Kosovo. The Government decision in April this year provided for the admission of up to 1,000 refugees of ethnic Albanian origin fleeing from Kosovo. There are over 800 refugees currently being catered for in ten centres under the Eastern, South-Eastern and Southern Health Boards. Over 190 refugees have been successfully repatriated and I pay tribute to the efforts of the three health boards in this important humanitarian task.
Deputies will be aware that earlier this year a decision was taken to mark the arrival of the new millennium with a bank holiday on New Year's Eve. Many of the services provided in the health area involve the commitment of staff on a 24 hour, seven day a week basis. The cost of £6.4 million provided in this Estimate reflects the cost of paying normal bank holiday pay to staff working on 31 December.
Much work has been carried out within the health services on ensuring that all systems of equipment are Y2K compliant. Most of the associated costs have arisen from the need to replace or upgrade systems and equipment. These costs have been met from within my Department's capital budget and from within the contingency reserve of £40 million being managed by the Department of Finance. The £3 million sought in the Supplementary Estimate is in respect of revenue costs which have been incurred in carrying out the detailed checking of equipment. Such costs include overtime and the replacement of staff assigned temporarily to this project.
An additional sum of £600,000 is provided in subhead E for legal expenses. The need for this additional funding arises from greater than expected costs associated with the two independent tribunals provided for in my Department's Vote, the hepatitis C and HIV tribunals. A sum of £5.1 million is included for the National Rehabilitation Board because of the delays by the EU Commission in the payment of European social fund moneys. A payment which was due this year will not be paid by the Commission until next year. In order to compensate the NRB and avoid the necessity for the board to operate a large overdraft over an extended period, it is proposed that the Exchequer provide this funding on a temporary basis. The money will be repaid next year once payment has been received from the Commission. Similar arrangements have been put in place for other agencies affected by this delay, including FÁS and CERT.
A sum of £2 million is provided in respect of local bargaining pay increases. This funding is being provided in particular in respect of section 65 health agencies. These are voluntary agencies in receipt of a contribution towards their costs from the health boards. Employees of these agencies are not health board staff but, in many instances, the pay of such staff tends to move in line with increases for similar grades in the health sector. The funding sought will allow health boards to recognise the cost increases experienced by section 65 agencies in paying special pay increases to staff.
I mentioned earlier that expenditure in the current year in respect of the Hepatitis C Compensation Tribunal is likely to be lower than originally anticipated. In this year's original Estimate, £96 million was made available to cover the cost of claims made to the compensation tribunal, associated legal costs and the cost of administering the tribunal. The number and level of awards so far this year have not been sufficient to utilise all the approved level of funding and a reduction of £35 million is made in this Estimate in the original provision.
The Supplementary Estimate provides for an additional £15 million for my Department's capital programme. The original capital allocation for 1997 was £155 million and the need for an increased provision must be seen in the context of the serious under-investment which has occurred in the past. I have prioritised the need to provide a modern infrastructure for our health services since taking up office. The national development plan provides £2 billion in capital investment for the health services over the next seven years. This is almost a trebling of the capital funding levels over the period 1993 to 1999. The extra £15 million in the Supplementary Estimate brings to £170 million the total capital provision this year. I said at the launch of the national development plan that we need to "set aside the narrow view that health capital spending represents a drain on resources rather than an investment in the future". I hope the committee will agree with my decision to take every opportunity which presents itself to make up for the under-investment in health infrastructure in the past.
The development of the general hospital services has continued in 1999, with the objective of ensuring that an efficient and effective hospital service is available around the country. Construction work has been proceeding on several major schemes, including the developments at St. James's, the BTSB, Limerick Regional Hospital, Ballinasloe, Galway Regional, Mayo, etc. Other hospital schemes will begin construction in 2000, including St. Vincent's Elm Park and Tullamore and my Department recently approved the acceptance of tenders for important developments at Naas and Kilkenny.
The capital commitments for each year arise generally from decisions on individual projects, many of which involve expenditure over a number of years. The timing of expenditure on capital projects tends to be influenced by several factors that are difficult to predict accurately in advance.No provision was included in the original allocation for the purchase by the Eastern Health Board of the Meath Hospital site because of uncertainty in relation to the timing of this funding requirement. In the event, the transaction was completed this year so provision must now be made for the necessary funding in the Supplementary Estimate.
The spending increases sought in this Estimate are partially offset by increased income available to my Department. It receives the 2% health contribution paid by employees and these revenues are an important source of funding in supporting service developments. In recent years the overall growth in the economy has led to significant buoyancy in these revenues. The Supplementary Estimate shows a revision of the Estimate for health contribution revenues in the current year to £417 million. This is £29 million higher than the original forecast.
My Department also receives income in respect of EU nationals who have an entitlement to services in one EU country and under reciprocal arrangements can exercise this entitlement in other EU countries. The main source of this income is from the UK authorities because of the number of tourists visiting from that country and the fact that many Irish people have an entitlement to treatment under UK regulations on the basis of social insurance contributions made while working in the UK. It is expected that income from this source will be £35.7 million higher than that provided for in the original Estimates.
This Supplementary Estimate will greatly assist health agencies in meeting the additional costs they are experiencing in a number of key areas. I recommend the Supplementary Estimate to the committee.
I am disappointed that the Minister makes no reference to any arrangements he might envisage being put in place, or that he might have acted as a catalyst to having put in place, to ensure something dramatic is done to tackle our waiting list crisis. The waiting list crisis for in-patient hospital care has escalated to a dramatic degree as a consequence of the nurses' strike. I will be interested to hear the Minister address the issue of how he envisages reducing waiting lists from the high of 37,500 at which they stood a few weeks ago.
With regard to the additional financial allocations, I welcome the additional £5 million being made available for the provision of equipment, aids and appliances for people with physical and sensory disabilities. However, this time last year the Minister, following Dáil motions, was forced to make additional funding available in this area. It is most unsatisfactory that the waiting list for aids and appliances only appears to be addressed at the end of each financial year as a type of financial afterthought. It is time to recognise that people who suffer disabilities have a right to access essential aids and equipment within a short time of their need being assessed and the required equipment noted. It should not require end of year Supplementary Estimates to find extra funds to meet an essential need and to provide aids and equipment which are a basic right to facilitate people who are suffering disability leading as normal and vigorous a life as possible within the confines of the disability from which they suffer.
I note the additional funding arising from the expenditure by health boards on the Kosovar refugees who came to this country. I am surprised that, given the large number of people who have come to this country seeking asylum and the well publicised difficulties experienced by the Eastern Health Board in coping with the demands made on it to provide essential health services in the one stop shop that was established and other necessary health services, there is not an additional provision in the Estimate for this area. There is a need for an additional allocation to the Eastern Health Board to ensure a coherent and comprehensive medical service is provided for those seeking asylum which would enable all necessary health issues to be addressed.
It is appropriate to raise a number of issues arising from the report on smoking that proposed a national anti-smoking strategy, which was approved by the committee and has been laid before the Dáil. Until July this year, people trying to cease smoking using certain nicotine replacement products could obtain a financial refund for them. The report highlights the fact that the new drugs payment scheme excludes nicotine replacement products and that these products do not currently come under the GMS and are not available without payment to medical card holders.
There is agreement on all sides, and the Minister has acknowledged, that smoking is giving rise to huge medical costs to the State. More than 6,000 people lose their lives annually from smoking related illnesses. Many thousands more are in hospitals and attending general practitioners as a consequence of such illnesses. We are tackling the symptoms but not the causes. It does not make any sense in the context of health policy that nicotine replacement therapies cannot be obtained through the GMS for people who are addicted to nicotine and currently smoking and that the drugs repayment scheme does not provide refunds for such products.
Following the publication of the cardio-vascular strategy report, the Minister has referred this issue to the cardio-vascular committee. However, this issue should not require any further deliberation by the cardio-vascular committee. It is obvious that it is in the public interest to make these therapies available. A political decision was made by the Minister to exclude them from the new drugs repayment scheme. A political decision can equally be made to include nicotine replacement products in the GMS and the drugs repayment scheme. All the verbiage to date about the evils of tobacco and smoking has not been backed up by appropriate action from the Department. The only action taken by the Minister this year was to exclude these products from the schemes.
I note the Minister has made provision for overtime payments in the context of the millennium and the two bank holidays on New Year's Eve and New Year's Day. Will he clarify the current position regarding talks that are taking place to address the claims being made by doctors and others in the hospital services? We must ensure that a dispute does not occur a day or two before the new millennium. Can the Minister give the committee assurances that arrangements have been agreed and are considered satisfactory by all the parties involved? Is there still a dispute? Are negotiations taking place and how soon does the Minister consider he will be in a position to indicate to the public that the required medical and hospital services will be maintained over the new year period? This issue is of considerable public importance.
Regarding the area with which the Minister deals in the context of inter-country adoptions, a report on this issue was prepared and an attempt has been made within the Eastern Health Board to tackle some of the difficulties which have arisen. However, my experience, and that of many other Deputies and I am sure the Minister, is that we are in receipt of continual complaints from couples seeking to adopt abroad about the difficulties which still confront them in having assessments carried out within a reasonable time by health boards to whom they apply. There are still particular complaints about the Eastern Health Board and I ask the Minister to clarify the current position in that context. What assurances can he give to members of the committee that people who are seeking such assessments will be treated reasonably, that the assessments will commence within a reasonable time and that they will be dealt with in a proper and correct manner?
I previously raised year 2000 issues with the Minister in the House. On the last occasion when this matter arose in parliamentary questions, he informed the House that 90% of all outstanding work had been done by the various health agencies. Approximately 10% remained but he was satisfied that all work would be completed before the millennium. As we are only three weeks away from the new year, is the Minister satisfied that all outstanding year 2000 compliance work has been completed by all relevant health agencies? Will he assure me that no difficulties will arise in the health area as a consequence of year 2000 non-compliance in the context of any essential medical equipment or services on which the public is reliant?
Before this meeting, I reread the debate on the Estimates to refresh my memory. The Minister said at that time in relation to the operation of health budgets that, once budgets are agreed, we must live within our means because to do otherwise would put at risk a continuation of present favourable circumstances. I accept that circumstances have been more favourable and that more money than expected is available. The sum of £244 million is a huge amount of money for a Supplementary Estimate.
However, during the same debate, the Minister made it clear that he did not consider himself a visionary. As I recall it, he was derogatory about visionaries in general. He saw himself as a manager but, even by his own criteria, the lack of management behind this Supplementary Estimate must be noted because the large injection of money is not being spent primarily on new initiatives. It is not being used for the best possible purposes. It is being used to deal with problems which have arisen because there has not been sufficient management in relation to the various schemes. For example, the considerable sum of £24 million had to be found for the community drugs scheme, despite the fact that people availing of it have to pay the higher amount of £42 a month and fewer prescriptions, drugs and medication are available to people using it.
I understand the Minister has not introduced the same drug budgeting arrangement which applies to GMS prescriptions. I pressed him on this matter during the Estimates debate but he did not give me a clear answer. I got the impression he was not 100% certain about what I was asking him so perhaps I should put the question again. The drug budgeting system applies for GMS procedures and given the large overrun, would he consider expanding it, if that is desirable? If it would not be a wise move, it should not be applied to GMS patients either on the grounds of equity.
The most startling aspect is the sum of £90 million for the GMS. Will the Minister give me a precise figure regarding the percentage increase? Am I correct that there is a 20% increase in the GMS budget? It is a remarkable amount. There is an unusual allocation being made to the GMS, but it is clear the Department either does not know what is happening or is not saying. According to the Minister, it was agreed with the Department of Finance, which is cross about it, that opportunities should be taken to conduct a thorough review of the increase in costs so that an assessment could be made of the ongoing implications for the finances. Does anyone know what is going on? Why do we need ongoing assessments, analyses and reviews which do not tell us anything?
We need to know why there is a major increase in the GMS budget, particularly when fewer people are qualifying for the GMS. Because of the difficulties getting the Supplementary Estimate, I did not have time to check my records. However, as I recall, 38% of the population availed of the GMS in 1998, while only 31% availed of it in 1999. Perhaps that could be explained by the change in the number of people over 70 years of age. I would be surprised if there has been a significant increase in the population availing of the GMS because there has been no population change other than in the over 70s age group. We do not have that many people over 70 years of age.
Some £102.5 million is mentioned for nurses. Why was this not provided for? We are not talking about the £20 million for which the nurses fought and went on strike. We had the same experience when the gardaí got the blue flu. Money was suddenly found, although we were promised there would not be a Supplementary Estimate. The Minister did not promise there would not be a Supplementary Estimate in this case. It is curious why nothing was factored in. I would like to know how these decisions are made. I welcome the pilot projects in the area of adoption and the extra money being provided. However, given that the Government introduced a budget which undermines the role of women in the home, the Minister would be well advised to remember that women who adopt children are expected to stay at home to rear them. It is presumed that parents, particularly the mother, will not put them into crèches, particularly as the child will have already lost a birth mother for whatever reason. That mother deserves respect for providing such care.
As regards management, £6.4 million additional money will be provided in the new year for what is called normal bank holiday pay. We all knew the bank holiday was coming; it was not a secret. If normal bank holiday pay is being provided, why did the Minister have to provide additional money? Deputy Shatter asked about the negotiations and discussions. I would like to know about the ambulance service run by the Dublin Fire Brigade. Some 11 ambulances are available. My understanding is that an extra service will not be provided this year, other than what is normally provided on New Year's Eve. Is the Minister satisfied that normal bank holiday pay is sufficient given the public festivities planned by his ministerial colleague and the prospect of things getting out of control?
Like candles.
And fireworks. When such activities are mixed with alcohol consumption, it is not always safe for everyone. Can we charge the EU Commission interest given that it has been so late in paying?
I am concerned that savings have been made, particularly in relation to the mental health commission. This issue should be addressed by the Minister. It is a disgrace that the Mental Health Bill has still not been introduced. It was presumed that because it was mentioned in the original Estimates and money was provided for a mental health commission it would be introduced quickly. However, we do not have a commission or a Bill. That is a grave shortcoming, particularly when people's rights are directly undermined.
There is a reference to the acquisition of the Meath Hospital, which is understandable. Is there a possibility of acquiring St. Michael's Hospital in Dún Laoghaire as a step down facility?
I would like the Minister to clarify one issue. What was the estimated receipts from the health levy as at 1 January this year and what is the projected increase in income from the health levy as at 31 December this year?
Many issues were raised. Deputy Shatter mentioned the waiting list initiative. We will continue with the approach we have adopted as a result of the work we have done, which is more systematic and structured than heretofore. This year we saw a reduction of 10% up to the time of the strike.
Increasing the level of resources in non-acute beds is as important in dealing with this issue as increasing the level of resources in acute beds. Before we made these changes, whatever little money the previous Administration put in was a decreasing figure. It was used in the acute hospital sector alone and it did not address the fact there were bed blockages in the system. It decreased the money because that was all the system could take as a result of the level of inappropriate placement in the acute hospital system. I always wondered why previous Administrations failed to address the full problem but now I finally realise that because the system could not take any more, they were reducing the waiting list initiative from £12 million to £8 million coming into an election year, which was crazy from their political point of view, if nothing else.
We will continue with the successful approach which has been adopted. There will be increased resources for the waiting list initiative next year. We have increased the money from £8 million to £12 million to £20 million. The total money provided next year will probably be approximately £28.5 million. That is a significant increase in the allocation, but it is not devoted totally to the acute hospital sector. We must also provide adequate services in other areas to ensure that what we spend in the acute hospital sector on waiting lists will have some prospect of success. We also need to look at a number of other things.
As regards aids and appliances, Deputy Shatter suggested that the Government is instigating policy at his behest as a result of motions he tabled. However, we did not have an aids and appliances budget until this Administration came into office. A major complaint from the disability sector was that the amount of money being allocated by the Department of Health and Children to health boards for aids and appliances had been reduced to a trickle. However, it was practically nil and many waiting lists grew during those enlightened and visionary years from 1995 to 1997. As a result, we decided to introduce an aids and appliances budget, which was a practical response to a definite problem and could immediately alleviate the basic needs of the disability sector and benefit thousands of people.
This year we have continued with that policy which was instigated by the Government. It has been looked at by a review group, which involved the Disability Federation of Ireland and the health boards, to see how it is working and how we can improve it. This year the money will go to the health boards. The health boards will devise the allocations through the co-ordinating committees, which will involve the input of the disability sector. Therefore, there are full participation arrangements for the allocation of that money.
It has been a tremendous success and widely welcomed. At a meeting yesterday with the Minister for Social, Community and Family Affairs, the Irish Wheelchair Association forwarded its agenda, the final issue on which was to thank the Cabinet for its efforts on behalf of people with disabilities. That is a real turnaround compared to the previous Administration.
The question is why the Minister does not make adequate provision at the start of each year to meet real needs rather than always having to plug a gap at the end of the year.
In fairness, we are not plugging gaps. This is a very creative way for me, with the agreement of the Government, to provide extra funds for aids and appliances over and above what we need for capital moneys. There was no capital budget for mental and physical capital during the enlightened and visionary years when the Deputy was in office. There was also practically no extra money.
The best aspect of the Estimates this year is the recognition by the disability sector that people are listening to their issues and are providing serious money to deal with the problems of people who have been excluded and marginalised for generations. We cannot be accused of reacting to pressure from vested interests, such as the consultants or other medical interests. I have taken a visionary political decision to manage this situation.
The Minister is never short of self praise.
It is a pity the public does not see it that way. The Minister should tell them.
I am responding to Deputy McManus who accused me of having no vision.
On a point of information, I said the Minister said he had no vision.
I never said that.
Yes he did.
That is how the Deputy interpreted what I said. I said I have nothing but contempt for people who engage in political semantics but who, when they get the opportunity to have responsibility for an area, do precious nothing. These people forgot who their so-called political constituencies were when they had the opportunity. I come here as a pragmatic republican, who believes in equality of opportunity——
The Minister should answer the question.
——and who is prepared to allocate unprecedented resources to a sector which is not the sole province of some minority parties, which seem to think it is. I am making that political point because a political point was made against me. Deputy McManus decided to make a political point in her opening remarks about how I am just managing the Department and have no idea of my priorities or who needs assistance.
I quoted the Minister.
The Deputy misquoted me.
Chapter and verse.
In the Deputy's first quote, she totally misquoted me.
On a point of order, is it necessary for us all to be caught in the middle of what appears to be a political marital row?
I can assure the Deputy it is certainly not marital. The fact is that a suggestion was made in the opening remarks. Unfortunately, these are the sound bites that go out without being challenged, as if they were the truth. Deputy McManus's opening comment was that I believe in budgets being agreed and, therefore, the very need for a Supplementary Estimate indicates mismanagement on my part.
I did not say that.
I will let the record show what the Deputy said.
I have to come back on that.
The Deputy will have an opportunity to come back on that in a moment. What I said in that speech, and what I have said publicly, is that I reached agreement with the Minister for Finance as a result of my having to implement the Health (Amendment) Act, 1996 - which I emphasise again had all-party agreement, because it is clearly the only sensible way to proceed with service developments in the health services on a ongoing basis. Money is allocated at the beginning of every year but, given the nature of the health services, some subheads of expenditure, which are clearly set out here - for example, the GMS, PRSI and superannuation - could not be adequately or accurately predicted on 1 January 1999.
Any Government, of any political composition, which would hoist itself on that petard would find itself in serious difficulty when it came to a Supplementary Estimate. They are basic and sensible arrangements and are not in any way unusual. The suggestion that I insist on dealing with the existing year's allocation and existing service plans should not be turned around to suggest I am in some way inflexible in relation to meeting unpredictable situations which, despite optimum health management, require some revisiting during the course of the year. That is my position. Anyone who puts my position in any other way is misrepresenting it.
Deputies Shatter and McManus referred to overtime payments for this New Year's Eve. That is in the LR process and meetings are continuing. The Labour Relations Commission is meeting tomorrow. There is a hearing of a claim from the alliance of health service unions for enhanced payments for staff working over the period from 28 December to 3 January. The management side is represented by the HSCA. Our approach has always been that we must operate within the overall public service situation. That may go on to a Labour Court hearing for a recommendation.
The fact is that the Department of Finance would be responsible for any increase on what was provided in the Estimate - that would be a central Exchequer requirement for all staff in the public service. It would not be a case of the Department of Health and Children looking after its particular extra sectoral expense but of the Department of Finance negotiating and dealing with it for everybody. That is why those procedures are in place at the moment. That will be dealt with in the normal way, once we complete that process. A similar process occurred with the nurses' pay issue, which also emanates from the Department of Finance. We made arrangements as a result of the agreement we reached with the alliance for the payment of the lump sums, etc., and the Department of Finance reimburses us on that basis. The new year holiday issue will be dealt with in the same way as any other extra public service pay commitment.
Deputy McManus raised a fair point about the mental health commission. She is correct that the allocation of £2.5 million was being provided for in 1999 in the hope that we would be able to start during the year. As I stated in reply to a number of oral and written parliamentary questions, the Northern issues took precedence for the parliamentary draftsman, which meant this Bill was a little down the list. However, I got approval today from Government for the publication of the mental health Bill which provides for the establishment of an independent agency, to be known as the mental health commission. I will not go into all that. The total full year cost will be £5.25 million. We are providing a cost of £4.7 million next year because we have to bring the legislation to the House to have it enacted. While I acknowledge there was a delay and slippage in the time-frame we had envisaged for that, other Government priorities took precedence. They were not domestic issues or ones arising within the Department of Health and Children but involved the extra work that occurred as a result of the Northern talks which put things somewhat askew.
As the Deputy said, during our last Question Time we had a progress report which confirmed we were at a very advanced stage of preparedness for Y2K, and that remains our position. One or two issues in a couple of agencies have been tested and finalised. Those issues will not have an impact on patient care. The target date for implementing the new patient administration system at the Mercy Hospital in Cork is early in the week commencing 13 December, that is, next week. The hospital is confident that this target date will be met.
At Beaumont Hospital they are currently testing a replacement for an existing non-compliant accident and emergency system which is scheduled for implementation on Tuesday, 14 December 1999. It will be fully integrated with the main patient systems there. All other systems have been deemed to be compliant and the hospital has assured the Department there is no threat to patient care. The main impact is loss of some management reporting facilities and a somewhat increased staff workload. All other significant systems in the hospital have been made year 2000 compliant.
The supplier of Tallaght Hospital's new financial system has just completed testing it and it is deemed to be Y2K compliant. It is planned to have the new version running live by the end of this week, that is, by Friday, 10 December 1999. The payroll is run on a separate system and the Y2K compliant version has already been implemented. All other significant systems in the hospital have been deemed to be compliant.
In recent weeks, the board of the BTSB has reported that the new version of a blood bank control system is running successfully in Dublin. It is scheduled for implementation in Cork over the coming weekend, that is, on 11 and 12 December 1999. The Department does not have cause for concern in relation to Y2K compliance at the BTSB. Those are the specifics and I am advised that all other issues are dealt with under the committee's arrangements.
The indicative drug target scheme, that is, the drug budgeting scheme, applies to the GMS population and it is the expenditure in respect of this population for which funding is being sought. The issue of additional funding for the GMS was flagged in the amended Estimates published in May. The increase in GMS spending is 27% in 1999 and the ongoing increase is 12%. The cost of all drugs is escalating and is a cause of concern to the Department and to hospitals that must administer them, quite apart from the GMS drugs scheme. The issue is subject to the drug budgeting scheme but it is a phenomenon in the provision of modern health services. The cost of drugs is expensive and their usage is more prevalent. In primary care, we have systems that seek to incentivise the prescribing of drugs in as cost efficient and efficacious a way as possible, but these are clinical decisions. The clinical independence of medical practitioners cannot be compromised. We are trying to deal with that situation all the time but there is no point in suggesting the phenomenon is peculiar to Ireland because every health system is facing these situations.
The review of the GMS board's finances, which has been carried out, focused on the appropriate cash provision for the board in 1999 and had no implications for the day to day services available to the public. I mentioned this matter in my speech on the Supplementary Estimate. Over a long number of years, the GMS was being dealt with on an overdraft facility basis because one cannot accurately establish what the cost of the GMS will be in any one year. I formed the view that it was necessary to get a once-off provision to improve both the cash flow and the historic budgeting situation. The GMS was never left with more than it needed because one was always trying to ensure that no one was getting encouragement to roll away because the good times had come. Over a period of years it appeared to me, based on discussing GMS finances with officials, that we needed to obtain the Department of Finance's agreement on what we were attempting to do. That interdepartmental review had the benefit of funding a once-off provision to assist what was seen as an historic situation which was developing all the time. It was unnecessarily affecting their cash flow and was an over-stringent approach to financing the GMS Board. That did not happen overnight; it was part of the control mechanism where an agency was spending very large sums of money. Every GMS payment has to be made because of the statutory provision to do so, yet the overdraft provision was being over-used and needed to be addressed in some way. As a result of these arrangements which we have put in place the board currently had no overdraft.
I raised two matters to which the Minister has not responded. The first is the fact that nicotine replacement therapies do not fall within either the drugs payment scheme or the GMS scheme. That is a false economy in the context of our health services. The Minister should make a political decision without delay to include those products within the relevant schemes. The second query I raised was whether he could provide the committee with the projected income from the health levy, as of 1 January 1999, for the full year. What is the projected income from the health levy as at 31 December 1999, as matters stand, from the financial information that is now available?
I have asked the advisory committee we set up under the cardiovascular group to report to me on whether it believes nicotine replacement therapy should be available under the GMS. It has been an outcome of the merging of the schemes that the NRT, which was an over-the-counter product, could be refunded. It is important, however, to seek the formal advice of the advisory committee who are working to a specific strategy. I have asked them to examine the matter as a priority.
Is the Minister aware of a report from that committee which unanimously proposes this step? Does he give any weight to that report? When a political decision was made by him to exclude nicotine replacement therapy from the new scheme - it is not an outcome that emerged from some vacuum - can he explain to the committee why——
There were inequities in the way the schemes operated - let us discuss the question of equity since people like talking about it these days - whereby a person on a medical card would have to pay for it. It was not on their list, but the person on a cross-subsidisation scheme could be reimbursed on a higher income level.
The correct way to address that issue was not to exclude it from the drugs payment scheme but to extend nicotine replacement therapy to the GMS.
That issue can be considered by the advisory committee now that we have a cardiovascular strategy. It was an outcome in that respect; it was not the reason we managed the schemes. Now that we also know what we want to do in general terms it should be asked if this should be part of it as a matter of priority. It was to be referred to the advisory committee and it is to revert to us. That is the present position.
Why can that not be made by way of a political decision? Why is it that every basic decision within the Department goes to a sub-group? Presumably the cardiovascular committee was not consulted to ascertain whether nicotine replacement therapy, having been in the old scheme, should be excluded from the drug payment scheme. A political decision was made in that context.
A political decision was made to merge the scheme in the interest of equity and to improve the situation where poor families were being required to buy their medication for up to three months and wait for another half a month, or a month and a half, before they could get their money back under what was supposed to be a subsidised scheme. I have simplified that.
What about an extension to GMS patients?
On the question of equity I said I would merge the schemes to avoid the situation where medical card holders must pay for something on which a person without a medical card could obtain a refund. If somebody claims that was equity they take a different view of it than I do.
Nobody is suggesting that.
The Deputy referred to a specific side effect of that decision. Every decision is not referred out, but to maintain the credibility of a strategy which has involved much work, we have an advisory committee which will advise me on meeting the objectives set out in the strategy, which is multi-annual in scope, and on whether NRT should be a central part of it as a matter of priority. I will take that advice. That is the way I operate. Perhaps the Deputy might indicate how he would operate.
The recommendations in the report from the committee is of no relevance to determining the outcome of that issue.
That is not correct.
That is what the Minister is effectively saying.
That is facile. I would be the first to acknowledge that the committee has done very good work on this issue. Others in my Department have also worked on it. A number of issues need to be addressed to progress matters. That is one part of the problems. NRT will be considered in the framework I have set up. I believe that is fair.
With regard to the health contributions, the original Estimate was £388 million. The Supplementary Estimate is for £29 million, so that brings the total to £417 million.
I take it that is purely from the health levy.
The Minister must recognise that medical opinion is of the view that the use of nicotine patches is the only thing that has been proved to be of value in terms of effectiveness. He should ensure that everybody is able to have access to this very helpful way of assisting people to give up smoking.
The Minister allowed additional moneys of 5% in the Estimate for the GMS, which was grossly short of the amount required. An additional 28% is required now and 12% from here on. Is that correct? What proportion of the population is involved in the GMS? The Minister says the main pressure on the scheme is from drugs. An analysis is required here, especially if one system involves drug budgeting while the other does not. The latter does not appear to be putting so much financial pressure on the Department. Is drug budgeting not providing value for money or is it the number of people who are sick?
The Minister gets very touchy, but before he starts telling me what I said he should listen to what I say. The record will show that I did not say what he thinks I said.
I will not argue with the Deputy, but it would not be the first time she misrepresented me.
I did not misrepresent the Minister.
She did, and I can cite a few instances which I did not pursue.
I did not misrepresent the Minister.
We will not elaborate on that but leave it, for the benefit of the committee. Given our increased prosperity, the number on the GMS would not be as great as it was some years ago. That is also against the background of an increased population. It is estimated that there is an extra 250,000 people living in the country since the 1996 Estimate.
I am not happy with the cost of drugs or about getting value for money. There is room for improvement, even allowing for the increasing cost of drugs, including the use of different, more expensive drugs and so on. This is not a unique phenomenon. It affects every modern health system of which I am aware. We need to see what further incentives we can provide. If we want to make a decision on compromising clinical autonomy there will not be co-operation, nor would agreement be possible on making a decision to restrict certain types of drugs to certain illnesses.
What is the percentage using the GMS?
It is 31%.
It is less than last year.
Yes. It is less as a percentage of the total population than last year.
Apart from asylum seekers, it would appear that most people returning to the country do not avail of the scheme.
That is fair enough. The ultimate costs are as I have outlined and they are rising, despite our incentive schemes. We provided for an additional 5% on the budget at the beginning of the year in the abridged Estimate because it is one of the items which I bring to the attention of the Minister for Finance. I do not need accurate figures because of a commitment that the statutory requirement will be met.
Does that apply to many things covered by the Estimate?
No. It applies to superannuation, PRSI, medical indemnity, GMS and the community drugs scheme.
Chairman, time has run out and I must leave the meeting. I mean no discourtesy to you or to the Minister.
Can we bring this matter to a conclusion? I do not propose to allow the Minister or Deputy Shatter make closing statements.
We look forward to our continuing discourse on health policy. I wish the Deputy a happy Christmas if I do not see him before then.
I also wish the Minister and his officials a happy Christmas with no Y2K problems. On occasion the committee gives them a difficult time. It is our job to ask questions. We appreciate the work they do and it is right for us to say that, as we come to the end of the year, the century and the millennium.
I wish to be associated with those good wishes for Christmas and the new year.