Dáil Éireann díospóireacht -
Thursday, 22 Mar 1984

Vol. 349 No. 2

Estimates, 1984: Vote 47: Health (Revised Estimate) (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £1,021,212,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1984, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.

—(Minister for Health).

Minister of State at the Department of Health (Mr. Donnellan)

The fluoridation of water supplies, which began in July 1964, is now virtually completed in so far as practically all water supplies serving populations of any consequences have been or are about to be fluoridated. At present 2.1 million people or approximately 61 per cent of the population are in receipt of fluoridated supplies. Of the water supplies which are unfluoridated, it is estimated that only 3 per cent of the population are served by supplies which are suitable for fluoridation.

The Department and Irish pharmacists are engaged in finding solutions to problems posed by proposals for EEC directives dealing with the free movement of pharmacists, right of establishment and mutual recognition of diplomas within the community. The purpose of these proposed directives is one which is central to the philosophy embodied in the Treaty of Rome, that is, a unified community where harmonisation of economic and social conditions and free movement of workers between member states exists. This objective is one which the Government support wholeheartedly.

Pharmacists understandably have reservations about the implementation of these proposed directives under the diverse regulations governing the opening of pharmacies throughout the community. There is a need for prior co-ordination of the conditions of the practice of pharmacy in all member states. Certain amendments to the draft directives have been suggested by the European Parliament which are intended to meet the problems raised.

The need for some form of State control over the distribution of pharmacies is a matter which has been raised on many occasions by representatives from the pharmacy profession in Ireland. The Irish Pharmaceutical Union prepared a report on the licensing of planned distribution of pharmacies some years ago. Naturally enough no member state would like to see its nationals placed at a disadvantage vis-á-vis their counterparts in other member states.

However, this whole question of localisation of pharmacies is one which raises many complex and difficult issues. The concept of professional freedom, constitutional rights to practice and succession and the complex area of corporate law have to be considered. The extent to which the State should become involved in this matter is one which requires high level discussion to iron out the issues.

The recent implementation in this country of regulations providing the pharmaceutical society with greater powers of control over the practice of pharmacy will provide them with more statistical information on the current distribution and ownership of pharmacies and on their staffing. The availability of this detailed information is a necessary prerequisite to any serious discussion on the wider issue of the distribution of pharmacists.

One particular area where I would like to see the undoubted talents of the pharmacist put to better use is in the area of health education. Today's community pharmacist is in an ideal position, by virtue of his face-to-face contact with the public, to promote the concept of a healthy lifestyle. We are all aware of the problem of increasing demand for drugs for every illness, no matter how minor. Health education has a vital role to play in the prevention of the misuse and abuse of drugs. The pharmacist is a professional who has the respect of the community, and I believe that the public will listen to his advice that there is a healthy alternative to a lifestyle dependent on drugs. Pharmacists have been involved, in recent years, in giving talks to community groups on the problem of drug abuse.

Before concluding, I would like to return to the theme of how our health services have evolved and the broad direction which they may take in the future. In this context, I would like to make brief mention of the major programme launched by the World Health Organisation entitled "Health for all by the year 2000".

The emphasis in this programme, and increasingly among those concerned internationally with the planning of health services, is on the maintenance of the best attainable good health rather than on the cure of sickness. Attention is focused in a major way on health promotion and primary health care. The whole concept of health promotion is not entirely new and in many ways it is concerned with changing existing patterns of behaviour which have a damaging effect on health. Such damage can be inflicted in the short or the long term and the actions of individuals may adversely affect not just their own health, but also that of many other people.

There is a compelling logic and attraction in the idea that many forms of illness could be avoided through greater consciousness on the part of individuals, and society in general of the possible consequences for health status of particular actions they take. This is particularly so in the case of illness the onset of which is heavily influenced by one's lifestyle.

I do not intend to dwell on this point as I feel that the overwhelming argument for prevention is self evident. The challenge in the future will be to translate these principles of prevention into the practical policies of the health services.

Mr. Fitzsimons

I should like to make a few brief observations on this Estimate which is an important one in that it covers a wide area. I should like to refer in particular to the care of the aged, a fundamental part of our health service. Unfortunately, although that service is getting better it is not improving fast enough. In the past we were not too proud of the service for caring for the aged and improvements today are hampered because of lack of money. The programme for the aged is suffering in most health board areas due to a lack of finance. In the North-Eastern Health Board area there are long waiting lists for entry to our geriatric hospitals. While these hospitals are doing a very good job, the waiting lists could be reduced if the home help service was substantially improved. This service encourages families to keep the elderly at home, and finance is provided for relatives or neighbours to look after the elderly rather than admitting them to our overcrowded geriatric hospitals.

This is an area at which we should look because if we live long enough — in our profession it is doubtful — we may not have anybody to look after us when we get old. It is then that we will appreciate the geriatric hospitals. It is better if elderly people can be kept at home and looked after by neighbours or relatives. This will give them the feeling of being wanted.

There is a scarcity of public health nurses and this is one area in which we are falling down. It is said that we should have one public health nurse to every 2,500 people but in reality the figure is in the area of one public health nurse to 3,500 people. The public health nurses are unable to cope because they have too much to do and that reflects on the aged and the elderly. The Minister should look at this area with a view to providing extra money. There is a small amount of money allocated to the programme for the aged but it is inadequate. I strongly recommend that more money be provided in this very important and sensitive area.

There is no doubt that the dental services are suffering for want of finance. In most health board areas there are hundreds of people waiting for dental services — adults and school-going children. The reason for this delay is simple — we have the dental clinics but we do not have the dentists because we are not able to pay them enough. Dentists earn much more in private practice than they would if they were employed by the health boards. Therein lies the problem. In the meantime the people, especially our young people, are suffering. We have to find a way to reduce these waiting lists and provide dental services.

In our clinics we hear of many cases of people waiting for orthodontic treatment. I appeal to the Minister to look at this situation to see if anything can be done about this problem. It is easy to be critical but without doubt the orthodontic service, particularly for school-children, is a sham.

Mr. Donnellan

There is a new dental health Bill in the Seanad and it will be before the Dáil before too long. This might alleviate the problem.

Mr. Fitzsimons

I am very pleased to hear that, because in my view the service does not exist.

Mr. Donnellan

We did not create the problem, we inherited it.

Dr. McCarthy

There is nothing in the Bill that will increase the services.

An Ceann Comhairle

That is not before the House.

Mr. Fitzsimons

The sooner this Bill comes to this House the better. If there is anything good in it we will welcome it because the present service is a sham and I hope something can be done about it.

There is the problem of insured persons needing dental treatment, for example, fillings. This service is provided by private dentists who participate in the dental treatment scheme for socially insured persons, but this has to be sanctioned by the health boards first. In most health boards there is a delay of up to eight months before the boards sanction treatment. This delay defeats the purpose of the scheme. This is not the fault of the dentist or the patient but of the Department and the health boards. This brings us back to the fundamental issue of the demand for the service and the inability of the Department to provide the money for the service.

It is a pity hardship was inflicted not only on the parents but on students themselves by the abolition of the medical cards for them. That move put the health of those students in jeopardy. Because of the struggle parents have trying to educate their children today, if second or third level students suffer from ill-health, their health will be neglected because their parents cannot afford to send them to a doctor. The Minister should not inflict any further defects on the medical card system. He should leave it alone and, if possible, restore medical cards to the students because while it may be saving money, in the long term it will affect the health of future generations. There is not much point in having unhealthy young people because one needs to be in the best of health to survive modern day living. This is an area the Minister should look at. I am not being political when I say this, but this will be a political issue if there is to be an election. Whether it is an issue in the European election is another matter.

Minister of State at the Department of Health (Mr. Donnellan)

I am sure the Deputy will make it an issue.

Mr. Fitzsimons

I am not politically vindictive enough.

Mr. Donnellan

I would not say it would be vindictive to do it.

Mr. Fitzsimons

We are very dignified on the eastern seaboard and would not know too much about that. I am more concerned about the health of people than making a political issue of it.

We have a very good old people's home, St. Joseph's in Trim, which looks after County Meath and parts of County Westmeath. I would hope that there could be extensions to these homes because they are doing a very good job. They are spotless and the people are well fed and well looked after. There are waiting lists for these homes and for geriatric hospitals and every Government should give compassionate consideration to providing money for these facilities.

Some years ago our local hospital, Our Lady's Hospital in Navan, was to come under the hammer subsequent to the Fitzgerald Report. Fortunately the folly of this was seen by the Minister for Health during the 1977-79 period, Deputy C. J. Haughey, and he decided that the hospital required up-dating because of the changing scene since the report was produced in the late sixties. Through his intervention a fair amount of finance was provided and there has been considerable improvement. The population in County Meath has risen from about 70,000 in 1971 to in excess of 100,000 today.

As well as the general hospital we also have an orthopaedic hospital which looks after Counties Louth, Meath, Westmeath, Longford, Cavan and Monaghan. It is an excellent hospital but suffers from the common problem of lack of finance and a shortage of beds. They are carrying out very successful hip operations which are greatly in demand because of the incidence of osteo-arthritis. There is a three-year waiting list for such an operation because of the shortage of beds. Three top-class orthopaedic surgeons are working almost round the clock in providing a service for these six counties. The Minister should give favourable consideration to the provision of money for the necessary beds.

I do not have to remind the Minister that this Government closed down the children's orthopaedic hospital at Coole in County Westmeath. The idea was to provide beds for these children in the Navan hospital but this has not been done. Clearly there is a dire need for beds in the north-eastern region which, for the purposes of the orthopaedic service, takes in Counties Westmeath and Longford.

Many old people suffering from osteo-arthritis of the hip die before the ailment can be treated and it is horrifying to see the pain they suffer. We have great professional expertise but we are not able to cope with the demand for treatment of this ailment. Many people suffering from this condition are cripples one month and are dancing a jig the next due to this extraordinarily successful operation. I speak specifically about the North-Eastern Health Board area but I know there are similar problems around the country. Perhaps the high incidence of this ailment is due to our damp climate. It appears to be becoming more prevalent and to be affecting lower age groups. Many of us carry scars from the football field, as the Minister will know. One of these orthopaedic surgeons in Navan is waiting to do a job on both my knees but I have not time yet to have it done.

Dr. McCarthy

After the European elections.

Mr. Fitzsimons

Possibly. Most of the people I am speaking about have not been involved in sporting activity to that extent. I remind the Minister that we had a maternity hospital in Trim which was closed by him last year. Clearly there is a need for a maternity hospital in the region because of our growing population. Most people in the country use the Dublin hospitals or the Lourdes hospital in Drogheda. Our population is increasing at the rate of about 3,000 a year because of our proximity to Dublin. The Dublin maternity hospitals are grossly overcrowded and mothers must leave the hospitals very quickly due to the demand for beds. In view of the fact that he closed down the maternity hospital which existed in Trim for many years, the Minister should consider providing an alternative maternity hospital in the near future. People in the area tend to marry very young, the population is rising and the desirability of such a hospital is evident.

The self-employed have been somewhat discriminated against in the determination of eligibility for medical cards. The health board seem to ignore even the income figures agreed by the Revenue Commissioners. Recently at Question Time Deputy Connolly referred to the case of an Offaly family, that case showed blatant discrimination against the self-employed. The Minister should issue guidelines to the various health boards so as to ensure that commonsense would prevail in relation to accepting the figures of the Revenue Commissioners. In this area, also, there is the question of farmers' health contributions. This is a question that is rather nebulous at the moment because of the Supreme Court decision in relation to the rating system for farmers. Instead of being based on PLV, the health contributions from farmers are based now on income but I understand that in many areas the health boards are having regard to the assessments made by the Revenue Commissioners as to farmer incomes rather than to the actual tax paid eventually. I understand that another problem in this regard is that many farmers do not receive application forms from the health boards. All farmers should be included in the scheme but they should be assessed on the commonsense basis of real income rather than on the basis of an assessment made by the Revenue Commissioners. This is another aspect of the unusual situation in respect of the taxation of farmers in general. It is an aspect that is finding its way into the area of the health services.

Regarding the handicapped, we in Navan are very proud of being able to look after people so afflicted by way of voluntary services of the community in providing schools for mildly handicapped and severely mentally handicapped. There is an active rehabilitation unit in Navan. There are many physically handicapped persons who are not ill in any sense of that word but whose physical handicap is the result of some childhood illness such as polio and who are in mental hospitals. This should not be the case. There should be available units geared specifically for the needs of the physically handicapped. It is a serious indictment of our health services that such people be detained in mental hospitals. This is an age-old Irish problem. These people are put out of the way as it were into these institutions. It has been a defect of our society down through the years that such a situation existed but one would hope, now that we are well into the winter of this century, that the situation would be arrested and that the physically handicapped would be accommodated in places designed specially for them.

The big problem in respect of health matters is that of finance. There is the difficulty of trying to spread available finances as much as possible. Apart from the usual health problems that beset a population we now have the enormous problem of drug abuse to contend with. In his speech the Minister impressed on us the size of the drug problem in Dublin. While drug abuse is a problem of great proportion in Dublin it has spread to towns and villages throughout the country. It is frightening to think that in Dublin alone there are 1,500 heroin addicts. There are probably twice as many experimenting with that drug.

The enormity of the problem and the complications of it have been brought home to us particularly in the recent past with the abducting of certain people in the city. This situation highlights the alarming problem of young people finding themselves at the mercy of hoodlums and gangsters. Another very sad aspect of this whole problem is its link with crime. As the Minister mentioned, invariably heroin addicts have to resort to crime in order to obtain the necessary money to feed a habit which can cost from £100 to £150 per day. The only way in which young people can find that sort of money is by robbing not only commercial premises but the homes of people all around this city and elsewhere. On the Order of Business I heard Deputy Brennan ask the Ceann Comhairle for permission to raise the matter of the incidence of old people being robbed in Sligo. I do not know whether that situation in Sligo arises from drug abuse but it is frightening that both old and young alike are being robbed. The increase in this type of crime must be linked with the drug abuse situation. It is horrifying to think that there is drug abuse among school children. This phenomenon is not confined to any one sector of society. I know that a governmental task force has been set up to consider this whole problem but the figures are alarming for such a small country. We must put a stop to the problem. Obviously, it is not one that can be eliminated overnight. One would hope that the Garda task force on drugs are being very vigilant in this area. Unfortunately the problem has spread to the provinces. It is a very serious situation and I know the Government are taking a very serious view of it.

The Minister mentioned the ophthalmic service. Again there are always delays. They may not be of as serious a dimension as the delays in the orthodontic service, but I hope this service can be improved and if money is needed that it will be provided.

The Minister is trying to ensure that there will be severe cutbacks in all hospital services. This will give us five-day-a-week hospitals with very limited treatment available at weekends. We cannot have five-day-a-week hospitals like five-day-a-week boarding schools because staff and teachers are not available to work at weekends. It would be intolerable to have five-day-a-week hospitals. I hope the Minister and the Government will reappraise that situation and ensure that it does not occur. If not, the Minister wants instant deliveries by pregnant mothers, with mothers coming into and leaving hospitals in the one day. That would be most undesirable.

There are many problems in the health area which basically take finance to solve. There is not much point in educating young doctors and turning out the best and most efficient medics in the world if we have not got the facilities for them to enable them to look after the health of the nation. The policy of the Government in relation to the cutbacks which are affecting the health of the nation needs to be re-appraised with a view to providing the finance in the very near future for these essential services.

Mr. Durkan

I am glad to have this opportunity to say a few words about this very pivotal Estimate for the Department of Health. Despite the straightened times in which we are living, a considerable budget has been approved for the Department. There is a figure of £1.021 billion approximately made up of a gross non-capital provision of £1,057 million and a capital provision of £55.5 million. In the non-capital area that represents an increase of approximately £30 million on last year's figure. Despite all the protestations and public manifestations of grief at the degree of the cuts which have been made, that represents a fairly considerable intention on the part of the Government with regard to the provision of very vital services in the health area.

I should like to record my appreciation of all those involved in the provision of the health services and under the aegis of the Minister and his Department. I want to pay tribute to the GPs who are working in the field and also to the public health nurses who are doing a tremendous job in looking after the sick and the elderly, and generally putting into effect the final stages of the whole array of services available to the public. They do a great deal in outlining to the public the scope of the services. In many cases people are not aware of their entitlement until they are made aware of them.

This Estimate is made up of a couple of main ingredients. I should like to deal quickly with the general and specialist hospitals. I am glad to note that in my own constituency of Kildare plans are at an advanced stage for the provision of an up-to-date and extended hospital in Naas. When the need for funds arises I hope they will be made available. Reference has been made to the specialist hospitals. If we want to see an indictment of our society all we have to do is go into some of our specialist hospitals and psychiatric institutions. In the second last decade of the twentieth century we have people housed in conditions which would scarcely do justice to the nineteenth century. Many of the buildings in which they are housed were built then.

People who want to get a true perception of this problem should travel to a number of those psychiatric institutions to sense for themselves the degree of hopelessness, the sense of decay, the sense of total and absolute loss and dependency on these institutions, and the total institutionalisation of the individuals. We then begin to recognise the almost total degradation of those unfortunate patients. It is a shame that at this stage of the twentieth century we have not been able to do more for them. Some work has been done over the past number of years, but I would like to see a definite programme for the replacement of all of those old institutions over as short a period as possible.

We would be doing ourselves a great service because, if we have to spend the money in any event, we might as well spend it now and reduce to some degree the misery experienced by some of the unfortunate people in those institutions. I feel very strongly about that subject because, as a member of a health board, I have seen the problem at first hand. My colleagues and I have seen at first hand the seriousness of the problem.

In many specialist hospitals we have housed a number of patients who should not be there at all. I am referring to the elderly or what are commonly known as psycho-geriatrics. The only reason they are there is that there is nowhere else to send them. This again is a very sad reflection on our society. There are people in those institutions who have spent 20 or 30 years there. They have become totally institutionalised. If they have any feelings left, they must feel absolutely forgotten. It is obvious that they are totally harmless. They even take a great interest in the very small event of a visiting committee passing through. It is very sad that such a small event should be such a big event for those unfortunate people.

There are many psycho-geriatrics in institutions and it is very difficult to care for them when they are among other patients who require a great deal of heavy nursing care. We would be doing a very great service if we put a programme into operation as quickly as possible which would have the effect of reducing the number of old fashioned and outdated institutions. I should like to pay tribute to the geriatricians who work for the health services and to acknowledge the wonderful work they are doing in creating the half-way houses and day care centres where patients who some years ago would have been committed permanently to psychiatric institutions now have at least some access to the outside world and the opportunity to meet and talk to the public.

The public attitude to people in the institutions I have mentioned leaves much to be desired. I have mentioned this before but it should be mentioned again and again. For some unknown reason they do not seem to command a great deal of public attention. Elections are never fought on the conditions in mental hospitals whereas they might well be fought on the issue of students' medical cards. When one considers the plight of these unfortunate patients it does not say much for society that we have so little regard for them. After all, there but for the grace of God could go any of us.

I should like to congratulate all concerned on the mental handicap unit at Cheeverstown which is to be opened shortly. Over the last couple of months a great deal of time and effort has gone into outlining the effects of cuts. We have had scares of hospital beds closing and patients being sent home overnight. I should like to pay a tribute to the health board with which I am involved who are apparently able to effect the necessary cuts while at the same time giving a very good standard of service. I am glad to note that there will be no diminution of the service in that area. I am amazed that other health boards seem to have such difficulty in responding to budget cuts.

Reference was made to five-day week hospitals. It seems to be very poor economics to hospitalise people on a Friday when there is little chance of doing anything for them until after the week-end. Patients should be discouraged from entering a hospital on a Friday except in cases of absolute necessity.

There appears to be an increase in the incidence of tuberculosis. This is a serious development and perhaps we have become a little complacent as a result of the great strides which were made in eliminating that disease some years ago. Perhaps it is time to take further stock to ensure that it does not become a serious problem once more.

Deputy Fitzsimons said that students' medical cards might become an election issue. I hope that does not happen because we would not be doing the students or anyone else any good by allowing ourselves to be drawn into such an arena. Possibly it has gone unnoticed that some families who did not qualify for medical cards before this revision may now qualify on the basis of their dependants who include students from whom medical cards have been withdrawn.

A great number of voluntary bodies are working very hard on behalf of the disabled. The Wheelchair Association are extremely active and effective in my constituency. The Minister should ensure, where possible, that the health boards should give favourable consideration to allowing as much funds as possible under the section 65 grants to be devoted to the activities of such organisations.

Mr. Wilson

I want to talk about Cavan General Hospital which brings an almost Pavlovian response when I mention it. The battle has been going on for some time with regard to the most recent attempt to provide us with a general hospital. I understand that in the most recent hearing of a rather odd case where a group of people are trying to stop the building of a hospital, the Minister said he intended going ahead with the building. At the same time, the court case was fixed for May. What specifically is going on regarding Cavan Hospital at present? Are the planners working on it now? If so, what kind of instructions did they get from the Minister and the Department of Health? I should like the Minister to clarify the position regarding the original plans and to ask him if there is any intention of changing them. If this is the intention, I fear it will cause great delay in starting work. The House knows — God knows it has been repeated often enough — that a certain amount of money has been spent on the site and planning already. I should now like to get the up-to-date position.

I do not intend making a case now for the hospital as I have already done so. The officials of the Department of Health and the Minister have accepted the necessity for this hospital. They inspected the existing surgical hospital and came to the only conclusion that any sane person would come to — the sooner it is replaced the better. Its existence, despite the dedication of highly-qualified staff, is a danger to the health of the community.

I wish to refer also to the parlous position of the handicapped in a certain age group. We are attempting to cater for the handicapped and, without ignoring the others, I wish to emphasise here the mentally handicapped in all three grades and the difficulty that arises when they reach a certain age in the middle teens. The Minister referred to this whole area in his speech but this House should be conscious of the serious problem that exists when children have been trained — and that is a word of flexible meaning depending on the degree of handicap — for a number of years and then have nowhere to go. This House, the Department of Health and the Minister would be well advised to consider this problem and to allocate adequate resources to this area.

On the question of medical cards, I would appreciate it if people at local level — I do not mean the headquarters of the health boards but I am referring to employees of the health boards in various sub-office areas — had a little more discretion in deciding cases. There are cases where, when considered prima facie, the applicant is not entitled to a medical card but local knowledge might indicate that he should be entitled to a card. Very often the apparent is not the real situation.

I put down a question recently about dental services in schools. I mentioned specifically one school in the mountainous area of west Cavan, namely, Barran national school, and I got a reply from the Minister. In that area, which includes Corravagh, Killinagh and Barran, there is a grave difficulty regarding access. It is on top of a mountain and one has to go through Glangevlin Gap to get to it. People find it difficult to get dental services there and if the school service falls down the people face considerable difficulty.

I was at a meeting last night of Ogra Fianna Fáil in south County Dublin and I found the young people very conscious of the drug problem not only in the areas highlighted but also in other areas. The Minister is aware of what I am talking about. The energies of this House and of the Department of Health, apart from the Department of Justice, should be directed towards a major campaign to deal with the drug problem.

The Minister had his quarrel with the students and some kind of resolution has been reached. I want to indicate again that the general principle very often conflicts with and inflicts damage on the individual. I can give the Minister an example of how this can happen. I refer to the case of a family nearly all of whom went to third level colleges, to the Regional Technical College in Athlone, to university and to the Regional Technical College in Dundalk and whose father died. One member of the family who is still a student in a agricultural college has developed a skin disease and he happens to be caught by the new regulations. His mother, who is now a widow, is having difficulty in coping with the new and very unexpected situation. That young man to whom I was speaking is not having medical treatment because he knows his mother cannot afford it. I will give the Minister details of his case and I hope it is the kind of case where the Minister, despite the apparent, may recognise the real situation and provide him with a medical card.

I endorse the remarks of Deputy Durkan about TB and the recrudescence of that disease. I understand that in the older age group there is a danger of this disease beginning to spread again. As the Deputy said, I do not think it will ever become the menace it used to be but it is something about which we should be on the alert.

Mrs. A. Doyle

I welcome the opportunity to say a few brief words on this most important discussion. As a society the amount of money devoted to our health services has increased enormously in recent years; in fact, by a factor of ten since 1973. Inflation played a major part and real spending doubled in those ten years. However, it is questionable whether the health of our nation bears witness to this fact.

A simple increase in the amount of money is no longer the answer. There are a number of services that are no longer essential. We have to face the fact that as a nation we have gross overbedding and rely too heavily on hospital care. In my view, we are neglecting the GP service and primary and community based health care. Unnecessary admissions to hospitals, particularly at weekends, could be avoided by improved co-operation with GPs and by consultation, not by unilateral action or by confrontation. No one is talking of a five-day hospital, as has been said across the floor of the House; all that is needed is a simple, reasonable approach to the matter.

It would appear that at the moment morale in the GMS is low. Many GPs feel alienated from it. The GP feels he is but the poor relation of the hospital consultant. Branches of the Medical Union are talking in terms of industrial action, even in advance of the report of the working party due shortly. I appeal to those responsible on both sides to get around the table and resolve their difficulties for all our sakes.

There are hospital-based services throughout the country that are no longer essential in the prevention and treatment of illness. To mind immediately springs the number of psychiatric hospitals even in my own region of the South-Eastern Health Board where bed occupancy rates no longer can justify the continuation of five such institutions. The savings in the closure of even one of these — without any redundancies, only the redeployment of staff — would finance from our existing allocation of £80 million the staffing and running of a very badly needed paediatric unit in Wexford General Hospital. This was approved in principle by An Comhairle in October 1982.

For many years we have had in our hospital a modern and fully equipped maternity unit catering for more than 2,000 births per annum. The nearest paediatrician is in Waterford and it often happens that instructions have to be given over the phone for the treatment of neonates. There is a large population under 14 years, all of whom must go to Waterford or Dublin for paediatric treatment or wait for the two visits per month from the overworked Waterford consultants who do all they possibly can. They join us, as do the Medical Union in Wexford, the medical and nursing staff in our general hospital, all the GPs, Wexford parents and AWCH in Wexford whom I commend for their ongoing efforts, as well as the South-Eastern Health Board, in asking the Minister to sanction the appointments necessary to run such a paediatric unit. The beds have been provided and we do not ask for any capital expenditure. At this point I must record my appreciation of the consultants in our hospitals for their generosity which underlines their commitment to our case. At the moment the case is with the Department for approval regarding the financial implications.

I am often reminded by those concerned with this issue that children do not have votes. They say they would not have to wait so long for a paediatrician if children had votes. Cynicism apart, I feel I can rely on the Minister to realise that our case is rationally presented with fully documented facts and figures to substantiate it. I know I can rely on him to respond positively and soon.

I look forward to the Minister's promised Green Paper on the financing and organisation of the health services. I hope pride of place and poll position will be given to primary care and community health care especially in the areas of geriatric services and mental health. These patients must be cared for as far as possible in the local community as much for their sake as for the sake of the local community. Shutting away these people in institutions has been a way of avoiding responsibility to those who in our materialistic society do not quite measure up. It has, ashamedly, been the case of out of sight out of mind. Those who need constant institutional care, our seriously handicapped both mentally and physically, are among the group who need priority in our hospital based services. Very often they, like our children, cannot speak for themselves. Services for the mentally ill, in particular, have not until recently received the priority due to them. I welcome the Minister's continued commitment to this group and the commitment of our health boards in this area.

I would like to commend the work in Wexford of the Association of Parents and Friends of the Mentally Handicapped and their vigilant and constant efforts which have resulted in the completion of the first stage of the residential unit for mentally handicapped adults in Enniscorthy. The health board are fully behind them and I feel the Minister is also. The matter is with the Minister for Finance at the moment and I hope it will not be too long before we receive good news in this most important priority area of the South-Eastern Health Board. We must not allow the quality and dignity of the lives of our mentally handicapped to be affected by Government cutbacks.

Time is very short and there is a lot more I would like to say. I would like to paraphrase a recent Irish Medical Times editorial which said:

Have we in the political arena, the vision and nerve to confront the vested interests in Irish medicine with the painful truth? At a time of relative scarcity true radical planning is required.

We must ensure that our proud promises coming into office are not discredited. We eagerly await the Minister's Green Paper.

Mr. Dowling

I want to very briefly draw attention to the existing situation in St. Luke's Hospital in Kilkenny. At a recent meeting of the local health committee, of which I am a member, a surgeon at the hospital, as quoted in the Kilkenny People this week, said:

The unenviable distinction of having the worst overcrowding of any health institution in the country now belongs to St. Luke's Hospital in Kilkenny. Studies have shown this to be an irrefutable fact.

This was stated by surgeon John F. O'Grady who described the current situation as appalling with beds continuously in the corridors. He further stated:

Attention has been drawn to this fact over a number of years by public representatives and members of the health boards in different capacities and little or no action has taken place. We have in the hospital also a newly equipped extension for the maternity service. That, because of lack of staff, remains unopened.

That situation cannot be tolerated. I ask the Minister to ensure, within the resources available to the South-Eastern Health Board, that every effort is made to deal with it, even if it means the deployment of staff from some other hospitals as a matter of extreme urgency.

I am aware that the St. Luke's extension programme was dropped but that it has come back into play. This is an important advance. I ask the Minister to state publicly that it is his intention to carry out the necessary development at St. Luke's Hospital to alleviate the gross overcrowding there. I have continuously listened to personnel from the hospital saying that of all the hospitals in the south-eastern region, St. Luke's Hospital in Kilkenny caters for a far greater level of patient intake and because of that——

An Leas-Cheann Comhairle

The Minister must get in now.

Mr. Dowling

I have spoken to the Minister and he has given me an extra few minutes.

An Leas-Cheann Comhairle

The Deputy may have two minutes.

Mr. Dowling

I await the response of the Minister to that demand. I would like to draw attention to the fact that in the Carlow area, which has a fairly sizeable urban population, there is no casualty service. This means that people requiring limited casualty treatment may have to travel 30 or 40 miles to a hospital outside the area. I ask the Minister to make use of the existing hospital facilities and to provide an adequate casualty service for the people of the town and region of Carlow.

With regard to Ardkeen Hospital I hope nothing will prevent the development of the new hospital in 1984. I would like to draw attention to the Minister's Estimate speech in which he said that when health contributions are based on profits derived from farming, less expense is actually incurred in earning these profits and that is how the health charges will be calculated in future. I want qualification in relation to this. Expenses incurred in the promotion of farm profits actually means reinvestment by farmers and for that reason reinvestment should not be a charge for health purposes. I would like to wish the Minister well. He has a very ambitious programme and is doing an excellent job.

Minister for Health (Mr. B. Desmond)

I would like to refer to some of the points raised in the last half hour and to deal with them first. With regard to the Cavan Hospital situation, I assure Deputy Wilson that I reconstituted the final project planning team immediately after the recent court decision. I expect to have the contractor on site within at the very most two months. I look forward to inviting Deputy John Wilson, as a formidable advocate of the development of that hospital, and his colleague to the contractors involvement on the site possibly during the month of May.

Mr. Wilson

I shall accept.

Mr. B. Desmond

The capital moneys for 1983 are available and I do not envisage any difficulty at this stage with the Department of Finance. I have taken careful note of the points made by Deputy Avril Doyle in relation to paediatric services for the Wexford Hospital. I assure Deputy Dowling also that I have taken careful note of his observations relating to St. Lukes and in relation to Ardkeen. I assure him that there will not be any undue delay in the major redevelopment and extension work in this hospital.

Regarding the debate at large, there is a common thread through the contributions of most of the Deputies who spoke on the Estimates, which relates to the desirability of certain developments within particularly the acute hospitals services, for example, in the area of maternity, paediatric, orthopaedic and dialysis. I agree with the Deputies that such developments are in many instances both necessary and desirable — but the essential fact remains that developments in the present financial climate can only take place if the agencies, health boards and voluntary boards concerned, can redeploy resources, dropping unnecessary services or services of a lesser priority. I firmly believe that in many instances they have the capacity to do so and it only requires an objective look at the matter to create a situation in which they can do so.

Regarding health expenditures generally a number of Deputies referred to the level of funds provided for health services in 1984. In no way do I want to deny that the allocations for the health agencies are extremely tight and that some reductions in real terms in expenditure on health services, particularly in the hospital areas, must be faced up to. I would point out, as I did in my Estimate speech, that expenditure on health has grown from £400 million to £1,064 million in the past six years, or from 6.25 per cent of gross national product in 1978 to approximately 7.3 per cent at present. It is perfectly obvious that it is no longer possible, or even desirable, to maintain and sustain this increasing trend of expenditure into the future. Consequently, there is an urgent need to evaluate critically all services and to identify ways and means of securing the necessary savings. I might make the point there that, despite a great deal of ruaille buaille at health board level, as yet, I have not been notified by any health board — and the first quarter of the year has now expired — of any redundancy of any health board staff. I do not know the name and address of anybody, of the 60,000 people employed in the health services, who has yet been formally laid off. I am not suggesting that they should be but, reading local papers, one would imagine that hundreds of people were being laid off in the health services every day of the week. Of course that is entirely untrue. As yet not one redundancy has been notified from any sector to my Department.

I would suggest that there is considerable scope for rationalisation of certain services and for the redeployment of financial and personnel resources. Of course this will take time. Meanwhile we have the immediate problem of aligning expenditure with funds available in the current year. All the health boards have now reported to me on the measures required to secure the necessary reductions in expenditure. These include: reductions in pay extras, in the employment of holiday substitutes and the nonfilling of certain vacancies which, while presenting problems, should not give rise to cuts in essential services. However, some health boards are in the situation in which they consider it necessary to scale down the volume of hospital services through the closure of wards and this is at present being examined. Therefore I am reviewing the overall situation in the light of the reports I have now received.

If I may refer to my recent observations regarding the use of public facilities and equipment by hospital consultants I had a meeting recently with a delegation from the Irish Medical Union to discuss various matters relevant to the health services. One of the questions discussed was the use of public facilities and equipment by consultants in the course of their private practice. On the question of private fees chargeable by medical consultants, it was agreed that a series of meetings at official level will take place over the coming weeks. It is expected that these discussions will be completed within the next four to six weeks.

Regarding the question of young nurses who are unemployed, I am aware of the need to improve the job opportunity of young people, particularly those of young trainee nurses. In order to improve these job opportunities I have decided that a more liberal attitude should be adopted towards the granting of special leave without pay to persons holding permanent appointments under health boards or other health agencies. Instructions are being issued to these bodies informing them that applications by health staffs for special leave without pay for a period not exceeding three years, as a general rule, should be granted and that all employees going on special leave without pay should be replaced.

I might add that quite a number of nurses wish to go abroad, wish to work in voluntary organisations, or take up some other activities, such as, for example, doing post-graduate work for three years or thereabouts, or leaving the health services for a period without pay. That decision will facilitate quite a number of staff in that regard.

Regarding the assessment of farm incomes, a number of Deputies referred to the different criteria used in means testing for medical cards, health contributions, income tax and social welfare benefits and to the question of standardising what is acceptable in terms of profit where farmers are concerned. I would point out that the definition of income for farmers' health contributions is the same as that used for other self-employed persons. Unlike the procedures relating to the payment of income tax, a deduction for capital expenditure is not allowable for health contribution purposes. This applies not only to the self-employed, including farmers, but also to the PAYE sector who equally are not entitled to an allowance for capital expenditure. I do accept that it is necessary to develop an agreed methodology and standard guidelines for assessing farmers' incomes, particularly in the case of persons applying for medical cards. That matter is currently being examined. A number of Deputies raised a number of points about the general medical services and, in reply, I should like to say something briefly about these services. One question Deputy O'Hanlon asked was why the new allowance for old age in the medical card guidelines will apply only from 1 July next. The rationale behind this is that the next round of social welfare increases will take place in July and the new allowance for old age has been timed to come into force then also. This new age allowance will ensure that elderly person in receipt of the increased maximum rate of non-contributory old age pension will retain their medical cards. This reflects our concern for safeguarding the special needs of elderly persons. As I said in my Estimates speech, a married couple, aged 80 years or over — having regard to the new age allowance — will normally be entitled to a medical card if they have an income of £101 per week or less.

Regarding the withdrawal of medical cards from the elderly I would presume that Deputies are referring to the fact that persons aged 66 or over who are in receipt of contributory social welfare pensions no longer qualify automatically for medical cards. I would remind Deputies of the sequence of events that culminated in this policy. Firstly arising out of the March 1982 budget the former Fianna Fáil Government decided to give medical cards from 1 July 1982 to all the elderly persons in the category I have mentioned. Secondly, the former Government decided, in October 1982, to revert to the normal position of assessing the eligibility of those persons on the basis of their financial circumstances. Thirdly, on taking up office, I reviewed the situation and decided that medical cards would continue to be issued on the basis of a person's income. I then conveyed this decision to the chief executive officers of the health boards. There has been no policy change whatever in that regard since then. I do want to make it quite clear that no medical card has been withdrawn from any elderly person without giving that person every opportunity of establishing entitlement on the basis of the income guidelines. Another point discussed at length on this Estimate was the question of students' medical cards. I might add that the policy in relation to students' medical cards has now been clarified for the Union of Students in Ireland and the health boards are proceeding with the task of implementing the provisions of the relevant regulations. There has been no change whatsoever in the overall position concerning the original regulations made in relation to student medical cards.

Regarding visiting rates under the general medical services, a further question was raised as to whether the number of visits for persons under the choice-of-doctor scheme had increased during the period 1974 to 1982. I might point out that the visiting rate increased from 5.51 in 1974 to 6.01 in 1982 and that the trend is definitely upwards. There are a number of factors which influence the visiting rate, including the needs of patients, and the actions of doctors participating in the scheme. Of course the number of doctors has increased as has the number of smaller panels. As a consequence these smaller panels are associated somewhat with a higher than average visiting rate.

Regarding the exclusion of items under the general medical services scheme the position is that on 1 October 1982 854 products were removed by the former Government from reimbursement under the scheme. In November of that year 12 of those were restored. When I came into office I deleted 70 items because they were no longer on the market. Sixty-three items were deleted because they were for hospital use only. One hundred items were deleted mainly because they were similar to items already excluded and 96 items were restored to the list. The position has now settled down and overall the position has been effectively clarified.

Regarding the question of private hospitals, I will be submitting proposals to Government for draft legislation in the next few weeks, following which I will seek the observations of all interests concerned.

In relation to the integration of public voluntary hospitals the suggestion was made that I am going to take over the voluntary hospitals. That is simply not correct. I have no intention of "taking over"— to use that phrase — voluntary hospitals as such. What I am doing is endeavouring to ensure that the taxpayers' money which at present entirely supports the activities of voluntary hospitals is spent to the best advantage of the community and that the services provided in them form an integral part of the complex of services available from the health board agencies.

I regret I have insufficient time to respond to Deputies in detail but, in brief, those are my general observations. I thank the Opposition spokesman, Deputy O'Hanlon, and the other Deputies for their contributions in the course of this discussion.

Question put and a division being demanded, it was postponed in accordance with Standing Order of the Dáil No. 123, as modified by order of the House, until 8.30 p.m. on the next day on which the Dáil sits.