We have a suggested time-table for today which is included in the papers before Members. This is to assist us in discharging our business. It is not rigid but if we do not follow it we may not have adequate time to discuss some aspects of the Estimates.
Vote 41—Health.
In the event of a Vote on the Order of Business will we adjourn this meeting for the duration Vote or can we continue?
That would depend on the numbers here and how they balance. If numbers balance reasonably well we may continue. If they do not we will have to adjourn.
I am happy to appear before the Committee of the House in this new format. It is something we all talked about and I am glad it has finally been established. The select committee is innovative and I believe will be of benefit to the overall working of the Dáil.
When I was appointed Minister for Health I was determined I would change the image of the Department and the health services. Unfairly, the Department of Health had come to be seen as an agency which appeared to be more concerned with saving money than almost anything else.
The truth is that the Department is and deserves to be seen as a caring organisation, concentrating all its efforts on the delivery of services to people who urgently need them. Since my appointment, I have been impressed more than anything else by the quality of the people who work in the service and by their determination, at every level, to ensure that the delivery of care is their first priority.
It is my aim to ensure that the message of care gets across and that those who need the public health service most will come to know they have a right and an entitlement to the highest possible level of care. To this end, I would like to see a health service in which the resources thereof are utilised in the most effective and cost efficient manner so as to ensure and provide for the health needs of all and to do so in an equitable manner. Access to medical treatment must always be based on the needs and not the resources of any particular patient.
The 1993 provision for the health service clearly indicates the Government's concern that the needs of the health service are accorded the highest priority in the allocation of resources nationally. The 1993 health Vote is over £1,700 million. This figure represents an increase of £183.1 million or 12 per cent over the original net Estimate for 1992. The provision for health represents over one-fifth of all Government spending on supply services this year. The allocation of such a large share of our national resources in the current difficult economic climate cannot but emphasise the importance the Government attaches to the provision of an effective and responsive health service.
I am very happy to say that a total of £8 million —£5 million revenue and £3 million capital — additional funding has been made available in the budget for the development of services for persons with disability. In addition, I have been able to make available from existing resources a further sum of £2 million which has been allocated to mental handicap services. It is proposed that this sum be allocated between services for persons with a mental handicap and physical/sensory disability on the following basis: mental handicap, £8.5 million, £6 million revenue and £2.5 million capital; physical sensory disability, £1.5 million, £1 million revenue and £0.5 million capital. This extra allocation is the largest additional allocation ever made in this area.
I intend to address the shortfall of services in a broad manner to ensure that as many people as possible benefit from the additional funds available. I propose to implement a package of measures which will address the most acute needs for service developments. Additional funds will be made available throughout the country, with particular attention to the health boards with the greatest number of clients without services. This funding will be on top of the additional funding of £6 million made available in 1992 which is being repeated this year.
The Government is determined to develop and expand services for people with mental handicap. The Programme for a Partnership Government includes a commitment to the provision of additional funding to enable the recommendations of the Review Group on Mental Handicap Services —"Needs and Abilities"— to be accelerated.
The number of people with mental handicap has increased by an estimated 25 per cent in the period since 1981. There are probably more adults with mental handicap now than at any previous time in our history. The additional services being provided this year will make a major contribution towards achieving the principle of developing the potential of each person with a mental handicap to live as full and as independent a life as possible. It will provide a firm foundation on which to build in future years but a great deal more remains to be done and there cannot be any reduction in our efforts to improve this service.
The recent interim report from the review group on services for people with physical or sensory disability identifies considerable unmet needs in community and residential services for people with such disability. I am pleased, therefore, to begin the implementation of the interim report.
The additional services which are to be put in place this year will include: the opening of additional independent living residential units together with appropriate support services; the extension of support services to people with disabilities living at home; respite services for families and relatives caring for people with disabilities; additional day care places and extra community-based therapists.
Provision has also been made for the capital investment necessary to support the initiatives being announced and to lay the groundwork for the further development of these services. Priorities include the purchase of hostels in the community and the conversion of existing accommodation to cater for more dependent people.
The European Community has designated 1993 as European Year of Older People and of Solidarity between Generations. The Community has chosen this year to honour its older citizens, to focus on the challenges and opportunities of an ageing Europe and to reinforce links between the generations.
As a mark of support for the objectives of the European Year, I have made £440,000 available to the national co-ordinating committee to fund its programme of promotion and sponsorship of activities to celebrate the year. The committee has sought proposals from organisations at national, regional and local level which plan to organise events to mark the year under three headings: the positive contibution which older people make to our society; all ages working and playing together and meeting the challenges of older age. Funding will be made available to groups wishing to organise activities on the recommendation of the committee.
The Health (Nursing Homes) Act, 1990 creates an important new legal framework for nursing home care in this country. The purpose of the Act is to provide for the registration of voluntary and private nursing homes by health boards and to introduce a new system for the subvention of dependent people in nursing homes.
The Programme for a Partnership Government includes a commitment that provision will be made in the 1993 Estimates to begin the phased implementations of the Health (Nursing Homes) Act. It is my intention to bring the Act into effect as soon as possible. Further discussions have been arranged with nursing home interests for 1 July. I am reasonably confident that these discussions can be completed quickly and that the Act will be implemented immediately thereafter. A provision of £4 million has been made available this year for this purpose.
The provision of dental and orthodontic care for special needs groups, for example, the handicapped and school-children, will continue to be a priority. Towards this end a sum of £2 million is being provided in the 1993 Estimates towards the implementation of the provisions contained in the Programme for a Partnership Government for the development of the dental services. In accordance with this programme, the process to put the necessary framework in place for the introduction of vocational training for dental graduates will commence in December 1993. I envisage that vocational training will, initially, be offered on a voluntary basis to dentists graduating in November 1994.
I propose to extend eligibility to schoolchildren up to age 14 with effect from 1 December 1993 and to extend such eligibility up to 16 years as agreed by the programme for Government. I also intend to keep up the momentum generated over the past few years in relation to the orthodontic services. Consultant orthodontists have now been appointed to six health boards and the remaining boards continue in their efforts to make appointments.
I have also examined the role of dental auxiliaries. A scheme for dental hygienists has been agreed and the grade will be introduced in the health service this year.
The situation about AIDS and HIV in Ireland continues to be a distressing problem both for persons who have contracted the illness and for their families and friends. To date, a total of 341 persons have developed AIDS and, of these, 150 have died. A total of 1,368 persons have tested positive for the virus under the voluntary HIV testing programme and it is estimated that a significantly higher number of persons have actually contracted the virus than is shown in the statistics.
When I was first appointed Minister for Health, I stated that the fight against AIDS would be one of my priorities. I am committed, therefore, not only to have in place programmes and services to treat persons who are infected with the virus but also to implement major initiatives to prevent its further spread.
It is recognised that the main routes of HIV transmission are through sexual intercourse and through sharing needles while abusing intravenous drugs. We must encourage people to behave in ways which will reduce or eliminate this risk. We know the surest way of avoiding sexually transmitted HIV infection is by being faithful to one person who is also faithful to you, assuming that neither person has shared needles while injecting drugs.
However, there are sexually active people who do not adhere to these guidelines for behaviour and we must encourage them to behave responsibly. Quite simply, we have to recognise this and advocate condom use since we know that safer sex practices, including the correct use of a good quality condom, represents the best method of reducing the risk of sexually-transmitted HIV. It was with this in mind that I recently launched the AIDS media campaign.
For many years, it has been recognised that a good quality condom, properly used, is effective. The promotion of the use of condoms and easy access to them are integral and fundamental components of an effective and comprehensive AIDS strategy.
Total funding of £4.4 million is being provided this year in addition to the general funding already provided for the care and management of persons with HIV/AIDS through the mainstream health services. The report of the investigation team which held an inquiry into the Kilkenny abuse case emphasised the urgent need to provide the necessary resources to implement the remaining sections of the Child Care Act, 1991 and, in particular, those parts of the Act which deal with the taking of children into care and which strengthen the powers of health boards, the Garda and the courts in relation to children at risk. The full implementation of the Child Care Act is the single biggest contribution we can make towards promoting the welfare of children and protecting those who are at risk. Nothing less, the report said, would be an adequate response to the terrible suffering experienced in the Kilkenny case and to the report of the investigation team.
I am pleased the Government has agreed to my proposals to implement all the remaining sections of the Child Care Act over a three year period, commencing with those provisions that relate to the protection of children from abuse and neglect. The task of recruiting the key personnel, putting the required arrangements in place, providing training and the myriad of other tasks to be undertaken to implement the Act has already commenced.
I have also been considering how I and my Department should respond to the growing incidence of child abuse. Because of the very much increased workload in this area I have decided to create a Child Care Policy Unit in my Department. This unit will play a key role in the implementation of the Child Care Act nationally, in considering and implementing the recommendations in this report and in developing policy in the whole area of child care and family support services. In addition, I have asked the Health Promotion Unit of my Department to develop a campaign to promote the welfare of children and to educate the public so that they can play a more effective role in this whole area.
The 1993 capital allocation for my Department is almost £44 million. While it has not been possible in present circumstances to provide for substantial extra capital investment, the moneys allocated will enable work to continue on projects at Ardkeen, Sligo, the Rotunda, St. Luke's Hospital, Kilkenny, the Mater laboratory and psychiatric unit and the Coombe OPD.
In addition to maintaining the work on such existing projects, several new projects will commence during this year. In particular, I am pleased to say the tendering process for the new Tallaght Hospital is under way and construction work will commence later in the year. Work will commence later in the year on the provision of additional theatres at Tullamore and on the next phase of Mullingar General Hospital. In addition, important improvement works will continue at Limerick Regional and Limerick Maternity Hospitals. The provision of improved facilities for elderly patients in Cavan, by adaptation of the Lisdarn facilities, is a particular priority.
I am aware of the good work being done by the Department in difficult circumstances in setting priorities and targets for the various sectors of the health services. At the same time, there is, I believe, a need for a clear vision on overall strategy for the development of the services.
A major task for me over the coming year will be to draw upon a comprehensive national health strategy. This strategy will have a clearly stated philosophy and clear and unequivocal objectives and targets including the necessary legislative measures to back them up. This strategy will guide the work of my Department for at least the next four years. My primary task remains the provision of the best possible standard of service for those who depend on the treatment and care provided under my auspices. In framing the 1993 Estimate the Government has made every effort to ensure that both these objectives are met in 1993 and that the current high standard of service is not only maintained but, where necessary, enhanced. The special provisions made in the budget for the health services are concrete evidence of the Government's commitment to the health services and I look forward to a year in which, working together, we will continue to provide services of the highest standard responsive to the needs of all who depend on our health services.
I would like to extend a welcome to the Minister for Health to the Select Committee on Social Affairs to deal with the Health Estimate. I know the Minister, as a former Whip of his party, was anxious, like myself, to engage in a comprehensive scheme of Dáil reform over the past number of years and one of the major planks of such a reform was a committee system of the type towards which we are now moving. I hope that between now and 4 p.m. we can have an in-depth look at spending in the Department of Health.
I would also like to welcome the many officials from the Department of Health who have joined us this morning. We have given power to our committees to call witnesses but I believe the next step for committees such as this one should be to have contributions from officials of the various Departments. I am sure they would be in a position to assist and enlighten us in the course of our deliberations. It is not possible to have a discussion in that format this afternoon but I hope the next step in the scheme of Dáil reform will be to allow for such active participation by officials. I would welcome such a move and I know the officials would also. I believe the format is good and I hope we will have an interesting discussion.
It must be said that there is an almost infinite amount of cash sought for the health services. No matter what increases are allocated, some groups will feel left out and disadvantaged and discriminated against. Health care must be looked at in the context of it being a fundamental human right. A nation that cannot look after its sick and infirm does not deserve to be classed among the civilised communities of the world.
The increases announced by the Minister are all welcome but the reality remains that the present Administration and the Labour Minister have failed miserably to deliver on specific undertakings that won so many seats for The Labour Party and contributed to the formation of the Government. In addition, no real effort has been made to reverse the trend of savage cuts in health care introduced since 1987 and which have continued on an annual basis since then. I will prove my point by pointing to the many hospitals that were closed in 1987 and thereafter, none of which have reopened. Wards and beds that were taken out of use in the late 1970s at an unprecedented level have not reopened or been put into use in the past 12 months or less.
It was sad to hear the Minister recently, in replying to a parliamentary question, justify ward closures by saying that such summer closures are now a fact of life and must be taken as the norm. They have become a fact of life only in recent years. The reason for summer closures was to allow for holidays in the hospitals, and summer holidays for many decades were the first two weeks of August. We are now using the concept of summer holidays to justify massive bed closures from early June until early September. We cannot justify that by saying it is the norm.
The Minister prides himself on health expenditure reaching 7 per cent of GDP but this is less than the percentage in 1986. On the basis that the average figure for OECD countries is 8 per cent, we still have some distance to go. The Department of Health is very much dictated to by the Minister for Finance. Planning for the most efficient use of this massive budget is essential especially when one considers our population structure with particular emphasis on the growing proportion of older people in the community. By the year 2001, which is not that far away, there will be an increase in the middle-age groups and an increase in those over the age of 65 years by figures in excess of 10,000. Most of these people will be dependent on the State. That is an indication of the challenge that faces us as a society with particular regard to the need to improve services in the health care area having regard to the population structure.
The Minister in his speech referred to the European Year of Older People but we have paid no more than lip-service to that because we have failed to implement improvements in our community care service along the lines recommended in the report, "The Years Ahead".
Adequate numbers of district nurses should be available, if only on a part-time basis, under the guidance of public health nurses, to allow for the provision of nursing care similar to that available in our hospitals. The main difficulties being experienced by elderly people in our community are the lack of a comprehensive dental programme for older people and the lack of a comprehensive physiotherapy, chiropody or home nursing programme. The provision of £440,000 is not very large when one looks at the overall health budget.
With particular reference to the European Year of Older People, I am very concerned about the draft nursing home regulations. The apparent inflexibility on the part of the Minister must be worrying. We had a solemn commitment that the Nursing Home Act would be implemented by 1 May 1993 but we now have a deferral with no indication of any flexibility on the part of the Minister. The elaborate and unfair system of means testing as provided in the draft will ensure that those paying huge weekly sums to provide for an elderly relative will not really benefit and suggestions of means testing sons and daughters, many of whom may have lost contact with the applicants, will ensure that the scheme will be unnecessarily bureaucratic and health boards will have the lawful excuse, that we so often hear from the Department of Social Welfare, insufficient information available. I hope that clause will not be used by the Department of Health to minimise subventions towards nursing home care.
It is regrettable that not only the income but the full circumstances of the applicant and his or her family will be subject to a detailed examination. The people who will lose out are those people on moderate incomes, the same people targeted by the Minister in the recent health care increase; the same people subjected to the 1 per cent levy; the same people whose estates will be caught by the probate tax. The £4 million allocated for the nursing homes is totally inadequate when one considers that it represents a mere £2.50 per patient as against the average daily cost of £40 per patient per day. It is significant to note the recent report of the Ombudsman where he comments on an increasing number of complaints and queries about the absence of long term care arrangements and the shortage of long-stay beds, which matters are presenting many problems for older people throughout the country.
I ask the Minister to clarify the legal position of responsibility of health boards in the provision of appropriate in-house services to patients in need of nursing care following their treatment in acute hospitals. Some hospitals are not being forthright with information to relatives. This gives rise to anxiety and uncertainty much of which is due to a lack of communication. Health boards and hospitals are deliberately withholding information from patients in the hope that they will be in a position to provide the necessary care from their own means.
Much has been said of the £20 million special waiting list fund. I welcome the allocation, as I have said in the Dáil. However, the sum must be set against the background of the stark reality that over 1 per cent of the population of this State is on public hospital waiting lists for some form of treatment. There are at present over 36,000 people awaiting treatment many of whom have been suffering for several years. The crack plan of action on the list will not succeed as long as the summer ward closures proceed unchecked.
Throughout the country elaborate arrangements are being set in place to postpone non-elective surgery for summer months to allow theatres to be used for those on waiting lists. This will merely have the effect of shaking up the waiting list and juggling the numbers around rather than tackling the problem in a planned and comprehensive manner. Waiting lists are a direct result of cutbacks in the Department over the past six years. Surely the main reason for such lists are the shortage of staff to perform operations, lack of beds and lack of theatre facilities.
The extent of the problem is reflected in area of cardiac surgery where in 1988, in the teeth of the O'Hanlon cutbacks, 111 people were awaiting treatment but in the early summer of 1993, as we speak the waiting list numbers 1,330. While the Minister accepts the need to prioritise cardiac surgery, he must also accept that in excess of £10 million is needed to deal with this area of suffering alone. I hope we will receive clarification from the Minister today on the matter of the new theatres being made available for cardiac surgery, the second one in the Mater and the new unit in St. James's Hospital. I would like to know the present position in those cases.
The two-tier nature of our health service is seen in the heart surgery area where last year proportionately more operations were performed in the private than in the public health sector in spite of there being 33 per cent more public patients waiting. In order to achieve equity between the public and private sectors, significant investment is necessary to provide beds, theatres, nurses and heart surgeons. There are five cardiac surgeons in this country for 3.5 million people. Holland, with a population of 14 million people and with a lower incidence of heart disease than Ireland, has 67 heart surgeons. There is a gross inequity between the private and public sectors, the lack of public beds has meant that people awaiting surgery did not live to reach the table. Assurances must be given that there will be a greater turnover of patients on a permanent basis. I am concerned that the waiting list crack plan of action will merely juggle the figures and at the end the waiting lists will remain.
I hope the Minister will avail of the opportunity in his speech today to outline his views on staffing at consultant level in our hospitals. There is a need for a more balanced staffing arrangement between consultants and non-consultant hospital doctors. At present there are 1,100 consultants and 2,200 non-consultant hospital doctors. I understand the contents of a recent report placed on the desk of the Minister recommends an increase in consultants of the order of 40 per cent, with a consequent reduction of non-consultant staff of almost 30 per cent. Criticism of an imbalance between consultants and non-consultants is well founded and I would have thought that, in the context of the waiting list, new appointments would have formed an essential ingredient. On that, we must look at the next step and ask, if the Minister decides to proceed by way of appointment to the figure recommended what effect will that have on our medical schools and on the work that is part of the training of our junior hospital doctors?
Recently, we had an opportunity of discussing the plight of people with a mental handicap and the Minister's response at that time was a grave disappointment to the 3,000 people who are without a proper level of service. As we look at the spending Estimates, it is a source of anger to note that the widely respected report "Needs and Abilities" and the recommendation contained therein have not been implemented. Neither have the similar solemn commitments in the Programme for Economic and Social Progress nor, most shamefully of all, those contained in an election manifesto entitled “Trust in Politics”, about which I am sure the Minister needs no reminding or advice. There is no reference to the £25 million promised in our briefing material for today. What kind of supplementary Estimate may we expect between now and the end of the year?
There is need for almost 1,300 residential places and a further 1,200 day care places as a matter of extreme urgency. Parents, themselves growing older, are fearful of falling ill or becoming unable to care for a handicapped son or daughter.
In the area of the physically handicapped, the picture is equally bleak and depressing. There is no coherent policy to look after the needs of persons with disability. Policy development has been hampered by huge gaps in basic information about the nature and extent of disability within our community. Without the tremendous work of the voluntary agencies services in many parts of the country would be nil. The disabled suffer from a lack of services from the cradle to the grave.
I believe roles have somewhat shifted in the past few months with the change of Administration and I would like to welcome warmly the appointment of a Minister with special responsibility for equality. There may perhaps be demarcation difficulties in so far as the role of the Minster of Equality in the area of the physically disabled is concerned. Looking at that Minister's overall budget, I do not believe that those with a physical handicap can expect any monetary contribution. Many voluntary agencies receive absolutely no funding whatever from the Department of Health. That is regrettable, particularly given the ever-increasing amount of national lottery funds at the disposal of Government.
We must also look at the availability of services in the area of genetic counselling. I welcome the fact that at last a comprehensive genetic counselling service is beginning to appear and I welcome a recent grant allocation by the Minister for Health in this regard. A comprehensive service could help significantly reduce the 1,600 babies born annually with a major handicap.
Families are unable to cope with caring in the home for handicapped children due to high cost. The estimated economic cost of home care in respect of a person with a moderate handicap is £160 per week, rising to £240 if the child is severely handicapped, while the care allowance for a disabled child is a mere £20 per week. An appalling gap exists. It is one which underlines the abandonment of the physically disabled in our community. Health boards provide a varying degree of speech therapy, physiotherapy and nursing services but it is haphazard and in many areas the service is particularly poor with respite care non-existent.
Employment for those with a disability is another problem. It is one that perhaps may now be the preserve of the Minister for Equality and Law Reform, Deputy Taylor. It is worth while looking at the targets that were set in the Programme for Economic and Social Progress.Quotas of 3 per cent were set with solemn commitments by all concerned that this quota would be honoured. A recent survey in County Clare shows we should have 200 people employed in the public service under the disabled scheme but we have a mere eight. The national trend is somewhat different.
Irish nursing staff are renowned throughout the world for the quality of care they give but the nursing profession in this country can no longer be regarded as a profession. Thousands of our nursing staff have emigrated over recent years, most because of the very poor conditions here in terms of work and in terms of time allocations. Most of our nursing staff are employed on a nearly permanent temporary basis with little in terms of a career opportunity.
I welcome the Minister's response to the AIDS crisis. The re-appointment of the National AIDS co-ordinator must now be the next step because a considerable amount of work remains to be done.
More than anything else what is required in the health area is long term planning as well as structural reform. Successive Ministers have failed miserably to provide for a caring and efficient level of health care. Much more needs to be done and I hope that between now and 4 o'clock we will have an opportunity of teasing out what should be the priorities in the area of health policy, as well as perhaps offering some scrutiny on the various Estimates.
I welcome the Minister for Health. I look forward to going through the details of the Estimate for this huge spending Department and the committee format is a very useful way to do this.
The Health Vote is a big spender right around the world in many countries and we are no exception. The huge cost of quality health service is self-evident given the size of this Vote but I do not think any country, including ours, can afford to cope with demands and problems in the area of health by simply spending more money. Individual demands for health care are virtually boundless and I think the Minister must constantly look to the collective good rather than the insatiable needs of individuals. The health area, as I have found since I took on this work, is riddled with vested interests. No matter where one goes to look objectively at the economics of health care, one never really gets a clear and objective view. This Committee will be useful in terms of thrashing out policies for the future in that, perhaps here, a healthy debate can take place on the economics of health care.
Cost containment measures will have to be built in to our health care planning policy and limits will have to be set to the costs of health care. The guiding principle the Minister should hold before him all the time is the primary objective of any health care system. I read a speech by Professor David Kennedy delivered at the third annual public Mulcahy lecture and I found his views are very closely allied with my own. He said that if we believe the principal objectives of our health care system should be to enable as many of our citizens as possible to reach their full life span and to improve the quality of life of the elderly and incapacitated, then it is questionable whether we are allocating our resources correctly. There is little international evidence to suggest that life expectation is improved by increasing expenditure on health care. He went on to say the majority of premature deaths under the age of 85 years in Ireland are caused by disease such as coronary heart disease, cancer, respiratory illnesses and accidents, the causes of which are understandably preventable.
The mortality rates for coronary disease in Ireland have been declining since 1964 but our record is not great. With the United Kingdom we still have the highest death rate from these diseases in the western world. This suggests that reallocating resources from treatment to prevention and the promotion of healthy life styles might help to increase the life expectation of many citizens.
As I said, throwing money at the health service, which is a bottomless pit in terms of what it wants, is not the answer. The USA spends over 12 per cent of its national income on health, almost double the share of income that we and many of our European partners spend on health and yet, during the recent presidential election there was huge concern and much disquiet about the level of health care, with upwards of 35 million people lacking adequate access to any medical care whatsoever. No matter how difficult or painful it is to take on board, we must face the fact that in health, as in many other aspects of State activity, there must be some rationing or restriction placed on the availability of services. Everybody cannot have a doctor living next door or a hospital just around the corner and we have to make the best use of whatever money is available. From that point of view, we must continually review and update the way in which we provide our services.
Recent OECD studies point to the trend for more managed markets, with doctors and hospitals competing to provide publicly funded or insurance funded services. Perhaps we can learn from some of our European partners and ensure a more efficient use of scarce resources. As a member of a party which has continually emphasised the need for competition right through the economy, we must have an open mind on introducing some aspects of competition.
It is important that these points are raised at a committee debate like this because this is a newly appointed Minister and he has indicated a willingness to look at innovative approaches to the way we spend this huge amount of money. We all know that it is not possible to have spending rising at a faster rate than our overall income for any prolonged period. For example, there is a tendency to demand ever increasing hi-technology facilities in our hospitals. This needs to be questioned. Perhaps it may be possible in the long term to achieve a broad social consensus on setting limits to how much each person can reasonably expect to receive, given the common good, not only in spending on health but in respect of other demands made on the State for education, welfare, housing and so on.
There is a healthy debate in the United States about rationing policies and how they might result in inequalities on the basis of ability to pay and that poor people might suffer. Perhaps we could broaden the wider availability of services but put a cap on what could be availed of. We have a hang-up about hi-technology and there must be a move back to ploughing resources into primary care and generally having a realistic approach to spending.
I do not know whether anybody has heard about the experience in the United States where in Oregon they enacted a law in 1989 called the Basic Health Services Act. They were trying to broaden the eligibility for medical care to 100,000 more people but at the same time putting a cap on the sort of services that everybody could avail of. They divided the categories into essential services, very important services and services important to certain individuals. For example, in vitro fertilisation, which is very expensive but which is only relevant to a small number of people, was ranked on a lesser criterion than more essential services which are applicable to everybody. The plan has not been implemented but it is seen as setting a precedent for introducing more equity into the system in the long term.
Our medical card system may well be an institution which needs to be broadened. Many low to middle income families just barely lose out on eligibility for a medical card and perhaps we could introduce some tapering of means so that those people who are just over the limit for eligibility for a medical card could be included, with the introduction of a broader capping of the general services available to everybody. That is something we can debate at a later stage.
Given a debate on the spiralling cost of health and a forthright approach based on pragamatism and the common good, I think we could stimulate a change in expectation leading to a questioning by Irish people about the level of health, disease prevention and care and indeed the whole process of dying. Maybe people will accept that we have to set limits on what can be done given our resources. In the United States it has been called "a recognition of a duty to die cheaply" but I do not think that would be acceptable here. There must be change. Very expensive technology is used to try to prolong life. We must accept the inevitability of death and concentrate on the health of people when they are living and not try to put off death.
The number of elderly people in our population is set to grow significantly. The National Council for the Aged has estimated that the number of people over 65 years in the Eastern Health board area will increase by almost 31 per cent between 1981 and 2006. In the case of Dublin county, the number of those aged over 75 years is expected to double in that period. The Minister is aware of these statistics and of the need for us to focus on a changed style of treatment and services for elderly people. The best possible care for elderly people may well be low-technological and community-based services. The Dublin hospital initiative group looked at this when trying to seek ways to reduce pressure on acute hospital beds and it became clear that the elderly accounted for a very substantial proportion of the demand placed on the system with those aged over 65 years comprising more than 25 per cent of admissions and over 40 per cent of bed days, although constituting only 11 per cent of the population. Inappropriate admissions of elderly people to acute hospital beds must be tackled.
That brings us on to the nursing homes legislation. I repeat the call for the Minister to implement regulations under the nursing homes Act. Many nursing homes find it impossible to organise their budgets for the year. The implementation of the regulations has been promised since May.
The Minister promised a national plan for women's health and I would like a progress report on that — where is it; what does it mean etc. Women's health has been seriously underfunded for many years and in particular women's mental health is on the decline. I am not surprised given that they have the primary burden of caring for everybody in the world, including their husbands, children, elderly parents and handicapped children. At last there is a growing acceptance that this can no longer be ignored and that the whole system of caring for carers has to be improved. I take on board the fact that the Minister for Social Welfare has moved to improve services for carers.
Many women in Ireland believe that maternity services have been diminished over the years. There is an ever-diminishing time that one is welcome in hospital after the birth of a baby. If women acquiesce to a diminishing postnatal care service, particularly since there is no follow-up community care at home, we will be presented with a roll-on, roll-off maternity service with babies being delivered in out-patient facilities.
When we are talking about womens' mental health, a problem which is of ongoing concern to the medical profession and to many women is the unresolved matter of the guidelines on abortion issued by the Medical Council. The Government gave a commitment to introduce legislation to give effect to the decision of the Supreme Court in the X case, including the three referenda. The Medical Council refuse either publicly or privately to clarify what they mean in their statement on the abortion guidelines. The second statement further confused the first confusing statement and it is very important that we know exactly what the Medical Council means. It is very important from the point of view of practitioners themselves, the Medical Defence Union and the Medical Protection Society who insure doctors against malpractice suits. They are equally concerned at the continuing fog on this subject. The possibility that even one woman's life would be put in danger through this confusion is intolerable and I call on the Medical Council to clarify what they mean. They said that "while the necessity for abortion to preserve the life or health of the sick mother remains to be proved, it is unethical always to withhold treatment beneficial to a pregnant woman by reason of a pregnancy". The first clause voices a clear doubt that there could ever be such a qualifying threat and substantially diminishes the strength of the second clause which is fine in itself. I wonder what sort of proof the Medical Council needs? Is it women's dead bodies? The proof is what we should not want to find. It is important and I know the Minister is concerned about this continuing confusion.
I am delighted that the Minister has promised more resources for child care. What has happened since the Kilkenny case? It is easy to say that we are committed to a phased implementation but every day is the same as yesterday. The inadequate services that were there when we had the Kilkenny incest case report ane still there and there are women and children in a dangerous situation. We have not the luxury of waiting and I would like to know what the Minister has done in the intervening months. Has any social worker been recruited?
I know the Minister agrees that there is need for refuges to protect women and to give security for women fleeing domestic violence. There is a social consensus that there is a need for refuges. At last Monday's city council meeting there was a strong attempt to block the building of the first ever purpose-built refuge on the north side of Dublin. Dublin Corporation was disposing of a piece of land to Aoibhneas to build a refuge and the four local councillors tabled a motion to stop this on the grounds that it was in some way detrimental to the residential environment. This was the first attempt to build a refuge and instead of giving leadership to the community, local politicians tried to block it. I am sorry to say that the Fianna Fáil group of the city council supported this block. It is a very serious precedent. Fortunately the rest of the council managed to achieve the disposal of the property.
There is a lot of hand wringing and concern about women's refuges and the safety of women but if that precedent had been set at last Monday's city council meeting a refuge would never have been built because it would have been accepted that it is in some way detrimental to the environment to have a refuge in a community. The refuge was to house ten families. Those who tried to block that are Members of this House. One of them is a member of the Joint Oireachtas Committee on Women's Rights. We must exercise leadership in the provision of all these services and it set a very bad example.
I welcome the Minister. I listened very carefully to his speech. I felt it was indicative of something that the first statement he made related to image and also that he failed to mention, towards the end of his speech, the matter of "strict control of the public finances and prudent management of the economy will continue to form key elements of the Government's approach to public policy". If I have a criticism of his officership I think there is a tendency for him to concentrate on the optics rather than the substance of his job.
I welcome the fact that he has initiated a national health strategy. It is something that my party put forward and now that he has decided to do this I would like to ensure that he establishes an effective one. If a strategy such as this is to be effective it must not be a cost cutting exercise but must target, people who have abnormally high incidences of life-threatening diseases and illnesses.
We all know about the link between deprivation and illnesses. That is something the Minister must redirect services towards if any strategy is to be effective. Clearly it is a matter of political will. It is not a question of scarce resources. At the moment, resources are directed towards the financially healthy. If one books into the Blackrock clinic one is subvented by the taxpayer but if one is poor and sick one has to battle it out as best one can through the system.
A simple but significant step forward would have been to institute common waiting lists for public and private patients. That was recommended by the commission on health spending as far back as 1989. The Minister did not mention the £20 million he allocated for waiting lists — there has been a lot of publicity about that.
I note that he was careful not to mention that while he was giving with one hand he was taking away with the other. In the Estimates there is an £8 million cutback in the non-pay element of the allocation to voluntry hospitals. That is a critical element when one considers that the pay costs are essentially locked into pay agreements.
In relation to the £5 million allocated to commence implementation of the Child Care Act, I have not heard the Minister comment on the total collapse of the out-of-hours service for homeless children in Dublin. I would be interested to hear whether the bulk of that £5 million is going towards the education and public information programmes he mentioned. If the resources and the services are not in place, what he will do is encourage children to tackle their experience of child abuse and that is the danger that existing services find: they are raising expectations without being able to provide for their resolution and that is more dangerous than anything else.
My advice to any child who is being abused and wants to escape from that abuse is to make sure they do it during office hours because if they do it out of hours in Dublin they will have no place to go except into a Garda cell. That is not the way to deal with child abuse.
There is no mention in the Estimates of run down, poorly equipped health centres. My own health centre in Bray is a classic example. It is run down, Dickensian, substandard, dingy, and lousy, though not in the strict sense. I invite the Minister to come and see for himself what I am talking about. I note that the capital programme is slightly down and if the Tallaght hospital is to be built and £1 million provided for the dental services it is all very welcome but I wonder what will happen to the humble health centre like the one I am talking about which has been top of the priority list in the Eastern Health Board for as long as I remember. It does not mean anything happens and it certainly does not mean it gets built.
Regarding expenditure on hospitals, it was estimated at the beginning of the year that a 10 per cent increase would be necessary just to keep the services going. An increase of 14 or 15 per cent would be needed to make any real impact, according to the hospitals. An allocation of only 7 per cent over last year is a figure which speaks for itself. In relation to this cutback in the non-pay element, I would like to know how you cut waiting lists in hospitals if you are actually making cutbacks at the same time? Is it a case that we are to have waiting lists reduced in certain areas and expanding in other areas? Is that what will be taking place before the end of the year? I suspect it is. The hospitals are already drawing up lists of bed closures for the summer. The Minister has been very good at presenting the photo opportunity but maybe not so good at presenting the facts. A most disturbing feature of these Estimates is not in the high cost in difficult areas like hospitals but in the cost beneficial areas that do not require huge investment but do bring a considerable return in health terms.
In Britain research was carried out among doctors, managers and the public to find out what they all thought should be the top priority in health care. They all came up with the same answer which was childhood immunization. This is not mentioned in the Minister's report and I am not surprised. The Minister is responsible for an immunization programme that is a shambles, a disgrace. I have raised this matter with him before by way of parliamentary question. I thought his response would shake the complacency a little bit. I would like to point out to him the reality of the primary immunization programme. A recent survey carried out in Dublin, in community care area 3 of the Eastern Health Board showed the general uptake at 57.4 per cent. For the pertussis vaccine it was as low as 45.7 per cent. The Minister may be interested to know that the primary immunization rate in community care area 3 of the Eastern Health Board is lower than the primary immunization rate in Bangladesh. This has to be sorted out. The Department is not doing the business when it comes to looking after the children. In one of Asia's most densely populated, poorest and most disaster prone countries they have managed to achieve a 62 per cent immunization rate. In this highly developed, technologically advanced city of Dublin, with a well educated population, we have miserable figures. Even for MMR, where there is a reporting system and where we know what we are talking about, the figures are miserable. Only in the two most affluent areas of the city do we exceed the 80 per cent target that has been set for underdeveloped countries and many of them have already passed that and are going on to a 90 per cent target. If we do not reach the target of at least 90 per cent we will not deal with the infectious diseases.
Children who are vaccinated are at risk at the moment and are contacting measles and whooping cough because the level of immunization is so low. In Britain doctors do not get paid unless they hit the 90 per cent immunization target and in the States I understand a child cannot start school without having all his or her injections. Here in Dublin we are seeing children not even attaining third world standards of immunization. Measles is on the increase in Dublin and Temple Street Hospital is overcrowded with cases of children with complications of measles. Nobody knows for certain about the pertussis figures because the reporting system is so unsatisfactory. What has happened is that the media stories about individual, very isolated cases of damage from vaccination have led the whole campaign on this account. We have not had the clear articulated message from the Department on a long-term basis. We have had Ministers in the past who have gone in for the photo opportunity and then disappeared. I am not talking about this Minister but other Ministers. The whole programme has sunk as a consequence. We need to have a proper programme set up that reports back and in which responsibilities are laid down. There must be a programme of education so that every child is guaranteed the right to immunization. The cost benefit over a certain period can be shown to be up to 10 to 1 because it means saving on hospitals, mental handicap, GP services, antibiotics and all the things the Minister says he is trying to do. It would be money well spent but it needs to be done now. It is extraordinary that in a highly developed, modern society like Ireland its capital city is seeing an increase in measles. People should not under-estimate the seriousness of a condition such as measles. The same type of lack lustre approach is being taken to health promotion. Again the returns are immensely good. If we are trying to save money we should be preventing people from getting ill. In the Estimates the figures are marginally down, if you take inflation into account, on health promotion. The commission on health spending recommended in 1989 that there should be a strengthening of health promotion and sickness prevention. At that time there was approximately £1 million being spent on health education. We have a very similar figure four years later. The message which has been spelt out by many doctors and medical people, that we need to target sickness prevention and health promotion programmes, has not been seen as sufficiently important and I believe it is crucial to any future health plan.
I am very curious about the long-term illness scheme and the drug subsidisation scheme which show no increase this year. I understand from the Estimates that the Department do not think that anybody extra will go on this scheme. I note that in the GMS they are providing for a 7 per cent increase but no increase in drug prices for these two schemes. Why is that? Are we not living longer? Does it mean that there will not be diabetics or epileptics? What kind of thinking has worked out on that we do not need any increase? When you take inflation into account you are talking, in real terms, of a decrease in the allocations. I suspect that there are to be changes in these schemes and they probably will not ve announced until we go into recess. I recall in the dim and distant past another Labour Minister adopting this approach and maybe this is why I am suspicious. Certainly in the past there were changes proposed in these schemes during a Dáil recess by, I think, Eileen Desmond.
This Labour Minister hiked up hospital charges and astonished many of his supporters who had not quite expected this kind of change. They were looking for something else but this is what they got. Even that approach is proving problematic. St. James's Hospital, for example, has done an estimation and already they reckon that they are 50 per cent down on the money they should be getting under hospital charges. The Minister has hiked up the charges but the people are not paying. How will hospitals resolve that shortfall if they are to be dependent on that income? I do not think a hospital can sustain that kind of loss indefinitely.
At the end of the day the question that has to be asked about these Estimates is whether they target those most in need, whether they signal a new approach that emphasises prevention. I do not see evidence of either. What we have is a mishmash approach, tucking in here, letting out there, responding to pressure here and ignoring needs there. If there is to be a genuine attempt at a national health strategy it will need political determination and a clarity of vision which is singularly lacking from what we have before us today.
Now we proceed to Vote 41. As we are 15 minutes behind our suggested timetable, I suggest that we discuss Subhead A in total. Is that agreed?
Salaries, wages and allowances — I take it that covers the salaries of the health promotion unit?
Yes.
Could we use this opportunity then to look at this area? There are genuine and widespread concerns there. It appears that there is either a substantial loss or a loss of some sort in the allocation to the health promotion area. All of us, on all sides of the House, would say this is an area that should not be cut. I was very concerned when the Health Education Bureau was dropped and the health promotion unit took its place. We were assured it would be better funded and more aggressive. I would like to be reassured by the Minister on the nature of the work being done by the unit and the planned development of the unit. I hope the Minister can allay some of our concerns.
In relation to Subhead A.1 — Salaries, Wages and Allowances — the Minister will recall that he introduced a very controversial proposal, the bringing in of advisers, programme managers and other people to help him run his Department from outside the remit and outside the scope of the public service. May I ask the Minister whether, the wages, allowances and expenses of the programme manager, the adviser and any other additional staff brought in are included under this subhead? What are the rates of pay and expenses in respect of each of the appointees? How would the Minister evaluate the impact, at this stage, of those additional people from outside the public service. How has it, for example, improved the quality of the service as and from the days of Dr. O'Hanlon, who relied strictly on the advice of the Civil Service? We notice that the Minister has around him a coterie of very welcome gentlemen — all gentlemen, not a single lady. May I ask the Minister if it is really necessary to bring in outside advice? Has it impacted or is the improvement perceptible at this stage as distinct from taking advice from the kind of people who have surrounded and accompanied the Minister here today?
I am concerned at the level of expenditure on administation in the health service. It is an issue with which I have been trying to deal over a number of years. I thought the Minister, due to the length of time he had in Opposition as spokesman on health for his party, would at least have some ideas on curbing the levels of administration. I thought, when the Minister was appointed, that he would come in immediately with a national health strategy because he had some great ideas when he was in Opposition but we are still awaiting a strategy. What we have at present is a "make it up as you go along" kind of health plan. It is very disjointed. Many of the decisions being made have more to do with political considerations than health needs. I would like the Minister to let us know when we can expect an overall national health strategy. We have had all the plans done in the Eastern Health Board area and in the Southern Health Board area. What are the Minister's views now, in Government, in relation to the health board structure? Does he intend at this stage to abolish the health boards and put in some other structure or does he intend to amalgamate some health boards? It all comes into the whole burden of administrative costs and should be dealt with under that heading.
Under Subhead A.4 — Telephones and Telex — I note a projected decrease in the expenditure on telephone charges in 1993. With the recently announced increases am I to take it that we will have severe cutbacks in the usage of telephones in the Department of Health or what allowance does the Minister intend to make for the increases in charges which are due from next September?
There is a 20 per cent increase on Subhead A.7 — Consultancy Services. Could the Minister tell me what is the value for money initiative?
I would welcome the opportunity to expand on this. It is appropriate to deal with the health promotion unit under this subhead if the committee is agreeable. I will give my reaction to the questions posed by Deputy Flaherty. I regard the whole issue of health promotion as very important. I have said that I want to change the image of the Department from being a Department of sickness to being a Department of Health. I am anxious that there should be a national strategy that would have, as an integral component, the whole notion of health promotion and analysis of the health of the nation in terms of the wellbeing of the people at every level. That involves a whole range of other issues that need to be addressed. That is ongoing now as part of the preparation for the national strategy. If I may just reply to Deputy Allen, I did not come into the Department with an instant strategy under my oxter. I do not think that would be appropriate; I do not think that anybody would expect it. I have to understand the workings of a Department as complex and as multifaceted as the Department of Health. However keen one can be in Opposition one cannot fully understand it until one has access to all the information that is available in the Department itself. Nobody would have thanked me for having instant solutions to add to water and stir the minute I walked into the Department of Health. There will be a national strategy by the end of this year and people are working very hard on it currently within my Department.
I will give some outline in relation to the specifics on the health promotion unit for this year. There is, as one can see from the Estimate, £1.08 million available under Subhead H of the Estimates for the health promotion unit. A further £500,000 has ben made available to me from the proceeds of the national lottery for health promotion. That is the total sum I have now. The expenditure to date has been on the most effective anti-tobacco campaign ever launched by the health promotion unit in the Department. There are two tranches, the first one began on Ash Wednesday which is National No Smoking Day and the other to coincide with World No Tobacco Day on 1 May. The total expenditure on both promotions, including the free telephone lines, writing to every GP and giving him a pack and contacting the schools is £300,000.
The second important campaign organised this year under the health promotion unit was the Aids prevention campaign. This campaign was launched to coincide with Irish National Aids Day on 29 May. I will not go into the detail of it because there was a great deal of focus on it and some minor difficulties were experienced in getting it broadcast. I am very pleased with the feedback analysis we have done in relation to that. The total cost of that project for the year, including the repeats to coincide with World Aids Day, will be £250,000. We had a national healthy eating week which is very important in terms of focusing on the diet of the people of the nation. That took place between 28 March and 3 April. It was an intensive programme which included public lectures, cookery demonstrations, school based initiatives and many media based activities including RTE and local radio stations programmes on diet and health. The total cost of that was £100,000. Other issues dealt with by the health promotion unit this year include dissemination of health related materials at a cost of £200,000 approximately; support of the Chair of health promotions in UCG at a cost of £50,000 and liaising with the Department of Education on health initiatives, including a substance abuse prevention programme at second level, which is very important. The substance abuse programme will cost about £50,000. My contribution to the child abuse prevention programme in primary schools will be £35,000. It has obviously been matched by the Department of Education. The health promoting school network will cost £20,000. The "Health is Looking Good" message competition which, again involves school children will cost £55,000.
There is a range of other products, I will mention the main ones. The drink awareness for youth programme will cost £30,000, the pilot project on alcohol and drug education for parents, £20,000. I have continued the convenience AIDS advertising. I mentioned it in response to a parliamentary question by Deputy McManus who came across them in public conveniences. The cost of that is £65,000 annually. Support of various voluntary organisations involved in health promotion cost another £100,000. That is the type of expenditure that is signalled for this year in health promotion. I want to see how the health promotion unit can gel with the national strategy. Hopefully, it will have a more developed role once the strategy is in place.
Deputy Higgins asked some specific questions in relation to staffing in my Department. A predecessor, Deputy O'Hanlon, employed Mr. Seagrave as special adviser. His salary was based on the maximum of the Assistant Secretary scale abated by his pension with the Eastern Health Board. The cost to the Department is £24,000 per annum. The amount paid to him in 1992 was £5,600. Subsequent Ministers did not employ special advisers. The annual salary of the special adviser I have appointed, Dr. Tim Collins, is £40,471. My partnership programme manager has a similar salary. No additional funding was provided by the Department of Finance for these posts. They will simply be met from the administrative budget which Members have before them.
Deputy Higgins's question was predictable enough because he has raised the matter by way of parliamentary question on the cost of an additional adviser. He asks what preceptible improvements have been made by the employment of these two people. They are extremely hard working and productive for the country and, certainly, for my Department. I leave it to others to judge, rather than make the judgment myself, what perceptible improvements their input has brought about. I know that most people who have come into contact with them will be able to answer that question readily.
There is no provision for the changes in telephone charges. We simply address the cost of telephone charges within the administrative budget. There is obviously an overall view that we get the best value for any money we expend and I make no apology for that.
I did not read every word in the prepared script simply because I only had 15 minutes. I tried, because I was warned by the Chairman to try to keep within the 15 minutes and I have done that.
Will we proceed to the next subhead, Subhead B.1?
If Members wish to come back to this subhead can they do so?
If Members so wish they can do so but they must bear in mind that I am trying to allow time for all the important sections. If Members speak after the Minister's reply, the Minister will have to be given the opportunity to reply again to points on administration. We could then find ourselves spending most of the available time on administration.
We have started discussion on another subhead and it is an important one.
Members should put their questions, the Minister be allowed to reply and we will then proceed to the next subhead.
A number of Members have not yet made a contribution and would like to do so.
I waited a few seconds before I asked the Minister to reply and no Member offered at the time. We will proceed to Subhead B.1.
I wish to make two points on the delivery of the service; one is in relation to medical cards. Would the Minister consider allocating medical cards to people who have already been means-tested by the Department of Social Welfare? People who are in receipt of full social welfare assistance are, obviously, within the guidelines for medical cards. Rather than having them assessed twice, which is expensive, would the Minister consider allocating them medical cards?
My other point refers to the elderly, particularly in this European Year of the Elderly. I agree with the Minister that providing funds for the implementation of the Health (Nursing Homes) Act is very important. However, I would not like to think we would lose sight of the need for support of the elderly at home as 95 per cent of the elderly live at home or with their relatives. The Minister will appreciate that there is need for support for the elderly in their homes. What I have in mind is the provision of aids for people who are incapacitated at home, for example, commodes and wheelchairs. Under the present system there is an investigation into their needs by a number of personnel in the health boards, and that should be looked at and a more rapid response to the needs of people in their homes might be adopted by the health boards.
Under this subhead we are spending almost £1 billion. It is worthy of further sub-division in future Estimates so as to give us more detail of the expenditure. It contains a huge element of all of the areas we will be concerned about. As this subhead covers community care, special hospitals, the general hospitals and central services, it is one on which general comments can be made. We did not get an opportunity to make general comments yet.
The spokesperson's contributions raised some very important issues of policy and highlighted some varied approaches. I welcome the statement by the Minister that he is going to change the image of the Department from one which seemed to be more concerned with saving money than almost anything else. I date that change back to another Labour Minister for Health who is now an MEP. I remember when I first began hearing, in the Dáil, questions of bed nights and costs. Previously I had only heard those expressions used in relation to tourists. It was a sea change. Questions on bed nights may have been necessary in the context of how we analyse our health services, but it was also a very disturbing trend that our health services came to be seen as a commercial entity. I would never support waste but I would be very careful of that kind of attitude. It has led to an examination of what is the appropriate general philosophy.
The Minister said he is developing a strategy. I would like to draw his attention to OECD studies carried out in the eighties into health care services throughout the world. They compared cost and satisfaction ratings. At that time, before Margaret Thatcher had done her worst with the British health service, it was a universal public free service. It was the most cost-effective and it was also the one that gave most public satisfaction. The country that was spending most of its GNP at that time — I do not know what the current figures are in relation to health services — was the United States of America. There, on the one hand, some people were getting a totally inadequate service while on the other there were people receiving treatments they perhaps did not need, simply because they were in a private system where expensive equipment had been bought which had to produce evidence of a certain amount of usage to make it worthwhile.
That is a very fundamental statistic. In the early eighties we had a public health service that, by and large, met the needs of the people. In the intervening years it has separated and has developed into a two-tiered system. If the Minister is saying that he is going to address that seriously, I welcome that. I have no problem with private medicine but it should be in the area of selection and of non-essential extra facilities and, perhaps, briefly shortening waiting periods for non-essential operations. Our primary concern is to make sure that our public service is adequate and responsive.
What the Progressive Democrats spokesperson said indicates that, whatever the national newspapers are saying, this is certainly one of the areas where we might have distinct differences in our philosophy. We might be closer to the Minister's party. Historically, however, Labour Party Ministers have not necessarily been the most protective of the services. A predecessor of the Minister's started this attitude. Questions of cost have relevance, but consideration of them has become overwhelming.
I am very concerned about the child care services within the community care services. They come under this wide heading. At the moment child care services have hit the headlines in a number of serious and critical cases. It was not surprising to any of us who were present when the Child Care Bill was passed and had argued for child care authorities in the local authorities, for a national advisory committee and for an amendment to the Constitution to ensure the rights of children were given equal status with those of their families. We all identified the problems indicated in the reports which are coming through now. I would like the Minister to outline to me what happens in the health boards at the moment? What is the structure for supervising the child care services? Are they not the Cinderella of community care which is already the Cinderella of the health board services, despite all of our strong desires to see the development of this area? How are our child care services structured?
The Minister has said he will set up a child policy unit in his Department. Did he not clearly see the need for a separate child care section in each health board? Should that not have been accepted? I do not remember if this is so but the Minister, and his party in Opposition, would surely have argued for this at certain stages in the debate on the child care services. As backbenchers, we were certainly arguing about it against our own Minister at that time.
Until that structural problem in the health board is resolved, the tiny amount of additional money that has been allocated under this and other headings, will not be monitored and policies will not be implemented adequately.
I share the concern of many of those who have spoken in relation to the services for the elderly. Deputy O'Donnell referred to the number of elderly people taking up hospital beds. I find it absolutely impossible to get a hospital bed for the most critical cases. I should not have to do so but, the way the health services have gone, it has become a feature of the average clinic. This is something which has occurred only since the late eighties. In the early eighties I very rarely had anybody coming to me trying to get an operation or trying to get a bed in a hospital. Since the late eighties it has become much more an element of our work as politicians to try to get people to the top of a waiting list or to help people to make their case. I do not know when I got a "yes" answer for somebody who clearly needed an acute hospital service. The families of these people were at the point of breakdown seeking such care.
I refer to a woman who had arthritis and who has been looking after her ailing husband for between 15 and 20 years. Towards the end she was visited by a public health nurse who not only got the husband into hospital but got her into hospital because she required two weeks of recuperation.
I have made representations but the places are not available. Similarly, adequate services in the community are not available.
I wonder why the Minister did not refer to his £20 million for the reduction of operation lists under which there will be more staff and more beds, we hope. When are these additional operations to start? Have they started? Given that the Minister is accepting the closures of beds during the summer, will we see this in the autumn? When are we going to see them having an impact and see extra beds, extra wards being opened and extra staff being taken on? In particular, the Minister might refer to the Dublin area in relation to that.
I am disappointed at the way Deputy Flaherty has tried to finger Labour Ministers for Health. I dread to think what might happen under a budgetary regime advocated by her Finance spokesperson where we would have a further cut of £200 million in public expenditure. What would we do then?
I would like to acknowledge the Minister's achievement in increasing by 12 percent the amount of money allocated for health expenditure this year. In particular, I welcome the specific initiative on waiting lists. Indeed, in his address to the Committee he pointed out that there were specific measures being taken there and I would like to acknowledge those being taken in my own health board area, that of the Midland Health Board. We were delighted to have the Minister visit there recently. The initiative in that area, as in other areas, will cover both capital investment, an increase in the procedures being done and the allocation of additional staff. That is what is needed in order to tackle the waiting lists.
Will the Minister outline briefly what his strategy is in relation to the reduction of waiting lists for the specialty services which were included in his programme? Furthermore, will he indicate in some detail what developments will take place from the additional £8.5 million which has been allocated for mentally and physically disabled persons this year?
On the point Deputy Flaherty made in relation to the balance between public and private development within the health service, I have just been reading an article on the American situation which has caught our imagination recently and on their attempts to solve the problem there. There are very timely lessons in their situation in relation to the dangers of relying on private services only and the need for balance in the development of our health services if we are to ensure that the most needy receive the kind of services which are essential to them.
Is the Minister happy about the balance within his Department in terms of priorities, staffing and focus between health care and the development of the social services side of health? I have suggested before that we should call his Department the Department of Health and Social Services in order to emphasise the balance which is needed and to ensure that there is proper development within the health boards of community care, proper focus on community care and of resources going to that sector. I would like to hear the Minister's comments on that, on how he thinks that balance can best be achieved and what his targets are for that.
In relation to the medical card service, what are the Minister's plans for the development of screening services for breast and cervical screening? Is the Minister satisfied with the current state of services available to those on the medical card? What plans has he to make screening more available to women who are unlikely to be able to afford those services? We have had a very uncertain state of development in relation to those services in recent years. I would like a clear policy to be announced by the Department.
The Minister has a tough task but I believe he has the ability to make an impact in this area. I wish him well in his Department as we now consider his first Estimate.
It is important to set out certain priorities in an area so vast. Events often force us to frame our priorities. I agree totally with the cogent argument put forward by Deputy Flanagan during the debate today and in a Private Member's motion earlier in the Dáil in relation to the needs of mentally handicapped persons in general. That is one area that must continue to be very important in our scale of priorities.
The whole area of child care is extremely important and received additional attention in recent times. One area referred to quite frequently this morning has been the subject of neglect in recent times, namely, services for the elderly. If I could make one request more than any other to the Minister, it would be to ask him to make that a priority in the years ahead.
As has been rightly said by Deputy O'Hanlon, this year has been designated European Year of the Elderly. It is important that we seek to make additional provisions for older people in the context of providing an adequate and good health service. If we look at our population structure, we will see we have a very big number of elderly people in our society. In addition to that, for reasons I will not specify, people are now living longer and that is good. It is a sign that we are making progress and our civilisation is advancing, but there is an obligation on all of us to ensure that they have a good and decent quality of life and that quality of life hinges on our putting in place a proper health and care service for elderly people. That mainly must be done in the context of having a well developed community care service because, as of now, there are not sufficient public health nurses, for example, to support people who are spending their latter years in their own homes. We do not have a sufficient number of public health nurses to provide assistance to families who are caring for their elderly relatives. If we had more public health nurses in the community that would be an enormous help.
I agree with Deputy O'Hanlon when he said there was grave need to make practical aids — walking aids, commodes and mechanical aids of that nature — available to families who are looking after elderly relatives. More than anything else there is need to increase the number of respite beds in every health board area. That is a key provision that needs to be made to enable people to look after their elderly relatives. Looking after a housebound and ailing person puts many demands on a woman who perhaps is at the same time rearing her children, maybe at a time when her own energy is beginning to decline and ebb away. Mothers need a great deal of assistance to enable them to do that without causing excessive damage to their own health.
I appeal to the Minister to look at the number of respite beds that are available in health board regions and to work towards increasing that number. It is very important. In my own area, Cork city, the number of respite beds available is only a fraction of the number needed. If that were done, people would continue to look after elderly relatives at home. I know of a case where a person who is 81 years of age is trying to look after her sister of 86 years of age in their home. The family have being trying to get a respite bed, even for a week, for the 86 year old and they cannot do so. One person's ailment is actually creating sickness in the other person. That has to be looked at.
In addition, there are not enough long-stay beds to cater for people who have reached a point where they cannot adequately be cared for in their own home. These are areas that must be looked at and catered for. Sufficient provision has not been made in the Estimates for this but we must make it a priority and ensure there will be greater funding for it next year. It is a very poor society that does not look after the very young and the very old.
A number of claims have been made, and rightly so, in relation to child care. We have proper legislation at last that will enable us to look after children provided we get the funding, but I do not think we have made proper provision for senior citizens. Now is the time to do that. One thing is certain; if we have the kind of good health care envisaged by the Minister, we will all live to be old and it is reasonable to expect that we would be cared for properly.
A great deal has been said about child care. It is crucially important that we have in place the kind of child care services that cater for all children in need of care. I do not just mean the kind of children who hit the headlines very often, children who are the subject of parental or social neglect, child abuse or educational neglect. Of course their needs are crucially important. They have priority needs and they must be catered for but there is a range of children in between who need a level of child care that is not currently available. I am talking about children of two parent working families, single parent families, disadvantaged families and many mothers working at home. This is an area where we can enlist the support of private medicine.
I have a proposal from a couple who are beginning to provide the kind of care that is working for children of the families I have described. They have made a submission which I intend passing on to the Minister and which I ask him to consider. They believe there could be a partnership between the private and public services to cater for a range of child care needs that could not be possibly catered for out of the public purse solely in the times in which we live because there is a limit to the amount of money we can give. I have no hang-up about private medicine or the relationship between private and public medicine. Perhaps we could explore such a partnership of funds, together with an input from employers and Government, that would enable us to extend child care to a range of children we could not possibly afford to reach out of public funds.
The Minister may have thought I was a bit hard on him at the outset in asking him to have instant answers to the ills of the health services. I was not being unreasonable because he had many ideas when he was in Opposition and I felt he was ready, willing and able to implement his views and ideas once he was in Government.
Sick people cannot wait for plans and strategies. Since hospital services take up most of our health budget, there should be a strategy in relation to hospital services and a role identified for each hospital. That would eliminate the type of competition there is at present between hospitals for services. The duplication I see in the health services at present is unhealthy while, at the same time, there are enormous gaps in those services. In the past, decisions were made which were not based on policy or health considerations but on political considerations. Too often this was the way the future of hospitals was decided.
If hospitals were given their own budgets and built-in incentives to create savings and value for money they would create an atmosphere that would bring about an improvement in their services. One can pour money into the health services year after year and increase the allocations, but if inefficiencies are not eliminated it will be like pouring money into a leaking bucket.
Most of the staff in the health services are committed and able people but there is an in-built greed among some people in the health services at present. People can become millionaires in a matter of years working in the health services area. I could name many of them. They become millionaires almost overnight because of the two-tier system that operates.
On the Order Paper today I have a question down about somebody on a hospital waiting list being forced to take private care. Despite the Minister's programme managers and advisers, I believe the two-tier system operates more so now than it did 12 months ago. The pressure on people to opt for private care is greater now than it was a year ago. I hope the £20 million the Minister allocated is spent effectively in dealing with real waiting lists but, if the first indications I have are correct, I believe the books are being cooked in that the in-patient waiting lists will be reduced because the out-patient waiting lists are now being closed. I have evidence of that.
In the Southern Health Board area waiting lists for orthopaedic surgery in the out-patient clinics are closed. If a person looks for an out-patient appointment he or she cannot get it. They cannot go on an in-patient waiting list. Therefore, the in-patient waiting list will be reduced substantially over a number of months. I hope all this is not camouflage or a cosmetic exercise. We must look at the out-patient lists in conjunction with the in-patient lists. If people are prevented from going on out-patient waiting lists, the figures and statistics, which will be false, will make the Minister's case look very impressive. At present, if you have money you will get an available service but if you have not, God help you. The poor and the sick cannot and should not have to wait until plans and strategies are put in place.
Community care has been the Cinderella of the health service for many years. Lip-service has been paid to it by successive Ministers but until such time as there is real investment in community care, there will be an ongoing escalation of in-hospital costs. If the Minister did little else but to break the vicious circle of escalating in-hospital costs and the ineffectiveness of the community care programme he would be doing a lot. Community care programmes must get an injection of substantial funds in order to upgrade them and this would bring about a reduction in hospital costs.
In relation to the care of the elderly, it is true that acute hospital beds are occupied by elderly people for the simple reason there are very few beds available for them in long term institutions or units. I regret that the Health (Nursing Homes) Act took such a long time to be implemented. Even now, the Minister's Department is not giving the attention it should to the long term care of the elderly.
We have had discussions in the Dáil regarding mental handicap. We discussed it this week and some weeks ago and the relevant spokesperson dealt with it adequately. I would ask for action to be taken in this area.
Acute hospital beds are occupied by young chronically sick people for the simple reason that there are few long term care beds available for them. I hope attention will be given to that area also.
I do not see any appreciable improvement in hospital services or health services, despite the Minister's claim that his programme manager costing £40,000 a year will bring about improvements in the delivery of service. I hope for the sake of people on waiting lists that improvements will be made. We can pour money into the health services forever without getting a proper return unless there is real reform. The Minister had good ideas when he was in Opposition and I hope he will have the political courage to bring about real reform in the delivery of the services otherwise we will have a third rate service at a first rate cost.
I welcome the Minister. He is not long in his Department and he has already made a great impact on it. He must be commended for his initiative in relation to the prevention of the spread of AIDS and also for his prompt action in the Kilkenny case.
An increase of £8 million has been provided this year for people with mental handicap. A Green Paper on mental health was published last year. Has he any proposals to put forward more detailed legislation? I am also pleased to note that the Minister has addressed the problem of physical and sensory disability especially for those being cared for at home. The Minister has also acknowledged the commitment and service provided by people who look after the ill and infirm at home. I urge the Minister for Health and the Minister for Social Welfare to further the interests of these people and lend them their support in the future.
Is the Minister in a position to indicate the proposals for the implementation of the nursing homes Act following the availability of £4 million in the 1993 Estimates?
I had experience at the weekend of orthodontic and dental services for children in the Kerry area. Will the Minister indicate the level of development anticipated in dental and orthodontic services as a result of £2 million provided in the 1993 Estimates?
I am curious to know what kind of research is carried out at health board level. It seems we are not well furnished with research as regards the health of the nation. When the question of mental handicap came up nobody seemed to know the numbers of people we were talking about. That seems extraordinary. If we are setting strategies, we need to know how healthy people are and how sick they are. What are we doing about research to make sure we know what we are targeting? What kind of research is being carried out in relation to child care services? Would the Minister not agree that we need to look continuously, at health board level, at how deprivation impacts on people's health? The health board worker and the GP are the two people who are closest to the individual. There has been a lot of talk about elderly people being cared for properly. One initiative that has been immensely successful is the home care team that operates in my own area to assist families who are caring for terminally ill patients at home. There is a tremendous professional backup and I would imagine it is very cost effective. From the point of view of the family it is providing support at the time and in a way that is appropriate. In the same way we have to look at other areas where families are at risk and need support because of poverty, deprivation and inadequacy. There is none of that professional help for such families.
The immunization programme must achieve a marked improvement. What role are the health boards given to set local goals to make sure that we hit the 90 per cent target? Are the health boards being given a target this year? What is it and how are they to assess whether they achieve it?
In relation to family planning, what role are the health board being given and what funding? I know there is a figure here which is fairly static. The health board worker, the health centre, is the closest link to the health services that most people will ever have, particularly in rural areas. Why is that not being used to provide full comprehensive family planning, particularly for people on the GMS? It is ludricous that it is only in the last couple of months that it has been recognised that the pill is a contraceptive. Even in the condom debate we have the Irish solution that a condom is not really a contraceptive, which means we get over all the problems there. If we are providing family planning it has to be available to eveybody and it has to be available on the GMS. That is not the case at the moment. Poor women are on the pill and that is medically inappropriate. In relation to the structure of the family the health board again has a very important role to play. Apart from the council housing lists, do we know accurately, in each health board area, how many single mothers there are, how many of them are teenagers, what are the supports for those families and whether we wish to see that trend continue? We have to look at the makeup of a family and the fact that there are so many single parent families around. If we accept that is the trend, then we must provide extra support. It is not easy to rear a family at the best of times but it is far more difficult if you are on your own and living in poverty. What role will the health board have in the coming year in relation to that area?
There are only 20 women TDs in the Dáil. The least the Minister could do, with all due respect, is get our names right.
May I first say to Deputy Gallagher that we are not attacking the Minister per se. We are reminding the Minister of very clear, specific promises made in advance of the general election during his time as a very articulate spokesman for the Labour Party in the Dáil over the past four years in relation to the delivery of service under the various subheads. We are analysing in depth and in detail the delivery or otherwise of the service and that is our entitlement. Deputy Gallagher is fast becoming the Deputy Ferris of the Social Affairs Committee. I suppose Deputy Ferris has not time now, opening and closing factories.
Thank you for the compliment.
This vote is the meat of the health Estimate and that is why we are taking so long on it. Every casualty department in every hospital is clogged up with people who have been sent there by GPs from the local catchment area. These are people who have routine illnesses and they are causing long queues. Recently, for example, I read a very detailed description of a 12-hour stint by somebody who accompanied an eighty-year-old patient at the outpatient department of the regional hospital in Galway. It took a solid 12 hours for an eighty-year-old person to be seen. The Minister and the health boards should sort out the GPs in those areas because many emergency cases are not getting the early treatment they deserve. As regards cardiac operations, the figure of 1,330 has been given. Recently I spoke to a cardiac specialist who told me that the number in fact is a fallacy. That number is static. The person in question said to me: "The next six people I will operate on are not on the list because they have been sent from Galway, from Cork, from Naas, from Letterkenny and there is one now on the way from Portiuncula in an ambulance". The waiting list is static because people have been leapfrogged and gazumped because of further emergencies coming on stream. The same person said to me that on a regular basis the specialists are asked to validate their waiting list. That means that they write out to everybody on the waiting list and they say: "You are on my waiting list for a cardiac operation. Are you still looking for the cardiac operation?". In some cases up to 30 and sometimes 40 people do not reply. I think we can draw our own conclusions as to what has happened. They have died in the meantime. There is an urgent need to look at the whole area of cardiac operations.
I would disagree somewhat with Deputy Liz O'Donnell. Competition is good but none of us want to see a Dutch auction ensue between St. James's and the Mater Hospital. In relation to hip replacement operations, in the Western Health Board area at present the wating time is four years minimum. The reason is that as and from next week the orthopaedic theatres in Galway will close down until September because they do not have clean air theatre facilities. They have had a new clean air theatre and a substitute theatre for the past three years but they simply cannot get the £380,000 to make it operational. The Minister may say it is contained within the budget and it is up to the Western Health Board to slice this budget in different directions. It simply cannot be done because the overall budget, the overall size of the cake, is inadequate. I had a reply to a Dáil question from the Minister last week which was couched in very much the same sympathetic terminology as one from the man sitting opposite me, Deputy O'Hanlon, when he was Minister. The same patient, 70 years of age now, has one artificial eye, a hip replacement, is blind from cataract in the other eye and is still waiting for a cataract operation. That should not happen in this day and age. It is also cock-eyed economics to bus people, to taxi people or to ferry people from a place like Belmullet in County Mayo to the regional hospital in Galway three times per week for kidney dialysis at a cost of £120 per taxi run. There are 12 patients in Mayo who are making a twice weekly or three times weekly journey to the regional hospital in Galway for kidney dialysis. The total weekly cost of the taxi bill is £3,300 or £150,000 per annum. Apart from the trauma of the journey it is cock-eyed economics, particularly when we have a kidney dialysis unit built but not equipped at the new general hospital in Castlebar. I know the Minister is meeting a delegation shortly. We have had meeting after meeting on this. What we need at this stage is the £250,000 to make it operational.
In relation to geriatrics, the ideal situation is care in the home. There are many families who would love to provide care in the home if it were a financial possibility. The carer's allowance is ludicrous in terms of the thresholds being applied in the means testing. The Minister should seriously look at providing a £50 or £60 grant with far more generous guidelines. Many people give up work to care for others but end up sending them to old folks' homes.
The monitoring envisaged under the Health (Nursing Homes) Act is not operating in terms of inspecting them on a fairly rigid basis. Nobody wants to be overly punitive but there have been a number of close-downs recently and I have noted that some of these nursing homes have managed to circumvent the law by re-opening again under the guise of rest homes or retirement homes. It seems the same restrictions and regulations do not apply. At least that is the impression I have. It is something that should be looked upon because there is a certain amount of abuse and over-commerciality in this area.
Last but not least the Minister made a very clear commitment. I presume he had an input, as a former health spokesman, to the drafting of the document Putting Trust Back into Government. One of the clearest commitments in bold capital letters was £25 million this year for the full implementation of the “Needs and Abilities” report on the clear understanding that it would be implemented to the letter. The Minister has delivered on less than one-third of that figure and the result is that we will, unfortunately, have more pickets by parents outside the gates of Leinster House.
I welcome the allocation we got in the Western Health Board for the waiting lists. It was a pity we did not get it earlier in the year so that we could have started working on it but the health board has written to thank the Minister for the allocation.
I am not as happy about the services for mentally handicapped and I want to ask a few questions on that. Following the debate recently in the Dáil I have had a lot of representations from organisations for the mentally handicapped who would like the Minister to think about setting up an all-party committee on services for mentally handicapped. It was regrettable that in the Western Health Board area we got just £158,000 of the extra £8.5 million that was allocated. I would like the Minister's views on that.
Many of these organisations are surviving on lottery funds. Can the Minister say whether these lottery funds will be ongoing? They certainly were a big help last year.
Some religious and voluntary organisations get funding from the Department directly and others get funding from the health board. Some former Ministers believed that perhaps all these organisations could be funded directly or that a lump sum would be given to a health board to distribute. It is important to get the Minister's views on that.
In the Minister's speech he mentioned that good quality condoms are the best method of reducing the risk of sexually transmitted HIV. I certainly agree with that but the Minister went on to say that a good quality condom, properly used, is effective in preventing the transmission of HIV. I do not really know if that is a medically sound statement. There are some medical people on the committee. It should be clarified because we should not mislead anyone. The first statement the Minister made is correct and I agree with that.
I want to make four points. I will attempt not to raise questions that have been asked by my colleagues. My first point is in relation to the whole area of medical defence. I have not seen specific reference to it under any subhead. I am assuming that it is under subhead B.1. It is an issue of grave concern and one upon which sadly we have seen no action by the Minister for Health or his predecessors. It is a scandal in the making as far as the costs to the Exchequer are concerned. It is one that requires immediate action. For example, in 1981 the average cost of medical defence for a consultant was £120 per annum. By 1987 that figure had risen to £1,100. By 1989, two years later, the average cost was £4,380. By 1991 that had spiralled to £9,300 and in 1993 obstetricians are paying the sum of £21,500 per annum for medical defence.
I suggest that we take some lessons from the United States, but not the type of lessons that Deputy O'Donnell would like us to take from the health service there which unfortunately is cold comfort to the disadvantaged within the community. From a medical defence point of view we are now the most litigious people in Europe. Every angle is being looked at to place a claim in the form of a civil action. The medical profession are now in the front line. An interdepartmental report was presented to the Minister some time ago on this whole area. I call for publication of that report. I understand that in reply to a question on the matter it was stated on the Minister's behalf that this report contained material that was politically sensitive. I cannot understand what that might be. If indeed there is politically sensitive material that means this report cannot be published, then I ask that at least the recommendations of the report be published. We cannot allow the spiralling cost of medical defence insurance to continue. We must look at a tribunal of assessment, an arbitration clause or some form of intermediary action that will deal in an efficient manner with any complaints that may be laid against members of the medical professison without the necessity of court actions.
An example is the recent Kenneth Best case in which a record sum of damages was awarded. Legal costs awarded were something of a record, second perhaps only to the Beef Tribunal. We cannot allow this to continue in the medical area. How much is being spent in terms of rebates from the Department to consultants in the health service? I ask the Minister for clarification on that figure. I do so because last year a senior official in the Department of Health stated that the figure was £12,000. Recently the Minister was quoted as saying it was £9 million. There is a difference of £3 million on which we should get clarification. It is a pity there is not an individual subhead for it but it is a matter that requires some active consideration. We must look at what happened in other jurisdictions to ensure that spurious claims of a type we have seen are not allowed place an unfair burden on the Exchequer.
Subhead B.1 which deals with spending by health boards is a huge heading. Deputy Gallagher congratulated the Minister on his recent visit to the Midland Health Board area, which is my own area as well. Is Deputy Gallagher or the Minister aware that today, as we speak, the Midland Health Board is preparing for a crisis meeting and that the budget may be rejected. As I am not there I cannot be accused of stirring up any political points within the Midland Health Board area on the matter of budget. I must leave that to the members of the board. It is quite likely that the Midland Health Board will reject the budget as outlined by the Minister.
All health boards, as of June 1993, are in the course of exceeding their budgets for the first half of the year. This has become commonplace. In the course of the late 1980s and into the 1990s health boards adopted a very responsible and constructive approach to the continued restrictions on expenditure within the allocations. Very difficult decisions were made in the guise of rationalisation of hospital services. Staff numbers were reduced by hundreds, assets were disposed of, lands and buildings that were not used were sold off and the money pumped into day to day spending in the health board area, bed numbers were reduced on a wide scale. Deputy O'Hanlon is well aware what happened in the late eighties. He has heard it many times before.
Value for money programmes were introduced of a type that we had never seen before. There was rationalisation in catering arrangements, food was cut back. Bulk buying in storage was introduced. We now have inferior quality linen and bandages as the norm in many of our hospitals. We cut back on laundry services and linen. Energy management was carefully introduced to such an extent as to give rise to disquiet. I recently had reason to visit a hospital and along with the bunch of flowers I brought with me I had to bring an electric bulb. Having visited the hospital three times previously in a week, I had seen the bulb over the bedside had not been replaced in spite of numerous requests and I had to take one with me.
We had the rationalisation of telephone services within hospitals resulting in phones not being available in rooms or in wards. There was the introduction of central sterile supply services and the reduction of premium pay costs for nursing and non-nursing staff. Where is this going to stop? What is the long term policy for ensuring an effective and acceptable level of care in our health board hospitals? How long will our health boards exceed their budgets on a quarterly basis with an overrun into the following year and a subsequent charge on the following year's budget?
I referred earlier to the fame throughout the world of the Irish nurse as a carer. Nursing is no longer a profession worthy of any consideration given the treatment of nurses within our health system. Many nurses are engaged in tasks far removed from their profession, such as making tea, hanging curtains, lifting stretchers, fixing beds and cleaning floors. This is totally unacceptable. Specialist increments for nurses need to be reviewed and incentives need to be given for nurses to pursue careers on an ongoing training basis in the health services.
As a result of EC directives, a particular difficulty exists for nurses pursuing careers in mental handicap and paediatrics. There is an EC directive causing extreme difficulty as far as the training of nurses is concerned. It means, in effect, that specialist nursing courses in areas of paediatrics and psychiatry are becoming the poor relation of the general nursing course. That will give rise to difficulties because we will not have the type of specialist nurse we have had for decades. Those courses will not attract trainees given the level of discrimination, under an EC directive, as far as training is concerned. There will be 12 weeks more training now for the general nurse, obviously placing that nurse in a superior position from a career point of view.
I would also like the Minister to clarify the EC directive on the working week. This will have extraordinary ramifications and consequences on the working of our health service system where we have junior hospital doctors working extraordinarily long hours, for example, 60 to 75 hours per week. If this EC directive is to take effect, what contingency plans have we within our hospital service for other employees, or will we have to cut back? In the alternative, are we going to seek a derogation from this directive and, if so, for how long?
This subhead is the most important we are to discuss today. Without taking from the importance of some of the later ones, they are of less consequence than this most important subhead where we are dealing with the spending of £1 billion.
The Minister said the major task over the coming year was to draw up a national health strategy for at least a four-year period. I welcome that. Over the past 10 or 11 years, we have had talk of cutbacks and lack of funding but, in fact, the position was not as bad as was being made out. There was a lot of hiding behind that excuse rather than making the best use of the funding that was available. I have experience of that as a member of a health board.
Mention has been made of the £20 million which the Minister provided to reduce the waiting list for operations. Any member of a health board who is making criticisms here would do better to apply himself in his own health board. The health board of which I am a member did not have a large claim. It is only in an orthopaedic field that we had one. From the day the announcement was made, the health board set out to put itself in a position to avail itself of that funding. We will make very good use of it. What has been said about a four year period does not stand up to examination. I have been a member of the health board for 20 years and I have applied myself to the task. There are people whose physical condition did not allow them to be operated on in those four years. The Minister should recommend to the health boards that they draw up more clearly defined waiting lists of people who are in a position to avail themselves of the services.
In many hospitals we are very badly in need of equipment. In Monaghan General Hospital we are in need of a substantial investment in equipment. It took years for most of the smaller hospitals to build up a proper consultancy team. It is regrettable, now that they have such teams, that they have not the proper equipment and the proper tools to make the best use of them.
I have recommended, at health board level, that the possibility of renting rather than purchasing equipment should be examined so as to make the best use of the available money, to ensure that consultants have the tools of their trade.
Mention was made of nursing levels. Some areas are very bad. Our health board has the lowest number of nurses per bed of any health board. We also have the lowest per capita allowance of any of the health boards, substantially lower than most. Perhaps the Minister would examine those areas.
Regarding kidney dialysis, I congratulate all those voluntary bodies and groups who are collecting substantial money to ensure that dialysis and various other services are available throughout the provinces. The Minister is sympathetic towards the provision of those services, especially dialysis. Some people have to travel 90 miles, so that it takes them almost 12 hours a day, several days a week, to get treatment in Dublin which could be provided in Cavan General Hospital which is now preparing to provide dialysis.
One of the biggest problems at health board level over recent years is the cost of drugs. Despite the various negotiations between health boards and the drug manufacturers the price of drugs is higher here than in any other country. In recent years, in Britain and the USA the authorities have demanded of their health services that they should use generic drugs rather than brand name drugs where these are of the proper quality. This has resulted in substantial savings. Bulk buying, and combined purchasing could also provide opportunities for substantial reductions in drug prices.
The Minister mentioned dental treatment. More use should be made of the private dentists to reduce the backlog among medical card holders requiring orthodontic treatment. There seems to be a continual increase in the demand for orthodontics and very few orthodontists available to carry out the work. Parents continually come to see public representatives about the very long delays.
There has been a substantial increase in funding for the mentally handicapped over recent years but we have a substantial increase in the numbers of people with mental handicap. Anyone who has been a member of a health board down the years would know there has been an increase in demand for services and a need for much additional money.
Deputy Flanagan mentioned medical defence which must concern a Minister and a Department more than anything else. Consultants and doctors in some areas are scared of what may occur and the amount of money they are paying in insurance for medical defence is substantial. The people themselves are causing this. We are a litigious breed compared to other countries. If this continues it could cause a serious problem.
Overall, we must be reasonably satisfied at the amount of money we are getting. Most health boards which are responsible are appreciative of the allocations which they have obtained.
Sitting suspended at 12.55 p.m. and resumed at 1.50 p.m.
If we are to build a better health system we should develop a good public health nursing service. Good public health nurses are worth their weight in gold. They can detect diseases early on and are aware of other problems that may exist.
Immunisation is an area that we will have to have greater regard to in the future, as more diseases will be amenable to immunisation, hopefully even AIDS. I am not a believer in having extra beds just for the sake of them. There are many procedures which could be carried out on an out-patient basis. If we improve our out-patient services that will alleviate many of the bed problems we have at present.
In some areas, extra beds may be needed and I am sure the Minister will not mind if I mention the case of Castlebar. He did not refer to it and I hope he has not forgotten about it. The out-patient service could be improved by greater streamlining of patients. Too many patients are recalled at present. Consultants bring patients back continually. There should be an acute referral service only, as many of those who are recalled could have their cases adequately dealt with by their own general practitioner. We should try to make the best use of consultants in hospitals. There will be a big demand for geriatric beds and I hope the district hospitals can service this need in time to come. Different areas have different needs. The dialysis unit in Castlebar was mentioned.
Deputy Flanagan referred to litigation. I will not go over what he said. We must look at the whole system and if we develop it along the lines I have mentioned it should lead to a good health service.
Deputy Higgins said general practitioners were responsible for cluttering up the casualty services but I do not agree. Patients should go to their own doctor initially and many cases could be dealt with adequately in this way. A smaller percentage could then be sent to casualty.
Earlier this year before the Easter recess four different people complained to me about the accident and emergency service offered in hospitals, particularly in Beaumont and in the Mater, and the long waiting periods of up to 48 hours. In one case a person with TB who needed to be isolated was left in a room for 24 hours still in the same clothes. Someone else with a life-threatening condition was left sitting on a bench without receiving any attention for hours. It took nearly 24 hours to get a bed for that person. What are the average waiting periods in the accident and emergency services? Are there problems in the north Dublin area?
The investigation into the Kilkenny case indicated a number of gaps in the services, particularly in the monitoring of critical cases. Arising out of that, did the Minister request or order all health boards to review the other cases on their files? We hope there are not too many similar cases but those who have worked in this area say there are many. Has the Minister instructed the health boards to review all their case loads to ensure that there is no other young woman or child being overlooked and has that type of review taken place in the various health boards?
There is still a serious problem regarding the blocking of expensive, acute hospital beds in the Dublin area. I would like to know how the Minister proposes to deal with that. What progress has been made in the area of prevention and education strategies in the fight against AIDS?
When we are discussing our health servicves, we devote a lot of time to certain areas but very little attention is paid to the people who carry the greatest burden of the health service on their shoulders, that is, the nurses. It is not appreciated that they are the coal face of the cutbacks in the health service. They are the people who suffer. I have met many groups of nurses representing their organisation or representing individual hospitals and they are finding the strain and stress of their profession interfering with their health. This is totally unjustified. Because of the spirit of their vocation they tend not to go for strike action but that does not mean that there is not an enormous amount of unrest, an enormous amount of disenchantment among the nursing profession.
I can speak for my own constituency of South Tipperary where, I might remind the Minister, the health service is being chipped away little by little and no firm decisions are being made about its future. We are fearful that the total health service is being gradually denuded and we may find ourselves having to go to different counties for a health service. We regret that and are hopeful that the Minister, Deputy Howlin, will devote his attention to the hospital services in South Tipperary. We have had three district hospitals closed, the orthopaedic services are to be removed and there is a lack of beds for geriatric patients. I am sure this is happening in every constituency.
I have had to meet delegations of nurses from each of our hospitals who are finding it impossible to cope with the environment and with the conditions under which they work. Wards are overcrowded, support services are unavailable and yet, because of the nature of the job, nurses have to try to give a service of the highest quality. Thankfully, they put the patients first. Indeed, for a long period over 50 per cent of the nurses in South Tipperary were temporary. Some nurses were on the staff of the hospitals for 15 years but still could not get a permanent position. We all know the down side of that. I hope that something will be done not only to provide adequate working conditions for nurses but also to give them better remuneration because of the nature of their job and the extent of their responsibility. Very few realise the responsibility, particularly on the sister of a ward. She can be in charge of a massive budget and can be responsibile for the protection and the delivery of extremely dangerous drugs. They are not remunerated for that. I hope I have drawn the Minister's attention to the conditions of nurses and that there will be a suitable response.
We will move to subheads B.2 and B.3.
Could we not have a response on B.1?
I was waiting until all subheads were finished and then we could have a response to the whole programme.
Subhead B.1 covers such a huge area. The Minister will lose everything because there have been so many questions.
There are five pages of questions on this subhead alone. It is really the meat of the Estimate, approaching £1 billion. A huge variety of issues has been raised. I will try to deal with as many of the questions as I can and to be as detailed as possible. If I leave anything out or if there is any aspect which needs further elaboration, I will happily come back to it.
Deputy O'Hanlon asked a couple of specific questions. The first was in relation to means testing for medical cards. He asked whether there could be an arrangement arrived at between the Department of Health and the Department of Social Welfare so that people who were already means-tested would not have to go through a further means test. There is co-operation and co-ordination between the health boards and Social Welfare. I have a certain reluctance in relation to this matter because the Department of Social Welfare operates a strict criterion: you are either eligible or not on a fixed basis. There is much more flexibility in the medical card criteria because the rates are guidelines and there is flexibility both in determining the entitlement and, more particularly, with the chief executive officer subsequently. While there is co-ordination, there would be people who might not qualify under strict Social Welfare guidelines who might well qualify for a medical card. Co-ordination is important but I do not think it should be the final arbiter of the person's entitlement.
A number of Deputies talked about the elderly and asked about services in the community and services which will be provided on foot of the enactment of the Health (Nursing Homes) Act. I will try to deal with a number of questions together. I have been working on the draft regulations under the nursing homes Act since I came into office. I had negotiations with a range of organisations. I think I listed about 20 organisations in response to a parliamentary question in the Dáil. I wanted to be as inclusive as I could to get the input of everybody. I had hoped genuinely that agreement would have been reached with the nursing homes organisations to allow me to implement the Act by 1 May. That did not prove possible. Two of the main interest groups, the Nursing Homes Association and the Catholic Private Nursing Homes have asked for additional discussions. They have set the date of 1 July and they have requested further discussions. The health boards are being given clearance to put the necessary administrative structures in place to implement the provisions of the Act and once the discussions with the interested parties are over I certainly want to commence the operation of the Act as soon as possible.
In relation to the community services, comments were made that there is a definite increase in the number of elderly. That is quite true. It is not a phenomenon exclusive to Ireland; thankfully it is happening everywhere as we increase longevity. Additional funds were made available in 1991 under the auspices of Deputy O'Hanlon to strengthen community services. The community support services are very important in enabling people for as long as they are able to live in their own homes. I very strongly support the increase in such services and it will be part of the strategy in relation to resourcing community care generally. I am aware of the comments of the Ombudsman in his recent report and I am happy to say that the nursing homes regulations, once they are enacted, will meet the points raised by him.
A number of Deputies talked about blocked beds, particularly in the Dublin area. As Deputies will already be aware, an addiional £500,000 was provided to the Eastern Health Board earlier this year to fund alternative accommodation for elderly people in acute hospitals who could be better accommodated in nursing home care and who did not need the acute level care they were getting. I am considering how further resources might be made available to deal with the problem as it may arise again with the onset of winter. Within a few days of coming into office I was met with a situation where because of an increase in respiratory problems a number of elderly people were admitted to general hospitals. This was inappropriate because they did not need acute care; they just needed a respite bed for a short period of time. I had to address the situation immediately by providing money to get them into a more appropriate nursing home setting. I want to address that in the longer term so that the situation can be dealt with on a continuing basis rather than on an annual emergency basis.
A number of Deputies talked in terms of the child care provisions and I am pleased that the recommendations of the Kilkenny case came to me so quickly. I am pleased that the report was circulated to all interested parties and that we have had a very expeditious and swift response to a number of very important recommendations. I believe it was right to establish a non-statutory inquiry. We could have had a statutory sworn inquiry that would have taken a year or more to get the same answers and probably with not as good a conclusion because staff would have been more reluctant to give forthright answers to a statutory inquiry. I am pleased with the way the report evolved. I know everybody in the House is most interested in providing the best possible care and support particularly for vulnerable children.
A meeting was held with the chief executive officers of the eight health boards to impress upon them the necessity to ensure that the recommendations in the report were put into place. A full working meeting was held with the appropriate programme managers to tease out the mechanics and mechanisms for implementing all the remaining sections of the Child Care Act. Bilateral meetings are taking place between each health board to agree specific needs under the Child Care Act. The £5 million which was made available to me allows me to put into place a structure to meet the needs that I outlined. I will give indicative ideas to this Committee in relation to how that £5 million is to be expended.
I engaged in discussions with each health board because I want to get the right mix of support staff. I have no absolute view in relation to the exact number of specialists required in each health board area. That will have to be teased out between now and the end of the year. I will indicate the types of specialists I am talking about rather than absolute numbers. We are talking about additional social workers, psychologists, child care workers for the existing children's homes, child psychiatric teams, increased and better staffing in the residential units, better hostels, quite a number of home makers to support families under stress, which I think is a significant new resource that needs to be available around the country, placement officers for difficult adolescents, improved support to foster parents, improved financial support to voluntary bodies who are active in the care of children and the expansion of day care services for children at risk. Refuges for battered wives were particularly mentioned and they certainly will be included in the resources provided.
There will be a range of other services. I will not waste the time of the committee by listing them. They are the sort of supports that will be put in place on foot of the extra £5 million that is available for this year, which is equivalent to £10 million in a full year and will be repeated for each of the next three years to enable me to bring in the sort of supports that are required to implement the Act properly. That will be welcomed by all parties in the House.
A number of Deputies also talked about the waiting lists initiative, Deputy McManus — I must make sure that the name is right — talked in terms of image and suggested that I was more concerned with image than substance. In five months exactly, since I came into office, the enactment of long awaited condoms legislation, the provision of realistic AIDS awareness programmes, a £20 million distribution of additional resources to attack waiting lists, a 12 per cent increase in the Health Vote in a very difficult year, agreement between the constituent hospitals authorities in the new Tallaght hospital, particularly the situation in relation to getting the Adelaide satisfied and the Adelaide ethos vindicated, a new drugs agreement for the next four years which was approved by Government this year and will mean substantial savings on drug costs across the public sector, would, I suggest, indicate a little bit more than image. I understand the Deputy's concern that there should be positive action but I am sure she is not churlish enough to think that all of that is without substance and I am sure on mature reflection she will feel otherwise.
I am admonished for not mentioning the £20 million waiting list initiative, so I would like to mention again that £20 million additional resources have been provided to attack in a real way the waiting lists which are a concern for every Deputy. The objective is to reduce waiting times. The crucial point that I cannot stress enough is that it is to reduce waiting time because numbers are a fluid entity. It is how long I have to wait for my hip replacement or my cataract operation or my cardiac treatment that I am concerned about, rather than the numbers of people who are on the lists. It is throughput rather than actual numbers that are important. The longest waiting times are in orthopaedic surgery, ophthalmology, ENT, cardiac surgery, vascular surgery and plastic surgery. I wanted to eliminate lists in excess of 12 months. Anything beyond that I felt was excessive. That was the import of the initiative and for children in the ENT areas the waiting time should be not longer than six months. Individual contracts have now been settled with health boards and health boards and hospitals have contracted to do specific work in relation to the waiting list initiative.
One Deputy said the allocation should have been made earlier in the year. I did not want to release the money earlier in the year because I wanted to have nailed down the normal 1993 throughput of each hospital so that the £20 million would not be absorbed into the general run. Once we agreed the working throughput for this year we would be talking about additionality to get real value for the extra money. The number of additional procedures being contracted for is in excess of 17,000 and I have given the details many times in the House. The number of people on waiting lists for over 12 months and, in the case of children, six months, is just over 18,000. There is a very substantial improvement to be made in relation to the waiting lists. If members wish me to do so, I can go through the number of procedures in each area, ENT, ophthalmology, orthopaedics, plastic surgery and so on, which are contracted for with each health agency on a specific basis.
Deputy Allen talked about the fear that this would have an impact elsewhere. That is why I wanted to have the throughput figures for this year agreed in advance. The out-patient throughput for 1992 was 1.5 million. There is a commitment by hospitals to maintain that level of activity in 1993. We are talking about additionality and we will be watching very carefully to ensure that we get it. Since the announcement of the £20 million, I have travelled around the country and I know there is a broad welcome from every aspect of the profession. Many health boards have been positively congratulating the Department in relation to this matter.
Deputy Flanagan mentioned cardiac surgery. Before I became Minister and since becoming Minister I have said I do not regard cardiac surgery as an unnecessary procedure. The number of people waiting for cardiac surgery is significant, at 1,300. I have determined that we are to increase the national throughput of cardiac surgery to 1,400 per annum which, on an annualised basis, is greater than the current waiting list. To do that I need to increase the capacity in the Mater hospital from the current 750 procedures to 1,000 procedures and to increase the Cork Hospital throughput from 200 to 400 procedures. That will cost £1 million and I have provided that. Capital investment in new theatre facilities will be involved in some instances and additional staff will have to be found on a permanent basis to maintain that throughput. That is something I am very pleased to have done. It will be of lasting benefit to the people who are waiting for cardiac procedures. That has been acknowledged by some of the most senior cardiac surgeons who have written privately to me to commend that effort and initiative.
Services for mentally and physically handicapped persons were mentioned by a number of people. I will deal with the general areas first, then I will go through the questions so that I can pick up anything I have missed. The following additional services will be put in place in 1993 for people with a mental handicap and their families. This is on foot of the additional £8.5 million for mental handicap services, the largest single increase for mental handicap services in the history of the State. It brings the total expenditure on mental handicap services to £209 million, an historic high. I am not suggesting that is enough. It will not be enough, but it is a very significant resource and it is a very significant delivery of commitment.
I understand Opposition Deputies in particular making much of the fact that we had, in my own party's election manifesto, a commitment for £25 million to implement what we perceived as being the necessary programme in the mental handicap area. I wish I could have delivered £25 million. I worked very hard before I became Minister for Health but right through the Programme for Government negotiations, because I have the interesting and unique distinction of negotiating with every party in this House. I say with absolute sincerity that the additional £8.5 million we delivered in this Programme for Government, which is additional money in 1993, would not have been delivered under the arrangement of the so called rainbow coalition. I know that from engaging those particular parties.
Deputy Flanagan's comments on additional moneys for a range of activities are in stark contrast to the views put forward by his party's Finance spokesman, Deputy Yates. My late colleague, Deputy Frank Cluskey, would say they are having an each way bet. Deputy Yates can say we need £200 million in public expenditure cuts and at the same time Deputy Flanagan can put on a different hat and say we need millions of pounds in additional public expenditure programmes. They cannot have it both ways. The people deserve to know what they are going to do. Trying to be all things to all men will not wash.
We have said £8.5 million is the amount of money we can provide. It is a huge additional resource which is welcomed by mental handicap agencies. We have done better than any other alternative Government that was on offer to the people at the last election.
(Interruptions.)
Let me spell out to the committee what the additional £8.5 million will provide. It will provide an additional 70 residential places, an additional 200 day places and an extension of respite services to support families. The reality is that if Deputy Yates was Minister for Finance there would be £200 million less available to spend.
(Interruptions.)
We should not have any interruption when any Deputy or Minister is speaking. There should be just one speaker at a time.
The Minister should tell the truth.
I have listened to an hour and a half or two hours of contributions and I have taken five pages of notes. I know the truth is painful for some. They are going to have to listen to me as I have listened to inaccuracies. I am putting the record straight and I intend to continue doing that.
There are additional home support services for between 800 and 900 families, improved services for those who are behaviourly disturbed, further transfer of people with mental handicap from psychiatric institutions into a more appropriate residential care, all very important. There will be extension and early intervention in child development services and further services. All these will be achieved.
I am not saying I am content with that but I am very content the commitment in the negotiated Programme for Government for substantial extra money has been delivered. The sum of £8.5 million is substantial in anybody's calculations and I am pleased to have been the Minister to deliver that.
The Green Paper on mental handicap, published last year was raised by Deputy Moynihan-Cronin. We have had in excess of 100 submissions on foot of that and the paper has received a very warm welcome from most of the agencies and individuals concerned. This is obviously very encouraging. A number of issues arise from the consultative process that need to be addressed. I am mindful of previous legislation in the psychiatric area which went through both Houses and was enacted but was never brought into force because it was considered to be flawed. I do not want to make the same mistake. I am most anxious that the consultative process will be as inclusive as I can make it to ensure that the psychiatric legislation will be as good as possible. I will not be confined in terms of a deadline to do that. I would hope to make a final decision before the end of the year but I am not convinced that I will be in a position to have draft legislation before the end of the year.
Many Deputies talked of the orthodontic and dental services in general and asked in particular what I was going to do with the additional £2 million provided in the budget. I have said in response to parliamentary questions that I am not happy with the dental services provided. That has been the case for a very long time, but we are making progress. Orthodontics has been a whole new growth area in the last four or five years and there is a huge demand for this service. What will I do with the £2 million? One million pounds of additional capital has been provided and the other £1 million is revenue. Of that £300,000 will be devoted to training health board dentists to provide an orthodontic service. Members will be aware that consultant orthodontists are provided in six health boards and we are still actively pursuing the other two to ensure that there is a consultant orthodontic service available nationwide. We want to train the health board dentists in orthodontics when the consultants are in place. It is an ongoing process and I have provided money for it.
A sum of £700,000 will be available for dental services for children under 16 on a phased basis. I have already indicated in my speech that I will extend eligibility to 14 year olds by the end of this year. The capital equipment will be provided from the sum of £1 million pounds to provide the devices and equipment necessary for orthodontic care. Obviously there will have to be a phased ongoing increase in dental services and in the provision for orthodontics in particular.
I was asked by one Deputy about drug prices. I am delighted, as I said, that I have come to an agreement with FICI, the umbrella organisation for the chemical industries in Ireland, on a very good deal for the health services. I would like to give the committee details of that agreement, which was only approved by Government on Tuesday. The main elements of the new agreement included a 6 per cent reduction in the cost of GMS drugs. This reduction is achieved by an immediate price decrease of 3 per cent on all drugs and an increase in the rebate payable on drugs supplied to the GMS scheme from 2 per cent to 5 per cent. Therefore, in real terms, it is a 6 per cent decrease in the cost of drugs to the GMS for this year and a further price freeze for three years subsequently.
The price freeze will, of course, be subject to review because I was concerned that some of the currency movement and fluctuations experienced last year were not allowed for. We will have an allowance for that so, if there is a currency fluctuation, we can also take advantage of it. In addition, the industry has agreed to give an ex gratia rebate to the State of £2 million to compensate for currency fluctuations. I am grateful and glad that is the case.
I believe the new agreement will have a very beneficial impact on drugs prices generally. It sets a headline for many negotiations because it is not usual to go into negotiation with suppliers, end up with a substantial decrease in cost and plan the next four years on that basis.
The whole area of immunisation was raised this morning and repeated subsequently under this subhead, so I would like to give the statistics in relation to immunisation rates lest any wrong impressions be created. I will give the Dublin and then the national figures. In Dublin, on average, the uptake is as follows: under the immunisation programme for diphtheria, polio and tetanus, which is the three-in-one, 80 per cent of children under one year are immunised; under the MMR programme, for measles, mumps and rubella, 75 per cent of children aged 15 months are immunised. Under the meningitis HIB vaccine programme there are no clear figures yet because the scheme started only last October. I relaunched it and have been in touch with a number of health agencies in relation to this, but all vaccine supplies have been distributed and there is an expected large uptake. I visited my own health centre and talked to the medical officer of health there and she is very pleased with the uptake.
The national figures are as follows: DPT, 60 to 75 per cent, DT, 95 per cent and MMR, 75 to 80 per cent. As I said, the exact figures for the HIB vaccine are not clear but over 200,000 doses have been distributed to date.
I hope that sets the record straight in relation to the figures for vaccination, so that there will be no fears about immunisation programmes.
I answered a question in relation to medical indemnity in the Dáil in a comprehensive way on 3 June. A specific question was asked regarding the cost of medical indemnity for the State. I will just give the committee those two figures. Last year the outturn figure was just over £13 million, at £13.1 million. This year the expected total figure is £16.7 million, of which £12.1 million will be the cost of indemnity refunds for consultants. A sum of £1.1 million for GPs and others, bringing it up to £16.7 million include indemnity for NCHDs, dentists and public health doctors.
An interdepartmental working group is examining the whole area of medical indemnity. The group has completed the first part of its remit and has submitted the interim report to me. A revised medical indemnity scheme was introduced on foot of that which includes non-consultant hospital doctors, dentists and community doctors.
The group is now proceeding to the next phase which is examining medical indemnity for consultants. As soon as that is arrived at, a number of decisions will be made. I have outlined in some detail my responses to that. There are a number of options open to us. We could do a number of different things to address the whole area of medical indemnity, but I am concerned that it is a growing feature of medical costs generally. I am concerned that we are more litigious, as a people, and we will have to look for other ways, rather than the traditional ways we have dealt with that, because the figures I have just given are alarming.
Deputy Flanagan referred to what he described as a crisis meeting of the health board in the midland area regarding its budget and I have asked my officials to talk to the chief executive officer of the Midland Health Board to get an update. Apparently a normal meeting will take place today——
It is a monthly meeting.
Why did the Deputy talk this morning of a crisis meeting?
The crisis is in the health board.
At its normal meeting today, I understand the board is considering a report from a sub-committee which is appointed to present a case for additional resources for the area. The Deputy will be aware that it is the area I visited most since I became Minister for Health. I think I gave fairly good news to Tullamore, Mullingar, and Portlaoise. These were the three priority areas submitted to me for additional resources. All three have been met within the first five months of my being Minister for Health and I do not think, that from the warmth of the reception I was given in each of those areas, that there is any particular emergency or crisis. I will, of course, listen to any submissions from the health board in relation to future service developments.
Why has the budget not been accepted by June 1993, if there is no problem?
I have no difficulty in listening to any particular submissions I receive, but I am aware that the additional resources provided under the additional capital programmes and the additional money under the waiting list initiatives have all been particularly welcomed.
Deputy Allen talked about the public/private mix and that obviously is a very important issue. When I was in Opposition I was concerned to ensure that access to proper health care was not determined by the thickness of one's wallet. That will characterise the way I approach negotiations with health agencies on the delivery of health services around the country. I agree with a large part of what Deputy Allen said in that regard. I dealt with Deputy Allen's comment in relation to the out-patient/in-patient impact. As I said, we have nailed down the throughput figures for this year separately.
Deputy McManus talked about family planning roles for health boards. I see a role for them, it will be part of the overall strategy addressed on foot of the national strategy which will map out the work for the Department over the next four years.
In relation to the clean air theatres in Galway Regional Hospital, I did not say they should get the £300,000 needed for that from their allocation. I went to Galway and I gave them an extra £300,000 to open those theatres. That was welcomed by the chief executive officer in Galway city and I think there was some local publicity about it. It was an additional sum of money. I am glad that the facilities in place can now be used for the welfare of people in Galway and the Western Health Board region generally.
Deputy Higgins and others raised the issue of dialysis. There are a number of requests for dialysis across the country and three in particular are at the top of the agenda in terms of demand, Castlebar, Tralee and Cavan. I am aware that people travel long distances for dialysis and I understand the inconvenience and trauma that can sometimes be part of that whole process. The running costs of those units is an additional £1 million a year. I do not want to segregate one but the claims of Castlebar, Tralee and Cavan are equally strong and I will be pressing as hard as I can to equip all three as soon as resources become available.
I dealt with the mental handicap services and the waiting lists. As Deputies will be aware, some agencies in the voluntary sector are funded directly by my Department and others by way of health board allocation. The one issue that I am most anxious to avoid is allowing voluntary agencies to have it both ways, in other words, to get an allocation from the health board and then to come to the Department of Health seeking a further allocation. If they are directly funded that is the end of it. I am looking at the structural area of health boards. A lot of work was initiated by my predecessors in relation to this matter in having better co-ordination in structural terms and accountability and in relation to the voluntary statutory bodies in each health board area. Whatever structural reorganisation is necessary will be brought forward as soon as possible.
The role of condoms was also raised by Deputy Kitt. I am satisfied that condoms, if used properly, provide a mechanical barrier for the prevention of the transmission of the AIDS virus. That is the opinion available to me from the World Health Organisation, from the centre for disease control in Atlanta in the United States and from the Paris coordination centre on AIDS. I asked my Department to check all the available data and, so far, there are 40 additional reports available. They all come to the same conclusion. There is no definitive scientific data that in any way runs counter to that conclusion. Obviously, nobody can guarantee that the use of a condom will prevent the transmission of AIDS. The only guarantee of that, as I have outlined more than once, is celibacy or being faithful to one partner who is faithful to you, assuming neither is a HIV drug abuser. Obviously, that is the ideal but if people are sexually active then we have to encourage them to be responsible in their actions and minimise the risk of transmission, to the best of our ability. That is the underlying philosophy of the legislation and the AIDS campaign that I authorised and have been running for the last couple of weeks.
I dealt with medical defence, the Beaumont inquiry, the cost of recruitment of consultants and so on. I am worried about the cost of the Beaumont inquiry. It is a significant sum of money which has been charged to the Medical Council. We will reflect on their conclusions and see what lessons can be learned when it is over.
Deputy Flanagan also said something when he spoke about the Midland Health Board this morning which I want to deny. It is inaccurate to state that substandard bandages are used in the Midland Health Board. Whatever about light bulbs, it is very important that patients in the charge of the Midland Health Board understand they are getting the best quality care. We all score political points but we should not do so by undermining confidence in a health service in the Midlands of a very high standard.
I understand that the Midland Health Board won awards for its catering facilities which is an interesting counterpoint to that made by Deputy Flanagan. We must be careful in relation to the points we make.
As regards the EC directive on the training of nurses, I am concerned that there may well be in the future, if the current directive is not followed through as we would expect with another directive on specialist nursing, a compartmentalised nursing service. I will raise the matter in discussions with my EC colleagues to ensure that there is not a compartmentalised or stratified level of nursing. We must attract nurses of the finest quality, such as we have, to each specialist area.
In relation to the directive on the working week a fear was raised by Deputy Flanagan in relation to non-consultant hospital doctors. For the information of the Deputy and the committee, NCHDs are not covered under that directive. Deputy Leonard talked in terms of the national health strategy and the best use of resources. I agree with his remarks. I also agree with his comments in relation to a more clearly defined waiting list. People apply to more than one hospital for the same procedures. There are people on waiting lists for cardiac surgery who have already had angioplasty and no longer need surgery, sometimes people change their minds. We need to constantly update our waiting lists.
Drug prices were raised by Deputy Leonard and I am very glad the FICI agreement was endorsed and approved by Government. It will be the guideline in relation to drug prices over the next four years. I understand his point in relation to the North-Eastern Health Board being in the lowest level.
Immediately following the allocations, every health board, except one, said that it was the most badly treated in the country and particularly disadvantaged in that its per capita allocation was worse than any other. This was an interesting phenomenon. A very complicated list of issues must be addressed. It is not simply a per capita basis but depends on the geography, the level of service available, the population and the age profile. All these things are taken into account and there is a very fair allocation. I do not think the north-east in particular can have any gripe this year about allocation.
Deputy Moffat spoke about Castlebar and the issue of dialysis. The capital works I outlined were not intended to be exhaustive but I will take careful note of what he said.
Deputy Kenny mentioned acute bed blocks. I also dealt with AIDS prevention and education programmes. Deputy Theresa Ahearn spoke about nurses and I do no think Mercer's hospital is bearing the brunt of cutbacks. I greatly appreciate and have applauded the work of nurses, we should be aware that there has been a significant increase in their numbers in recent times. At the end of December 1988 there were 23,036 full-time nurses employed in the health services and at the end of 1991 this had increased to 25,215. This number has increased further since then. The exact figure is being checked for me.
That does not mean extra staff?
No. We are talking about the number of nurses available to carry out the services. We must know the facts and the figures and be accurate in these matters. I join the Deputies in commending our nursing staff, we are extremely well served by a very motivated, skilled and dedicated staff.
Deputy Ahearn also spoke about uncertainties in relation to hospital services in the south Tipperary area. I do not think she would expect me to decide what is appropriate for the South Eastern Health Board. That is a matter for it. It is the local representatives and when it makes a decision I will be very happy to hear it. Obviously I have more than a passing interest in the South Eastern Health Board.
I acknowledge the time and the detailed replies the Minister has given.
Is the Minister satisfied that the present structures in the health board are adequate or is there a need for a separate child care section? Arising from the Kilkenny case did all programme managers undertake a review of their existing case loads? Were they instructed to do so? If that has not been done it should be to ensure that no other cases fall through the net.
I have appointed a child care unit within the Department to co-ordinate the national child care policy unit, devise the draft regulations and motivate and drive the health boards. Currently at health board level, child care is structured as part of the community care programme but each health board has now been instructed to proceed with the appointment of a particular person in the management support unit to be responsible for both the development and delivery of child care services. That instruction has been given by my Department to each health board to ensure that the precise arrangements in relation to the delivery of child care services are met in each health board.
The child care advisory committees have now been established in each health board and I anticipate that their establishment and the new management structures which will be in place immediately will put the whole area of child care on a much sharper and more professional basis. The additional resources to be allocated immediately should complete the child care provision at local community level.
I give credit to the Minister for making that move. I was worried that since the Kilkenny case we had not done anything specific. It is important to have an accountable co-ordinating manager. It was very obvious in the Kilkenny case, that management structures to co-ordinate people's efforts were lacking.
I commend the Minister for carrying on the fine tradition of previous Ministers of Health, Deputies O'Hanlon and O'Rourke over the last number of years. A report commissioned some years ago into the hospitals in Cork, the Kenny report, is on the Minister's desk. Will any action be taken regarding that report in the near future? Cancer treatment is a large cost element in any hospital and in the Cork region there is no oncologist. It is important that we would have the services of an oncologist. Will the Minister tell us whether he is considering the provision of such a service?
In relatlion to the Kenny report, Deputy Ahern will be aware that I circulated it for observations to all public representatives and local authorities affected in the Cork region. I am waiting for their replies. I have received some, not all enthusiastic, about the recommendations included in the report. When the discussions are over obviously I will have to make decisions. I have taken note of the Deputy's views in relation to the need for an oncologist in Cork. I will reply directly to him.
My question on subhead B.2 refers to the disabled person's maintenance allowance, a very useful and helpful allowance for many people who cannot avail of support by any other means. The Minister will be aware of a number of queries that I raised regarding situations which arise where people may end up in the poverty trap, for example, if a spouse earns any extra income outside the home, the recipient of the disabled person's maintenance allowance can be penalised on a pound for pound basis. While I agree that the payment of this allowance, given its nature, needs a certain amount of means testing we have experience in other areas, mainly in social welfare, of the damage caused by the poverty trap.
Does the Minister consider it appropriate that the disabled person's maintenance allowance should be administered by the health boards? There is an unemployment scheme, an unemployment assistance scheme and a disability benefit scheme but there is no disability assistance. In fact the disability assistance is the disabled person's maintenance allowance administered by the health board. The disabled person's maintenance allowance is a means tested allowance. In this age of computerisation, the Department of Social Welfare have easy access to people's means. As a result of changes in the social welfare Acts over a number of years, there are more people nowadays looking for disabled person's maintenance allowance, which, to date, has been paid out of the health board's budget which in many ways is unfair because the board must meet it from what they would normally spend on hospital beds or elsewhere in the community. Have there been any discussions with the Department of Social Welfare to arrange for it to take over the disabled person's maintenance allowance and to provide it as a disability assistance for people who are medically unfit for work?
I have two brief questions. One relates to the long term illness scheme and the other to the drug cost subsidisation scheme. Will the Minister explain why no allowance is made for an anticipated growth in demand and how that decision came to be made in relation to the long term illness scheme? The statement about the drug deal with the companies, which is very welcome, relates to GMS drugs but the problem about the drug cost subsidisation scheme is that it deals with drugs outside the GMS. If the Department has not allowed for any increase — indeed in effect it has built in a decrease because of the 3 per cent inflation — how will that problem be solved if there is a shortfall?
I agree with the point raised by Deputy Gallagher of the hardship inflicted on spouses of people on disabled person's maintenance allowance because of means testing. It is particularly anti-women. I know the Minister said on a previous occasion he is reviewing the matter but I would like to stress the urgency. I agree with the point made by Deputy O'Hanlon as far as the disabled person's maintenance allowance is concerned, that perhaps it may be more suitably the preserve of the Department of Social Welfare. There is a serious information problem regarding many of these allowances through the health boards and I would like the Minister to consider an information scheme. Many people in different health board areas are unaware of allowances — particularly the domiciliary care allowance for the handicapped. There is a huge gap in the service from an information point of view. Obviously it suits the health boards if people do not know their entitlements because they save money. The Department should direct the health boards to make information leaflets available so that the public may be informed of schemes and facilities.
One thing causes considerable difficulty from time to time, the accompanying free travel pass with the disabled person's maintenance allowance. There seem to be huge delays in qualification for the free travel pass. I cannot understand why there should be such delays but it seems to be a recurring problem. Perhaps the Minister will say how this matter might be addressed. In the overall context it is a very small problem but one giving rise to individual hardship.
I have two brief questions. In relation to what Deputy Flanagan said would the officials send me on details of the DPRA scheme, the disabled rehabilitation allowance and the mobility allowance for handicapped persons.
In relation to the long term illness scheme, I also have a query about the freezing of the amounts. Is the long term illness scheme now effectively frozen, written off, with no plans to include any other conditions? Is the drug cost subsidisation scheme now the Department's chosen means of assisting those with long term illnesses that are not the very limited list covered by the long term illness scheme?
Deputy Gallagher mentioned anomalies in relation to disabled person's maintenance allowance and I largely support what he said. Everybody is inclined to compare social welfare schemes with this particular scheme under my ambit but there are differences. The disabled person's maintenance allowance scheme, for example, does not take into account home support or home maintenance as part of the determination whereas a means tested social welfare scheme would. Therefore, a disabled person's maintenance allowance recipient would be advantaged in that. Notwithstanding that, anomalies need to be addressed and I am doing that.
A much more fundamental question was raised by Deputy O'Hanlon in relation to the administration of disabled person's maintenance allowance generally. I support the idea that it would be more appropriate if they were in an inclusive way in the Department of Social Welfare. I have already written to my colleague, the Minister for Social Welfare, expressing that view, one I held in Opposition and which has not changed. Deputy Flanagan raised a point on free travel passes which are issued by the Department of Social Welfare. It is another argument in favour of better coordination. There is a body of argument now in favour of that and I will certainly continue to push it with my Cabinet colleagues.
In relation to the moneys listed under the subhead for disabled person's maintenance allowance purposes, the same answer will apply to the long term illness scheme and the drug refund schemes. I was asked why there is no allowance for increases this year. There never is. They are demand led schemes and the understanding we have with the Department of Finance is we cannot predict how many new claimants where will be for disabled person's maintenance allowance; we cannot predict the number of drug claims during the course of the year so by practice and understanding — because they are a demand led scheme — anybody who applies for them will get them. As we do not know how many will apply, we need to meet the amount at the end of the year by a supplementary Estimate. That has always been the way and will continue to be the practice. The figures are the outturn figures for last year, upgraded for inflation.
The FICI agreement will have an effect in pushing down the price of drugs generally. I am working on the mechanisms for doing that. I will not be specific but it will impact in a positive way from the Exchequer's perspective.
Deputy Flanagan raised an important issue of information about health services and entitlements. I find sometimes when people ask specific questions that you have to rack your brains and perhaps make a 'phone call before you can give a precise answer to a certain set of circumstances. For that reason, I have asked my Department to prepare a comprehensive booklet of health information and I am glad to inform the committee — I hope Deputy McManus will forgive me — that it will be launched publicly next Monday. I am sure it will be welcomed by everybody as a comprehensive guide to the health services. I will provide copies for every Member of the Oireachtas and I am sure they will be well thumbed before long. I accept the point Deputy Flanagan made and I hope the publication of this information booklet next week will go a long way towards providing that sort of information to the public at large. Copies of it will be available to all the various agencies dealing with people, the NRB, the National Social Services Board, the community information centres, local authorities and any place else that require them. That will be available from next week and I know the Deputy will welcome that. In conjunction with that information leaflets on specific schemes are also being prepared and will be available from next week.
Will the drug cost subsidisation scheme replace the long term illness scheme?
I have not added the long term illness scheme to the listed illnesses since I came to office. There are four different drug refund schemes now available and I want to see how they work. I have been lobbied by various interest groups but there is a very significant cost to automatically giving an entitlement to a particular category of illness without reference to income or anything else. I am not sure it is the most cost effective way of dealing with scarce resources and impacting on people's real drugs needs. I will certainly keep the matter under review to see how the various schemes inter-relate. I hope the best possible comprehensive scheme will be provided so that, ultimately, nobody with a certified long term illness will pay more than the £8 per week agreed under the current schemes.
As we have 28 minutes left before we conclude, we will take the remaining subheads B.3, B.4, B.5, B.6 and B.7. Is that agreed? Agreed.
On Subhead B.3 — Medical Cards — the Minister made a very welcome announcement soon after taking up office that they would be allocated on the basis of net rather than gross pay. However, his move this year was confined to the employees' PRSI which is a very tiny element of the total cost of PRSI and tax. It is a welcome step but it does not remove the anomaly and many discriminations against people at work. Obviously, I would encourage the Minister to move ahead with that as fast as he can.
What progress can the Minister report on the appeals system for medical cards, with particular reference to the independence of such an appeal system? The eligibility has given rise to some concern. Different health boards adopt various conditions, requirements and contingencies. An appeal system, if it is to be satisfactory, must be independent.
Secondly, as regards the GMS, I welcome the concept of the GP units in each region. What is the present status of the units? How many do we have and how many is it foreseen we will have? I do not see an individual budgetary allocation in the figures but I am sure it is there. Perhaps we could have some information on that.
How will the fund for the development of general practice be deployed?
In relation to subhead B.4, the non-pay element shows a reduction of £8 million. How will that be managed over the coming year? The pay elements are all up, that is inevitable and taken care of but the non-pay element in subhead B.4 shows a reduction over 1992-93 of £8 million. How is that to be sustained?
I had to go to another meeting in the last half hour and I am sorry if these questions have been asked already. In relation to the agreement on drugs costs, will the Minister indicate what savings will be made under the non-pay element? Perhaps that is part of the point made by Deputy McManus. Will the Minister also indicate, in relation to the Child Care Act, 1991, what contribution the £5 million additional funding in 1993 will make in regard to its full implementation and give us information on what is being done to follow up the recommendations made in the McGuinness report?
Finally, will the Minister comment on the arrangements agreed for the future management of Tallaght Hospital.
Before the Minister comes back on Subhead B.4 (2) — emergency grants on behalf of the health boards and certain other health bodies — notwithstanding the fact that it is a public hospital, some reference will have to be made to the situation in St. Ita's, Portrane. Will the Minister address this problem? It is giving rise to serious concern at a time when great emphasis is being placed on concern for psychiatric patients. It is an intolerable situation which requires the urgent attention of the Minister.
On the matter of funds for the mentally handicapped, it is important to give consideration to the level of general medical care available to residential mentally handicapped patients in terms of regulations for general physical check-up for people who may have a disorder requiring medical attention but who, because of their handicap, are unable to bring that problem to the attention of the authorities in the institution. Strict monitoring by way of regulation is essential. I would go so far as to say that perhaps there should be an annual physical check-up for people who may not be in a position to make a formal complaint to their general practitioner regarding an illness or ailment. Often it is too late and they are at an advanced stage of illness when the attention of the appropriate medical practitioner is drawn to it. Greater consideration should be given to the area of prevention.
On the matter of child care services, I agree with Deputy Bell who expressed concern on the matter of the follow-up to the Kilkenny report. In short, I formally suggest to you, as Chairman of this committee, that a day be set aside during the summer months for this committee to examine the report? The debate in the Dáil was less than satisfactory. It was an excellent report and credit is due to the Minister for the manner in which it was commissioned and published.
In relation to subhead B.4, Part 2, I notice in the allocation of grants for homes for mentally handicapped persons administered by voluntary bodies that there is an increase of almost £11 million for the year. I assume that is part of the initiative which the Minister has taken in relation to services for mentally handicapped people. Will he elaborate further on the detail of that allocation?
Subhead B.7 relates to the national lottery. There is a decrease there which is explained in the attached note. I would like some further elaboration on the allocation to specific services made from national lottery funding.
Regarding psychiatric services, Deputy Flanagan mentioned St. Ita's Hospital. I also wish to raise the general question of the care of the mentally ill. There seems to be a balance in favour of psychiatry rather than psychology. I understand the ratio of the number of psychologists per head of population is extremely low. Does the Minister have any plans, perhaps under the implementation of the Child Care Act to increase the number of psychologists working in our health care system?
In relation to child care services, under subhead B. 7, a full meeting on the implementation of the Child Care Act would be in order at this point, given that it tops the agenda in terms of resources promised and social consensus. I fully agree with holding such a meeting out of plenary session time.
In relation to child care services, one aspect is being put on the back boiler, inevitably, given the demand for resources. Because of the high incidence of alleged child sex abuse, we are concentrating on those aspects of the child care legislation which deal with child protection and child safety in cases of child abuse, but there is an outstanding section in relation to the regulation of pre-school care. This will be shelved because of the push for very valuable resources in other aspects of child care. It might be in order for the Minister for Health to give this area over to the Minister for Education or to the Minister for the Environment or, perhaps, devolve it to the local authorities. There is a vacuum in relation to policy and legislation at the planning and subsequent stages, for people setting up pre-schools, for parents sending their children to pre-schools, for their administration and for the required hygiene and regulatory standards. We cannot afford to put this off forever. What are the Minister's views?
Before the Minister replies, I would like to draw the attention of Members to a slight omission from the brief they were given. Subhead B. 6 which refers to the grants to research bodies is missing. A brief note is being circulated to Members about it now. This subhead covers the grant to the Health Research Board, a statutory body with primary responsibility for co-ordinating health research in higher education institutes and hospitals.
In regard to subhead B. 5 relating to the homes for mentally handicapped administered by voluntary bodies, St. Michael's House is the major provider of this service in my constituency and in most of the north side of Dublin city. The Minister indicated that there will be 70 additional places. In the Eastern Health Board region alone we need about 1,400. I presume this is the beginning of a programme of additional places. Are there any applications to the Minister for provision of additional residential places on the north side of the city? At what stage are those applications? There is a great need for them.
The list of questions on subhead B is wide-ranging. I will try to be as comprehensive as I can.
Deputy Flaherty asked a question in relation to the announcement about medical cards being allocated to persons on their net rather than on their gross incomes. That was not announced. I, very carefully, said that as an initial step, for which many people had argued for a long time, PRSI contributions would not be taken into account, in relation to the determination of entitlement. It is a significant step for some people, it makes the difference between being entitled and not being entitled to a medical card. I do not wish to trumpet it, but it is a great success. It is a move in the right direction. PAYE workers in particular have felt disadvantaged in relation to other categories of workers in terms of applications for medical cards. I think the distribution of medical cards would lend some weight to that belief. Therefore, it was a step in the right direction although I accept that there are other steps to be made before we have equality in relation to the treatment of medical card applicants.
With regard to the appeals mechanism raised by Deputy Flanagan, I am determined, as I said, to put in place a national appeals system. Most Deputies are aware that there is at least a feeling that eligibility is determined by where one applies and that some programme managers or chief executive officers allow medical cards in certain circumstances while the same circumstances would not be accepted for eligibility in a different health board region. To overcome that, I have asked my Departmental staff to prepare a memorandum in relation to a national scheme. I will have to go to Government in relation to this because, like everything else, there is a cost implication. Final proposals are being put together now for submission to Government. I hope to come back to this committee and to the House with details when it is approved. I agree with Deputy Flanagan that it will be crucial to have the right people making the determinations. Obviously they will need to have certain skills which will be important.
Several Deputies talked about GP units. As part of the 1992 GMS agreement concluded at the end of last year, the Government is investing a sum of £12.5 million in the development of general practice. Nine million pounds of this fund appeared in the Book of Estimates under subhead B.3 which is a fund for the development of general practice. The investment of £3.5 million under subhead B.1, grants to health boards, is in respect of improved rostering and out of hours arrangements, practice maintenance, equipment and development, supplementary grants towards the employment of practice nurses and practice secretaries. The balance, a sum of about £3.5 million, will be expended in respect of the establishment of the GP units at both local and national level, in improvements in care in specific areas and in the implementation of the recommendation of the blueprints on general practice developments. If Deputies want very detailed replies I will be happy to give them to them separately. Rather than giving a long answer now I would just say there is an investment package of £12.5 million in general practice. That is very important.
GP units have been established in most health board areas and will be established soon in all areas. I have seen some of them already in my travels around the country. They will have the effect of resourcing primary care. We have had discussions at Question Time in relation to this matter. I have an ambition to allow the development and growth of primary care facilities and health centres. I want to talk about health centres, particularly, when we get on to the topic of the capital programme so I will leave it until then. I am well disposed to focusing whatever resources I can get my hands on to improve primary care and that will be done in the course of the next few years.
Deputy McManus referred to Subhead B.4 — voluntary hospital and homes for the mentally handicapped. I assure the Deputy that this does not represent a reduction in the capacity of the hospitals and homes to deliver the agreed level of service for this year which will be at least equal to last year's approved levels. The overall provision under subhead B.4 has been increased by £20 million. The reducition in the non-pay provision will be compensated by increases in direct income to the hospitals from the treatment of VHI members and by savings which will be achieved under the value for money programme.
Some Deputies were a little disparaging this morning about a programme of value for money and we must address that. An energy audit in our hospitals, which is a value for money programme, must be welcome from the economy and environmental fronts. We need to look at ways of saving money, for example on heating systems. We could start in Leinster House — and then go outside my health board area — to look at heating systems and the way we spend money on them.
There will be savings in relation to the way we buy. I am encouraging common purchasing and better negotiation for the purchase of equipment. We can make and have made savings and obtained better value for money. I do not think anybody should be disparaging about that. It has implications not only from a cost basis but, in some instances, from an environmental and quality of care basis where one can get better deals all round. I hope that explains the changes in relation to that subhead.
Deputy Bell asked about child care provision and the £5 million. I have answered that at some length and he will forgive me if I do not repeat it. The Deputy also asked about Tallaght Hospital. I am glad we now have an agreement in relation to the structure of the board of Tallaght Hospital as it has been talked about for a long time. It was potentially a very divisive issue and I publicly commend the great efforts of Professor David Kennedy and Mr. David Kingston who acted as facilitators between the three hospitals and reached an agreement which safeguarded the vital interests of all the hospitals. There is a new enthusiasm from the hospital staffs in regard to going to the new campus. I put huge pressure on since I became Minister in January to achieve the Tallaght project. I commend the trojan efforts from the staff of my Department. Some people have burned the midnight oil, lost weekends and worked consistently to ram this whole project through at a pace most people felt, at the beginning of the year, was unattainable. I hope the tender documents will be approved in the next few weeks and that construction work will commence, as promised, well before the end of this year. It is a great credit to the facilitators who negotiated the agreement, to the Tallaght Hospital board itself which was so patient in the past and which was encouraged to get moving from the beginning of this year and really put their backs into it. Not least, I commend the facilitators, David Kennedy and David Kingston, for their marvellous work. Without them, it would not have been possible to get the required agreement.
Deputy Flaherty asked a question about St. Ita's Hospital. It has been given an additional immediate capital allocation of £200,000 this year to upgrade facilities. I am accelerating the process of moving mentally handicapped patients from inappropriate care to more appropriate care. There has been staff reorganisation and most people will agree that there has been a very significant improvement generally in the facilities provided in St. Ita's Hospital.
Deputy McManus said that St. James's Hospital was not achieving its targeted income. I have rechecked that and it is simply not true.
Deputy Gallagher talked about additional resources for the mentally handicapped. As part of the £8.5 million, I gave £2 million directly to the voluntary agencies because they were fairly threadbare, in resource terms. I have given them £2 million of additional money to put them in a slightly more comfortable position.
Two changes explain the decrease in the national lottery allocation to the Department of Health. One is the end of the once-off payment to haemophiliacs, which was a very sizeable sum of money last year. I am very glad that haemophilia sufferers got that additional allocation. The other is that some items funded from the lottery in the past have now been incorporated in the core vote, which is a better way of dealing with it.
Deputy O'Donnell talked about pre-school elements of the Child Care Act. There is a difficulty here to which I have to alert people in advance. When we enact the provisions of the Child Care Act in relation to pre-schools and enforce standards, a great number of them will close because they will not comply with the standards. That will have a very significant impact, so I am hastening slowly in encouraging people to bring themselves up to the standards instead of implementing legislation which would close down a huge number of facilities and, I think, would have a number of very irate parent payments on our backs very quickly. I will not move from the required standards the Oireachtas has set for pre-school services and I am encouraging health boards to prepare people for the legislative impact of bringing these provisions into force. However, I want to warn people that there will be an impact.
Deputy Flaherty mentioned St. Michael's House under subhead B.5. The allocation of specific places is a matter for the co-ordinating committees in each health board region. All voluntary bodies in the mental handicap area are represented on the monitoring committees. Therefore, rather than deciding, myself, where the particular places are to go, I have given the allocation to the health boards on the basis of the perceived need in each health board area. I have left it to the mental handicap co-ordinating committees to designate the exact expenditure, the specific places and their exact locations.
Will the Members agree to forego their concluding statements to take the remaining subheads of this estimate?
Deputies
Agreed.
We will take subheads C, D, E, F, G1, G2, H and I together.
Under subhead C, we are all concerned about the proposal to move the register from Dublin to Roscommon. We would all like to see Roscommon facilitated but this move takes the register from the location of the highest population density. Many arguments have also been made against the move on the grounds that the established tourist and other genealogy, traffic related to it has been established and will have to be relocated. Does the Minister have any up-to-date information on the Taoiseach's thinking in relation to this, because he announced it originally?
Under subhead C, is it proposed to have a register of stillbirths? That would be relevant to the reorganisation of the registration process.
On subhead G.2, in relation to people allegedly damaged by vaccination, particularly the pertussis vaccine, I see there is no money for this at the moment. I know the Minister is releasing files to the relatives and families of people who claim they have been damaged by vaccines. Is he releasing those files with a view to facilitating litigation by those families or is he considering, as I proposed earlier this month, a trust fund to deal with the finite number of families who have been and could be assessed again with a view to compensating them? They should not be dragged through the courts.
The Commission for the Status of Women made a number of recommendations in relation to the registration of births and the choice of name used. Will the Minister look at these with a view to implementing some of them?
On subhead C, I share Deputy Flaherty's concern at the proposed transfer of the General Register Office to Roscommon. I understand it was an overall Government decision. Has the Minister considered the matter with the Minister for Tourism? Obviously the Minister will agree on its importance for tourism. There will be a certain amount of inconvenience caused by virtue of having to travel to Roscommon for records.
I do not see reference to a register of stillbirths. I take it that this would be the subhead under which such funding would be allocated. Does that mean that we will not have the register of stillbirths this year? The Minister accepted the need for this and indicated his intentions in that regard. I would hope that we will have such a register.
In relation to subhead G.2, dealing with payments in respect of persons claiming to have been damaged by vaccination, my concern is that there are children at risk because they are not being vaccinated. Maybe the Minister might shake himself out of his complacency in this regard. It is unfortunate I do not have a chance to go into this because I looked forward to setting the record straight. I resent deeply the accusation that I am being alarmist. It is not I who have been alarmist. There are doctors also who feel this. Irish immunization rates remain low. I have all kinds of studies and reports that would challenge the Minister on this. I would have been quite happy to hear him say that he is concerned, that he is going to act on it and that he will try to deal with the matter. He has not taken that approach and I want to state my dissatisfaction and disappointment on that point. There may come a day when somebody will challenge the Minister about damage from lack of vaccination rather than from vaccination.
We should look at the question of how we can get through the Estimates and still have some means of wrapping up outstanding details which inevitably arise during the debate. Madame Curie only took 12 minutes to give her dissertation on X-rays and we might learn from her conciseness. There is a point in relation to vaccination that I can only raise now, even though clearly it is not appropriate. There is a serious problem that must be tackled. In one area in the Eastern Health Board region the vaccination has only a 48 per cent uptake. The MMR is the only form of vaccination that we can seriously discuss because it is the only one that has a proper reporting system. The uptake which we need is 90 to 95 per cent.
I am totally dissatisfied with the response on this. I ask the Minister to deliberate on the need for a proper, effective immunisation campaign. He can have all the photocalls he likes on this one. I will not knock him for it because that is the message we must get across. At the moment parents are afraid to vaccinate their children. The media have the set the pace and it is up to the Minister to redress the matter.
Deputy Flaherty and others raised the GRO and the implications of the previous Government's decision to relocate it to Roscommon. Since I became Minister I have been looking at it. I have received a number of queries and submissions both from local authorities and individuals in relation to it. I am examining the implications and ultimately will have discussions with my Cabinet colleagues, including the Taoiseach. Whatever decisions are ultimately implemented will have to ensure that there is an adequate facility in Dublin for genealogical research at a minimum. I hope that whatever final arrangements are arrived at will satisfy everybody.
In relation to Deputy O'Donnell's query on the stillbirth register — a point echoed by Deputy Flanagan — I am committed to the establishment of a stillbirth register. The Minister for Equality and Law Reform is working on that as it has been transferred to his area. He has advertised for submissions and hopes to bring legislation forward very quickly.
On subhead G2 and the whole issue of vaccine damaged children, the subhead is just a token subhead of £1,000 that could be used if needed.
I authorised the release of files in relation to analysis carried out by an expert group into possible vaccine damaged children in the past. No doubt the legal representatives advising parents and families in such circumstances will do whatever is best for the children or adults concerned. I do not think the notion of a fund set up by my Department should be considered at this stage.
The Commission for the Status of Women recommendation in relation to discriminating application forms is a matter that will be looked at. It is primarily the responsibility of the Minister for Equality and Law Reform but as it impacts on the health services I will look at it myself.
Regarding the point made by Deputy McManus on vaccination, I have given the figures presented to me by my Departmental staff. I accept their accuracy. It may well be that there are individual locations — I accept the good faith of Deputy McManus — in the Eastern Health Board area where there is a significant below par uptake in vaccination. That would cause me concern. I will reflect on the figures available to me and contact the Eastern Health Board to get specific data to ensure that the maximum possible number of vaccinations are carried out.
I share the Deputy's concern that adverse publicity arising out of perceived or real damage that happened some time ago might in any way discourage people from taking up a vaccine programme for their children. I have made public statements about the matter. I will look again at the uptake for all vaccination programmes and see how best we can address the problem of low take up. Perhaps we could involve the health promotion unit in my Department, as well as the health boards, in seeing how black spots could be addressed. I am sorry the Deputy is disapproving but I suppose we could not get through the day without the Deputy being disappointed in some way by my responses.
We are not talking about black spots. There is not one place that I can find that has a 90 to 95 per cent uptake. We are talking about the entire programme.
I have given the figures available to me. I obviously would prefer 100 per cent uptake but in the Dublin area for the three-in-one — diphtheria, polio and tetanus — the uptake is 80 per cent and for the MMR it is 75 per cent of children aged up to 15 months. We do not have figures for HIB vaccine because the programme only started. That is not ideal but it is hardly of the proportion that would cause us all to panic unduly. I will bear what the Deputy has said in mind and see how we can devise programmes to improve the uptake.
All immunisations are not recorded.
They are over-estimated too.
What goes into the health boards is accurate, but some immunisations are not recorded.
I share the concern of Deputy McManus about the possible non take-up of immunisation arising from fears of previous vaccine damage. Does the Minister not think that allowing seven or eight more cases to weave their way through the court will contribute to this concern and that it would be better to finalise that finite number of cases? These children are now adults. Would it not be better to solve it now by responding to those families who were damaged in the past and let the vaccine programme continue?
The award in the Best case was £2.5 million.
That case was different.
If there are legal grounds for proving culpability I am sure that the legal advice available to the families concerned will express the best legal route to proceed with that. I am anxious to ensure two things: one, that a comprehensive vaccination programme is provided around the country and, two, that there is a significant take-up. We cannot force people to vaccinate their children. People have rights and choices. One cannot force people or families to be vaccinated. We will encourage and support them but ultimately, in any society, parents will make the final decisions. We must make the best information available to them to make informed decisions.
Which is not happening at the moment. Parents come forward when the Department makes an effort to encourage vaccination, as they did when that small child with measles damage was on the "Late Late Show". There was a huge uptake then but it has faded away again. What is needed is a consisent programme.
I am taking a leaf from Madame Curie's book. Subhead J.1 speaks for itself. It is disappointing that the figure for capial services for buildings has been reduced. On the question of Tallaght Hospital, I compliment the Minister on the speed with which he resolved the difficulties associated with it. As he said, he knocked heads together. I hope his determination to proceed with the building will be of the same level and type that we have seen in the last few months. It was a job well done.
I indicated that the capital programme is £44 million, including the initial £3 million provided in the budget. It will allow work to continue on projects in Ardkeen, Waterford and Sligo, the Rotunda in Dubin, St. Luke's in Kilkenny, the Mater laboratory and psychiatric unit and the Coombe outpatients department. In relation to the Tallaght Hospital, I hope to have the tendering process completed in the next few weeks and to have construction commenced well in advance of the end of this year. Work will also commence this year on the additional operating theatres in Tullamore and the next phase of the major capital programme at Mullingar General Hospital. Planning will continue in the remaining components of phase I of St. James's in Dublin, including the proposed new bone marrow transplant unit. I hope that construction work on that project can also commence later this year.
The new theatres for Cork Regional Hospital and St. Mary's Hospital in Gurranebraher are currently proceding and I hope that they will be completed in the foreseeable future. Provision will also be made for the continuation of planning, in relation to the development at the Mercy Hospital, Cork, and Portiuncula Hospital, Ballinasloe. Building work will continue on the new psychiatric admissions unit at St. Vincent's Hospial, Fairview, and the new centre for autistic persons will also be built at that location. A new acute unit and residential accommodation for the mentally handicapped at St. Vincent's Centre, Navan Road, will be completed this year. Funding will be provided, as I said, for orthodontic and dental services from the capital side and existing commitments in relation to equipment replacement, fire precautions and maintenance already entered into will be fully met. An ambitious capital programme is under way and will continue for the remainder of this year.
We do not support the Estimate. In spite of that I thank the Minister and his officials most sincerely for this day long debate. It was a worthwhile procedure, the first of its type, we can learn from it and perhaps improve on it for next year. I also thank you, Chairman, for the manner in which the meeting was conducted. We are all in the business of ensuring a proper level of health care in the State and we must also ensure that the health service is patient friendly. If it is patient led we will never solve the financial demand. The health manager is important in the system to set targets and ensure that those targets are met and that we have a patient friendly, efficient and effective health service with high quality standards.
I thank the Minister for coming here today to answer questions on the Estimates, he did so comprehensively. Obviously we have points of disagreement but I wish him well in implementing these Estimates. I am still very concerned at the fact that there is essential inequity depending on your ability to pay, that really is the major project in relation to changing the way the health services operate. Also, we should look at the way disadvantage and deprivation affects people's health. There are really two forms of inequity, one is access to the health services and the other is the way that poverty, unemployment and deprivation make people ill. I know the Minister is concerned about these areas, I appreciate he does not have an unlimited budget but he does have the opportunity to make a few bold strokes in this regard. I hope the health strategy will not simply mean managing the cost better. If it is it will serve no purpose apart from the bureaucratic one. There is an opportunity there. The Minister is well able to take it up and I hope he will.
I would like to be associated with the remarks made by other Deputies and to thank the Minister for coming here today. We are very fortunate to have a Minister who is so well up in his brief. He has not been long in the Department but has already made his mark. I would also like to thank the officials, you Mr. Chairman, and the convener.
I would also like to thank the Minister. I very much enjoyed the committee meeting today. It was about allocating resources and I am glad the Minister does not think it insulting to talk about value for money. That is what this Committee is all about, given our limited resources.
There is one item I would like to raise with the Minister but his officials have left.
A Deputy
The Fianna Fáil side of the House would also like to offer our best wishes to the Minister.
I thank the Chairman and all the Members for their incisive questioning of Department officials and me today. It is a great improvement on the old format where I went into the Dáil as an Opposition spokesman, had my ten minutes set speech and where the Minister, at the end of a ten minute speech from each of the Opposition spokespersons, read a ten minute speech he had prepared before hearing Members and made the whole process irrelevant. We have moved very dramatically into a much more relevant forum here and I very much welcome it because ultimately it not only makes for public accountability, which is very important, but will impact directly on the way we deliver services. I will bear in mind all the points made by Deputies here, I welcome them and value all the comments made. In essence I want to thank everybody for their contributions. The health services do not belong to Government or to any particular set of politicians, they belong to all the citizens. It will be my job, as long as I am Minister for Health, to ensure that the health services are provided in an efficient and equitable way. I will certainly appreciate the help of this committee and all my colleagues in the Oireachtas to achieve that aim.
That concludes our consideration of the Health Estimates. I want to thank the Minister, his officials and Members of the Committee for their contributions to the debate today. The Committee will meet again next Tuesday to consider the Social Welfare Estimates and briefing material has already been circulated.
I know this meeting was held today to facilitate Members but there was an important debate on the Structural Funds in the House. The original proposal was that we would meet on Tuesdays and Fridays. We will meet on Tuesday next week, a morning when the Dáil is not sitting. We will have concluded by Order of Business. We are considering it in Fine Gael and we would prefer to have meetings on Tuesdays or Fridays. It is inappropriate to meet when the Dáil is sitting. People should be available to attend to discuss important matters.
We had a very hostile reaction to sitting on Fridays.
I think it is time you put your foot down because other committees have just gone ahead and sat on Tuesdays and Fridays. Look at the numbers here. As long as you are facilitating the main spokesmen——
The Members who objected to sitting on Friday did not turn up on Tuesdays or Thursdays.
Yes. I would have loved to have attended some of the Structural Fund debate.
Well, pity the poor Chairman who could not even get out for five minutes.
Some of the committees have appointed vice chairs.
There is provision in some committees but there is no provision in the legislative committees.
The Select Committee adjourned at 4.10 p.m. until 10.15 a.m. on Tuesday, 22 June 1993.