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Estimates, 1996.
Vote 41: Health.

I welcome the Minister for Health, Deputy Michael Noonan, and his officials, Mr. Jerry O'Dwyer, Secretary; Mr. Dermot Smyth, Director, Finance Unit; Mr. Dave Smith, Assistant Principal, Finance Unit; Mr. Frank Ahern, Principal Officer, Secondary Care; Dr. Ruth Barrington, Director, Continuing Care; Mr. Jimmy Duggan, Principal Officer; Mr. John O'Toole, Assistant Principal, Finance Unit; Mr. Alan Aylward, Principal Officer, GMS; Ms Frances Fletcher, Assistant Principal, Mental Handicap Services and Mr. Dermot McCarthy, Secondary Care.

The Select Committee is considering the Department of Health Estimate today. A suggested timetable has been circulated which is intended to assist us in discharging our business. However, the timetable is not rigid and I propose to be a little flexible on the matter. If we want to finish within the timeframe this evening, however, we should endeavour to stick to the timetable as far as possible. Is the timetable agreed? Agreed.

Limerick East):I will read the preliminary statement as you requested, Chairman, and I have a brief on the various issues which people will want to raise. I will be calling in the officials to give extra details so the committee will forgive me if it becomes a little informal at that stage.

I am pleased to present to the committee the details of the Health Estimate for 1996. First, I reiterate my continuing personal commitment and that of the Government to the principles outlined in the Health Strategy, as stated in the Government ProgrammeA Government of Renewal. As the committee is no doubt aware, the strategy’s central objective is to promote greater levels of efficiency, effectiveness and accountability in the health services 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, setting 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. It also contains a four year action plan which sets out specific targets for developments across a wide range of services designed to achieve these goals.

The 1996 Estimate is designed to achieve further progress in meeting the targets set out in the action plan and reflects the fundamental values set out in the strategy. As every Member is acutely aware, the Government faces strict targets in relation to public expenditure arising from the need to meet the Maastricht criteria to enable this country to enter the Economic and Monetary Union which is vital for our future prosperity. This has implications for all public expenditure, including expenditure on the health services. However, I am pleased to inform the committee that within the limitations imposed by the policy in relation to the management of the public finances, the resources provided will enable further progress to be achieved in developing services, particularly those for children at risk, the mentally handicapped, the physically disabled, the elderly and other groups with special needs. It has also been possible to provide for additional developments in the acute hospital sector to meet the critical service pressures on these services, including the continuation of the hospital waiting list initiative.

One of the central elements of the health strategy is the emphasis on encouraging people to take more responsibility for their own health. To achieve this we must provide people with the necessary information and support to help them take that responsibility. I am pleased, therefore, to announce that I have been able to provide again this year some additional funding for health promotion, to enable my Department's Health Promotion Unit and the health boards to continue their vital work in this area.

The 1996 gross Health Vote is just over £2.4 billion which represents nearly one-fifth of all Government spending on supply services this year. This is nominally a decrease of £32 million, or 1 per cent, on the 1995 outturn. However, in comparing the provision for health services for the two years it is necessary to take into account the fact that the 1995 figure includes £60 million for disabled person's maintenance allowance payments which are now the responsibility of the Minister for Social Welfare and the £60 million allocated to the Compensation Tribunal for those who contracted hepatitis C from blood products supplied by the Blood Transfusion Service Board. When these are taken into account, there is an actual increase of £88 million or 4 per cent. I do not propose to go into the details of the Estimate as I am conscious that our time is limited. I want, however, to touch on some of the main aspects.

With regard to services for children at risk, I emphasise that this Government is committed to completing the implementation of the Child Care Act, 1991, by the end of the year. The final phase of implementation involves the commencement of Parts VII and VIII of the Act which deal with the supervision and inspection of pre-school services and the registration of children's residential centres operated by voluntary bodies, respectively. I am pleased to report that we are on schedule to achieve our target for this year.

Last month my colleague, the Minister of State at the Department of Health with special responsibility for children, Deputy Currie, launched a detailed child care action plan for 1996 which sets out the new child care developments approved for each health board area. The plan includes a number of initiatives ranging from an increase in the fostering allowance for children aged 12 and over to £60 per week to increased funding for preventative services, such as family resource centres, youth projects and day nurseries. Nationally, 50 extra posts have been approved bringing to over 900 the total number of new posts created for the child care services since 1993.

The full year cost of the measures in all health boards is £5 million. In addition, £3.5 million has been made available for capital projects. This investment brings to £35 million on an annual basis the total additional revenue funding provided since 1993 to develop child care and family support services and to strengthen the capacity of the health boards to meet the demands imposed by the implementation of the 1991 Child Care Act. However, I am conscious of the pressures on our child welfare services. There are still needs which must be met and new pressures are emerging which call for the investment of further resources. I am preparing proposals for Government for financing a new child care programme for the period 1997 to 1999 which will be brought to Government shortly.

I also take this opportunity to bring Members up to date with a number of other initiatives in relation to child care being undertaken in the Department of Health. My officials are currently working on the details of establishing the social services inspectorate which I recently announced. While the inspectorate will be initially concerned with child care, it will in time take on responsibility for other vulnerable groups such as the dependent elderly and persons with disabilities. I envisage that the principal functions of the inspectorate will be the quality assurance and audit of child care practice and I know it will contribute substantially to the overall quality improvement process and the promotion of good practice. The inspectorate will also be charged with undertaking inquiries on behalf of the Minister.

As regards the consultative process on mandatory reporting, the closing date for the receipt of submissions in response toPutting Children First, the discussion document on mandatory reporting launched in February by the Minister of State at the Department of Health, Deputy Currie, was reached last week. I am pleased to report that approximately 125 submissions were received in response to the discussion document. While they reflect the diversity of views on mandatory reporting, all share a common commitment to the welfare and protection of children. All submissions will be closely examined over the next couple of months and the Minister of State, Deputy Currie, will provide a forum for all interested parties to come together to debate the complex issues involved following an examination of all the submissions.

There have been significant developments in recent years in the level of services available to persons with a mental handicap. Additional funding of £44.58 million was invested in the development of services in the period 1990-95, which has enabled the health boards to put in place over 1,000 additional residential respite places and 2,100 new day care places. A further £12 million is being provided in 1996 to continue this ongoing development programme. I am satisfied that this additional funding has made a significant impact on the numbers of persons with a mental handicap awaiting services. However, I am aware that more needs to be done. The Government is committed under its programme,A Government of Renewal, to the continued development of the services as resources become available.

That commitment is reflected in my decision to prepare a five year development plan to meet the needs identified by the new mental handicap database which will provide my Department with a more accurate estimate of current and future needs. A preliminary report on the information on the database was published last week. The number of people with a moderate, severe and profound mental handicap identified has increased by 29 per cent over the 1974 census. This increase can be explained by better identification and by the increased longevity of this group. Most of this increase has taken place in the 35 to 54 age group and indicates decreased mortality among those with more severe levels of mental handicap. The high prevalence rates among young adults will mean increased pressures on adult day services and an increased need for residential services for this group. The five year plan will identify the needs of the different groups to a degree of sophistication not previously possible.

The plan will be based on regional plans which the health boards are currently compiling. A number of health boards have already submitted draft plans to my Department and the remaining boards are in the process of completing theirs. I expect the national plan to be ready later this year so that it can play an important role in the Estimates discussions. It is my intention to seek additional funding in 1997 and future years for the continued development of services to persons with a mental handicap based on the needs and priorities identified in the plan.

One of the major issues we face is the continuing problem related to drug abuse. In the original allocation for 1996 a sum of £1.655 million was provided for HIV AIDS and drugs services. This was to meet the full year costs of certain developments which commenced in 1995, as well as funding new developments in 1996. However, in recognition of the serious drug problem throughout the country and in response to a proposal which I put to it in February, the Government announced a package of demand reduction measures to prevent drug misuse. The total cost of this package in 1996 will be £3.5 million. The sum is in addition to that provided in the Estimates.

The problem of drug misuse arises at two levels. First, the misuse of so-called soft drugs, such as cannabis and ecstasy, which is widespread and, secondly, heroin misuse, which is confined mainly to certain areas of Dublin and is a major concern. To tackle these problems, the health response is based on two key considerations. The first is to reduce the number of people turning to drugs in the first instance through education and prevention programmes and the second is to provide a range of treatment options, including methadone maintenance, detoxification and other programmes for those addicted to drugs, especially people addicted to heroin.

The main components of the Government package include a major public media awareness campaign which will commence at the end of June. The committee will be aware that my Department has been working on the development of this campaign, which will include television, cinema, radio and poster messages. It has been tested on a number of focus groups and has been favourably received. A drugs information line will be provided in parallel with the first run of the campaign. A range of information will also be available to those seeking it. In addition to the national awareness campaign, each health board will play a more active role in local education and prevention initiatives. Deputies will be aware that the commencement of the television advertising campaign will coincide with the semi-finals of the European Cup and will continue through the final stages of that competition.

We also made a decision about the appointment of a programme manager in the Eastern Health Board, with specific responsibility for the development of prevention and treatment services, and the appropriate authority is in the final stages of the selection process. The expansion of the Eastern Health Board services, such as increasing access to methadone with the opening of two more treatment centres, will increase the number of patients on treatment from 1,400 to 2,500.

Other elements of the programme encourage more GP involvement in the treatment of addicts, the establishment of an intermediate treatment centre for young people, a seven day service to be offered in drug treatment centres and a special programme to be targeted at young people who smoke heroin. Deputies will be aware that smoking heroin is becoming an increasing problem as distinct from the injection of heroin which is the more traditional method. We have also decided that rehabilitation places will be increased from 60 to 250, outpatient detoxification facilities in community drug centres will be extended, parenting programmes will be provided for drug using parents in the north and south inner city and an information database will be established. We have also decided that a regional telephone helpline will be established, that each health board will establish local co-ordination committees and involve voluntary and community groups in the decision-making process and that a new unit will be established to ensure that the businesses involved with controlled drugs comply fully with the terms of the Misuse of Drugs Acts, 1977 and 1984, and the UN Convention on Narcotic Drugs and Psychotropic Substances.

My Department is actively engaged in a multifaceted approach to tackling the drug problem. The Government has provided the resources to build up prevention and treatment services. It is now up to everybody involved in the fight against drugs to work in a concerted, coordinated fashion to eliminate this scourge from our society.

The extension of the dental treatment services scheme to certain additional categories of adults with medical card entitlement came into effect on 1 June 1996. Routine dental services now available to the 16 to 34 age group and full denture treatment for persons with no natural teeth is being extended to all persons with medical card entitlement. Under the scheme services are provided by private practitioners at their practice premises and by health board dental surgeons at local clinics.

Emergency dental treatment for the relief of pain or urgent denture repairs is available to all persons who are 16 years of age or older with medical card entitlement who require urgent dental treatment for the relief of pain or urgent denture repairs. Routine dental treatment is now being provided to persons with medical card entitlement in the age groups 16 to 34 years of age, inclusive, and 65 years and over. This will be extended at a later stage to other age groups on a phased basis. The phasing depends on the availability of resources. That is why we are implementing this change on a phased basis. Priority full denture treatment will be provided to all persons with medical card entitlement who have no natural teeth. These dentures will be provided mainly at health board dental clinics.

The full year cost of implementing phase 2 of the scheme will be £3 million. This is in addition to the current provision of £6.8 million provided on a full year basis for Phase I of the scheme. The extension involves the introduction of an additional 300,000 medical card holders into the routine element of the scheme. Dentures will now be available for all medical card holders who are without any natural teeth. The scheme to date has provided treatment for over 130,000 medical card holders.

The Estimate includes approximately £10 million to cover the costs in 1996 of developments in the acute hospitals sector. This includes the roll forward costs of developments already initiated and new developments, including the continued development of the ambulance service and the breast screening programme which is at present established on a pilot basis. I have also allocated a further £7 million to continue the hospital waiting list initiative. In addition I am in a position to provide additional funding for accident and emergency services including £1 million for acute hospitals.

In respect of services for the elderly, Deputies will be aware that life expectancy in Western societies has increased substantially. While in Ireland the age profile is still younger than that of the European Union generally the number of elderly as a proportion of the population is growing. It has been estimated that between the years 1981 and 2006 there will have been an increase of 20 per cent in the number of persons over 75 years of age and an increase of 28 per cent in the number of persons over 80 years of age.

The objective of Government health policy in relation to the elderly as set out in the reportThe Years Ahead is to support the care of dependent elderly at home for as long as possible and ensure that when they can longer be cared for at home, there are appropriate specialist and extended care facilities to meet their needs. As part of the continuing development of these services £2.5 million has been allocated to further develop community nursing units, day centres and community services for the elderly.

Since taking office I have been conscious of the need to address specific issues in relation to cancer services. Cancer was identified in the health strategy as one of the three major causes of death in the under 65 age group in Ireland. The strategy set a target of reducing the death rate from cancer in the under 65 age group by 15 per cent in the ten year period from 1994. I am conscious of the considerable effects of cancer on health status in this country. For example, the disease accounts for about one third of all deaths in those under 65 years of age. There are about 18,000 new cases of cancer in Ireland each year. Last year alone there were over 49,000 hospital episodes due to cancer. The health strategy also pointed out that Ireland has a higher mortality from cancer than the average for European Union countries. Our death rate per 100,000 in the years 1988 to 1992 was 273, compared with a European Union average of 245 per 100,000.

With these factors in mind, I set about preparing a national cancer strategy last year. My Department has consulted widely on how best cancer services should be provided. The consultative process included discussions with a group of cancer specialists whose views were very useful. The strategy will deal with the full continuum of cancer services, ranging from health promotion, screening and early detection, to treatment services, rehabilitation and palliative care.

Its principal objectives will be to take all measures possible to reduce the rates of illness and death from cancer, in line with the targets established inShaping a Healthier Future, to ensure that those who develop cancer receive the most effective care and treatment and that their quality of life is enhanced to the greatest extent possible. I am now finalising the strategy and hope to publish it without delay.

As I already indicated, the Government is operating to strict limits in relation to public expenditure. Given the significant demands for health services and the limited resources available, it is important to ensure those resources are used to best effect in the provision of a quality healthcare system. The best use of available resources must be maximised. The health strategy recognises that and highlights the need for systems to evaluate economy, efficiency and, increasingly, effectiveness in the provision of quality health services.

One such area which receives particular attention in my Department relates to value for money. Spending must be carefully monitored to ensure that the health services, the patient and the taxpayer get the best possible value. This is extremely important and subject to close and critical scrutiny at a number of levels, including by my political colleagues and others interested in the health services. To underline the importance of value for money, the Government decided that in 1996 savings equivalent of 0.7 per cent of the 1995 outturn be identified in relation to health expenditure and that those savings be applied to service developments in 1996.

All the health agencies co-operated in this exercise and identified the required savings in their service plans. My Department will be monitoring the savings as the year progresses.

Furthermore, the health services are responding to the needs of a changing environment and developing systems which allow for greater co-operation between health boards and other health agencies with a view to ensuring the most economical use of resources. This is clearly the way to proceed and offers major benefits for all involved.

Healthcare evaluation is a central part of my Department's health strategy. Much is already being done in this regard and more will be done in future. My Department is at present examining further ways in which it can help ensure that the limited resources available are used to best effect to deliver a quality service for all concerned. That can only be achieved if healthcare evaluation remains at the centre of our strategy for the future and I am committed to ensuring that it does.

The Health (Amendment) Bill, 1996, has three main objectives: to improve financial accountability and expenditure control procedures in health boards, to clarify the respective roles of the members of health boards and their chief executive officers and to begin the process of removing the Department of Health from detailed involvement in operational matters.

The first of these objectives, to strengthen the financial accountability arrangements in health boards, is the most pertinent to today's discussion on the Health Estimates. The Government is determined that health boards will, in future, operate in an environment of service planning aligned to strict financial control and accountability.

The Bill aims to modernise the planning, management and accountability systems in the health boards. It will change the way health boards conduct their business. It will require them to work within a planning framework which is linked to clear objectives and specific resources. It brings accountability much more to the fore both in planning and reporting terms. It also reflects the Government's Strategic Management Initiative with its emphasis on making the public service more responsive, accountable and open.

In short, the Bill is at the very centre of the process to require health boards to carry out their tasks in a context which emphasises planning, strategic management and accountability. The Bill is due to come before this committee shortly and I look forward to discussing details of its provisions with Members.

I have outlined the main areas of this years Estimate. There are, of course, many initiatives which are being undertaken which I do not have time to go into. My principal objective is to provide a high quality service for those who will come into contact with the service. In framing the 1996 Estimate, the Government has provided the necessary resources to facilitate the achievement of this objective. I, therefore, commend the Estimate to the committee.

I respond to the Minister's invitation to be informal by saying that is also my wish and that of my party at this committee. In this way we can get a lot of work done in a relatively short time. It must be very frustrating to be Minister for Health. Although he holds the purse strings for such a vital part of the economy, in many ways he is curtailed in that he is dependent on agencies such as the health boards to spend the increases in funds he obtains.

I welcome the accountability legislation which is long overdue. It will place an onus on health boards to be accountable for their expenditure and will probably lift the lid on allegations about hospitals not being managed properly and funds not being spent in the most effective and efficient way possible. Successive Governments and Ministers for Health have provided increasing amounts of money for the provision of healthcare throughout the country, particularly in relation to the waiting list initiative. However, desirable results are not always achieved. It is important to clarify the respective roles of members of health boards and chief executive officers. When a problem arises in a health board area, members of the board state that it is the chief executive's fault and responsibility andvice versa. It is important that such clarification be given and this committee will co-operate in that regard in relation to the Bill.

Childcare is a very important and fundamental issue which has occupied most of our energies during the past five to six years. Ongoing and increasing problems are faced by the Department and everyone else with regard to this issue. We must question the adequacy of the provisions in the Estimate in respect of childcare. Everyone appreciates that the extra sections of the Child Care Act are being implemented — 61 of the 79 sections have been implemented and the remainder may come into force in the near future. There have been a catalogue of inquiries and reports, including those relating to the Kilkenny incest case, Kelly Fitzgerald, Madonna House, etc., which made virtually the same recommendations for change.

The Minister of State at the Department of Health seems to be sensitive about this issue but perhaps the Minister could inform the committee as to how many people are employed in the childcare section of the Department? Regrettably, childcare seems to be the growth area in the Department of Health and it is important that the section dealing with it should be adequately staffed to respond to the growing need for childcare services throughout the country. Could some of the additional provision for childcare in this year's Estimate be accounted for by services which were initiated in 1995? I am sure the Minister will be able to inform the committee about the division between services initiated in 1995 and new services coming into place this year.

I recently tabled a parliamentary question about the Goldenbridge controversy. When such an event occurs, it is very important that counselling which is seen to be independent is made available. I am not sure that the people who made allegations of abuse in relation to Goldenbridge and other childcare institutions have great confidence in a service that is administered and paid for by those whom they perceive as having caused their injuries. I suggested to the Minister of State at the Department of Health, Deputy Currie, who gave a commitment to consider the matter with officials from this Department, that a better way to deal with this would be to provide an independent service which could be funded through cash contributions from the various religious orders and lay organisations involved in the provision of these services throughout the country. Those who were injured could then have confidence in a system which was seen to be independent.

I welcome the Minister's statement on drugs and the proposals he outlined in this regard. The problem of drugs is a scourge which affects health, justice and other areas of Government policy. It is important, through outlining the Minister's proposals for action and putting in place various provisions, that this problem is at last being taken seriously. Alcohol is a widely available and legal drug which provides young people with their first taste of the drug culture. When used with great care alcohol is a wonderful thing and can be enjoyable. Unfortunately, however, a large percentage of the annual Health Estimate is spent on people with alcohol dependencies. I recently spoke to the Minister's official, Dr. Barrington, in relation to making young people aware of the dangers of alcohol, perhaps through the drug awareness campaign or a separate campaign.

The Department of Health initiated a very successful campaign in relation to smoking. It has taken heavy smokers such as Deputies O'Malley, O'Donoghue and others some time to get the message from that very effective campaign. If information about the dangers of alcohol could be incorporated into the drug awareness campaign, it would be very useful. However, I welcome the Minister's proposals. Members on this side of the House may make suggestions as to how the campaign might be expanded when we see it in operation.

Opposition Members have also followed the development of the cancer strategy with great interest. It is my party's view that screening for breast cancer must be extended as quickly as possible to all areas of the country. Each year many women die unnecessarily from breast cancer. We must prevent as many of those deaths as possible and this can be achieved and if a screening programme is available. I accept that this would not be effective for all age groups, but it would be very effective for a specific, targeted age group. I urge the Minister to produce the cancer strategy as quickly as possible. Many cancer patients in Munster and in areas along the western seaboard must travel to Dublin on a regular basis because the entire range of treatment services is not available in their region. The oncologists made a very worth-while submission to the Minister which suggested that there should be two centres outside the capital to deal with the west and Munster, respectively. This would ease the hardship and great burden on people who must travel to Dublin for treatment. I urge the Minister to produce a comprehensive cancer strategy.

The initiative relating to hospital waiting lists was very worth while and should be continued. However, I wonder if adequate provision has been made in this regard. From a reply to a recent parliamentary question, I discovered that the figures available to the end of 1995 showed that the total was 4,000 higher than in December 1994. While the money is being provided, we are not achieving as sharp a reduction as in earlier years. The figure has actually increased. Why has this problem arisen and why are the figures not being reduced? Waiting lists are the bane of everyone's life and infuriate patients who must be continuously placed on them. Is there some way that the funding could be increased to achieve a reduction? Could someone discover why £8 million was provided last year and the numbers on waiting lists increased? The provision has been reduced this year to £7 million.

When we reach the months October to February accident and emergency services will face the same problems they have every year at that time. The pilot GP clinic in St. James's Hospital worked effectively and efficiently and bore results. Are there proposals to extend that initiative elsewhere in Dublin and the country?

During Question Time recently, the Minister mentioned that University College Hospital, Galway, has seemingly insurmountable problems. It must be possible to put a strategy in place now to deal with the huge bulge in A and E over the winter months.

We have spoken in the past of making step down facilities available for patients who do not need acute hospital care but require strong nursing care over a period. Those patients are taking up acute hospital beds which should be available for others — if they were, it would allow people to be brought in immediately and thereby reduce the waiting lists. It would be useful to put the strategy in place now to take care of the problem. Equally, the lack of coordination in the Eastern Health Board ambulance service is a cause of great concern. It should not be necessary for two ambulance services to go to the same emergency. Is there a way to coordinate them so that does not happen and our services are effective and efficient?

The provision for hepatitis C sufferers is £2 million. I know that is an estimate but will that amount be sufficient? We have been told that the figure for each hepatitis C victim in any one year is about £5,000 and in view of the number of victims the provision may not be enough. Will the Minister give a commitment to provide whatever is necessary in a Supplementary Estimate to cover the generous health care package agreed for hepatitis C victims? He shares my concern that, whatever service is made available, it is uniform in every health board. We do not want hepatitis C victims dealt with differently in different health boards. They all have the same disease and need the same range of services, so there should not be a difference between health boards.

I put down a number of parliamentary questions to the Minister about the Blood Transfusion Service Board facing legal actions from abroad and on a number of other points. He did not have the information and passed the questions on to the board but, so far, I have not received a response. I ask him to again raise those matters with the board because it is important that those questions are answered.

Care for the elderly will become a bigger issue for all of us interested in the health area. More people are living longer and the traditional extended family is gone, more of our elderly go into nursing homes or homes for the aged in health board areas. We must deal with it in a number of ways, first from the carers' viewpoint. The Carers' Association has made representations to Members that its funding has decreased since it was moved from the Department of Social Welfare to the Department of Health and it is concerned and angry about this. Perhaps the Minister could indicate what he intends to do. The step down facilities are also important — they treat another health area but they also provide a service for the elderly which is much needed.

Alzheimer's disease is on the increase. It is sometimes referred to as a disease of the elderly but it can strike people in their mid-40s. I have a personal interest in this area and am concerned that normal health board nursing homes or homes for the aged do not cater for the intensive nursing care which an Alzheimer's patient needs. I have spoken to the Minister about health boards having specific units available, even if only small ones, which can provide the intensive, 24 hour care which is necessary. Families of Alzheimer's victims have a difficult time because the disease is, as the medical profession says, a "living death". It is important that support services and care be available to them so that, if a family eventually has to put an Alzheimer's patient into care, he or she will receive 24 hour nursing.

The Minister spoke about the amount of money available for acute hospitals. He said the provision would cover the costs for 1996 of developments in the acute hospital sector but that cost includes services initiated last year so what other new services does he intend to cover in 1996 and beyond? I have a personal and parochial interest in this because University College Hospital, Galway, continues to cause headaches for all of us, as the Minister acknowledged. Will hospitals like that be included in new developments and services this year? How much of the Estimate will be concerned with further new developments which have not yet been announced?

To return to the cancer strategy, there seems to be a drive in every community, certainly in every county, to have a hospice development. The development of palliative care and hospices must be examined by the Department of Health and standards must be clearly set. There has not been an audit of what a hospice is supposed to do or how it is supposed to integrate with the local medical and nursing services. I would hate to see beautiful buildings in every county without the financial support to back up the service. For those to be developed coherently throughout the country the Department must set down minimum standards and do an audit of what is required, what care should be given and how it should gel, so that this does not develop as an independent, outside wing of the health service but meshes with the Minister's cancer strategy. Perhaps he could indicate whether, as part of that strategy, there will be provision for hospice care.

We on this side of the House would never be happy with the amount of money provided in a Health Estimate, because it is a vital part of our business and of people's lives. It affects everyone in his or her lifetime, whether in a large or small way. It is only when it knocks on one's own door that one becomes annoyed about the lack of or insufficient provision for services in a health board area. Having said that, we will support the Estimate and will have individual questions on the various subheads.

I will make a few general comments about the administration of the health services and I will deal with specific points later. There is a great disparity in the size of the different health boards. The Midland Health Board serves a population of 203,000 while the Eastern Health Board serves a population over six times larger — 1.25 million people. Two boards — the Eastern Health Board and the Southern Health Board — serve over half the population while it takes half a dozen to cater for the other 49 per cent.

There is also a wide disparity in service costs among the health boards. Based on the 1994 figures, health board spending per head of population in the north-west at £607 is at more than twice the level in the eastern region at £300. This is a phenomenal gap; given that health requirements are broadly similar across the different board areas, spending per head should be reasonably similar.

The regional variations are great: administration costs work out at £57 per head of population in the north-west region compared with £22 in the eastern region. Nursing costs vary from a high of £162 per head of population in the western region to £54 per head in the eastern region. Each health board has a spending category for transport costs which varys from £20 per head of population in the north-west region to £6.65 per head in the southern region. Yet the differences between hospitals in the southern region are among the largest in the country.

Such cost differentials cannot be explained by size differentials or economies of scale. One might expect the Eastern Health Board to enjoy the greatest advantage in this respect, but how do we explain the relative efficiency of the North Eastern Health Board? It is one of the smallest in the country with a population of 300,000 spread across five counties. Its area extends from the Dublin suburbs to the Fermanagh border, yet it is the second most efficient of all the boards and its costs per head of population are almost as low as those of the lowest cost operator — the Eastern Health Board.

There is a need for detailed analysis of health care costs under several headings in the board areas. The Department of Health is charged with the responsibility for monitoring and evaluating public spending in this area and it should be able to produce an annual report which gives details of the variations in health care costs around the country.

Everybody accepts it is expensive to deliver health care in sparsely populated rural areas, particularly along the western seaboard. However, we should seek some explanation as to why costs per head are almost £120 per head per annum higher in the south-east than in the north-east, where population densities are broadly similar.

The process of financial reporting in the health boards must be dramatically improved. As the Minister mentioned, new legislation is going through the Oireachtas which will compel the boards to publish annual reports within six months of the year end. However, much more than just publication is required. We must also look at the future management needs of the health boards and cast the net as widely as possible in recruiting senior managers for the health service. In particular, we should seek to attract people with senior management experience in large scale service organisations in the private sector.

We need a comparative analysis at national level, also published within six months of the end of the year. If the national analysis is not published in a timely fashion it becomes useless. The committee should have such a document before it today so that it could make an informed assessment of the efficiency and effectiveness with which the health service is being run.

Are we getting value for money from the health service? Annual spending on health has risen by £760 million over the last five years. The 1996 Estimates represent a 46 per cent increase on the outturn for 1991. That figure is higher if one takes into account what the Minister said about the transfer of certain expenditures to the Department of Social Welfare and the non-recurring nature of some of last year's Estimate. Therefore, health spending is almost 50 per cent higher than five years ago. Is the health service 50 per cent better? Clearly it is not.

The mark of the level of civilisation in any society is the degree and nature of health services it provides for the elderly, ill or handicapped. We spend one fifth of our total supply services on health, which is an extremely high proportion. Only about one third of the population is fully covered for health services and the other two thirds have to provide the services in whole or in part at their own expense. We are spending an extraordinarily high proportion of our annual resources on health.

I do not believe we get value for money for that spending and a determined effort will have to be made to break the vicious cycle in which we find ourselves, whereby when a service or an agency is established its cost seems to rise inexorably without any great increase or improvement in its level of service.

The Minister made only a passing reference to the Blood Transfusion Service Board and the costs arising from its misdemeanours. It is one of the most extraordinary events in the history of Irish public administration for which there has been little or no accountability. The official attitude is that it is unfortunate it happened; there is a collective shrug of the shoulders, we grin and bear it and the taxpayer pays for it. It seems totally unsatisfactory because several thousand people are seriously ill, needlessly. The illness was inflicted on them by the negligence of a public body for which there has been no accountability. Furthermore, the cost of trying to treat those who, through no fault of their own, now have serious illnesses falls on the taxpayer without apology or regret. As I pointed out in the Dáil, there have been incidents of similar official neglect or worse, and this is worse than neglect. It happened in France in relation to contaminated blood, where a number of people, including senior people, ended up in jail. By contrast, in this country they did not end up in jail and were not even reprimanded. What they got, apparently with the blessing of the Department of Health and of Ministers for Health over a couple of years now, was a golden handshake. That is the reward for the sort of conduct that resulted in a jail sentence elsewhere. I wonder if that is the right approach to take either to the administration of the health services or to any aspect of Irish public administration.

We now move to the general question and answer session on Vote 41. We will take the subheads A1 to A7, Administration.

Does the committee want me to reply at this stage to the specific questions posed by Deputy Geoghegan-Quinn?

We will try to be as informal as possible so if the Minister wishes to respond to questions already raised I take it that the meeting has no objection.

I thank Deputies Geoghegan-Quinn and O'Malley for their contributions. The child care unit in the Department consists of a principal officer, three assistant principal officers, one social work adviser, two administrative officers, two HEOs, two EOs and two clerical staff. I agree with Deputy Geoghegan-Quinn that that is not sufficient for the prospective workload. I hope we can get resources for extra personnel, otherwise we will not be able to carry out the work programme we planned.

It is hard to plan the work programme because each new dramatic incident in the child care area opens up new fronts. For example, Goldenbridge and analogous problems which may arise and come into the public domain in future, left us with a new area of work that is opening up. This includes, for example, the social services inspectorate and the issue of mandatory reporting. The same section deals with adoption so issues like foreign adoptions, particularly Chinese adoptions, puts extra pressure on that section of the Department. I thank the officials in that section who are certainly overworked, yet continue to produce high quality work in difficult circumstances.

Deputies will be interested to hear that the Adoption Bill was cleared by the Government on Wednesday. It includes the rights of the father which run from the Keegan case and it also makes provision for foreign adoptions. It will go to the printers today so Deputies should have the Bill next week and we will try to take Second Stage before the recess.

As regards the child care funding question, the roll forward costs developed since 1995 are £6 million, while the new developments are £2.5 million on the revenue side and £3.5 million on the capital side, which is another £6 million. We will have to include an additional £2.5 million in the 1997 figures for the roll on costs of what we will do in 1996.

The Sisters of Mercy contacted the Dublin Rape Crisis Centre to provide counselling for persons who may have been damaged by their experiences as children in Goldenbridge and Rathdrum. These were independent arrangements. Health boards are also preparing a response to victims of abuse, because, while Goldenbridge was historically a child care issue, it is now an issue concerning adults who may have been disturbed by their experiences as children. So, health boards at chief executive officer level are preparing a response to victims of abuse in situations like Goldenbridge.

Other institutions may be accused of wrongdoing in future. There may even be revelations to suggest that persons who went through different types of boarding school also had problems. We are well on the way towards putting in place an initiative to deal with the difficulties of persons, who are now in their adult life, arising from their experiences as children.

I appreciate Deputy GeogheganQuinn's comments on the drugs package which is already proving effective even though it is only in the early stages. I hope significant progress can be made there. I also agree with the Deputy about alcohol misuse. We are in the final stages of formulating an integrated alcohol policy. We will approach it in a sensible way rather than in a wide-eyed fashion and we hope our targets will be achievable. It will emphasise the connection between moderation and good health and include more of a response across different Departments, including the Department of Health. We were dealing with that this morning and we are proceeding fairly quickly with it.

Before the end of this Dáil session I hope to make a comprehensive policy statement on cancer strategy. It will deal with breast and cervical screening as well as ensuring that the principles of equity and accessibility, to which the Deputy referred, will be clearly reflected in the policy. The needs of the western area will not be overlooked, and it will also include a section on palliative care.

I agree with Deputy Geoghegan-Quinn that the conventional wisdom about the hospice movement is out of line with best practice at the moment in many parts of the country. Well motivated organisations collect huge amounts of money to build large hospices with a bed complement in excess of requirements. While palliative care was delivered in residential accommodation until recently, it now tends to be delivered in the community by nurses. The residential beds we need should more appropriately be attached to acute hospitals where a full range of services including palliative care, would be available.

Where there have been major investments in hospices by well motivated people backed up by the community, we are in discussion to see if we can use part of that accommodation for palliative care and for the terminally ill even in circumstances where their illness is not cancer related.

We would like to find other uses for some of what I consider surplus beds in some of the new developments. For example, in Galway — where a fine hospice has been constructed which I hope to visit before the end of the month — officials of my Department and the Western Health Board have been discussing how we can use the accommodation not only for palliative care but for other needs that may arise, or which already exist, in the Western health Board area.

As Deputy Geoghegan-Quinn knows, we had a three hour debate in the Dáil over the last two nights on the hepatitis C issue. There is sufficient money in the Estimate but, if not, it is a demand led scheme so the money will be provided. If we miss out by a couple of hundred thousand pounds in the Estimates the surplus will be provided. Deputies may be interested to know that up to today 890 applications have been made to the tribunal. A solicitor also informed the tribunal that an additional 300 applications will be lodged before the closing date and the tribunal has advised me that it expects 1,300 to 1,400 applications before then.

Deputy O'Malley also referred to this issue. The reason there is not extensive reference to hepatitis C and the BTSB is that there was a three hour debate about it over the past two nights in the Dáil and I did not want to go over the same ground. The situation in France was not similar to the situation in Ireland. The report of the expert group under Dr. Miriam Hederman O'Brien found that it arose in the first instance from an infected donor in 1976 and, in the second instance, a later donor in the 1980s and that the anti-D product was not withdrawn from use in 1991 when the Blood Transfusion Services Board was informed that archival samples sent to Middlesex in 1976 proved to have hepatitis C when tests became available at the start of the 1990s.

To ensure confidence in the blood transfusion service, we appointed a new chief medical officer and a new chief executive. In appointing the management team, vacancies had to be created. This was done by the resignation of the incumbents and on resignation they had certain pension rights. This is clearly understood and to describe them as a reward or golden handshake is pejorative in circumstances where the difficulties were clearly known.

The Deputy voiced the often heard opinion that people should have gone to jail. That is a strong statement. One must read the expert report and ask what the charge would have been. A charge of criminal negligence has been suggested but I do not know from what statute that charge derives. I understood it to be a common law offence and it would be difficult to prove such an offence where the accusations are sins of omission rather than sins of commission. The DPP makes these decisions and I have been informed that Positive Action sent the expert report to the DPP for his consideration. It is up to him to decide if there is a basis for a prosecution.

I took the situation as I found it and ensured that confidence would be maintained in the blood transfusion service by appointing a new chief executive and chief medical officer. I sympathise with the anger being expressed but I have yet to hear a more reasonable course of action suggested. That is not to take from the many valid criticisms by Deputy Geoghegan-Quinn and others of the arrangements we have made to try to deal with the result of the hepatitis C problem.

There is also the issue of the numbers involved. The number we gave last night was 1,356 although there was an estimate of 1,600. The discrepancy is not caused by people who were included previously being cut out. We knew from the screening how many women contracted hepatitis C from the anti-D product. We also knew how many haemophiliacs and Irish Kidney Association members had contracted it. However, the number of people who had contracted hepatitis C as a result of a blood transfusion was an estimate and we discovered that we overestimated that number. The "look back" programme and the national screening programme are not yielding the numbers we expected. The figure given is not a hard one and as the screening programme develops others will be added. Serious questions have been asked about this and there was an implication that we had included named people in the first instance who we were now eliminating on the grounds of reducing costs. That is not the case. The figure for the fourth group of people is variable and we have a better idea now of what it will be.

Deputy Geoghegan-Quinn asked about acute hospitals, care of the elderly and accident and emergency facilities. We took many initiatives in Dublin last year. They applied to the six large acute hospitals, not just in St. James's Hospital. They included consultant led services in accident and emergency, better bed management, step down facilities being provided throughout Dublin and greater use of more experienced doctors, as in the St. James's Hospital experience. That was replicated to some degree in various parts of the country. As a result of those initiatives we did not have the type of crisis last winter that had become the norm over winters in recent years. We started planning it in August but we failed to take Galway into account. However, we are taking it into account this year and we commenced two months ago putting a Galway package in place specifically dedicated to accident and emergency. We are trying to get movement through discussion with the health board and the hospital authorities and we hope significant progress will be made. There is a problem in Galway and we must analyse what is causing it.

The waiting list initiative was mentioned as it increased this year. Sometimes the very availability of the service increases the demand. One is not dealing with a given waiting list which one can tick off and reduce. Sometimes it is only when certain facilities are available that people think it worth their while seeking them. We will try to get extra resources in that regard. There was an increase in emergency admissions during the winter of 1995-96 and the average length of stay for these emergencies also increased. A total of 12,000 additional patients were seen at out patient clinics and many of these went on the waiting list. Progress is being made. The people on the waiting list are constantly changing because as people are treated they are removed while those awaiting treatment are added to it. There is great movement forward but I am disappointed that there was an increase of 6,000 and I hope we can reverse that.

With regard to the ambulance services, proposals are now in place to provide a single response to each incident. There is particular co-ordination in the Eastern Health Board area. These proposals are being discussed with the trade unions at present because there is a problem in that regard. If the proposals are accepted the new arrangements will be place by the end of the year.

On a point of information, not all hepatitis C patients cost £5,000 each year. A liver biopsy would not be performed each year and some patients are not on medication. There are big variations in individual cases and the advice is that the £2 million should be sufficient. If there is an excess in demand it will be met.

The 1996 acute hospital developments are in diabetes clinics, spinal injury services, ENT services for children, plastic surgery, neo-natalogy services, cardiology, vascular surgery, genetics, new bone transplant unit, cystic fibrosis, enhancement of anaesthetic services, enhanced intensive care services and oncology. In Galway, about which the Deputy asked, there will be enhanced plastic surgery services and general support services in addition to safe chemotherapy services. That was where the development money was spent.

In recognition of the growing challenge of Alzheimer's disease an annual grant of £80,000 has been made towards the running costs of the Alzheimer's Association. This is the first time the association has been grant-aided in this way. Funding has also been made available for day services in various parts of the country, one of which is in Adare in the Limerick West constituency. An additional psychiatrist specialising in the care of the elderly has recently taken up duty in south east Dublin. Associated staff and facilities have also been made available and other appointments are planned in Cork and Galway. Health boards are in the process of adapting accommodation to meet the needs of those with Alzheimer's disease. Examples of work currently under way are the Sacred Heart Home in Castlebar and the home for the elderly in Roscommon. As part of our European Presidency, I am organising a major conference on Alzheimer's disease in Limerick in November.

I wonder why it is in Limerick.

It is convenient for me to have it there. My constituents appreciate these initiatives. It is jointly organised by myself and Commissioner Flynn and 75 per cent of the funding will come by vote of the European Parliament. I will be pleased to invite the Deputies interested, in particular the spokespersons for the different parties.

I am interested in Deputy O'Malley's comparative figures and there is merit in what he says. In my health board days, there was always an argument that some health boards were under-funded and others over-funded. It was rather like the argument in county councils, that the base should be put right by increasing on a once-off basis. We had that argument in the Mid-Western Health Board for a long time.

There are disparities, but they are not all of the order mentioned by Deputy O'Malley. The spending levels mainly reflect the state of development of services. The gap between the North-Eastern Health Board and others is now narrowing. Comparisons with the Eastern Health Board area need to be carefully analysed. For those of us who came through health boards, the North-Eastern Health Board probably got the worst funding of all. It is only in the last three or four years that it got decent money. The services were poor for the general population in the north-east. There is also a distortion in the east because the major voluntary hospitals, St. Vincent's, the Mater, Beaumont and St. James's hospitals are not health board hospitals. That has an effect on the north-east spend, because many people from Louth and Meath come to Dublin for their hospital services. I take the general point about comparative figures and analyses on a yearly basis.

I am interested in getting the Accountability Bill in place and making new arrangements for the Eastern Health Board. Over 66,000 people are employed in the health services and between 300 and 400 in the Department of Health. Often in the Department of Health, instead of assessing the value of the spend and in developing policy, much of the time of senior officials is involved in crisis management of bushfires that break out in health board areas. The second area which occupies a lot of time is that the relationship between the voluntary sector is vertical to the Department of Health, not horizontal to the health board. For example, the Department of Health, in dealing with the Sisters or Brothers of Charity providing services for the mentally handicapped, is constantly involved in negotiating budgets. The Department of Health decides the budget of the Mater Hospital in a bilateral discussion. The health boards are not within the loop. I want to devolve that function to the health boards so that the voluntary sector has a new relationship with the health boards and the Department of Health. It should be principally involved with the development of policy, value for money and ensuring accountability. Without going into the specific comparative figures, I agree with Deputy O'Malley. I am glad he made the point so forcefully.

We are trying to refocus the work of the Department of Health and the Accountability Bill will be a start. The other initiatives of establishing real funding relationships between the voluntary sector and the health boards will be a major benefit. The nature and focus of the Department's report is also being reviewed. The kind of report envisaged by Deputy O'Malley is in line with my thinking. I compliment my officials in so far as the Department of Health is like the Department of Justice in ways — a lot of the time the programme for the week or month cannot be pre-planned. One can be driven off course, as the two former Ministers for Justice here will appreciate, by the latest crisis. All the best resources of the Department are frequently dedicated to solving a particular problem. One of the difficulties is that when it is solved, we are back at the point where we started. If we could get the health boards to take more responsibility for what I think they should be doing, the core group within the Department would be free for the two primary functions which they should be involved in — policy development and ensuring output of that policy; and value for money and accountability.

Many of the points Members intended to raise under the various subheads have possibly been referred to. We will go through the subheads because there may be some questions that have not yet arisen that Members may want to address. Subheads A1 to A8 covers administration.

Under subhead A2, the provision for 1995 is £ 518,000 and £494,000 for 1996. From where did the figure of £518,000 come? The components are £40,000 for home travel, £60,000 for EU travel and £218,000 for other foreign travel.

I think the mistake is with the figure for £40,000. It should be £240,000.

Under subheads A7, how many consultancy services are ongoing in the Department of Health? Under subhead A8, which the Minister may have addressed already, does he intend to have any conferences, other than the Limerick Alzheimer's, in the course of the EU Presidency. Is there an informal council?

No. There is a colloquium to which Ministers are invited. It is on the subject of self-sufficiency and safety of blood products in Europe. There is an international interest in it and we hope to have it in September. It will be a three day colloquium where the lead-in will involve officials, medical and blood transfusion people. The final day will be a Minister's meeting where we hope to prepare agreed policy positions to submit to the Irish Health Council in November.

In relation to consultancies, health insurance was £165,000, pregnancy research was £100,000, the health service study centre was £100,000 and medical indemnity was £70,000. Does the Deputy need the names of the consultancy firms?

Will less money be spent on staff training in 1996 than in 1995?

Mr. Smyth

Exceptional costs arose in 1995 which may not recur in 1996. The SMI was one of them.

We will move on to subheads B1 to B8.

Under subhead B3, one of the issues which the Minister and I debated in the Dáil on a number of occasions is the fund for the development of general practice. I gave an example where I thought development of a general practice had reduced quite considerably the number of patients who had to be admitted by a GP to the acute general hospital in Galway. Why has there been a reduction in the fund? Does it mean the Department has given up on the development of general practice?

I know there is a note at the end saying that subheads A1, A2 and B1 can be added to that but A1 deals with salaries and wages and allowances, A2 deals with travelling expenses and B1 relates to superannuation, social welfare, pay and so on. One is talking about the fund for the development of the practice here and there is a reduction of almost £2 million. Why? The better approach is to encourage general practitioners to do various procedures in their GP practice. This would ensure that patients would not have to take up a bed for a day or a couple of nights in an acute hospital.

Mr. Alyward is the official who deals with that section. We have sent for him so we will give the Deputy a detailed answer in a minute. I will take groups of questions together.

I want to inquire about two points which arise under these subheads. The first relates to dental treatment which the Minister dealt with in his speech. We are talking about public dental services which traditionally have been not just abysmal but, by and large, non-existent. There has been an effort in recent years to introduce some form of public dental service which is to be welcomed. It is late in the day but better late than never.

One of the matters referred to several times by the Minister was denture treatment. In each case to which he refers, treatment is available only to people who do not have any teeth. It seems to be a rather primitive way of dealing with people. I know more than most about the receiving end of dentistry after an approximately 40 year career at that end. Any tooth is valuable and to make it a prerequisite that all a person's teeth are removed before he or she gets treatment seems monstrous. It is repeated two or three times in the speech.

The Minister should rethink this matter. We should have a less primitive system. There was a time when the only public dental treatment available was a procedure known as extraction. Whether it was required or not one got extraction because there was nothing else. I hoped we had moved on from that. It is not good enough to say that somebody will only get treatment by way of prosthesis if he or she does not have any teeth. It is primitive and unacceptable.

The other point on which I would like to hear the Minister's comments arises from one of the points he made relating to drugs. He referred to his proposal to expand the Eastern Health Board services this year and gave examples, including increasing access to methadone. This will be achieved through the opening of two more treatment centres which will increase the number of patients in treatment from 1400 to 2,500.

I have had a one-sided correspondence with the Minister on the question of methadone in that I did not get any answers. There are some public methadone treatment centres in the eastern region. Unfortunately, I do not think there are any in any other region. There are limited centres — I think two — in Dublin. That is obviously inadequate and the awful level of dependency on drugs means that people are resorting to private practitioners for methadone prescriptions.

It was brought to my attention some months ago that in a north eastern part of Dublin city a private practitioner does not have a practice it appears, other than writing prescriptions for methadone addicts at £15 or £20 a prescription, which he is paid in cash. He prescribes for up to 100 people a day. This has caused appalling difficulties for people who are unfortunate enough to live in the residential area where he has his house and which he uses as a kind of clinic.

I have endeavoured to correspond on that matter with the medical council, but writing to the medical council is a forlorn task that one has to abandon. It is not accountable to anybody, it writes long pages of legalism which do not advance the matter and then refers you to the Department of Health in any event. The Department of Health, unfortunately, has not answered any of my queries in relation to this matter. It is totally unsatisfactory that drug addicts should be able to resort to a private doctor in these circumstances.

There should be some control in these situations. Nobody has any objection to a doctor prescribing for his own patients and people in his own locality. However, it becomes anti-social when the addicts are coming from 50, 70 and 80 miles away because it is known he will give them prescriptions. The question of the fitness to practise also arises. The medical council apparently is not prepared to deal with it. It says it is a matter for the Department of Health, but I cannot get any information there.

I have asked the Minister for a copy of the regulations relating to prescribing methadone which the medical council will not give me. It says it is a matter for the Department of Health. I have also asked whether a doctor should prescribe for up to 100 people a day, some of them coming 60 or 80 miles to him, others who are frequently very ill or commit serious anti-social activities in the immediate vicinity of the doctor's house. It is unbearable for the people who have to live in that area and some effort should be made to come to grips with it.

I would very much welcome the provision of methadone treatment centres where these prescriptions could be given, and perhaps the drug itself prescribed. It should not be confined to Dublin; it should also be available elsewhere. The need is less elsewhere but there is a need nonetheless, in the other cities particularly.

Deputy O'Malley's comment about the public dental services is correct. The area was neglected and it comes back to another point made by the Deputy. I think he said that since 1991 the Health Estimate has increased by 46 per cent and he wondered whether the health service has improvedpro rata. Quite clearly it has not improved pro rata because there were built in costs as well, but it has improved significantly. There have been huge investments in the areas of mental health, the waiting list initiative and dental health. There has been a huge additional investment in areas which had previously been neglected and the dental services for public patients was one of them. Most of the progress has been made by establishing multi-annual programmes because one cannot get the resources to do it in one year and often cannot get the agreement of the professional body to implement the strategies on a short-term basis.

The way the dental plan was approached, apart from significantly improving orthodontic services, was that persons over the age of 65 years of age were the first cohort of people guaranteed free service, then persons up to 14 years of age and then 16 years of age. This year it is from age 16 to 34 years of age. With the resources available, we identified an area of need which we decided to target. I will look at this again to see if there is anything further we can do in that area. We intend to progress it further next year. We have covered a significant portion of the population and we will continue on the basis of availability of resources to cover everybody on the public health side for free dental care. I take the point the Deputy made.

As regards methadone, I read Deputy O'Malley's letter which I believe referred to Clontarf.

That is right. I am aware of the case and there is power to act under the Misuse of Drugs Act. However, sufficient evidence has not been made available to move in that direction. We are reducing the need for persons to go to a particular practitioner who might be abusing the dispensing of methadone.

As regards the strategies, of the 1,400 people on methadone, about 700 are getting it from the clinics to which the Deputy referred, while the other 700 are getting it from general practitioners. We have negotiated a methadone Protocol with the medical people and I will get a copy of it for the Deputy if he requests that information. We are trying to involve a lot of general practitioners who would cater for very small numbers of addicts rather than having few general practitioners catering for huge numbers with which they cannot cope.

Before the Protocol was negotiated, doctors were prescribing methadone to their own patients and to additional ones. However, there was no suggestion of abuse in those cases. They simply believed in methadone as a form of treatment. Since the Protocol has been put in place, many extra people have come on board and we are making progress with the clinics. There is a new initiative where we are using health board property and inviting GPs on to the property to prescribe methadone. The centre in Kilbarrack, which has been open for the past four to six weeks, is very successful. A centre was opened in Ballymun with the co-operation of the local community in the past five or six weeks and a mobile clinic has also been organised. When the programme manager is in place in the Eastern Health Board, all these initiatives will be driven forward.

There are about 700 people on the waiting list, but we do not believe this represents the full demand which is the reason we are pitching for 2,500 persons to have methadone treatment by the end of the year. We are very much aware of the situation in Howth. I will write back to the Deputy as quickly as possible with the information he requested about the methadone prescribing Protocolumn

The Secretary of the Department will answer the question on general practice.

I am advised we must go into private session if an official speaks.

The Deputy will be aware that we are putting back into general practice savings on the drug savings programmes. There was a reduction in the amount of savings between 1994 and 1995 of £2 million, so there is less money to plough back. That stands to reason since the programmes remain in place over a couple of years while we bring prescribing down to the level we want. There would not be the same scope in the system to generate the savings but we did put an extra £1 million in on capital, which is under a different subhead.

As regards the methadone issue raised by Deputy O'Malley, one of the points made about those clinics in Dublin was that the taking of the methadone was not supervised. The Minister will recall that Deputy O'Donnell and I raised this issue a number of months ago in the Dáil. Certain addicts were getting methadone which they were selling. Has there been a reduction in that? Is there any proposal in the Department where the person receiving methadone must take it under supervision?

When we talk about the misuse of drugs, we are talking about people being involved in a criminal activity. To be in possession of or trading in heroin is a serious criminal offence. There is a culture of secrecy in this area and it is hard to know exactly what is happening from time to time. Methadone is a substitute drug for heroin. It is not ideal to be on methadone but it is a lot better than being on heroin. The ideal would be a drug free lifestyle but, unfortunately, that ideal is achieved by only a small proportion of former addicts.

There are two tendencies as regards international advice. One is to be very rigorous, to control everything and to stand over the addict while they consume their methadone, while the other is more liberal in that, for example, methadone should be given out without urine testing. One of the conditions here is that if somebody is on heroin, they do not get methadone. We test to see if they have taken heroin in the previous 48 hours and they will be refused if they have. Many European countries have moved away from that because they say there are always gaps in supply, people may go on heroin and all one achieves by depriving them of methadone is to ensure they go on the rampage to get the wherewithal for more heroin. It is very hard to strike a balance.

The priority must be to get members of the medical profession sufficiently involved, each dealing with small numbers -initially their own patients with perhaps a few extra. If co-operation with the chemists continues, we will be fairly well positioned. Those supplying heroin are in business and they do not like to see their market evaporating, which would happen if significant numbers of addicts went on methadone. We must also consider the security issue. Medical people need the protection of the gardaí in certain circumstances and we are trying to ensure it is available.

Methadone is taken under supervision in the clinics. There has been some leakage, especially at weekends because until now there has not been a seven day service but a five day one. It is part of the takeaway industry in that a person gets a supply of methadone on a Friday to tide them over the weekend. People share or sell it; that is one of the abuses. Part of the plan adopted by the Eastern Health Board, with our encouragement, is a seven day dispensing regime which will do away with the take away element which was where the abuse occurred. A colour code is also being considered to see what is being legitimately dispensed. There is also a black market in methadone. We are not sure of its source but it must be coming through some element of the pharmaceutical industry.

While I understand Deputy O'Malley's reaction to the tale about Howth, there is another way of looking at it. That doctor risked his practice. However, that kind of response to albeit an enormous need puts use of the GP service into question. Maybe the answer is, as the Minister outlined, to have a more controlled and general use of the GP service.

What percentage of known addicts are on methadone and what plans are there to increase that cohort in the next year? Are there active targets or are people moving as the opportunity comes? I perceive a significant shift in opinion in Dublin which will make it easier to provide those services. Although the affected communities want to target drug addicts, they have sympathy for those affected who may be children or neighbours. There is a deeper understanding of the problem and therefore, a greater willingness to move slowly towards accepting services they would rather not have, such as methadone clinics, because the alternatives are worse and they see the need for it among people they know. They cannot just treat them as criminals when they see them in a more personal way. There may be a more fundamental change in understanding in the communities most affected by the problem which will make these services easier to provide in the years ahead. We have seen it recently in Ballymun and it seems to be emerging in the same way in Finglas.

I welcome the identification by the Minister of child care and services for the mentally handicapped for additional attention. They both need it significantly. There has been substantial additional investment in both areas recently. There might be a tendency to say those issues can be taken off the agenda for a while, but that is clearly not an option.

The Minister has proposed a five year plan. While there was substantial funding in this year's Estimates for child care services — there is a reference to X addition of posts being created — is the Minister satisfied and will he examine whether the structures at health board level governing child care are sufficiently strong to manage, develop and oversee the area? When we were discussing the Child Care Bill, I argued for a separate child care programme at health board level and suggested that if it was not developed, this would become the cinderella service which would be tagged on to the other extras and would not get adequate attention. The Eastern Health Board has finally moved towards making a specified senior officer responsible but not at programme manager level.

The Minister recommended the appointment of a programme manager for the drugs services. Will issues like that come within the ambit of the five year plan? In mental handicap, the Minister requires five year plans from the health boards. We also need them in the child care area. There is still insufficient planning. We depend on voluntary agencies, which is the case in the handicap and child care areas, to provide many of the services. That is not adequate. It means that mentally handicapped and severely disturbed children are not treated. The courts have helped and are forcing health boards to take responsibility for children. However, that is not the way it should happen — it should come from central planning. Will that issue be dealt with in the five year plan?

The Minister referred to the progress made on mandatory reporting of offences against children. Last year I raised the issue of the physical punishment of children, on which this committee has continued to work, and I was disappointed by the official response to it. The country has been shocked by the revelation of the severe abuse of children — we are spending much of our time working out systems to respond to it; whether we should have mandatory reporting, for example. However, when I raised this issue and the Law Reform Commission's recommendations that we should begin to think of educating parents towards the non-violent upbringing of children, the Department's response was that this was far tooavant garde and should not be touched with a barge pole.

When this policy was adopted and organised centrally in other countries, it started, for example, with concerns of doctors in casualty wards with the nature and extent of injuries suffered by children. In the matter of mandatory reporting, it will be far easier for social and child care workers and teachers to know what to report if they are dealing with an environment in which the issue of physical punishment of children is clear.

One of the problems with the Kelly Fitzgerald and other cases related to where reasonable chastisement, allowed under our laws and supported by the State, ended and abuse began? If it is clear that physical punishment is not acceptable in dealing with children, then it will be much easier for people to intervene when it is clearly being used. These children have often either ended up dead or the subject of major hospital cases. How many of these children have gone to out-patients clinics with severe injuries? For example, one boy's father drove over him with his tractor. Is there a more active role for the Department of Health in identifying the extent of the problem and in being more active, as the Law Reform Commission recommended, in teaching parents positive parenting rather than the use of physical punishment?

All these matters would have been helped when the child care legislation was discussed if we had established some form of child care authority or ombudsman as was found useful in other countries, to ensure the policy on child care does not only become highlighted at times of crisis, but that there is maintenance of steady consideration of policies, analysis of international trends etc. This committee is continuing to work to prepare initial proposals in this area and we will send them to the Ministers for Justice and Health when they are ready. Since our last meeting, we studied the situation in Sweden at first hand and discovered some useful and interesting information on how and why it changed and the impact it had. This committee will be come back to this matter.

I am glad to see the Minister acknowledge that despite the substantial spending on mental handicap, a serious gap still exists. In the northside of Dublin, the Minister is aware — the Eastern Health Board has attempted to respond to this — that there is a great shortage of beds for the mentally handicapped. There are only two providers of mental handicap services in the northside while there are up to nine in the southside. The Eastern Health Board is again relying on voluntary agencies. When resources are being allocated, naturally the area with seven agencies will get more than that with two. There have been attempts in the last year as a result of strong campaigns by parents and providers on the northside to try to redress that imbalance but again it comes back to depending on voluntary agencies. The Department of Health, the central body, issues money through health boards and by the time it gets down to agencies it is diluted. There is not sufficient focus on what we get at the end of the day. There is an element of random chance in the different elements rather than a decision on what the priorities are. There has been significant progress in day care placement in the northside of the city but there is increasing concern about the huge waiting list for residential care. Up to 250 residential places were provided for the mentally handicapped as a result of the funds provided in previous years. This year, because of a series of circumstances, the equivalent figure is only about 65 beds.

There is a perception, despite the increased money, that the impetus is easing up and there is a need to restart it in a significant way. There is certainly going to be a very focused campaign on this in Dublin in the run-up to the next election. They are advising people to make it an issue for all parties. There is a real need which is not being met and there is a need to maintain a high public profile on this issue. In the Eastern Health Board £500,000 of the funds allocated have been retained for the provision of emergency care rather than ongoing services. There is a real shortage there.

We are looking forward to the document on cancer and I welcome the fact that the Minister made this a priority. We welcome the investment in St. Luke's and other services. There still seems to be quite a dramatic length of time that people can be waiting for treatment. When you have been diagnosed with having a lump or a mole that needs investigation every week that you wait is a week of intense anxiety. Even for people who are in the midst of treatment and have had treatment for the removal of tumours the time involved in getting appointments would be seem to be extraordinarily long to a non-medical person, given the life threatening natures of these illnesses. There is a need for this strategy and we are looking forward to seeing it in detail.

Will the Minister clarify if the dental care service for children is only for children up to the age of 14? The school service continues up to the age of 14, whereas it used to end when they finished primary school. Who gets what between 14 and 16 years of age?

The first element of the service was as far as 14 years and we extended that to 16 years. The range of services is available to 16 year olds.

Does that include the local clinics that are associated with schools?

Who is entitled to a medical card? Does a person become eligible at 16 or 18?

Is it universal for 14 to 16 year olds now?

But not necessarily in the clinic where that person would have been going for primary school care?

I will check the method of delivery for the Deputy.

I rang the Department about a specific case last week and got different information.

The Minister states that provision will be made for the mentally handicapped as resources become available. I was hoping he would prioritise mental handicap, especially the problems that arise in St. Ita's in regard to the profoundly handicapped where facilitiesin situ should be improved. If people who are in psychiatric hospitals have to be treated on site the new facilities should be improved for the mentally handicapped.

In reply to Deputy Flaherty, the Eastern Health Board document contains the targets for methadone treatment, clinics and the method of delivery. There are numbers related to different outlets and to GP's. We have circulated that information this week. There are specific targets which we think we can achieve.

Most of us would not have believed the kind of abuse that some children have been subjected to and the source of the abuse. If we were told these stories ten years ago, we would not have given them any credence. We all have to revise our view of what is happening in society and gear up the services to respond. Many of the new child care workers that have been taken on are quite young. We have taken on 850 extra staff approximately in the last two and a half to three years. They are very well qualified but they are also inexperienced. There are growing pains and stresses within the system.

The management structures are adequate but could be improved, especially with so many new staff joining the services. A separate programme is probably not the answer. The protection of children should involve every member of staff in the health board. It cannot be hived off to one head of child care in a particular section because, as the Deputy said, the best source of information might be through casualty in a hospital. The programme managers on the hospital side would certainly want to be involved as well. There is a need to co-ordinate and strengthen management arrangements to protect children in each board area. That is one of the issues to be addressed in the programme for the child care initiative which will stretch until 1999.

I would be interested in the committee's recommendations on the physical punishment issue when they come forward with them. Ten years ago I would have said parents should be entitled to punish and chastise their children as they see fit, but we have to revise our opinions in view of the abuse of children. If the committee were to recommend that the health promotion section of the Department get involved in a programme of advocating that parents try to rear their children without resorting to physical punishment I would look favourably on that.

I was listening to Marian Finucane's radio show yesterday. A woman who phoned was quite straightforward in talking about her children. The issue was the kind of clothes they wore, but in the course of it all she referred to her daughter and said that she was a lovely girl but she had smacked her a couple of times in the past when she did not know better and she wanted to apologise to her. This was put in as a kind of afterthought in the middle of a straightforward conversation. A lot of people are reviewing their positions on these issues and in respect of the physical punishment of children there is a review of attitude in the minds of many people.

There has been a big investment in the area of mental handicap. We did not have as much on the current side this year as we had previously but we had quite extensive investment on the capital side. Some of the facilities that were put in place over the last couple of years were not adequately housed so there is a catch-up process in investing the capital around the services that were put in place over those years. We have established a database, because while there was a good response over the last three years or so it was done on the basis of estimated need without an accurate base. We have asked the health boards to help us with the database. It is quite interesting and we have sufficient copies to give to Members of the committee. It gives us an actual database which will certainly help me to bring a programme to Government because rather than trying to estimate the need, I will be looking for funds to deal with actual need and projecting that over a number of years. Let us see how we get on in the negotiations for next year's Estimate on that basis. It is a priority.

The Department will announce the national cancer strategy before the summer recess. The waiting periods, to which Deputy Flaherty referred, probably arise from the problems which the great success at St. Vincent's Hospital has created. Huge numbers of people from well outside that hospital's catchment area are now looking for treatment there. The Department and the hospital have discussed the provision of extra clinics and facilities to shorten the waiting lists. In addition, we are asking the expert cancer staff at St. Vincent's Hospital to link with colleagues down the country. Rather than simply accepting referrals from colleagues, the Department is asking them to help to bring their colleagues down the country up to best practice so that persons who are now travelling long distances to Dublin could be treated by their local consultant. There is no reason for not doing this. It is not as if this is the cutting edge of medicine. What is happening now is well within the skills range of the normal consultant. There should be no need for continued journeys to St. Vincent's Hospital but the expertise in that hospital should be used for training purposes.

Returning to mental handicap services, there will be approximately 70 additional residential respite places in 1996. On St. Ita's Hospital, to which Deputy Moffat referred, the ongoing programme to improve conditions by strengthening the staffing structure and reducing the numbers on the campus is continuing. A multi-disciplinary team is now in place which is assisting in the provision of services to meet individual client needs. Because of the age profile of carers and persons with a mental handicap, the provision of emergency places is continuing to cause problems. However, the five year plan will identify these specific needs.

One of the fallouts of Madonna House is that the Eastern Health Board had to take it over and the sum of £2 million was made available for that purpose. About half the place is to be provided for the mentally handicapped residents of St. Ita's Hospital.

Can the Minister confirm they will all be from the southside of Dublin?

There is a regional disparity in Dublin.

It is in favour of the southside.

The Department will write to the Deputy about the dental health question. The policy position is that services are available to persons up to the age of 16, but I do not want to say something categorical on the method of the provision between the ages of 14 and 15 until I check it as I am familiar with the practice around the country.

We will move on to the other services.

University College Hospital Galway is not referred to here.

I will visit Galway at the end of the month and I hope Deputy Geoghegan-Quinn will be there to welcome me. A number of issues arise in Galway: the hospice, accident and emergency and the hospital's development plan. I hope to be able to give definitive replies on all the issues on that day. There are ongoing discussions and we are finalising matters, but it is not forgotten. I am aware of the need and I thank Deputy Geoghegan-Quinn for bringing some of the real difficulties to my attention in a straightforward, helpful way without any kind of political point scoring.

With regard to the food safety and advisory board, what input had the Minister to the BSE crisis? Will he have an ongoing input?

When it was sprung on us by my colleague, the British Secretary of State for Health, Mr. Stephen Dorrell and the Department of Agriculture, Food and Forestry received two hours' notice and my Department received even less notice. We asked the food safety advisory board to examine the Irish situation to see if the procedures which had been put in place some years ago by the Department of Agriculture, Food and Forestry in consultation with my Department were adequate. The board produced a report and I think I circulated copies to Deputies. That was my initial involvement.

Minister of State, Deputy O'Shea gave my Department's position in the first debate in the House. About ten days later we received and issued the report from the food safety advisory board and gave the assurances which ran from it about the safety of Irish beef, having regard to the procedures put in place by the Minister for Agriculture, Food and Forestry, Deputy Yates.

I discussed with my colleagues in Government the manner in which responsibility for food standards and safety is spread over so many Departments. While there would be responsibility in the Department of Health through the health boards, it has to do with food hygiene. The responsibility for safety during the manufacturing process rests with the parent Department, so the Department of Agriculture, Food and Forestry is responsible for meat until it leaves the factory and arrives on the shelves in the shops or butchers. Fish is the responsibility of the Department of the Marine. The Department of Enterprise and Employment has responsibility on the consumer side with the Director of Consumer Affairs. We found out that water safety was the responsibility of three Departments, depending on whether it came out of a bottle, a tap or a well. There is this diffusion of responsibility and a high level interdepartmental committee is trying to focus on the difficulties caused by this confusion. It looks as if responsibility for food safety will end up in the Department of Health but that will require legislation. That is how it has impacted on the Department of Health.

We must pull it together because consumers are more conscious of food safety than they ever were before. It is a much wider issue. It has gone beyond getting a bad taste from cooked ham, for instance, or poor refrigeration in small shops. We must have the statutory framework to be able to cope with the bigger issues, such as those which have bedevilled our colleagues in the United Kingdom for five or six years.

We will move on to the final subhead, subhead J, Appropriations-in-aid.

The Department receives extra money from the Health Levy which is paid through the PRSI system. The money coming through in Appropriations-in-aid confirms the booming economy. We think we are running beyond what we have estimated but it is still early in the year.

Does the Minister wish to make any concluding remarks on the Estimate?

I want to thank you, Chairman, your efficient staff, my colleague, Deputy Flaherty and the spokespersons, Deputy Geoghegan-Quinn and Deputy O'Malley, who contributed. We do not have Deputy O'Malley on the health wicket except infrequently but Deputy Geoghegan-Quinn is always my main protagonist, and I thank her for her helpful approach to the Estimate. I thank Deputies Moffatt and Tom Foxe and the other Deputies who attended earlier also.

On behalf of Fianna Fáil, I thank the Minister for his forthcoming responses to the questions raised. I also thank the officials in the Department of Health. Although we criticise the Department on a weekly and, sometimes, daily basis, I hope they regard it as constructive criticism because we are all interested in providing a better health service. From time to time we look for information from the Department by way of a Private Members' motion or a parliamentary question and I know the amount of time and energy officials need to provide the answers. We do not often get the opportunity to thank them. I take this opportunity to thank the Minister and his officials who are efficient and courteous to us all.

That concludes our consideration of the Estimates for the Department of Health. I thank the Minister and his officials for the efficient and courteous manner in which the Estimate was prepared. I thank all the Members of the committee who participated.

The Select Committee adjourned at 4.50 p.m.