The suggested timetable has been circulated to members and it is intended to assist us in discharging our business in a businesslike manner. However, I propose to adopt a flexible approach to this matter. Is that agreed? Agreed.
Vote 41— Health (Revised Estimate).
I am delighted to present to the committee the details of the Estimate for 1994 for my Department. When I launched the health strategy, Shaping a Healthier Future, last month I indicated that it was not designed or intended for the bookshelf. I was aware of the possibility that it would be regarded as another aspirational document which, while accepted in its ambition, would be questioned as to its implementation. I made it clear that I saw the strategy as not only the re-focusing of our health care system but also a blueprint for action for the next four years. The four year action plan sets national targets for the reductions in risk factors associated with premature mortality together with improvements in other indicators of health status. I further indicated that these targets would be implemented as rapidly as resources could be made available.
This is the first Estimate to be presented against the background of the national health strategy. From now on I would expect and hope that each year's Estimate will be judged to a significant degree by the contribution it makes to the advancement of the objectives set out in the strategy. Although this Estimate was formulated and approved prior to the publication of the strategy. I believe it reflects the fundamental values which are incorporated in the strategy and represents an important first contribution to the implementation of the four year action plan.
I am particularly pleased that it has been possible to restore to health agencies the ability to deal in a professional and decent manner with trade and other creditors; that the budget for health promotion has been increased by one third; that significant additional resources are being made available for handicapped, at risk and disadvantaged groups; that community services are being strengthened; and that we are continuing to address those aspects of acute hospital services which are essential to maintaining proper standards for patients and staff. Clearly, I am happy to be associated with these developments, which build on what we have achieved in 1993 and signal the type of development that we can expect to see in the coming years.
I now turn the principal features of the 1994 Estimate before the committee. The 1994 net Health Vote, when the additions in the budget are taken into account, is over £1,900 million. The provision for health represents over one-fifth of all Government spending on supply services this year. In a service which will cost over £2 billion this year, now more than ever there is a need to demonstrate effectiveness and value for money for the taxpayer. The health strategy sets out arrangements for improved legal and financial accountability within the context of agreed objectives, and the necessary legislation to underpin that is currently being prepared.
In comparing the provisions for health services for 1993 and 1994, it is necessary to set aside a significant volume of once-off expenditure which occurs in both years in order to get an accurate picture of the increased amount available for ongoing services. The main items which must be taken into account are the substantial pay arrears in 1993 and the financing of health agency debt in 1994. When these factors are taken into account the increase in the post budget net vote in 1994 over the post budget net vote in 1993 is approximately £154 million, or approximately 9 per cent. I have circulated to members two tables which provide additional details on the changes in 1994 over 1993.
The special allocation of £100 million announced in the budget will address the problem of the accumulated excess debt of health agencies. This excess debt was funded by high bank overdrafts, by running up extended periods of trade credit with suppliers and by delaying payments to other creditors. The injection of this £100 million into the service will enable the agencies to deal with their banks and creditors on a normal commercial basis. It will assist considerably traders and voluntary organisations in receipt of health board grants. It will enable the agencies to operate more efficiently in their purchasing and financing. Various measures have been put in place to ensure that there is no recurrence of this problem. These measures will be reinforced by legislation which will be published later this year and will considerably strengthen the accountability of health boards.
The strategy, Shaping a Healthier Future, will guide the development and improvement of health services in the 1990s and beyond that. The main theme of the health strategy is the reorientation of our health services so that improving peoples’ health and quality of life become the primary and unifying focus of all our efforts. The strategy is built in the underlying principles of equity, quality and accountability.
I believe that in the coming years the strategy will be seen as marking a new era for our health services. I hope it will sustain and strengthen the sense of shared purpose and pride in the Irish health service. The developments which are being undertaken in 1994 are the beginning of the implementation of the four-year action plan which translates the strategy into specific targets for action over the next four years.
Health promotion is the obvious starting point in the refocusing of the health services towards improved health status and quality of life. Very good progress has been made in improving the health of our population in recent decades. However, much remains to be done. Over one-fifth of all deaths in Ireland were of people aged less than 65 years. This is premature mortality and much of it is preventable. I am happy therefore that an additional £0.5 million has been allocated in the 1994 Estimate for health promotion activities. Major health promotion campaigns this year will aim to reduce some of these avoidable deaths. These campaigns include an anti-tobacco campaign, two AIDS prevention campaigns and a nutrition education campaign based around a healthy eating week.
My Department is preparing a discussion document on women's health which takes account of the recommendations of the Second Commission on the Status of Women. This document will be published later this year and I intend to have in-depth consultation on the issues concerned. I wish to mention just two of the priorities for developing women's health services, subject to what emerges from consultations with interested groups on the discussion document. These are to make maternity services more responsive to the needs of mothers, who now seek more individual care and a greater say in decision-making about their care: and to expand the services for women who are victims of rape and domestic violence and to co-ordinate these services more effectively with other health services.
As I have already indicated to Deputies, treatment for those who test positive for Hepatitis C arising from the national blood screening programme is being provided at six designated hospitals: St. Vincent's, Beaumont and the Mater Hospitals, Dublin, St. James' Hospital, Dublin, Cork Regional Hospital and University College Hospital, Galway. Any treatment for those who test positive for Hepatitis C arising from the national blood screening programme is being provided by the public hospital service free of charge.
The board of the VHI on 17 May 1994 announced its decision to provide cover towards the cost of private hospital accommodation and consultants' charges for members who test positive for Hepatitis C arising from the national screening programme. My Department will continue to cover the costs of any drugs and medicines prescribed by clinicians for all patients, including VHI subscribers who opt for private care.
Counselling is being provided at the Blood Transfusion Service Board's headquarters in Dublin and at the regional centre in Cork for people who have tested positive for Hepatitis C. Counselling is provided by the Blood Transfusion Service Board consultants and by doctors employed specifically to provide this service. General practitioners throughout the country are also providing a counselling service. In addition, arrangements have been made for counselling to be provided by other health professionals where this is deemed to be appropriate. The Blood Transfusion Service Board will continue to see people on an individual basis and, in addition, are initiating a programme whereby people will be given the opportunity to participate in a series of up to three group sessions. These sessions will comprise 12 women coming together to meet with a Hepatitis C specialist and a specialist in stress/anxiety management for a presentation on Hepatitis C and a question and answer session.
I am determined as Minister for Health to strengthen support services for children at risk and families in difficulty, in accordance with the principles enshrined in the Child Care Act. All sections of the Child Care Act will be implemented, as I have already indicated, by the end of 1996. Priority will be given to those provisions which confer new and approved powers on health boards, the Garda and the Courts to intervene more effectively in cases of child abuse and neglect.
A major programme of investment in the child care services has been drawn up to ensure that the Act is fully and properly implemented. During 1993 a range of new service developments, costing £10 million in a full year, were approved which considerably expanded the staff and services provided in this area. A provision for new developments costing £10 million in a full year was included in the 1994 Estimates. This will enable the further development of services, including specialised counselling and treatment services for disturbed and damaged children and for adolescents. I intend to announce within the next week details of an agreed development package which has been worked out with the health boards for child care services for 1994.
An area of particular interest to me has been the development of services for people with mental handicap. Since becoming Minister for Health I have worked on the development of appropriate residential and community based facilities, with a special concern for catering for unmet need. I am very pleased to say that a total of £12.5 million in additional funding is being made available for mental handicap services in 1994, which will become part of the ongoing annual service thereafter. Of this funding, £10 million will be used to provide a range of additional services along the following lines: 250 residential places, 700 day care places, the continued improvement and expansion of home support programme to benefit 1,600 clients and families, the transfer of approximately 156 persons with a mental handicap from psychiatric hospitals to more appropriate community services and the development of plans for services for persons with autism.
A feature of modern Western society is that the great majority of people will live into old age and many into advanced old age. The increasing proportion of the elderly in the population will increase the number of ill and dependent elderly. The Nursing Homes Act provides for the registration of all nursing homes by I September this year. A sum of £5 million has been made available to implement the Act. Funding of £2 million in 1995 and a further £1 million has been agreed in principle for 1996. The strategy spells out clearly that priority will be given in the implementation of the four year action plan to strengthening home, community and hospital services to provide much needed support to elderly people who are ill or dependent and to assist those who care for them. This I see as being particularly important, given the rapid rise we are facing in the numbers of elderly people.
This year I have allocated an additional £4.4 million towards the cost of implementing the dental health action plan, which I launched last week. This is an ambitious plan which aims to substantially improve the public dental system. For the first time in the history of the State a clear statement about the aims of the dental service has been brought forward. The dental action plan provides for the setting of oral health goals and the improvement of oral health promotion, including substantial investment in the national foundation programme; a more clearly defined role for health board dentists and a significant increase in dental manpower; the extension of eligibility to children under 16 years of age; the improvement of orthodontic services in the community and hospital based oral surgery services through the appointment of additional consultant oral surgeons; new arrangements for adult dental services involving private dental practitioners, an emergency dental service for medical card holders and the provision of full dentures to medical card holders over 65 who require them.
The plan also provides for a new Dublin Dental Hospital and School. The Government approved the provision of £1 million in 1994 to commence the refurbishment and extension of the Dublin Dental Hospital in Lincoln Place and Westland Row which will be completed over four years at an estimated total cost of £9 million. This is a most welcome development. It will ensure the future of the hospital as a first class public dental facility availed of by thousands of citizens each year, many of whom would otherwise have difficulty in getting dental treatment, and as a modern training facility for dentists.
HIV/AIDS and the associated problem of drug abuse continue to be an issue of serious social and public health concern and an additional sum of £3.44 million is being provided this year to address these problems. This will allow for the extension of the network of satellite clinics, with new clinics in the south inner city and the north west of the city, the further development of AIDS/HIV services at the Mater and Beaumont hospitals and at Limerick, Cork, Sligo, and Galway, the development for the first time of a paediatric AIDS service, continuing financial assistance to the voluntary bodies in this area and improved palliative care for people in the terminal stages of AIDS. These developments will further strengthen the Department's four-strand stategy on AIDS based on surveillance, prevention, care and management and anti-discrimination.
The waiting list initiative I announced in 1993 has led to a very significant reduction in the number of people on hospital waiting lists. In June 1993 there were over 40,000 people awaiting admission to acute hospitals nationally. At the end of December 1993 this figure had been reduced by 14,757 to 25,373, a reduction of 37 per cent. I wish to pay a special tribute to those hospital staff who co-operated so wholeheartedly in the Government's waiting list initiative, thereby making this reduction possible.
The Government is anxious to build on the success of last year's initiative. The continuation of the initiative in 1994 with the special allocation of £10 million announced in the budget will enable further inroads to be made in reducing waiting lists. The initiative is targeted speedily at those areas of hospital treatment where long waiting times were causing great hardship, which include orthopaedics, ophthalmology, ENT, cardiac surgery, vascular surgery, plastic surgery and general surgery.
As set out in the Programme for a Partnership Government, the overall aim is to eliminate waiting times in excess of 12 months for adults in the problem specialities and six months for children for ENT and ophthalmology. I will shortly be announcing a further initiative in relation to hospital waiting lists, together with plans for the improvement and development of ambulance services.
I am pleased to say that the Health capital allocation for 1994 is £63.5 million, which is an increase of over 43 per cent on last year's allocation. The increase is mainly due to the inclusion of the Tallaght hospital project. I am continuing the development of the general hospital services throughout the country. Apart from the major flagship project of Tallaght, work will continue on the hospital schemes at St. James', Mullingar. Tullamore, Navan, Waterford, Kilkenny, Cork Regional and Gurranebraher. I am happy to say that planning will start or continue on important hospital projects at University College Hospital, Galway, Limerick Regional Hospital and at the Mercy Hospital, Cork. Minor improvement schemes will continue around the country also.
The capital programme also provides for the development of community based facilities. In the psychiatric services, for example, hostels, day hospitals, day care centres and other community facilities will be provided. A new care facility for autistic people will be completed at St. Vincent's Hospital, Fairview. New psychiatric units are being planned or provided at general hospitals at Portlaoise, Navan, Kilkenny and Waterford, and a psychiatric unit to replace that at Vergemount will also be planned. Community psychiatric facilities will be provided at various locations, including Rathdowney, Carndonagh, Donegal and Clonmel.
A major programme to provide additional training centres for persons with handicaps will be launched this year and provision will be made for the planning of two units for the young chronically ill in Dublin. There will be a balanced health centre development programme commencing this year, including some developments on large, medium and small centres. The large centres will be in Waterford, Bray, Swords, Fortunestown and Deansrath. Investment in facilities for the elderly will be increased this year to provide for two community nursing units in Dublin and an improvement in services in a number of areas, including Limerick, Cavan and St. Luke's in Cork. New public analyst laboratories are being provided at Dublin, Cork and Galway.
Having considered the recommendations of the review group on hospital charges I decided to make the following changes, which took effect from 1 March 1994; the anomaly which led to a double charge for people admitted to hospital overnight was removed; the £6 out patient charge for attendances at outpatient departments has been abolished; the £6 charges at accident and emergency departments has also been abolished. However, persons who attend the accident and emergency department directly without having a referral note from their general practitioner are liable for a charge of £12, which will apply only to the first visit for any episode of care.
I am happy that these reforms have removed anomalies within the system while supporting the development of primary care particularly in urban areas, and have helped to remove the incentive to use the accident and emergency departments for the treatment of conditions which would be more appropriately dealt with by the general practitioner. They have also greatly simplified collection and administration procedures in hospitals.
I have briefly outlined the main features of the 1994 Estimate. There are, of course, many other initiatives which have been taken, such as clinical management, medical indemnity, transport for disabled persons, a pilot sheltered employment scheme, the new Food Safety Board and increased health allowances.
I have started the process of developing a health service in which the resources allocated by the Dáil 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. I believe that the developments which are contained in the 1994 Health Estimate are an important start to the implementation of the four-year action plan which translates the national health strategy into a specific plan of action. I am determined that the targets and the timescale which are set out in the strategy will be adhered to.
I thank the chairman for his remarks and I hope to hear the committee's thoughts in relation to the developments planned for this year and I looked forward to having an opportunity to respond.
I compliment the Minister for bringing the Estimate before the committee. I hope that all of the aspirations he outlined in the health strategy will be realised. I would like to be more complimentary but it ill behoves one to be overly complimentary to Ministers, especially at election time, because often many of the aspirations and promises outlined in the heat of election campaigns do not translate into reality afterwards.
I was a little surprised that the Minister did not reiterate his announcement of yesterday about west Mayo-I am sure it was an omission on his part which I hope is not permanent. I do not represent that constituency but I was aware of the heated debate which has taken place about the Castlebar hospital. While I am somewhat cynical at the hurried manner in which the announcement was made, I would have thought that the Minister would have reaffirmed his intentions today. I hope he will respond to that point at a later stage.
The Minister is right in saying that the Department of Health requires a great deal of expenditure. The only question I would have on the success or otherwise of his programme so far is that I am not sure if advances in dealing with the problems are keeping step with the increases in expenditure and there are a number of areas where I would have serious reservations in that regard. For example, in relation to hospital waiting lists, six months for children and 12 months for adults may be an improvement on previous times but it is not acceptable. All of us have had numerous representations from people who are directly involved and who have family members on long waiting lists. Anyone who has ever had a child who was ill and on a waiting list for admission to hospital for whatever reason has that extra worry. Six months is a long time in such cases.
The Minister may say that some progress has been made in the last 12 months but we are far from the ideal. How long more will we have to wait before we have a situation comparable to that of other countries, particularly our closest neighbour?
In the context of the general capital programme the Minister mentioned the Tallaght hospital and we are glad that the construction is up and running. While we are on that subject, I hope that we will not have to wait for a by-election for an announcement on the Naas General Hospital which is in my constituency.
Is the Deputy feeling poorly?
I am not feeling poorly and I hope that I will not.
That is the main thing.
I would hope not to be the cause of the by-election to which I referred.
I hope the Deputy has VHI cover.
I would certainly need VHI cover. This issue is equally important to all the other capital works announced and the need for it has been stressed over the last few years. I remind the Minister that it is an important issue and I hope it will be considered with equal anxiety and concern to that with which his colleagues in Government have considered the Castlebar hospital.
I am disappointed — I am sure the Minister must feel the same way — in regard to the handling of children at risk, child care and the ability of our services to deal with this problem. I could go back five to six years and review the situation. Some changes that will improve the service have been made and others are pending. However, I am not happy with it, and last Thursday's Question Time would underline this. Even when medical evidence indicating that sexual abuse of children has taken place is clearly available, it is not possible to deal with the problem effectively and quickly put the child into a place of safety. There are two sides to that argument. One must always take care not to pre-empt a situation by taking unilateral action that could cause unnecessary trauma and suffering to innocent people. The skill and technique involved become obvious when one can tell such abuse is taking place with a reasonable degree of accuracy without causing that kind of trauma. It is at that stage when the right services are being established.
I fail to understand why if medical evidence indicates such an abuse is taking place, it is not possible for the Minister to tell either this committee or the House that henceforth the services can move in and put that child in a place of safety. There is no reason once this evidence exists why one should stand by. The Minister might clarify further today the questions that were not answered last Thursday. I could understand this difficulty if it was a question of doubt, if the medical evidence was not clearly indicated or was not there. However, once it exists there should not be a problem.
Some will say that one cannot afford to make mistakes in that area. There is a certain opinion which suggests that when one errs it should be on the side of safety. That is not a safe bet either because that sort of thinking can also have serious consequences. One can become involved in ongoing litigation, for example. There are sufficient procedures currently available to the services, through school medical and other examinations, which make it possible to identify a problem with reasonable accuracy, even almost beyond doubt, and to act upon it. However, we are not progressing in that area. From my knowledge of cases that come before every public representative, there is great area for improvement.
The Minister also referred to dental services. They have received additional funding this year, especially in relation to children. I cannot mention it without referring to the word "orthodontics". Again, at the risk of repeating myself, I am sure every member must experience similar frustrations and annoyances on this issue. Our present orthodontics system is a joke. Category III patients will never receive attention, category II may have some chance and category I, in theory, should receive attention. The exacting science of that area comes into play in determining who is in each category. If one can determine who is in what category and then decide, one would automatically know when the child would receive attention. There have, of course, been instances where private orthodontists have said that such a person should not be in category III but in category II, or should be moved from category II to category I. As a result, that child is not on the list, is not imminent for treatment and is not the responsibility of the services at this stage. Therefore, they are not an immediate and pressing problem.
I compliment the Minister on the general thrust of his health strategy programme and its aim to tackle the problem of women's health. This area has been neglected for far too long. It was taken for granted that women would seek out these services and improvements for themselves. However, it did not take into account their need for special attention and the fact that their specific health needs and problems were not being directly addressed.
I have doubts about the way the Hepatitis C problem was handled. I am saying that not out of disrespect to the Minister, because from the beginning he attempted to face up to the responsibilities involved. However, the Minister goes on to use the same phraseology that I have seen being regurgitated on every occasion since last February. Such words as "counselling" flow freely from the Minister's lips. All of the women I have spoken to on this issue are disappointed with the level of counselling made available to them. I do not know if the Minister or his Department are aware of this. The extent of counselling the Minister believes to exist is not there. If it did exist, it might be possible to alleviate some of the trauma caused by its absence. Neither I nor the women who have been the victims of Hepatitis C from this treatment are impressed by the Minister. Perhaps he might address that problem in the near future. He proposes to meet the support group set up to tackle this issue and I compliment him on that. At that stage I hope the Minister will recognise that the statements from the Opposition benches are not conjured up from our imaginations, but actually exist. The fears of these women are real and they are not at all impressed by the manner in which they have been treated so far.
I spoke to a woman last evening who recently had a liver biopsy. Her reaction to the screening and checking process was that it was demeaning and she was not impressed with it. That was her view, not mine. I hope the Minister will see fit to address both that problem and other ongoing ones that are likely to arise, such as compensation, which has to be faced at some stage. That it is not being addressed at this moment and is in itself a source of worry and concern to women. The situation there is not in accordance with what the Minister appears to think.
Although there is a pay element involved, I wish to refer to the delivery of services from junior hospital doctors. That does not seem to have received a great deal of attention during this or last year and for the next 12 months. I am worried about that because it is essential in the provision of the service to the community. How well are these doctors capable of operating under the stress levels they experience? It is not possible to work for long hours without sleep and be expected to deliver the highest possible standard of service at the same time. It is not satisfactory and is dangerous. It can, and will, cause serious problems.
Perhaps more attention night be paid to eliminating the apparent increase in litigation over the past couple of years. Although there will always be a certain degree of error requiring recourse to litigation by one side or another. This is a cause of concern because confidence in the services would be shaken if there is any further escalation in this area. It is a serious problem because the degree to which there is confidence in a service determines how the service will flourish and whether the public wish to be associated with it or supportive of it. The Minister should recognise this and take corrective measures.
The Minister referred to families in difficulties and I support the outreach programmes and so on which are supposed to operate in this area. It is enlightening to be a member of a health board, as I have been for many years. The service is not working effectively except in pockets or through pilot schemes. There are countless instances where public representatives are the only people with direct contact on an ongoing basis with some of the families at risk and this should not be the case. It is an issue which requires attention. I am aware of several families who should at least have contact on a weekly basis, if not every three or four days, with a social worker or somebody qualified in that area but who do not receive such services. The longer this situation continues the greater the problems will be further down the road, with teenage pregnancies and so on. Indeed, many of the unfortunate people involved in this situation end up in prison. This is a snowballing situation, directly related to community care and to community psychiatric services, which requires urgent attention and is not getting it. There are several other areas on which I will raise questions at a later stage.
I welcome the opportunity to put forward the perspective of the Progressive Democrats on this high spending Department. The Department of Health has always been a big spender in successive Governments, as it should be because it covers not only health in respect of hospitals but also the panoply of social services. These are all covered by the Estimate which amounts to as close to £2 billion as makes no difference.
In view of the announcement by the Minister yesterday of another extension, at an estimated cost of £7.5 million, to the hospital at Castlebar, perhaps there should be a separate category or appendix to the Estimate dealing with spending based on political promises. In consideration of this extension, presumably the Government expects the withdrawal of Dr. Crowley, the hospital candidate in the by-election for the Mayo-West constituency on 9 June 1994. Doubtless also the Government, expects the people of the constituency to deliver a seat for the Government parties in consequence of this promise.
If there is one thing the Labour Party likes better than spending money, it is promising to spend money. There has been a rash of this over the past couple of weeks and doubtless there will be more promises to spend money next week before the elections. In view of this is it any wonder that Irish people are so cynical on the door steps? Anybody canvassing both in the European elections and by-elections campaigns will get such cynicism on the door steps. People do not believe a word spoken by any politician. They cannot be blamed for his. I advise the people of County Mayo to accept the extension to the hospital, if it ever arises, but to use their sophisticated powers of analysis and, based on history, relate this analysis to the power of political promises when casting their vote. Regarding the Labour Party slogan of bringing trust back into politics, the Minister for Enterprise and Employment announced jobs for Kilkenny which never materialised; there have been several promises regarding the opening of Tallaght hospital; the revised national plan, in its rephrased or butchered state, is being held over until after the elections——
This is a Department of Health Estimate and the Deputy should adhere to that.
The Deputy is making a party political broadcast.
The committee has had the Minister's party political broadcast on the Estimate. The revised national plan, in its rephrased or butchered state, is being held over because of the bad news——
Deputy, you are out of order. Relate your remarks to the Estimate, please.
I note the comment by the Labour Party chairman.
I resent an accusation that the Chair is partial. The Deputy must withdraw her remark.
I withdraw my remark.
Thank you, Deputy. Please proceed on the Department of Health Estimate.
Before the extension to the hospital at Castlebar proceeds, will the Minister advise if the new wing is to be called the Howlin-Cooper-Flynn wing? Doubtless this will be its title in due course.
The Minister's recent national health strategy plan provides a welcome blueprint for the reform of the health services. It is full of promises, but is there anything in the Estimate which is specifically allocated for the implementation of the plan?
There is confirmation in the Estimate of £100 million to fund a debt refinancing package for the health boards. This is earmarked to clear the black hole of debt accumulated by the health boards due to years of mismanagement and bad planning. Is there provision in the Estimate to pay GPs around the country in respect of their recent testing for Hepatitis C infections arising from anti D serum injection, as to date they have not been paid for providing this service? Will the health boards or the blood transfusion service provide this funding?
I note with satisfaction that the VHI has recently been shamed into extending cover to those women who were infected and who needed to be tested for Hepatitis C arising from anti D serum injections. These women had been excluded from cover by the VHI on the grounds that the infection arose from a sexually transmitted disease. It was regrettable that the VHI had to be shamed into providing this cover.
Will the Minister confirm that the present levels of counselling will be enhanced? Many women have complained to their public representatives of a demeaning sense of service and level of care. In this respect the issue of compensation must be addressed. Is the Government intent on dragging women through the courts, as it has done in other areas such as the EU Directive on equality, before it compensates women who have been damaged by this infection?
Regarding the national health strategy plan, is there anything in the Estimate to fund the establishment of the public health departments in each health board area, as recommended in the plan? It is fundamental to the implementation of the entire strategy since these departments will plan and evaluate for the health services. The departments will undertake audits and so on, and on the basis of such information decisions will be made as to how the health boards will spend their money. The establishment of these public health departments in each health board is therefore a vital part of the implementation of the strategy.
I am never slow to compliment the Minister and there are many good measures which have been undertaken since I attended a debate on the Department of Health Estimate last year, such as improving services for the mentally handicapped, reducing the waiting lists and so on. However, the Minister must be criticised for the wilful postponement of major sections of the Child Care Act, 1991, until the end of 1996. This Act contains all the provisions necessary for the protection of children at risk. Since the report on the Kilkenny incest case, I have hounded the Minister for action on the promise he made to implement these sections.
To date the Minister has failed to bring into law the remaining necessary sections to the Act to give the statutory powers and responsibilities to the health boards. His declared and preferred strategy is to put in place personnel and resources on a phased basis. I fundamentally disagree with this because it is a soft policy. Protection postponed is protection denied to children at risk now. There is still no nationally agreed procedure for the linking of the Garda with health boards in cases of alleged sexual abuse. The Minister talks about draft procedures on a pilot basis. This is the language of fudge and does not change services which are in need of immediate reform. This soft policy falls short of statutory obligations. We need to give health boards statutory responsibility. A soft policy, with no statutory obligation or responsibility for mandatory reporting of instances of children who are abused and at risk, is not good enough and does not have the necessary teeth.
Section 19 of the Child Care Act deals with supervision orders. This would give health boards powers to enter a child's home for regular visits where a supervision order is in place. It would allow a health board to oversee a dysfunctional family in situ and allow a child to be taken and examined if there was medical evidence that he or she was being interfered with. Health boards and social workers live in fear of overstepping the mark. Their constant fear is that the power of the family is such as to prevent them from having the statutory power to intervene. They live in fear of crossing that boundary and overstepping their statutory powers. To leave health boards without the statutory power to take action is an abdication of the Minister’s responsibility for children at risk. Whenever there are scandals such as the Kilkenny and Monaghan cases, social workers, as can be seen whenever they are interviewed, take up defensive positions. The Minister also takes up defensive positions. We will have many more missed opportunities and cases of non-intervention to protect children unless the Minister introduces laws to give powers to social workers to cross the bridge from non-intervention to intervention.
Another key recommendation of the Kilkenny report was that each health board should provide a minimum number of refuge places in its area. In reply to a parliamentary question on 26 May, the Minister outlined the miserable extent to which health boards have fulfilled this requirement. There are 16 refuges in the State. These are of varying standards and capacities; there are about nine proper refuges. There is none in Carlow, Laois, Offaly, Monaghan, Donegal, Kerry and Mayo. There are huge tracts of rural Ireland where there are no refuges or places of hiding for women and children fleeing the "Charlos" of this world. The refuges that exist have only a handful of child care workers and psychologists to counsel children who are damaged by the abuse and violence they have witnessed or to which they have been subjected.
Homelessness is another aspect of the Minister's responsiblity. There are a growing number of homeless children on our streets, particularly in Dublin and bigger urban centres. The best the health boards can offer them in the main is bed and breakfast accommodation. These children wander the streets during the day and get involved in petty crime, such as handbag snatches. Horrifically, some are involved in child prostitution. I note with horror that yesterday an application to Dublin Corporation for permission to convert a private house in Glasnevin for accommodation for ten homeless boys and staff was opposed by Fianna Fáil, Labour and Fine Gael councillors. A similar objection was raised when the first ever purpose built refuge on the northside of the city was proposed at Dublin Corporation level. Opposition to this was spearheaded by local residents and was given leadership by a member of the Oireachtas Joint Committee on Women' Rights, Deputy Callely. He opposed this refuge from beginning to end and managed to reduce it from 24 units to 12. The message of support from the Minister for the homeless and for refuges is not transmitted down to local level. At local authority level councillors object to the housing of ten homeless boys on the grounds that this is planned for a residential area, which is much too good for them. This message must be channelled down to local authorities so that it becomes politically incorrect to oppose the housing of such unfortunates in residential areas.
I have an ongoing concern about the health of children in the travelling community. There is growing evidence that they stil have high mortality rates and that their health care is in a poor state. Deputy McManus is involved in the task force on travellers. I am worried that nobody is taking a strong active role in protecting and intervening in this issue. There is even less interest and more reluctance to intervene when travelling children are at risk than their is in the case of children in settled families. Every day we see them lying on cold pavements. To me these are children at risk.
The Minister is committed to a women's health strategy and this is welcome. Previous Governments have ignored the physical and mental health of women, both of which are on the decline. There is a higher suicide rate among married women working in the home. This is related to economic dependency and the burden of childcare, which is still primarily on women's shoulders. The other sections of the Child Care Act, which the Minister has had to longfinger because of the priority which must be given to the protection of children at risk, deal with the regulation of pre-schools and the whole policy area in relation to child care provision, which is in a vacuum at present. This is linked to the physical and mental health of women. Unless policies are put in place to ease the burden of child care on women, their health will continue to be on the decline.
The enhancement of primary care has been identified by the Minister in his strategy as being vital to the overall improvement of health care. From speaking to general practitioners, I know they feel they are discriminated against when they employ support staff, such as nurses and receptionists, to enhance their practices because of the problems they have with withholding tax. We have raised this issue with the Department of Finance and I would be grateful if the Minister would raise it with his colleague, the Minister for Finance. The subsidy given by the Government to doctors to employ people to enhance their services is subject to withholding tax which means that the subsidy is not worth much. This tax creates serious cash flow problems for GPs.
Broadly speaking, the Estimate is a good one. The expenditure which has been announced and confirmed in the Estimate cannot be criticised. As an Opposition Deputy I am politically and ethically obliged to point out areas which I feel have been overlooked, such as child care and the homeless. Also, there has not been much improvement since last year in the provision for research. I look forward to hearing what the Minister will say in response to my comments.
I am glad to have the opportunity to speak on this Estimate because it shows up a fundamental flaw in the Minister's approach to his health portfolio. On the one hand, he has launched a magnificent looking national health strategy document, which states it is based on fundamental principles of accountability and equity within the system. That is what the document says but the Minister's actions are often in flagrant disregard of those principles. He is guilty of applying a double standard. Yesterday's announcement of a £7.5 million windfall for Mayo shows that his priorities are not about equity but about elections. It needs to be stated here that there is a double standard at work.
At a simpler level, the Minister is also either unable or unwilling, which is worse, to provide basic information which he is duty bound to provide. When a simple statistical question was asked last week in the Dáil he gave wrong information. He was asked about operations carried out outside the jurisdiction of the State and he omitted to include a considerable number of hip replacement operations which were carried out in Belfast.
He then compounded the misinformation by stating that there was only one outstanding issue in the public doctors' dispute, which related to pay. His statement has been flatly contradicted by Dr. George McNeice, the chief executive of the IMO, who stated that there were about eight items which were still to be agreed. He stated in the Irish Medical News that public health doctors were not seeking a doubling of their salaries, which is what the Minister indicated, but that totally new posts are being created and that it is wrong to make comparison. He said that the Minister’s comments would suggest some confusion in the Department as to the distinction between existing posts and proposed new structures.
I am concerned about that confusion and lack of accountability. It is something which is not new in my experience. I was reminded coming into this meeting of an Estimates meeting which I attended last year when I challenged the Minister about the rising measles epidemic in Dublin. I put it to him that there was a major crisis building up because of a failure to carry out childhood vaccination. That epidemic led to the death of two young children.
At the time the Minister simply refused to acknowledge what was going on and again peddled a line which was misleading and inaccurate. He changed his tune totally a short time after when he introduced a new initiative to encourage parents to have their children vaccinated. It was a response which was too little and too late, certainly for two children. Many of the children who contacted measles over the period need not have done so if the Minister and his Department were doing their job and taking their role seriously in relation to what is a primary matter in health care. He did not deal with it swiftly enough and at the time when I raised it, he did not even recognise that the crisis existed.
Frankly, I feel that the Minister is not on top of his brief for this Estimate either. There is an issue relating to health promotion which is not just another item on an Estimate but one of the critical pillars of the national health strategy. I do not see that new initiative being reflected in the Estimate. There is a certain amount of extra money but nothing like the amount which would be needed if health promotion was being taken seriously as a key element in improving the health status of our nation. Shoving a few leaflets into doctors' surgeries, a couple of television advertisements stating that people should wear condoms or setting up photo opportunities at press conferences will not change how people behave and promote health in the way which is needed, particularly in targeting people in a sophisticated way.
We are seeing more of the same, with a bit more money being thrown at it. I do not see the radical shift to primary care, to care at community level. I would be interested to hear the Minister pointing out in the Estimate where that radical shift is occurring. I see increases - I am not arguing that point. There is a proportional increase, but I do not see the clear political direction which is indicated, without being spelled out, in the national health strategy. That is the double standard and double think of which I believe the Minister is guilty. We are having the wool pulled over our eyes in relation to a new departure in health care.
I do not believe that the Minister is willing to face up to the difficult decisions. There are hard questions and challenges which are going to have to be met if these aspirations in the health strategy are to be lived up to. We are not even getting the basic information. Last week a question was asked in the Dáil and the Opposition Deputy did not receive the correct reply. That worries me. Responsibility begins at the top. When sermons are being preached about accountability, the Minister must begin with his own record.
The other fundamental pillar is that of equity, which is a principle in health care to which I am very committed. Again, the Minister has flunked it, avoided the issue and failed the test. He talked about equity in his document. However, it is one thing to talk about it but another to say how it is to be reached. It is interesting that no health professional has really raised any serious complaint about the health strategy. I am sure that some people would say that that is great and means that it is accepted by everybody. I question that. I think it is a sign of weaknes, that the document is so broad, aspirational and wishy washy that nobody feels that they will have to change their ways and, therefore, they do not see any reason to argue about it. If it does not upset anybody in the system, then clearly the system will remain as it is.
Equity means equality of treatment, recognising that we have major inequalities within our present system and that the pursuance of private care can and does militate against many public patients. However, the Minister does not refer to this in the national health strategy, apart from soothing any concerns which the consultants might have about how it might interfere with the private care system.
He does not deal with the issue of the child who is at the moment a public patient seeking an appointment with an ENT surgeon in Dublin. I was interested to see that he mentioned it in his speech. It is a very important matter which I raised as a parliamentary question. The response I received, which bewildered me, was that within four and 11 months a child would get an appointment as a public patient. I checked around and asked a major children's hospital in Dublin about their approach. I was specifically told that the standard was 12 months for routine cases. Urgent cases are individually considered by the consultant. The routine is 12 months, which is more than even the maximum which the Department stated.
I am beginning to feel that it is not really worth asking parliamentary questions because I am not getting the information I seek. Getting the facts is the basic minimum of accountability. The Department also informed me that it does not check to see what period of time a child seeking a private appointment with an ENT surgeon would have to wait. I telephoned and found out that it is a matter of a fortnight or so. That is what we were talking about when we talk about equity. We are talking about children who go to national school and cannot hear what the teacher says because they are waiting for six or 12 months to have grommets put in and children who are unnecessarily on antibiotics because of recurring infection.
It is not stated in the national health strategy that every child should be considered equal when it comes to treatment, regardless of whether they are paying privately or are public patients. Adults should be treated in the same way. The waiting lists must be combined before we can even begin to consider that equity is in any way within reach, even in the long term. Otherwise, we will always have a two tier system. The reality will always be, regardless of what the Minister says, that those who can afford to pay, regardless of their need, will have access to this system.
I am disappointed because I believed that the Minister was going to grasp the nettle. I believe that because of his commitment over the years there was going to be certainly a battle. Previous Ministers from his party shaped up in the past and had tremendous battles with consultants and various vested interests in health. Instead we get this document which says all the politically correct things without facing the harsh realities that patients, particularly public patients, have to face everyday.
I can cite a more extreme example. I have on file the case of an 82 year old great grandmother. She is a widow who went out to work, paid her taxes and is now on an old age pension. She never applied for a medical card. Her family contribute enormously and save the State vast quantities of money because they care for her at home. She now needs medical treatment and finally decided to apply for a medical card. The woman applied to the health board and got a reply yesterday. They informed her that because her parents are not in receipt of a medical card, she is disqualified. I ask the Minister to explain that. Where is the accountability or equity in that case? After the shock the woman began to laugh because it was so ludicrous. If that happened in her case, what happened in cases where people did not have the wit to contact their TD or "The Gay Byrne Show" and kick up a fuss.
There are many old age pensioners who do not and will never have a medical card because they are just over the limit. Old people who are very often living alone simply cannot get a medical card. I have to make cases for them. They feel degraded and I feel degraded on their behalf. They made a contribution over the years and at the end of the day they cannot get the basic equality which others feel is automatic,. People are amazed that there are old age pensioners who cannot get a medical card. Those who are not dealing directly with the area presume that every old age pensioner gets a medical card without question.
The Minister has to deal with the waiting lists. He is making an effort and I commend him for that, but I am concerned that it is simply not enough. There is the probability that he will always be chasing but will never catch up. The national health strategy does not contain any real action on the Tierney report. It will all be put into abeyance while the Minister examines this and that, makes consultations and so on.
There is no commitment that because resources are finite all people, whether public or private, will be treated the same. It is not an economic decision; it is a political one. It is not in the document or the Estimates. The commitment to expand the number of consultants is a political decision. There are political questions involved in that issue. It is a good political principle to expand the number of consultants. The Minister himself used the term "consultant provided service" rather than "consultant driven service". He says that in the Dáil, but he does not say it where it really matters and where it will cause the sparks to fly.
What happens in the strategy has a follow-up in the Estimates. It is a strategy which technically is carried over a short period of time. If there are not major changes in the Estimates for 1994, we can take it that the rate of change will be slow and will not meet the major aspirations. I am glad that some aspirations will be met, but the fundamental issues and the fundamental flaws in the Minister's approach have yet to be dealt with. Those are the issues of equality of health and equality in the health service.
The Minister responded to a question I tabled in the Dáil concerning the waiting list in the Mater Hospital and the difference between public and private patients. I did not get the answer I sought; but I can tell the Minister that even though the Department's answer said that people on the urgent case list — there are over 100 of them — would be treated within two months, the reality is different. There is a woman on my files who has been told that she is on the urgent list. She has been waiting two months and is going to have to wait longer. If she had money her problems would be solved, and that is the reality of equity in the health system.
I want to briefly mention the Child Care Act. I urge the Minister to empower social workers and the statutory authorities to enable them to take the initiative. If the Minister keeps saying he must wait for full training and resources and is cautious in his approach, there is a danger that we will lose the opportunity to get on top of the area of sexual abuse of children. We cannot afford to wait. The biggest problem facing social workers is the fact that their hands are tied. I ask the Minister to untie their hands.
I do not agree that social workers are automatically defensive when a case hits the headlines. Many of them are dealing with these cases all the time. Changes are needed in their powers which have been couched in traditional terms in the past. Essentially the understanding under which social workers operated was that there was to be no interference with the family. Because of the manner in which their guidelines were framed the family was sacrosanct and intervention was the last resort and not to be recommended. That has to change. We have to ensure that social workers who clearly see evidence of abuse can intervene. It is a matter that cannot be put aside for consultation or whatever.
I welcome the long overdue attention to women's health. I would point out that in general men die younger than women. An examination of mortality rates indicates the need to start considering men's health. The health strategy in Australia has targeted men. One of the most important factors which should be examined and assessed is the inequality between unemployed and employed men. At present a middle age unemployed man has twice the chance of having a heart attack than a middle aged professional man.
We need to examine how class and poverty shorten people's lives and make those lives ones of ill health and suffering. It should colour everything that is done in the health service. It relates back to what I said at the outset. There are good and sound points in the strategy which I support absolutely. However, much of it is nothing more than hot air. I have to be blunt about it. We must assess and alter what happens in the health service and in the classes in our society. I am disappointed that in these Estimates I do not see the type of fresh thinking that was such a promise of the new Minister for Health. It is not translated into action. I can only hope as this strategy progresses that those hard challenges will be tackled and that the Minister acquires some courage when it comes to taking the flak.
Laoighis-Offaly): We will open the debate to questions. There are two options open to the committee. We can divide the time between the various subheads or have a general debate on Vote 41. As it seems that there will be ample time for people to make contributions, I suggest a general debate on Vote 41, without restriction to particular subheads. Is that agreed? Agreed.
I welcome the four year dental health plan. Most health boards have encountered considerable problems in this area over the years and my health board has probably had more problems than most. Over the years we found there was no problem recruiting dentists for the southern part of the health board area because it has easier access to Dublin. However, it was practically impossible to recruit dentists for the other part and the people there did not get the treatment they deserved. It was so bad at one stage that I put down a motion at a meeting of the health board suggesting that some incentive should be given to make that area more attractive to people.
If that problem were to rise again, I hope this plan will ensure an equal spread of the benefits of the dental and orthodontic service over the complete region. There was little we could do at health board level. We advertised for dentists but there was a very poor take up. Admittedly, the situation has improved considerably in recent years. However, the new plan is likely to put more pressure on the system and additional dentists will probably be required.
I also greatly welcome the Minster's commitment that the Child Care Act will be implemented by 1996. At present there are a large number of problems in that area and my county featured none too creditably in the past number of weeks. I welcome the Minister's additional funding to deal with the problem of child abuse. Given the actions of the community care monitor in my health board area, I know that he intends to come to grips with any problems that may exist. I welcome the funding for this area and I ask the Minster to push for the full implementation of the Child Care Act by 1996.
We must be most satisfied with the additional funding that has been made available to tackle the problems of those with a mental handicap. Constructive proposals made by the health board were well received by the Department and funding was provided. Money provided for respite care is money well spent and funds should be channelled into this area. It gives people a break so that they are not continually caring for patients, whom they dearly wish to keep at home. However, the pressure on them can be so great at times that a break is a godsend, even if it is only three to five weeks or less in a year. It is true recognition of the work of these people in ensuring that others are not institutionalised. There could be a substantial reduction in the numbers who would perhaps otherwise require full time care in geriatric institutions if the nursing homes legislation is used to its fullest.
The training of people with a mental handicap has continued apace in recent years. The point that has been reached regarding training could not have been anticipated years ago. A large amount of work has been done in this area and many centres have been provided for people with a mental handicap. Many such people get work in the form of small jobs from corporate bodies and outside groups. However, the amount of work could be increased greatly. I visited a particular training centre which did work for co-ops, Aer Lingus and a number of others. I hoped, given the increased numbers and activity in such centres, that there would be a corresponding increase in demand from groups for their services in different areas — for example, packing.
There has been a substantial improvement in the provision of funding for many matters and it is more apparent in my area. The Minister mentioned the funding he made available for the excess debt that existed. My health board was one of the more responsible boards in the region. However, sometimes one can suffer for being responsible; one pays a price. When we compared services that were provided, we found that we came out very badly. However, efforts are being made to improve the situation though a better balance. The Minister has been forthcoming when proposals were put to him in that regard.
In the future I hope the situation of massive overexpenditure will not develop. It is impossible for bodies, whether they are commercial, health boards or others, to operate properly or commercially if they do not have the money or at least a guarantee that the money will be paid within a specified period. Delays and debts mount up. I have always made the point that health boards should jointly use their equipment. High tech equipment is expensive and one wonders how they provide the finance for such items. Health boards should work together to ensure that we get the best possible value for money in an area where so much money is required. Progress has been made and I hope it will continue in 1994.
I welcome the Minister. I congratulate him on his health initiatives since he came into office. He was left a legacy that he could not deal with in one year and all members accept that. However, he has made great inroads. The waiting list initiative is an example. Over 40,000 people were waiting admission and that figure is well down. The numbers are not ideal, but hopefully in the next numbers of years we will reach a point where we will not have a waiting list.
I welcome the discussion document on women's health and the maternity services. Perhaps the Minister would investigate my health board area where there appears to be a three year waiting list to see gynaecologists. I am delighted that all sections of the Child Care Act will be implemented by the end of 1996. Recently we have seen how necessary that legislation is. If it had been implemented many years ago we might have avoided some problems.
On the nursing home legislation, my constituents have brought to my notice a difficulty about subventions which occurs where sons and daughters are assessed as being able to contribute even though they cannot or will not contribute. Sometimes old people without family get the subvention while those with a family will not although the family is not willing to contribute. Will the Minster investigate that problem?
The Minister spoke about the dental health action plan. There is a difficulty in this regard because dentists do not apply for temporary posts. Only permanent posts attract applications. In my constituency when the dentist, whose post was temporary, went on maternity leave nobody was willing to take up the locum. If the posts were permanent dentists would be more likely to accept them.
I agree with the last speaker's comments on the health boards. The allocation of £100 million to relieve their financial difficulties was welcome. Many small businesses almost closed as a result of debts to them by health boards. However, the health boards must be more careful in spending money. They should adapt a common approach in making economies by buying in bulk and take other measures so that we will never see such debts again. The Minister deserves congratulations for dealing with that issue.
I welcome the Minister's proposal to publish a document on women's health. What will be the priorities in that document? We are still scandalously behind the times in our treatment of breast cancer. Specialists in this field are continuously saying that the waiting lists and the waiting times for treatment are too long. There is no walk-in service and treatment which should be available at this stage in the development of our health services. What are the Minister's plans in that regard?
A few days ago I raised with the Minster the question of using bed and breakfast accommodation for young people in Dublin. I was very disappointed that the Minister did not say he would issue guidelines to health boards prohibiting the use of such accommodation. In the past week, up to 25 children were still using such accommodation in Dublin. What does the Minister intend to do about resources for children in this situation?
The timescale of three years for the implementation of the Child Care Act is too long and it should be reassessed. The Minister has taken action in this area and I praise him for that. However, his problem was that he was starting from a very low base. This aspect of the Department's responsibilities and the development of child care services have received so little money that the Minister's efforts are not enough. Most child care professionals in the health boards are still dealing with crisis cases and are not able to do the preventive work necessary.
We are very far behind in developing an inspectorate for residential homes. If we are to have adequate standards in residential care we must have guidelines and an inspectorate. They have always been needed and, with increasing awareness of child sexual abuse, they are more necessary than before. Has the Minister plans to develop an inspectorate?
I welcome the health promotion campaign on AIDS. On the anti-tobacco campaign, the increasing use of tobacco by women is a serious problem. It is clear that international advertising agencies are targeting women. There were disturbing reports today that 25 per cent of the adult population smokes. We cannot be slow in dealing with this problem. We must have strong campaigns and I urge the Minister to target one such campaign at women given the increase in the number of women who smoke. Many young boys have got the health promotion message about smoking. Young girls, unfortunately, have not. Part of the reason is that they are being targeted successfully by international advertising agencies.
What is the position in regard to waiting lists for heart surgery? Does the Minister expect to be able to reduce the waiting time substantially as opposed to his indication that there will be a general reduction in hospital waiting lists? He has written to me about specific cases but, given the degree of concern of patients' families, this matter requires extra attention. People will say that politicians should not be involved in such matters; that they should be left to the professionals. I have had at least one experience — I am sure other politicians have had a similar experience - of a patient who died while the argument went on. While it can be assumed that the patient might have died even if he had received the service, it cannot be taken for granted that the politicians do not know because they often have many queries.
I will try to be as comprehensive as possible in dealing with the matters raised. Deputy Durkan commented on Castlebar hospital. Lest there be any doubt, yesterday I announced sanction for the detailed planning of phase 2 of Mayo General Hospital, a very important capital project on which, over the past 12 months there has been correspondence with the health board. On 15 April 1994 I received an outline sketch of the revised phase 2 from the health board and was delighted to give the go-ahead for the planning phase yesterday.
I have made many announcements about hospital and other developments in the past 12 months and this is the first occasion an announcement was made during an election. I did not need an election to sanction the hospital in Tullamore and last week I was delighted to visit the facilities there which are almost completed. I did not need an election to sanction the developments in Mullingar, Kilkenny or Tallaght. This is a developmental phase for hospitals. It can be seen from the significant increase in the capital vote that I consider it necessary to improve the fabric of some of our major hospitals.
In the National Development Plan I indicated that the location of the hospitals has being finalised. I must, however, enter the caveat that a review group is looking at the provision of acute surgical services in south Tipperary. In the main, the geographical location and framework of our acute services has now been determined. There are national services which will only be available in designated centres but as far as possible each region should have a reasonable mix of acute services available to it.
In that context I was delighted yesterday to agree to the beginning for the planning phase of Mayo General Hospital. The leader of Deputy Durkan's party was in Castlebar a fortnight ago and committed his party to putting the Mayo hospital at the top of its capital programme, should it ever be in Government again. I was able to deliver on the promise slightly more speedily than that.
Deputies voiced some reservations on waiting lists and said the progress made is insufficient and I share that view. I am not happy that people are on waiting lists for elective surgery and no Deputy would be happy with that. However, waiting lists are a feature of every health service in the world, although some services are more efficient and better resourced than others. I am pleased that we have targeted new resources to that area and for the first time in many years waiting lists have been reduced by 37 per cent last year. More needs to be done. Unfortunately not every good announcement can be made before the election on June 9 and I will be unable to announce details of this year's initiative on waiting lists before then.
Deputy Durkan also spoke about child care, a point that was touched on by many Deputies. I was heavily involved in the gestation of the child care legislation producing a Private Members' Bill in 1987. I served on the child care committee in all its phases. On becoming Minister for Health I was determined the Child Care Act, 1990 would not simply be a piece of paper but its provisions would be implemented.
On the optimum time frame for implementing the provisions of the Act I was told it could be implemented on a phased basis, having all sections in operation by 1996. I would have preferred to have that implemented sooner — I am particularly anxious about the care provisions for children — but it is necessary to establish an infrastructure — to build refuges, to train personnel and to improve the psychiatric and psychological support services to ensure the legislation has an impact.
I have estabished the child care policy unit in my Department to drive the Act. Work is currently being done on complex regulations on a number of issues. As I indicated in reply to a parliamentary question last week, two subcommittees, drawing together the professionals in the child care area, are working on the regulations. That is proceeding apace and I am not complacent about the matter. I will drive this as hard as I can.
I am glad the Government accepted the time frame and resourced the measure in the way I asked. We spent £5 million last year and the cost of maintaining those developments this year is £10 million. Another set of developments relating to the Child Care Act, costing £10 million, will be announced this week. We will work hard in this area.
I am as concerned as anyone about the cases which have arisen. They send shivers through us all. On the other hand, no matter what provision is in place, I could never guarantee there would be no horrific cases, whether in the home or the community. We have to be vigilant and try to provide the best services possible within the resources the State can afford.
Deputy Durkan asked about medical evidence of abuse and action on such evidence. One must always judge where the balance lies and each case must be considered on its merits. The professionals working on a case will make the best decision and I will not try to second guess them.
The Deputy also mentioned dental services, specifically orthodontics. The inadequacy of these services has been talked about for years. We have launched a national dental plan which will achieve its aims. The Irish Dental Association, and individual practitioners, have spoken of the dental plan as the most important development in dentistry, not merely in recent years but in recent decades. Once it is completed, the resources given and the personnel hired and trained, dental services in Ireland will be on a par with any other EU country.
I told the Dáil last week I do not want to mislead people about the difficulty we will have with orthodontics. It was indicated that we need nine consultant orthodontists and we are seeking to recruit those. We will have a number of orthodontic specialists working in the system and we will train general dentists. We are increasing the number of dental teams from 300 to 410 and will recruit a different mix of dental team which will include dental hygienists for the first time in the public dental system.
This major development will impact on our dental services. Medical card holders will over a number of years be entitled to avail of private dental services. Once the plan is approved by the Irish Dental Association, all medical card holders will have access to their local dentists on an emergency basis. There will be a vast improvement on the existing provision and I look forward to everything being put in place.
Many Deputies mentioned women's health, and hepatitis C in particular. There was no easy way of dealing with an issue which arose suddenly one Friday in the Department of Health, when I was informed of the prospect that women who had been given the anti D immunoglobulin might have indvertently been given hepatitis C. There is not a right decision in these matters but although it was not an easy decision, I resolved that we must immediately screen all women who had received anti D. We made this public the following Monday, having worked through the weekend to put the screening process and the information bases into places.
I do not deny that there were gaps in the system. However, if we wanted to screen 50,000 women, in normal circumstances it would take more than four days to put the scheme together. We did not have more time because I was determined women should know. I took criticism for not telling doctors in advance but I believe my decision was right and I would not hesitate to do the same again. It would be impossible to brief individual doctors and somehow keep the matter secret from the women most affected. I would have been rightly criticised if I had taken that course. I chose to reveal the information.
Both through the National Blood Transfusion Service Board and the resources of the Department, we have done our best to provide counselling and support for all the women who have tested positive. As Deputies know, there are three tests and the final confirmatory tests carried out in Edinburgh are still ongoing. I met many women anxious about hepatitis C. It is not as if we have a huge reservoir of knowledge about the condition — information on the condition is patchy. It is necessary to inform doctors and we are doing so. We are trying to rectify the gaps in the service. I appeal to women, who have not yet come forward, to attend for testing if they received the anti D treatment. I assure the committee that we are constantly monitoring the services.
I met one of the founding members of the support group last week and I look forward to meeting the remaining members. During a long discussion with me, she pointed out that many small things caused upset, including the manner of some consultants, some treatments and the way information was given. These issues need to be addressed. She gave me the details of the things we can address and we will look at those immediately. By and large a good screening programme was carried out and most women were counselled. The process is ongoing and is filtering out to spouses and children. Many people, who thought they had good health, are now anxious because they may have a virus they know nothing about. It is not possible to make this a lesser burden. It is a real burden and we must acknowledge and understand that.
The role of NCHDs was also raised by Deputy Durkan. I am concerned — I said this when the Tierney report was published — that there is an imbalance in the number of consultants to junior hospital doctors. That is being examined. We are more advanced in terms of working hours for NCHDs than for instance the United Kingdom. NCHDs work a basic 39 hour week, but are liable to be rostered up to a maximum of 65 hours a week. Overtime is paid for in excess of 39 hours worked. It can and does happen that people are rostered over their 65 hours. A collaborative study group, consisting of representatives of my Department, Comhairle na nOspidéal, and the Postgraduate Medical and Dental Board, examined the distribution of personnel. The group's report has been circulated as a discussion document. The responses generated from that discussion document are being examined. This is still on the agenda.
Deputy O'Donnell said the Department of Health has always been a high spender and that is true. In this morning's newspapers, she accused me of being a spendthrift Minister, but in her comments on the Estimate today she said she supports the expenditure. It is fine to be theoretically correct in fiscal matters, but when one asks what area should be cut, one sometimes gets a different response. I understand that is also part of politics.
I am concerned about her comment that people should not believe a word a politician says. Like her, I have been on the hustings for some time now and I have talked to people in my constituency and in Leinster, Munster and Connacht-Ulster in recent weeks. I have not encountered the level of cynicism Deputy O'Donnell encountered, but, perhaps, there are certain reasons for that which need not be pointed out to this committee. Deputy O'Donnell mentioned difficulties in paying GPs for the anti D testing. I assure the Deputy that the Department will pick up the tab. I also pointed out to Deputy O'Donnell that the Irish Medical Organisation, as soon as I requested it, started negotiations with my officials about a fee for the testing. I was anxious to have the details confirmed as soon as possible. A relatively generous fee was negotiated for the work. This was necessary and the cost will be paid by the State.
On where the department of public health medicine was mentioned in the Estimate, there is an initial allocation of £300,000 for the establishment this year of that department. I am determined that will happen.
On Child Care Act, 1990, it is over the top and unacceptable for Deputy O'Donnell to accuse me of wilfully postponing its implementation. It is being implemented at the optimum speed. The dates of enactment have not changed since the day I brought the proposals to Government and it accepted them. We are working flat out on that timeframe. The Bill did not make any progress when the Progressive Democrats was in Government. Deputy O'Donnell may wish to address that fact. I am determined to implement this Bill in my term as Minister for Health and we are working hard to do so. The money is being spent to put the support mechanisms in place.
On contact between gardaí and the health boards under the Child Care Act, we dealt with this matter last week in the Dáil during Question Time. However, the point I made did not impact on Deputy O'Donnell who said I fudged the issue and had adopted a soft approach. I carefully explained in the Dáil last week that this is not a simple matter. I cannot and will not require the mandatory reporting of all suspected cases of abuse just because it seems the politically correct thing to do. For example, if a 17 year old, or a child younger, becomes pregnant, it will give rise to the suspicion that an offence has been committed. If a 16 year old girl becomes pregnant by her teenage boyfriend, I am anxious that she would feel confident and safe in going to the health board and the health services. If that young woman felt her partner could be prosecuted as a result of her going to the health services she might end up having her child on the side of a ditch, as happened before. I will take great care when introducing new procedures because I want to ensure that the safety of children and young women is maintained. The pilot contact mechanisms which will be concluded shortly will lead to the best practice. I will continue to work towards better liaison between the health boards and the Garda in the most careful and most sensitive way possible.
Deputy O'Donnell also talked about social workers living in fear of overstepping their powers. There is a balance and we have seen the United Kingdom's excesses on both sides. We have seen inaction, where children suffered, and we have seen overreaction where children were taken from their families causing great trauma to the families and children concerned. These decisions are best made by the clinical professionals. There are no straightforward simplistic rules which give the right answer in every case.
Women's refuges have been a priority. We have put significant resources into refuges and these will continue to be resourced as part of the ongoing funding I outlined.
Travellers' health was also mentioned by Deputy O'Donnell. As Deputy McManus is aware, a working group is looking at the issue of travellers' health. On the conclusion of their considerations, I hope to be in a position to act on this matter. The health strategy should target geographical groups or groups of people whose health status is below the norm and travellers fit into that category.
Deputy O'Donnell complained there was no sign of additional resources for research. She obviously did not look carefully at the Estimate. The allocation for medical research last year was £1.8 million, but it is £2.3 million this year, an increase of 28 per cent. I am delighted I was in a position to do this and it was strongly welcomed earlier this year by the Health Research Board.
Deputy McManus accused me of having double standards. I understand why the Deputy would make a political charge this week but I refute it. I invariably did what I said I would do. I have not made promises on which I have been unable to deliver. This is on record if anybody wants to check.
Deputy McManus spoke about the lack of basic information and, more seriously, instanced that parlimentary questions were not fully answered. I am determined to give the fullest information to Deputies. If additional information is sought on any occasion, I will happily hear direct questions by telephone or by fax to my office. I am anxious to provide a complete and open information system to Members. Deputy McManus also mentioned the insufficient money for health promotion. An additional £500,000 has been allocated this year. Although we could never provide enough, it is the biggest increase for health promotion for some time.
She spoke too about equity. Equity amounts to access to services on the basis of need. We are working towards that. I understand she has a particular view on private medicine and may wish that private medicine did not exist in Ireland. Maybe that would apply if there was a common waiting list. I suggest we are working on a balanced basis whereby people are treated according to need. That is the essence of the waiting list initiative and of the funding made available to improve hospital services. It is the underlying principle enshrined in the health strategy.
While I understand Deputy McManus's enthusiasm for a battle with consultants, I prefer, as far as possible, to achieve my objectives without public battles. I do not share her view that it is a sign of weakness in the health strategy that everybody has welcomed it. There is a certain perversion in the logic that if something is not upsetting, it is not doing any good. There is a notion that if medicine does not taste bad, it cannot do any good. There has been a strong welcome for the health strategy among the 64,000 people who work in the health services because they understand the need for change and are enthusiastic, rather than resistant to it.
Deputy McManus spoke about always catching up on waiting lists. In a way she is right as we will always be catching up because people will be continually sick. When I spoke to my Danish counterpart, Mr. Lund, about a major initiative on hips, he said when one solves hip problems, the knees give out because they than come under pressure. There are waiting lists for knee operations in Denmark. I am sure if we operate on knees, ankles will then give out. We will never sort out waiting lists because there will always be new pressures on health services.
Deputies McManus and Durkan raised an important point on cardiac surgery. The need for better facilities for cardiac surgery and heart bypasses is essential. I have provided an additional £2.5 million capital to the national cardiac unit in the Mater Hospital in the past 12 months and an additional £1.3 million revenue this year to improve services. The net impact of that will be to increase the number of bypasses by 250 each year, bringing the total activity in the Mater Hospital to 1,000 each year from the current 750. Although capital works have taken some time to put into place, that provision has been strongly welcomed.
We have also invested £1 million in the Cork cardiac unit to increase its capacity from 200 bypass operations to 400. There has been huge investment in cardiac surgery to tackle the long waiting times. I do not share the view expressed by some that cardiac operations are an optional extra or are non-essential. In some instances, they are an important life-saving procedure. I meet many people who have had them and whose quality of life has remarkably improved since. That is why I had no hesitation in taking the action I did on that matter.
Deputy Leonard welcomed the dental plan and mentioned the difficulty in recruiting dentists. This difficulty is also experienced in the south east. When the dental plan is being implemented we may need to look again at incentives in regions where there are difficulties. I do not have a closed mind on that.
I thank Deputy Leonard for his comments on provisions for the mentally handicapped and agree on the need to focus on respite care, to give a break to people caring for the handicapped at home. On employment for the handicapped, Members know the initiatives we have taken this year. I hope inroads will be made into the worrying unemployment rate among the handicapped.
I also share Deputy Leonard's view that there should not be a recurrence of the massive over-expenditure of health boards. Along with the £100 million allocated to health boards and voluntary agencies to address excessive debt, we will introduce legislation, now with the parliamentary draftsman, to provide for a level of accountability by health boards. Most Members will welcome that.
Deputy Moynihan-Cronin spoke about gynaecological services in County Kerry and I will consider how the difficulties she raised may be addressed. She also mentioned nursing home legislation and difficulties with sons and daughters, some of whom are less than enthusiastic about supporting their parents. I have difficulty with this. Traditionally, sons and daughters had a responsibility to care for their parents or to at least contribute to their care and welfare. It is something we considered carefully when drawing up the regulations. Most people feel they should return some of the care they got from their parents. However, at the end of the day parents should not be punished for the lack of support from their children who should be encouraged to look after them in their twilight years. That is not an unreasonable expectation. There is, of course, flexibility where there is no real income and support, to grant-aid the elderly person.
On the dental plan, I accept that the post of temporary dentist is not a popular one. The new resources I announced for dentistry this year will enable us to establish a service we would all like. Over the next four years, I hope to achieve the objectives laid out in the dental plan. Deputy F. Fitzgerald spoke about the women's health document. As regards breast cancer, the Irish Country Women's Association has lobbied the Department on this issue and I applaud it. I look forward to meeting representatives of the association. I had arranged to meet them some weeks ago but they could not attend because they got a better offer; they were invited to appear on "Live at Three" on the same day. I look forward to discussing this matter with them soon as it is a cause of concern to them. There is some inaccurate information abroad on it and I gave the details to the Dáil when we debated a Private Members' Motion on the matter. The jury is out on the effectiveness of screening, for example. I am giving Members the views expressed to me, and I have talked to 600 women at a public meeting as well as some of the specialists involved. Only two European Union countries, Holland and the United Kingdom, have national screening programmes. We have a lower incidence of breast cancer than the Dutch, who have a national screening programme. I am advised that false positives and false negatives are diagnosed because mammography is not an exact science, although it is a very skilled science. These can cause more anxiety than confer benefit.
The general current position is that referrals are made by GPs on the basis of suspicion. I would like to see enhanced mammography services to ensure that once people are referred they are treated speedily. I am considering resourcing this area and am looking forward to the result of the Eccles Street project. We, and a number of other European Union countries, are working together to ascertain the effectiveness of screening. We will make final decisions on national screening on the basis of the results from that.
There are a number of issues other than simply a national screening programme, for instance education and self awareness. Screening is largely useless for younger women, so we need more effective mechanisms for younger women to detect possible cancers. All of that is very much on our agenda and will be part of the women's health document later this year.
Deputy Fitzgerald raised the matter of bed and breakfast for young people having raised it in the Dáil at Question Time. I said then that it is probably the least satisfactory option but it has to be there so that when somebody is found on the street and there is no more appropriate place it can be used. Caring for the homeless child is an integral part of the resources we are putting into child care. The investment this year is £10 million on top of the £10 million cost last year. New services are coming on stream and we will look in particular at the area of youth homelessness.
On an inspectorate for residential homes, there is a need for standards. I have established a working group to prepare a draft set of standards to form the basis of regulations. Two working groups are looking at regulations under the Child Care Act. The group represents the Irish Association of Care Workers, the Resident Managers Association, the Conference of Major Religious Superiors and the health boards as well as my Department. I hope to have draft standards available before the end of this year.
Health promotion was also raised by Deputy Fitzgerald and she sought a campaign targeted at women. The latest statistics available to me, to the end of July last, show that 28 per cent of people aged 15 years and over smoke, that is, 31 per cent of men and 26 per cent of women. This compares with an overall prevalence of 43 per cent in the early 1970s so we have made improvements. In the 1970s the figure was 43 per cent to an overall prevalence now of 28 per cent.
Analyses have shown that recently young girls have begun to smoke although we have got the message through to the young boys. The data indicates that the number of young girls smoking has plateaued — there has not been an increase in the numbers. A major national survey on smoking was conducted last year by the health promotion unit and this too showed that the incidence of smoking among young girls and women is plateauing.
We still need targeted campaigns. My instinct last year in the anti-smoking campaign was not to tell people that smoking is killing them. We have been telling them that for years and they know it. It is printed in bold letters on all the cigarette packages. There is one brand of cigarettes called "Death" on sale in parts of the European Union. It is a black attack on the marketing strategy of health promotion. Most people want to give up smoking and we have to help them. That was the thrust of last year's anti-smoking campaigns. We will look, following Deputy Fitzgerald's comments, at how we can get through to young girls and women and, perhaps, Deputy Fitzgerald might also reflect on it. If any Deputy has suggestions on the matter, I will welcome them.
I hope I have dealt comprehensively with most of the issues raised.
On the implementation of the provision of the Child Care Act, the Minister mentions a timetable of three years. Has he any timetable on the aspects he is implementing, on providing better psychological services and on training personnel? People would feel more reassured about its implementation if he could give greater details of how he intends to proceed over the next three years.
On the bed and breakfast accommodation, the Minster is being a bit complacent in saying that it has to be there. We are seeing a dangerous escalation in its use. I am afraid that it will become accepted in all the health board areas that bed and breakfasts must be used and, therefore, more appropriate services will not develop.
I congratulate the Minster on the announcement of the money made available for the hospital in Castlebar. While I am not from that constituency I live near the Mayo border. We have a very modern general hospital in Sligo and I am delighted that the Minister allocated the necessary funds to complete the hospital in Castlebar. Deputy O'Donnell's remarks would go down well in Mayo-West at the moment in a speech outside a church gate in Belmullet.
I have been approached by a number of people who have for a number of years worked as temporary home helps. Some of them have been temporary for 11 or 12 years. They are giving an excellent service, and working at weekends. Will the Minister consider making these people permanent, especially when they have worked for so long and done an excellent job.
Nursing homes and the nursing home legislation was also mentioned. I congratulate the Minister and the Government on making the finance available to subsidise people in nursing homes. The weekly allowance is wonderful because there was a shortfall between the cost of nursing home care and the old age pension.
Day care centres are a great facility. A new day care centre was built recently in Tubbercurry and it gives great service to the people in that area. I would like to see a small 15 to 20 bed nursing unit attached to it. Elderly people are better off in their own homes and environments than 25 or 30 miles away. I hope the Minster can see his way to developing smaller nursing homes with a view to keeping elderly people in their own areas. I would also like to see a day centre in Collooney, County Sligo as soon as possible.
The Minster referred to funding to reduce waiting lists. I hope he will be as generous as possible having regard to the effectiveness of last year's funding in reducing the numbers of people in severe pain begging to get into hospital. The consultants and hospital staff in most instances are to be congratulated for their response. In the orthopaedic hospital in the area I represent they responded effectively — and without complaint — to the additional work. Surveys indicate that my constituency has the highest incidence per capita of hip replacements and perhaps the Minister would look into that. We like to think that it is due to a stronger work ethic but——
It wears them out.
—— we never found out why. The extra funding has been effective in that area and I hope the Minister will make all possible resources available to continue the good work.
I appreciate that the Minister just happened to be in Castlebar and that it had nothing to do with the by-election.
I was there to open a new medical centre worth £14 million.
I am sure it is normal for the Minister, in the course of his week's work, to chase down to Castlebar and various other places. I hope his announcement will have an impact after the election because there is a tendency by Government to forget about things when the threat of an election recedes.
Give one commitment I have not delivered on.
It would not tax my powers of recollection to list a number.
Tax away; one will do.
Does the Minister propose to change the system of allocation of proceeds from the national lottery? It has caused some controversy in the past. Opposition parties have great ideas as to how to allocate lottery funds on an equitable basis, to which I subscribe. Unfortunately, history has shown that when parties get into Government they do not carry the same sense of idealism with them. I hope the Minister might transmit that idealism into action in this case.
On the Child Care Act I agree with the Minister about the services reacting too soon. It is an exacting and difficult science and I am sure we have all dealt with cases where the services reacted too soon. After child sex abuse the next worst crime is to wrongly accuse a parent or guardian because the damage cannot be redressed. However, where medical evidence clearly indicates that abuse took place there should be no delay, and that is what I want the Minister to clarify.
Will he give us some idea as to when he expects all the information to be available from the review group on the VHI given that deregulation will affect that area? I am concerned about the VHI in the new market conditions which will prevail after 1 September.
On hospital charges, the uncaring edge of the services, I have dealt with a number of medical card holders, in some cases stroke patients, who receive belligerent demands for charges in respect of services, for example, long stay geriatric care. That is unnecessary; it should not recur as it causes considerable distress to the people concerned. These are cases in which all the people involved are in receipt of no other income except social welfare. This happens on a regular basis and it would help if somebody could key the correct information into the computer.
On the private nursing home sub-vention, the Minister seemed to imply that sons and daughters do not take the same care of relatives as in the past. I do not agree with that. The world has changed and circumstances are such that more and more husbands, wives, sons and daughters go out to work and have other pressing demands. We are all aware of cases where families under severe financial pressure find an income assessment distressing and it is wrong to suggest that sons and daughters do not care as much for their parents as in the past. Previously they were available as they did not have the same commitments. They now have a combination of problems which did not exist to the same extent some years ago. I am sorry that the Minister does not concur but if he wants evidence I can supply it. People now have excessively high mortgages, little disposable income after meeting all mandatory outgoings and costs associated with caring for relatives — not necessarily residential care costs. Will the Minister bear in mind that it is not as simple as families not being as caring as they were; they are, but they are not as readily available.
Deputy Frances Fitzgerald asked about the schedule for phasing in the Child Care Act. As I indicated previously, 17 sections are being implemented. Most of the preventative and service delivery provisions contained in Part II of the legislation are in place. The remaining sections will be brought into operation in phases up to the end of 1996 in accordance with the time frame I have outlined. Part III, emergency care orders; Part IV, care and supervision orders; Part V, the court procedures and Part VI, the new regulations on foster and residential care and the new access provisions will be in place by the end of 1995. Most of these require detailed regulations that are as complex to draft as the initial Act, which took many years to devise. Part VII, the supervision of pre-schools and Part VIII, the registration of childrens' homes will be implemented by the end of 1996. That is the determined phasing and it will be implemented as quickly as possible.
Deputy Fitzgerald also referred to placing children in bed and breakfast accommodation. As the Deputy will be aware, this practice is a final resort and is not widespread. It is mainly confined to the Eastern Health Board region and not normally used in health board areas. Unfortunately, the Eastern Health Board region has the highest incidence of homeless youth. There are six children under 16 years of age and 19 children between 16 and 18 years of age in bed and breakfast accommodation in the Eastern Health Board area. I will strive to improve that situation. If children are found on the street who have nowhere to go and have not been put into residential care. They are sometimes given bed and breakfast accommodation. It is not a fixed entity; obviously numbers would change or any given day.
Deputy Mattie Brennan referred to home help and I agree with him on this. Indeed, I have answered questions in the Dáil and have asked the chief executives of the health boards to review this issue. There is a great variety of treatments across the country. Some are employed full time while others work part time. Some are only looking after a neighbour while others have virtually a full time job. There are many difficulties. I dealt with the case of a woman involved in this work for 20 years. Although she was paid what she regarded as a wage every week, she had no pension entitlements. There are a number of issues to be addressed in the home help area and I have asked the chief executives to see what improvements can be made. The lowest rate of pay for home helpers, which is far too low a rate, should be increased to a more acceptable level.
Deputy Brennan commented on day care centres and I also agree with him on this matter. We are developing health centres which are bringing community care directly to the local areas. The Deputy will be aware that it is policy to have smaller nursing units for the elderly. The average range is now between 27 and 32 beds, which is much smaller than the larger numbers in existence in the past.
Deputy Leonard mentioned waiting lists. I am glad to tell the Deputy that I will shortly announce a new 1994 waiting list initiative, with £10 million provided from the budget for it. I too congratulate consultants in getting real value for money for the £20 million that was expended last year.
Deputy Durkan raised a number of issues. I have changed the procedures to apply for a national lottery grant since I became Minister for Health. From 1 January, anyone applying automatically gets a standard application form which is forwarded directly to the finance unit in my Department. A financial statement from the group concerned is also required. That is then vetted in my Department, who make a recommendation to me. Ultimately, the decisions are made on the basis of these recommendations. Unfortunately, the percentage of discretionary lottery funds in the Department of Health is limited. Although the Department gets money from the national lottery, virtually all of it is already earmarked for other areas. Therefore, I have little discretion on the matter.
Of the £30 million total that I will expand in national lottery allocations, some £13 million will go to child care, the elderly, the physically and mentally handicapped, public health, AIDS and to the health boards. There are also the block grants to the health boards. Health promotion gets £.5 million and the National Social Services Board £1 million. The National Cancer Registry is funded, as is the Disability Federation of Ireland. The rape crisis centres in Dublin, Limerick, Kilkenny, Clonmel, Waterford, Cork, Kerry, Galway and Castlebar, the Wexford Counselling Service, the Irish Kidney Association and others also get funds from the national lottery. After all of the allocated moneys have been issued, the amount remaining is small. The procedure is as I have outlined. I have already referred to the Child Care Act. I am, determined that the VHI will operate within the new open competitive environment required by the European Union. A review group is looking at its current status and I look forward to its report. I will introduce two new pieces of legislation this year. The first one, which will have to be introduced before the summer recess, is to determine the market for open competition. It will include holding, in Irish law, the important principles of open enrolment, life time cover and community rating. The details of that Bill will be made available to Deputies within the next few weeks.
Medical card holders are exempt, as Deputy Durkan knows, from hospital charges. Better hospital computerisation is needed and we are currently working on that. The introduction of computerised medical card systems which can be integrated into the hospital system will greatly reduce the incidence of incorrect charging. Steady progress is being made on this issue. Inevitably, mistakes will be made, but medical card holders are exempt from all charges. During the course of this year, I made positive changes in the charging system, abolished the outpatient charge and changed the accident and emergency charge.
On private nursing homes Deputy Durkan might have seen from my expression that I do not agree fully with his statements. I might be a little old fashioned in believing that children have a responsibility to their parents. It is not a matter of thinking of other expenses and doubting whether they can afford to care for a mother or father. It is a matter of priority. If someone suggested that a couple, because of their many expenses, could not afford to feed and cloth their children, the Deputy would be outraged. Therefore, why should they feel they have no responsibility to——
The Minister is taking a callous attitude towards the elderly. They have worked all of their lives.
The Deputy is suggesting that a callous society exists and I do not believe that.
It does exist.
The vast majority of people want to support their parents in their old age.
They do.
Many people look after them at home. When this is no longer possible, many would want to contribute to their nursing home care. It is not unreasonable to seek——
Maybe they are not capable of caring for them.
If they are not capable, this is a different matter, which can be examined. One should not decide that the parents should go on the list after the mortgage. That is an indication of a society that I do not believe exists in Ireland. There will be total discretion to the health board to make the award when there is a real need.
We have made remarkable improvements since last September. I introduced the Health (Nursing Homes) Act and we provided considerable moneys last year, to be repeated this year, to resource the Act. Many people are now being sub-vented which was not the case before September 1993. There have been teething problems in some of the assessments and registrations. I hope these will be resolved to enable a better system of support to be put in place.
On the issue of senior citizens——
Deputy, I had asked the Minister to conclude.
I appreciate that, but there is some time remaining to the committee and I wish to address the issue of senior citizens. Senior citizens who have worked all their lives should not be hounded afterwards. Neither should their families be hounded to ensure that every iota of information available is extracted from them before they are paid any money. It is unacceptable, and our senior citizens are entitled to a little respect. I accept the Minister's remarks on families being expected to assist but I do not accept the attitude prevailing in some quarters where it is seen as necessary and desirable, that upon an elderly person appearing to become a burden on the State, he should be hunted down and searched for all possible assets, to ensure that the State does not have to accept any responsibility for that person.
I thank the Chairman, and all Members, for the debate and the close questioning. The committee is a useful forum. It strengthens the whole area of public accountability, and this is important. I will consider all the points raised by the Deputies today on the expenditure of moneys. The health services do not belong to me nor to the Government, but to all our citizens.
As Minister for Health it is my job to ensure that the health services are delivered in a cost effective, equitable and efficient way. I am happy to be associated with the developments I have outlined and I am delighted that this year has marked, for the first time in our history, the publication of a national health strategy. I look forward to keeping all Members fully appraised of the developments as they arise, and to being fully accountable for them.
Thank you again, Chairman, for the diligent way in which the committee undertook its work today.
This concludes the comittee's consideration of the Department of Health Estimate. I thank the Minister and his officials for their attendance and the comprehensive response to the points raised. I thank the Members of the committee for their co-operation in consideration of the Estimate.
The Select Committee will meet again on Wednesday, 15 June 1994 at 3 p.m. to consider the Estimate for the Department of Arts, Culture and the Gaeltacht.
The Select Committee adjourned at 5.15 p.m.