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.