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SELECT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 5 Dec 2000

Vol. 3 No. 4

Estimates for Public Services, 2000.

Vote 33 - Department of Health and Children (Supplementary).

On behalf of the Select Committee I welcome the Minister for Health and Children, Deputy Martin, and his officials. The purpose of today's meeting is to consider the Supplementary Estimate falling within the remit of the Department of Health and Children, namely, Vote 33.

The proposed timetable has been circulated for today's meeting and it allows for an opening statement by the Minister and the Opposition spokesperson, followed by an open discussion on the Supplementary Estimate by way of a question and answer session. Is that agreed? Agreed. I now invite the Minister to make his opening statement.

I am pleased to have this opportunity to bring the Supplementary Health Estimate before the Select Committee on Health and Children. The annual Estimates are the basis for funding health agencies in any one year. This gives agencies a proper indication regarding funding for the year and allows them to plan the services to be delivered with this funding. However, there are issues which will arise during the year which cannot be planned for and a number of these are provided for in today's Supplementary Estimate.

The gross additional requirement in this Estimate is for £158.5 million. This figure is partially offset by additional appropriations in aid of £47 million which gives a net figure of £111.5 million. Some £500,000 of the total requirement is for capital spending and the remainder is non-capital.

The Supplementary Estimate also takes account of the fact that a total of almost £5 million funding in the areas of the Irish Medicines Board, the North-South Food Safety Promotion Board, home helps' pay, the Springboard Initiative for children at risk, and health insurance consultancies will not now be required in the current year. I assure the select committee that the necessary funding will be made available for all these agencies in 2001.

Following the dissolution of the National Rehabilitation Board in June this year, my Department will surrender £18 million to the Department of Finance, which is the element of funding no longer required by this Department. This funding will in turn be transferred by way of Supplementary Estimate to the relevant Departments, namely, the Department of Enterprise, Trade and Employment, the Department of Justice, Equality and Law Reform and the Department of Social, Community and Family Affairs. These are the parent Departments for the organisations established to provide services formerly provided by the NRB.

The additional moneys sought are necessary in order to fund adequately a number of items within the health service, which have given rise to additional expenditure. A number of the items for which funding is sought relate to areas where there is an inevitable degree of uncertainty in forecasting the actual costs in any one year, and, consequently, the original Estimates may not provide fully for these costs. The agreed practice has been to seek supplementary funding in these areas when the actual amount needed becomes apparent during the year. The items recognised by the Department of Finance as falling within this category are medical indemnity insurance, superannuation costs, PRSI costs, demand-led schemes and the general medical service payments board, which consists of the community drugs scheme and certain capitation payments, such as the domiciliary care allowance. That these items would be finalised through the Supplementary Estimate in the context of expenditure trends in the year to date is of very significant benefit to health agencies in managing the remainder of expenditure within the level agreed at the start of the year.

Expenditure in these demand-led items is influenced by a number of factors which are difficult to predict in advance. The cost of providing medical indemnity cover for doctors working in hospitals continues to be of concern. The increasing frequency of claims and the growth in the size of awards, plus the associated legal costs, inevitably feed through in the form of increased insurance and indemnity costs. In August my Department circulated to all relevant parties a briefing paper containing proposals for major change in the area.

In future, indemnity cover for doctors will be provided on the basis of enterprise liability, whereby hospitals and health boards will assume vicarious liability for the actions of their medical staff, as they do for their other staff at present. This change should result in significant economies through the rationalisation of the existing fragmented insurance covers. It should also eliminate the need for separate legal representation for the multiple parties on the defence side in personal injury claims. Most importantly, it will facilitate the introduction of comprehensive clinical risk management programmes in Irish hospitals. This step is critical if we are to reduce the number of incidents which give rise to claims. Such systems have a major role to play in improving patient safety. Additional funding of £1.3 million is required for this area.

The additional superannuation costs for which funding is sought are due to the age profile of personnel in the health sector. Agencies are experiencing increasing numbers of retirements, including those opting for early retirement, and a consequent increase in the yearly budget provision is required. A sum of over £14 million in additional funding is required.

In relation to PRSI, modified social insurance status does not apply to workers recruited into the public service after 6 April 1995. This means that health agencies experience increased costs in respect of employers' PRSI contributions when recruiting such employees to replace existing staff. This item requires additional funding of almost £5.4 million.

Expenditure on the community drug schemes is a factor of the number and cost of claims under these schemes which, again, is difficult to predict in advance. As Deputies will be aware, there is a statutory right to relief for expenditure on prescribed drugs and medicines in excess of the expenditure thresholds which are laid down. There is an additional requirement of just over £41 million in respect of these schemes. Of this, £12 million is required in respect of 1999 costs.

An additional £21.75 million is sought to meet the costs of the general medical services, the GMS. The costs of the GMS, especially the costs of providing prescription drugs and medicines, have increased considerably in recent years and have proved to be greater than that provided in the annual Estimates. An amount of £10 million is in respect of speeding up the payments due to pharmacists through the development of electronic transfer arrangements and is a once off cost. The remaining funding is for the increased demand within the schemes.

A sum of almost £4 million is sought in respect of recombinant blood products. These are clotting factor products used in the treatment of haemophilia. Expenditure in this area can be particularly unpredictable since in certain circumstances very intensive treatment of a patient is required involving the administration of high doses of what are very expensive products. The introduction of these products in recent years has been based on expert clinical opinion as to their greater efficacy over alternative treatments. The increase in expenditure during this year arises from an increase in usage and an increase in the price of these products.

An additional total sum of £19.5 million is required in 2000 to meet the costs associated with the two independent tribunals provided for in my Department's Vote - the hepatitis C and HIV tribunals. The need for this additional funding arises from significant increases in the average amount awarded, the cost of appeals to the High Court and the variety and complexity of the issues being examined.

The issue of organ retention has resulted in significant costs, primarily for the children's hospitals and maternity hospitals. Additional clerical staff were required to deal with inquiries; pathology and social workers are working additional hours, and communication with parents and media have given rise to additional unplanned expenditure. A sum of £2 million is required to meet those costs.

The Eastern Regional Health Authority has been discussing with my Department capital proposals relating to the provision of a range of new facilities in the non-acute hospital sector for the Dublin area. Additional funding of £500,000 is being provided in the current year towards the costs of these facilities. It is intended that the bulk of the costs for this project will be met from the overall NDP funding available to the authority from 2001 onwards.

A sum of £5.5 million is included in this Supplementary Estimate to cover the cost in the current year of contracting at least 500 additional nursing home places and also to allow for the purchase of medical aids and appliances for older people. A major factor affecting the ability of hospitals to provide beds for patients over the winter period is the high number of acute beds which are inappropriately occupied by patients who have completed the acute phase of their illness. Many of these patients are in the older age category and require a further level of care in a more appropriate environment. These 500 places are being made available to patients from public hospitals who have completed the acute phase of their treatment in general hospitals and who require to be cared for in a less acute setting.

Additional management resources have also been provided to enable health boards to manage this initiative to ensure the optimum use of the contracted places. A sum of £4 million is required to meet the cost in the current year of the contracted places and management infrastructure. A sum of £1.5 million is included for the purpose of medical aids and appliances for older people. The set of measures which I have taken as part of the winter initiative should go a considerable distance in helping to alleviate service pressures in the acute hospital sector, especially in ensuring that hospital beds are more readily available for people who require acute treatment.

An amount of £5 million is being provided to fund a range of projects on a once-off basis. In the main this funding will be given to voluntary organisations towards the cost of projects which, due to the limited funding available, will not receive grants from the Department of Health and Children allocation of national lottery funds. These projects cover a range of issues, including the replacement of transport, refurbishment of premises and upgrading of facilities.

My Department, the Health Services Employers Agency and the Irish Medical Organisation have reached an agreement on all the major concerns of non-consultant hospital doctors. The proposals include a very significant improvement in the overtime rates paid to NCHDs. In addition, a senior manager is to be appointed in each major hospital with specific responsibility to manage NCHD hours. A concerted effort is to be made to improve the working conditions and to reduce NCHD working hours, with particular attention to long periods of continuous duty. There is also a multi-million pound training package to be put in place. This will allow doctors in training in Ireland to participate in further training programmes, attend conferences and courses and further their medical training.

Some of the issues which affect NCHDs' working conditions cannot be resolved immediately. Among these are the twin issues of working hours and the restructuring of the medical career hierarchy. The working hours of NCHDs have been the subject of negotiations at European level in the context of the proposed extension of the EU Directive on Working Time to doctors in training. Ireland has always stated that it will reduce junior doctors' working hours to an average of 48 per week at least as quickly as required by any EU directives. Additional funding of £36.8 million is sought for this element this year.

The major new nursing recruitment and retention initiative, which I launched last Wednesday, is aimed at addressing the current shortage of nurses and midwives. The initiative has three objectives, first, to attract nurses and midwives who have left the system back into it, second, to retain nurses and midwives in the public health service and, third, to address the need for more nurses in specialised areas of clinical practice. It is a shared objective of the Government, health service employers and the nursing unions that we have sufficient nurses and midwives to staff our health services now and into the future. I am confident this latest initiative represents a further important step along the road to achieving that objective.

Following from the Buckley report, a number of retired hospital consultants, who retired prior to 1991, felt that they should have received pension benefits equivalent to 50% of the salary of current hospital consultants. The view was that as the present consultants' work practices have been expanded so dramatically by both the 1991 and the 1997 contracts, absolute parity could not be acceptable. The Department was prepared to offer the percentage increases in line with the Buckley No. 36 and No. 37 reports but not the basic uplift granted in 1991. The total number of consultants, spouses and dependants involved is 357. Agreement has been reached by the parties involved and agencies are being advised to pay the appropriate amounts to the retired staff concerned by Christmas.

A sum of £4 million is being provided to meet the anticipated costs in the current year arising from the agreement reached on fees for general practitioners for administering influenza and pneumococcal vaccine. The indications to date are that there has been a good uptake of these vaccines, especially the influenza vaccine, this autumn.

During this year we made significant progress in establishing structures for partnership in the health services. We now have a well functioning National Partnership Forum, partnership committees in selected pilot sites and local partnership working groups. I see partnership as the best way forward for modernising our health services and it has a key role in implementing the programme of modernisation in the health sector as set out in the PPF. A sum of £2.8 million was set aside for partnership this year and it has been used in a range of areas, including facilitating the establishment of the process, training of partnership facilitators and participants and initial set-up costs.

Earlier this year the Government accepted in principle the recommendations of the expert group on various health professionals. The professionals covered comprise physiotherapists, occupational therapists, speech and language therapists, dieticians, social workers, chiropodists, care workers, orthoptists, audiologists and biochemists. The report deals with such important issues as career structures, pay scales, recruitment and retention, and training and education. The Government is providing £6.4 million in the current year to implement the recommendations of the report and is working closely with the Health Services Employers Agency and the unions representing these grades to progress the implementation process.

I am pleased to note that the Health Services Employers Agency, in conjunction with my Department, negotiated an important agreement with the relevant unions in relation to family support workers. This agreement will help ensure the provision of quality services to clients and will help to underline the importance of these vital staff in supporting some of our most vulnerable members of society. In accordance with the provisions of the Employment Equality Act, 1998, it is no longer permissible to remunerate staff on the basis of pay scales which provide for payments related to the age of the employee. Given this, it is necessary to abolish such age-related pay scales and this is now being done across the whole of the public sector on a phased basis in accordance with the provisions of the Act. The initial cost of this phasing out is £460,000.

An agreement was also reached between the Health Services Employers Agency and IMPACT in relation to the payment of a loyalty bonus to skilled IT staff in the health services who were engaged in year 2000 remedial work. A sum of almost £1.7 million is provided to cover the cost of the bonus. The additional costs to the administrative budget can be attributed to the creation of a number of additional posts, the pay award on age-related pay scales and increased travel and subsistence rates. The total additional requirement for all these items is £0.325 million.

The spending increases sought in this Estimate are partially offset by increased income available to my Department. My Department receives the 2% health contribution paid by employees and these revenues are an important source of funding in supporting service developments. In recent years the overall growth in the economy has led to significant buoyancy in these revenues. This Supplementary Estimate includes a revision of the estimate for health contribution revenues in the current year, providing £44 million additional revenue this year.

My Department also receives income in respect of EU nationals who have an entitlement to services in one EU country and under reciprocal arrangements can exercise this entitlement in other EU countries. The main source of this income is from the UK authorities. It is expected that income from this source will be £3 million higher than that provided for in the original Estimates.

This Supplementary Estimate will greatly assist health agencies in meeting the additional costs they are experiencing in a number of key areas. I commend it to the committee.

A Supplementary Estimate totalling £158.5 million is large. I do not know how much it costs to run the entire Oireachtas for a year but it is close to this figure. The Minister has also introduced a supplementary appropriations-in-aid provision of £47 million, which is also a significant figure. The Minister said it is often difficult to forecast at the beginning of the year what these amounts will be, but it is extraordinary that he never has a surplus to surrender. At the end of the year we are presented with large Supplementary Estimates. Why was it not possible, for example, to forecast the £47 million appropriations-in-aid provision?

A more strategic rather than operational and crisis management approach is needed in general on health issues. My experience as health spokesperson bears out my experience as a Deputy, that there is no overall strategy in place. It is made up as one goes along. I am taken aback by the number of fora, committees, consultancy groups and commission expert groups, which the Minister regularly sets up and refers to on various issues. It is similar to shoring up the ship to keep it afloat rather than having a ship of State that is heading in a particular direction.

The most unparliamentary and mean exercise is the establishment of the forum on fluoridation which will take place following advertisements in the newspapers last week. If that happened in the House of Commons, the Minister would have to appear before the equivalent of the Committee on Procedure and Privileges for contempt of Parliament. This committee is in the process of preparing a report on fluoridation. Our rapporteur is about to introduce his interim report and the Minister advertised for submissions to be made to his forum over the past weekend. That is an affront to the committee.

What are the Minister's priorities in terms of ending the apartheid in the health system whereby if one can pay, one can enter the Blackrock Clinic and will not have to suffer in pain but if one happens to come from the poorer parts of my constituency, for example, one can suffer for long periods? A lady whose legs and arms are twisted inwards is brought into my clinic on Mondays by her husband. Every time the date of her appointment for an operation is imminent it is changed. If she could write a cheque, she would be seen to immediately.

Is the Minister aware, given the number of deaths from heart disease and cancer in particular, that if Ireland's population lived in France we would live 13 million years longer? What are his priorities in terms of preventive medicine to ensure people are not just dealt with after the event? The Minister does not grasp the extent of the problem in the capital. Dublin hospitals are under enormous pressure. One fifth of all patients treated in acute hospitals in the Dublin region come from outside it. Does Dublin need another hospital? Has the Minister conducted a strategic study in this regard because many hospitals in the inner city have been closed down and a number have been upgraded?

Will the Minister comment on the incidence of TB, which is increasing? What is the cause of this increase? What steps have been taken to address it? I am also concerned about the rate of alcohol abuse. I acknowledge the Minister's campaign and the committee's report on smoking, which is very good. The committee will undertake its own investigations. Will the Minister consider a Green Paper on alcohol abuse? I do not know where the demand came from for the new opening hours for public houses in Dublin in particular. Nobody came to my clinics seeking extended opening hours.

I received a letter from my good friends in Guinness's, which is in my constituency and whose product I occasionally taste, in which they took me to task in regard to what I said in the Dáil. I reiterate the company's current advertising campaign is completely over the top. It has taken out full page advertisements in newspapers on everything from a celebration to the hair of the dog. While the Minister is devoting a great deal of energy to anti-smoking campaigns, which I support, more damage is done by alcohol. Will the Minister consider a Green Paper on alcohol abuse so that we can establish all the facts?

We have tried to bring about the integrated delivery of a number of services in my constituency. The Garda and the local authorities, for example, are co-operating much more effectively in estate management, but part of the reason 75% of the population of Mountjoy comes from five areas of Dublin is that educational and health services are not integrated in the delivery of services. What plans has the Minister for the integrated delivery of health services, particularly in urban areas, so that there is a co-ordinated approach such as that in the area of drug abuse? Education, Garda activity and estate management and good health practice are part of the problem.

More than 3,000 old people in the Eastern Regional Health Authority area are waiting for bath and shower fittings and stair rails to be fitted in their homes. This involves relatively small expenditure to allow them to remain at home and move around the same as young people. Many of them have been waiting for more than 12 months to be assessed for these medical aids. What proposals has the Minister, using the extra funds in the Supplementary Estimate, to deal with this problem?

What numbers are employed by health boards in comparison to when they were set up? If the Minister does not have the information, perhaps he will provide the committee with a note. What is the reason for the huge increase? Does the workload the staff has taken on reflect the increase in employee numbers? Has the Minister conducted a study in this regard? For example, work undertaken in parts of the Eastern Regional Health Authority was done by Dublin Corporation 30 years ago. I know its role has greatly increased but a huge number of people appear to be employed in the health boards. Has there been monitoring of the growth in health boards and the delivery of the services they provide?

The Minister mentioned the flu vaccine. Is it widely available? It has not been in recent weeks. Will the Minister make a statement on the death of a 15-year-old boy who, according to newspaper reports, apparently died from a brain tumour while awaiting hospital admission? Is that correct? What steps has the Department taken to investigate this matter? What steps has the Minister taken to ensure there will be no repeat of such a terrible outcome?

I wish to ask some questions so the Minister can take them and comments at the same time. On superannuation, how did this shortfall of £14.3 million arise? Is the Minister satisfied now that this sum clears all superannuation shortfalls in the health sector?

On the GMS board, £10 million relates to bringing pharmacists' payments within normal criteria. Were payments being made late? Is that the reason for this? Do other suppliers to the Department have to wait excessive periods for payment? What is the problem?

On the loyalty bonus of £1.7 million, will the Minister clarify the effectiveness of this initiative? Does he intend to extend it to other areas of the overstretched health services?

Will the Minister comment on the winter beds initiative? How many short-term beds will be put in place as part of the initiative? How much will be spent on aids and appliances for older people to use this winter? When will the new consultant appointments be made?

Will the Minister give some indication about helping to house or providing housing facilities for nurses in the capital? Is he prepared to consider some type of assistance to encourage the recruitment of nurses to Dublin hospitals? Is he considering some assistance with housing which would deal with that?

Will the Minister give further details about the transfer of £5.5 million to the Department of Defence? I am not clear what is intended in that. I note under the children at risk project that £900,000 is being handed back. Perhaps the Minister will explain that.

As the Minister said, the community drugs scheme is demand led. What measures does the Department have in place to ensure value for money in this highly necessary but nonetheless expensive scheme? What monitoring is in place? I would appreciate if the Minister would address those matters so we can decide on this Estimate.

I will ask a few questions so the Minister can reply. On the loyalty bonus, perhaps the Government should give it to the Minister of State, Deputy O'Dea. It might make him behave better in future.

As Deputy Mitchell said, this is a considerable amount of money for a Supplementary Estimate. Notwithstanding that, it appears it will not make any impact on patients. The health boards will benefit in terms of their current position where many of them have budget overruns. This is something which was addressed before by way of legislation, yet the debt problem seems to be re-appearing in health boards. We must recognise that although this is a great deal of money, we are still not spending enough and as a percentage of GDP, it is well behind most European countries.

As it is the greatest failure of the Government, the failure to make any real impact on waiting lists must be highlighted. A commitment was made in the Government programme to tackle waiting lists. This was the top priority that was going to make the difference. This was the health issue which got the Government elected. Approximately £80 million has been spent by the Government on the waiting lists initiative and we are not even back to the level of March 1996. While the Minister can take a certain amount of pleasure in the fact that the overall figure is slightly lower in the last quarter, what is of great concern is that the waiting lists of some hospitals are longer than they were a year ago and the issue of waiting times is no longer mentioned.

I recall the Minister's predecessor making clear statements, with some justification, that it was the waiting time which was more important than the numbers. The number of people generally in all key specialities waiting more than a year has increased during the Government's period in office. In all areas, including cardiac surgery, vascular surgery, ophthalmology, ear, nose and throat and gynaecology, comparing December 1996 with June 2000, the percentage of people waiting more than a year for these necessary procedures has increased.

The Government is very good at claiming successes but it needs to acknowledge the failure. The Minister's Department also needs to acknowledge that whatever is the way to resolve this issue, it has not yet found it. While the Government has invested a great deal of money, it has not received the return on it. The sooner that is addressed, the better. We have validation procedures which clearly make an impact on numbers. How many of those who have been removed from the lists have died because of the length they were waiting? How many went away or sought private treatment?

The Mater hospital now has the longest waiting list in the country. It is a tertiary hospital. I note from newspaper reports that the Mater hospital spokesperson pointed out that 3,000 extra procedures were carried out during the year. How many were carried out on public patients? Are we reaching the people who need care most? When one reads about a case the St. Vincent de Paul highlighted of an elderly woman with gangrene in both feet who was not able to access hospital care until the St. Vincent de Paul came up with enough money to pay for a private bed, there is something fundamentally unfair, wrong and not working within the system.

The Minister has been good at using the media to sell his message, but sometimes the message has been misleading. The winter beds initiative is an example of that. First, the Minister said he was creating 500 beds. Now it is clearly the case that the new beds do not exist. The 500 beds were taken out of the existing pool of nursing homes. I have already had one consultant explain his frustration at moving younger patients out of hospitals into nursing home beds to have hospital beds occupied by elderly people who cannot access nursing home care and who do not need to be in hospital. They are older than the patients he releases.

When we discussed the Estimates and by way of parliamentary questions since then I asked the Minister how many new step-down facilities and beds have been provided. In this regard I will give full marks for consistency in that the Department has been unable to tell me how many new step-down beds were created this year or last year.

Only last week the Minister said the problem was solved.

I receive answers from individual hospitals and health boards because these questions refer to them. It is not that I do not get answers, but I do not get full answers.

It is not the answer to the problem to claim that this is the solution to a real and genuine difficulty within the health service and to claim that 25 accident and emergency consultants are being appointed as if it were part of the winter beds initiative. Everyone wants to see these consultants appointed and I will be the first to give the Minister credit for allowing for that and for providing the money for it. What is underhand is to package it as part of the winter beds initiative. The Minister is now saying the intention was not that they would be in place for January. We no longer need to pretend. When does the Minister think the accident and emergency consultants will be available? Will they be available for next winter? Can the Minister even give that guarantee? We all know how long Comhairle takes in this regard. It would be nice to know when these consultants will be appointed.

We all recognise the need to spend money wisely. I fully appreciate it is not possible to estimate exactly how much money is needed in the GMS. It is clear the cost of drugs is a major factor in increased costs. Is it possible for the Minister to itemise whether there has been an increase in terms of GP costs as opposed to drug costs under the GMS? Since the percentage of the population in the GMS has been steadily decreasing because of the improvement in the economy, it seems the rising costs are related to drugs rather than capitation fees to GPs. I am interested in this as we should be able to provide free GP care and I wonder if the increase can be substantiated.

I welcome the indemnity proposals, though I am not clear about the Department's view in relation to obstetricians and gynaecologists. There are maternity units in private hospitals and it is unsustainable for obstetricians to carry on under the current insurance cover arrangements. Will these units have to close? The Bon Secours was mentioned in the media. The Minister is talking about doctors working within the health board hospitals. Is he talking about voluntary and private hospitals? I presume not. I am glad to see the Department addressing it, but I am concerned about the huge costs which are arising.

Regarding the smart card, I wonder how extensively it is being used among community pharmacists. I am not aware of it in my constituency, but that does not mean it is not present elsewhere. When does the Minister expect the scheme will be country wide? It is good that the drugs payment scheme has been simplified. People are continuing and completing the courses of medication more readily because of the cost management. However, it is important that pharmacists are engaged more directly in ensuring patients continue and complete their courses of medication. It is also important that vaccines such as pneumovax and the flu vaccine are available under this scheme. I do not understand why they are not and perhaps the Minister will comment on this.

I thought the review of bed capacity for the Eastern Regional Health Authority would be finished long before now. As far as I am aware it has not been published, but I would like his view as it has huge implications and will, I hope, contain much information in terms of the future direction of the Department.

Nursing shortages, apart from the provision of £5 million and the various initiatives taken, are a matter of serious concern. When we raised this originally in the joint committee the shortage was about 800: it now stands at 1,388 nurses, which is frightening. Even replacing nurses who are leaving is causing problems.

During the debate on the Estimates the Minister said he was assessing different systems of funding health services and I wonder if any progress has been made in this regard.

The Irish Medicines Board recently banned the contraceptive drug Levonele. The Minister must address this as it is a disgrace that a drug which would prevent crisis pregnancies and help reduce our rate of abortion has been banned. The role of the Minister in terms of the IMB is irrelevant. It is far too important for us to have this ludicrous and hypocritical position where a drug has been banned on the grounds that it is supposedly an abortifacient while another drug is being used as a morning after pill. This drug has been tried and tested, is being used elsewhere and must become available here. Doctors and women are seeking it and the IMB must be held to account.

It is a pity that a project dealing with children at risk is an area in which the Minister has made a saving. The Minister of State has made great play of the fact that all sorts of wonderful things are happening in terms of the care of children, but here a saving is being made because the Minister could not deliver when it came to it.

The first issue I wish to raise is the demand for blood this Christmas. In Dublin hospitals and in Castlebar hospital operations have had to be cancelled due to lack of blood. Leaving aside all the fancy campaigns and PR jobs, what proposals has the Department to encourage people to donate blood? The transfusion board does not seem able to get people to donate blood because of what has happened over recent years. What will the Minister do at this late stage to encourage people to give blood? I made a proposal in the Dáil a number of weeks ago and spoke to the Captain of the Guard about it last week. On any given day there are 700 people in the Oireachtas and I ask the Minister to contact the transfusion board to ask them to attend here on a Tuesday, Wednesday or Thursday, which would give a lead and be good in terms of PR.

I also wish to raise the issue of administration staff in health boards. What is the Minister doing in this regard? According to a recent Sunday newspaper the chief executive of the Western Health Board has a private PR person working with her who is earning about £32,000 per year to provide information, which is not good information. All the information coming from the health board is negative as people cannot get hip or heart operations or any other type of operation. I see the health board is now looking for an assistant PR person.

There is so much bad information to give out, that is the problem.

I suppose that is the problem. What will be done about the administration of the health services?

Is the Deputy a member of the health board?

No, but I wish I was. I know the chief executive likes smiling, having photographs taken and positive PR, but——

I have given the Deputy some latitude.

Deputy Mitchell raised the issue of estimating and forecasting. There is an agreement with the Department of Finance in terms of demand-led schemes and one cannot be precise in terms of forecasting or estimating the eventual outturn. They are ring-fenced from the normal expenditure items or subheads under which one is not meant to go over budget. The subheads concern medical indemnity and the demand-led schemes in particular.

Regarding demand-led schemes - Deputy McManus raised the issue of proportionality between drugs and GP costs - there is a dramatic increase in the cost of prescription drugs. Much of it is due to the emergence of newer and better drugs, such as in the area of cardiovascular treatment etc. Many of the new oncology drugs are equally expensive, and that makes up the bulk of the increase in both the GMS and community drug refund schemes. I do not think costs in this regard can be estimated with any great degree of certainty.

We could have decided not to settle with the junior doctors and to allow a strike to proceed. Dramatic reform was required. I do not think anyone believed that the system which had built up over the years where junior doctors got half the rate after 60 hours was tenable. Settling with the junior doctors was a big budget item, at a cost of £36 million, in terms of the Supplementary Estimate. We were delighted to resolve this issue through negotiation because it represents the first building block in the substantial reform of the entire junior doctor system in regard to training, conditions, overtime rates etc.

In regard to the allied health professionals, we awaited the report of the expert review group which was established two years ago. The original Estimate did not provide for the full implementation of the recommendations simply because the recommendations were not to hand. When I received the report, I immediately went to Cabinet to secure the additional funding required to implement the plan in full. We have had problems historically on the paramedic side and we need to address those urgently. It was very important that we sent out a signal to health professionals that we were serious about the expert review group and its recommendations. A significant number of demand-led schemes, in addition to the extra issues I have mentioned, form the bulk of the Supplementary Estimate.

In regard to areas in which there were savings, reference was made to the springboard initiative. Ring-fenced funding comes to the Department from the Cabinet Sub-committee on Social Inclusion which took a decision to finance the initiative from the outset. Some projects were set up sooner than the budgeted provision allowed and the funding will carry on into next year to run the centres which did not get off the ground for logistical reasons.

The first real health strategy was initiated in 1994 in the form of Shaping a Healthier Future. That is the basis from which the health services and health policy evolved. I decided to review the strategy and to embark on a process to develop a new comprehensive health strategy which will cover the next six to seven years and beyond. The strategy will encompass all the issues identified here, one of the key issues being that of eligibility. Irrespective of what side of the floor Deputies are on, every political party, including Fine Gael, has presided over the system described as apartheid by Deputy Mitchell.

Fine Gael was in office for two and a half of the past 13 years. The Minister is trying to score political points.

I am not. We are determined to produce a comprehensive strategy which will shape the future of our health services over the next decade and which will have a profound impact on their evolution. The strategy will involve a far greater degree of consultation with people on the ground than has happened heretofore. Significant strategic developments have occurred within the Department. The cardiovascular strategy is a good example, as is the national cancer strategy. Substantial funding has been earmarked towards the implementation of these strategies.

The Department does not lack strategic focus. We know where we are going. It is timely to review the 1994 strategy, build on it and address areas which were omitted from that strategy. We will particularly consider the issue of eligibility and the development of a fairer public health system. The key to doing this is to build up the public sector hospital capacity because we do not have sufficient capacity in the system at the moment, either physically or in terms of human resources.

Is the Minister only discovering that in his fourth year in Government?

This is not about who is in Government in any two or three year period. We discovered a very poor plant provision on taking over from the previous Government.

We have statues which have moved quicker than the Government.

Fianna Fáil has been in office for 14 out of 18 years.

We have invested very substantially in health, both on the current and capital side since taking office because, historically, there was a low health base. We have made very significant decisions on building up public sector capacity. The numbers being treated in our hospitals are increasing every year.

Are they being treated privately?

No, publicly.

That is not the feeling on the ground.

It is the fact.

One need only look at the waiting lists to know that is not happening.

Major capital infrastructural projects are under way throughout the country because this Government decided to modernise the health services. The previous Government did not take that decision but we provided the funding for that to happen.

Why did a 15-year-old boy die while he waited to go into hospital?

The Government is spending four times as much this year as——

It is taxpayers' money, not the Minister's money, and we are not getting results from it. If people are rich, they can get treatment but if they do not have money, they cannot. The Minister has lost touch with reality if he cannot see that.

The Deputy has made his point.

I have travelled around the country and visited many hospitals etc. I am fully aware of the scale and volume of investment required in the health services over the next five years. I agree with Deputy McManus that significant additional investment is required although I am not sure the Opposition parties have quantified that. It is essential that we prioritise the areas in which money is spent. The building up of the public sector capacity to treat patients on an ongoing basis must remain a key priority.

The three big killers in Ireland are heart disease, cancer and death or injury from accidents in the home and workplace, and the Government has put in place strategies to address those.

I apologise for interrupting the Minister but I must leave the meeting to attend another engagement. Before I leave I would like to put one question to him. The building up of bed capacity etc. is one way of dealing with the two-tier system but it does not address the reality that patients are treated differently and have different relationships with hospital consultants depending on whether they are public or private patients. Even if the public sector capacity is increased, that problem will not be eliminated. How does the Minister intend to deal withthat?

That is the second issue of eligibility in terms of the two-tier system and it will be addressed in the context of the new health strategy. The Opposition parties have suggested an approach in a discussion document——

I would like to read the Minister's document.

It is all very well to produce a discussion document.

I would genuinely love to read the Minister's proposals although I suspect he does not have any.

I hope the Deputy will not only read them when they are published but will also welcome them.

If the Minister's ideas are better than ours, I will be happy to welcome them.

Reference was made to the fact that one fifth of patients attend hospitals in Dublin. There are two issues in question here. The first is the degree to which some of those patients should be coming to Dublin in the first instance. The ERHA is addressing this issue to some extent. We need to continue to build up capacity in the regions. We feel we are obtaining value for money as we develop the regions in terms of their response rates to waiting lists etc. We will continue to make individual health boards more self-sufficient and that will, I hope, lead to a reduction in pressure and demand on the Dublin hospital system.

Phase 1 of the bed review capacity is completed. I hope phase 2 will be completed by March when the full bed review capacity will be carried out comprehensively. That will be the basis on which we will invest in additional beds in the public sector. I am not sure whether this relates to the issue of another Dublin hospital. A day hospital was also suggested. These issues are currently being reviewed in the context of the bed review capacity.

There are approximately 500 cases of TB per year. There has been no significant increase in the incidence of this disease in recent years.

On fluoridation, as Minister of the day, I can appoint review bodies if I so wish in the execution of my duties.

From the people.

I am entitled as Minister and as a member of the Executive to make a decision.

The Minister is accountable to us. We give him that money on behalf of the taxpayer.

I am not worried about being accountable to anyone.

It has more to do with not sharing the glory with anyone else.

The Deputy did not realise that the forum for fluoridation was established long beforehand.

The Minister advertised for submissions last week.

I did not advertise, the forum advertised.

The Minister authorised the advertisement.

I did not. The Deputy should withdraw that remark. We could have a lot of propaganda about this. As a Government Minister, I reserve the right to appoint authorities and forums to advise me on policy issues.

Under the Constitution, the Minister is responsible to this committee. He is accountable to parliament for the short time he will be a Minister.

(Interruptions.)

I wish to inform Deputy Mitchell that I have the greatest respect for the committee and for parliament, but parliament is not the Executive. The Executive is certainly accountable to the parliament for what it does and the Minister is also accountable to parliament. We established the forum on fluoridation as an indication of our openness to the issue raised by many concerned groups in relation to fluoridation and getting many different perspectives in terms of a comprehensive scientific look at it. That does not take from what this committee is doing, and both can compliment each other. It is a very healthy exercise. To suggest that what I did was an affront to the committee is outrageous.

If the Minister believes he can use that amount of public money, we are giving him too much money. We will have to consider much more closely the amount of money we give him if he squanders it like that.

A major policy document called the National Alcohol Strategy was produced in 1996. I do not know if people wish to go through that exercise again four years later. However, I accept the importance of the issue. The Minister of State with responsibility for the issue of drug abuse, Deputy Eoin Ryan, conducted a nationwide review of the anti-drugs policy. That review clearly indicates that there is great concern about the consumption of alcohol among young people. It is currently a major problem among under-age people. I am very concerned about this issue and a new public awareness campaign on alcohol abuse among young people will be launched in the new year.

A major substance abuse programme called the Walk Tall Project was launched almost two years ago. This has been disseminated to every school and involved considerable inservice training. This is the best route to take to deal with the issue of substance abuse generally and alcohol abuse. We will work with industry in terms of training bar staff and so on and we are running a new awareness campaign. It is timely to consider advertising and its impact. Research has been ongoing on the impact of alcohol advertising on young people. That research is almost complete and this will feed into our proposals on combating alcohol abuse among young people.

The Slone survey was useful in terms of giving us a snapshot of where we are today in relation to alcohol consumption. This does not paint a pretty picture. We are providing resources in this regard.

On the integrated delivery of services, the Government developed a major pilot project involving four areas. The purpose of this was to identify the best model of integration for all statutory agencies in areas of significant socio-economic disadvantage. That project is coming to a conclusion. The Government and health boards in each of the regions participated fully in the integrated services programme. The intention is to roll that out in other urban areas. The model has been well developed in these pilot schemes.

On aids and appliances, this Estimate will provide £1.5 million to be spent up to Christmas in this area. We have already spent £5 million this year on aids and appliances. A further £5 million will be provided next year in the Estimate for aids and appliances. We have made substantial improvements in terms of what was provided for aids and appliances in the past.

People cannot even get an assessment in regional health board areas.

They should be able to organise this because funding is available.

I will raise the issue on the Adjournment Debate.

On the flu vaccine, we have provided 50% more vaccine this year than previous years. This has been distributed throughout the country. The indications are that there has been a significant uptake in the numbers who have availed of the flu vaccine this year as compared to last year. This has been a far more successful campaign. We have not yet received the definitive figures but far more people have availed of the flu vaccine this year.

When they can get it.

Earlier we negotiated a good agreement with the GPs which facilitated the early start up of the campaign. We provided £4 million in the current year arising from the agreement I reached with the general practitioners in terms of their fees for administering influenza and pneumococcal vaccine to general service patients. Some 460,000 doses of vaccine, which is an increase of 50% on that purchased in 1999, have been ordered. Of that, 438,000 vaccines have been distributed so far. We are awaiting the detailed uptake rates. This clearly suggests a significantly higher uptake than in previous years.

On the winter initiative and so on, people asked how many beds have been contracted. There seems to be a lot of cynicism regarding the reaction to that initiative. Approximately 375 of the 500 beds have already been contracted. Given that approximately 12,500 nursing home beds exist in the system, up to this initiative we subvented approximately 7,100 beds. That leaves another 5,500 beds. The initiative simply contracted in a minimum of 500 additional beds - this may be more by March. That is what we said we would do. It would be unrealistic to expect that in two months we could build 500 beds. We never said we would build 500 beds, we said we would contract in 500 beds to alleviate the immediate pressures over the winter period, because in previous winters we had difficulties. Last year approximately 200 beds were contracted in and this year we will contract 500 beds throughout the country.

It is interesting that in the ERHA area, people are saying we are taking from the private sector. In addition to the numbers I mentioned, an additional 300 nursing home beds have either come on stream or are in the process of coming on stream in the ERHA area. Therefore, the impact has been grossly over-stated and exaggerated. We are talking about alleviating the pressure on the acute hospital sector to give opportunities for high dependency patients to move into more appropriate placement and for others to come into the acute beds. Given the pressures on the public hospital system, if we did not take that initiative, mayhem could ensue.

The Minister announced 12 new beds in north Mayo and took them out of the acute hospitals, therefore, there was no gain. That is the PR job.

I was interested to read yesterday that Tony Blair announced a winter crisis before it has even started in the United Kingdom in terms of waiting lists and so on. That is the national health system. We are trying to head off this by intervening in advance.

On the 25 A & E consultants, the Opposition is being very cynical in attacking this proposal. People are now saying I should have had three press releases instead of one. If I had three press releases, I would have been attacked for being a PR maniac.

The Minister should get out of his Mercedes and go to see what it is like on the ground.

If the Minister comes to Mayo we will show him.

A woman with gangrene and bone disease could not get in to be treated.

We are about to appoint 19 accident and emergency consultants and we have sanctioned and provided funding for an additional 25 accident and emergency department consultants, which represents a substantial increase.

In Galway last week a man gave five pints of blood for his operation today but was sent home on Friday last because an anaesthetist was not available to assist at the operation. The patient has been called again for operation on Thursday next. The Minister tells us there is a great health service but I will not listen to him.

Last week a woman died in my constituency and her family had to wait four days for a post mortem examination to be carried out. The reason given was that three bodies had been sent from Mayo to Galway for post mortems. At the time of the woman's death her family was told it was not possible to say when the post mortem examination would be carried out.

Deputy Ring should try to become a member of his local health board. Many people mistakenly believe the Minister is responsible for every action of a health board.

Every morning, noon and night the Minister is heard claiming responsibility for good news, but he does not like bad news.

There will be more good news tomorrow.

They are all PR men. There are more of them outside the door than there are hospital beds.

There has been a greater degree of investment in the health service by this Government than by the previous Government.

This is more PR. Another PR person was appointed by the Government today. I do not know what all the PR is for.

Several points have been raised but clearly members do not wish to hear about increased investment in the health service. I have always acknowledged the difficulties in the health service. I have not described it as a great health service, as Deputy Ring claimed. We are determined to improve the health service and to do the best we can to ensure a better quality health service in the future. We can not cure all the ills of the past. We are affected by many of the shortages which arise from the Celtic tiger economy but we have taken very good measures to resolve those shortages, not least that announced last week to deal with the nursing shortage. The figures quoted by Deputy McManus were for September. We have halved the number of shortages since then. By January we will see a far better picture in the Dublin hospitals due to the registration of nurses from the Philippines, the arrival of nurses from training and a number of other initiatives. We have adopted every measure possible to deal with the nursing shortage and that should be acknowledged.

It is amazing that two members of a cumann, who were 46 years of age, were accepted in Castlebar.

A number of questions have not been answered. If they cannot be answered in the allocated time I ask for written replies. I asked about the number of staff on health boards but the Minister did not refer to that.

I apologise for that. I will get that figure for the Deputy. I did not have the comparative figure for the 1970 staff complement of health boards.

I asked about the 15-year-old boy who died. I thought the Minister would at least have referred to that.

I was interrupted and did not get a chance to answer that question. It seemed that members did not wish to hear any more.

The Minister did not answer my questions about superannuation, the loyalty bonus, nurse recruitment, children at risk projects or increases to cover drug costs.

The question of the 15-year-old child is a specific one to which the Minister can provide a written answer to the Deputy.

I will report to the Deputy on that matter.

Will the Minister deal with the superannuation issue?

I referred to that matter in my speech. It relates to early retirement of people working in the health service.

Does this meet all outstanding superannuation problems for the sector for this year?

I take it we have now completed the consideration of the Supplementary Estimate.

I would be happy for the Minister to write to me with replies to the other questions.

Which ones?

The various questions that have not been answered. The Minister has a battery of people to note questions.

I will go through them all. I can stay until 9 o'clock.

Why have I not received an answer regarding the boy who died? What investigation has taken place?

Is that not a specific question? The Minister should be given an opportunity to get the necessary information and relay it to you, Deputy.

The matter is of such importance that I am sure the Minister has been briefed on it.

I will come back with a comprehensive reply on that issue. We are discussing the items which make up the Supplementary Estimate.

The Minister is implying there is enough in the Supplementary Estimate to solve many of the problems.

We should not assume that all of these issues relate to funding. It will be necessary to investigate the case referred to by the Deputy.

I do not know the reason for that. I asked the Minister a question and gave him an opportunity to reply.

It would be wrong to assume that all of these issues relate to funding. They do not. Some of the things mentioned should not have happened. The lady whose case has been raised by the Society of St. Vincent de Paul is being followed up. A woman in that condition should not be denied access to the public hospital system and I do not accept that there is not enough funding to allow for that. One of the issues raised by Deputy Mitchell is the subject of a parliamentary question.

I do not know whether the problem is one of resources, strategic management or something else. However, we require an explanation. I gave the Minister an oppor-tunity to reply but he did not even refer to the matter.

That is unfair. I had not finished. I understood this meeting was scheduled to last until 9 o'clock.

The Minister asked what questions I had asked.

It is now 8.15 p.m. I am prepared to stay until 9 o'clock to answer any questions the Deputy wishes to ask.

I have asked the Minister to answer my questions. I will stay here as well. I have asked about the 15-year-old, the numbers in the health boards——

I have given an answer to the latter question. We have 80,000 working in the health boards at the moment.

I asked how this compares to 30 years ago——

I do not have the figure for 30 years ago.

——and what the increase in output has been.

I will get that information for the Deputy. What differentiation is the Deputy making in that figure? How does he define administrators?

I said local authorities ran these services 30 years ago.

They did not run these services.

They ran many services.

The Deputy should get real.

Local authorities ran many services. There has been a huge increase in the number of people on health boards. Has the output from health boards been commensurate with the numbers of people employed by them?

We are doing a value for money audit on the health service which will answer many of those questions.

There is no need to do that. The Minister knows the answer. We are not getting value and we are not getting a service. We have too many administrative staff and not enough doctors, nurses, anaesthetists or accident and emergency department consultants.

I am endeavouring to appoint anaesthetists and accident and emergency department consultants. I hear many people complain that we do not have enough of this or that.

We have not.

We will do the job if we are allowed.

The Minister's party has been in Government for 14 of the past 18 years and it still has not done it.

I have answered all of Deputy Mitchell's questions.

I asked about the payments being made to pharmacists. Are those payments late?

Prior to the introduction of electronic transfer of claims, payments were made by the GMS payments board to pharmacists one month in arrears. Electronic transfer has facilitated payment within 14 days of receipt of claims. For example, claims submitted at the end of September will be paid in mid-October.

Loyalty bonuses in relation to year 2000 compliance were paid in all Departments. Their purpose was to retain staff and to give additional bonuses to make sure the health service was Y2K compliant. The system worked effectively although there had been much concern about what might happen.

Will the Minister consider extending it to other health sector workers?

The bonus was a once-off payment in respect of Y2K compliance.

Will the Minister consider extending it to other over-stretched areas in the health sector?

The question is not appropriate.

Why is it not appropriate?

This was a specific bonus paid in relation to Y2K compliance. We will not need Y2K compliance next year.

Will loyalty bonuses be paid to other over-stretched health sector workers?

No. Broader bonuses or allowances are a matter which must be negotiated with the social partners in the context of the social partnership agreement.

What about the Dublin weighting?

That would be considered in the same context. A weighting allowance can only be considered in the context of the social partnership talks. However, some Dublin hospitals are already purchasing houses and accommodation for nursing staff. We are quite flexible with regard to local initiatives agencies may wish to take to retain their staff. We have communicated this to the hospitals, the health boards and the RHA. The issues of pay, conditions and weighting allowances are matters which can only be dealt with in the context of social partnership. The remainder must be dealt with at local level and we can be flexible in that regard.

What about the children in this project?

I dealt with this point. The money is provided under the young people's facilities and services fund, which is administered by the Social Inclusion Committee. That money is spent as the services come into being. It will cover the running costs of units established later than anticipated. It is not a question of a cutback or shortage of funding.

Will the Minister deal with the serious question about blood? Will he also say what is in tomorrow's budget?

Hospitals require approximately 3,000 units of blood every week. Collecting this amount of blood is a challenge at the best of times and it is compounded by the current negative publicity surrounding the IBTS. Under the new safety measures, various categories of people are no longer allowed to donate blood so the donor population is reduced. There was a blood shortage some weeks ago but this has now been overcome.

A new donor clinic has opened in D'Olier Street in Dublin and I hope this convenient location's extended opening hours will encourage more donors to come forward. It is intended to open donor clinics in other areas in the coming year. New collection teams are being set up in Carlow and Ardee to service the south east and north east, respectively.

I have spoken to the chief executive of the IBTS on the Deputy's suggestion about the utilisation of Leinster House. The IBTS had been in touch with Leinster House and my understanding is that the authorities were worried about whether there was room available given the building works.

I am a member of the House committee and will raise the matter at tomorrow's meeting.

It is a good idea of which I am supportive. I think it was done a number of years ago.

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