I move:
That a sum not exceeding £845,574,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1982, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chlaraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.
I had hoped to give a more comprehensive speech but because of the time limit, I have substantially cut my speech.
The gross non-capital provision in the Estimate amounts to £865.874 million. Allowing for appropriations-in-aid at £69.5 million the net non-capital grant provision is £796.374 million. The net non-capital grant provision represents an increase of about £67 million on the out-turn for 1981.
The capital provision included in the Estimate amounts to £49.2 million.
Vote 51 — increases in remuneration and pensions — contains £53.657 million in respect of the 1982 Exchequer liability arising from pay adjustments for health services personnel based on the proposals for an agreement on pay in the public service. The 1982 budget provisions for the health services will be covered in a Supplementary Estimate which will be introduced later in the year.
The Estimate which I have moved was prepared by my predecessor who approved of non-capital allocations for health agencies which were related to the level of grant provision in the Estimate.
When I assumed office I found that the reaction from health agencies to the levels of allocations approved had been distinctly unfavourable. There was general agreement among health boards that unless the allocations were increased serious consequences for the health services could not be avoided. It emerged that the overall allocation was about £48 million short of what was needed to maintain services at 1981 levels. The seriousness of the position was made clear at a meeting which I had with the chairman and chief executive officers of health boards on 2 April last. Among the more drastic measures which were considered to be necessary to contain expenditure within approved levels were the closure of hospital wards for protracted periods, significant reductions in numbers covered by medical cards, severe curtailment of vital community services such as home help services and meals on wheels and cutbacks in services for disadvantaged groups such as the mentally ill and the mentally handicapped. Unprecedented reductions in numbers employed would also have been required to secure the necessary savings.
Despite the financial constraints imposed by the difficult economic situation, the Government considered that it was necessary to provide extra funds to ensure that community based health services could at least be maintained at a reasonable level and that the measures which would undoubtedly be required to control expenditure on hospital services would not be such as to deprive people of essential hospital care. The Government, therefore, decided to provide an additional £28 million in the budget to ease the severe financial constraints in the health services. The effect of these extra funds has been to reduce the overall deficiency in the allocation for health services to about £20 million.
Despite the extra funds provided for health boards, voluntary hospitals and homes for mentally handicapped persons, there is still undoubtedly a gap between the increased allocation levels approved and estimated requirements. I know that difficulties are arising in bridging this gap. I must, however, emphasise that the Government have gone as far as they can go in providing extra funds for health services in the current year. It is now the responsibility of the health agencies to achieve the necessary economies. This will require the full support of all personnel, both in hospitals and in the community. But I must emphasise that the situation is now in my opinion manageable, if undoubtedly difficult. It represents a challenge, not an impossibility.
Expenditure on health services has risen rapidly in recent years. In 1977 the net non-capital cost amounted to £328 million. In the current year, taking account of increases in pay costs and the budget provisions for the health services, the cost will reach £978 million. In 1977 health services absorbed 6 per cent of GNP. This year the percentage will be about 8 per cent. Some of this can be accounted for by the increasing welfare dimensions in the form of better community-based health and personal social services. This is a development which we have promoted.
Other factors which have given rise to the increase in health costs over this period include extensions in entitlement to services, specific developments in the services, improvements in medical technology and the increasing demand for services, partly accounted for by a rising population.
The main reasons for the rising costs are, however, increases in pay and increases in the price of goods and services. Pay costs have increased from £197 million in 1977 to about £652 million in the current year. This is due to increases in the numbers of personnel employed in the health services, the application of national pay awards to health services staffs and, in particular, to costly special pay awards for many grades of health personnel settled under the established negotiating machinery. Pay costs now represent 64 per cent of overall expenditure on health services and about 70 per cent of expenditure in the acute hospital sector. It is clear, therefore, that measures to contain expenditure on health services must centre largely on the area of pay and personnel.
Unless the pay element in the cost of health services can be stabilised there is a real danger that the funds that can be provided by the Exchequer for our health services will not be sufficient to support the present work force, and that largescale disemployment and disruption of services will inevitably take place.
During the course of the past 12 months because of the present difficult economic situation the Government have found it necessary to restrain the creation of additional employment in the health services. These constraints apply not only to the health services but are of general application throughout the public service. In the present circumstances, therefore, it is of increasing importance to make the most effective use of our existing staff so as to enable essential improvements and developments to take place. It is important that there should be maximum flexibility in the deployment of personnel and posts in order to ensure that they are allocated to the best advantage.
It is clear, therefore, that over the next few years, funds required to effect essential improvements in the health services must largely come from savings on existing services. It is, therefore, imperative to research, as quickly as possible, how savings can be achieved and to take the necessary steps as soon as possible to realise these savings. I have, therefore, set up a special unit in my Department to explore ways and means of identifying areas where savings in cost can be achieved without detriment to the effectiveness of the services concerned.
One such area for close examination is the general hospital service. Institutional services account for 75 per cent of the expenditure on health services and about two-thirds of the institutional services costs relate to general hospitals. This year the average cost per patient in a general teaching hospital will amount to about £665 a week. It is noteworthy that in the period 1960 to 1980 the numbers admitted to acute general hospitals increased from 250,000 to 540,000 per annum. We must now try to concentrate the minds of all concerned on the steps required to stem the tide of hospital admissions, to ensure that only those who really need to be admitted are referred for in-patient care and to provide treatment to the maximum degree possible either at general practitioner level or on an out-patient or day care basis.
It is also essential to eliminate any unnecessary expenditure on hospital services for those who are admitted. The aim should be to provide services with the maximum degree of efficiency. Evaluation of efficiency depends largely on the development of better information systems regarding comparative costs in order that each hospital can assess its own performance by reference to the performance of other comparable hospitals.
A number of preliminary studies have already been undertaken by my Department and these have shown wide variations in certain areas of expenditure between hospitals in broadly similar categories, variations which cannot be readily explained. For example, the cost of drugs in one major hospital was 30 per cent greater than in another comparable hospital. These comparative costings will be of considerable value to the new research unit in probing further into this complex, but I hope rewarding, examination.
I have circulated to Deputies the most up-to-date volume of statistical information relevant to the health services. This information is set out by reference to the main health programmes. It will help Deputies to understand what is happening in each programme. I would like to refer here to some features of the vital and health statistics which are of particular relevance.
The percentage of the population in the dependant age groups — that is under 15 years of age or over 65 years of age — is important because it is from these age groups that the major demands are made on the health services. 41.3 per cent of the Irish population was in this category at the time of the 1979 population census. This, by international standards, is high. It is higher than the corresponding percentage for any other member state of the EEC.
The Irish birth rate continues to be, by far, the highest of the EEC member state. In 1980 the rate was 21.9 live births per 1,000 population, a total of 74,388 births. This is the highest annual number of births recorded in this century. Less than 1 per cent of these births now take place at home. It is very encouraging to report that infant mortality, which is accepted as one of the important indicators of the general state of health of a community, is continuing to decline in Ireland. As recently as 1960, the rate was 29.3 infant deaths per 1,000 live births. By 1970 this rate had fallen to 19.5. In 1980 it was down to 11.2.
I have already mentioned the continuing increase in the number of persons being admitted to the acute hospitals. In 1980 the number of admissions was about 540,000 or 158 admissions per 1,000 of the population. This is one of the areas which will be studied by the new research unit to see what scope there may be to control admissions to our very efficient but very costly hospitals.
In the psychiatric hospitals the number of patients in residence continues to decline. It has fallen from about 20,000 in 1963 to about 13,000 in 1981. On the other hand, the number of admissions to mental hospitals has increased from about 20,000 in 1969 to 27,000 in 1979. In recent years alcoholism has emerged as the major single cause of admission. In 1979 this condition accounted for 26.2 per cent of all admissions. These figures reflect greater activity in the treatment of the mentally ill and the strengthening of services in the community for their care and rehabilitation.
I would like to say a few words on the question of substance abuse. I am very conscious of the increasing incidence of alcohol and drug abuse among young people and I am taking immediate steps to alert and educate parents and young people to the dangers inherent for them in the whole area of substance abuse. I recently allocated an additional £¼ million to the Health Education Bureau to undertake an urgent national programme on substance abuse.
The bureau's programme will involve the training of teachers, doctors, pharmacists, career guidance counsellors, health board personnel, gardaí and clergy as drug educators. These will be available to act extensively throughout the community, and particularly in schools. This aspect of the programme is aimed primarily at parents, to inform them as to the nature and extent of the problem, to equip them to guide their children away from becoming involved with drugs and train them to react appropriately in organising treatment and support if their child has a drug problem.
Young people themselves must also be alerted, advised and educated outside the home as to the dangers of drug abuse. The school is the obvious place through which to impart information. To this end the Health Education Bureau, with the full support and co-operation of the Department of Education, are arranging for the preparation of educational materials on all forms of substance abuse for second level school children. This is being piloted in selected schools at present and will be extended to all schools from September 1982.
Education in relation to abuse of alcohol will be a component of this comprehensive programme for schools. There is also a special alcohol education programme for second level schools in the process of being designed at present by the bureau. The aim of the programme is to develop a responsible attitude in young people to the use of alcohol. It is expected to be in operation early next year.
In relation to the problem of glue sniffing, while glue is not a drug or a poison, it is a substance subject to abuse, which can become a health hazard. As such, it rates for inclusion among the substances subject to abuse for which preventive measures are being formulated by the Health Education Bureau. Although glue-sniffing is seen in the context of the drug problem generally, glue in itself is not a dangerous substance and would not, therefore, come within the scope of controls relating to such substance administered by other Departments, for example, explosives, toxic chemicals, and so on.
Glue is not a drug or a poison and therefore cannot be considered in the context of the Poisons Act or Misuse of Drugs Act. Similarly, it is not possible under those Acts to control other commonly available items which are occasionally reported as being the subject of abuse. The 1908 Children's Act prohibits the sale of cigarettes and intoxicating liquor to persons under 18 years. It is proposed to extend this provision in the new Children's Bill to apply to "such other substances or products as may be prescribed by the Minister from time to time". This will give a new facility and new enabling legislation to the Minister to control such materials as are considered necessary.
This year marks the tenth anniversary of the introduction of the choice-of-doctor scheme for medical card holders. The service provided for patients has, in general, been satisfactory. The abolition of the dispensary system after so many years will, I feel sure, be regarded as one of the most significant developments when the history of our health services comes to be written. There have been problems associated with the new service. Chief among those has been the question of cost associated with the visiting and prescribing rates, each of which has been substantially greater than the rates which were anticipated when the scheme was being negotiated. There is, therefore, need for constant monitoring of the scheme in the interests of all concerned.
The supply of drugs in the general medical service has been the subject of a report by Trident Management Consultants. I am currently engaged in a detailed examination of their recommendations, in preparation for consultation and discussion with the relevant interests.
Responding to the request of the medical profession I am establishing a working party to examine the position of general practitioners who are engaged in the general medical service. They have been pressing for a change in the terms of their contracts to include provision for superannuation and related benefits for contracting doctors. Such a radical change in their terms of service should not, in my view, be considered in isolation from their conditions generally and from the experience of the operation of the service over the past ten years. I expect that the working party will report with all possible speed and that their recommendations will provide a basis on which to secure the development not only of the general medical service but of general practice as a whole for the years ahead.
I should like to say something very briefly about the health capital programme. I am engaged in the preparation of a medium-term programme which will allow of the orderly achievement of developments which I am endeavouring to promote within a period of five or six years. The commitment of resources in this way will remove from the scene much of the aggravation hitherto associated with the stop-go approach which has bedevilled planning development in the past. My time in this debate is quite limited so I had an opportunity to cover only a number of the items currently in progress in the Department.
Eligibility for the health services has been raised from £8,500 to £9,500 from I June. I could say a good deal about the Voluntary Health Insurance Board and their relevance to workers and people in general. I should also like to have said something about infectious diseases. I am particularly concerned about the reappearance of polio due mainly to complacency about vaccination, and also the increased incidence of whooping cough. Work is also going on in the area of hygiene. One of the most outstanding features of this area is, that despite the very valuable work involving the hygiene awards being done by the Health Education Bureau, in 1981 there was a 60 per cent increase in notifications of infectious hepatitis over the previous year. This is due principally to poor food hygiene and poor personal hygiene. We are pursuing these matters vigorously at present. Because of the hygiene awards and the efforts of the health boards and the Health Education Bureau, there has been a tremendous improvement in standards, but we are quite concerned about this aspect at the moment.
I should like also to have referred at some length to the work of the Health Education Bureau which is becoming much more penetrating than perhaps it was in the past. The bureau concern themselves in particular with young people, children in school, and the different age groups. I am sure the work being done will be very effective. A great deal is happening in the community care services, in the area of home help and meals on wheels. I am particularly attached to these services and I am very anxious to see them being developed. In the extra £28 million being provided, we are ensuring that the home help service can continue at its present level. I am having an examination carried out into the further development of this service.
We have a whole series of health centres being developed throughout the country, some of which are at an advanced stage, and others are at various stages of planning. Ultimately, they will provide a very important basis within communities for the delivery of community-related and community-based health services.
I should like to have dwelt on the dental and ophthalmic services. The National Community Development Agency Bill is being debated in the House at present. It is covered in this debate having been transferred from the Social Welfare Estimate to the Health Estimate. The National Council for the Aged are working quite well. They have five committees, one dealing with income maintenance, one dealing with housing and institutional care, one dealing with community services, one dealing with the role of the elderly in society, and one dealing with the progress on the implementation of the recommendations in the Report of the Care of the Aged, published in 1968. We have already had a report from the National Council for the Aged which I set up last year, relating to day hospitals and their function within the services generally. I expect very worthwhile contributions from those committees on the areas they are studying.
I know the House has a considerable interest in the question of the care of children. I hope to make a statement very shortly on the outcome of the report on the O'Brien and Sutton cases. I hope also to announce shortly the setting up of the National Council for Children.
We could say a good deal about our psychiatric services. We have a very strong commitment to continually improving our psychiatric services, with particular reference to the development of community-based services. There is a great deal of activity in the area of mental handicap. I am particularly concerned about the services for the adult mentally handicapped. They will be given priority in the work of my Department. One of the difficulties is that the children's units are being filled, if you like, by adult mentally handicapped people who stay on there because of a lack of other facilities. This must be tackled as a major priority. By providing adult facilities, more facilities will be available for children.
We have a fairly substantial legislative programme to come before the House shortly. We have the National Community Development Agency Bill. We will have a Dentists' Bill in the autumn. We have a Nurses' Bill and a Children's Bill which I hope to have circulated relatively soon. We have poisons regulations which are very detailed and complex. We have the Health (Mental Services) Regulations. We have a Bill to provide for statutory registration for certain paramedical professions. The Green Paper on the handicapped will be published in the autumn.
In the time available to me I have gone briefly over some of the main activities of my Department. I look forward to hearing comments by Deputies and I recommend the Estimate to the House.
