On behalf of the committee, I welcome the Minister for Health and Children, Deputy Martin, without his officials.
Estimates for Public Services, 2000.
Vote 33 - Department of Health and Children (Revised).
I was unsure whether they could come in.
They can come in. We would not like to see the Minister isolated. The purpose of the meeting is to consider the Estimates that fall within the remit of the Department of Health and Children, namely, Vote 33. A proposed timetable for the meeting has been circulated which allows for opening statements by the Minister and Opposition spokespersons and then an open discussion on the individual subheads by way of a question and answer session. Is that agreed? Agreed. I invite the Minister to make his opening statement.
Will the Chairman clarify if this is an official public meeting or a local Cork constituency meeting?
It is very much public and national.
Sorry, I could not resist that.
The Minister and I like to have a national profile.
I am delighted to have the opportunity to bring this Estimate before the Select Committee on Health and Children. The select committee plays an important role in examining the Department's Estimate. The health service impinges on the lives of the public in a way that is unique in the public service. For this reason, it is essential that the workings of the service are the subject of full and open debate. This debate is also an important feature at local level where there is considerable democratic input into the planning of services by health boards.
The health service is the focus of considerable and ongoing attention and this is inevitably the case when the standards expected of the service are not met. Rarely, however, are the improvements in the service given proper acknowledgement. There have been positive developments recently in the health service which need to be acknowledged, not least among these is the Estimate before the committee.
This year's Estimate provides a gross sum of £4,297,030,000. The figure shows an increase of £492 million, or 13%, over the outturn for last year. This is a record increase in the original provision for the health service. When the Government came to office in 1997, the provision for the health service was £2.754 billion. The 2000 provision represents a 56% increase in funding. Over a three year period, the Government has increased spending from approximately £7.5 million per day to almost £12 million. Over £1.5 billion in additional resources is being invested in the health service. This increase in long awaited resources has allowed for a major acceleration in the development of a range of services.
The Government has also recognised that, in moving forward, the current health infrastructure is inadequate for the delivery of a truly modern and efficient service. Under the national development plan £2 billion in capital spending has been made available to develop health facilities of the highest order. The inclusion of health in the national development plan was a statement of priority in its own right since it is recognition for the first time of the central importance of health facilities in the social and economic infrastructure of the country. The £2 billion now being provided is almost treble the capital resources provided over the pervious seven year period. The first fruits of the NDP can be seen in this year's Estimate, where there is a record capital provision of £231 million. I will set out some of the key initiatives being progressed this year as a result of the considerable extra resources made available. It is important for the morale of the service that we do not gloss over the improvements which are being implemented or fail to acknowledge the considerable strides being made in developing services.
I readily admit that more needs to be done in a number of areas before we achieve the transformation of services which is required. In this regard, while I do not want to see the progress already under way ignored, I am very interested in discussing with the select committee what remains to be done in terms of further investment and reform.
The ongoing development of services to meet the identified needs of those with an intellectual disability and their families has been a top priority of this Government. Despite the allocation by the Government of significant additional funding totalling £53 million up to the end of 1999, there is still a backlog of need in relation to residential, respite and day services. The Government is committed to clearing this backlog over the next three years. The additional revenue funding provided in 2000 for these services is £38.7 million. This funding will provide, at a minimum, 555 new residential places, 185 new respite places, 700 new day places, health-related support services for persons with autism, the continuation of the programme to transfer persons with an intellectual disability from psychiatric hospitals and other inappropriate placements and additional specialist and other support services.
This is the largest single new revenue investment ever made in the services. It is testimony to the commitment of my predecessor, Deputy Cowen, and the Minister for Finance, to address the needs which had been identified of this population group. The national representative bodies in this area will be involved in monitoring the spending of this money so as to ensure the greatest impact possible is achieved. A definite commitment is being made by the Government to those with an intellectual disability and their families. Those in need of a service will have their needs met within a defined timeframe of three years. A fully developed programme to achieve this is being put in place, starting with a major acceleration of investment, both capital and revenue, in the current year. We are now in a position where the Government, the health boards, voluntary agencies and families can work together to a clearly laid out programme in tackling the deficiencies which have been identified within these services.
Additional revenue of £20 million is being invested this year in services for people with a physical and sensory disability. This is the largest ever single additional revenue investment in these services. The funding provided is being targeted at the provision of additional day care places and home supports. An additional 400 day care places will be provided and additional home support services, which includes personal assistance, to cost £3 million in 2000 and increasing to £6 million in 2001, will be made available. These additional services will enable a substantial number of people with severe physical disabilities to live independently in the community and will provide relief to a significant number of carers. In addition, the extra funding allows for the application of the domiciliary care allowance scheme to eligible children under two years of age for the first time. Furthermore, a respite care grant of £300 is being extended to all recipients of the domiciliary care allowance.
In addition to the £20 million in extra resources being made available for these services this year, a further sum of £5 million is incorporated in the Estimates for the purchase of aids and appliances. Deputies will recall that over the past couple of years funding for this purpose has been provided in the Supplementary Estimate as a result of savings in other Departments. While this funding was very welcome it did not allow for proper planning of such purchases over the course of the year. I am happy that this year the Department of Finance has responded favourably to a request to incorporate this funding into the base provision for the Department of Health and Children from the outset. I know this course of action was also proposed by Deputies. This year and into the future the new arrangements will allow the demand for aids and appliances to be met in a much more effective way.
The intellectual disability database is now well established as an important planning tool and the development of a similar database for physical and sensory disabilities is proceeding apace. The development of this new database will enable the Department to enhance services in a planned and co-ordinated manner. This has already been achieved in the case of the intellectual disability services and the Government's commitment to those services sets a precedent for the physical and sensory disability sector, facilitating the setting of similar targets as the statutory-voluntary partnership develops in this area and is consolidated over the next few years.
A total of £30 million in additional revenue is being made available for child care services. These resources will allow increased emphasis to be put on the prevention of problems through supporting vulnerable children in the family and community setting while also ensuring that services are promptly available to children at risk. There is no more onerous duty than the protection of children and the promotion of child welfare. The responsibilities imposed upon health boards in this area have expanded greatly. As one indication of this, the number of reported cases of child abuse has increased by approximately 290% in 12 years while the number of confirmed cases has increased by approximately 200% over the same period. While legislation is in place, this must be backed up by resources. For example, funding made available in 1998 and 1999 provided for an additional 750 staff, including social workers, to be employed in the child care area.
Ensuring consistent standards apply throughout the service is also a major part of the Government's child care strategy. To this end a social services inspectorate was established in April last year. This inspectorate will concentrate on the child care services for an initial three year period. The publication in September 1999 of Children First - National Guidelines for the Protection and Welfare of Children represented a major development in strengthening arrangements for the protection of children.
Funding is also provided in this year's Estimate for the establishment of the office of an ombudsman for children which will promote the welfare and rights of children. Encompassing all these developments will be a national children's strategy which is currently being prepared. This strategy will set out a co-ordinated policy designed to integrate service delivery for children.
A sum of £12.2 million has been provided for improvements in mental health services. This additional funding will allow for the further development of community-based mental health services. These resources will be targeted at the improvement of the psychology and social work services which have been identified by the Inspector of Mental Hospitals as major deficits. It is also the intention to continue to improve services for children and adolescents, older people and the forensic psychiatric services. New suicide prevention and research programmes and a pilot project for the rehabilitation of long-stay patients in psychiatric hospitals are also being developed.
A new Mental Health Bill will shortly reach Committee Stage and this Bill will provide greater safeguards for patients who require to be admitted on an involuntary basis to mental health facilities. Funding of £2.5 million has been provided in the current year for this Bill's enactment.
It is clear that very significant funding is going towards developing the non-hospital sector. These developments are crucial in improving the quality of life of often marginalised groups such as those with a physical or intellectual disability, vulnerable children, older people, those suffering from mental illness and drug users. There is an obvious need for further sustained effort in each of these areas.
In many ways, the availability and quality of hospital services sets the context for the perception of the health services as a whole. There is no escaping the fact that certain key areas, particularly waiting lists and accident and emergency services, are critical to the public perception of the health services. Only when the performance in these areas is improved and hospital services are integrated properly with primary and community care services will our health services be seen as meeting the best standards. It is also clear that problems in areas such as waiting lists and accident and emergency services cannot be solved in isolation. Integrated solutions are the key. This will involve developing and refining appropriate roles for acute primary care and community services. For example, the £35.4 million in additional funding this year for services for the elderly has a key role to play in putting in place the community facilities, home help and nursing supports required to allow older people to move out of the hospital setting once the acute phase of their treatment is completed. This investment will be complemented by dedicated funding of £5 million for tackling difficulties in accident and emergency services. This funding will go in large measure towards increasing the number of sub-acute beds, particularly in the Dublin region, to allow acute hospitals to free up beds occupied by the elderly and chronic sick.
Therefore, integration of strategies for the development of services for older people and accident and emergency services offers the best means of meeting the policy aim of supporting older people in the community and achieving the best possible performance within hospitals. The role of primary care, and in particular GPs, is also of central importance within the overall system. Under the NDP there will be very significant development of primary care involving investment in multi-purpose health centres. These will be local hubs for the provision of a range of primary care health and personal social services leading to a more comprehensive and integrated service to patients. Under the Programme for Prosperity and Fairness the Government is committed to establishing at least four primary care pilot projects which will allow for the development of 24 hour, seven day services and £1 million has been made available for this purpose in the current year. Already the GP pilot in Carlow, CAREDOC, is operating successfully, as are initiatives in Dublin such as DUBDOC, centred around St. James's Hospital. A further pilot in the North Eastern Health Board is due to commence in July. The roll-out of a properly evaluated primary care model will be of major importance in allowing patients to access health care at the most appropriate level.
The cardiovascular health strategy offers an integrated approach to the prevention and treatment of cardiovascular disease. This year £3.6 million is being invested in expanding cardiac treatment capacity in acute hospitals in order to address waiting lists. We also need to tackle the underlying causes of cardiovascular disease. The cardiovascular health strategy, Building Healthier Hearts, provides us with a comprehensive and far-reaching blueprint for the way forward. A medium-term objective has been set to bring our levels of premature deaths from cardiovascular disease into line with the EU average at a minimum.
A sum of £12 million is provided in the Estimate to begin the implementation of the cardiovascular health strategy. This additional funding of £12 million - £24 million in a full year - will be the foundation for the implementation of some of the more immediate recommendations across the health services. Progress is already being achieved this year in health promotion, primary care, pre-hospital care, hospital care and in the area of audit and evaluation. The model used for the cardiovascular strategy builds on the experience in implementing the national cancer strategy. A further £8.3 million has been made available in the Estimate for the continued implementation of this strategy. Separate sums of £2.3 million and £3.6 million have been provided for the development of breast and cervical screening services. Cancer treatment services throughout the country are undergoing rigorous improvement. This involves investment in screening, diagnosis, treatment and palliative care facilities in order to bring services up to the best international standards.
Strategies for cancer, cardiovascular and services for older people clearly span the acute and non-acute sectors. However, specific attention has to be paid to performance within acute hospitals. I wish to see an all-out assault on waiting lists. Waiting lists for a number of procedures are unacceptable and will be reduced. In reviewing the overall performance of the current system it is worth noting that in-patient waiting lists represent just 4% of the total discharges from acute hospitals. While waiting lists are unacceptable and must be addressed, let us not forget the level and quality of service provided to the other 96% of patients.
The new Eastern Regional Health Authority has already established a dedicated team to address this issue and I have agreed with each health board accelerated work plans for addressing waiting lists. A total of almost £33 million will be spent on addressing acute hospital waiting lists this year. During the first quarter of this year waiting lists fell by 2,485. This was an encouraging reduction, particularly since traditionally elective work suffers in the early months of the year as the number of emergency medical admissions increases. In order to accelerate progress in this area even more quickly, last month I announced a targeted initiative to deliver an additional 7,600 waiting list procedures by the end of the year. These 7,600 procedures will be over and above the waiting list activity agreed with agencies at the start of the year. This latest initiative will cost £10 million.
The Government is implementing an overall national policy to enhance regional services so that patients do not have to travel from all over the country to Dublin to access hospital services. This policy will ensure availability of treatment throughout the country based on uniform standards of quality. An important aspect of investment in regional services is that it will free up capacity in the Dublin hospitals and provide more scope for addressing waiting lists. A total of£11.5 million is provided in the Estimate for the commissioning of new acute hospital facilities around the country. These facilities include major developments in Limerick Regional Hospital, UCH Galway and Mayo General Hospital.
My Department has commenced a review of the adequacy of bed capacity in the acute and non-acute settings. This review will identify capacity issues against the background of substantial increase in demand as a result of changing demography and advances in medical treatment. It is my intention that the results of this review will be addressed in the context of next year's Estimate.
I appreciate that funding, while vital, is only the starting point in accomplishing radical improvement. I believe there is significant scope to improve standards of customer service within hospitals and all those engaged in the health sector must put this concern at the centre of all their operations. The way the service is organised, managed and delivered is undergoing considerable change and these improvements must continue. Patients attending all hospitals, in every area of the country, are entitled to expect a quality service. I wish to see performance rewarded and I have told health boards that this is the basis on which I will make additional funds available. The Government will continue to work with all concerned in investing resources and energy in the improvement of services. It will take all opportunities to bring the necessary services on stream quicker. It will also lead to reform for the benefit of the public patient.
The setting up of the new Eastern Regional Health Authority in March was the most significant structural reform in the health services since the 1970s. The ERHA has set about resolving problems in the wider Dublin region created by unwieldy structures and poor co-ordination of services. The reform will ensure services are integrated around the patient. In particular, the new arrangements will provide for a smoother interface between acute and community services. The ERHA will work with all health agencies in its region to ensure that the best standards which are currently being set by some will in future be achieved by all providers of services. There is enormous potential in the setting up of the ERHA for improving the co-ordination of the acute sector. In excess of 50% of the ERHA's budget will be spent on acute hospital services and maximising the return to the public from this spend will be a key concern of the authority.
The need to put in place a modern health service available to all on the basis of need has been spoken of often in this committee and in the House. Those who speak on this subject do so with an urgency which I share. Much remains to be done but I am proud of the Government's record of delivering on its commitments in the health area. With the resources now available it is essential that the opportunities which this provides are fully realised and real and lasting improvements are delivered. The challenge facing everyone working within the health sector is to ensure that the public gets the maximum benefit from these resources and that the delivery of quality health services available to all who need them is at last achieved.
I presume, as the Minister's 15 minutes extended to almost 25 minutes, some flexibility will be shown to members of the Opposition.
Naturally.
The Government should be ashamed of its record on the management of the health service and addressing a broad range of issues which demand to be addressed. It is difficult to take seriously the Minister's commitment to address problems with urgency. Effectively in the first three years of this Government's term of office we have watched hospital waiting lists grow, chaos in accident and emergency departments, hundreds of children alleged to be victims of child abuse having their cases not investigated, in some instances for months and for years in other instances, a total incapacity on the part of the Minister and the Department to publish long awaited legislation across a broad range of areas with reasonable speed, a total paralysis in dealing with essential reforms in the health insurance system and a complete lack of vision as to how to provide a modern, cohesive and responsive health service that meets people's needs.
The Government should be ashamed because we are going through a period of unprecedented prosperity. The Minister and his predecessor should have had funding which allowed for many of the problems the Minister now says will be addressed with some sense of urgency to have been addressed and resolved by now. In that context the Government has failed. It came to office at a time when hospital waiting lists were 29,000 - they were 34,500 on 31 March 2000, 5,500 more than when the Government took office in 1997. At the end of December 1999 waiting lists had grown to 36,500. That is a deplorable record.
The Minister has sought some degree of praise in the media for the fact that waiting lists at the end of March 2000 were less than at the end of December and he seeks to use the figures to portray the Government as having done a good job. The reality is that the numbers may be down between December and March but they are substantially higher than when the Government took office. However, even more worrying is the fact that waiting times for serious essential procedures for children and adults are continuing to lengthen. The March 2000 figures across a broad range of areas showed a continued increase in waiting times and the number of people waiting.
For example, in Our Lady's Hospital for Sick Children, Crumlin, as at 31 March 2000, 324 children had been waiting longer than six months for a bed, 32 children had been waiting longer than six months in Tallaght hospital and 1,073 children had been waiting longer than six months in Temple Street Hospital. However, since 1997 it has been the Government's objective to ensure that no child requiring inpatient hospital treatment should wait for longer than six months.
In Cork university hospital in the Minister's constituency, 102 children have been waiting for a bed for over six months. In Our Lady of Lourdes Hospital, Drogheda, 84 children were waiting more than six months for a bed. The figure is 179 children at Sligo Regional Hospital and at Tullamore hospital, in the Minister's predecessor's constituency, the figure is 400 children waiting for a bed for over six months, mostly for ear, nose and throat procedures. Many of these children have been waiting for two to three years. I am merely referring to the "over six months" objective that the Government prescribed for itself on taking office. There are 177 children waiting over six months for a broad range of procedures at University College Hospital, Galway.
There has been a very substantial increase in waiting times for children and adults, depending on the type of surgery required. On 31 March 1999 69% of those on the waiting list for cardiac surgery had been waiting 12 months or more. The figure on 1 March 2000 was 72%. A total of 92% of children on the waiting list for cardiac surgery on 31 March 2000 had been waiting six months or more, and we now know that children who require urgent cardiac surgery have to be sent abroad, adding to their trauma and that of their parents. This is a deplorable record.
There are more than 5,000 adults on the ENT waiting list, of whom 3,000 or exactly 60% have been waiting over 12 months. Some have been waiting two to three years. There are 2,000 children on the list, of whom 1,615 or 78% have been waiting over six months. Many will have to wait one to two years.
I could go through a series of additional statistics which show the extent to which waiting times have increased across practically every specialty. This is a record to be ashamed of and which condemns the Government as one which has been totally incapable of properly managing the health service.
There is chaos in the accident and emergency departments of major acute hospitals. There are particular and major difficulties in Dublin. I have received reports that in recent weeks patients had to wait three and four days for a bed on trolleys in the accident and emergency department of St. James's Hospital. This is mirrored across the country. This shows a failure of planning and to come to terms with the needs of patients. Many of those being admitted through accident and emergency departments because their conditions have deteriorated have been left languishing for far too long on hospital waiting lists. We have a hospital service that is not worthy of a first world country. This is completely unacceptable.
It is unacceptable that the Government has not marshalled the huge resources available to it to ensure they are properly targeted and the problems to which I have referred are properly addressed. In this context the Minister referred to the additional sum being spent this year. What proportion of GDP is being spent on the health service this year? The average throughout the lifetime of the Government has been just under 6%. This rises to above the 6% margin when the private spend on medical care is included. The OECD average is just under 9%. Will the Minister clarify whether we are yet in line with other OECD countries in terms of hospital spend?
I wish to refer briefly to a number of other issues. It is notable that the Minister did not refer to health promotion, which the Government has completely failed to properly resource. There was no mention of the Government spend or commitment to tackle the tobacco issue. The Minister's speech and his comments elsewhere on the issue were largely aspirational. The Government does not consider that the Health (Miscellaneous Provisions) Bill merits sufficient priority to be taken in the House before the end of the session. It is not on the agenda for this week. Perhaps the Minister will persuade his colleagues to place it on the agenda for next week. This is a disgrace.
The Minister is proposing to ban cigarette advertising and sponsorship by tobacco companies. While I support him in this, the wrong legal procedures are being used and I am concerned that they will be challenged by either the newspaper industry or tobacco companies. I have serious doubts, therefore, that he will be able to maintain a ban on cigarette advertising and sponsorship after 1 July but I hope I am wrong. The methodology being applied and the manner in which he is dealing with the matter give rise to real problems.
In its report laid before the Dáil last November this committee recommended that nicotine replacement therapy be provided for in the drug payment scheme and made available to medical card holders, but the Government is resolutely refusing to do so. This is unbelievable. In February the Minister published a statement about the Government's aspiration to put in place smoking cessation programmes. How many such programmes have been put in place? What health spend has been targeted? How many programmes have been put in place to co-ordinate the activities of health boards and schools, as recommended by this committee, to ensure young people hooked on tobacco have a means to break the nicotine bind?
The Minister referred to the commitment to those suffering from a disability. Steps are being taken but, like so much else about the Government's health policy, the sad reality is that there is no sense of urgency. Announcements are made, the world meanders on and steps announced in 1998 may be implemented by 2002. This is indicative of the problems being encountered in managing the health service. Far too little is being done in the area of autism.
This committee was informed in a recent hearing on the subject that under the procedures the Department of Education and Science has in place children who reach the age of seven may be detected within our schools as suffering from dyslexia. Under tests now available children as young as two can be identified as dyslexic. I tabled a parliamentary question to the Minister asking if his Department would assume responsibility for this area but it was transferred to the Minister for Education and Science. The Department of Health and Children does not believe that it has a role to play in putting in place a policy to determine whether very young children suffer from dyslexia. If it could be detected at the age of two, three or four the children concerned would not suffer from educational disadvantage in their early years in primary school.
On the Blood Transfusion Service, there is ongoing internecine warfare between Cork and Dublin, on which this committee has published a report, but the Minister has failed to intervene to resolve the problem. If there is genuine concern about the fall-off in the number of blood donors the Minister and those responsible for running the Blood Transfusion Service should be clear that it is the direct consequence not just of what has happened within recent tribunals but also the divisions, difficulties and lack of cohesion within the service. The problem has still not been addressed. It is time for the Minister to step in and resolve it rather than stand back and observe.
There have been difficulties in recent weeks with Dr. Elwood, an elderly locum working as a pathologist in a number of hospitals, whose capacity to make judgments and diagnoses has been open to serious question. The Minister has formed a committee or group to look at how this type of issue should be dealt with in future. I call on him to implement immediately a policy under which no consultant over the age of 70 would be employed as a locum in the State. This would ensure the difficulties which have arisen in the Elwood case are not repeated. The Minister should issue a guideline to all health boards and public hospitals to this effect. If he fails to do so and similar difficulties arise concerning an elderly locum recruited in one of our hospitals, he will bear the responsibility. One of the main hospitals in England which experienced difficulties with Dr. Elwood has issued such a guideline, and I cannot understand why the same cannot be done here.
There are three children's issues to which I will return, and I will mention them briefly. On foster care, in a parliamentary question I sought statistics from the Department of Health and Children for the number of foster parents fostering three or more children, but it did not know the answer as the information was not available and the Minister gave no indication that I would ever receive a reply. I am receiving reports that, because of a shortage of places, under the fosterage arrangements being operated by some health boards, between five and ten children are being fostered by the one family. If that is the case we are looking at huge problems and the matter should be investigated. If, because of a shortage of places, families are fostering between five and ten children in ordinary houses, it is not a fosterage arrangement but a residential home or institution. We may rue the day when we turned our eye away and allowed some health boards to operate such an arrangement. I want the Department to tell me within the next two weeks whether this is true and indicate the number of instances in which this is occurring and the controls in place to ensure the children concerned are being properly cared for. If what I am being told is inaccurate and untrue, well and good, but it is a source of concern and the Department has not been able to answer that question.
On adoption, the Government has failed to address the issue of tracing - parents and children. Legislation has been promised for three years but it seems there is total paralysis on the issue. The Minister should tell us what is happening.
The Government has a disgraceful record in its failure to provide appropriate places within a reasonable timeframe for children with behavioural difficulties who require special facilities. It is moving forward only on foot of continuous criticism by High Court judges and High Court judges prescribing by court order timeframes within which results must be achieved. What is happening in this area is completely unacceptable. If one takes a stroll around Grafton Street and St. Stephen's Green in Dublin at 7 p.m. or 8 p.m. on any evening of the week, one will find lying on blankets up to half a dozen teenagers settling down for the night. That is not acceptable in the prosperous Ireland of 2000.
Last Thursday evening I witnessed a 13 year old child who had bedded himself down 100 yards from the Shelbourne Hotel being lifted off the pavement, with a degree of insight and sensitivity, by two members of the Garda Síochána, placed in a van and driven away, I hope to a place where he would be cared for. A half dozen people, both locals and tourists, stood nearby and were amazed that this could happen in Ireland. I have nothing but praise for the members of the Garda Síochána who dealt with the child concerned. They dealt with him well and sensitively but they should not have had to do it. Why was this child sleeping on the streets? I walked by four other teenagers before reaching him and I was only out to get some fresh air. This eloquently says something about social values in Ireland in 2000 and the total hypocrisy of the Government's claim to put children first.
Clearly, children's issues and the resolving of major problems affecting children across a broad range of areas have not been given priority, as evidenced by the fact that health boards have admitted that there are 1,000 children in respect of whom allegations of child abuse have been made and whose family circumstances have yet to be assessed. I predict that in 2010 there will be yet another tribunal inquiring into why so many children were abused in Ireland in the latter part of the 1990s and the early part of 2000 in circumstances where they had been reported as being at risk while health boards simply did nothing, because of a lack of personnel, to conduct essential assessments and take the necessary action to guarantee to the children concerned the protection to which they were entitled.
I thank the Minister for his statement. While additional funding for health services is welcome - it would be amazing if there was no additional funding given the state of the economy - it is important that this document is seen as factual. It is important to separate the actual increase in terms of Government policy. The Minister has presented it in such a way that the Government has, through its munificence, provided for an increase of 13% in funding, but that is not the case. As I read the Estimates there is a very considerable increase in Appropriations-in-Aid and the health levy. What this means is that the net increase is 8%. It is important to state this to ensure we know what we are talking about. I would also like the Minister to tell us exactly what the rate of medical inflation is. I understand it is among the highest in Europe.
Listening to the Minister giving a glowing report on increased funding and the wonderful job the Government is doing, any member of the public would have great difficulty reconciling that message with the reality if he or she ever gets sick and ends up in hospital. It is clear to everyone, layman and professional, that there is a serious crisis in the health service, despite the allocation of additional funding. Waiting lists have not been brought back to the level they were at when the Government took office. That is an extraordinary record for a Government three years in office in times of unprecedented economic growth.
There are structural problems within the health service. While there have been limited improvements aimed at organising services within health boards, there are still major manpower problems and, if anything, they are getting worse. Sick people are being denied services because of a shortage of nurses. Services are also being put under threat because NCHDs are being exploited. The constant threat, emerging again, of industrial action by junior doctors is extremely worrying. Allied professionals such as psychologists, dentists and social workers, the mainstays of a quality health service, are in short supply. The tackling of staff shortages is not evident. It is not clear when one goes looking that the Minister has made a serious impact in dealing with the problem. Where is the report of the medical manpower forum established two years ago? Where are the improvements and the major policy initiatives promised for so long?
I too would like to know for what percentage of GDP the increased funding accounts. It is to our shame as a society that we are so far behind our partners across Europe despite the increased funding. I would like to know the current percentage of GDP because it is to our shame as a society that we are so far behind our partners throughout Europe, given that in terms of economic growth we are ahead of other European countries. I can think of no more serious example of how the system is failing than the current measles epidemic. According to today's newspapers, there were 930 cases of measles by the beginning of this month in contrast to last year when the national total number of cases was 148. In terms of the average level of vaccination throughout the country, we are below the level set by the World Health Organisation for African countries. I find it difficult to listen to Deputy Callely, chairman of the health authority, decrying the fact that asylum seekers are bringing illnesses to this country, given that he has never pointed to a measles epidemic in Ireland, which would be unheard of in some of the countries from which these people are coming. Two children have died from measles in Ireland and the Minister has failed to prevent this from happening.
Vaccination is a simple and not very costly measure. Very few parts of the country have reached the required level. Perhaps just one area has reached the required level of 90% - the autumn level is higher. Very serious questions in this regard must be answered if we cannot prevent mortality rates among children and ensure that children do not suffer from deafness and mental disability. In the Estimates people are being compensated for the whooping cough vaccine, and rightly so, and I support fully vaccination programmes to prevent whooping cough because the disease is so serious. In future will there be payments to unfortunate children who have lost their faculties as a result of unnecessarily contracting measles because the Minister for Health and Children neglected to protect them?
There is a fundamental issue in relation to the services, particularly hospital services, which is due to the two-tier nature of services which has developed in Ireland. I drew up a Labour Party document proposing how to deal with the two-tier system and provide a new dispensation where every citizen from the cradle to the grave would be protected and offered the security of a decent health service. Fianna Fáil's knee-jerk reaction to this was interesting. There was an organised campaign whereby the press office issued a press release on behalf of each TD stating that the Labour Party would close down local hospitals. It was fascinating to read the same press release reports in the provincial newspapers from various Deputies. Unfortunately, this committee was used as part of the campaign against our proposals and the chairman had to apologise to members of this committee. A serious set of proposals were put in the public arena for discussion and it was interesting that when the Minister responded in the media there was no coherent argument as to why this should not be the way forward. There were a few minor points of detail but there was no coherent rebuttal or, more importantly, an alternative proposal to deal with this two-tier system where patients suffer and die and must go on long waiting lists because they cannot afford private health care.
The Minister for Health and Children can do something about this gross injustice but he could not present a coherent set of principles or arguments to deal with the issue. I thought this was curious because I presume Departments pay attention to policy and long-term planning. There is much in Ministers' statements, including statements by the Minister for Health and Children, about strategic and long-term planning. However, there seems to be no policy on how to tackle the fundamental inequality experienced daily by ill, poor and very often elderly people who, given our economic growth, deserve better from a Minister who has a certain reputation.
The health service needs to be reformed. The fact that the Estimates do not appear to provide extra funding for research, data collection, health promotion and preventative medicine indicates that we are not seeking the information which would make a difference to people's lives in terms of their health status. I welcome the fact that there is a commitment to geographic inequality. I would like the Minister to talk about cancer services. A report has been drawn up on cancer services which has been a cause for some concern. I would like the Minister to respond to that issue. He should explain why there is no paediatric service in the east coast area health board. There is no paediatrician in an area which includes south Dublin and north Wicklow. Each year there may be a different Minister in office but the same Government has been in office for over three years. The Government set its own targets to tackle the waiting list crisis but waiting lists are longer now than when the Government took office.
There is a commitment in the Estimates to improve mental health services for people suffering from autism but after three years the experience is not good. One need only look at the report of the Inspector of Mental Hospitals to see just how poor the services are. There was a commitment to review medical card eligibility for large families. Who can recall that this was a commitment in the Government's programme? I am sure members of large and small families are still attending the clinic of the Minister for Health and Children, as they are mine. These people are at the end of their tether because they cannot afford to go to their GP and provide the necessary drugs for their children. That stress and anxiety in a time of plenty is impossible to justify, yet it is not even mentioned in the Estimates.
We will now proceed to the general discussion on the Estimates. I suggest that we begin with subhead A, administration.
Will the Chairman inform us what falls under the heading "entertainment"?
I was wondering if the Deputy would ever get to that.
It covers State receptions and international conferences which we assist organisations in hosting. There was a very good one recently on palliative care.
From an Opposition perspective some of the Minister's aspirational comments in the context of the Government's past performance tend to fall under the heading "Entertainment".
Subhead A.7 - consultancy services - shows a very considerable increase of 337%. A sum of £1 million is being allocated for financial advice on the issue of the future of the VHI. This is a lot of money. How will the consultancy contract be allocated? Will tenders be sought or has this already been done and, if so, who has been allocated the contract? On the overall figure, even allowing for the items included in the briefing note, there remains a sum of about £750,000 which is not provided for. Not one penny is provided for IT consultancy contracts. I would have thought that this would be a priority for a Department which does not seem to be able to collate data. At times there are serious deficiencies. Is the sum of £750,000 which has not been provided for being set aside for the Minister or——
The increase.
There is £750,000 outstanding. The Minister has provided for the VHI and the value for money audit.
About £350,000 has been provided for the value for money audit.
As I read the Estimate there is an outstanding amount which seems to have been provided for another consultancy service. There is also the question of decentralising the disease surveillance unit in respect of which I cited the measles epidemic in Dublin as an example. I would have thought that this would have alerted the Minister to the dangers associated with transferring such a unit out of Dublin. It certainly caused much concern among those working within the unit. Will the Minister continue along that route or will he adopt a better approach and retain the unit in Dublin?
On consultancy services, in addition to what is included in the briefing note, for a number of years we have retained Mercers to advise us on a continuing basis on the VHI and the ongoing development of the health insurance sector. I have a list of consultancy contracts which I can forward to the Deputy if she so wishes——
Is it very long?
It is reasonably long.
More than 30.
No, about 18. Personally, I do not engage consultants.
What about Drury consultants?
I do not.
They are employed by the Department.
They are no longer employed by it.
On the VHI, is the Minister saying——
The consultancy firm, Mercers, advises us on an ongoing basis on the health insurance sector.
The £1 million, therefore, is over and above——
It relates to advice on the corporate status of the company and future structural changes which are or may be in the pipeline.
Will the same company be allocated the contract?
Not necessarily. We are not in a position to be specific at this stage.
Will tenders be sought?
Yes. They have to be. About £350,000 has been provided for the value for money audit. We have asked the firm concerned to look at different systems of funding health services, as per the Deputy's party's policy document.
I am very glad to hear that.
We take the Deputy seriously from time to time. It is worth looking at international experience in terms of the methodology applied in funding health services. There are other issues which affect their delivery.
Will the Minister publish that information?
Yes.
What is the position on the disease surveillance unit?
That issue is being considered. I met staff of the national disease surveillance centre. It is not a critical issue in terms of the measles outbreak. We would be codding ourselves if we thought it was, although it might be useful politically to juxtapose it alongside the epidemic.
Among others, the Deputy identified the issue of vaccination programmes. Many of the issues raised relate to structures vis-à-vis the interface between the centre and regional health authorities. It seems our performance on vaccination in different health boards has not been good. Having received the figures we have asked all health boards to look again at their vaccination programmes. The bottom line is that there have been 1,000 cases this year due to the low uptake of immunisation. No excuses can be made. Perhaps complacency has set in among the general population in recent times because many diseases have been more or less eradicated and people are of the view that they will not come back to haunt us. There is a need for a more aggressive programme in certain areas. The northern area health board responded actively once the issue emerged by way of higher numbers by establishing clinics and visiting schools to immunise children but we are still not happy. We have spoken to the programme managers of the various health boards to ensure the uptake is increased to 95%. We will set renewed targets between now and the end of the year.
All Deputies have referred to the Government, but there has been significant devolution of statutory authority and powers, not just to health boards but also to the professionals in terms of manpower. For example, the Medical Council has responsibilities in the Dr. Elwood case while An Comhairle has responsibilities in respect of the appointment of consultants. We have to make up our minds as to whether we are serious about devolution of statutory authority. I am not trying to absolve the Government of responsibility but all too easily we tend to come back to the centre. Regardless of whether we like it, considerable authority has been devolved.
On subhead A, it is the Department which allocates funds and determines national policies. The difficulties to which the Minister referred with regard to health boards which have a degree of independence under legislation derive from the inability of the Department to maintain an overview of what is happening in the health service generally. This stems from a lack of up-to-date information. In seeking what I would regard as basic background statistical information across a broad range of issues affecting health boards and which is essential to facilitate the Minister and the Department in making policy decisions which may be implemented further down the line, I am constantly amazed that it does not exist within the Department. On previous occasions with the Minister and his predecessor I have been beating the drum on the manner in which we deal with waiting list figures. There is a three month accumulation of statistics. The figures at the end of March are published in early June and so on. The information systems are grossly outdated.
I raised a question about the facilities available for diabetics across the country, information I thought the Department would have in the context of determining if national policy initiatives were required with regard to diabetes. The response was that the Department had none of the information and would arrange for the health boards to send it to me. Over a period of about eight weeks I got multiple letters from health boards and probably now have the greatest information base on diabetes services in the country, unless the health boards sent the Department copies of the letters. This is an indictment of the management systems in the Department and says something about the capacity of the Minister to make policy decisions. National policy decisions cannot be made in a broad range of areas when the Government does not have access to up-to-date information.
I wish to return to the figure of zero for IT consultancy services raised by Deputy McManus as I feel extremely strongly about it. She was right to raise it and the Minister has not responded to it. I do not understand the figure. There is a reference to computer and data preparation equipment under subhead A.5. Perhaps the Minister will clarify how this relates to subhead A.7. We should have modern information systems interfacing between hospitals and medical practitioners and available to the general public through a website showing not just the status of the waiting lists in the context of each hospital in real time on a daily basis but the waiting times for the different procedures and the waiting times to get on a waiting list, what Fine Gael has referred to as the secret waiting list. People referred by their GPs to consultants may have to wait ten or 12 months to get the appointment. Why is it that I can check the website of a particular hospital in the English health service and be given details of the name of every consultant in the hospital, the waiting times to see them, their specialities and the waiting times and numbers for each medical procedure, while this is not available for Irish hospitals? GPs could use the information to ensure consultancy referrals are spread among consultants with expertise in particular specialities and that one consultant does not have a far greater waiting list than others to the detriment of patients. I do not understand why we cannot better organise our health service.
Deputy McManus raised the issue of consultants examining consultants. I have grave reservations about a Department which is so dependent on outside consultancies to learn what should be done across a broad range of decision-making areas in the health service. Is the Government examining the structure of the Department of Health and Children? I hope this is not regarded as an attack on any individual in the Department. Much of the outside expertise for which the Department pays substantial sums of money should be in-house. We have been operating the VHI for decades but are dependent on Mercer Consultants to keep up to date on what is happening worldwide with health insurance schemes and to assess how to deal with ours. If nothing else the Department should have its own in-house expertise in this area and I wonder why this is not the case.
The VHI has made it known this week that there will be a further increase of 9% in health insurance premiums from next September. It says the increase is not just due to medical inflation but is because of the Government's failure to implement the risk equalisation scheme in the context of seeking moneys which BUPA, under existing legislation, should have paid VHI. That issue has been in cold storage for the past two years. Is this because the Government has no policy and does not know what to do? Has the Government abdicated its function to Mercer Consultants, or whatever other consultancy it might appoint? Is there a view on this issue? If there is, why is nothing happening? Does the Minister regard it as credible that the 9% increase from next September is not simply due to medical inflation and the increased cost of private beds in public hospitals, but because the VHI alleges it has an older customer base? VHI says one thing and BUPA says another. Does the Department have a view or is it waiting until Mercer Consultants tells it what its view should be?
Regarding the VHI, this morning the Cabinet approved a Bill which clearly sets out Government policy in relation to risk equalisation, community rating etc. which we will shortly be publishing. We take on board the various views which have been articulated. We have a definitive position in relation to this as articulated in the White Paper which was published last year. There are a number of areas which must be balanced in terms of developing the correct response and the legislation had to be prepared. In a number of areas such as this it is important that we seek expert advice. I am not a great believer in having consultancies all over the place, but in certain key areas it is important to seek expert advice, particularly when examining worldwide trends etc.
Does the Minister agree it is extraordinary that there are currently 18 consultancies?
I do not have the exact percentage of the overall budget of £4 billion spent on consultancies, but it is very small. The consultancies are not excessive or superfluous to what we are doing.
The point is well made in relation to management and information. Information and knowledge are key in terms of policy development. Historically the health service has had deficiencies in terms of information gathering and information systems. There has been considerable progress in recent years in terms of the HIPE system and the case mix approach etc. and in terms of the disability service. One of the fundamental pillars of the increased investment in intellectual disability was the database developed by the health research board, which is now preparing a similar database for physical and sensory disability which will inform future policy and investment decisions. We have more to do in terms of information and funding in the national development plan for IT represents a 100% increase on previous spending. On average we will be spending about £20 million on IT systems in future and in the first years of the national development plan we front-loaded expenditure primarily on IT and equipment in hospitals and health boards. This is recognition of the fact that we must build up better information systems to provide the data to which the Deputy referred.
We are also preparing for the development of a health information strategy in the Department. A group is currently meeting and it hopes to report early next year.
In the Estimate for 2000 the figure for IT systems is about £14.5 million. In terms of consultancies, the health boards return to us with proposals and they include the advice they receive from consultancy agencies regarding IT.
In the context of hospitals with national specialities, are there guidelines in place to ensure IT systems across the ten health boards will be compatible and will interface and interact with each other, and that it will not be a case of everybody trying to separately re-invent the wheel?
The Deputy will be glad to know we have an in-house IT unit which is developing a national, uniform approach. Issues of compatibility are not as difficult now as previously in terms of different systems and so on.
How far ahead is the unit looking? There is a view that the Internet will be the way of the future in terms of storage of information. Is the Minister talking about a unit that is simply trying to manage current systems to ensure they are compatible or about a unit that is projecting ahead?
A unit that is projecting ahead in terms of the type of technology and the new systems coming on board.
If they were to be invited to come before the committee I would be interested to hear their views. On medical information, what is the rate?
About 7% or 8%; I think I have given these figures previously. The OECD total for average public spend is about 5.7% of GDP. The OECD total, including private, averages over 7.8%. Ireland's 1997 figures for public were 4.9% of GDP, our total overall for private was 6.3%. We are catching up because of recent expenditure increases.
Are there no more recent figures than 1997?
Not from the OECD.
The Irish one.
What is it as a proportion of our own GDP?
We have not got the figure for 1999.
We will come back to it.
We move on to subhead B. Does the Minister wish to make a statement on subhead B? Are there any questions arising from same?
I want to raise a particular question on the drug payments scheme. The Minister will be aware that in the context of the drug payments scheme Deputies from all parties raised questions about certain items being excluded. Originally this scheme was known as the drug costs subsidisation scheme. The constant response is that this scheme will not be revised and that it is harmonised with the general medical scheme. I fully favour harmony but I am concerned that a broad range of items that should be included under both are excluded under the drug payment scheme. It is almost incomprehensible that some of them would be excluded from medical card holders. I wish to draw to the Minister's attention two which I find so totally bizarre as to be incomprehensible and I could probably add to this list. The old drug costs subsidisation scheme made provision for venom immunotherapy. A small number of people suffer an anaphylactic reaction to either bee or wasp stings. In highly sensitive patients the sting can kill. I would have thought that if I or my family or anybody I knew was at risk from a wasp sting whatever medication was required would be available under the GMS and would fall under the drug payments scheme. A consultant physician who is a clinical immunologist and who works in this area has already communicated concerns about this to the Eastern Regional Health Authority.
The treatment for those who suffer from this condition requires regular injections of bee or wasp venom on a fixed basis. In the earlier years monthly injections of 100 microgrammes of this venom is required and after three years perhaps an injection once or twice a year. Apparently this is excluded from the drug payments scheme. It is extraordinary that it is excluded from the GMS. We are talking about a small number of people who, if stung, can die, while the venom immunotherapy protects them. Will someone explain why that is excluded from the drug payments scheme?
Another thing I find extraordinary - I declare an interest here as one who is slightly asthmatic but happily this does not affect me - is that parents of young asthmatic children are recommended to use aerochambers to deliver an inhaler to a child who is too young to use the puffer. There are a large number of children whose general practitioners are of the view that the aerochamber is the correct technique to use for young asthmatic children. This aero chamber which fell within the drug costs subsidisation scheme as did the bee and wasp venom is excluded from the drug payments scheme. Why would we not allow parents of young asthmatic children to claim or be covered for aero chambers for children? Is it excluded from the GMS? If so, it should not be as it is the most effective remedy. I could itemise 15 other items which should be included in the scheme. One relates to something that could kill a person if they do not have access to venom. Asthma is a growing problem in young children and yet the recommended means is excluded. Will the Minister arrange to have these included as they were previously under the old scheme?
The reply which Fianna Fáil. Fine Gael, Labour and Independent Members of the Dáil have got whenever we table questions about the drug payments scheme is that it was decided last July what comes under the scheme and we are not doing anything about it. That is the effect of the replies. There is actually a standard form of words which runs to one and half pages. One has only to slot in the particular item that has been mentioned. It is time the scheme was revised as it has been in operation for almost a year. A whole series of items are excluded from it which any sane health service would include.
Would the Deputy agree with any of those which were excluded?
I suspect I would. Some items are excluded which I would see no reason to include. However it makes no sense to exclude a number of other items. I mentioned two examples which are glaringly obvious. Is there a real problem in the Department or has the Minister adopted an attitude? I do wish to blame the Department or the officials. Political decisions were made about the drug payments scheme which was sold by the Government as an improvement. Under the Freedom of Information Act I have all the internal documentation that flowed between the Department of Finance and the Department of Health and Children prior to the December 1998 budget and the introduction of the drug payments scheme. It is clear that one of the reasons for advocating the new scheme on the part of the Minister's predecessor was that it would save the Department of Finance money. A PR job was done on selling it as a better scheme but the internal politics of it was that there toing and froing from the Departments of Health and Children and Finance and the Minister's predecessor, Deputy Cowen, convinced the Minister for Finance that the new scheme was a good idea because the Department would save money. Money has been saved by deleting items that should be included.
I shall have the two items identified by the Deputy checked out and I will respond to him fairly quickly. It would not be our objective that items relating to the children's health or people generally would be left out of the scheme. The Health (Amendment) Bill, which is currently before us is part of the process described by the Deputy. There was a genuine motivation to tidy up the different schemes. Certainly we will look at the list of areas that have been taken off, in particular those identified by the Deputy. I will come back to her on the venom immunotherapy and the aerochamber.
I want to ask a number of questions on this subhead. The numbers of people on medical cards as a proportion of the population has been steadily decreasing. As I recall, the figure for 1998 was about 38% and in 1999 it was 31%. What is the estimated figure for the year 2000? I am concerned that there does not seem to be any benefit arising from the fact that fewer people are qualifying for the GMS. Clearly there are savings for the Department - I believe the figure is approximately £20 million. Allowing for the fact that last year there was a special payment of £50 million, there has been a reduction across the board, not just for the drugs but also in payments to GPs and pharmacists. Even the public service pay element is reduced. Presumably the reduction is because more people are at work and also more people, sadly, are not qualifying because incomes are increasing, although I am sure inflation is having a devastating effect on people on low pay.
The Minister referred to the fund for the development of general practice when he talked about providing more organised co-ordinated services. Allowing for ordinary inflation, let alone medical inflation, the fund for the development of general practice has not really increased in absolute terms, which is astonishing because the Minister should be making savings and presumably those savings should be——
We are not making real savings.
On the GMS? Of course savings are being made because fewer people are coming in.
No. The percentage is approximately 31% but people are getting older. We are not actually making real savings in terms of the GMS budget from year to year.
It is extraordinary that on the one hand the Minister talked about investing in general practice but there is no evidence in the Estimates of any real extension of funding for general practice services in terms of the grant for the development of general practice. There is a small increase but if we allow for inflation, and certainly for medical inflation——
The sum the Deputy is referring to is £17.7 million but I referred to an extra £1 million which will go directly to the health boards and which is not in that subhead.
So it will go to the health boards——
Directly, yes.
——to develop health centres where GPs can meet and so on?
Yes.
So it will not directly develop GP services?
It will develop primary care services in Carlow and Dublin and so on, and there is one coming on stream in the north-west.
I understand there is one in Meath.
Yes, and we are hoping to do more. Currently the ICGPR is examining a strategy document and we are working with it on a new strategy for primary care generally which obviously would inform future budgetary allocations.
Is the Minister saying that grant aiding for general practice will come via the health boards or that the health boards will manage and direct how it is done?
In consultation with the health boards.
Somebody has to be responsible. I would like to have the percentage figure. I asked the Minister's predecessor a question several times but I never got a reply. The index of drug budgeting is used for GMS patients in terms of the drugs or treatment they may need. Efforts are made to use generic drugs to try to reduce the costs and there is a different arrangement in terms of budgeting for drugs. If this is perfectly valid in terms of providing the right treatment for the GMS patient, why has it not been extended to fee paying patients? If it is not good enough for the fee paying patients, why is it being applied to the GMS patient? Perhaps the Minister does not know what I am talking about.
I do. The Deputy is asking why it is not extended to fee paying patients. Under what system?
The indicative drug budgeting, as I understand, applies for GMS patients, is that not correct?
Yes, under the GMS scheme for general practitioners.
Why can that not be extended to include private patients?
Obviously in terms of the extra costs that we reimburse, it has not been developed.
The Minister has a terrific amount of subvention under the schemes.
We do, yes.
Last year the Minister had to provide an extra £50 million for the drug budget.
We have agreed with the Irish Medical Organisation on the extension of the principles of the ITGS scheme to private prescribing, so we are moving towards that.
The Minister is doing that?
We will do that, yes.
When does the Minister expect that will be done?
The methodology will be tested on the basis of dedicated pilot projects and we reckon it will be about 12 months before we will have that bedded down. It will be about 12 months before we have the pilot projects in place and working, so we are looking at a two year period before it will be fully in place.
The other question is the percentage.
Thirty one percent.
That is the figure for 1999. What is the projected figure for 2000?
The projected figure is still around 31% but it might increase because of different factors.
It might be increased? Could the Minister give us a clue as to the reason for that?
Additional people coming into the country would be on the GMS.
On the indicative drug budgeting scheme and the possibility of it being extended, could the Minister indicate the qualitative research that has been undertaken to ensure that the application of the scheme does not result in patients receiving treatments or medicines that fall short of the best medicines available to treat their particular condition? It has been suggested to me that generics are not necessarily as effective and as up to date as some of the branded products which pharmaceuticals have available now for certain conditions. Based on more recent research, new products coming on the market more efficiently target particular illnesses or conditions. While it is correct that the State has an objective to ensure that the drug spend is not more than it need be, there is a concern that because of the financial incentive to GPs to operate the scheme - it will not be operated without a financial incentive - patients are not getting the best treatment available for particular conditions. Has that been assessed? Has anything been done to examine that in terms of a group of patients who might have the generic brand for a particular condition and another group who might have the latest product available and monitoring how well they do? Those on generics may ultimately add to greater medical expense to the State by ending up in hospital for particular conditions that would have been better treated if they were not on generics. I do not have the answer to this but I am concerned that we may travel a particular route and extend it further without having the qualitative research undertaken using cohorts of people on the different medications to ensure that we are travelling the right route. It may be there are short-term savings in some of these cases with long-term health implications for the State.
The Deputy's point is well made and it is one that we are conscious of, particularly in terms of the cardiovascular strategy, for example, and certain medication for strokes and so on which have been identified. There is flexibility even within the existing system to allow GPs to prescribe appropriately in that area.
We have had discussions with the pharmaceutical associations and the GPs on those specific issues. We have also asked the national pharmacology centre to conduct an in-depth examination of the dynamics of prescribing for GMS and non-GMS patients, to examine the differences that exist in prescribing patterns between GMS and non-GMS prescribing, to quantify the differences not only in economic terms but to indicate whether those differences are justifiable on therapeutic grounds and to make recommendations on the position to date.
When are we likely to get the outcome of that?
I do not have a specific timeframe on that.
I am concerned that people, irrespective of whether they are in private care or GMS care, get the correct treatment.
Yes.
Is there a possibility the Government will make a decision to extend the scheme to medicines that fall under the drugs payments scheme without having this research carried out, assessments made and results obtained?
It has been described as the Murphy report - it was produced by Professor Michael Murphy who is chair of the EHRB. He and the Comptroller and Auditor General, although the C&AG would not bring a health dimension to it, show no diminution in the quality prescribed as a result of the introduction of this scheme. Generics are more or less of the same quality.
They should be.
There are timeframes within which new products become available in respect of which there are not generics to target particular ailments.
Yes, but there would be flexibility in dealing with those situations. There is no hard and fast exclusion of new products that come on stream.
We will move on to other services that come under subheads C to H. Do members have any questions?
I am curious about subhead C, which indicates an increase of 250% in the allocation to the registrars of births, deaths and marriages. What is there such an increase in the allocation to this area?
With regard to that area, I wish to refer to the problems raised by genealogists who wish to gain access to up to date records, the difficulties surrounding that area and the provision of efficient systems. What is the Department doing to improve access to records and to ensure that the systems operate efficiently? While I appreciate this falls within the bailiwick of the health boards, from personal experience I have grave doubts as to how efficiently some of the health boards operate record systems when it comes to the simple issue of people having access to death certificates. There seems to be a wide variation of standards in services, which cause a great deal of unnecessary upset and result in people wasting an awful lot of time trying to get access to records that the State should more readily and simply make available.
We have secured additional staff for the GRO. The Department of Finance recently granted approval for the recruitment of 12 additional staff. A major project involving the compilation of births, deaths and marriages and associated indexes in an electronic format has been ongoing in Roscommon for some time. There have been difficulties associated with that project and numerous parliamentary questions have been tabled on it. Until the necessary capital investment is in place for that project, we will continue to have problems but we have made a number of improvements to date and recruitment of such additional staff is taking place at present.
I understand that to date that project has cost double its original estimated cost. Can the Minister indicate what the current cost of it is, what the future projections are and when that work will be concluded?
I do not have that information with me but I will supply it to the Deputy. The cost of the project is substantial. We provided an estimate recently in reply to a parliamentary question. There are two projects involved, the computerisation of the archival records and the modernisation of the registration service, including the computerisation of the registration processing system. An amount of £7.3 million was approved by Government for the modernisation programme in 1999. On the genealogical side, the computerisation of the archival records is taking place, which will mean that those records will be available on a electronic database. That project has cost £3.35 million to date and the estimated cost of completing it is £6.2 million. The modernisation of the registration service, including computerisation of the registration process, will cost about £7.3 million.
Is that double the original estimate?
That is not indicated in my notes, but I do not think it is double the original estimate. I will check that.
This is not a trick question.
I know that. I do not think it is double the original estimated cost. I think I gave similar figures in reply to a parliamentary question tabled earlier in the year.
I understand there were major difficulties regarding one of these schemes. What was the reason for that? Were the wrong systems used initially? Did we get the wrong advice?
The Roscommon project may cost more than originally estimated.
I understand that one of those projects will cost double the original projected amount. I am not clear why that should be the case.
I will find that out for the Deputy.
Under subhead E, can the Minister tell us what is the cost to the State to date of defending the various court cases brought on behalf of children for whom we do not have proper facilities? What has the State had to spend on legal counsel? How many orders for costs have been made against the State in these type of cases? To date what has been the spend on those? How many are in the pipeline in the sense of court orders for costs being made against the State but the cost of them not yet having been taxed by the Taxing Master of the High Court?
We are covered by the Chief State Solicitor's Office in terms of expenditure our Department would incur in terms of counsel in the courts. Health boards would have separate costs for their representation in various cases. I do not have their figures but I can get them for the Deputy.
This issue is not one of funding. We provided the funding template to provide for the various units that should be established to cater for children with behavioural difficulties and children who need help and secure units. In some instances, health boards have not managed to meet the timetable originally set. The ERHA will almost have one of its facilities in place for this month.
I do not say this in a political sense, but the point must be made that nothing was done for children with significant problems in the 1990s and no foundation to provide for them was laid, even when the Government came into office in the late 1990s. I know that from my time as Minister for Education and Science. The subhead for children on remand in St. Michael's was nil in education in 1997. I had to suggest that we create a new subhead for a £25 million development programme for Trinity House, St. Michael's and for Oberstown. The same applied throughout the health board region. They did not have units and this area was not developed. A funding template is now in place. From the Department's perspective, it is particularly frustrating that we do not have units in place in certain health board areas where funding exists to have them in place. We have got various reasons they are not in place.
The Minister of State, Deputy Hanafin, has been in regular contact with the health board personnel in different regions to try to remove obstacles to putting such units in place. The NIMBY factor has also played a role. There have been objections in certain communities to the establishment of such secure units for young children. It is appalling that people adopt the attitude of objecting to the provision of facilities of this kind for children who desperately need them. Some health boards have experienced difficulties securing qualified staff to operate these particular units. It is a priority of the Minister of State. We want to put the court cases behind the Department. It is an indictment of society as a whole that cases are regularly heard by the High Court. We are determined to ensure there will be sufficient places to cater for children with very difficult personal histories who should not have to pursue their rights through the High Court.
In February 1999 the High Court made an order against the Minister and the Department because they had presented one set of plans in 1997 and 1998 and another in 1999 by which time they had changed their minds. The problem, therefore, is not confined to health boards. There was a clear difficulty within the Department because the Government could not make up its mind on what its strategy should be. As a consequence it was subject to substantial criticism. In January or February this year the same judge had to make further orders in another area requiring that certain steps be completed within a particular timeframe. Will the Minister make available the details of the legal expenses incurred?
We can arrange to do that.
I suspect the legal expenses would have paid for one of the residential institutions which should have been established a long time ago.
The Minister raised the issue of professional staff. I suspect that without different pay scales some of the staff required will never be recruited. The day when one could get qualified staff with specialist expertise and training to work with very difficult children on the cheap is gone. This needs to be looked at. Financial mechanisms and pay rates that will attract the staff required should be provided. Instead money is being wasted on lawyers in the courts. On occasion I do not mind people wasting the odd few bob on me as a lawyer but it is extraordinary that money that could be better spent providing direct services for these children is being spent on barristers and soliticors to explain on behalf of the health boards in court why the State is not meeting its obligations. This is a dreadful waste of public resources.
Subhead F covers the Irish Medicines Board. Having had hearings at this committee I wish to raise an issue that I think——
On the staffing and manpower issue, I agree with the Deputy that it is unacceptable that so much money is being wasted on legal fees on an issue such as this. It should not happen. Health boards and the Department are represented in court by senior counsel. This should not continue. We hope the benchmarking process under the Programme for Prosperity and Fairness will present an opportunity to consider the remuneration of those working in areas such as this and allow specific jobs to be benchmarked or valued against what is happening in the private sector. Under the system of social partnership relativities come into play whereby movement in one area has a ripple effect in terms of pay. The benchmarking process may give us an opportunity to offer something extra. We know from early experience in other centres that attrition rates and turnover are high.
What progress is being made in the Irish Medicines Board in providing a new regulatory system for herbal remedies and medicines? Has there been any review or revision of the Government's approach or attitude to St. John's wort or will the current position continue indefinitely? May I use the Postgraduate Medical and Dental Board as a convenient excuse to again ask the Minister when a new medical practitioners Bill will be introduced? I have read what was published in the newspapers last week and what the Minister said about the Dr. Elwood issue was a replica of what his predecessor said in 1997, 1998 and 1999. Now that the former secretary general is assisting the Department on a special consultancy contract is it likely that a new medical practitioners Bill will be published in the early autumn?
I am aware that terms such as "early autumn", "late autumn" and "the end of the year" are interchangeable but I hope to introduce a new Bill before the end of the year. The appointment of the former general secretary on a consultancy contract will speed up its drafting. Much legislation is being drafted inhouse but this is an important Bill about which we have been in contact with the various representative bodies which are anxious that it be moved on. We hope to publish it next session. The target date is November.
On St. John's wort, my predecessor acted on the advice of the IMB. If a Minister was to go against its recommendations on what should be prescribed it would create a difficult precedent. The day politicians start to make such decisions we will be on the road to chaos. In one sense the decision had a positive effect. It acted as a catalyst for significant debate in which a variety of interests in the field of alternative medicine have engaged. I have had meetings with a range of groups. People are moving slowly towards the idea of regulation of products and practitioners.
The possibility of introducing an interim national licensing system for traditional use products is being examined. In this context the appointment of a senior assessor by the IMB has been sanctioned. We are also looking at the establishment of a third committee within the IMB with specific expertise to look at alternative medicine products.
On practitioners, I am looking at the possibility of establishing a forum on which all interests would be represented to progress and seek consensus on the issue. Our priority is the regulation of professionals in the paramedical field, on which officials of my Department are concentrating their efforts. They hope to have the heads of a Bill ready by the end of the year. The forum would do much of the groundwork before legislation aimed at regulation of the sector is prepared.
I understand the alternative medicines sector has been seeking some form of regulation for a very long time. It is a little unfair, therefore, to say that people are only now coming around to the idea. Perhaps it is the officials of the Department who are now coming around to the idea that they should get involved. There has been a strong lobby for some time to ensure certain standards are laid down. It is welcome that legislation has now been promised on paramedics. I hope this long awaited Bill will be published before the end of the year. Does the Minister have his own parliamentary draftsman in the Department?
We do not.
I would have thought that this would be very helpful.
It is a matter at which we are looking.
There is one item in the Estimates that jars at a time when there is extra money available. Will the Minister explain why the budget given to the National Council on Ageing and Older People has been reduced? I am sure I do not need to remind him that in the mid-term review of the Government programme there is a reference to giving particular emphasis to services for the elderly. Perhaps additional money is being given to health boards for this purpose, and the Minister will probably say that he is doing this in some context. Given that a national council is in existence and that it has an important input to the work of the Department, it is pity that its allocation has been reduced.
Aside from the work of health boards, responsibility for caring for the elderly falls largely on the voluntary sector and individual families. If this matter is considered only in terms of statutory bodies providing services, the big picture will be missed and the sustenance and support that people require, and need to feel they have received from the Minister for Health and Children, will not be provided.
The decrease is due to the fact that last year was the Year of the Older Person.
So the Minister is forgetting about the older person this year. That explains it.
No. I understand there were many specific projects last year and extra funding of over £400,000 was provided. Apparently, they have expressed satisfaction with the allocation this year.
They were afraid the Minister would reduce it further.
No. Significant additional moneys for older people in general have been provided to health boards this year. An additional £23.6 million has been provided this year for services for older people compared to approximately £16 million in 1999.
I will not labour the point.
There is additional funding for community supports in terms of support for Alzheimer's sufferers, carers, home helps, etc. There is no argument about the annual revenue budget received by organisations in this area.
The Minister is missing my point. It would be unfortunate if this type of body was judged in terms of whether it kicked up a fuss. The Minister said they are not complaining, therefore we do not have to be concerned about them. I understand why he is doing that but my point is that if one goes around the country, as the Minister does, one will often——
Does that mean there will not be a millennium committee next year?
——find that there is no sense among people who are caring for the elderly, trying to manage home help services and reach out to families that they receive due regard for their work. It is a pity that a national council that is already established is not being given a surprising amount from its point of view. People presume that they will not receive much because they have never received much in the past. Ireland is now a wealthy country and the Government said it wants to emphasise services for the elderly. However, at the same time, the national council is expected to take less this year because this is not the Year of the Older Person. This should be noted because it is indicative of a type of thinking that is unfortunate.
It is unfortunate that the Deputy is making a meal out of this issue. The bottom line is that, in 1998, the organisation received £460,000. Last year a national committee was established to arrange various national events in conjunction with the Year of the Older Person. It received specific funding for specific projects that it requested last year to celebrate the year properly. This is the only background to this matter. The amount was substantially above the 1998 figure and the Deputy is not being positive towards the elderly by suggesting that this year's allocation is indicative of a wider agenda. She is overstating the case.
I am talking about the wider reality for many people who are caring for the elderly.
We are committed to the elderly and I acknowledge that we have much to do in terms of improving services for them. It is our intention to implement a significant action programme for the elderly over the next number of months and years.
There are references to the Women's Health Council and the document, A Plan for Women's Health, in the list of groups under this subhead. These provide a convenient way for me to raise an issue I mentioned earlier to which the Minister has not responded. We now know that 40% of young women between the ages of 15 and 17 years in certain socio-economic groups smoke cigarettes and are addicted to nicotine. Earlier I referred to what the Minister is doing about setting up the promised smoking cessation programme and what, if anything, is happening to require health boards to put in place co-ordinated smoking cessation programmes in schools to tackle the real problem of teenage smoking.
As I mentioned in the report prepared for this committee, the report of the Plan for Women's Health referred to the impact of tobacco and cigarettes on women and lung and other cancers. A Government commitment to tackle this problem has not been met. Is there any particular objective at this stage in this area rather than just the occasional piecemeal initiative? Before the Minister plays politics in this area, the 1994 departmental strategy document - I am not sure if it was the strategy document of the Labour/Fianna Fáil Government or the Labour/Fine Gael/Democratic Left Government; I cannot recall who was in office when it was published but that would not have mattered because it would have been published anyway - set an objective of ensuring that at least 80% of the population would be non-smokers by 2000. However, having set the objective, no Government did anything to ensure that it could be achieved. Is there an objective now or are there only piecemeal initiatives?
In the context of women's health and male and female teenagers, will the Minister deal with the other issue I raised in relation to the drugs payment scheme? May I take it that he intends to ignore the recommendation of this committee that nicotine replacement products should be available under the drugs payment scheme and to GMS patients? I draw his attention to the fact that, in approximately two or three weeks, a new pharmaceutical product will be available on the market. A person can take tablets once, twice or three times a day for approximately eight weeks and, over that period, the drug will apparently affect brain cells in a manner which reduces dependence on nicotine and gets the person off tobacco. Will that pharmaceutical product be available under the GMS? If so, will there be the ridiculous situation where nicotine replacement therapies that do not involve taking tablets will not be available? Would people be encouraged to use these products if they were included in the drugs payment scheme? The Minister did not respond to these points earlier; perhaps he could do so now.
I said in the Seanad recently that a policy decision has been made to include nicotine replacement therapies in the GMS. I understand the Department asked the advisory forum on cardiovascular health to develop proposals on how best nicotine replacement therapies could be made available to GMS patients. There were some concerns in terms of take-up, waste, etc., and whether it should be done in the context of smoking cessation programmes or if products should be made available generally on the GMS. Issues in this area need to be teased out and I have met a number of people on the advisory committee. My officials have asked that a report be prepared quickly in terms of the application of nicotine replacement therapies under the GMS.
The Deputy may not take it that I intend to ignore the recommendation of this committee on this issue or the recommendation of the Towards a Tobacco Free Society which was launched in March. We accept the value and importance of nicotine replacement therapy. It has a role to play in terms of reducing the number of people who smoke in Ireland. We accept the thesis that the person who smokes is addicted and needs help to break the addiction. Our objective is Towards a Tobacco Free Society.
Part of the problem in the past has been the absence of a national body or group whose sole aim would be to drive anti-tobacco policy. In the last two months we have established the Office of Tobacco Control, with a director. The board has been established and it will be the operational room to drive the policy of attaining the objectives of Towards a Tobacco Free Society. Substantial work has been done on a new tobacco Bill which we hope to introduce in the autumn session. It will be substantive and will address many of the issues set out in the report of this committee and Towards a Tobacco Free Society. It will overshadow the provisions of the current legislation and give stronger powers to the Government and the Department to take measures on tobacco. Many of the issues Deputy Shatter has raised will be contained in the Bill, although we may not agree on all its provisions. The Office of Tobacco Control has been very helpful in terms of working on that agenda.
With regard to the development of smoking cessation programmes, this is the first year that significant funding has been made available under which health boards can develop these programmes. They are being activated by health boards and we want to try and get as reasonable a geographic base as possible in terms of developing the programmes. The funding is there within the £12 million provided this year for the implementation of this strategy. We also provided approximately £200,000 over the last number of years for intervention training programmes for GPs so that they can be in a better position to raise with their patients the issue of smoking cessation, etc.
I am not impressed. Last October in response to a Dáil question I tabled on nicotine replacement therapy, the Minister's predecessor told me the issue would be looked at by the cardiovascular strategy group. I understand the nicotine replacement therapy scheme was included under the drugs subsidisation scheme. On 1 July last year the Government decided to remove it from the scheme and by way of cover said the cardiovascular strategy group would look at it. What has the group being looking at for the past nine months?
This is where I constantly hark back to the lethargy of implementing health policy. Why was not the nicotine replacement therapy scheme looked at before it was removed from the drugs payment scheme, which replaced the drugs subsidisation scheme? Three months later, in response to political embarrassment, the Minister's predecessor announced that the cardiovascular strategy group to look at it. Nine months later it is still looking at it. What is the group doing? Does it have a picture of drug replacement therapy on the wall to look at every day? What consideration does this require? Do people have to lie in the sun contemplating their navels to work out how we deal with this issue? It is not that complex.
There is no sense of urgency about anything in the health area. Some 40% of teenage girls in the lower socio-economic groupings and 35% in the higher socio-economic groupings are addicted to tobacco. An average of 33% of young teenage boys are also addicted. The matter is being thought about. Perhaps the cardiovascular strategy group will hold a meeting, perhaps it will send an opinion to the Minister which he may get next month, August, September or October. Perhaps somebody will implement a decision next December, and if one is implemented it may not become operative until July 2001. One and a half years later nothing has happened while another 200,000 youngsters become addicted to tobacco.
I have a personal view on this issue and I am not concerned with playing party politics. There is a lethargy and a lack of a sense of urgency. The system meanders on. Inevitably a decision will be made by someone somewhere that will change something, but I do not understand why this could not have been dealt with sooner.
The health boards have been given an allocation to provide smoking cessation programmes. What guidelines have they been given? Is each health board going to again invent the wheel and work out how it is to proceed? Should it done by community care teams, health centres or in spare rooms in hospitals? Should they talk to schools? Why can they not be given guidelines to the effect that their smoking cessation programme should mean putting programmes in place with every secondary school in the country, operative from 1 September? I would like to bet that will not happen within a single health board area. At the end of the year the Minister will say he allocated the money but the health boards did not spend it.
There is complete lethargy about this issue. It is not a minor issue. Some 700,000 lives are lost annually. It affects the whole community and the whole health service. There is a failure to implement the type of national strategy this committee recommended. I do not believe the commmitee's recommendations are written in tablets of stone, that changes cannot be made to them or that other proposals might be more or less effective. However, nothing is happening except for the odd piecemeal initiative. When the Minister refers to the cardiovascular strategy group and the £12 million made available to it, the reality is that not enough money or focus has been put in to dealing with the tobacco issue. The establishment of the body referred to by the Minister is not sufficient. It is a body starting to get off the ground. The Department should have a greater focus.
Some £1 billion will be taken by the State this year in tobacco taxes, of which £150 million will derive from the extra 50p on the price of 20 cigarettes imposed on 1 December. An additional £150 million is floating through the system as a result of an additional tobacco tax, of which £12 million is being put into the cardiovascular strategy group and £450,000, an increase of £200,000, has gone to the Health Promotion Unit. We are not yet dealing seriously with this issue.
The price of a packet of 20 cigarettes was increased by 50p in the budget, which is a clear indication of the Government's commitment and determination on the issue.
An additional £150 million.
Two areas have been identified as the key determinants in terms of making smoking attractive or unattractive. Taxation is one and advertising is the other. I have identified them as key issues. We have made decisions on the taxation side and on advertising.
On the question of schools, I have initiated contact with the Department of Education and Science. A health promotion pilot project has been ongoing for some time in schools. Every school should be a health promoting school. It will involve specific action on smoking.
Existing programmes achieve nothing.
I do not accept that.
The anti-smoking programme for schools has been in operation while the increase in smoking has continued.
I am referring to the overall health promoting schools project. A number of schools have been involved on a pilot basis, but every school should be a health promoting school which looks at issues such as life styles and self-esteem. It has an impact over time. It is only last year that for the first time a coherent substance abuse programme, the Walk Tall programme, was developed for primary schools. Resources were allocated in 1998 to enable the 3,000 primary schools not only adopt the programme but to have proper in-service training of teachers.
The key to anti-smoking or dealing with substance abuse is to build up self-esteem and self-confidence among children so that they will not take up these habits. By next May almost all primary schools will have the Walk Tall programme in place and staff will have undertaken in-service training to deliver it.
With regard to second level schools, the On My Own Two Feet programme was published a number of years ago and has been disseminated to all schools. I accept that we need a more focused approach in terms of specific posts of responsibilities for teachers to deliver the programme. I have been working with the drugs advisory committee and the interdepartmental group on drugs to see if we can develop that proposal with my colleague in the Department of Education and Science.
I have made a decision on the nicotine replacement therapy. I am committed to making it part of the GMS. There is a group set up which ismeant to advise on it and I told it I want a report quickly. I do not want to delay.
Will the Minister extend the drugs payment scheme?
I am looking at the GMS and I will look at that in due course. I hope to have reached definite decisions on this issue within a month.
I am determined that the Bill, which is currently being prepared, will go before Government and will be published in the autumn. There will be no lethargy on my part in pursuing this issue. I will say no more than that, and in six or seven months we can reflect on the progress made.
Due to the constraints of time, we may have to take subheads H and I together.
On the hospital building programme, facilities and furnishings, how many extra hospital beds and step down beds will be provided by the end of 2000?
I do not have that figure to hand. There are two issues here. On the capital programmes, we will be modernising existing wards. That, in itself, will not increase bed capacity.
I appreciate that.
The critical issue is that we are now engaged in a bed capacity review as per the Programme for Prosperity and Fairness.
I want an estimate of the number of extra hospital beds which will be provided. There are fewer hospital beds available. Presumably the Minister can work it out. I realise that builders might not be available and there may be delays, but I presume the Department has estimated the number of extra hospital beds and step down facilities to be provided by the end of the year. I had a similar experience to that of Deputy Shatter when I tried to find out about step down beds from the Department. I ended up getting letters from all over the country from health boards, some of which stated that they did not categorise step down beds within the health board region. Will the Department have a clear idea at the end of this work? Taking only the issues of hospital beds and step down beds, what will be the increase in bed numbers?
We will try to get the end of year figures for the Deputy, but the real answer to the question lies in the bed capacity review which the Department is undertaking with the health boards. The Deputy is correct. If one looks over a ten year period, the number of beds available would have been higher in the mid-1980s. There are a number of relevant factors involved, such as the increase in day activity which has increased by 10% per annum over the past number of years. That said, in line with the PPF, the bed capacity review will identify future needs in the system in terms of extra acute and non-acute beds. That will include step down, intensive care and medical beds. We hope to have that initial review completed by the end of the summer to feed into next year's Estimates process.
I am not making a political point, but I find that disturbing. The idea of conducting research on capacity is a good one. I understand the review is being conducted for the Eastern Regional Health Authority.
It is for the whole country.
If it is for the whole country, that is great. The Minister and I know that there is a problem at present, particularly about step down beds. We all know that.
Yes. We are working on it.
We have known it for a long time. I would have thought that, notwithstanding the research being conducted, he would have had a phased programme to increase the capacity. One thing of which the Minister can be sure is that he will not be seeking a reduction in the number of step down beds. I think he could presume——
Much of the capital programme will increase the number of step down facilities. There is no question about that.
That is what I want to know. What is the Estimate for this year?
I do not have the figure for this year to hand but I will get it for the Deputy. She will be aware that buildings takes time to construct.
I realise that, but it is a matter of bricks and mortar and it is easy to assess.
Does anybody want to make a closing statement?
We were talking earlier about nicotine replacement therapy, the methadone treatment programme and drug addiction. Would the Minister indicate where those programmes stand at this stage?
Some people are now raising issue with the efficacy of methadone and the problems associated with it. I would be interested in the Minister's views on that and to know whether there are still waiting lists of people trying to participate in these programmes. The waiting lists are a big problem because there are moments in addicts' lives when they have the capacity to make the decision to come off drugs. If those moments pass, you may not get them again and you may not be able to help them. I do not wish to make a lengthy speech, but I want up to date information on that issue.
The other area of concern is the Mental Health Bill, 1999. We dealt with Second Stage and I am concerned at the delay in taking Committee Stage. I want to know when the Department will be in a position to start taking Committee Stage because there is an urgent need to update the mental health Acts and replace the Mental Treatment Act, 1961.
I also want the Minister to clarify one matter which, as far as I am aware, he was not asked about on Second Stage. It is one thing to pass the Mental Health Bill, 1999, but it is quite another to have it brought into force. There are provisions in the Bill to allow the Minister to bring it into force at a later stage after its passage through the Houses. I am conscious that the Child Care Act was passed in 1991, and most of its provisions did not become operative until 1995. In the context of this year's Estimates perhaps the Minister would indicate generally whether the Estimates envisage this Bill coming into force this year or if he anticipates there will be a long delay after its enactment before it is brought into force.
There has been a great deal of concern expressed for a number of years about St. Ita's Hospital. I realise that the Government has made money available for a restructuring and rebuilding programme to address a broad range of problems there. Like everything else in the health services, it seems to be taking a long time to get started. The staff of St. Ita's Hospital are upset greatly about the conditions under which they work. There is legitimate public concern about the conditions under which patients must live in that facility. I want the Minister to clarify what is happening in that regard.
What work has been done to date by the inspectorate on children? In so far as there are in existence residential units for children under the auspices of health boards, what ability does the social service inspectorate have to investigate allegations that children are being mistreated in any health board residential institution? They are operating without statutory powers. I am not sure the extent to which a social services inspectorate operates at present and the Minister might clarify this. May we have some indication of when there will be legislation on a social services inspectorate? I do not see how an inspectorate can operate without statutory powers to investigate difficulties which may arise in some of the institutions as opposed to what went on in children's institutions in the past.
I am satisfied that the methadone treatment programme has been effective. From talking to personnel within the ERHA where the bulk of the heroin problem is located and the National Drugs Advisory Committee, the numbers of people who take up the methadone programme and who go back to work are actually higher than comparable figures in the European Union. These people are still on methadone while they are back at work.
There are about 400 on the waiting list in the ERHA region. We have had discussions with representatives of the ERHA and they expect that approximately 5,200 people will be in treatment by July and that the current waiting list will be completely dealt with by the end of June. However, they believe that they should be aiming towards making 7,000 places available and they estimate they are on target to achieve that within the next 12 months. Not everyone comes forward for treatment and the greatest obstacle has been the NIMBY factor, namely, objections from local communities.
The board has adopted a consultative approach to this matter and such an approach takes time. Nonetheless, it has proven to be effective in the long-term because good consultation with communities usually leads to the establishment of treatment centres which, in turn, gain greater acceptance from those communities. We have had very good outcomes in this area.
With regard to the Mental Health Bill, we have been involved in ongoing consultations with the various stakeholders in the mental health area. There are a number of issues in respect of which the parties concerned sought clarification. We have taken action in respect of the issue of wards of court and, in that context, we are developing amendments in consultation with the President of the High Court. We want to complete the debate on the Bill in the autumn because it is unlikely that Committee Stage will be taken before the conclusion of the current session.
I am conscious of the Deputy's point in respect of implementation and subsequent regulations. We intend to be in a position to implement the Bill as soon as possible after it is passed. That means that a number of regulations will be ready for introduction. A sum of £2 million is provided in the Estimate in respect of the implementation of the Bill. We are planning to establish the mental health commission on an administrative basis in advance of the legislation being passed. This will be of assistance in terms of the subsequent implementation of the Bill, when enacted.
With regard to St. Ita's, a development plan with an estimated cost of £13 million has been implemented at this institution. However, the planning and tendering processes will not be complete until early 2001. I take the Deputy's point that people will be obliged to wait for a considerable period before modern facilities are put in place.
In relation to the social services inspectorate, the inspection programme has commenced as envisaged and one inspection was carried out in each health board area by the end of May of this year. A preliminary pilot inspection was conducted in the South Eastern Health Board area last November. To date, formal inspections have been carried out at Tír na nÓg children's residential centre in the NEHB area; Brookwood children's residential centre in the Eastern Health Board area; Bartres children's residential centre in the NEHB area; the Auburn children's residential centre in the Midland Health Board area; the Tallaght children's residential centre in the Eastern Health Board area; the Haven hostel for homeless children in Limerick; Áras Gael children's residential centre in Galway in the Western Health Board area, Gleann Alainn children's residential centre in Cork in the Southern Health Board area; Lios na nÓg children's residential centre in the North Western Health Board area and St. Joseph's children's residential centre in Kilkenny. These investigations were completed in the initial ten inspection programme. There are approximately 50 residential homes run by the health boards, so it is estimated that the full programme of inspections will take two years.
These are single inspections?
Yes.
If a child is in a residential institution for which a health board is responsible and if the child states that he or she is being assaulted there, to whom should his parents report such assaults?
If the child has reports to his parents that he or she is being assaulted?
If the parent goes to the health board which has taken the child into care, the health board will be legally defensive. If the parent goes to the social services inspectorate, it may only get around to visiting the home in 18 months time. To whom should a parent report the type of problem to which I refer?
If there is an allegation of assault, the parent should notify the health board and the Garda Síochána.
The Garda Síochána, 20 years ago, were not able to investigate the matters the Laffoy commission is currently considering.
The children who were mistreated 20 or 30 years ago did not have an opportunity to talk to anybody. Obviously, the inspectorate will be monitoring on an ongoing basis the reports prepared by health boards in respect of children's residential centres and voluntary centres which come under their auspices.
How many staff are employed by the inspectorate?
There are currently four inspectors in its employment.
Do I take it that four inspectors are obliged to cover the entire country? I realise that time is against us but I wish to put down a marker. The Government has been in office for three years and, at various stages, the concept of establishing a social services inspectorate or appointing an ombudsman for children have been given priority over each other. Eventually, we were informed that the social services inspectorate would be given priority. I do not believe that a staff of four is adequate to carry out the functions of the inspectorate. In addition, carrying out those functions without statutory powers makes those inspectors toothless tigers. Given that it will take between two and two and a half years to inspect every residential institution for which the health boards are responsible, it appears we are merely genuflecting in the direction of addressing a serious issue. The social services inspectorate was promoted as a body which could ensure that the type of things that happened in the past could not happen today. I do not believe it will have the capacity to do that.
I raise this matter for no reason other than the fact that I have genuine concerns that the problems the Laffoy commission is investigating are being replicated elsewhere and that we have no capacity to monitor the situation. The Minister has not had an opportunity to reply to my earlier query on fosterage. I hope he will follow up on that matter and reply to me by way of written correspondence.