Estimates 1996.

Vote 41 Health (Supplementary).

Today we are discussing the Supplementary Estimate for the Department of Health. I welcome the Minister for Health, Deputy Noonan, to the committee.

I am pleased to have this opportunity to bring the Supplementary Health Estimate before the committee for examination.

The sum required is a net additional figure of just over £47 million; the precise sum is £47,024,000. In 1996, the original gross sum provided by the Government for the health services was £2,148,707. When account is taken of the Supplementary Estimate, the total gross provision for the health service in 1996 will be £2,195,731. The additional moneys now sought are necessary in order to adequately fund a number of items within the health service which have given rise to additional expenditure which was unforeseen or could not be computed accurately when the original Estimate was passed earlier this year.

I am seeking an additional £620,000 on a once-off basis to cover unforeseen costs in four areas. The first area is additional costs which arose in relation to court proceedings arising from the hepatitis C tragedy. A sum of £120,000 is being sought mainly to cover overtime which had to be worked in order to prepare the documentation for the proceedings. A further £50,000 is being sought to cover additional costs which arose because of the EU Presidency. In addition, £300,000 is being sought to cover the cost of equipment for the computerisation of the registers of births, deaths and marriages in the General Registrar's Office. The Adoption Board was based in my Department for some years but this arrangement has proved to be unsatisfactory for prospective adoptive parents and natural mothers. As a result, it was necessary to find new premises for the board. The Office of Public Works identified Shelbourne House as suitable and I am seeking extra funding of £150,000 to refurbish the new premises.

I am seeking £3.75 million for drug misuse initiatives. The issue of drug misuse has been a major priority for the Government in 1996. In February of this year, in recognition of the serious problems posed by drug misuse, the Government approved proposals on demand reduction measures. These measures included strengthening existing school-based substance abuse programmes in conjunction with the Department of Education; boosting locally based initiatives on education and prevention, in conjunction with education personnel, the Garda and other agencies; running national and locally based drug awareness campaigns aimed at young people and their parents and targeting specific education programmes in high risk areas such as the inner city.

The total amount of money allocated annually to health boards for HIV/AIDS and drug treatment and prevention services has increased steadily since 1992. As a result of the Government's proposals, all the regional health boards, especially the Eastern Health Board where the problem is most acute, are expanding their existing services. In total, my Department has allocated an additional £5.305 million in 1996 in order to expand prevention and treatment services. Some £3.75 million of this sum is included in this Supplementary Estimate.

Drug treatment services are being developed in conjunction with, and with the support of, voluntary and community groups. Health boards have established, or are in the process of establishing, regional co-ordinating committees to monitor the problem in their area and to make recommendations on the appropriate response. This is vital for success as there should be co-ordination of all services, both voluntary and statutory, so that there is a unified approach to addressing the problem. Treatment services for cannabis or ecstasy misuse generally take the form of counselling and support, while for those misusing heroin treatment involves a number of other therapies including drug substitution therapy, that is, methadone. Where in-patient treatment is required, this can be provided through the psychiatric services.

The importance of drug education and prevention cannot be over-emphasised. Schools play an important role in drug prevention. The school provides an ideal setting where young people are receptive to health messages and where life skills such as assertiveness and high self-esteem can be encouraged, thereby enabling young people to improve their chances of making the best decisions when faced with lifestyle choices in a difficult environment. My Department has been involved in developing and disseminating a number of education and prevention strategies in several settings, including programmes for schools, the non-formal education sector, community groups and parents.

The Government is confident that the package of measures being put in place this year will go a long way to meet the immediate needs. However, developments will be closely monitored and the adequacy of services kept under constant review and, if necessary, proposals for further developments will be brought forward. In addition, following the publication of the first report of a ministerial task force on measures to reduce the demand for drugs on 10 November last, further Government decisions have been made regarding expanding and improving services, particularly in ten priority areas in the Eastern Health Board and one in the Southern Health Board. The implementation of the recommendations made by the Government will realistically address the chronic problem of drug misuse in certain areas, particularly in Dublin. The Eastern Health Board is confident that its waiting list for treatment will be eliminated during 1997 and, with the support of other Departments and non-statutory agencies, it is hoped that through concerted co-ordinated action the problem of drug misuse can be contained and minimised.

I now turn to the issue of the additional moneys being sought to pay for the increased costs of medical indemnity this year. As Members know, this country has, in common with all developed countries, experienced a significant growth both in the number and in the average cost of civil claims against doctors. A sum of £2.912 million is required to meet the increased cost of subscriptions to the medical defence organisations. Hospital consultants in the public health service are required by their contracts of employment to indemnify themselves against claims for negligence, etc. Their contracts also provide for between 80 per cent and 90 per cent of the cost of subscriptions to be reimbursed by their employer.

My Department has taken a number of initiatives to reduce costs in this area. These included the introduction of a group medical indemnity scheme in 1992 which provides cover for non-consultant hospital doctors, public health doctors and dentists employed by health boards and some others. A number of risk management pilot projects have also been established with the object of identifying and eliminating adverse incidents which give rise to claims. These have had an impact on controlling costs in recent years. For example, the total cost of the indemnity for those covered by the medical indemnity scheme was maintained at £3.5 million per annum from 1 July 1992 to 30 June 1995.

However, because both the number and the average cost of civil claims against doctors continues to rise, the cost of medical indemnity for both hospital consultants and for those covered by the medical indemnity scheme has risen in the current year. The increased cost to the health service this year for medical indemnity cover for hospital consultants is £1.562 million. The cost of the medical indemnity scheme covering non-consultant hospital doctors, public health doctors and dentists employed by health boards and some others has risen by £1.35 million.

I am concerned at the significant amounts of money being expended on medical indemnity and at the prospect of costs continuing to increase. To address these concerns, my Department retained the services of consultants at the beginning of this year with the task of evaluating the existing arrangements and making recommendations on possible alternative cost effective ways of providing this cover. The consultants have submitted a preliminary report on their findings. Some further work is being undertaken by the consultants to enable my Department to fully evaluate the possible options. I hope to make a significant policy decision on the future arrangements for medical indemnity early in 1997.

In the area of child care services an additional £1.85 million is included in the Supplementary Estimate. This sum has been sought in respect of additional expenditure incurred by the health boards in the provision of child care services. The most significant reasons for this expenditure are the increasing costs faced by boards in responding to the needs of a number of children with severe behavioural problems and the costs associated with a series of legal cases arising under the Child Care Act, 1991.

It is a regrettable fact of modern life that there are a number of very vulnerable children, with a diverse and complex range of personal problems, who require a range of special therapeutic services which are very costly. Overruns have occurred in a number of health boards in attempting to provide the highly specialised therapeutic services required by these children. In addition, substantial legal costs have been incurred by health boards arising from cases under the Child Care Act, 1991. These relate to a number of judicial review proceedings on various aspects of the Child Care Act, 1991; costs for all parties being awarded against health boards even in cases where the finding is in favour of the health board; the appointment on a regular basis of solicitors and guardians of the litigants in accordance with sections 25 and 26 of the Child care Act, 1991 — health boards are liable for the costs associated with such appointments.

The Government is committed to the ongoing development of child care services. It is important that the needs of all children, including those at the margins of society, are met in a caring, sensitive and appropriate manner. The investment of £35 million on an annualised basis since 1993 on the development of child care services has seen a highly significant improvement in their range and effectiveness. However, much work still needs to be done and the Supplementary Estimate reflects the increasingly complex and specialised nature of child care services.

Deputies will be aware of the Government's ongoing efforts to improve waiting times for hospital treatment. This process has been an important element of the Government's efforts to improve equity of access to hospital services as set out in the health strategy. When the waiting list initiative commenced in June 1993, there were 40,130 people on waiting lists for hospital treatment. By the end of June 1996 this figure had been reduced by 9,683 or 24 per cent over a period of three years. A total of 60,376 persons have benefited to date from this earmarked funding.

In June 1996, the Government made available an allocation of £6 million nationally to enable an additional 7,770 in-patient procedures to be carried out. This year's initiative is again targeting out-patient waiting lists and an additional 1,530 persons at present awaiting an out-patient appointment will also be seen. A further £1 million has been allocated for a cardiac surgery waiting list initiative and this will enable 200 patients, currently on the public hospital waiting list for cardiac surgery, to have their operations. Funds are also being allocated to enable 100 cardiac patients to avail of cardiology treatment.

However, due to my concerns that the overall waiting list for in-patient treatment had risen over the past 12 months, I decided that immediate action was required to tackle this increase. Consequently, this Supplementary Estimate makes provision for an additional allocation of £5 million to tackle the problem. This brings to £12 million the total funding provided in 1996 for the waiting list initiative and demonstrates the Government's concern to ensure that the necessary resources are provided to improve waiting times for treatment.

A sum of £7.5 million is required in the Supplementary Estimate to meet the additional costs arising from superannuation payments. Health agencies have for some time been reporting shortfalls in the funding required to meet their superannuation costs. My Department recently conducted a survey of all health agencies to ascertain the extent of the superannuation problem, and the reasons for the difficulties in this area. The principal findings were that during the 1960s and early 1970s there was a significant expansion throughout the health service. Many of those recruited at that time are now reaching retirement age or availing of early retirement opportunities. These developments have placed serious pressure on superannuation budgets. The analysis indicates that this trend will continue for the foreseeable future.

An additional £3.12 million is being sought for increased pay related social insurance costs associated with revised regulations introduced by the Minister for Social Welfare in 1995. These amending regulations provide that modified social insurance status would no longer apply to public servants, including health service workers, appointed on or after 6 April 1995. The effect of these regulations is to increase the employers' share of PRSI for those classes of officer affected.

I would like to turn to an area about which I have been particularly concerned, the accident and emergency services. The accident and emergency services provided by our acute hospitals are second to none. However, from time to time, they come under extreme pressure. This is not a problem confined to Ireland but a feature in other developed countries also.

The main causes of the problems are the sheer volume of patients who present at casualty units and the upsurge in the number of elderly patients who require acute hospital care over the winter. Since becoming Minister, I have been implementing a programme which is tackling these difficulties in a more comprehensive and integrated way than heretofore.

The successful management of accident and emergency departments involves tackling a number of areas, including services for the elderly, the chronically disabled and the management of services provided by the acute hospitals. Following the experience of last year's successful campaign, I am seeking £750,000 in 1996 to put further measures in place. First, I have directed that the public education campaign on the appropriate use of accident and emergency services be relaunched. This campaign is intended to redirect people with minor problems to their general practitioner. Second, for our ageing population the winter brings its own problems. After a period of treatment in our acute hospitals, many of our elderly patients require a recovery period in sub-acute accommodation. The shortage of sub-acute facilities, particularly in Dublin, has caused problems in that acute hospitals have not been able to discharge patients in sufficient numbers and quickly enough to cater for new patients seeking admission. Additional sub-acute accommodation will be provided. Third, in the acute hospitals in Dublin a number of measures will be implemented to deal with problems as they arise. These measures include: improvements in admission and discharge policies; the opening of extra beds and the recruitment of additional staff. It is my intention that, as in the winter of 1995-96, a successful integrated programme of action can be put in place for the winter of 1996-97.

The sum of £888,000 for a special haemophiliac case relates to the costs to a young boy who is suffering from a very rare and serious blood disease. There has been exceptional co-operation between the clinicians and hospitals involved to allow therapy to be administered close to his parents' home, thus minimising distress and inconvenience. Protocols were put in place to ensure constant case review and the most economic purchasing arrangements for the therapeutic products. However, the estimated cost for this young boy's treatment in the current year alone is in excess of £800,000.

I am pleased I have been informed that this boy's progress after treatment has been excellent. His lifestyle has improved dramatically, allowing him to lead an active life where he can attend school on a regular basis.

A further £350,000 is sought to meet the necessary safe disposal of clinical waste. Current small hospital based incinerators are technically unadaptable to meet EU standards. As some difficulties still remain with the use of disposal facilities in the UK, two further outlets have been negotiated in Holland and Denmark as it is vital that security of service is provided. It is intended that a new clinical waste service, to be located in Ireland, will commence before the end of 1997 and tenderers have been invited to submit bids by 16 December next. This service is being put in place with the Department of Health and Social Services in Northern Ireland and it will provide for a solution to this problem on an island basis.

The single largest item in this Supplementary Estimate is the provision of £15 million in respect of the community drug schemes which include the drugs refund scheme, the drug cost subsidisation scheme, long-term illness scheme and a number of other smaller allowances. These schemes are commonly referred to as the demand led schemes, as they are statutory schemes which confer statutory entitlements on claimants. As such, it is not possible for the health boards to impose a budgetary limit on expenditure incurred on them. The purpose of these schemes is to support people who incur significant expenses on necessary prescription medicines. Despite the £15 million requirement, Ireland continues to have one of the lowestper capita consumption of pharmaceuticals. In common with other EU countries we are experiencing a continuing growth in expenditure on drugs and medicines. Increases in expenditure in this area arise from an increase in the number of persons claiming under these schemes in the number of items per claim and in the cost of the drugs. This is due in the main to the prescribing of newer, more expensive drugs which has been a feature of prescribing trends in recent years.

These drugs have significantly improved the quality of life of many people. For example, drugs for the treatment of peptic ulcer disease figure prominently in the list of drugs of significant cost both in the GMS and the community drugs schemes, as do drugs for the treatment of asthma. Such therapies are examples of the advances achieved in treatments which are reducing the need for people to be treated in hospital and are allowing people to maintain a significantly improved quality of life in the community.

My Department is continuing its efforts to encourage the rational, safe and cost effective prescribing and dispensing of medicines. For example this year an agreement was reached with the Irish Pharmaceutical Union which will facilitate the better management of community drug schemes. The new arrangement will include third party verification and information on prescribing under all schemes including the drugs refund scheme. This agreement comes into effect from January 1997.

I have also agreed in principle to the establishment of a pharmacoeconomic centre at Trinity College/St. James's Hospital. Part of the remit of this centre will be to examine various forms of drug therapy from the cost effectiveness point of view. In conjunction with the national medicines information centre, which has already been established at St. James's Hospital, it is envisaged that this centre will become a source of expert information on rational, safe and cost effective prescribing and dispensing for doctors and pharmacists throughout the country.

I am pleased that additional payments were made to recipients of certain assistance allowances from health boards during the week commencing 2 December 1996. In line with social welfare payments, health boards have been authorised to make additional payments of an amount equivalent to 70 per cent of the value of a single week's payment or a minimum payment of £20 where 70 per cent of the value is less than £20. The allowances covered are the disabled person's rehabilitative allowance, the infectious diseases maintenance allowance, the supplementary blind welfare allowance, the domiciliary care allowance, the mobility allowance, the motorised transport grant and the spending allowance for persons in long-term care institutions. The total cost of payment is estimated at £520,000.

The 1996 Estimate provided £162.238 million for balance due to health agencies for services provided in previous years. The figure in the 1996 Estimate was calculated prior to the inclusion of special pay arrears in the 1995 Vote at the end of last year. Based on the final 1995 outturn a further £3.875 million is due to health agencies in respect of balances.

It has been agreed that a grant of £60,000 would be provided to enable the Centre for Independent Living to continue its Vantastic transport operation. The operation is run by the Centre for Independent Living on behalf of people with a disability, in the absence of accessible mainstream public transport.

I agreed the health care package for persons who have contracted hepatitis C from the use within the State of whole blood or blood products with the representative groups of those affected, Positive Action, Transfusion Positive, the Irish Kidney Association and the Irish Haemophilia Society. The package was published in December 1995 and includes acute hospital services, primary care services, counselling services, a special hepatitis C research programme and the establishment of a consultative council on hepatitis C.

The Health (Amendment) Act, 1996, was enacted to provide a statutory basis for the delivery of the primary care services contained in the package. These services, which are free of charge include general practitioner services and drugs and medicines for all medical conditions, home nursing services, home help services, dental and ophthalmic services and counselling services. The Act came into operation on 23 September 1996. The provision of services under the Act is essentially demand driven. Health boards have received 910 applications for service cards, and 854 cards have issued to date. It is estimated that approximately 1,400 people will qualify for the service card eventually. The demand for services will increase in accordance with the increase in the number of persons receiving the services card and the increase in awareness of the services available under the Act. A sum of £600,000 is being provided for legal costs associated with the hepatitis C tribunal of inquiry.

I agreed to provide funding to Positive Action, the support group representing those women who were infected with hepatitis C through the administration of anti-D, on the basis of a contribution towards the administration and other costs incurred by the group in providing a support network for its members. I also accepted that Positive Action would require legal advice in respect of the negotiations between Positive Action and the Department of Health on the content of the compensation scheme and the health care package. In accordance with this agreement, I approved the payment of £293,776.46, as taxed by the taxing master of the superior courts, to cover the legal costs incurred by Positive Action during the period I September 1994 to 31 December 1995. Additional funding of £185,000 is required to cover legal costs in a number of other judicial review cases.

The Supplementary Estimate provides for an additional £9.55 million for the capital programme. This arises for a number of reasons. As deputies will be aware, the capital commitments for each year arise generally from decisions on individual projects, many of which involve expenditure over a number of years. The timing of expenditure on capital projects tends to be influenced by several factors that are difficult to predict accurately in advance. Building on projects has proceeded rapidly this year and the additional capital requirement will help to fund these projects. The pressures on the capital budget this year have resulted in a postponement of expenditure on replacement hospital equipment. The point has now been reached where it is not possible to postpone further the purchase of essential equipment without damaging the fabric of our services, so the Supplementary Estimate will also cater for this element. Various minor capital schemes, including fire precautions and maintenance works, have had to be carried out by health agencies around the country and the extra funding will be used to finance these. The commitments entered into in relation to the continuing care services, which cover areas such as services for the handicapped, psychiatry, and services for the elderly, are now maturing for payment. The income under appropriations in aid is now likely to exceed the initial estimate by some £10 million. There has been an increase in the amounts paid to the Department by the United Kingdom in respect of the recovery of health costs under European Union regulations.

This Supplementary Estimate reflects the commitment of the Government to adequately fund and maintain highest level of care within our health services and, where necessary, as for example in the case of child care, to expand and develop these services to ensure the health and welfare of those in need. I, accordingly, recommend the Supplementary Estimate to the committee for its approval.

While the discussion of health care issues is a very serious matter, if Dermot Morgan looked at the seven fine gentlemen in front of us he would get a great deal of material about the Department of Health not being an equal opportunities employer.

Any discussion of health care matters is very serious, but particularly the discussion of a Supplementary Estimate. I support the Supplementary Estimate because it would not be in the interests of this side of the House to oppose extra spending to provide the highest level of health care possible for all our citizens. However, there was a number of notable occurrences in the past 12 months which I will go through.

We are facing what promises to be a very serious nurses' dispute. I know the Minister has concerns in relation to this issue which my colleague, Deputy O'Donnell, and I have raised in the Dáil on a number of occasions. I am very concerned about nurses, who are the least militant of trade unionists, being forced to strike and to put patients' lives at risk. They need the support of the Minister and the management to help them find a resolution acceptable to both sides within the PCW. I believe that is possible and the Minister also believes it. I hope he will urge the management to get involved immediately in further negotiations to prevent a dispute.

There have been further announcements this year about the capital programme. I am interested in the Minister's statement that he is looking for an extra £9.55 million for the capital programme. Will he identify those projects, particularly those for the latter six months of 1996? Are outstanding projects, which have already been publicly announced, being held up due to lack of sanction by the Department? I am particularly interested from a parochial point of view in any project involving UCHG.

We had a very good discussion here on Committee Stage of the Accountability of Health Boards Bill regarding the uniform implementation of policy in health boards. We repeatedly find that some health boards are very good at dealing with specific problems, whether in the areas of child care, the elderly or other initiatives. However, there seems to then be a breakdown in communication between health boards and the good developments in one area do not seem to translate across the whole sector. Has any action been taken by the division in the Department which deals with health boards on having more discussion and co-operation between health boards, and not just the chief executives but, more particularly, the programme managers involved in specific areas? It is important for that to be done.

I greatly welcome the provision of £60,000 to cope with the transport problems of the Centre for Independent Living. What co-operation is there between the Department of Health and the Department of Transport, Energy and Communications or CIÉ in regard to substantially addressing the difficulties disabled people have in availing of public transport? That problem arises again and again.

In relation to child care, one of the interesting developments this year was the seminar in Malahide held by the Minister of State, Deputy Currie, to which representatives of all health care agencies and professionals were invited. The Minister of State recently gave a commitment to the Dáil that he would examine with his officials the question of mandatory reporting. The Minister is aware of my view on mandatory reporting. However, until a Minister decides to introduce mandatory reporting there will be no development, progress or co-operation but a stand off between the professionals and the Department. In a recent opinion poll scientifically conducted on behalf of the ISPCC, 87 per cent of those polled felt that mandatory reporting would have to be introduced. I know there are concerns among the professionals in relation to the type of abuse which should be reported, how it should be reported and to whom, and who should report. However, until a decision is made to introduce it nobody will work out the guidelines and Protocols. The sooner the Minister makes that decision the better for everybody concerned, particularly the children who continue to be at risk in our communities.

I have already said publicly that providing £5 million at the latter end of the year to reduce waiting lists is a waste of time. Significant improvements were made in 1993 and 1994 because the Government decided to provide £30 million towards a special waiting list initiative. A great deal of good work was done and there was a huge reduction of the waiting lists, which the Minister has acknowledged. The Minister got £8 million in 1995 and he will get £12 million this year. Had the progress of the two previous years been continued, we would now have manageable waiting lists in every health board and hospital.

We all acknowledge that from the beginning of November until the middle of March there is huge pressure on accident and emergency departments, particularly from the growing elderly community who get flu, colds, pneumonia and other infections. This lengthens the waiting lists. That is why any initiative must be taken at the beginning of the year so that hospitals can be informed of what is available and perhaps prevent shutting wards in the summer.

This will be remembered as the year of the infection. We first had the controversy which has been ongoing for two years in relation to hepatitis C. We continuously harassed and harangued the Minister on that issue in the Dáil regarding information which was not been made available and misinformation being put out by others. We finally had to beat down the door to get an agreement to the establishment of a statutory tribunal from the Minister and the Government.

A great deal of information has emerged from that tribunal in a very short period. That information would never have come into the public domain were it not for the fact that women and others infected with hepatitis C were courageous enough to continue the battle, with very little public support, for a long time. The Minister, the Department and the Minister's successors will have to face very serious questions for many years to come in relation to the Blood Transfusion Service Board and public confidence in that board and the whole blood transfusion service arising out of what people perceive as the incompetence of the management of that board. That incompetence is illustrated on a daily basis by the horror stories being reported from the tribunal. Great credit is due to all the people who consistently pushed for the establishment of such a tribunal.

We then had a hepatitis B scare, with a number of cases being reported in health care workers. The case which raised many questions recently related to the Mater Hospital and the Blackrock Clinic.

This raises the entire issue of the infectious diseases advisory group which the Minister correctly established and asked to report. It had experts and all the information available to it and we are told it provided this comprehensively in a report. However, it sat on the Minister's desk for the past 14 months and we have yet to see it. The least the public needs is the publication of the report. The Opposition can only speculate about its recommendations but the public deserves the publication of the report and the implementation of its recommendations.

I appreciate there will be difficulties in that regard and that the Irish Medical Organisation and the Medical Council will have a central role to play in putting the recommendations in place. I listened carefully to Mr. Hugh Bredin, the President of the IMO, on a radio programme recently when he said the IMO is prepared to co-operate with the Minister and Department officials in the implementation of the recommendations.

I was interested in the Minister's recent unilateral decision in relation to testing medical staff. I recall that in 1995, in either February or September, the Minister gave an interview about this matter in which he stated he could not conceive a situation where only certain medical staff must present themselves for testing. The Minister made the valid point that if it only affected new or foreign medical staff, somebody could take a case against him and the Department. Will the Minister elaborate on how he decided it is now possible to make a unilateral decision in relation to certain medical staff? What advice did he take in reaching that decision? When will the report of the infectious diseases advisory group be published? The Medical Council, the IMO and all those involved in health care are interested in it and we should operate in a co-operative rather than, as at present, a confrontational way with them. Their co-operation is necessary and the report should be in the public domain to ensure that is secured.

Another issue was unearthed this week in relation to HIV infection. Arising from the experience and pain of the last two years regarding hepatitis C, I would have expected, when the top management in the Blood Transfusion Service Board had been replaced, that communication would be instant between the Department and the board. That is the least the public would expect, and the least the Minister and his Department should demand. It is extraordinary and unbelievable that something as serious as HIV infection has happened. We are all aware of the seriousness of HIV and the Minister has admitted that, in principle, this situation is as serious now as hepatitis C was originally.

It is unbelievable that the Blood Transfusion Service Board would seek legal advice, hold discussions about such advice between May and August 1996 and finally get definitive advice in August, but the Department was not informed at any time during that period or since until last Sunday. I question that because HIV is an infectious disease and under the Act there is an obligation for it to be notified.

When the matter was brought to the attention of the chief executive officer of the Blood Transfusion Service Board last May, was there not an equal obligation and duty on him to notify it to the Department of Health? Did he do so? If not, there is a serious question mark over Mr. Dunbar. If he notified it, to whom was the notification given in the Department and what happened to it? Serious questions need to be answered in relation to this matter. When were the Minister and the Department informed?

In reply to a question in the Dáil yesterday, the Minister said he was aware of the reference to the HIV incident in relation to one of the plasma donors from the expert group report. I also note the Minister said he was generally aware of difficulties in the BTSB with regard to the absence of certain despatch records. Was that general awareness in relation to HIV infected blood and the non-availability of despatch records or general information in relation to missing despatch records for blood product? As the Minister said last night, the question of the comprehensive look back was addressed by the scientific committee of the Blood Transfusion Service Board in May 1996. Was that notified at that time to the Department? Did the Blood Transfusion Service Board or anybody working there tell the Department they were addressing the issue of a comprehensive look back?

It is equally extraordinary that the Blood Transfusion Service Board communicated with 45 hospitals, but that HIV infection was not mentioned anywhere in the communication. Is that correct? Deputy O'Donnell and I are in the unfortunate position that we do not have the documentation relating to this matter. Did the notification which was issued mention HIV infection? Was the notification marked urgent? It is reasonable to seek answers to these questions in view of what we learned, or should have learned, from the hepatitis C scandal.

I understand the chief executive officer of the BTSB said people did not want to cause a scare. We do not want to cause a scare but if one cannot reveal the presence of HIV infection to a hospital, to whom can it be revealed? This matter is extraordinary. It is equally extraordinary that the Blood Transfusion Service Board, knowing that it was HIV infected blood, waited four months for 31 hospitals to respond. The blame shifts from the hospitals because it appears they were not told that the Blood Transfusion Service Board was worried about HIV infected blood and there was no sense of urgency relating to the correspondence. The emphasis returns to the Blood Transfusion Service Board. Why did it not go after the hospitals? After all we learned from hepatitis C, why does it appear there is a repeat performance by the Blood Transfusion Service Board and the Department of Health on this issue?

The Minister said last night in the Dáil:

I am informed by my Department that the unfortunate health care worker in Kilkenny is the first person in Ireland infected with HIV as a result of infected blood. Over the years 16,000 HIV cases have been identified in this country and the blood transfusion was produced in only one instance as the primary risk factor. When traced, that transfusion had been administered abroad.

I am sure the Minister will now accept that, although unknowingly — in view of the information now available on the public record in relation to the South Eastern Health Board — he misled the House by giving that information.

If that is the case, did the Department of Health know, when the Minister went into the House to respond, that the information he was about to give was not the truth? If the Department of Health did not know that, did the Blood Transfusion Service Board know? I presume the Minister, as a responsible Minister, met Mr. Dunbar before he went to the House yesterday to respond to the Private Notice Question. I ask the Minister to confirm that but I presume, as a good Minister on top of his job, that he at least met the chief executive officer of the Blood Transfusion Service Board and established in his mind the facts of the case in addition to information from his officials. If that is the case, who was misleading whom yesterday?

As well as the cases which have now come out in relation to others in the South-Eastern Health Board area, is there any other case of a health care worker involved in a sensitive area in the same health board with a haemophiliac patient who received a HIV infected blood transfusion and has since passed on? I am informed that happened some time in the late 1980s. It would be interesting to know if and when the Minister was made aware of that.

Yesterday the Minister said he could not explain the reason nothing happened in the Blood Transfusion Service Board between 1985 and 1989. Did he ask anybody in the BTSB at that time or his officials why nothing happened? He also said he was informed yesterday, 9 December, of the detail of the Kilkenny case and that he was told by his officials that the Department of Health was informed on 8 December about this case. Does that mean, as I suspect, that the Department had already been informed about the general HIV problem perhaps some time between the beginning of May and the end of August and that the Minister gave us the factual position yesterday, stating that the Department was only informed on 8 December, which was as soon as the South-Eastern Health Board became aware of the problem? It is important to clarify these issues.

It is not enough for the Minister to say he presumes or expects things. We have learned so much from the hepatitis C controversy. It is vital that all the information in relation to this latest situation is put on the record so that nobody can say the Minister misled the Dáil because he was misled or because somebody did not tell him what was going on.

A number of questions I asked in the Dáil yesterday were not answered. I asked how the Blood Transfusion Service Board could justify the claim that most of those who received potentially infected blood transfusions before 1985 would have died from the underlying illness. How can the BTSB justify that claim? It tried to make the same justification in relation to hepatitis C but we nailed that. How can it repeat the same utterances it made during the hepatitis C controversy? Why did it wait until 1994 and the hepatitis/anti-D experience to begin its targeted look back programme for recipients of potentially HIV infected blood transfusions? Was there a reason this was not made public then?

In 1995 the Minister informed us that the screening programme initiated for hepatitis C in 1994 was introduced on the advice of the Attorney General. Could the same advice not have been given in relation to HIV infected blood? Is this infection not as serious, if not more, than hepatitis C? Did the same principle not apply in relation to HIV as to hepatitis C? The public deserve answers to those questions. I look forward to the Minister's response and I welcome the Supplementary Estimate. However, we need answers to serious questions concerning this Estimate.

It is difficult for a politician to criticise spending on a project or on an aspect of the health service. We all want the best possible standard of care for citizens. When health spending rises, there is a tendency for the public to be very understanding. We all appreciate the pressures pushing up health spending which do not affect other Departments. As the Minister indicated, the age profile of our population is increasing and greater demands are being placed on our health service.

The pace of technological change in medicine is rapid and unforeseeable. People now receive very expensive treatments which were only invented a few years ago. There is an understandable and possibly insatiable appetite for more health spending so that the people can receive the best possible treatment. The rapid pace of technological change means that the rate of inflation in health care services tends to run ahead of inflation by a significant margin. Notwithstanding that, there is an obligation on us to take a closer look at the extent to which health spending has increased in recent years.

The Book of Estimates published every December includes a summary table which provides an analysis of current Government spending under a number of major headings. That shows spending on the health services has practically doubled over the past five years from £1.1 billion to over £2.2 billion. It now costs us a £1 billion more to run the health services than it did in 1991. This is a dramatic increase by any stretch of the imagination. It is a challenge to politicians to ensure we get value for money given the dramatic rise in spending. We must ensure it is not a matter of throwing money at the health service and responding to political demands. We must ensure value for money and that the services are good quality.

Given the scale of the increase, does the Minister have any plans to commission a full appraisal of the health care budget? We should ask if the 100 per cent increase in health spending over the past five years has resulted in a 100 per cent improvement in the quality of the health service. We should ask about standards of efficiency and effectiveness and satisfaction on the part of the consumer. As Deputy Geoghegan-Quinn said, we should ask about the health boards and discrepancies in terms of quality and if the effectiveness of services in the various health boards can be applied and evaluated more uniformly.

We did a study earlier this year and we found huge cost differentials across the health boards. Spending per head of population by the North-Western Health Board is twice that of the Eastern Health Board. Can that be explained solely by population density? Spending per head by the South-Eastern Health Board is one-third higher than in the North-Eastern Health Board area, although both have similar population profiles. These differentials are difficult to explain.

It is also difficult to explain the difference in management and administration costs in the health boards. Administration costs amount to over £17 per head of population per year in the North-Eastern Health Board but the figure rises to £38 per head in the North-Western Health Board. Those differences are so wide that they merit some evaluation by the Department. Has the Department carried out a comparative evaluation of the performance of the different health boards in recent years? If so, will the Minister publish those documents? Given the huge amount of public money involved and the vital importance of the health care provided by the health boards, I would be surprised if the health board had not undertaken an evaluation of this kind.

In many areas of politics and public spending there is a tendency to respond to political demands by promising or asking for more resources. In some areas, however, the problem is not resources but proper and accountable management structures. This is particularly relevant to the health boards. In the child care area, for example, there has been a long awaited improvement in child care provision and that is welcome. However, I wonder if that relates to resources. Many of the failings in quality, efficiency and adequacy of service in the child care area over the last few years have not related primarily to resources but to bad and unaccountable management procedures. That is particularly true with regard to the scandals resulting from the failures of health boards in the protection of children. We have not come to grips with the fact that this issue is not about money and more jobs but proper and accountable management structures.

Mandatory reporting is a related issue. It has been depressing to witness the procrastination on this issue during the past two years. There has been a definite political policy to put mandatory reporting on the long finger. It is almost six years since the Law Reform Commission, which looked at the aspects of the issue which are now being fiddled over by this Government, recommended that mandatory reporting be introduced. It is three years since the Kilkenny incest report, which also looked at the options, made the same recommendation. However, the Minister of State with responsibility for this issue still declares he has an open mind on it.

It was also depressing to attend the conference in Malahide and see the backsliding by professional bodies from the recommendation of mandatory reporting. Client confidentiality and other red herrings are being raised but these same issues are never raised in the context of reporting other types of crime. Although it is a complex area, these matters are not beyond resolution if there is political will. I share the views of Deputy Geoghegan-Quinn, the ISPCC and the public, as shown in surveys, that mandatory reporting must be introduced. All that is required is the political will. The peripheral matters which have been raised by various vested interests must be addressed but the primacy of protecting the child must be asserted. The discussion document produced by the Government, "Putting Children First", should more properly be titled "Putting Children Last" because the rights of everybody else were considered first. That is the problem. There must be a total commitment to the primacy of the child before the rights of everybody else, including those of the person against whom allegations are made and the doctors, social workers and care workers involved. While their rights are important they must yield to the primacy of the child's rights.

With regard to quality of services and comparisons between the public and private sectors, many companies in the private sector have an ISO quality management certificate to ensure high quality of service. Services such as health boards, the BTSB and other health agencies might consider establishing a similar accountable standard against which their services could be measured. The public has a right to expect the highest quality service from such important agencies.

Deputy Geoghegan-Quinn raised a matter which must be discussed in the context of the Estimates. A similar set of circumstances to those which applied to the hepatitis C issue surround this matter. It is remarkable that the Minister was not in possession of information over which he has ultimate political responsibility. It has been known by the BTSB since 1985, and was known to the new management of that agency since it took office, that possibly 16 people had been infected with HIV following transfusions of blood from the BTSB. Although the Minister could not have political responsibility for what did not happen between 1985 and 1994, the BTSB has serious questions to answer in that regard.

What was known for 11 years was not acted on. The BTSB had the batch numbers which would have enabled it to trace the people who had received suspect transfusions. Although it had that information since 1985 no action was taken to trace the people concerned. Now, in the space of four days, two people have been traced. The first was traced only because she came forward and presented herself as a recipient after she tragically contracted HIV as a result of the blood transfusion. Today we heard that another person has been traced. It seems extraordinary that within four days two people were traced while over 11 years nothing happened. The public is right to be concerned about this.

The BTSB, in a statement issued today, said the reason it did not mention HIV infection in its letters of September to the various hospitals was that it did not want to cause a scare. This type of maladministration causes more fear in the public. The fact that a letter, whose motivation is to trace suspect batches of blood, does not mention that motivation is evidence of a frightening level of service by the BTSB under its current management. We have been through a great deal with the BTSB and its management and, after a new management structure and board being established, this development is extremely disappointing.

The scientific committee of the board dealt with this matter in May, took legal advice in August and on the basis of that legal advice and its advised duty of care the BTSB sent a letter to the hospitals without informing the Minister. That is incredible. It appears no lessons have been learned from the hepatitis C issue and that the same bad practices are being followed by the current board. The Minister has not been made aware of matters for which he has political responsibility. Many questions must be answered in this regard. When I asked the Minister four times yesterday about when his Department knew of the general problem — not the Kilkenny HIV infection case — that 16 people might have been infected, I did not get a clear answer. The Minister said he was told about the case on 9 December and the Department had been made aware of it on 8 December. The Minister must reply to the question. Were the Minister and his Department made aware of the fact that there were 16 possible cases of people being infected with HIV.

The Minister should publish the letter to these hospitals if it was so general in tone as to mislead them. The hospitals may have failed to respond because it looked like a routine rather than an urgent letter. The situation is further exacerbated if there was no sense of urgency in that letter.

It took 11 years to make any effort at tracing when they had the batch numbers since 1985. The letter was eventually sent on legal advice. Whoever gave the legal advice to send the letter on the basis of their duty of care to those recipients and to the public in general, would have seen the letter. It is important we know the source of this letter, the level of the Minister's knowledge of it and of matters generally relating to the HIV infection. We will have an opportunity on Tuesday to question the Minister further.

On the basis of information now coming into the public arena there have been many missed opportunities when the BTSB could have come clean on this matter. There was a public appetite for disclosure when we set up the screening programme in relation to the hepatitis C and anti-D controversy. The tribunal of inquiry is sitting and still on a related matter, and in principle just as grave a matter, there has been a reversion to the old tactic of retention of information, even with regard to the hospitals to which they wrote, not to mention the Minister and the people who were concerned. Obviously, the earlier people know they have HIV, the better. It is a life-altering infection and one has to change ones social habits. It is a disgrace that people were not informed and every effort was not made by the authorities since 1985 and since the new management took over to immediately trace these persons.

Will the Minister look at the problems in the Mater Hospital which arose from bringing prisoners to the accident and emergency service there? Many of these prisoners' minor accidents and emergencies could be dealt with in prison. There have been many complaints from doctors, nurses and other paramedics in the hospital about this matter.

The Minister said the current clinical waste problem has been solved. Where will it be located?

I am disappointed that the area of mental handicap is not being properly catered for. We talk about waiting lists in general but the waiting lists for mentally handicapped people are a disgrace and something will have to be done urgently. Portrane Psychiatric Hospital has about 345 mentally handicapped patients and the standard there is not acceptable. Despite raising this matter on numerous occasions, it has not been ameliorated.

Much is desired in tracing and in giving information on HIV. On the capital programme, there is no word yet about the second phase of the Mayo General Hospital.

I welcome the increased spending in many areas in the Estimates. Increased spending in child care is critical as we are coming from a very low base in this area. There are many more aspects of child care that will need further funding over the coming years, particularly services for adolescents. We have seen many cases where there are no nation-wide services available for these young people. I welcome the increase in spending in that area.

The key question which arises today is that of blood supply. Does the Minister believe confidence can be maintained in the blood supply? Confidence was maintained during the hepatitis C and anti-D saga, but any people facing operations will be concerned. Obviously systems have now changed but clearly there was a bad breakdown. At the core of the problem is the lack of partnership and openness in the health services in relation to patients and consumers. I would like the Minister to address this. How does he see this changing over the years? It is a key aspect of services which will have to change. Consumers are demanding it and I think a modern health service will have to mean there is more equal involvement between the providers of the service and those who receive it. It is important we move towards a more open health service.

As regards health services for women, will money be provided for a cervical cancer screening service nationwide? We are behind other countries in relation to this. The service should be provided throughout the country and be available to every woman. Deaths can be prevented if we provide this service. Will the Minister examine whether the budget will be able to tackle this issue?

As regards the pay and conditions of nurses, it is clear that over the years nurses have not had the status and opportunities they would have liked. They want to be seen as partners within the health service. The current dispute is not just about pay and conditions but equally about these issues. While I appreciate there are difficult discussions going on as regards pay and negotiations, does the Minister think these other issues of opportunity, training, status and playing an equal part in management, will be addressed in the coming months and years?

I thank the Deputies for their contributions and questions. I will try to deal with them as fully as I can. I thank Deputy Geoghegan-Quinn and Deputy O'Donnell for agreeing the Estimate on behalf of their respective parties.

Deputy Geoghegan-Quinn referred to the nurse's dispute, as did Deputy Frances Fitzgerald. Deputies will be aware of the negotiation process which took place. The negotiations are in the context of phase three of the PCW, which is almost concluded. This involved a certain amount of bargaining and pay increases in exchange for productivity. The nursing unions formed an alliance of the four unions which represent them. They put forward a set of claims and identified what they considered to be the main difficulties the nursing profession had at this time.

Although they mentioned other areas, initially they highlighted two. First, a nurse's maximum pay was low for such a responsible job, following a long period of education and training, so the demand was to increase the maximum beyond £20,000. That would be added to by the normal roster allowances of between £4,000 and £5,000 to produce the maximum for 95 per cent of nurses. There was an initial negotiation and Deputies will be aware of the Government decision which nurses voted on and turned down. Then the Government put in place an adjudication process in which an independent person evaluated the difficulties between contending parties and, as a final phase of negotiation, came forward with recommendations. The adjudicator recommended solutions on what were identified by both sides as the outstanding issues, which increased the value of the award significantly, to approximately £50 million. The Government accepted the adjudicator's recommendations and put it by way of formal offer on the understanding that a final phase of negotiation had been reached. The nursing unions put it to a ballot; as Deputies are aware, the Psychiatric Nurses' Association and SIPTU accepted the offer, but IMPACT nurses marginally rejected the offer and the INO rejected it by a significant margin. The INO has proceeded to conduct a strike ballot of its members, the result of which should be available later in the year.

I am concerned that a nurses' dispute could seriously affect the health services in the early part of 1997. However, as Deputies know, the new PCW is being negotiated at present; the private sector elements have been concluded, the public sector elements were negotiated today and yesterday are going well. Deputies will also be aware of an intervention by Mr. Bill Attlee on behalf of SIPTU, also speaking in his capacity as a member of Congress, to suggest a commission to look into nurses' pay and conditions.

I have made strong efforts to solve this problem and have addressed many of the anomalies and grievances brought to me by the nursing unions but, because of centralised bargaining, nurses like other public servants have received pay increases under wage agreements over the years, so grievances, anomalies and differences that arose from the profession not only were not, but could not, have been addressed within the straitjacket of centralised bargaining. The last time nurses' pay was looked at within the wider context was in 1980. The negotiations are taking place within the constraints of PCW phase 3, in which pay is tied to productivity, so it is not possible to address the wider issues. While we have been flexible in our interpretation of the parameters of phase 3 of the PCW, we have strained it to address some problems which are legitimate but could only be addressed in a general context. I am anxious to make progress but the current position is that another PCW is being negotiated between the social partners and the Government, the nurses are balloting for strike action, which if approved could take place in February.

Deputy Geoghegan-Quinn asked about capital projects. The Book of Estimates for 1997 — as distinct from this Supplementary Estimate — was published on Monday, in which a sum of £108 million was included for such projects. The Deputy will be aware that this is a significant amount of money and I hope I will be able to fulfil the commitments I have given in this respect, not only in Galway but around the country.

Is there anything outstanding for Galway awaiting sanction?

The normal process is that the Department of Health would authorise the project but on large projects from that we still need to get individual sanction from the Department of Finance. That Department has not sanctioned the project but there is nothing unusual in that, because until we fix the Estimate for 1997 it would be reluctant to give individual sanction. I do not see any particular difficulty in getting sanction and it will run with the projects for 1997, because we have significant amounts of money in the Estimate for next year.

The other capital expenditure in the Supplementary Estimate includes development in St. James's Hospital, an X-ray section in Clonmel, theatre equipment in Portiuncula, minor capital works and electrical works in the Royal Hospital, a general unit in the Rotunda, and fire precaution and minor maintenance works all around the country. Other service issues include £500,000 for the central remedial clinic, £1 million for the training centres for mental handicap and £500,000 for small health centres. Miscellaneous small projects would be included in the Supplementary Estimate for capital projects.

The Deputy asked what kind of co-operation there was from health boards and referred to the discussion we had previously about applying best practice everywhere; some were more advanced in certain areas of activity than others. chief executive officers quite regularly have meetings, which act as a clearing house for best practice in some respects. Deputies know from talking to each other what happens in different health boards. What works in one area usually comes to be applied in a neighbouring health board, although there may be a time lag.

I have taken initiatives of which Deputies will be aware. I recently announced the new arrangements for the Eastern Health Board; in the context of that announcement I also mentioned the management of health boards. The dual role of Mr. Dónal O'Shea in the North-Western Health Board and the North-Eastern Health Board will not continue, nor will Mr. Doherty's dual role in the Midland Health Board and the Mid-Western Health Board. In January I hope to announce vacancies at chief executive officer level in the North-Western, Western and Mid-Western Health Boards. I have also invited Mr. Doherty, while maintaining his role as chief executive officer of the Midland Health Board, to take over responsibility for the development of management in health boards. Significant advances can be made there; I believe that not only do the health boards need better management procedures but management people must be drawn also. A pool of managers must be available to a service with over 66,000 employees and a budget of £2.5 billion, coming to almost 20 per cent of total budget expenditure. Those managers must be developed professionally. The medical papers have suggested that Mr. Doherty is being head-hunted by the VHI but I do not want to comment on that.

He did not tell the Minister?

No, I saw it in the newspapers. I think it is true but I have no idea whether he will opt for that or stay in the role I have identified for him.

We put arrangements in place for the Centre for Independent Living. Deputy Geoghegan-Quinn asked about the use of public transport by the disabled. the report of the Commission on the Status of Persons with Disability was published by my colleague the Minister, Deputy Taylor, and an interdepartmental task force was set up for its implementation. It goes across a range of issues and the issue of disability and disabilities faced by the disabled will be discussed fully in that context.

Child care was raised by both Deputy O'Donnell and Deputy Geoghegan-Quinn, with particular reference to mandatory reporting which both Deputies seemed to favour. I do not think it is such an open-and-shut case, given the various arguments put forward by the medical bodies, but the position is that the Minister of State, Deputy Currie, held the forum to which many Deputies referred, which received input by many people from the professions and the voluntary organisations. He gave a commitment to make a decision by the end of the year.

Deputy Geoghegan-Quinn asked about the waiting list initiatives. A sum of £5 million was provided late this year to make a total of £12 million for the year. It is not true that the £5 million was given at a time when it could not be used effectively. We identified hospitals and health board areas, but particularly hospitals, where there were significant waiting lists in respect of some specialities and we left hospitals where there was some spare capacity to use extra funding to make interventions. They accepted that they would make a certain number of interventions and when I checked late last week they were all on target and saying they would fulfil their obligations under the waiting list initiative.

We hope to get between 6,000 and 7,000 interventions from that £5 million, although that does not mean the waiting list will come down by 6,000 or 7,000. Quite frequently what is taken off the top of a waiting list is supplemented by other people going in at the bottom. There are very human examples such as the man who has not been out an about for a while getting a new hip and suddenly being seen out and about. A number of people will be very impressed by this and join the waiting list. Very often the success of a waiting list initiative can add to those waiting lists. We should think in terms of waiting times as much as waiting lists.

Since the waiting list initiative first began in 1993 more than 60,000 extra operations have been completed. If it was not for the waiting list initiatives 60,000 people would still be on the waiting lists which would be scandalous at this stage. There will always be waiting lists. A person will go to a GP who will make an appointment with a consultant who will decide to operate and will send that person into hospital. After the initial appointment with the consultant a person could be on a waiting list. That people are on waiting lists is not significant. The length of time they spend on the waiting list is the significant factor and we will continue to work on that.

Deputy Geoghegan-Quinn referred to the hepatitis C tribunal and remarked that an extraordinary amount of information seems to be coming out. That seems to be the case. I listen to the reports on radio and read the reports in the papers. When the hepatitis C issue was brought to Government attention when Deputy Howlin was Minister and when Deputy Geoghegan-Quinn was Minister for Justice the decision at that time was not to have a judicial inquiry, but to have a group of experts examine the situation, to look for everybody's co-operation and to bring forward the best possible report, come to conclusions and make recommendations. The decision not to have a judicial inquiry was not my decision. I am not saying that had I been in Government at the time I would have made a different decision. I am saying that the decision to go with the Miriam Hederman O'Brien group was made by the previous Government.

That group reported then to me and I got the report, as Deputies know, in the spring of 1995. When the report came out it was published and people thought we had got to the bottom of the situation. Deputies will recall there was a general welcome for the report when it was published and there was a general feeling that we had the fullest possible information, that the conclusions were valid and the recommendations were good. In general terms we set about implementing the recommendations. If Deputies cast their minds back they will find that nobody cast doubt on it for almost a year. It was around spring of 1996 before anybody said there was information the group had not seen. Everybody knew it had not interviewed all employees because there was a list of those who had been interviewed attached to the report. Everybody knew as well it had not seen every file because it was not a paperchase inquiry, it was an inquiry that looked for co-operation and spoke to people.

By May 1996 great concern was being expressed in the Dáil and people were saying we should have a judicial inquiry. Like all these things, it started off as a murmur — would the Minister consider an inquiry — and then it became a demand. The position I took was that because a case was listed for hearing at an early date, if there were gaps in our knowledge, the High Court would fill those gaps, that under cross examination those gaps would be filled. Perhaps I should have moved in May for a judicial inquiry, but many people are rewriting history at the moment. Nobody cast any doubt until the late spring of 1996 and when I said I did not think a judicial inquiry was justified, it was in the context of a court case coming up in the High Court. I said on several occasions that if there was a gap in our information, it would be identified there. We know the sequel to that and we know the way the judicial inquiry was set up.

I do not know whether a different Minister would have done anything different, but the decision to go through an informal inquiry was the decision of the previous Government, not my decision. I got the Miriam Hederman O'Brien report and accepted it, as did everybody else, as a full and frank exposition of everything that has happened. When demands began to come for a judicial inquiry in May, 1996, we knew there was a High Court case coming up and I thought the situation would be elucidated there.

As soon as I found there unfortunately would not be a High Court case, because of the death of Mrs. Brigid McCole, I moved immediately to go to Government for a judicial tribunal. In the rewriting of history people say I went to Government because of the tragedy. I was very upset by the tragedy but I did not go to Government on account of it on the judicial inquiry issue. I went because I could not say to the Government that any other High Court case would come up or if a High Court case would come up that it would come up in a reasonable timeframe. I could not say if or when there would be a High Court case.

It is early days yet. The tribunal has only been listening to evidence for a few days yet. It is a very effective tribunal so far, and I hope in due course it will reach conclusions. Deputies will recall that the manner in which the Houses of the Oireachtas authorised the terms of reference mandates the judicial person to come back after 20 days of oral hearing. People may have forgotten the detail but after 20 days of oral hearing former Judge Henley is obliged to come back to the Oireachtas with a progress report and also a request for any change in terms of reference. It seems to me the tribunal is moving very rapidly and he will have a very significant progress report to make.

Deputies will be aware of the sequence as well. All the issues chronologically referring to the BTSB are being examined and that will go on for some time. I presume then it will move to the drugs board and to the Department because in respect of the stated court cases there were three defendants and whereas the Department was tied in with the State and the Attorney General, effectively we are looking at three areas of inquiry. Those three areas were covered in the terms of reference.

The hepatitis C issue is serious but it was dealt with by me on the basis of the information which I had and I think I dealt with it effectively. We have an agreed health care programme, we have money in the Estimate for that programme and we are also proceeding with the compensation tribunal. I had a communication from the former Supreme Court Judge who heads up the compensation tribunal. He envisages a very serious increase in the workload at the tribunal and that is an issue to which we will have to return because it was meant to be a speedy resolution of people's compensation claims. The level of application and the number of people requesting dates for hearing is such that the tribunal could have up to four years work and that is significantly longer than anticipated.

Deputy Geoghegan-Quinn raised the issue of infectious diseases. I introduced a hepatitis B Protocol unilaterally because I was hoping I would be able to move on Protocols in respect of infectious diseases for health care workers and patients on a broader front. I hoped to make progress on the other infectious disease also but, with the event in the Mater Hospital and the attitudes of professional organisations and various unions, unless I moved on something even on an instalment basis very little would happen. I will examine the advisory group's report again to see if it can be published. It was not constructed on that basis. People were invited to give expert advice but not on the basis that that advice would be published. I have asked my officials if we can put it in the Oireachtas Library. It is not drawn up like a report one would send to a printer but there is information in it. If there is no legal problem with putting it in the Oireachtas Library Deputies will be able to see the issues raised in it. I am grateful to those who participated in it. There was a firm recommendation to move as I did on hepatitis B but much of the advice after that is general in nature and, as Deputies know, there are other issues. Deputy Geoghegan-Quinn challenged me on why I said in an interview that I could not move on one sector of health care workers without moving on all of them. I moved with all in respect of hepatitis B. All new entrants into employment with the health services will be covered by the Protocols. It was being said, obliquely, that we should test all foreign doctors, especially those from the Third World, and nobody else. I am not prepared to go with that. It is grossly discriminatory. It was not that I would not move unilaterally but I would not move on one sector of health care workers for reasons that would only be concerned with country of origin or racial background.

Hepatitis B does not have the range of issues attached to it that other infectious diseases have. That is because there is a vaccine. HIV is not a notifiable disease under the infectious diseases regulations. Considerations of confidentiality arise and in addition there is a concern that people would not come forward if it was notifiable. When HIV and AIDS came into public awareness in the 1980s, there was an attitude taken in most countries that it should not be notifiable and it was driven underground. It arises in any Protocols about hospitals and health care workers. What arises directly is the issue of patients infecting staff members. It is seen frequently as one-way, that a doctor who is HIV-positive may infect a patient, but I am advised that the risks from the opposite direction are greater. I hope to move on this but, as with many issues in my Department, when I became Minister I was faced with a situation for which no preparatory work had been done. I had to get a group of experts together to give me preliminary advice. I could have moved unilaterally on hepatitis B some months ago but I hoped to move it forward and deliver on a wider agenda because other issues arise as well.

The latest case was raised by Deputy Geoghegan-Quinn in the Dáil yesterday. I have little to add to the Dáil debate. I was at a pharmaceutical conference as president of the health care Ministers of Europe on Monday in Frankfurt. When I returned on Monday night I was briefed fully on this. I knew of a health care worker possibly being HIV-positive since Friday night but only on Monday did I learn that it was due to infected blood. At first I thought it was another case within the system of HIV from causes unknown. The blood problem was communicated to me on Monday when I returned to Dublin and met with my officials for several hours. The same happened on Tuesday morning as I knew I had to report to the Dáil. I got as much information as I could and put it on the record of the Dáil yesterday, answering questions as fully as I could. It is a difficult situation. Deputy Geoghegan-Quinn said I misled the Dáil in respect of the 1,600 people identified with HIV over the years that only one of them had contracted it from infected blood and that that blood had been donated abroad. I was not including the Kilkenny worker in that and I made that clear in the report.

Before coming to this meeting I read a transcript of an interview given by Mr. John Cooney of the South-Eastern Health Board. He has said that as they continue to search, checking the batch numbers against the batch numbers in the hospital, they have discovered another issue of blood was given to a man in St. Luke's Hospital in Kilkenny in 1981. That man did not revisit the hospital but died some years afterward when very elderly. That is another issue traced. I can say no more about that. He also said that in Waterford, which hospital is also in his remit, an issue of blood was traced to a laboratory there that he did not know. They were still checking if that was ever administered to a patient. He also mentioned that it seemed to be in the late 1970s; the cut-off point for blood infected by HIV is 1980. A lot of people say 1981. If it was the late 1970s they would have traced one more but, from yesterday's information, that might be one of the 15 of 31 that was pre-1980. It is not necessarily an extra one and the checking is continuing.

The Blood Transfusion Service Board, when it issued its letter to hospitals, did not specifically mention HIV but it was in communication with hospitals all the time. There have been ongoing look-back programmes in respect of hepatitis C. There is a lot of communication between blood transfusion specialists and the health boards. When they decided on the look-back, they felt the best way was in a letter asking if batch numbers were there. Their explanation is that because they knew the number of people was so small — a maximum of 15, and their own estimation was a lot fewer — in the record search within the Department one would not be dealing with medical people but administrative staff and a name might leak. I remind the committee that in the 1980s someone with HIV or AIDS was treated like a pariah by society. Frequently it was difficult for them to get medical treatment and that context should be considered.

Deputy Geoghegan-Quinn asked me about the inaccuracies in the records. I have said on numerous occasions in the House that there was a problem with some of the records in the Blood Transfusion Service Board, in particular with the look-back programme. Deputy Geoghegan-Quinn made the point that those programmes would not be very effective because of the inadequacy of the records. However, the records proved to be better than we thought and the programmes were very successful.

There was also a problem with records in some hospitals. The problem was universal but since 1980 the health board hospitals seem to have good records while some of the larger voluntary hospitals have inadequacies in records. In the present search it is difficult to know whether everybody will be as successful as the South-Eastern Health Board. The chief executive officer there has checked all the batch numbers and has uncovered the unfortunate health care person, although that was found through a test and not the search, the elderly men who did not revisit hospital and who died several years later, and a possible third case. He is confident his check has been thorough. I do not know how long it will take to do further checks.

The duty of care applies in identifying persons who have contracted HIV from infected blood products in all cases. I have insufficient information to make a decision about an optional testing programme. As soon as I am in a position to make that decision I will inform the Deputies.

On a number of occasions I have been asked what I knew about the situation and why I was not informed. I do not know why I was not informed. I should have been when the Blood Transfusion Service Board decided it would have a look-back programme. It said that one of its medical people was doing a review of the look-back programmes and in May discovered that a very small number of blood issues had not been checked due to the lack of checking between 1985 and 1989. It intended establishing what the risk was, which it believed to be four or five as Mr. Dunbar said. I do not know if it is right in that estimate but its intention seemed to be that it would inform the Minister after it had done the preliminary checking. I have still to meet many people but I accept that before the board embarked on a look-back targeted at very few people, it should have informed me. I will be making further inquiries about this.

The Department became aware of the details of the problem and of the specific arrangements for the look-back on 8 and 9 December. According to my officials, this was the first information that the BTSB gave the Department indicating that a specific look-back on blood issues with possible HIV infection was taking place. The Department was aware of the various look-backs into hepatitis C.

In the Miriam Hederman-O'Brien report, there was a specific reference to a plasma donor who tested HIV positive. When this was checked the anti-D product tested negative. The explanation was that the heat treatment in the manufacture process was sufficient to kill the HIV infection. Yesterday I divided cases between 1985-9. I said there were some before 1989 but there was one after 1989 that we knew about, the one matching that in the Miriam Hederman-O'Brien report.

I was aware as an Opposition Deputy that if HIV testing was introduced in 1985, then the issue arose internationally of possible infection prior to that year. The best advice was that there was no need to be concerned for the period prior to 1980, although a lot of medical people will say that the cut-off point is well into 1981. The difficult years are 1980-5. It was always an issue that persons had been infected by blood donations but there was reason for optimism because of the statistics which I have outlined. The maturation period for HIV is ten or 11 years. From 1985 back to 1980 you are looking at people who either got HIV 11 years ago or up to 15 years ago. In the normal process of testing they should be coming to attention without any look-back programme. This is why I said yesterday that infected blood was not identified as a risk in any of the 1,600 transfusions except in the case of the one person who got the transfusion abroad. The health care worker in Kilkenny seems to have got blood in 1985, so you are looking at the outer reach of it. It was 1996 before she developed an illness which doctors associated with HIV.

People are asking why their was no testing done between 1985-9. Frankly, I do not know.

Did the Minister ask?

I am trying to find out. I will not let this rest as it is a very serious issue. Thankfully, the potential numbers are small and I believe they are significantly smaller than 15. However, it is an issue that has to be addressed.

A number of things must be looked at. I am trying to find out what was known by the BTSB and the Department between 1985-9 but the key people have long since departed. People have died. I do not know if they were key people but I am doing my best to give as much information as possible. It is very easy to be contentious but I can assure you that, whoever else has learned from the hepatitis C affair, I have learned. I would like to see if we can get to the bottom of this.

The individual cases, if they exist, are tragic. There is a duty of care to find out who they are. We have reasonable grounds for optimism because of the work done by the present management of the BTSB which could give us accurate information quickly regarding the risk. We also have grounds for optimism because if there was significant infection it should have become evident by now in the normal course of testing.

We need to know precisely what happened and I will do my best to find out.

What about confidence in blood supply given the history, events and lack of information, even to the Minister?

We have a very good blood supply which is among the safest in Europe. That is not a patriotic boast. Mr. Sean McCann who was the haematologist at the BTSB and has returned to Trinity College as professor of haematology insisted the latest tests be introduced as quickly as possible. He was at the forefront of introducing the best possible rather than lagging behind. The letter's not mentioning HIV meant it was treated as any normal letter in some hospitals resulting in a delay in replying. However, I assure the Deputy it is no longer in the system.

Deputy Geoghegan-Quinn asked about a haemophiliac in the South-Eastern Health Board region in the 1980s. That does not ring any bell with me. I could have it checked out if she gave me precise details.

The Minister continuously says there are grounds for optimism. I cannot find any with the current management of the BTSB. Over 1,000 patients have gone through pain with hepatitis C due to lack of information and lack of communication. This is the same thing happening all over again. What is the communication system between the Blood Transfusion Service Board and the Minister's Department? The BTSB is conducting serious legal work and a look-back of the period between May and August 1996. It appears as if someone decided there was no necessity to tell either their political or departmental masters despite the fact that this was as potentially serious a matter as hepatitis C. What is the line of communication? How bad does it have to get before the Minister takes action?

I used the word "optimism" in a narrow context. I was trying to explain that we are not looking at 1,500 to 1,600 people as was the case with the hepatitis C affair. The only context in which I used "optimism" was that, on the basis of information presented to me, the look-back is trying to track down 15 issues of blood which would represent fewer than 15 people. I do not know if it is correct but persons in the BTSB have mentioned a figure of four or five. That is the context in which I used the word "optimism".

Why did the Minister not request information when the look-back started in May?

That must be found out. As regards the question of personnel, when the Deputy was Minister for Justice and the issue of hepatitis C was first brought to the Government's attention, the then Minister for Health, Deputy Howlin, appointed a new chairman, Mr. Joe Holloway, as the board came up for replacement. The board, which has been there since the Deputy's time in Government apart from some appointments I have made, is, by and large, a new board. There are some very able and distinguished people on it who are freely giving of their time. The chairman is the only member who is in receipt of an honorarium. They are dedicated people.

When the hepatitis C crisis occurred, Mr. Sean McCann, the bone marrow consultant at St. James's Hospital, Dublin, and associate professor of haematology in Trinity College, came in to help. He was not applying for a job as he had plenty to do. It was a burden on him which he took on as a public duty. He has returned to his original work but he was with the board until recently. He was not available over the past days because he was in the United States but would have been available during the summer. A new and permanent haematologist has been appointed to the BTSB. Mr. Liam Dunbar was an effective hospital manager in St. James's Hospital, had plenty to do there and had a good career.

Before we rush to judgment, we owe certain people a debt of gratitude for coming in and using their talents to sort out a most difficult situation. They are well aware of the difficulties in ensuring and maintaining confidence in the blood supply. They have also had an extraordinary amount of work. As well as restoring confidence in the service, they have had to reorganise the management and structures in Pelican House from a less than satisfactory situation. I then got them involved in the look-back programmes which became necessary for the hepatitis C affair. Phenomenal pressure was exerted on senior staff in Pelican House. On top of that, legal cases occurred, especially the Brigid McCole case. Again, the staff tried to ensure all relevant documentation was produced for the court under its order. They did what they were legally obliged to do. I do not say they were great people in doing that but that it was a load of work on top of people who came in to help out in a crucial area of the health services. On top of that there was a judicial inquiry. What would have been the priority since last October for long-term employees in Pelican House, both medical administrative, who were suddenly faced with a judicial inquiry?

Mr. Dunbar should have informed me that this look-back programme was happening but I am not prepared to criticise him until I have a fuller explanation. He has carried a heavy burden. He had nothing to do with the events which gave rise to the hepatitis C problem or this one. Both he and Professor McCann came in, not because they were well rewarded but to do a public service duty. It was put to them by me and the Secretary of the Department that this would not be easy but, in the interests of the health services, this had to be done by someone.

Did the Minister not meet him since?

Mr. McCann is away but I would like to meet him. I did not meet Mr. Dunbar but intend meeting him. The reason I did not do so was because I met my officials when I came back on Monday night. I knew I would be reporting to the Dáil on Tuesday. Through the Secretary of my Department, I put arrangements in place to collect the maximum amount of information possible. I do not believe in a management system where the Minister blunders around interviewing people at certain times. However, I will meet him.

The Minister must if the issue is crucial.

I accept that the information he supplies to the Secretary of the Department would be what I requested. I co-ordinated the information to ensure I could give the Deputy the fullest amount possible. She will get more if I have any before Tuesday.

Decisions must be taken soon. I am prepared to take them when I have sufficient information to justify taking them. The Deputy has put her finger on one of them on a number of occasions which is that, although the group is potentially very small, the issue of the duty of care as a principle is the same as in the issues we previously faced. I may have logistical difficulties if I set up a voluntary screening programme. I will probably have to go to the viral laboratory and have it run from a section of the Department. However, what must be done will be done. We will see where gaps exist as we get more information. The fact that they have moved quickly in the south east and succeeded in tracking down one or two relevant issues does not mean that progress will be as rapid in other areas.

Deputy Moffatt spoke about the accident and emergency facilities in the Mater Hospital. I was concerned last year but we made significant improvements. One never knows with this area. Things are always busy in the winter and ten or 15 extra patients can exacerbate the problem. We hope that this will not happen but extra money is included in the Supplementary Estimate which I am using to provide additional facilities so that we have step down facilities in Dublin.

However, if there is very cold or foggy weather after Christmas this will put pressure on the health of the elderly. Foggy weather causes bronchial infections and most GPs refer the elderly, especially those living alone, to hospital. This could result in a rise in admissions to what is known as 110 per cent occupancy. When this happens the extra 10 per cent are on trolleys in corridors and in unsuitable accommodation.

I was mostly interested in the prisoners' issue.

I do not have specific answers to that but we can communicate by letter. The investment in mental health since 1990 is £56 million. A data base has been established for those who need residential or day care facilities. While there is some money in the Estimates I hope that the Government will support other initiatives between now and the budget. I am conscious of the fact that more needs to be done in this area.

The same applies to Mayo Phase II as to Galway. There is £108 million included in the 1997 estimate on the capital side. That will allow for processing commitments already made.

The women's health policy document which was published in June 1995 was the subject of consultation with 156 voluntary and women's groups throughout the country. I am almost ready to publish a plan for women's health which will be one of the next policy documents published by the Department.

In view of the fact that the Minister has not yet spoken to Mr. Dunbar and that he was told last Friday, and definitively on Monday, about this, does he not consider it odd that there is a divorced relationship between the person with political responsibility for this matter and the person who presided over its administration during the summer? When will the Minister meet Mr. Dunbar given that he is giving press statements but has not spoken to this democratic assembly? When will the Minister inform the House of the reasons he was not made aware that this activity was taking place on legal advice to the BTSB in August and that the letters were being sent out to hospitals without the Minister or the Department knowing about any of these events?

The information I was given was that there was a healthcare worker in Kilkenny who was HIV positive. That could be from a variety of sources and, while it is disturbing, it is a different issue. It was only late on Monday that I was told that the person had been infected by blood products. I returned late to Dublin, had a meeting with my officials and put systems in place to get the maximum possible information. In that situation I would work through the Secretary of the Department and the decision not to meet different personnel was valid. I hope to have met Mr. Dunbar before next Tuesday.

There is nothing extraordinary about that. The BTSB is a scientific and specialist group and it carries out its activities within its remit. The route of information back to me is through the Secretary of the Department. I have met Mr. Dunbar, Mr. McCann and the chairman of the board on several occasions. My primary responsibility is to the patients but I also have a responsibility to the House. I wanted to have the maximum possible information and Deputies will agree that in a short period of time, because of the good information in the BTSB, we were able to put accurate information on the record of the House yesterday.

If the nurse had not come forward——

The Deputy said this yesterday but she is wrong again. The BTSB was not reacting to the nurse's illness. When the BTSB reviewed its targeted look back programmes it found a gap and decided to address it. That process was commenced in May. It should not be said that a person gave notice of someone being sick in Kilkenny and then everyone jumped to action. I have told the Deputy the issues that have arisen in terms of why I was not informed but I have no doubt that I would have been told as soon as the targeted look back took place and the scope of the problem had been identified.

Is that a rule of thumb?

The Deputy can be contentious but I will not react. I am trying to give the fullest information that I have in the context of estimates. Most of the people with me are financial people from different sections of the Department. I have outlined the situation as fairly as I can.

I would like to make a proposition before the meeting concludes.

That depends on the proposition.

In view of the fact I believe that the new management of the BTSB has learned nothing regarding administration procedures as a result of the hepatitis C affair, I would like the Clerk to the Committee to write to Mr. Dunbar and invite him to come before us to explain these matters.

It is important to acknowledge what he has done.

I am sorry to interrupt the Minister but we must conclude.

If we are not careful we will reach a situation where people will not take on public duty in crises because they will be afraid of the risks.

Afraid of accountability?

Report of Select Committee.

That concludes our consideration of the Supplementary Estimate. The committee having completed its consideration of Supplementary Estimates in respect of a number of Votes, I propose the following draft report to the Dáil:

The Select Committee on Social Affairs has considered the Supplementary Estimates for the Public Services for the service of the year ending 31 December 1996 in respect of the following Votes:

Vote 26: Office of the Minister for Education

Vote 27: First-Level Education

Vote 29: Third-Level and Further Education

Vote 41: Health

Vote 42 : Department of Arts, Culture and the Gaeltacht.

Vote 43: National Gallery.

The Supplementary Estimates are hereby reported to Dáil Éireann.

Is that agreed? Agreed.

Report agreed to.

Ordered to report to the Dáil accordingly.

The Select Committee adjourned at 5.30 p.m.