A suggested timetable has been circulated which is intended to assist in discharging our business in a businesslike fashion. While it is not a rigid timetable and I will be a little flexible, I hope Members will stick to it as closely as possible. Is the timetable agreed? Agreed. Today the committee will consider the Estimate for the Department of Health and I am sure Members will wish to contribute. I now call the Minister for Health, Deputy Noonan, to make his opening statement.
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Vote 41 — Health (Revised Estimate).
Limerick East): I am delighted to present to the committee details of the Health Estimate for 1995, which is my first as Minister for Health. First, I wish to state my personal commitment and that of the Government to the principles contained in the health strategy published last year. The central thrust of the strategy is the reorientation of the health systems towards greater effectiveness, efficiency and accountability by reshaping the way the services are planned and delivered.
It places the concepts of health gain and social gain at the centre of the health agenda and highlights the need to adequately identify the population's health needs, the setting of clear objectives and the attainment of measurable targets in all areas of the health services. The strategy is based on the three key principles of equity, quality and accountability and is accompanied by a four year action plan with real and attainable targets designed to achieve these goals.
The strategy has been endorsed in A Government of Renewal as the basis for this Government’s programme in the health area. I have made clear in my visits to health boards the Government’s commitment to the strategy as the basis of health policy and have been pleased at the extent to which the plans and practices of the boards and the values by which they judge their performance are already being influenced by the strategy.
This Estimate is framed to make a significant contribution towards the further achievement of the targets set out in the four year plan and reflects the fundamental values which are incorporated in the strategy. I am pleased to be able to confirm to the committee that, within the policy enunciated in relation to the management of public finances, the resources provided will enable further progress to be achieved in developing services for children at risk, for the mentally handicapped, the physically disabled, the elderly, and other groups with special needs. It will also be possible to provide for additional developments in the acute hospital sector in order to meet the critical pressures on services.
One of the main aspects of the health strategy is the emphasis in encouraging people to take more responsibility for their own health. In order to achieve this we need to provide the necessary information and support to help people take that responsibility. I am pleased to say, therefore, that the additional funding for my Department's health promotion unit will be provided to enable it to carry on its vital work in this area.
The overall provision in this Estimate represents a further significant advance in developing a wide range of health services. Coupled with the improvements made in 1993 and 1994, it aims to further promote the health of the people, give particular preference to those with pressing needs, some of whom may have received relatively little priority over the years, and bring waiting times for certain conditions nearer to an acceptable level. While we are unlikely to be able to sustain this rate of improvement in 1996, those with special needs will not be neglected.
I now turn to the principal features of the 1995 Estimate which is before the committee. The 1995 Health Vote, when the budget provisions are taken into account, is over £2 billion. The provision for health represents one-fifth of all Government spending on supply services this year. The 1995 net Estimate is £2.07 billion and represents an increase of approximately £28 million, or 1 per cent, in the outturn for 1994.
However, in comparing the provision for the health services for 1994 and 1995, it is necessary to take into account the substantial amount of money, £45 million, which has been transferred to the Department of Social Welfare this year. This arises because that Department will assume responsibility for the payment of disabled persons maintenance allowance from 1 July onwards. When this adjustment is taken into account, the increase is £73 million or 4 per cent. I have circulated two tables which provide additional details on changes in 1995 over 1994.
I already mentioned that health promotion is a key element in the health strategy and is an obvious starting point for refocusing the health services, improving people's state of health and quality of life. Progress has been made in improving the health of our population in recent decades. Life expectancy in Ireland has increased substantially and there has been a dramatic drop in infant mortality. Other encouraging facts are that childhood vaccination schemes have had a major impact on communicable diseases, the death rate from strokes has almost halved since 1972 and the mortality from road traffic accidents and other accidents has shown a welcome drop in recent years.
However, much remains to be done. Over one-fifth of all deaths in Ireland were of people aged less than 65. Much of this premature mortality is preventable. It is critically important therefore that the necessary information is made available to enable people to make healthier choices about their lifestyles. I am pleased, therefore, that an additional £300,000 has been allocated in the Estimate for health promotion. The major campaigns this year will continue to be targeted at reducing some of these avoidable deaths. They will include anti-tobacco campaign, the AIDS awareness campaign, and educational programmes in the areas of drugs and alcohol misuse.
In addition, my Department's health promotion unit has included a special provision in its budget for the promotion of breast feeding. Within the next four weeks a health promotion strategy will be published. The essential message will be a simple one. We must create the conditions in which it is easier to exercise the healthy choice and we must give the people the information and the encouragement to choose the healthy option.
My Department will soon be publishing a discussion document on women's health which takes account of the recommendation of the Second Commission on the Status of Women and builds on the principles set out in the health strategy. The Government is committed under the terms of A Government of Renewal to publish a plan for the development of health services for women. The discussion document will be an important step towards developing that plan. The document will form the basis for consultation with all those interested in improving the health and welfare of women.
I wish to refer to recent events and developments in the Blood Transfusion Service Board. This, as Members already know, has been the subject of discussions in both Houses of the Oireachtas and with the Oireachtas Joint Committee on Women's Rights. The services put in place for persons who have tested positive for hepatitis C under the national blood screening programme, which includes counselling treatment in six designated hospitals and prescribed medication, will be available for as long as they are required. The needs of those who have been diagnosed as positive for hepatitis C will be monitored and reassessed on an ongoing basis to ensure that the necessary support services are provided to meet their needs. All these services are being provided free of charge by the hospital system.
The Government has decided to establish as a matter of urgency a tribunal which will assess compensation on an ex-gratia basis in respect of Anti D recipients who are infected with hepatitis C antibodies/virus and the partners and children of these women who are also infected with hepatitis C antibodies/virus. This will meet the Government’s commitment to these people in the policy document, A Government of Renewal.
There is ongoing consideration in my Department of the position in relation to people who are positive for hepatitis C who were recipients of blood transfustions. I have met with representatives of these groups — the Irish Kidney Association, the Irish Haemophilia Society and Transfusion Positive — and advised them that decisions in relation to access to the compensation tribunal, when established, for groups other than Anti-D recipients will be made by the Government in due course.
In the child welfare area, the Government is fully committed to the development of a comprehensive range of services and supports for the care and protection of children. The process of coming to terms with the reality of child abuse in our midst has been a painful one. The continuing revelations of sexual and other abuse of children has reinforced the resolve of the Government to confront this horrific problem head on and take whatever action is necessary to protect our children, in so far as is humanly possible, from abuse and neglect.
The Government is firmly committed to the rapid implementation of the Child Care Act. This ws identified by the report of the Kilkenny incest investigation as the biggest single contribution that could be made to the protection of children and the promotion of their welfare. The Child Care Act is central to the Government's overall strategy for protecting children from all forms of abuse and neglect and we are determined to ensure that it is brought into operation in its entirely within the shortest possible time frame.
For this legislation to be effective, it must be backed up by a programme of investment in the development of new childcare services and family supports which are capable of responding to the needs of those whom the Act is designed to help. I assure the committee that the Government will fully implement its commitments under the Act and in accordance with the timetable already announced. A sum of £10 million has been set aside in this year's Estimate for the further development of childcare services.
My Department has finalised, in consultation with the health boards, a range of important new developments which are designed to ensure that: (1) our child protection services are strengthened and equipped to the needs of children who are not receiving adequate care and protection; (2) intensive counselling and treatment is provided for victims of child abuse; (3) special therapeutic care is provided for those who have been damaged by abuse and neglect; (4) an adequate range of accommodation and supports is available to help homeless youngsters; (5) children in foster care and residential care are supervised and monitored on a systematic basis; and (6) locally based helping services are in place to assist families in difficulty.
I intend to proceed in the autumn with the commencement of the core provisions of the Child Care Act that will strengthen the powers of the health boards, the Garda and the courts to intervene to protect children who are being abused or neglected. The special allocation for child care in the Estimate will facilitate the achievement of this important objective. These important developments underline the commitment of the Government to putting in place a comprehensive framework for the care and protection of vulnerable children.
As a public representative — in common with all those here — I am very aware of the anxieties of families who have sons or daughters, brothers or sisters with mental handicap on a waiting list for services. As a result of the increased longevity of persons with mental handicap, there are now more adults with mental handicap within this population group than at any other period in our history. At the same time, their parents are reaching old age and are no longer in a position to care for them. This factors has led to particular problems in the provision of services. In addition to the requirement for new services, existing services have had to change to take account of the needs of the growing number of older persons with mental handicap.
Since 1990, additional funding amounting to £32.58 million has been made available to develop services for persons with mental handicap. Up to the end of 1994, over 780 new residential and 1,650 new day care places have been provided. Various significant steps, both at national and European level, have been initiated recently to upgrade and extend the provisions of good quality training and viable employment opportunities, which I view as a priority issue for all persons with a disability.
The home support services, which were initiated in 1992, have been expanded in subsequent years. These services are now established as an essential component in the range of services available to support and assist persons with mental handicap and their families. Assistance has also been given to agencies in recent years to meet identified needs in existing services. Overall expenditure on the services financed by the Exchequer increased from £161 million to £238 million in the period 1990-94.
I wish to reaffirm the commitment of the Government to the continued development of services to persons with mental handicap. The Government is making an additional £10 million available this year, which will become part of ongoing expenditure on the services, and £2 million of this is being used to meet identified needs in existing services. Sums of £8 million revenue and £2 million capital will be used for the further development of new services for persons with a mental handicap.
This funding will enable the health boards and other service providers to put in place a broad range of additional services as follows: 189 additional residential and respite places; 418 additional day care places; the further extension of the home support services; additional funding for the improvement of services for persons with mental handicap who are also behavourably disturbed; implementation of the Department's policy document on services for persons with autism; the provision of hepatitis B vaccinations for staff working in the mental handicap services and client groups who are considered to be at risk; and the continuation of the programme to transfer persons with mental handicap from psychiatric hospitals and other unsuitable placements to more appropriate care settings. Capital expenditure will be directly related to the agreed service developments. The precise services which will be put in place are now being agreed by the regional mental handicap co-ordinating committees within the guidelines issued by my Department.
I wish to briefly refer to the issue of mental health legislation. There is a clear commitment to the early introduction of new mental health legislation to update the Mental Treatment Act, 1945, and subsequent amending legislation. As a prelude to the enactment of this legislation, I have sought the authority of the Government to publish a White Paper on Mental Health Legislation which will set out the Government's intentions on the content of new legislation in this area. The publication of the White Paper will mark the end of a consultative process with interested parties on proposed legislative provisions which began with the publication of a Green Paper on Mental Health in June 1992. New legislation will provide a modern framework within which the relatively small number of people with mental disorder who refuse or who are incapable of seeking treatment or protection in their own interest or others can be cared for and treated.
One of the great achievements of western societies in this century has been the opportunity provided to the majority of citizens to live to an ald age. Economic and social progress and improved health services have reduced premature mortality. Life expectancy is increasing in all member states of the European Union. As a result there are over 60 million people in the EU who are aged 60 or over. One in five of the population in the Community is an older citizen. The ratio is set to rise to one in four by the year 2000.
In Ireland there are 528,000 people aged 60 or over, or one in seven of the population. In Ireland, too, the elderly population is growing and the expected increase in this country in the number of elderly reaching advanced old age is dramatic. It has been estimated that between 1981 and 2006 there will be a 20 per cent increase in the number of people aged 75 and over and a 28 per cent increase in the number of people aged 80 and over.
The objectives of Government health policy, as set out in the report The Years Ahead — A Policy for the Elderly and reinforced in the health strategy, is to support the care of dependent elderly people at home for as long as possible and to ensure that when the elderly can no longer be cared for at home, there are appropriate specialist and extended care facilities to meet their needs. The priorities of service development at present are to strengthen the capacity of the health services to care for the person at home; to provide specialist facilities in acute hospitals; to reorganise our system of nursing home care; and to meet the need of the increasing number of elderly mentally infirm. To this end, the Estimate provides £2.1 million to further develop services specifically for the elderly. These include the development of acute geriatric units in hospitals, day centres and the strengthening of the home help service.
The Health Estimate for 1995 contains an additional £4.4 million for the development of services for people with physical disabilities, which is divided between £2 million revenue and £2.4 million capital. This funding will be used to develop a wide range of services, including: home care; day care; respite care; community based therapy; residential care; technical aids and appliances; and funding for voluntary organisations. In addition, £2.4 million is being provided from a mix of European and Exchequer investment for the development and upgrading of training centres for people with disabilities. This funding will be of considerable benefit to people with physical disabilities.
Following the publication of the interim report of the review group on services for people with physical and sensory disabilities, additional funding of £1.5 million was approved in 1993. A further £1.5 million was approved in 1994, while the additional funding of £4.5 million in 1995 continues this process. The final report of the review group will be available later this summer. It is intended to consult with interested organisations and service providers prior to the publication of the report.
The dental health action plan sets out my Department's intentions for the implementatiom of the provisions on dental health contained in the strategy. The fundamental objective of the plan is the achievement of health gains by the promotion of oral health and the reduction of disease through preventative and screening programmes. Enhanced treatment services must also be made available for those in need of such services. In 1994 an additional £5.6 million was provided by the Government as the first phase of the plan.
The Government is also providing additional resources of £6.5 million to the health boards this year under the dental health action plan. This will allow for the following: health boards to meet the full cost of developments approved in 1994; the further development of the children's dental services and services to special needs groups, the provision of services to children up to 14 years of age in accordance with the extension of eligibility under the plan from 12 years of age, as it was, and the further development of orthodontic services.
The additional resources to be provided in 1995 allow for the further development of dental services for medical card holders through the new dental treatment services scheme. Capital moneys amounting to £3 million to assist health boards in providing the necessary infrastructural developments associated with these major service developments is also being provided by my Department.
One of the major problems facing our society is drug abuse and the associated health and crime problems which go with it. In the area of health services a number of initiatives have been undertaken in recent years. These involve action in the areas of supply and demand reduction and increased access to treatment and rehabilitation programmes, together with co-ordination mechanisms geared towards effective implememtation.
While the health strategy advocates a drug free lifestyle as the ideal, it recognises that the various drug treatment options are required to deal with the needs of individual drug misusers. Such options would include methadone maintenance, needle exchange, detoxification and rehabilitation and could be provided by statutory agencies working in close collaboration with the voluntary sector.
Since 1992 special funding has been allocated each year to allow for the development of extensive prevention and treatment services by the Eastern Health Board, which, together with the drug treatment centre in Pearse Street and voluntary organisations, provided such services in the Dublin area. In addition, all health boards have designated a HIV / AIDS and drug service co-ordinator and funds are being made available through these individuals to implement regional based initiatives, as appropriate. Funding for HIV / AIDS and drug services was £3.4 million in 1994. In 1995, a further sum of £1.627 million was added to this figure to allow for the expansion of the services.
I know many Deputies are concerned about the provision for accident and emergency services. Since coming into office I have recognised as a priority issue the question of how best to manage the accident and emergency service in our acute hospitals. While there is generally sufficient capacity within the accident and emergency service to deal with the need of patients, peaks in demand do result in delays from time to time. With regard to the upsurge in activity during last winter, the Irish experience is by no means unique. Hospitals all over northern Europe have experienced an upsurge in accident and emergency activity similar to the situatin in this country.
This Government has taken action to remedy this problem through the provision of funding for additional facilities for the care of the elderly in the Dublin area. Earlier this year I provided £850,000 to the Eastern Health Board to provide additional alternative accommodation for patients in acute hospitals who no longer require acute care. Placing such patients in accommodation more appropriate to their needs eases the pressure on the acute hospitals and reduces the delays in admitting patients to hospital. I assure the committee of the Government's continuing concern that the accident and emergency hospitals are enabled to respond effectively to the demands placed upon them and I will continue to keep this matter under close review.
I now turn to the question of waiting lists for in patient treatment. Following the conclusion of the 1994 waiting list initiative, my Department conducted a detailed analysis of the waiting list position at the end of last year. This exercise revealed that by the end of 1994, further reductions in waiting lists and shorter waiting times for treatment had been achieved.
It goes without saying that the real measure of the success of the initiative is the effect which it has had on the number of people waiting for treatment and the length of time which the individual patient must wait. The committee will, therefore, be pleased to know that the number of people waiting for treatment in all specialities has shown a reduction and waiting times for treatment continue to be reduced. From the commencement of the waiting list initiative in June 1993 to the end of December 1994, the total in patient waiting list fell by 16,295 or 51 per cent. Even more impressive progress has been made in those specialities which were targeted for special attention. At the end of March 1994, 40 per cent of all adults waiting in the problem specialities had been waiting over 12 months. By the end of 1994 the proportion of waiting in excess of 12 months had been reduced to 35 per cent.
Similar progress has been made in relation to children's waiting lists. The proportion of children waiting over six months for treatment has fallen from almost 57 per cent at the end of March 1994 to 40 per cent at the end of last December, a reduction of 17 percentage points in the numbers waiting over six months.
Finally, I would like to briefly mention the capital programme. It has been increased from £65.5 million last year to £103 million this year, £10 million of which will be provided by borrowing. This is a 57 per cent increase on last year. The programme will provide for a wide range of projects including the developments at Tallaght, Ardkeen, Limerick, Galway, Cork and the Dublin Dental Hospital. In addition, it will provide for the further development of facilities for the elderly, the mentally handicapped, the physically disabled, services for the mentally ill and health centres. It will also provide for the continued development of information technology systems.
I have outlined the main areas of this year's Estimate. There are, of course, many initiatives which have been undertaken, such as additional funding for rape crisis centres, management development and increases in health allowances, which I do not have time to go into. My principal objective is to provide a high quality, cost effective service which seeks to deliver the best possible standard of service for those who will come into contact with our health services. In framing the 1995 Estimate, the Government has provided the necessary resources to facilitate the achievement of this objective. I am confident that with the support and goodwill of the personnel in the health services, who provide such excellent care, that the current high standards can be maintained and, where necessary, enhanced. I commend the Estimate to the committee.
Ar dtús gabhaim buíochas leis an Aire as ucht na hóráide atá sé tar éis a thabhairt dúinn. B'fhéidir go mbeidh rudaí searbha le rá agam anois agus arís faoi féin agus faoin a Roinn ach tá súil agam go bhfuil sé in ann glacadh leis sin ar an mbonn go bhfuilimid ar fad ag iarraidh ar rud a léigh sé amach ag deireadh a óráide: "The Minister's prime objective is to provide a high quality, cost effective health service." That is the principal objective of us all. We want to be supportive and helpful in this regard, but it may be necessary to point out areas from time to time where we have difficulties or where we feel that the Minister needs to give further clarification.
The Minister has painted a rosy picture of the health affairs of this nation. The Minister has promised much, not just now but indeed since he became Minister for Health. Obviously, I have to question the delivery that has been given so far. For example, we have listened for a long time to doctors, specialists and community and women's groups from all over the country calling for a national programme for breast screening. It has not been given the priority it deserves. When one remembers that breast cancer accounts for some 10 per cent of the deaths of females under 65 years of age, it shows how urgent it is to set up such a programme.
I know the Minister has said consistently in the Dáil that he is committed to delivering such a programme, but there needs to be a firming up of that commitment. The latest study on this topic conclusively shows that a national programme could uncover more than 500 new cases of breast cancer in our female population each year which would otherwise go undetected. That study also established that cure rates and the early detection of cancer among women with breast cancer could be substantially improved with a screening programme.
I know the Minister has said several times that he would move quickly in setting up a national programme for breast cancer; he even told us recently that this would take place shortly. Coupled with and complementary to that is the national policy on women's health. That was promised by the previous Minister for Health in a Government of which I was a member. I was pleased that what I would regard as neglect by various Governments over the years on the issue of women's health had finally come to an end. Once and for all, we would have the priority attached to it that it deserved. As a woman, I believe that women would never make this a priority. Their priority is always the health of their husband, partner or family, but their own health would be at the end of everything. It is important that the national policy on women's health is published. From the Minister's speech, I see that he is prepared to do that and that is welcome. Firm dates for action are now required and I hope that women's health will not be one of the areas that will suffer because of the Government cutbacks; I would like to get more details on that from the Minister when he responds.
It is also important for the Minister to tell us about the current position on the implementation of the Child Care Act as a result of the Kilkenny incest report. There was a reference to the improvement that had been made to the health area in the Government's statement last Thursday night after the Dáil had adjourned. The press release said that the implementation of the Child Care Act had created ". . . pressures which now must be managed in a timely way as to protect basic services." Does this mean that the schedule for implementation of the Child Care Act has now been abandoned? To date, only 17 of the 79 provisions contained in the Act have been implemented. Will the Minister guarantee that all provisions will be enforced by 1996 as originally planned? The Minister also promised that the key provisions of the Child Care Act would be enacted before the end of this year. We require assurances that that will remain the case.
Childcare has been dealt with by providing resources and personnel on a phased basis. Until recently one of the areas which caused much difficulty has been ignored. This area involves liaison between the various groups involved, namely, the healthcare workers, social workers, etc., and the Garda Síochána. I am aware that guidelines have recently been introduced. It would be interesting to know if the Minister accepts that these guidelines are working in as efficient a way as possible, or whether certain health care workers will be involved in the examination and investigation of cases for a period of up to nine months, in some instances, prior to those cases ever being reported to the Garda. I am sure the Minister does not accept that that could be the position and I certainly could not accept it. Perhaps he could give a guarantee that, in so far as he and the Minister of State can assure the committee, there will be a proactive approach and there will be no delay in reporting cases.
One of the key recommendations of the Kilkenny report was that places of refuge would be provided throughout the country. While I accept that places of refuge have been provided in certain cities, Dublin and elsewhere, the Kilkenny case, the Sligo case, the Mayo case, the Monaghan case, etc. occurred in rural areas where there was no chance of a place of refuge being available for children at risk. This whole area must be considered if we are serious about the development of childcare and that key provision of the Kilkenny report.
The committee is aware that there was an inquiry into Madonna House. Our understanding is, from questions the Minister has previously answered, that there may be some legal difficulty, perhaps, in relation to the publication of a report on the matter. If the findings of the inquiry cannot be published in their entirety, there must be some form of public accountability with regard to what occurred in Madonna House. People will remain confused while the report is unpublished.
In relation to nursing services, we all agree that nurses perform some of the most vital work in the country's health services. They are at the receiving end of abuse given by patients, who are lying on trolleys in accident and emergency departments, or their families and friends. Nurses do have to work under difficult conditions. Those in accident and emergency have to work in intolerable conditions at certain times of the year. During the next three to four years, over 4,000 student nurses will be out of the system when they attend university for training. Extra posts will then be required in acute hospitals. What is the Minister's position on this? How will he be making the case for the health services to Cabinet? It is important that the committee know what is the Minister's understanding of the decision in relation to the cutbacks made by the Minister for Finance. We need to know if this will affect the numbers in hospitals, numbers employed by the health boards, the crusade on cancer, the improvements in treatment, etc.
When the health strategy document, Shaping a Healthier Future, was published last year, the then Government promised that this would be a living document and would not sit on a shelf somewhere gathering dust. I am happy to see that the Minister is committed to the implementation of the health strategy. However, it is important for the committee to know what has happened to that document and its proposals. The strategy was intended to run until 1997 and promised action on many areas including cardiovascular disease and accidents. At present there are over 1,600 people on waiting lists for heart operations. There is a shortage of cardiologists and only two centres where by-pass operations are carried out on public patients. Is this one of the areas which will suffer as a result of the cutbacks? The committee could not counterance a situation where very expensive cardiology equipment would remain idle in modern hospital units because of budgetary constraints.
The other area of priority, which the Minister mentioned at length in his speech, that needs to be tackled urgently is that of accident and emergency. We were all distressed and concerned about what happened to accident and emergency departments throughout the country earlier this year, most particularly those in Dublin that were publicised. I have stated before that this bulge is something which happens at this particular time each year. There must be a strategy that the Department of Health can adopt together with the health board and the hospitals. I know that the reorganisation of the Eastern Health Board is required to help in that situation. That legislation is urgently required. However, the health board, the hospital management authorities, the trade unions involved and the Department could surely organise a strategy together to deal with the bulge at this time of the year. This happens in hospitals in the United Kingdom and across Europe, but strategies and policies have been put in place there to deal with it. We do not seem to able to do that in Ireland.
The health strategy also promised to develop a stronger network of community based services and links between hospitals, general practitioners and community services. The committee needs to know what process, if any, has been made on this. The crisis in accident and emergency highlights the lack of step-down facilities, as the Minister mentioned. This was promised and money provided for it in the Dublin area. How was that money spent? How many facilities and beds were provided as a result?
In relation to geriatric care, the Minister stated that we now have an ageing population whereas a number of years ago over 50 per cent of people were under 25 years of age. This must be dealt with and facilities provided — either in the community, to give support to families to look after their elderly relatives, or on health board/hospital campus areas. In a situation where the Department is providing or sanctioning geriatric care, would the Minister favour a purpose-built, single-storey unit provided on the campus of an acute hospital? Does he think that the alternative of a health board purchasing an old, several-storey building and spending several million pounds to convert it for use in geriatric care would be better? Which option does the Minister think will save the State most money? The purpose-built unit would be the most economical and from the point of view of safety, fire prevention and health, it is better to have geriatric patients on the same level.
While we are discussing geriatric care, I might mention the area of Alzheimer's disease, which seems to be growing. I am very concerned about this because I have had personal experience of a patient suffering with the disease. First, I am concerned that health boards, with a number of notable exceptions, do not have the requisite facilities and ordinary private nursing homes are not as equipped as they could be to deal with Alzheimer patients. These patients need a particular type of care and require more staff to care for them. Second, I am concerned because younger people are beginning to develop Alzheimer's disease for whatever reason. In my county there are people in their fifties who are Alzheimer patients. We are not necessarily talking about a very aged population in this regard. It will be interesting to see how health boards around the country face up to this development.
There was a plan to introduce clearly defined national targets in the areas of smoking, alcohol and exercise to increase the life-expectancy of the Irish public. I am happy that the Minister has made provision for moneys for the health promotion unit and other such projects in the Estimate. I believe that much of the crime the country is experiencing at the moment is a direct result of drug abuse. As a former Minister for Justice, the Minister would probably agree with that. It is not sufficient for the Department of Justice, the Department of Education or the Department of Health on their own to develop a strategy to deal with this evil. All three Departments should work together to put a policy in place which will be responsive to existing needs.
Most of the discussion in the media at the moment is focused on the Garda and Customs with very little on health education where a lot of the focus should be. We need a wider approach to prevention which has to include parents, because for most teenagers the first drug of abuse is alcohol. It is a legal drug, yet it constitutes one of the greatest problems in society and there is great denial regarding its damaging effects on families, in the workplace and in society generally. It is socially acceptable, yet it is a contributing factor in a spectrum of crimes from child abuse, incest, wife battering and assault to road deaths, murder and robbery. Many children who are reared in alcoholic families go on either to develop the disease themselves or to become extremely psychiatrically disturbed.
Organisations like Coolmine House, which are doing a tremendous amount of therapeutic work, need to be strongly supported. School programmes are also necessary to create a healthy outlook and an antipathy to drugs. Such programmes need to start at the earliest level, in primary school if possible. Young people often believe that they are indestructible, as we ourselves did when we were young. They feel that it is never going to happen to them; but, unfortunately, it does and it can creep up very easily.
Parents need to be informed and empowered, otherwise they resort to denying that the problem is there at all. They need information and simple parenting hints, which can often be given through community care and the health services, on how to take a stand at home on drugs and what to do when they discover one of their children has become addicted or is in that kind of company.
Before the Minister took up his current portfolio Beaumont Hospital was a burning issue. I should not let the opportunity pass today without trying to establish what the up to date position is there. The Minister will recall that the previous Minister for Health, Deputy Howlin, had a central role of involvement in this issue. Using a source who seriously misled him and caused him to seriously mislead the Dáil caused a lot of damage to the reputation of that fine hospital and its staff. We need to know whether the present Minister for Health is satisfied that the allegations which were supported by Minister Howlin about standards of medical care in Beaumont or about the ability of the hospital to provide neurosurgical treatment for children were without foundation. In so far as the Minister knows, was Minister Howlin so satisfied and is the Minister satisfied that the hospital board and management of the hospital dealt with the problems properly?
Since the High Court judgment it is clear that a series of allegations made by Deputy Howlin about Beaumont Hospital since 1989 were untrue. As we all know, those allegations caused enormous public disquiet and were seriously damaging to the reputation of the hospital, particularly to the reputation of staff in the neurosurgical department.
All the allegations have since been found to be unfounded by the Medical Council as well as the High Court. The hospital was put under considerable pressure to publicly defend its standards of care and to reassure the public that its medical insurance cover had not been put in jeopardy as a result of the publicity which attached to the parliamentary question initially raised in the Dáil by Deputy Howlin. In the interests of openness, transparency and accountability there is an onus on the present Minister, in his own capacity, to uphold the good name of that hospital. Equally, there is an onus on the previous Minister for Health — who at the time was an Opposition Deputy and who made such serious allegations which have now been found to be untrue — to come up front and say that he was wrong.
There are specific questions which I want to raise when we go through the Estimate subhead by subhead.
I call on Deputy Liz O'Donnell, who is making the opening statement for the Progressive Democrats.
Health is the big spender across all the OECD countries in the western world. It is also the big spender for this Government and all Governments really. Because of the nature of the service, there tends to be an insatiable need to provide more services. Health spending in this country now represents 15.5 per cent of all Government spending. Our expenditure on health has increased by 40 per cent over the last four years. Between 1991 and 1995 Government expenditure on health increased from £1.5 billion to £2.1 billion.
While welcoming the Government's decision to tighten belts all round, I would like to tease out what sort of priorities will be set by this Minister in relation to the essential services which were promised and which may now have to be pulled back on.
All Estimates and budgets are about political choices and there certainly are some aspects in the Department of Health which are not politically postponable. I refer in particular to the promise to implement the remaining sections of the Child Care Act. I would like to tease out whether the Minister will be able to live up to the commitment to implement remaining sections of that Act by the end of 1996.
It would be interesting to gauge how healthier we are, given the huge 40 per cent rise in health spending over the last four years. One would imagine that with such a huge increase we would have a completely efficient and effective health service for our small population. However, the reality is that Irish people still have a lower life expectency than the European average 72.2 years for men and 77.7 years for women.
In his opening statement the Minister accepted that a few issues in the last year or so, including the hepatitis C scandal, have severely embarrassed the health services. Although there have been improvements in waiting lists, there are still large waiting lists for coronary by-pass surgery. The present service is so patchy and would appear to be so uncertain that 1.3 million of us entitled to free health services are paying privately to have a feeling of security so that they will be assured of access to services if they become ill. That fear and lack of confidence in the free health services is something that has to be taken cognisance of. Those people spend an additional £211 million on health care costs by way of VHI premia. If you cannot afford to pay for private health care you have to join the 24,000 people who are already waiting — some of them for years — for admission to an acute hospital for whatever reason.
In his opening statement the Minister indicated that there is a need to refocus on efficiency throughout the expensive services we offer. The Minister for Health has offered to draw up a strategy to reduce the number of deaths from cancer, which is a laudable aspiration, but we are stil refusing to allow women to avail of free screening tests for cervical cancer. This is one of the most easily treated forms of cancer which needlessly kills 70 women in Ireland per annum.
I echo the views of other speakers and the Minister in saying that we have to spend more money, and an extra £300,000 has been allocated for health promotion and disease prevention. It is amazing, however, that in such a huge budget so little is consistently allocated for disease prevention. It shows a lack of nerve and lack of belief in the power of health promotion programmes to influences people's quality of life and to guard them against becoming sick.
The rate of breast cancer for Irish women is far too high and is unacceptably high politically. Women in Ireland are not speaking out sufficiently, given that we have the highest rate of deaths from this disease in Europe — 600 Irish women die each year from breast cancer. In light of this, a national screening service for women with a high risk of breast cancer should be introduced. I am sure the Minister will find no difficulty in prioritising this much needed service, which will provide targeted women — those with familial history of breast cancer and those over 40 — with free mammograms every two years, which would go a long way to respecting women's rights to this service. Medical card holders, who make up one-third of the population, are not entitled to a free smear test to screen for cervical cancer. A free national screening programme for all women for this most treatable form of cancer should be introduced.
As has been said, there is not enough teaching in our schools about healthy lifestyles and a healthy diet. I was surprised to hear of the fall-off in the number of children participating in sports, particularly young adolescents. That is an important factor to be taken into account. An integrated approach should be taken by the Department of Education and Department of Health to this matter, because if fewer children are participating in sports, especially team sports, they are likely to digress into unhealthy alternatives.
The Minister mentioned overcrowding and huge waiting times in A and E departments. We have consistently argued — and this argument has a sound basis — that community based primary care centres could, if properly staffed with GPs, practice nurses, treatment nurses and other paramedics, take the pressure off A and E departments.
It has been suggested by experts in the field that GPs could act as a gate-keeper against the expense of hospital service. Accident and emergency departments are manned largely by junior hospital doctors, whose first reaction is to perform multiple tests and investigations and to hospitalise. All these expensive options should be the last resort. If, instead, GPs worked in the A and E departments of hospitals, people could be treated at the first point of contact. That, combined with a proper bed management policy, could go a long way to easing current pressure on A and E departments without affecting the Exchequer.
We also need to increase the step down facility, such as nursing homes for people who have been treated in hospital. The Minister has accepted that because of our ageing population there are far too many elderly people taking places in acute hospital beds. If there were cheaper nursing homes or other less expensive options, pressure would come off the waiting lists.
According to TCD economist, Dr. Seán Barrett, hospital bed costs in Ireland exceed every other country in the OECD. The current cost per day in an Irish hospital is £279 or £102,000 per annum, which is 13 times the GNP per head of population. Ireland exceeds every OECD country in its hospital costs, including Germany, Switzerland and Japan. The Minister is correct to say it is not beyond the capacity of his Department to rein in expense, waste and, in some cases, incompetence in spending, to provide a better health service without adding to the resources needed to run the service.
There have been major embarrassments in the health services, not least in the powers the Minister delegates to the health boards for the care and protection of children. In some instances the system has failed to protect children and the health boards must have more accountability in respect of the social services provided to children at risk.
I am sorry to see that the Minister and the Department are only at the stage of a discussion document on women's health. When the former Minister, Deputy Howlin, introduced his health strategy, we were talking about such documents. Women's health has been paralysed by debate and I have identified areas such as cancer where recommendations could be implemented without further analysis by the Department.
The Estimate comprises £2.07 billion, which is substantial. When responding I ask the Minister to clarify the effect of the embargo on the recruitment of psychologists under the Child Care Act. This would have increased the number of psychologists available to child guideance clinics, the units which treat children who have been victims of abuse, children are risk, children of lone parents, high risk children and those who would be at risk from substance abuse and crime, etc. When the Minister is prioritising I hope savings can be made in non-essential areas, if such areas exist in the health service. This is about political choices, and child care has been the poor relation over the years in terms of resources.
When we discussed the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act, we were promised that enhanced contraceptive service and counselling would be available as part of the implementation of the legislation. How does that fare, given the embargo? I will deal later with specifics. The Minister for Finance, Deputy Quinn, has invited his colleagues to save £77 million. How much does the Minister for Health hope to cut from his Department?
I wish the Minister well. It is a difficult area and there is an established need for services to be improved, but I believe the vast moneys spent on health services can be cut back if we prioritise properly and make the system more efficient.
We now come to the question and answer session on Vote 41.
(Limerick-East): In their very full contributions, Deputy Geoghegan-Quinn and Deputy O’Donnell asked a series of questions. If it suits the committee, I will respond to them first. They may ask more questions if they want more detail. I have supplementary information.
Is that agreed? Agreed.
(Limerick-East): Some threads ran through the questions, one of which was how the decisions of last week would impact on the health services, which is of concern to everyone. The opening position is that the health budget is approximately £2.3 billion; the voted Estimate is £2.1 billion, but there are appropriations-in-aid of £200 million to make up the figure. We spend those appropriations-in-aid, which are in excess of 20 per cent of the total. The money involved in health spending is therefore huge and the numbers delivering the service are huge also. According to the census of those involved in the health service, taken on 31 December 1994, the figure was 64,000.
To improve the health services along the lines of the health strategy and the specific commitments made in the Government's policy document A Programme of Renewal, money is required, and that is provided in the Estimate. However, much of the delivery of the service will rely on a combination of pay and non-pay elements, so people as well as money will be required to deliver improvements. We already have 64,000 people and that is an increase over the past four years. The numbers matched the expenditure. Retrenchment took place from 1987-89 and there was a decrease of approximately 6,000 people, but then it increased again. Approval was given in 1992 for approximately 750 jobs and 485 were filled. In 1993, the first year of the Labour-Fianna Fáil Government, 1,273 jobs were added to that figure and in 1994, 2,137 jobs were added on. These are big increases. One may recall that the 1989 election became a health election half way through the campaign. In 1990, during the Progressive Democrats-Fianna Fáil Government, 2,300 jobs were added on.
Some recruitment has already been undertaken. I will be able to undertake more recruitment as the year progresses because the exception on the close down is related to the social commitments of the Government, as Members will know from the press statement, and also to persons with special needs. I was in Cabinet today to seek clarification on that and I am permitted by the Government to continue recruitment to fulfil our objectives in the health service. The numbers must be negotiated with the Minister for Finance. I will not have the 2,000 extra people in the health services which were available last year. However, that number are still available this year because they are part of the 64,000 people. I cannot give Members an exact number yet, but we were recruiting in the first half of the year for permanent and temporary posts and I have permission from the Government to continue recruitment. However, I must get agreement on exact numbers with the Minister for Finance.
The Government has agreed that, in terms of numbers, child care and mental and physical health will be the priority areas. In order to fulfil the other commitments I made over the year and those in A Government of Renewal, I will also need extra numbers. I am sure the committee appreciates that there must be flexibility because the amount of money and the number of people needed are substantial. There is no absolute flexibility in the use of resources. There are approximately 25,000 nurses in hospitals, but it would not be tenable to put 300 of them into child care because they do not have the necessary background or specialist qualifications. However, there are flexibilities in the system which we can use. I have no doubt Members will want to return to this issue.
As regards breast cancer, a successful programme, the Eccles programme, is based in the Mater Hospital and there are two active control groups in the south-west. These are doing well and a detailed analysis is being conducted at present. Screening has its benefits. The Mater screening programme targets women between 50 and 64 years of age and it is being evaluated at present.
I do not have a problem with money or numbers, but if I announced to morrow morning that we were bringing in a national breast screening programme there would be too many false positives and negatives to make it worthwhile because the procedures would not be standardised and new people would be brought in too quickly. I want to systematically extend the Mater programme to other parts of the country. We do not have a lot of information about the best areas to which to extend in order to get the quickest effect. The conventional wisdom is that the incidence of breast cancer is reasonably standard throughout the country. However, evidence suggests that may not be so.
There is a national cancer registry attached to University College, Cork. The Southern Health Board is ahead of the rest of the country because it kept a cancer registry for many years. Information about the incidence of cancer in that area was put on a database, but it only became a national database at the begining of last year. Its first report was published last Friday and it relates to the Cork and Kerry areas. The incidence of breast cancer in Cork and Kerry seems to be higher than the rest of the country. I have not made a decision on this yet, but if evidence suggests a higher incidence in one area, it would be proper to prioritise that area for the extension of a breast screening programme. I am talking about the systematic implementation of the Mater Hospital project for the best possible reasons until we get a national system in place.
I do not want to take away from people's concerns about the serious issue of breast cancer, but I want to put it in the context of cancer in general. Lung cancer in women is becoming at least as serious an issue as breast cancer. The statistics for women contracting lung cancer is time lagged in respect of men. In anecdotal terms, fewer women smoked as heavily as men in the 1940s and 1950s, but they began to catch up on the 1960s and early 1970s. The incidence of lung cancer among women in their 50s is not high. I do not want to give an impression that if we concentrate on breast cancer we will solve the cancer issue as far as women are concerned. A number of Deputies correctly drew attention to cervical cancer, which is also an issue. Some 75 women died of cervical cancer.
The national policy on women's health will be published before the Dáil recess, sometime in June. Deputy O'Donnell mentioned a further discussion document. We will not stop caring for women's health while we are waiting for the discussion document because that would be lunacy. We are not depending on initiatives on breast cancer. I have read the policy document, which is significant, and we are now putting the publication details in place. Members will be interested in this document and it should be discussed as soon as possible by an appropriate committee of the House, such as the Joint Committee on Women's Rights. I am not waiting for feedback before we begin the implementation phase. This is not a delaying device.
The Child Care Act, 1991, will get priority, as laid out in the Estimates. Some £10 million has been allocated this year for the more significant sections which deal specifically with child abuse. I cannot be as categoric about the commitments for next year. Some sections have been left for 1996. I must still negotiate a 1996 Estimate, but I am not drawing back from the commitment to implement the Act in its totality in 1996. I cannot be as certain about the commitment I gave for 1996 because we do not have the Estimate yet. However, I am certain that all the areas relevant to child abuse will be implemented this year.
As regards liaison between the different groups, the Protocol announced by the Minister of State at the Department of Health, Deputy Currie, between the health boards and the Garda Síochána is now being implemented. It was only recently published, so it would not be correct to say that it is implemented in full. It has been accepted by both sides and they are proceeding to implement it. I hope it will improve the situation. We will take up the points made because they are important. As regards places of refuge, this is important and I will return to it when I get a briefing note because I do not have that information to hand.
The report on the Madonna House situation was submitted to me and to the Sisters of Charity on 9 March. A preliminary examination took place in the Department of Health and we sought the advice of the Attorney General on 24 March on whether the report could be published. In fairness to Official A, Official X or whoever he was at the time, he came back to us four days later, on 28 March. He does not delay all the time.
He was fired for his efforts.
(Limerick East): He confirmed that the report could not be published in full because of the need to protect the identities of parties and to avoid interference with ongoing investigations and legal proceedings. Along with everybody else who is aware of the circumstances, I am anxious that as much as possible be published. I do not want to go through it with a blue pencil or get somebody else to do so and publish a censored document. We therefore got the State solicitor to engage a barrister to write a summary. His instruction is to give as much as the factual information as possible without getting into any kind of legal difficulty. I hope, therefore, to be in a position to put the full facts before the committee, but under a summary rewrite of the document by a legal person who avoids the legal pitfalls. That work is progressing at present. I do not know when it will be available.
With regard to the issue of nursing services, the embargo on recruitment only arises where nurse training is moved to university. When it is moved to university, as it has in Galway and as it will in Limerick and Beaumont, the status of the student changes. At present the student nurse is a member of the staff of the hospital. The student nurse who attends Limerick or Galway next September or October will be a student in the same way as somebody studying for a BA, or whatever. They will have moved from being a staff member of a hospital to being a student, but that will not affect the numbers assigned to the Department of Health. If, say, x number of student nurses are in the group of 64,000 to which I referred, next year the figure will be 64,000 less whatever the figure is, but we will be in a position to fill the vacancies as they can be filled with staff nurses. The embargo is on the number. Supposing, for example, the status of 1,000 student nurses was changed from being staffed to being student, there will be 1,000 positions in the hospitals system which I can fill on a staffed basis. They are not, therefore, caught in the embargo. There is a misunderstanding about this which was highlighted by the INO. We are in the process of discussing it with the INO; so it is not an issue, unless somebody gets a bright idea after these deliberations.
What about the figure of 4,000?
No, I do not believe——
Ms Donnell
They are not part of the figures as they have not been included in the 64,000.
They would have been included under the old training system and those that remain on the old training system will remain at that status. However, as they move into the university system the places vacated will be filled. It is being introduced systematically, so it would not be up to 4,000 or anything like that.
With regard to the health strategy document, much of my speech on the Estimate detailed commitments in the health strategy that are being fulfilled, such as to the mentally handicapped and so on. There is a four year implementation date and we will be doing our best to meet it. As the Deputies will be aware, especially those in contact with or on health boards, when I visit a health board area I have a meeting with my management team and the management team of the different health boards at the start of my visit. It is effectively a one item agenda: the health strategy is the policy of the Government and we require a progress report on its implementation with details of the difficulties encountered. It is a living document and we are actively pursuing its implementation. In that context, on the issue of heart operations, cardiology and by-pass operations and so on, significant progress was made by my predecessor in getting a bigger throughput at the Mater Hospital and the hospital at University College, Cork.
Various demands are made in this area. For example, cardiologists from St. James's Hospital attend the Mater Hospital to undertake their work. Similarly, there have been demands by other centres such as Galway. At present we are getting a better marginal return by concentrating the resources at two locations and bringing in the expertise rather than developing a third location with its overheads. We have, therefore, the overheads in place at the hospital at University College, Cork, and at the Mater Hospital. However, I am conscious of the demands on Galway and on St. James's Hospial. If we were to expand the system they would be on the short list for new locations.
With regard to the accident and emergency services, I agree with what has been said. There has been an ongoing annual difficulty. Ignoring the human aspect, and considering the matter in economic and financial terms, it is very difficult to gear any service where there is a huge peak in demand, because the peak in demand itself is not geared for. It is similar to not being able to get taxis at 1 o'clock in the morning at Christmas. Taxi plates cannot be issued in Dublin on the basis of the two weeks around Christmas. By contrast, there is always a severe difficulty after Christmas, but one can gear annually for that. However, I agree with the suggestions that have been made regarding the use of step down facilities and further use of GPs, which both Deputy Geoghegan-Quinn and Deputy O'Donnell spoke about.
There is pilot study underway in St. James's Hospital where GPs are brought in and this appears to be successful. There is a pilot study of a different kind in Tralee where all the referrals are assessed again, in house, in the hospital. This kind of second opinion reassurance has succeeded to the extent that approximately 30 per cent of those referred go home happy without taking up a hospital bed. There is, therefore, a lot of scope on this issue, which we are considering. It is an annual event. The difference this year was that the peak went higher and lasted longer. Hope-fully, next year we will have some of these strategies in place to address it.
With regard to Deputy O'Donnell's question on funding of £850,000 in respect of the Eastern Health Board, 109 patients were accommodated in more appropriate settings.
Are they permanent settings?
(Limerick East): Yes. It will relieve the situation somewhat. With regard to the ageing population, the figures I have submitted to the committee illustrate that further strategies must be put in place because we will be dealing with great numbers. It is not any one intervention. There will be a range of strategies, from the district nurse calling in once a month to see if somebody is all right, to somebody who has to have a dedicated bed in a geriatric centre or a dedicated Alzheimer’s unit in hospitals. How ever I fare over the next two years, my successors will have a very serious problem with the care of the aged because of the way the statistics are developing. We can see the pattern we are facing by considering the experience in Europe, which has arrived at the balance of population we are heading towards.
We would like to do more on health promotion. A document will be issued. The Minister of State, Deputy Brian O'Shea, looks after this area. I agree with Deputy Geoghegan-Quinn's remarks on alcohol. We soft pedal on alcohol. Its evils can be listed in dramatic terms. They are undeniable. While it may be unfashionable to say this, there is a culture of alcohol which permeates down to the schools, school teams and so on. We will produce a policy document on alcohol in the second half of the year.
I will leave the issue of Beaumont Hospital aside because it is a hand-written note. I will come back to it.
Are you trying to hide it?
(Limerick East): I am not, but my eyes are not great.
That is the old age.
(Interruptions.)
(Limerick East): These glasses are more for cosmetic purposes than any useful function. I will come back to the women’s refuge issue and Beaumont Hospital in a moment.
We are big spenders, Deputy O'Donnell. We have gone through that. It is about stacking priorities, there is no doubt about it. The priorities, as far as I am concerned, are in the Programme for Government. That is my bible. I simply run the Department on the basis of that priority list because that is what was agreed between the three parties. In terms of matching resources to the priorities and in the context of any cut-backs there are, the priorities will be the Child Care Act, 1991, followed by the treatment of the handicapped, mental and physical, followed by the care of the aged. I am conscious of the difficulties in accident and emergency but that needs a whole series of strategies, some of which may cost money and more of which may not cost any money at all. There are a whole lot of other items too which depend on resources being made available.
Deputy O'Donnell asked a good question: how much healthier are we after all the expenditure? Part of the health strategy involves measuring this so we will lay out targets. This is one of the big changes in the health strategy. We have targets, we prioritise and we measure results. In the Southern Health Board in Cork I talked to the new Director of Public Health, Dr. Elizabeth Keane, about the measurement she is putting in place to measure the effectiveness of what is happening. Therefore, while I cannot answer the question of how much healthier we are today——
It has been asked.
(Limerick East): ——there are measurement procedures being put in place. It is a double-edged sword, of course, because I also told them and the other health boards that we will allocate resources on the basis of what they measure. It is the only way one can. If one talks of big sums of money and prioritisation, the first thing one must do is be able to get away from the scope and measure results.
But are resources being allocated on the basis of people being less healthy or more healthy?
(Limerick East): The institution that delivers the most effective service at the most competitive rate will get more resources, as far as I am concerned. The inefficient ones will not be given more money to waste, but measurement is essential in order to put that in place.
We dealt with the issue of hepatitis C in great detail before. I am not including that in priority listing because it is a separate issue which is covered by a separate commitment and there is an absolute commitment to fair compensation.
So the cost is outside——
(Limerick-East): It will all run into the health figures at the finish, but it will not be affected by any decision about financial prudence, management or anything else. If I can get a tribunal in place — and I think I will with the agreement of the interested parties — the tribunal will be free to decide the going rate. That will be a bill the Exchequer must meet. What way it will appear in terms of the presentation of the figures, whether it will be integral to the Estimate or taken separately, is not decided yet. I will talk to the Department of Finance and the Minister in due course, but it is an absolute commitment. It will not fall out of the equation. I have not forgotten the hepatits C issue because I talk of child care or mental health. It is there as a separate issue which stands beyond all other commitments.
As there is great concern about it, I said today in the speech that a lot of the women who have hepatitis C are looking for guarantees that their health care needs in the future will be looked after. They talk of having this on a statutory basis. I pointed out today that they already have that guarantee under the Health Acts. There is a statutory based guarantee under the Health Acts that the effects of hepatitis C will be treated by the State in our hospitals for the lifetime of the people affected. I do not think they are fully aware of that position.
Does the Minister mean that even people who were not affected by the blood bank scandal?
Does the Minister mean by the nature of hepatitis C?
(Limerick-East): Yes, everybody. To be explicit about it,——
Is it notifiable?
It is. That is the point. In the Infectious Diseases Act, which is where the notifiable issues arises, there is a schedule of notifiable diseases. Hepatitis C was not known at the time the Act passed through the Houses of the Oireachtas, but it allows for hepatitis non-A and non-B and we clearly defined that within the Department as including hepatits C and any other letter of the alphabet that comes into the hepatitis spectrum. I want to stress they will be fully covered on that basis. There is an unreal fear that as soon as we stop talking about it in the Dáil and the Minister moves on to other issues, they will be forgotten. That is not the position——
Does it include children, because there is one child of five years of age?
(Limerick East): Yes, and spouses. It includes the whole cohort. It is not simply because of any ill attention in the blood transfusion service. It applies to anybody who has hepatitis C. They will be covered whatever the source. There is some background level of hepatitis C. It is much lower than in other countries. It is not blood related at all and it is quite high if one looks at some subgroups. In the drug community, for example, there is quite a high level of it. Under the Health Acts because it is notifiable, as Deputy Lynch says, people are statutorily covered for their health needs as long as they have hepatitis C.
Will the Minister tell the officials that? This issue has been up front and major treatment has been provided and is covered. However, where they get particular medicines, for example, they find they must rely on the VHI. They are then left short by the VHI and must wait to get money back from the VHI. There is confusion there in that regard. Some women suggested they should have a hepatitis C card in order to avail of services quickly and everybody knows the service is there.
(Limerick East): The officials dealing with this have been excellent. It is a new area.
I understand they know at the top level.
(Limerick East): Before the Miriam Hederman-O’Brien report was published, there were some difficulties in contact with the blood transfusion board and the Department intervened to try to sort that out. It has improved now to the degree that we have a strong ongoing relationship between individual women, the representative groups and the officials in the Department. I take the Deputies point and I mentioned it to Deputy Geoghegan-Quinn in the Dáil one day. The issue is not so much the availability of medicine or hospital care but that if a woman goes to her GP, she still must pay £15 or whatever the charge is. If that becomes a regular event, it can become quite costly.
I had a case, Minister——
In order to clarify the situation, the Minister is replying to the opening statements of spokespersons. I am in the hands of the committee.
(Limerick East): I will leave the hepatitis C and come back to it. It was on Deputy O’Donnell’s list and I was dealing with it. I can deal with it now or we can come back to it.
It is just a question of deciding——
I do not mind.
The Minister should conclude his replies to the opening statement and we can then——
The Minister was throwing out questions all around.
The Minister may continue his reply.
(Limerick East): The waiting list initiative has been effective. The point I make now is simple enough but when people talk of being 12 months on a waiting list, they are not talking about the same people. Obviously, there are people coming off the top of the list and others joining the bottom of it. They are talking about the way it moves.
Like the prison population?
(Limerick East): Maybe it is not as good a revolving door as that but it keeps moving along. If one looks at length of time or waiting lists, it gives one impression. If one looks at throughput, and it is the more interesting figure, it shows how effective the initiative has been. We have maintained it this year and the £8 million has gone into it.
I take Deputy O'Donnell's point that there is extra money beyond the Estimate going into VHI cover. There are two ways of looking at it. There is no better thing to spend money on than one's health. One wants to make sure they are not queue jumping. We should stick to the two track system because if one can pick and choose and get an advantage that is not fair.
We are working on the cancer policy for the summer. I take the point made about cervical cancer and breast cancer and I have made my position clear on the breast cancer issue. I hope we will be able to take a series of decisions on cancer policy in the autumn. I looked for submissions and we received very many. There is a group in the Department dealing with that now, auditing and prioritising it and coming to policy conclusions. Given that it is such a serious issue and the cost implications are significant, I will have to go to Government with the policy rather than do it in the Department, and I would hope to get it to Government in the autumn. When I bring it to Government it will come down to a question of how we can organise the implementation to match the resources.
In conversations I have had with the Minister for Finance over the last week or so I have mentioned that I am interested in a cancer policy and that it will be coming up for implementation in 1996. That is not to say we will not extend the Mater Hospital scheme in advance of that. Simply because there is work in place does not mean that one does not have to deal with people who have cancer at present. Ongoing procedures will continue.
There is an increase of £300,000 in the preventative budget. The total budget on the health promotion side is over £2 million. More could be done and it is an area we should look at. There is a European dimension to the issue because health promotion and ill health prevention can become European issues.
I take the point made about sport and the fall-off in sport. The committee may not be aware of it, but Deputy O'Donnell has strong credentials on this matter. I knew her in Limerick as an athlete of some note so she knows what she is talking about when she is discussing sport.
Deputy O'Donnell raised the accident and emergency difficulties, especially with regard to the better use of GPs. I agree people should be treated at the first point of contact and we should have step-down facilities, and we are working on something in that regard. I still think I will have difficulties after Christmas next year but I will try to reduce the difficulties. I do not think I will solve the problem in one 12 month period but I will try to reduce the difficulties.
At Question Time in the Dáil, when Deputy O'Donnell and I raised the issue of accident and emergency problems, the Minister made a valid point, which we accepted, that he does not have control over a substantial number of hospitals in the Dublin area. For that the Minister needs the reorganisation scheme for the Eastern Health Board. How soon will that be before us?
(Limerick East): I have not yet figured out the best way to do it, so I will not tie myself down to a date.
So it will not be this year?
(Limerick East): It will not be before the summer recess. I would be aiming for the autumn. My difficulty is that the Eastern Health Board delivers only about a third of the hospital services in the greater Dublin area. There is a large voluntary hospital sector that has a direct relationship with the Department of Health in terms of funding. If one thinks of the hospitals in Dublin one thinks of the big voluntary hospitals such as the Mater and St. Vincent’s.
If we are to change the relationship and the voluntary hospitals will negotiate in future with the Eastern Health Board for their grants, I want to be sure the Eastern Health Board is strong enough to carry that. I am thinking it through and having some discussions on it at present. It would be easy for me to give a commitment now that in the Mid-Western Health Board area the new relationship between the health board and the voluntary agencies and hospitals will be implemented quickly, because I would only be dealing with St. John's Hospital, which would have 3 or 4 per cent of the activity.
However, if one looks at Dublin, about 60 per cent of the activity is in the voluntary sector. In Cork about a third of the activity is in the voluntary sector. The Mercy Hospital would do a significant proportion of the acute hospital work in Cork, whereas the Cork Regional University Hospital would be the health board hospital. The same considerations will arise there, but Dublin is the main case. I will not tie myself to it now. It is not an issue which has an ideological or political bias; it is a management issue. If anybody has a view or advice to give it will be welcome. The changes have to take place, but change is not always synonymous with improvement. I will be more interested in improvements than change. I am sorry it is not further advanced but that is the present position.
With regard to the cost of hospital beds being highest, according to Seán Barrett of TCD based on OECD information, if one takes the per capita costs as a percentage of GNP or GDP, one can do anything with the figure. In the cost of any high-tech hospital bed in Ireland there are certain fixed costs which are internationally valid. If that is applied to a lower GNP one has to come top of the table. It is a peculiar way to run the statistic. I do not think it is a sensible way of reckoning the cost.
We are in an international market when it comes to consultants. The best of our poeple get their fourth level training in America and we cannot give specialists the same money as they get in America to attract them back from the US. We have to give them significant incomes, good private practice and the promise of a good lifestyle here when they come back with their families from America.
The technology, put in in terms of plant and machinery, will not vary significantly between Ireland and elsewhere. There are fixed international costs; and if we are dividing that into a variable because our GNP will be at the bottom of the table for OECD countries, it is not a valid way of calculating cost. I would not think Seán Barret is right on that point.
There have been health board embarrassments with regard to certain cases involving the protection of children. The most high profile cases this year were historic rather than current.
On that point, the Minister has indicated that a review is taking place of the management of the Kelly Fitzgerald case by the particular health board. Will the Minister publish that report when it is finalised?
(Limerick East): Some things cannot be published because one does not get the information unless one enters into commitments of confidentiality.
What is the point of it then? What is the point of the independent review of how the health board managed the case if it is not to be published? For whose information is it?
(Limerick East): For the information of the Minister for Health and the Department so there is no repetition and that strategies are put in place so that the same mistakes are not made again.
The Minister is not running a private company. This concerns public powers delegated to the health board. Does the Minister not think it should be published if the health board made errors?
(Limerick East): As a general principle, as much information as possible should be published. However, I do not believe that matters can be changed for the better simply measured against levels of public outrage. If a report is published and the public and the media have their day out, and everybody wrings their hands and says it is awful, somebody still has to take the problem by the scruff of the neck and change it so that it does not happen again. The benefit is that even if a report is not published but is available to those who are in authority, they can make changes so that it does not happen again.
What was the point of the Kilkenny incest report then and the Hederman O'Brien report on the blood bank? Surely the function of a report in a democracy is that lessons can be learned and changes introduced.
(Limerick East): The Deputy is back to her primary profession of cross examination.
I cannot believe the Minister is not going to publish that report.
(Limerick East): Some reports can be published in full and it is in the public interest to publish them in full. Other reports, like the Madonna House report, cannot be published in full because the actual structure of the reports and the way they are written put one in tremendous legal difficulties. There are other reports again where, to ensure one gets information at all, one has to enter into commitments of confidentiality. In any report I will get my purpose will be to put as much of it as possible into the public domain, but no Minister is entirely a free agent in any of these things. Further, it is not true to say that a report is useless if it cannot be published. If a report is confidential and a Minister cannot publish it, provided he takes to heart the implications of the report and makes the necessary changes in, for example, a health board to ensure that nothing similar happens again and the Protocols are in place to protect those at risk, it has then been a worthwhile report and it is not true to say that it is a useless exercise because one cannot publish. That is not to say that we might not publish it at the end of the day.
The Minister knows that I have a strong view on all of these reports. No health board should be investigating its own difficulties and problems and there should be a central investigative unit which would initially have expertise in this area and which would, as it investigated various complaints against health boards and health board staff, build up the specialist services that would be required. I know we are talking about old historical cases, but as the Child Care Act, 1991, is implemented in full, we will find more of these cases arising and there will be allegations made from time to time against gardaí, health care workers, social workers, nurses, general practitioners or whoever. It would be worth-while to have central investigative unit that would have backup specialist facilities. I asked the Minister in the Dal to consider that. I do not want him to respond now but I would like him and his Department to consider that seriously.
(Limerick East): It is being considered. The idea of an inspectorate — I do not know what the title would be — is a good idea and is worth exploring. We have an Inspector of Mental Hospitals who is a statutory officer and who carries out certain functions. We will explore the idea. The Minister of State, Deputy Currie, was interested in the Deputy’s suggestion in the Dáil on that day and it was carried forward.
There was a question on women's refuges and I will read the note on that. There are a total of 16 centres providing refuge accommodation for women nationally. Refuge or hostel facilities are available in each of the eight health board areas and include 135 places for women and 400 places for children. Earlier this year, the National Federation of Women's Refuges submitted a policy document for consideration. This document has been circulated to all the health boards and I have requested each board to review the adequacy of the services for victims of domestic violence in the context of the preparation of the service plans for 1995. As well as that, apart from the question of the disabled person's maintenance allowance which I referred to earlier, there was a further transfer of funds from the Department of Social Welfare to the Department of Health for the purpose of providing support for victims of family violence. A sum of £55,000 has been provided for the Women's Aid national freephone helpline. A sum of £20,000 has been provided through the Federation of Women's Refuges for abused women and their children. At the end of the Estimates process this year, the Minister for Social Welfare took some functions which were traditionally under the Department of Health, with a budget of less than £2 million, and some functions of the Department of Social Welfare were transferred to the Department of Health, so there was more done there.
How much was transferred for respite care? Was it the full £500,000?
(Limerick East): Yes, it was the full amount. Last year developments costing £350,000 were approved for all health boards. In the Eastern Health Board area £50,000 was provided to support women’s refuges. In the Midlands Health Board area new counselling services for victims of family violence were approved for centres in Athlone and Tullamore. The North-Eastern Health Board provided new services for victims of domestic violence in Dundalk. The North-Western Health Board provided additional funding for Women’s Aid, Letterkenny, to develop services for victims of domestic violence. The Mid-Western Health Board increased financial support for Adapt House refuge in Limerick to employ a child care worker. In the South-Eastern Board area increased funding was approved for Oasis House in Waterford for places of refuge. In the Southern Health Board area increased support was approved for the Adapt women’s refuge in Tralee and for Cuamlee Hostel in Cork. In the Western Health Board area approval was given for the development of a facility in Castlebar for the victims of domestic violence. We hope to make continued progress in this area. The places outside of the main urban areas are beginning to be developed.
Can I come in on this?
The Minister has concluded his reply. We have now less than one hour of our allocated time left and I want to make the best use of it. Does the committee agree to take the subheads as they are outlined in the timetable or do Members want to have an open question and answer session? Do Members want to go through the subheads in an orderly fashion?
I sugest that we carry on as we are. In the short time that is available, we will end up discussing one or two subheads and then running out of time.
Is that agreed? Agreed.
I compliment the Minister for his frankness in dealing with the Vote here and also with the possible effects of recent Government decisions on the public finances. I will focus on the areas of interest to myself. One of them relates to the Child Care Act, 1991. The Minister has indicated in his speech that he is going to try to meet the deadline set down by his predecessor for the implementation of the Act by the end of 1996. I note that the Minister has stated that he will have to look at the situation next year to see if he can achieve that particular objective. That is of concern to many Members with an interest in this area because the Child Care Act has been an on and off affair, first of all, in coming forward for legislation and, secondly, in relation to the provision of resources over the years. I thought that under the Minister's predecessor we had put down the marker that, whatever else happened, the implementation of the child Care Act within a specified period of time would not be altered. The timing is specifically about resources and the question of extra staffing arrangements required to be put in place is important. I hope that we will see a situation where the implementation will not be adversely affected and that we will meet the deadline already set down and which is looked forward to by a lot of people in both the voluntary sector as well as in the State agencies. There are problems out there, as I am sure the Minister will be aware, with regard to the care of young people and homeless people. From time to time we see individual cases highlighted in the media. We may know of other cases through our own work as public representatives and people working in the area. The resources have simply been too skimpy to deal adequately with the needs of young people as encompassed by the Child Care Act, particularly at the cutting edge, which always seems to be the problem of most difficulty. That obviously relates to young homeless, to children in danger, and so on. I am pleased that the Minister talks about implementing in the autumn the provisions of the Child Care Act regarding the removal of the children to a place of safety by the health board or the gardaí.
However, other provisions of the Child Care Act are equally important. I was a little disappointed that the Minister's wide ranging speech did not discuss the particular health needs of the minority in our society, the travelling community. During my short time as Minister in the Department of Health I identified this group as one with special health needs. Its members have needs in other areas as well, but this is particularly the case in the context of health.
The Eastern Health Board provided a mobile health facility in its region and it was my intention to develop that service throughout the country in order to bring basic health care to members of the travelling community, particularly children and expectant mothers. The care would be given on site and no questions would be asked about whether the sites were or were not authorised. It was intended to provide the care wherever the people were through the local health services and the community care areas. Even though the presence of members of the travelling community on unauthorised sites in some parts of the country might be sparse, we should try to develop that service. Perhaps the health boards are already dealing with this or propose to put such services in place.
The other area I wish to discuss is the dental service provided by health boards. The provision of orthodontic treatment is a serious bone of contention for people throughout the country. It has never been satisfactorily tackled. A number of reasons are given as to why a proper and adequate service has not been put in place. The fact remains, however, that even today children are waiting up to eight years for treatment. There is wide disparity in the provision of the service from one health board area to another. That is wrong, because if one lives one side of the border between health board areas one might get the treatment more quickly.
This issue must be tackled urgently through the introduction of radical proposals. The Minister's predecessors made some attempts in that regard but the service is still not nearly adequate. When one makes inquiries about individual cases one is told that the individual was probably put on a list in 1992 but they are still dealing cases from 1988. However, the youngsters awaiting treatment are growing towards adulthood and many of them are in urgent need of the service. It can have a major impact on their personalities as well as on their health. One is not talking about cosmetic orthodontics; one is talking about a service that is required for health reasons. I hope the service does not suffer as a result of the Minister's need to comply with the latest statement from the Minister for Finance or as a result of cutbacks that might be made to cater for additional demands. I understand that the country's finances must be run properly, whether it is in the Department of Health or in any other Department. However, some areas are untouchable.
The Minister indicated his commitment to the Child Care Act but entered the caveat that it might not be possible to implement it fully by the end of 1996. I presume that will be because of lack of resources. He also said that he would continue to support the development of the mental handicap services. I am glad that the Minister succeeded in protecting that area. Until the last couple of years it has been starved of adequate resources. However, that commitment calls into question how the Minister will be able to develop further services for the elderly. He made a significant reference to our ageing population and the fact that there will be a problem in this area, if not for him certainly for his successor.
We need to tackle the provision of services for the elderly now. Acute geriatric units, day care centres and home help services must be developed. That will cost resources but we must establish priorities. If we fail to provide those services, as the Minister rightly said, his successor will reap the whirlwind. As public representatives we receive more and more representations on behalf of elderly people who, in the honest opinions of their families and sometimes their doctors, require full-time care at home and cannot or are not getting it. That area of the health services will be the next crisis. We should tackle it now. I hope that the financial situation in the Department, about which, the Minister spoke, will not result in a dangerous legacy as a result of being unable to tackle this area because of restrictions on resources.
I welcome the Minister and his commitment to maintaining the significant progress of recent years, particularly with regard to waiting lists, the implementation of the Child Care Act and the mental health services. Like my colleagues, I offer him our support in the battle with the Department of Finance. There are still great gaps in the health services and great needs to be met. The quality of society is defined by its health service. All sides of the House, regardless of our economic philosophy, should fight on behalf of our health service.
The Minister suggested in a reply that OECD figures in relation to GNP are not specifically relevant. The one time I looked at such figures in detail was when I was spokesperson for Health. One of the findings that struck me as being universally valid was that the country with the lowest per capitaspending on its health services was the country with the highest satisfaction rate with the services supplied. That country was Britain. The reason was that Britain had a universal public system which was being provided with less expenditure. Obviously, there was a small element of private care. However, it had the highest rate of public satisfaction. Perhaps the Minister might comment on whether that model is still valid, because my statistics are a few years out of date. The United States, in contrast, spends huge amounts of its GNP on health care. Much of it goes on private health care, unnecessary interventions and elective procedures. The Minister’s objective in the development of the public health system is that it be economically efficient while delivering a good service. That is an objective I hope to continue to pursue during my political life.
I share my colleagues' desire that everything possible should be made public about the current investigations into childcare cases and cases of concern. During the debate on the recent incest Bill in the Dáil I said that until childcare is adequately developed — it certainly is not adequately developed yet in this country — it needs all the publicity it can get in its fight for resources and for a huge change in public attitude. We have a great deal of doubtful thinking about children, seeing them as possessions and as elements in the family. There is a total failure to acknowledge children as people in their own right and not as half adults, as the ISPCA put it. They are still the only group in our society as we have discussed in this committee in other circumstances, for whom we accept physical punishment. People would be horrified to see us doing to animals what is considered to be legal in relation to children within families. They need to publicise the problems they face in the fight for resources. Until we have an adequate system, with a legal basis, and social services, we should not flinch from the publicity and we should not flinch from putting responsibility on people and making them take these matters into account.
Studies have shown that child abuse, sex abuse and physical abuse often begin in the area of reasonable chastisement. The Kelly Fitzgerald case involved arguments over whether she was working and eating properly. She had to obey and this led to the reasonable area of control and order. Reasonable chastisement often descends into abuse, and even sexual abuse, because in that case she was stripped naked and chastised. It crosses the border very easily.
A recent Law Reform Commission report which this committee has been examining recommended that in the context of moving this country towards a full ban on physical punishment of children, we should consider a programme of public education on positive parenting. The Minister's Department is the only one appropriate to deal with creating a better attitude to the rearing of children and to the safety, security and care of children. It may be in the education area, but it is more relevant to child care and the Department of Health has been given responsibility for the care of children up to 18 years. Would the Department look at this? Has it considered it at all?
How is health promotion structured in the Minister's Department at present? The old unit is gone and much of the healty promotion work seems to occur at health board level. There should be a national initiative or support for the ISPCC's voluntary campaign. There could be some specific State funding for the area. The legal issue of a total ban could become a reality, but parents must be educated towards that, as recommended by the Law Reform Commission. There should be an intermediate phase.
The sums of money expended by the health boards on hostels are tiny when compared to the need. The total figure for last year is 135 places. The tiny Aoibhneas hostel in Ballymun is run in a three bedroom flat and up to 800 women and children were turned away from it in one year. That is the scale of the need. There is need for great emphasis in this area, specifically on the north side. The Aoibhneas hostel has planning permission for the development of a much larger purpose built unit on the north side and has acquired substantial Department of the Environment funding for it. They did some fund-raising and there is a £200,000 gap.
The services they want to provide within their unit include counselling, therapy rooms, playrooms for the children, secure surroundings and physical security to prevent the intrusion of hostile family members. These are not housing elements and they cannot get that money from the Department of the Environment. This is one major purpose built unit which is ready to go but there is a funding gap. They have applied to the Minister to help fill that gap and I have been in touch with his Department directly about it. There are some discretionary funds at the Minister's disposal because of the small surplus in his national lottery funding. I make a special plea for them as it would make a major contribution. People say the services are there in Dublin, but those figures from Ballymun show the inadequacy of just one hostel on the south side and another on the north side, which is only a three bedroom flat, in terms of the needs of the capital city.
A group called Recovery Incorporated is seeking funding to develop a national programme in the mental health area. The group is trying to develop a therapy for people who have suffered from depression and other forms of mental ill health and help them to build their lives again. This has been developed as a self help group in Dublin and they are now ready to spread throughout the country. For one year they are looking for some money to send people out to develop the self help structures in different regions. Once they are up and running they will be self financing, but they need to send the people out from Dublin to the various centres and develop the service. Seed funding is required, but the short investment over two years could lead to the development of a nationwide service which would be self funding because it operates from private halls and existing community rooms. The money is only necessary for the programme of expansion.
The Minister is trying to achieve greater accountability and analyse the type of services being delivered for the huge sums of money being spent on the health services. I am interested in the structures in the health boards. The Minister has been doing a tour of health boards. Are health board chief executives brought in on a regular basis? Do they meet annually or quarterly? Do they analyse what they are doing, because there are tremendous differences in different health boards? Some health boards do things very well while others do certain things very well. If that type of activity is not in place, it should be.
The Eastern Health Board at last is beginning to release its land bank. It sat on it despite every effort to release it for various social and public uses. There has finally been a decision to use it for capital investment in services. A major decision in my own constituency will see the sale of land to DCU, which is a marvellous public development. It will release about £4 million to £5 million for the Eastern Health Board to develop new services for the elderly throughout the north side of the city, replacing 90 units in an old installation with five purpose built 50 bed units. I ask the Minister for his view on this development, particularly in cities where health boards have valuable land banks. There are obviously current costs associated with any of these developments but the developments are welcome. I would like to hear the view of the Department because most of these projects will require departmental sanction if they are to go ahead.
I thank the Minister for his openness and frankness in answering questions. I will be briefer than the other contributors to date and just refer to my own interest as my party's spokesperson on senior citizens. I stress the words "senior citizens" because I read a European wide survey which found that most senior citizens strongly object to the word "elderly". In many instances we cannot avoid using it but there is a feeling that "elderly" means a burden on society while "senior citizen" strongly conveys that they are still citizens but more senior than most of us. That survey and information is contained in a recent social policy booklet and the Minister might consider using where possible the terms "senior citizen" or some other preference as indicated in the survey rather than the word "elderly". I cannot give a personal opinion because I am not in that category, but the Minister has experts in his own Department.
There has been much reference today to child abuse. I recognise the necessity for that because there was one particular horrific case in my own county. However, one notices the amount of concern in both European literature and Irish studies about elderly abuse. I have to recognise that it is there but I do not know how extensive it is. Has the Minister's Department considered the matter? Has the Minister any policy for combating elderly abuse and informing the public or people who may be suffering from it in their homes or elsewhere as to how it may be avoided? We must recognise it is taking place and I would like to know if the Minister has any view on this. An excellent study on this matter, which received wide publicity, was carried out by recently by a senior social worker in the Eastern Health Board. If it takes place to any appreciable extent, the people who suffer invariably become a termendous burden on the health system and require hospitalisation for all sorts of ailments. I would like to know the Minister's view on this.
I welcome the increased budget for the health promotion unit. The Minister would like to have the flexibility to make more money available for it. It is an essential aid in curbing the upward spiral. Because of demographic changes it is important that when people retire at 55 or 60 years of age, we give them every possible encouragment to lead healthy lifestyles. We mainly preach pious aspirations about this. I cannot talk about what happens in cities, but people in rural Ireland who retire at 55 or 60 years of age are left to their own devices and there is no organised healthy living activity for them.
I recently wrote to the health promotion unit and asked them about their work. I received a lengthy reply and a substantial number of leaflets. In my visits to various GP practices, health board clinics and elsewhere in the last six months, I have not seen any of these leaflets on display.
Is it possible to have a more structured approach to funding for voluntary organisations who take an interest in providing healthy living for those in retirement? With regard to health, they are the most vulnerable group in the population and have greater demands for health services and more long term health requirments. Has the Minister any view on the excellent housing aid for the elderly scheme which the Department operates?
Responsibility for the disabled person's maintenance allowance has been transferred to the Department of Social Welfare and I see the logic of this. Would the Minister consider an examination of the merits or otherwise of the transfer of this scheme to local authorities to be operated solely by them? There appears to be some duplication in this area. I am not criticising the scheme. I have great praise for it as a supplement to the essential repair scheme. Would there be a better and more coherent delivery of service to those most in need if one organisation in each county dealt with it rather than there being a duplication of resources?
I appreciate that on the one hand we criticise increases in public expenditure and claim it is excessive, but on the other hand we are constantly calling for improvements in services. The Minister may have received a recent study from the Irish Nursing Homes Association. The subvention to nursing homes has not increased since the Nursing Home Act came into being and the three ranges of subvention remain the same despite the fact that there has been inflation in the meantime. There appears to be a continuing widening gap between the subvention given to those who are entitled to it and what the people who are in receipt of the service must make up their own resources.
Private nursing homes provide in excess of 10,000 beds whereas 8,000 beds are provided by long-stay public geriatric hospitals. Therefore, these homes are the majority provider of his type of service. There should be a narrowing of the gap between what people have to pay out of their own pockets and what is provided from the public purse so that this worthwhile alternative private service continues to be fostered and expanded as much as possible.
People should be encouraged at as early a stage in life as possible to provide for their own private pensions. I know this is not within the Minister's ambit but he will appreciate what I am saying. The issue of pensions will be as much of a problem to deal with as the fact that our population is ageing. I appreciate the Minister's concern and awareness and his honesty in saying that what is now a problem for him will become a much more serious problem for his successor. People should be encouraged not to depend on the level of public service which they have come to expect being in existence in ten or 15 years' time. They should put some money aside, in the form of suitable pension plans, to ensure they have the wherewithal to pay for the services they will demand.
I welcome the emphasis in the discussion document on women's health. We must not forget the other side of the coin. Statistics prove that men live three or four years less than women.
That is only right.
There is obviously a reason for this. I am not saying that men are less healthy than women. We will have to fight our own corner.
They are worn out.
We can talk about statistics and various types of cancer but we must also recognise the huge number of people who are subject to ill-health and the dreaded effects of testicular and prostrate cancer, which can be easily cured if there is sufficient public health awareness. I ask if sufficient is being done by the Department about this.
I thank the Minister for providing a women's refuge centre in Castlebar. This has been my first indication of it. His party colleagues have not taken the usual liberty of publicising it but I will certainly do so this evening.
I compliment the Minister for his knowledge of the health area. Deputy Hughes must be going to the holistic clinics. There is plenty information provided in GP surgeries in Ballina and elsewhere in Mayo.
There are a number of flagships provided for in the capital programme. I presume "flagships" is a new word for hospitals. These flagships are not of convenience in certain locations throughout the country. What is the situation with regard to the second phase of the Castlebar hospital?
The recommendations of The Psychiatric Services: Planning for the Futureare still being implemented, but very slowly, especially in relation to day hostels, community facilities and respite care. The new psychiatric units attached to general hospitals are still not a feature of our landscape. The walls have come down around psychiatric hospitals; but what are patients, nurses, doctors, relatives and the general public thinking about in regard to what has happened in Castlerea? This is the wonder of the west. Will the wall which has been built be called the wall of Roscommon? Where does the Western Health Board stand on this episode?
It is Deputy Owen's wall now.
Where will all these psychiatric patients be relocated? There is still a problem with the provision of residential care, respite care and day care for the mentally handicapped. If it was not for voluntary organisations such as Western Care, with their collections, sponsored walks and so on, the position would be much worse. I must remind the Minister that there are 40 vacancies in Áras Attracta in Swinford and there is an outcry for residential care. I ask the Minister to see if that situation could be improved in the near future.
Adolescent psychiatry is still very poorly developed in each of the health board areas. This area will have to receive more attention as there are problems today with eating disorders, drugs, alcoholism and the recent problems with suicide. Perhaps these issues will be dealt with in the White Paper, but I do not see any funding for the inevitable financial implications of that White Paper. Could the Minister make a statement on the White Paper, which is supposed to be published soon? Also, will there be any hospital ward closures this summer?
I congratulate the Minister on his address to the committee and the priorities which he outlined. I know that he has already discussed the whole area of child care but I welcome the Government's commitment to implementing the Child Care Act by the end of 1996. That is very important and a key issue.
The first point which the Minister made in his address was in relation to the need for greater effectiveness, efficiency and accountability by reshaping how the services are planned and delivered. Could he outline his thinking in this area in terms of the sort of management changes which he regards as necessary in the health boards and in the delivery of our services? Change is clearly needed. We do not want to make the mistakes which have been made in England, but on the other hand we want to move towards greater efficiency, effectiveness and accountability. How satisfied is the Minister with the procedures which are in place to monitor the spending of his Department's very large budget and how would he like those to be developed in the short and long term?
With regard to the elderly, I note that the Minister has given £805,000 to the Eastern Health Board for additional places to ease the pressure, particularly on acute hospital beds. The average life span is increasing and people are worried about the cost of care. How does he see the demands on the health services by this increasingly large elderly population developing in the years ahead? How is the Department planning for this?
I can see that he has made a start in many areas and there is a move to greater community care. However, it seems that more respite care will also be necessary to give families short term breaks and to ease the burden of care. I would like to see more focus on community care. A small input to a family can often make the difference between somebody staying in the community and going into residential care.
I have come across a number of situations recently where families sold houses and raised money to keep an elderly person in a private nursing home. They then become very concerned when the funds begin to run out and wonder if the person will have to move, if the health board will maintain them in the private accommodation or whether they will have to make a change at what is a very vulnerable time. I would like to hear the Minister's views on that.
I know that the Minister has discussed screening for breast cancer, but there are different views on the development of that screening. If we are going to develop screening for breast cancer it is important that the services associated with such screening are developed well. Women are anxious about this area. I will not spend much time on it because it has been discussed already, but I am concerned that women have to wait so long for the service, for example, in St. Vincent's Hospital. The service is very good but we have extremely long waiting lists. There is clearly a need to develop more centres of excellence in relation to the treatment of breast cancer.
Someone asked if we are healthier as a nation and the Minister replied that he is trying to measure it. I think he will agree that we are much healthier and a great deal of excellent work has been done over the years. One only has to look at how healthy school-children are playing football and so on — speaking of football, if we were healthier we might do better than we did last weekend. People are living longer and, more importantly, are living healthier and fuller lives. This is all part of the input which has been made over the years to healthier lifestyles.
A concern which I have about all Estimates is that I feel we should look at the progress in the Estimate in relation to the need. Naturally, the Minister will say that in certain areas there is substantial and increasing need, which is true in relation to the elderly, mentally handicapped and so on. However, we as a committee should be in a position to measure the need and plan to meet those needs. If we had those figures in front of us we would see what the real needs and priorities are and how much progress is being made in relation to those priorities.
A very useful piece of research in Cork and Kerry showed that breast cancer has increased quite substantially, with a rise of 30 per cent in the past ten years. On the northside of Dublin people are very concerned about the extent of cancer. From time to time I have asked the health boards and health officials about the causes and reasons and if our area was different from other areas. We are not that far from Sellafield and people are genuinely concerned about that. There is evidence of radiation and we are told that it is under the recommended levels and is quite acceptable. Nevertheless, people are increasingly concerned about this. According to the study, Ireland had 70 deaths per 100,000 of population from breast cancer while China had 20 deaths.
Perhaps the most frightening aspect and the matter of greatest concern is that lung cancer is set to become a major problem and to outstrip breast cancer. According to this study, it is 95 per cent preventable, as it is by and large a preventable disease if people do not smoke and inhale tobacco. Has the Minister made any estimates of the extent of the growth of lung cancer and does his information confirm the findings of the study in Cork and Kerry? We previously had a figure of around 75 per cent as the direct relationship between lung cancer and tobacco smoking, which has now gone up to 95 per cent. This is a major issue which needs be tackled in a substantial way.
That brings me on to the whole question of the health promotion unit, particularly in relation to women's health. The unit was able to supply excellent material when we went to it with an issue. I see there is an increase of £300,000 for that unit in this Estimate, but I wonder whether it is time the health promotion unit was set up as a separate free standing health board. It was a health education bureau at one stage. People would claim that perhaps it was not fulfilling its objectives satisfactorily at the time, but it now seems to be getting to grips with its problems and it may well be time to give it an extra boost and let it get on with its task. The whole area of drugs and drugs awareness is very important — it is one of the most important issues we face as public representatives. Smoking and its relationship with cancer and alcohol is also a constant problem. The health promotion unit is the best agency to work in that area.
In relation to the question of hepatitis C, I have suggested launching some sort of card. Perhaps the Minister will consider that. I had a person with me yesterday who was unable to get a particular service, so there is still some confusion about that. I know the Minister is concerned about it and there may be some way of making it all a bit clearer to those affected. There is a huge problem with drug treatment services at present because of the extent of drug abuse. We have a very big problem on the northside of Dublin.
Parents want treatment for their children, but just cannot get it as the number of people who need treatment is too great. There is an improvement, extra money has been provided here, but it is not meeting the current demand to any real extent. I know that it has built up particularly in recent times and extended quite suddenly and I know that other aspects of the problem, such as the legal and criminal aspects, are being tackled. Nevertheless, we have a huge drug treatment problem and this is an area about which parents approach me a great deal.
Extra services are needed in this area. Those seeking treatment have to come into Pearse Street and it is nearly impossible to get an appointment or treatment because of the numbers who are now looking for that treatment. A drug treatment service is needed on the northside. Perhaps the Minister could look at where it is best to have the service. Certainly there is huge demand in this area and the Minister would have our full support in pursuing resources for that purpose.
In relation to people with disabilities, whether they be physical or mental handicaps or other disabilities, whatever happens with the cutbacks — and I presume the Minister is waiting to see how the situation develops over the next week — we should be giving priority to people with disabilities. It is not acceptable that they are being left behind when other groups are not. Extra funds are being provided, but it is a question of identifying needs. For instance, in the area of mental handicap several Deputies have mentioned fears of ageing parents for the future of their mentally handicapped children. There is a great need for respite care, for houses in the community, which are very successful and which are, by and large, being integrated into the community.
There is the possibility of establishing schemes for the unemployed to support people who are mentally or physically handicapped in the community. There would be very little real cost on the unemployment side where so many unemployed people would be available as assistants. Additional costs would have to be met but in-care have shown what can be done with a pilot project in that area and that is something which needs to be pursued.
This Estimate holds a great deal of interest for Deputies. It touches the community very closely and consequently there are many other issues which one could discuss. I wish the Minister every success in his work in the Department of Health. He must have the support of the House and of the committee in dealing with the many priority areas which he has to confront. In dealing with the Department of Finance or whoever else he should be conscious of the fact that he has powerful support in emphasising the priorities which are there to be met.
According to the agreed timetable we are to adjourn at 5.15 p.m. Many questions have been asked by Deputies to which, I am sure, the Minister will want to reply, so perhaps Deputy O'Donnell will be very brief.
What steps have been taken to enhance the accountability of the health boards, not only in relation to the provision of services and the quality of that service but also in relation to their disbursement of public money? What measures have been taken to ensure that they do not build up the debts, which were such a feature of the recent past? The Minister will recall that the health board debts were cleared by a one-off payment from the tax amnesty. What steps have been taken in order to ensure that this sort of bad management does not take place again?
I wish to make a point in relation to embarrassments, as we have euphemistically called them, in relation to the provision of services, in particular the protection of children, which is the direct statutory responsibility of the health boards. The Minister has indicated that he has set up a review of the circumstances surrounding the Kelly Fitzgerald matter. He has indicated today that he is not willing to publish the findings of that review. How soon does he expect to be in a position to present any detail, any learning points, admission of fault or responsibility, failure or system failure? I make no apology for asking questions about this matter. The child is dead and the abuse was caused by her own parents, so nobody else will ask how the health board dealt with this matter. When will the Minister be in a position to come back to the House or to this committee with findings or learning points which he hopes to put in place following on the handling of that matter?
In relation to hepatitis C, the Minister has indicated that the 1,100 women who have been infected with hepatitis C because of the blood bank failures are covered under the normal medical regulations. Would the Minister accept that these women, who have been infected by the failure of a State agency, have a right to expect a very flexible and high standard of continuing medical care rather than just to make do with the normal free medical care? Would he not agree with me that special care will have to be put in place for these women because of the psychological feeling of being wounded by the failure of a State agency and that their care should be very flexible? If they want to go acupuncturists, for example, or opt for alternative systems rather than interferon, which is expensive and has a lot of side effects, they should be free to do so.
As regards the drug problems in the large cities such as Dublin, have Protocols been put in place for pharmacists? I believe that at their recent conference they indicated that they requested Protocols two years ago to dispense methadone at pharmacy level. They need a Protocol to be agreed with the Department of Health to enable them to do so.
Do any health boards meet in public? I know the Eastern Health Board does not. Recently when the Eastern Health Board met with the Ballymun committee and Dublin Corporation, it went berserk when we brought in a journalist. The Minister outlined what he expects to get from the different health boards. Where will special therapeutic care be provided? There is a list of things which health boards will provide. Who will provide them and where will they be provided? What type of new accommodation will be provided, particularly for the homeless in the Eastern Health Board area? Many homeless people are being put up in bed and breakfasts at present. How many additional social workers/ counsellors have been appointed as a result of the moneys?
(Limerick East): As regards Beaumont Hospital, the position taken by the hospital board and its management has been fully vindicated as a result of the inquiries and the hearing in the High Court. The hospital is a centre of excellence and the controversy was in the neurosurgery area. There are many other specialities in Beaumont Hospital about which nobody has raised any issue or question and it is worthwhile putting it in that context. It is a recognised centre of excellence and a teaching centre in terms of postgraduate medical nursing staff. It does an excellent job in carrying out that work. It makes every effort to give as good a service as possible and to improve it.
On the question of charges made by my predecessor when he was in Opposition, I do not believe I should go into that. I can see why Deputy Geoghegan-Quinn might raise that question, but it is not for me to answer. I have a function at the end of the day because there is an appeal before me at present from the neurosurgeon who was subject to sanction. I am in a difficult position because I must adjudicate on the appeal and for that reason I am reluctant to comment on the controversy.
Had the Minister made those allegations before being appointed Minister for Health and they were found to be untrue, I take it that he would have been prepared to go public and say that he was wrong to take them. I ask the Minister for openness, transparency and accountability.
(Limerick East): Deputy Geoghegan-Quinn sat across the table from him for two years. The Deputy’s question would be valid had she not been in Government with him for two years. She could have asked him herself.
It was not up to me to ask him.
(Limerick East): It is not for me to answer, but I believe the Deputy gave it a fair airing. I would not like to do anything which might tie my hands when dealing with a difficult issue which is still on my desk.
Deputy Hughes asked about housing aid for the elderly. It is a Department of the Environment scheme rather than a Department of Health one. There is merit in what he said about transferring it to the local authorities. I will get the management team, in particular the departmental secretary and his colleague in the Department of the Environment, to discuss it with the chief executive officers to see if something can be done.
On the issue of elderly abuse, we accept that there is a problem, but we do not know the extent or nature of it at national level. The study to which Deputy Hughes referred was carried out by Ann O'Loughlin, President of the Irish Association of Social Workers. The National Council for the Elderly has played an important role in conducting research into different aspects of the elderly and ageing. The national council, which is an advisory body, could be asked to carry out research on the problem of elderly abuse and to make recommendations on its prevention. We will follow that route and I thank Deputy Hughes for bringing it to our attention.
Deputy Flaherty asked about Recovery Incorporated. We are not aware of any application for funding but I would be sympathetic if I received one. As regards the spend in the UK as against that here and which provides the better, in terms of the percentage of GNP, the UK spends 6.6 per cent and we spent 8 per cent. This relates to the point I made about Sean Barrett's statistics in that if we look at it in terms of GDP or GNP, we get a skewed result. In 1991 the spend per capita in the UK was £1,035 per person and £840 per person in Ireland. While the GDP percentage is much higher here, the per capitaspend is higher in the UK. I believe aper capita spend is a far more accurate measure of cost of service than a GDP one.
Deputy Flaherty referred to a ban on physical punishment. The Department of Justice is examining the Law Reform Commission report on non-fatal offences against the person, including the question of whether parents should be permitted to impose corporal punishment on children. We have no plans to undertake a public education programme on the issue. There are widely differing views on the subject as evidenced by the public reaction to the ISPC anti-slapping campaign. The stay safe programme addresses all forms of abuse and it has been made available to all primary schools. Part of the programme involves meetings with parents where such questions are discussed and maybe that is the route to take.
Deputy Flood raised the issue of the special needs of travellers. I acknowledge his contribution, particularly to this issue, when he was in the Department of Health. The mobile clinic initiative which he was instrumental in putting in place is continuing, has developed further and is effective in intervention. He should claim credit for this good initiative. The health boards recognise the special needs of travellers and a number have identified special initiatives for them. We will get a chance to discuss this again because there is a section on the health of women travellers in the women's health policy document. There are significant things in that which I am sure the Deputy would like to take up. However, that is not to say that men travellers do not have health problems because the statistic which is part of conventional wisdom is that the life expectancy of travellers is lower than that of the settled population. Every adult in the country knows that. There are other specific issues which are not generally known and the Deputy might like to come back to it in that context.
Deputy Flood also asked about dental services. It is now a consultant driven service and the consultant works with a team of dentists. People come to a central unit and the throughput is very good. There has been difficulty in getting consultants in some health board areas and we had to advertise on a number of occasions. There have been more difficulties in the Eastern Health Board than anywhere else. It is true that the situation between the health boards is uneven. As part of the programme an extra £1 million has been allocated to orthodontics this year. There is also the development of the dental programme. As I stated earlier, the eligibility age will rise from 12 to 14.
There are also improvements in the overall dental programme in so far as it applies to medical card holders. In the first instance priority will be given to those over 65 this year. This has come down because there are extra resources in the system which enable us to go below that. The target for the overall programme from 1994-98 is that a further £28 million will be put into the service.
There has been a problem in terms of supply and demand with regard to orthodontics. An insufficient number of orthodontists were available in the public service. The consultant led service in the health boards is training in more orthodontists and while they are not all being retained, quite a number are being retained within the system. Although one should not use the word "cosmetic", one could argue the point — to use the words of the strategy — at which health need becomes social need in terms of orthodontic treatment.
We are conscious of both the health and social needs. Both are supposed to be measured as part of the health strategy. In my view, there is a point in orthodontic treatment where it is principally a health need at one end of the spectrum and principally a social need at the other end. In so far as resources are scarce, as they will always be, they must be stacked in favour of the health need. The members are all familiar with the points system. It is uneven, but it is picking up and the Eastern Health Board is the laggard in the system.
Deputy Flaherty mentioned the sale of assets, particularly in the Eastern Health Board. We have agreed a four year development plan with the board for the disposal of assets. Discusions are at an advanced stage on the extension of the plan. Particular attention has been given to providing additional facilities for the elderly on the northside of the city where there is a low level of existing provision. We work on a partnership basis. One of the hospitals in Dublin recently had discussions with the health board. They agreed to sell assets to the tune of £4 million and we agreed to back it pound for pound. This is the way we leverage sales of assets. We enter joint venture projects and match it pound for pound. This seems to be working.
It would desirable on every front for the community.
(Limerick East): Nursing homes subventions will increase by over 2 per cent this year in line with increases in health non pay inflation. They will take effect from 1 July and we will monitor the adequacy of the subvention rates. I received the report from the private nursing homes last week. They are clearly fulfilling a very key role in the provision of services to the elderly. They have their difficulties — I am sure we can all recite some of them — but they are also in private business. They will now receive £15 million that they did not receive 18 months ago. Even though the level of subvention has not been increased, there have been very big increases in the total cost of the scheme due to a wider spread and more eligibility.
I promised I would look at the particular consultants report which they submitted, and the situation is uneven. The cost of nursing homes in the Dublin area is significantly higher than around the country and the level of subvention paid in the Eastern Health Board area is much higher. It tends towards the maximum, whereas it is in the middle to lower range in the Deputy's part of the country. It is a new scheme and it must be evaluated. It is a significant improvement that it exists at all and it is a very beneficial scheme. It needs to be finetuned and it may also need extra resources. However, the priority at present is to fine-tune it.
Deputy Moffatt mentioned summer ward closures. There will be summer ward closures every year as they are part of the holiday arrangements in hospitals. When consultants are off in the summer months there is no point having four wards open if the throughput can be handled in two wards. Nurses also take holidays, so there will be closures in the context of summer and Christmas vacations.
Is it not an economic aspect also?
(Limerick East): It was some years ago because summer closures for vacation purposes were also a type of financial adjuster. However, I do not think that was the case last year or the year before; it was purely vacation driven. For example, in terms of accident and emergency in Dublin this week, there is absolutely no problem. We are coming into the summer months and even though closures will be coming up in July, one would not envisage any problems at all. The peaks are usually in the winter months.
Deputy Fitzgerald mentioned the effectiveness of the boards. Each board has been asked to develop effectiveness measures for each subprogramme on a phased basis commencing in 1995. That is in place and the Deputy put her finger on many issues in relation to the boards on the question of accountability and on outputs and expenditure monitoring by the Department in accordance with agreed annual plans. There is also a working capital control system, which is now working well, and there has been particular success in controlling expenditure within budgets.
Regarding accountability, we have held discussions with the health board. Ultimately, this will be a matter for legislation, which is almost ready to go. We will be setting the financial accountability requirements of the health boards on a statutory basis. The chief executive officers have already been told and they are anticipating the statutory provisions in the administrative provisions which they have put in place since the beginning of this year.
Deputy Flaherty asked about the frequency of meetings with chief executive officers. The management team in the Department of Health meets each chief executive officer not less than six times a year and sometimes more. I occasionally meet them when I go around the country, but this time I am carrying out a systematic run through all the health boards.
Do they meet together?
(Limerick East): Yes, they meet together on a monthly basis. We put specific tasks before them. For example, we have asked them to examine home help services. There are variations and much aggravation between the various health boards. We recently put it to them to corporately come up with suggestions on that matter.
Deputy Fitzgerald or Deputy O'Donnell asked specifically how we know they will stay within budget in the future. The first reason is the accountability aspect. However, secondly, once they got an infusion of funds to clear their overdrafts, any overrun was the first charge in the next year's Estimate. That was very clear and it was applied. They kept below 1 per cent of allocation last year, which was quite good. The position is clear. If they run over by £1 million or £.05 million, it is the first charge in the following year's Estimate and we will not depart from that.
Deputy Moffatt mentioned the White Paper on Mental Health. It is legislation for involuntary detention of patients with mental disorders. The new legislation is required to bring our law into line with the European Convention on Human Rights. The White Paper will not give rise to much additional cost because psychiatric hospitals and services already exist. They are well staffed and well funded so the fact that they must do things in a different way does not necessarily involve extra cost. However, there will be some costs — for example, the administration of a review and appeal arrangement which must be put into the system. There will also be some parallel developments.
There has been a major expansion in child and adolescent psychiatry. Every health board now has a service, which is very significant. Regarding the time frame for the White Paper on Mental Health, it is more or less ready. I will be dealing with it in terms of its publication probably in July or August; I am not particularly interested in timing it for the high season of publicity. A short period of consultation, maybe three months, will take place. The White Paper is not quite drafted and framed to the format of the heads of a Bill, but it is near enough. Therefore, there will not be much work involved in moving it from White Paper status to that of heads of a Bill. I hope to get the heads of the Bill to Government some time in the autumn, put it through the Office of the Attorney General and the draftsman's office as fast as we can, with a view to bringing in a Bill sometime in 1996. I do not mean to give a vague commitment, but that is the kind of timetable we are talking about. I do not want to say that I will introduce the Bill in January 1996 and not be able to fulfil that commitment. However, it is important legislation.
I have a note on the Kelly Fitzgerald case that I would like to read.
On Tuesday 2 May 1995, the chief executive officer of the board announced the establishment of a team to examine the circumstances of the board's involvement with the late Kelly Fitzgerald and her family. The investigation team is chaired by Owen Keenan, Director of Barnardo's. The other members of the team are Siobhan Keogh, a senior social worker, Midland Health Board, and Mary Finucane, a former superintendent and public health nurse, Mid-western Health Board. The terms of reference of the investigation team are to examine the circumstances of the Western Health Board's involvement with the late Kelly Fitzgerald and her family; two, to make recommendations for any necessary changes in the Western Health Board's child protection practices and procedures in the light of this examination; three, to make such other recommendations as are considered relevant to the case and four, to report to the chief executive officer of the board in the matter as soon as practicable. The investigation team has been asked to complete its work as quickly as possible. Subject to legal advice, the chief executive officer hopes to publish its report. A copy will be submitted to the Minister.
The inquiry was set up by the Western Health Board. The Department assisted the board in establishing the review. I did not say that I would not publish the report and I will not stop the board from publishing it. However, both the board and the Department must have regard to the legal advice which will be given when the report is available. We should operate in the light of day — Deputy Flaherty mentioned this as well — as far as possible and I have no problem with that.
There was a commitment to publish the Dr. Miriam Hederman-O'Brien report and I published it in full without a comma being changed. The second report that came to me was the Bain and Co. report on the health board, which was an internal quasi-business consultants report into the operations of the place. I had no obligation or commitment to publish that but I did so in full without changing a comma. There were commitments given that the Madonna House report would be published in full before I became a Minister. When the report came to me the legal restrictions did not allow me to publish it in full, but I have a mechanism in place to put every relevant part of it into the public domain in a manner which is legally safe and I will do that. I hope the Western Health Board will be able to publish the Kelly Fitzgerald report in full, but much will depend on the way in which the committee drafts and writes it. If there is something in the text of the report, for example, that defames or makes an allegation against a third party in a way in which is difficult to substantiate, then there is a publication difficulty. I hope this report will be published. If there is some difficulty with its publication, I will hope to put as much of it as possible in the public domain through some mechanism in that area.
In other words, it would be pointless discussing that report?
(Limerick East): I am not saying that at all. Deputy O’Donnell is going into accusatory mode.
I am not. I make no apology for taking the Minister up on this.
(Limerick East): I am not asking for an apology.
The Minister alleged that I was going into accusatorial form. That is not true.
(Limerick East): Deputy O’Donnell is trying to put me in a false position; she is misinterpreting my position. Deputy O’Donnell is publicly restating what I am saying in a way which is incorrect. That is accusatory and is argumentative beyond what is necessary.
Am I not allowed to be argumentative, Minister? This is the Estimate and we are talking about a matter of extreme public interest. A child is dead and the health board were meant to be responsible for her care. She was at risk and I make no apology for raising this.
(Limerick East): Deputy O’Donnell is entitled to raise it. I am not looking for an apology.
He will not get one.
(Limerick East): I am not making any allegation at all except that I want the right to reply. This depends on what Deputy O’Donnell is looking for. If Deputy O’Donnell is looking for information and commitments from me, I am giving her frank answers. If Deputy O’Donnell is playing politics with it, we will have an argument.
Am I playing politics by raising this matter? The Minister indicated earlier that it was for his eyes only, that he would look at it and make the decision.
(Limerick East): I did not say that at all.
I challenged the Minister on that and I am entitled to do so.
(Limerick East): I would be the first to recognise Deputy O’Donnell’s right to challenge me on that. She can challenge me on this all night, but she cannot take away my right to explain my position.
Absolutely.
(Limerick East): Deputy O’Donnell can state her position and I can state mine. Our only area of conflict is when she tries to state my position and it is not correct.
The Minister said earlier that the decision to publish the report would be his. I then said what was the point of seeking to have this report commissioned if it was not going to be published. The Minister then said that it was for his eyes as Minister to see if we could learn any lessons from it.
(Limerick East): I did not say that. Deputy O’Donnell went from the particular to the general——
Then let us clarify it. What are we going to get?
(Limerick East): ——and asked me what was the purpose of the report. Deputy O’Donnell asked me about the Kelly Fitzgerald report and I told her that I would do my best to publish it but that there might be difficulties. Then Deputy O’Donnell went from the particular to the general when she asked what is the purpose of reports or investigations if one cannot publish them. I then gave the Deputy an indication of my view on the general issue of reports. Sometimes one can publish them in full and sometimes one cannot.
Is the Minister saying that he cannot publish them?
(Limerick East): No.
Then the Minister should outline the cases he cannot publish.
(Limerick East): One cannot publish some reports.
What are the circumstances in a democracy when one cannot publish a report into an investigation of a health board?
(Limerick East): Can you protect me from this argumentative woman, Chairman?
Can Deputy O'Donnell allow the Minister to reply to the question?
(Limerick East): I gave Deputy O’Donnell a good example with the Madonna House report. Commitments were given to publish that report in full. It is now not possible to do this for legal reasons, which fall into two categories. First, the publication might interfere with the possibility of further cases being carried with the prosecution process — Deputy O’Donnell is fully aware of what I am talking about.
Yes.
(Limerick East): The second area is that of civil law. Because a report is written by professionals who are not legal people, they may write it in a way that the rights of third parties are infringed and the particular agency, the people writing the report and the Department may then be open to challenge and defamation claims. Because of those two areas of difficulty, it became impossible to publish the Madonna House report in full.
After much consultation with the Department of Health — the investigation was conducted by the Western Health Board, and I have named the people who were on that board — the Kelly Fitzgerald report will be first submitted to the chief executive officer of the Western Health Board, Mr. Eamonn Hannan, and a copy will then be forwarded to me. The chief executive officer of the Western Health Board hopes to publish the report. However, it would be easy for me to say that we will publish it, but I do not want to come back to the Dáil in the autumn and explain to the House why I cannot do this. I am signalling that while he hopes to publish the report, it cannot be published in full if legal difficulties arise. I will do my best, if it cannot be published in full, to put every relevant detail into the public domain in a way which is legally safe. I am not hiding anything and it is unfair to try and put me in that position when I am being open on the matter.
I never said that the Minister was hiding anything. However, it is an important principle in a democracy. Is the Minister saying that if this report is not published, we can assume there was fault found?
(Limerick East): No. One can often publish a report where it indicates fault. The fact that there was fault found does not mean a report does not have to be published.
: There was a fault found in the Blood Transfusion Services Board, although the Minister did not seek any resignations.
(Limerick East): It was published.
: It was published but no resignations were sought; it was a case of golden handshakes again. This is a bigger problem. Minister. One can move from the specific to the general.
The Minister is replying to the question and I ask him to continue.
(Limerick East): I have said all I wanted to say on this issue. I cannot say anymore about the Kelly Fitzgerald report. I hope that I have made my position clear on it.
With regard to Deputy Flood's point in relation to the Child Care Act, there is an absolute commitment that the sections committed to will be implemented this year. It is my priority that the remainder of the Child Care Act, as committed already, will be implemented next year. The only point I would make is that because we do not have multi-annual Estimate or budget systems, the finances will have to be negotiated in the context of the 1996 Estimate. I am not drawing back from it in any way whatsoever. I am simply pointing out to the committee that we work on a year to year basis. It is my opinion that we should not be working on that basis. I would much prefer a rolling budget with rolling personnel numbers and rolling financial allocations that could be carried until the end of 1996. It was in that context that I made the remark. There is no comeback from it.
I appreciate what the Minister says, but it was written in stone, as it were, by his predecessor that this would be done by 1996. I accept that the Minister inherited this situation. If a different scenario emerges next year because of the VAT situation it may be understandable. Everyone expects that it will be implemented.
(Limerick East): The commitment stands, as a Government commitment and a ministerial one. I am simply saying that the Estimate must be negotiated. With regard to Deputy Flaherty’s point——
Who is responsible for providing the secure therapeutic unit for children? Is it being provided by one of the health boards? Who is providing it and where will it be situated?
(Limerick East): Is the Deputy referring to wayward children who are difficult?
All sorts of children. Most of them would have exhibited it by waywardness of one sort or another. They would not be regarded as criminals.
A secure therapeutic unit.
A therapeutic unit first. Secure units are needed also. Are there any specific new facilities around the country?
(Limerick East): There was a court case which gave rise to a certain amount of difficulty. On 24 March 1995, Justice Geoghegan held that the Child Care Act, 1991, does not permit any kind of civil containment or detention by the health board. The 1991 Act essentially gives the health board the powers of a parent in certain suitable cases. Just as a parent cannot cope with certain hyperkinetic children, neither can the health board. The court went on to say that the State is under a constitutional duty to cater for children with very special needs which cannot be provided by parents or guardians.
It has been decided that the health boards will develop and operate special care facilities for children who are out of control but are not offenders, while the Department of Education has undertaken to increase the number of places for young offenders. An emergency facility has already been provided by the Eastern Health Baord at Palmerstown for a number who have been the subject of judicial review proceedings. The board intend to provide a second facility at Trudder House, Newtownmountkennedy, County Wicklow, which will require extensive renovations and security adaptations. These have commenced and it is expected that the house will be ready for opening by the end of October of this year. The unit will provide accommodation for six to eight children of both sexes. Arising out of further High Court proceedings, the Southern Health Board is developing a special unit on the grounds of St. Stephen's Hospital, Cork.
One is to be located at Palmerstown. What is the location of the other unit?
(Limerick East): Trudder House. They are the two locations. They will cater for very small children with specific difficulties. The Deputy is probably aware of the legal difficulty which gave rise to the need for these units. In relation the moving of the Aoibhneas refuge from Ballymun to Coolock, the shortfall is in the region of £750,000. We may be able to take some action at the end of this year or early next year. If they submit, the money might be split between two years. I will discuss the issue in greater detail with Deputy Flaherty.
With regard to leaflets on display and the health promotion issue, the movement is toward devolution from the Department of Health to the health boards. We hope that the health boards will take the leading role in future and that the policy will be laid down centrally. We hope that they will then be responsible for putting any health promotion into places where the public are most likely to see it.
The second phase of Castlebar Hospital is proceeding. A psychiatric unit has already been authorised. The orthopaedic demands in County Mayo are currently a matter of controversy. There is no decision on that aspect.
On the subject of Castlerea, the psychiatric hospital with the big wall around it, the Department of Health's mental health policy is to withdraw from the old, obsolete psychiatric hospitals. Whether it becomes a prison or not, the policy remains that we are withdrawing from larger psychiatric hospitals and moving into the community.
I am delighted to hear this. The Minister was highly complimented at a meeting in Castlerea last night, unlike his colleagues, the Minister for Justice and the Minister for Finance.
(Limerick East): Do not be trying to upset the solidarity of the Cabinet.
I am not trying to upset the solidarity at all.
One side off the wall.
I am giving credit where credit is due.
What is the position regarding Tallaght?
(Limerick East): I take the point in relation to the voluntary organisations for the care of the handicapped. No matter what gearing up is carried out, in terms of personnel or finances, the role of the voluntary organisation is crucial. The policy of cooperating with the voluntary organisations will be maintained. The only major change in the health strategy is that previously the relationship in terms of negotiating the budget and calling policy options was between the voluntary organisations and the Department of Health. The health strategy states that that relationship will now be between the voluntary organisations and the health boards. This could be easily done if we were discussing voluntary organisations dealing with mental handicap, where the budget is between £1.5 million and £2 million. However, in the case of the Mater Hospital, or other large Dublin hospitals and the voluntary hospitals, a management and organisational change would be required on a magnitude that would take time to complete. I take the point that this is an important issue, however.
I will communicate with Deputy Moffatt regarding Áras Attracta in Swinford on a subsequent occasion. The service in relation to adolescent psychiatry has improved. The issue of suicide is one of great concern. We have had some preliminary discussions to see if we can do anything valid, rather than agonising about the matter. It is a real issue.
I agree with practically everything that was said regarding care of the elderly. There is a spectrum of interventions from a level of where people are not in any need of particular care from the health services, to their requiring specialised units. This must be considered. The problem is increasing because the numbers are increasing. It is worth saying that to be old is not synonymous with being ill. Most older people are not ill.
Deputy Woods raised a number of issues, particularly the question of facilities for people with drug problems. I accept that a waiting list has developed at the satellite dispensaries currently in operation. The additional moneys being provided this year will allow for the development of additional clinics in Dublin as well as the creation of extra community addiction teams. Money is included in this year's Estimate to allow for an expansion of the units and extra involvement for dispensary doctors also. There is a difficulty because once a location is selected, people in that community protest. The siting of the facility will probably be the——
The problem.
(Limerick East): ——problem issue rather than the financing of it or the employment of personnel. That is the major difficulty there.
Deputy Woods spoke about cancer as well. I am very supportive of his remarks, for which I thank him. In the Dáil I suggested something along the lines of the hepatitis C card to Deputy Máire Geoghegan-Quinn. We would have to call it something else anyway because there was not a great reaction to the name.
There was a green card at one time.
(Limerick East): I know what you are saying. Deputy Liz O’Donnell made the same point. It is not just a minimum public health figure which is being requested, there must be a little more than that. That was the idea of the card which would cover GP services and a variety of other things. We have a good relationship with Positive Action in particular but also with other groups and with the individual women involved. We are exploring all this and we are making progress. Every meeting seems to be a fairly good one and some progress is made on it all the time.
As regards respite care for older people and the involvement of the unemployed, there is already a scheme with some physically handicapped people where you have assistants.
The in-care scheme.
(Limerick East): Is it something on that model that you are suggesting?
Yes. A lot of unemployed people are interested, so it is the additional cost you are talking about. Obviously, the pilot study may have been set up on a high cost basis, so you might have to look at something that is not quite as high as that.
(Limerick East): Yes, there was a very high cost. It nearly crashed last March and we renewed it. It is an exceptionally high cost. It is worth looking at the possibilities of increasing it.
Does anybody want to raise anything else? I think that I have dealt with most things in so far as I had the information.
That concludes our consideration of the Health Estimate. I thank the Minister and his officials for their help as well as the Members of the committee for all their contributions.
The next meeting of this committee will take place on Thursday, 15 June at 2.30 p.m. in room G2 to consider the Estimates for the Department of Social Welfare.
The Select Committee adjourned at 5.55 p.m.