Dáil Éireann díospóireacht -
Tuesday, 20 Nov 1984

Vol. 354 No. 1

Private Members' Business. - Health Services: Motion.

Dr. O'Hanlon

I move:

That Dáil Éireann condemns the cutbacks in the Health Services and calls on the Government to take immediate steps to provide the necessary financial assistance so as to restore the standard of general medical services and of patient care to the levels which have hitherto prevailed.

The reason for the motion is the obvious hardship being inflicted on our people by the savage cutbacks in the health services, especially since the Coalition took office two years ago. We are concerned about the effect they are having on the less well off, not alone those in the lower income group but also those who are now being described as the new poor because of the amount of taxation and the number of levies they have to pay. Many people who are just above medical card limits are unable to meet their commitments. The limit in the refund drugs scheme went from £12 to £28 per month since the Government took office. Those without medical cards are now obliged to pay for school transport. In other words, the medical card is being used as a guideline not alone for health purposes but also for school transport, something that no Member could ever envisage or any person in his sanity should have accepted.

The amount of tax or PRSI a person pays is not taken into account when a person applies for a medical card. I am aware of a person with five children with a gross income of £140 per week, paying £28 tax and PRSI leaving him with £112 in take home pay, who was not considered eligible for a medical card. The Government went before the people on a Joint Programme for Government and it is no harm to recall what they said about their policy on health care. In their document they stated:

We recognise that there is a need for a radical review of the operation of Health Boards and that a shift in emphasis from hospital to community services is necessary both to provide the type of service most appropriate to the needs of patients and to reduce the wasteful use of scarce resources. In carrying through this programme of reform we shall ensure that the existing level and quality of health care will be maintained.

In particular, care must be taken to ensure that any adjustments do not militate against the less well off.

The Government are doing the exact opposite. The joint programme commitment in regard to the existing level and quality of health care has not been carried out. The quality has not been maintained and the people will recognise that before 1985. It is my belief that the services will collapse before the end of next month. It is the less well off who are suffering most.

A Labour backbencher when speaking to the motion of no confidence on the day the last Fianna Fáil Government fell in November 1982 warned the Minister, and the incoming Government, the present Coalition, that any attempt to worsen the health service would be resisted with all the powers at the disposal of the Labour Party. However, here we have a Labour Minister responsible for administering the savage cutbacks agreed by the Government. There have been cutbacks in all services but, in particular, in the community care service. The Government were not long in power when they removed medical cards from old age pensioners. Such cards were given automatically to those people by Deputy Woods when he was Minister for Health. The Coalition also removed medical cards from students.

The Minister promised a review of the 900 items removed in the summer of 1982 and, in fairness to him, he carried out that review but what did he do? The Minister took more items off that list. Before that second review the simple stomach mixture, the simple white bottle, so necessary for many people, the elderly in particular, was on the list but the Minister removed it. The result is there is no antacid on the list. Such people must now buy the white mixture. It is significant that in the last year that these antacids were allowed it cost £500,000 while in 1983 the substitute, Cimethadine cost £1.8 million and was the most expensive drug on the list of prescribed drugs in the GMS. That has been brought about by the behaviour of the Government.

Health boards are doing their best within their reduced allocation. They made savings on maintenance, the amount of stock they hold and on transport. In fact the saving on transport has been so much that the scheme has been brought to a level where it is totally inadequate. I am aware of dispensary patients who have to pay £28 to travel from Carrickmacross to Monaghan to attend a clinic. That is more than half an old age pension. I am aware of a mother who had an appointment with a surgeon while her child had an appointment with a paediatrician but because they were on two different days in the same week, the mother who could only afford the car once, opted to bring the child to the paediatrician thereby neglecting her own health. That is an indication of what is going on.

The Minister closed the maternity unit at Bantry hospital and in my constituency he threatened to close Monaghan hospital and sell it before he would agree to open a hospital in Cavan. He has partially reversed that decision and, hopefully, wisdom will prevail and he will go the rest of the way and ensure the continuance of the maternity facilities at Monaghan County Hospital.

Fianna Fáil are not opposed to reviewing the cost of the health services because we accept that they are expensive. We believe in greater efficiency in that service but I accuse the Government of being so preoccupied with financial rectitude that they have no concern for the people. They are totally insensitive to the hardship and poverty they have created as a result of their social policy. The only figure they quote in relation to our costs as against those of other countries is the GNP because our GNP is relatively high compared to other EC member states and OECD countries. If one looks at the per capita cost, one will see that we are the second lowest in Europe — only Greece has a lower per capita cost for health services. The time has come when the Government must ask themselves what kind of health service they intend providing. If they do not provide a sufficient allocation to run at least a minimal health service, the whole service will collapse.

We have fewer doctors than any other EC country, including Greece. I appeal to the Government not to be so hung up on the GNP and financial rectitude that they will dismantle a health service which took many years and a lot of hard work on the part of Governments, Departments, health boards, county councils and the many people who worked in the administration of a health service, to build.

There has been a cut down in the number of hospital beds and admissions to hospitals, wards were closed in practically every county during the summer months, some for one or two months; locum cover, overtime and weekend cover has been reduced. All this has created very serious problems for many people.

The operations for the replacement of knee joints have come to a halt. In Cork they are not doing any hip replacements at present. I understand it is only because of good management on the part of staff in the existing orthopaedic hospitals that they are able to carry out hip replacements, they happen to have a supply of hip joints in stock.

It is difficult to know how the psychiatric services will carry on next year. In the Eastern Health Board area the number attending the out-patients department have increased dramatically. There is a big demand for admission of the elderly because they are not able to maintain themselves and their relatives are not able to maintain them in the community. There has been an increase in out-patients because of depression and the people have lost confidence because of the policies this Government have pursued. Over the last two years unemployment has increased by over 60,000. This has created a loss of confidence which is reflected in the figures of those attending psychiatric services, particularly in the Dublin area.

The rehabilitation service are unable to find jobs for those who previously would have been easy to place. This is a direct result of the Government policy. In the spring of 1983 the Taoiseach told us that, because of financial rectitude their policies would be diametrically opposed to the policies necessary to create jobs.

All over the country equipment and buildings are standing idle. When I asked the Minister if he could tell me what buildings and equipment were vacant as a result of insufficient funding the answer I got was:

The information requested by the Deputy is not collected by my Department on a routine basis. The Deputy may get the information he requires by addressing an appropriate inquiry to the chief executive officers of the health boards who are in a position to provide the information requested.

It is an indictment of the Government and the Minister that he is not sufficiently interested to know what is happening around the country as a result of Government policies. A cat-scanner which cost £500,000 is not in use. A maternity unit in Galway is not in use because there are no funds. There are any number of buildings vacant around the country. Fourteen buildings for the mentally handicapped are lying idle. The Minister's reply to my question on 12 June 1984 was that "because of the current restrictions on recruitment in the public sector and the lack of development funds are not operational". In their economic plan the Government said they would develop facilities for the mentally handicapped.

I will give examples of the kind of letters I got from hospitals. I will quote from a letter I got from a doctor about a young man who is bleeding from his kidney, a potentially very serious condition:

We will get these investigations carried out as soon as possible. As you are very well aware, we have some problems with cutbacks in so far as 40% of our beds in the G.U. are closed at present.

Another letter to a doctor at the other end of the country, from Our Lady's Hospital for Sick Children, Crumlin, reads:

Clinics were booked in anticipation of there being available Senior Staff, sufficient in number, to service three OPD Clinics on an on-going basis. Unfortunately in the absence of approval from the Department of Health of staff required to support these Clinics it has been necessary to reduce, with effect from 1st May, 1984, the extent of service available and to re-schedule existing appointment.

We regret, therefore, it is not possible at this time to make the appointment you request.

That is the type of letters which are issuing from hospitals. From the Wilton Hospital, Cork, a doctor wrote to me saying:

...The chaos caused by these closures made it obvious that further closures were unthinkable, and that at this time, the number of beds closed down stands at approximately thirty-five. ...Sick patients are put through the hardship of waiting for as long as five hours in day rooms, from which they can observe wards full of empty beds. Patients find this absurd, and the Nursing and Medical Staff have to take the brunt of their indignation.

This is very understandable.

As a result of the increased difficulty in admitting patients, the backlog at the Out-Patient Department has got worse. In addition, out-patient facilities have also been cut.

The Southern Health Board placed an advertisement in The Cork Examiner on 11 October telling the public they were not able to provide the level of service and the steps they were taking to ensure that they would be able to live within their reduced allocation for the remainder of 1984.

On the community care side, the dental services have been cut; there are no ad hoc dental services in the Southern Health Board area. The opthalmic service has been cut. There is a waiting list of four years in County Louth for the sight testing scheme, 12 to 14 months in Cavan-Monaghan and there is no scheme in the Southern Health Board or the Mid-Western Health Boards. These are the types of problems people are confronted with and still the Government seem to be totally unaware of them. In every statement the Minister says there is money for this and money for that. If he stopped telling the people that it would be something. He is giving people false hopes and false expectations that there is money available for essential services. The reality is that there is not.

In this year's allocation there was no word that the Government would remove food subsidies at the beginning of the summer. That created chaos for the health boards and for everybody else and had a penal effect on poorer people. They got no compensation from the State. It cost the Eastern Health Board £80,000 and the Southern Health Board £85,000. That would have helped to create an ad hoc dental service or an ophthalmic service and would have prevented people from waiting an inordinate time for these services.

On 1 November I asked the Minister the estimated deficit in each health board for the current year and he replied as follows:

It is not possible at this stage to predict with any degree of certainty the extent to which health boards will succeed in curtailing expenditure within approved limits.

The Government are responsible for the allocation to health boards yet on 1 November the Minister for Health did not know the estimated deficit expected in each of the eight health boards, although all the health boards had publicly announced what the deficit would be. Anybody who read the newspapers knew what the deficit would be.

Dr. Ormonde

He knew but he was not prepared to admit it.

Dr. O'Hanlon

Perhaps he knew that the health boards would be £10 million short and perhaps he did not want to disclose it. Maybe he thought we did not read the newspapers or that we might know only what was happening in our own health board area. He may not have wanted us to know it. It is even worse if he did not know the figure. It is a very serious indictment of the Government and of the Minister for Health in particular that they were not sufficiently interested in the consequences of their action in 1984 to find out the expected deficit in each area. The figures are as follows: The South-Eastern Health Board, £1.8 million; the Eastern Health Board, £2 million; the Southern Health Board, £2.6 million; the North-Eastern Health Board, £0.4 million; the Mid-Western Health Board, £1 million; the North-Western Health Board, £750,000; the Western Health Board, £600,000; and the Midland Health Board, £0.5 million. That is the situation in 1984.

The Minister has pointed out on many occasions that the deficit must be the first charge on the allocation in 1985. Presumably the health boards will suffer the same deficit in 1985 and the minimum deficits will be as follows: the South Eastern Health Board, £5.4 million; the Eastern Health Board, £9 million; the Southern Health Board, £7.8 million; the North-Eastern Health Board, £2.45 million; the Mid-Western Health Board, £5.89 million; the North-Western Health Board, £2.8 million; the Western Health Board, £4.04 million; and the Midland Health Board, £1.9 million. That gives a total deficit of £36.84 million. It would be impossible for the health boards to deliver any kind of service. There is an obligation on the Minister to tell the health boards what they are to do because they have a statutory obligation to implement and deliver services and it would be a tragedy if they were to eliminate those services which are non-statutory, such as grants to voluntary bodies and the home help service. Somebody must tell them what to do.

The Minister met the CEOs and the chairmen of the health boards last Friday and spelled out certain aspects of the national plan. One area of the plan is the promotion of good health but in another section of the plan the Government announce their intention to extend the licensing laws. That could be a debate on its own but certainly it is not in the interests of promoting good health to extend the licensing laws since one of the greatest causes of ill health is the excessive drinking of alcohol.

The Minister stated that any excess expenditure in 1984 must be absorbed in 1985. A very serious situation will develop in 1985 because up to now health boards have been able to maintain permanent staff, although a number of temporary staff have been let go. The training schools have gone in a number of places, including St. Davnet's hospital in Monaghan. For the last two years no student psychiatric nurses have been taken into that excellent school. It is detrimental to the interests of this hospital which is recognised for the standard of its teaching. If that situation is allowed to continue there will be very serious problems in the psychiatric service. Davnet's is not alone. In six of the eight health board areas they did not take in any students this year.

The Minister said last Friday that there would be a £45 million reduction in the payroll over the next three years. He told us about two months ago in the House that the reduction would be £30 million but it has now been increased to £45 million. That means 4,500 jobs in the health service. In the document he circulated he stated:

The Government has decided that, throughout 1985, the arrangements whereby two thirds of vacancies occurring in the Civil Service (excluding vacancies arising from career breaks) are held open will continue in force and that measures at least equivalent in effect in terms of the numbers of posts, which must remain unfilled and/or pay their costs, are to be applied in health agencies.

How in the name of all that is wonderful could you run a health service and reduce staff by two-thirds? Operating theatres will have to close down. Areas of the country will be left without doctors and public health nurses. I do not believe the people who conceived this idea know how the service operates, particularly in rural Ireland. The Minister stressed again that any excess expenditure in 1984 must be a primary charge on the accounts of 1985. In other words, the health boards will be bankrupt by the end of 1985, although my view is that they will not be able to carry on until then in the situation as outlined by the Minister last Friday.

Private and semi-private charges will be increased in State hospitals. In 1978 the cost was £91 per week but in 1984 it is £500 per week for a private bed in a public hospital. It is more expensive now for a private bed in a public hospital than it is in St. Vincent's Private Nursing Home in Elm Park. I know that the Minister's philosophy is against private medicine but nevertheless if people want private treatment it is their right. It also relieves the Exchequer because it cuts waiting lists and relieves public beds for public patients. It is not to be deprecated by the Minister or the Government. Each year 60,000 people are leaving the VHI. These are people who were prepared to pay their own way but they are now leaving the VHI and crowding the already overloaded public sector. The Minister decided to charge consultants for the use of equipment in private hospitals. He tried to get the consultants to agree to this. I will read from a letter dated 13 August 1984 from the secretary of the Department to the chief executive officers of each Health Board and to the secretary managers of each public voluntary hospital board. There is one paragraph dealing with his consultations with the consultants. The letter stated that it did not prove possible to reach agreement on this matter in the discussions which took place between the Minister and the organisation and the Minister informed the organisation of his intention to proceed with his decision by way of discussion at local level. He went on to say that accordingly health boards and the other public hospital management were directed to enter into discussions with the consultants or their representatives with a view to securing a reasonable contribution.

That contribution will be passed on to the consumer who is already over taxed and is paying for health services through tax and health contributions. In the document handed out last Friday the Minister said that every possible effort must be made to maintain good relations with all staff and all trade unions and to avoid damaging disputes. How does he reconcile the two? He is directing the health boards to get into conflict with the consultants about charging for the use of equipment in public hospitals and, at the same time, he is telling them to maintain good relations. The consultants in the hospitals have done their job well. All workers in hospitals have pulled their weight in an effort to ensure that the health boards can survive within their allocations. I will conclude now because I am giving some time to my colleague, Deputy Conaghan.

An Ceann Comhairle

Níl sé anseo.

Dr. O'Hanlon

Everybody in the service has worked hard and diligently to live within the reduced allocations for 1984. The Minister is directing the health boards to consult with the consultants about this matter. That is destined to cause problems. This is a very ill-timed and ill-judged decision. The £1.4 million the Minister wants will not come out of the pockets of the consultants. It will come out of the pockets of the consumer. It will be passed on to the patient, and the patient will have to pay. The tragedy is that this will put further pressure on the Voluntary Health Insurance Board, a semi-State body who have served the people well. Approximately 20 per cent of the population are not entitled to full, free and comprehensive hospital care and they depend on the VHI. The policies being pursued by the Government will create such serious problems that more and more people will not be able to afford voluntary health insurance. Between excessive charges for private accommodation in public hospitals and the extra money the Minister wants to take in — £1.4 million from the consultants and £4.6 million by way of increased charges in 1985 — serious problems will be created for people who want to pay their way and get something to which they are entitled.

The Minister told the CEOs and the chairmen of health boards that he had other ideas on how they might deal with their reduced allocation next year. He said the first and, indeed, obvious suggestion was to reduce the level of admissions to hospitals and institutions. He suggested more rigorous admission and casualty department policies in general hospitals to ensure that patients who can be treated in the community are not admitted to or treated in hospitals. That sounds very good in the sense that, if people can be treated in the community, they should not be admitted to hospital. The reality is that because of the reduced funding they cannot be treated in the community or in outpatient departments. There is none of the transfer which the Government talked about in their policy on community care. There is a reduction in community care just as there is a reduction in every other service. Therefore people cannot be treated in the community. There is a reduction in outpatient facilities and it is not possible to treat them in outpatient departments.

The psychiatric service maintain that there is a bigger and bigger demand for admission to hospital beds for the elderly because of poverty. That is a social welfare problem and I will not go into it now. Because of poverty more and more people are demanding admission to hospital because they cannot survive on the money they have as a result of totally inadequate funding by the Government. Any country can be judged on the way it treats the less well off in society. Over the past two years we have fallen down very badly in that respect. We are providing a totally inadequate health service and we are providing totally insufficient money for the unfortunate people who have to depend on social welfare. It is no wonder that the psychiatric service tell us that more and more people are demanding admission into hospital.

The Minister said we should identify and close surplus facilities. I do not know what that means. I do not know where these surplus facilities are. The demand is there for the existing facilities. I said that when wards were closed for a month or two in the summer there was chaos. A young man could not be taken in for investigation. He was bleeding from a kidney, a potentially hazardous condition. The Minister recommended that they should face the shortfall and reduce seven day beds to five day beds. Illness is not like that. Unfortunately it is seven days a week and 24 hours a day, and the service must be provided for 24 hours a day seven days of the week.

The Minister suggested that they should reduce locum cover and eliminate substitution. Locum cover has been reduced. Nurses, doctors, social workers and all the staff were very co-operative in ensuring that the level of service was maintained as far as possible. The quality of the service was maintained. Obviously the level of service had to drop.

He suggested that they should cut out all premiums to staff. That suggests that staff working in the health care service should not get overtime like anybody else, that they should work a 40 hour week and if they work overtime they should be treated as if they were working in the health service. Nurses and people working in the health service work extremely hard at week-ends and when they are on night duty. It is beyond comprehension that anyone should suggest that.

The Minister also talked about the elimination of advertising. That is very interesting. Formerly health boards advertised jobs. Now they are advertising to tell the people about the facilities which are not available. Both advertisements are important: advertising to recruit new staff and to tell people you are no longer in a position to provide statutory services which you have an obligation to provide. The Western Health Board have put in that type of advertisement. I quoted from one in The Cork Examiner in October. The Minister referred to a restriction on the number of people seeking acute hospital services. I do not know how you could do that. By and large the service works very well. There is a very good balance between the general practitioner service and the hospital service. I do not see how the Minister can use words like “restriction” and “restraint”— and they are the Minister's words — on the number of people seeking acute hospital services.

The Minister suggested reducing sick leave levels to not more than 4 per cent. How do you do that if there is a flu epidemic? Nobody in this house or in the health services has control over that. I should love to know the answer. I hope the Minister of State will have the answer for me when he speaks. I find that fascinating. How can a health board reduce sick leave levels to not more than 4 per cent?

The Government have no concept of the effect their social policies are having on the people. They have no concept of what happened in the health services over the past few years. If they had they would not career downhill in this manner. It will create very serious problems. There will be very serious consequences, hopefully not tragic consequences. From what I read about what is supposed to happen next year, I would not be surprised if there are tragic consequences for some people.

It is obvious that the health services are slowly being dismantled and will not be able to go through 1985 without some major collapse of the services. In conclusion, I want to quote from a debate on 3 November 1982 — confidence motion in the Government, the speaker being Deputy B. Desmond, as he then was, column 678, Volume 388, No. 4:

While there should not be waste in the delivery of public expenditure programmes and waste should be eliminated at all levels in programmes, nevertheless we must maintain basic Exchequer moneys and taxation to ensure that the best standards of health care are available to those in need.

I would fully support the then Deputy, now Minister for Health, in that statement. I ask the question — why the U-turn?

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

I move amendment No. A 1.

To delete all words after "Dáil Éireann" and substitute the following:—

"notes that the Government has continued to provide an excellent standard of health care within the allocation of £986 million for 1984 and will continue to do so within the allocation of £1,019 million for 1985, £1,078 million for 1986 and £1,123 million for 1987.".

I would like in the first place to clarify the situation as regards the funds which will be available for health services in the period to 1987.

As regards the current year, it has been made clear repeatedly that no extra funds can be provided for health services by way of a Supplementary Estimate. This situation cannot be changed.

With regard to future years, Deputies will be aware that the Government, in the national plan, have determined what the Exchequer provision will be for each or the years, 1985 to 1987. The non-capital provision for 1985 will be £1,019 million. The provision for 1986 will be £1,078 million and the provision for 1987 will be £1,123 million. The expenditure by health agencies cannot exceed the levels which these allocations will support. By any standards these are substantial expenditure levels. In this regard it is interesting to recall that in 1973-1974 net non-capital expenditure on health services amounted to about £143 million, representing about 5.2 per cent of GNP. In the current year expenditure is estimated at £1,087 million, representing about 7.5% of GNP. Undoubtedly, over the years we have as a nation succeeded in bringing our health services and health indicators into line with the developed wealthy countries. From the mid-sixties onwards the range of our services has grown at a rapid rate and took on board the ever-growing technological advances and other developments which were a feature of those times. There was a matching increase in staffing numbers from 40,000 to 60,000.

No one would deny that this has been a difficult year as regards the management and provision of health services. In the aftermath of a decade and more which had witnessed a steady, sustained and unparallelled growth in the level of financial and personnel resources made available to the health services, in common with many other sectors of the public service, the urgent need to control the levels of public expenditure has meant that the resources available to the health services have had to be limited, in line with the overall budgetary limits on public expenditure.

It would be unrealistic to expect that in a situation which called for curbs in the growth of public expenditure generally, the health services, which absorb almost 20 per cent of overall public expenditure, could be exempted from the requirement to secure reductions in costs. The situation required immediate action to identify and implement measures to secure alignment of expenditure with allocation levels. I am glad to say that in general health agencies responded in a most co-operative way and by various strategies succeeded in reducing health costs substantially. The range of measures adopted included the following:—

On the non-pay side: reduction in stock levels, generally and improved stock control; economies in catering, heating, etc.; deferment of non-essential purchases of equipment; streamlining of maintenance expenditure.

On the pay side: non-filling of vacancies arising, wherever possible; minimisation of supplements to basic pay such as overtime, locums and premia payments etc.

The major changes in services activity necessitated by these measures were limited and included carefully selected ward closures, mainly in the summer months, by particular hospitals.

One comment I would like to make is that nobody who required urgent treatment during the year was denied that treatment because of financial restrictions. I would emphasise that we intend to ensure that this approach will be maintained in the next three years.

Despite the efforts of the various health agencies, it now seems likely that excesses on allocation levels will arise in 1984. It is difficult to be precise at this stage about the extent of the problem.

Dr. O'Hanlon

Will it be £10 million?

Mr. Donnellan

I was listening to the Deputy quoting figures but did not like to interrupt him. He indicated that he knew exactly what the figures would be, I was going to ask why the Deputy put down a question to the Minister if he seemed to know the answer, as he was suggesting?

Dr. O'Hanlon

I got the information only on last Friday, from the Minister's document.

Mr. Donnellan

The outlook for 1985 would be considerably improved if overruns in 1984 could be eliminated or minimised. Clearly there is still some way to go before expenditure is brought into line with what can be afforded and, to do that, I think it is clear that we have to work together in a more planned, purposeful and co-ordinated way.

I find it strange, as will taxpayers burdened by penal rates of taxation, that some wish us to increase health expenditure in cash terms ad infinitum, while paying scant and negligible regard to the taxation resources base from which services must at the end of the day be funded. The major problem inherent in the constantly escalating cost of delivery of any given volume of health services is one that simply must be faced, tackled and overcome. Although spending on health services in real terms has roughly doubled in the last decade or so, no one will seriously attempt to argue that the population are twice as healthy now as they were then. This and the overall need to control public expenditure within a planned framework impelled the Government to include in the national plan specific allocations for health services for each of the years 1985 to 1987 as well as certain decisions as regards where costs should be reduced and some planning guidelines. This leads me to the national plan and its main thrust so far as the health services are concerned.

There are three points stressed in the plan in relation to approach and attitudes which I think are worth recounting.

I quote:— (i) First, wherever possible and justifiable, Government assistance in the social area should become more specific and more carefully aimed at, and delivered to, the poor and under privileged — those in need — instead of using generalised measures which provide help to the better off, who do not need it, as well as to the poor. (ii) Second, all possible measures must be taken to increase the efficiency and cost-effectiveness of the administration of the social services. (iii) Third, it is important that everyone in the community — whether those in the public sector administering the social services, or the recipients of the services, or all taxpayers financing the services — should be prepared to accept changes over the years.

Dr. O'Hanlon

That is not in the general policy of the plan.

Mr. Donnellan

I continue the quotation:

The needs of the country have changed greatly in the last decade so that the range of social services and the way in which they are provided must also change. We must all be prepared to accept a reduction in, and even abandonment of, established services and structures which are no longer appropriate to current needs or requirements, so as to enable an efficient and streamlined system to provide economically for the needs of the future.

In relation to the health services, a number of tasks have been highlighted. These might be summarised as follows:—

(i) Promote health (a task which involves many Departments and agencies) and prevent illness; (ii) Wherever possible (provided it is cost-effective) provides services on a community or out-patient basis; in the medium to long term bring about a redistribution away from institutional services; (iii) Make necessary inpatient care available to all; improve efficiency and cost-effectiveness by closures of outmoded or non-essential facilities and by improvement of information systems; (iv) Maintain a range of care and support (welfare) services, with particular reference to children at risk, low income groups not availing of services, and the disabled; (v) Continue to improve efficiency.

We must take account also of the objectives and targets which have arisen or will arise out of recent or pending reviews of aspects of the health services, for example:

Review of organisation of community care; report of working party on GMS; review of psychiatric services; review of mental handicap services; implementation of the Green Paper on the Disabled; review of the public health nursing service; implementation of systems policy and programme; implementation of Children and Adoption Bills.

While these reviews will lead to a more rational and effective use of resources, net additional costs of perhaps £5 million to £8 million could arise on both the capital and revenue fronts during the period of the plan. As I have mentioned already, the revenue Exchequer allocations for each of the three years have been determined at £1,019 million in 1985, £1,078 million in 1986 and £1,123 million in 1987. The expenditure on health services must be aligned with these allocations. The allocations take into account the specific measures incorporated in the national plan and the Government decisions associated with it. The main features include the following:

(i) Specific decisions in relation to pay budgets; (ii) Any excess expenditure over budget in 1984 or indeed, subsequent years, must be absorbed; (iii) Private and semi-private in-patient charges will be increased by perhaps as much as 20 per cent in 1985. These will realise about £4.6 million in 1985; (iv) A contribution of about £1.4 million in 1985 is to be secured from hospital consultants in respect of the use of public facilities for private practice.

Dr. Ormonde

They are paying it already. Their salaries have abated by between 15 and 20 per cent.

Dr. O'Hanlon

If the Government do not know what the deficits are they can hardly have that information either.

Mr. Donnellan

(v) Savings on drugs expenditure in the GMS of £2.0 million are to be achieved in 1985; (vi) The Government have decided that, throughout 1985, the arrangements whereby two-thirds of vacancies occurring in the Civil Service, excluding vacancies arising from career breaks, are held open will continue in force and that measures at least equivalent in effect in terms of the numbers of posts, which must remain unfilled and/or their pay costs, are to be applied in health agencies.

In spite of the constraints affecting public spending generally the Government see fit to allocate money in the plan for the following specific purposes in the health services: a sum of £2.5 million has been set aside in each of the three years for improvements in community services; I have allocated already from this sum £500,000 to the Health Education Bureau for health promotion purposes; — a similar provision has been made to enable a limited number of new units of accommodation to be commissioned.

I am under no illusion as to the magnitude of the task we face. If there were not any overruns in 1984 our task would be considerably easier. The position in respect of the two subsequent years will not be quite so difficult provided the budget allocations for 1985 are adhered to in full. I must stress that any excess expenditure in 1984 must be made a primary charge on the accounts for 1985.

We obviously need to have a clear strategy, a detailed plan, and arrangements for implementation which will be capable of being closely monitored and adapted, as circumstances require. I should now like to address these issues.

Our initial thinking should be radical and should not be unduly influenced by past negative experience. Otherwise, some desirable options may be ignored. Decisions in relation to any curtailment of the quantity or quality of services and the reduction of pay budgets must be seen to be taken on a planned, co-ordinated and logical basis.

The strategy must take account of the objectives to be achieved during the full period of the plan. Any initiatives or development, capital or revenue, must have manageable revenue consequences in the years subsequent to the plan.

The health sector of the plan must not fail because of any individual or collective lack of will, imagination or commitment on the part of those charged with directing and managing the services. Steps taken by managment in implementing the plan must be seen to be realistic and constructive and deserving of the Government's full support. If these conditions can be fulfilled, we can be reasonably optimistic about the chances of success.

All health agencies will be informed shortly of the level of permissible spending in 1985 and will, in the light of the funds that can be provided, have to determine the measures to be taken in 1985.

Dr. Ormonde

Were they not told on Friday last?

Mr. Donnellan

Not officially.

Dr. O'Hanlon

We were told at our health board meeting yesterday that our deficit would be £1.25 million.

Mr. Donnellan

The Minister for Health and Social Welfare met the CEO and the Chairman of each of the health boards on Friday last. They had been telexed before then about what was to happen generally but they have to receive the official notification.

Dr. Ormonde

We were told on Thursday last what the allocation for the South-Eastern Health Board would be.

An Leas-Cheann Comhairle

The Minister must be allowed to continue without interruption.

Mr. Donnellan

Some of the obvious areas which must be looked at deserve to be mentioned. The first and, indeed, obvious suggestion is to reduce the level of admissions to hospitals and institutions. A more rigorous admission and casualty department policy is needed in general hospitals to ensure that patients who can be treated in the community are not admitted to or treated in hospitals. Secondly, surplus institutional facilities should be identified and closed. This is a very difficult issue. But it makes no sense to allow the quality of service in essential facilities to be threatened while we waste resources by maintaining facilities that are functioning for no better reason than their being there.

Any closures might be undertaken on the understanding that no compulsory redundancies will be involved, provided there is full co-operation on redeployment, retraining, relocation and, where necessary, change of employer.

Thirdly, careful and detailed consideration should be given to changes in the role or use of certain in-patient facilities. A number of approaches could be envisaged under this heading. Various combinations of the following actions might be taken:

(i) reduce number of seven day in-patient beds;

(ii) reduce seven day beds to five day beds;

Mr. D. Gallagher

How can the Minister stand over that departmental jargon?

Mr. Donnellan

The two doctors opposite might educate their colleague in these health matters.

Dr. O'Hanlon

Is one to arrange to become ill only during a five day week and, if so, on which day?

Mr. D. Gallagher

This is nonsensical.

Mr. Donnellan

I said that various combinations of these actions might be taken. It is a matter basically for a health board to operate the services within the amounts of money allocated to them. I shall continue: (iii) increase use of outpatient facilities; (iv) convert small hospital to health centre-hostel-day activity centre; (v) redeploy or retrain staff for work in their existing institution or in another institution or in the community.

The basic assumption would be that the resources now devoted to the facility would be left within the health board area and would be redeployed to reflect local need and the objectives of the plan, while reducing pay costs. It is perhaps mainly through this strategem and the use of the limited development funds available under the plan that additional resources can be deployed to community services.

Fourth, and very obviously, we have to reduce expenditure on pay. The actions taken in relation to the closure or change of use of hospitals could contribute under this heading. In addition, action could be taken under various other combinations. For example, we need to examine very carefully the extent to which we can:

(i) Maximise non-filling of vacant posts, consistent with maintenance of agreed standards of service.

(ii) Reduce locum cover. Prima facie, there are wide variations between boards in the extent to which savings are being achieved under this heading.

(iii) Restructure rosters to improve efficiency. There is insufficient information available to enable an assessment to be made of the potential savings under this heading. However, it is an option that should be quickly examined and the implications of change fully assessed.

(iv) Introduce permanent, part-time staff. This would enable a more flexible approach to rostering and would enable staff to be concentrated on the work at the busiest times. This suggestion is already being examined by my Department.

(v) Reduce the volume of premium pay. The key question is to what extent we can run our hospital services on a five or six day week basis. The rostering of staffs on Sunday is particularly expensive.

Dr. O'Hanlon

Do not get sick on Sunday.

Mr. Donnellan

These are but a few suggestions which might be considered. Other policy initiatives which are a matter for central determination are being considered by my Department. I am confident that the general excellence of current patient care can be fully maintained in this framework.

In addition to the relevant steps which I have suggested earlier, the following steps might be considered:

(a) Accelerate and extend the present range of reviews and establish a suitable mechanism for monitoring implementation and results. I have already redeployed staff to this work within my Department.

(b) Review role of hospital consultants to extend role of consultant and reduce reliance on junior hospital doctors. Any suggestions from health agencies on changes which might prove most beneficial and cost-effective would be welcomed.

(c) Push ahead with systems implementation, giving priority to community care, to major hospitals, to financial and personnel systems.

(d) Establish management development committee to help improve management potential and performance, particularly at senior levels. The benefits of developing a more uniform management philosophy and style seems to me to be worthy of urgent consideration.

(e) Establish nursing practice research unit in a large general hospital to constantly review effectiveness of nursing procedures and communicate results throughout the service.

As I have stated earlier the successful implementation of the plan requires a co-ordinated, planned approach to the management of the service as a whole and tremendous co-operation among all parts of the service. It will not be enough for each agency to allocate the available funds between programmes, even if these allocations accurately reflect the philosophy, intent and decisions of the plan. Clearly, in the light of previous experience and having regard to the multiplicity of fronts on which the problems must be tackled, a detailed plan must be drawn up by each health board and agency, setting out in sufficient detail the precise actions which have to be taken in order to ensure that the level of expenditure is brought into line with the approved allocations. The decisions required to do this will have to be taken quickly. After all, the biggest challenge arises in 1985.

Over the next month or so, therefore, the concentration must be on achieving three things. First, it will be necessary for each agency to draw up a realistic action plan setting out how it proposes to ensure that its expenditure in 1985 will be in line with the approved allocation, taking full account of the liability arising from any excess expenditure incurred in 1984. Second, in the case of health boards the available funds must be distributed between programmes to reflect the assumption made in the action plan and the policies for health set out in the national plan.

I am fully aware that all of this and the continuing effort through the period of the plan will place a great strain on health agencies and their staffs. Nevertheless, I suspect that most people will welcome a situation in which we now clearly know what has to be achieved over the next three years and will recognise that, as well as difficulties, there will be opportunities to do sensible things which might not otherwise be done. With the co-operation of all concerned I am confident that we can secure the necessary realignment of services over the next few years within the framework of the national plan.

Dr. O'Hanlon

It is all about money — not a word about patient care.

Mr. Donnellan

I was listening to the Deputies opposite talking about the transport service available. If Deputy O'Hanlon does not know about this Deputy Gallagher will give him an education about the way that service was abused over the years. They have been critical of the Government without saying what they would do themselves if they were in a position to do anything. The cost of the health service in 1983 was £1,043 million. This year it is £1,064 million. The number of people employed in the service had been 40,000. It is now 60,000. Deputy O'Hanlon, as a medical doctor, must realise how necessary it is to get the cost of the service down to a sensible proportion of GNP.

Dr. O'Hanlon

In that respect we are the second lowest in the EC.

Mr. Donnellan

As a leader of his party, the Deputy has not done anything whatsoever about it. Would some of the Deputies opposite give us a detailed plan of what they would do if they were in Government?

Dr. Ormonde

It seems incredible that the Minister for Health is not present at this important debate.

Mr. Donnellan

The Minister is in Brussels on urgent business concerning the Department of Health.

Dr. Ormonde

Or is he afraid to face us? I am glad of the opportunity to contribute to this debate. All of us who are discerning people must have felt that all our problems concerning health had come to an end when we were presented with a Labour Minister for Health in December 1982. We as medical people felt that our cup runneth over when we heard that Deputy Barry Desmond had been appointed as Minister. He was the most outspoken member of the Labour Party when in Opposition against the supposed health cuts at that time. Did he not help to bring down the then Fianna Fáil Government in November 1982 on the basis of health cuts? His party colleague, Deputy Seán Treacy spoke during the confidence motion and stated:

No matter what the financial difficulties of any Government might be, certain things should be sacrosanct. The Labour Party believe that health is sacrosanct. We helped to create the welfare state by our stance in this House and the ideology to which we have always subscribed, and we will not lightly stand for the tearing down of services, especially health services.

I warn the Minister and the next Government to be established in this House that any attempt to worsen the health services or interfere with the hospitals in South Tipperary will be resisted with all the powers and influence at our disposal.

I hope he will be consistent tomorrow night when he votes on this motion.

The Minister for Health was the most outspoken member of the Coalition in relation to the retention of food subsidies but we all saw how he and his Labour colleagues performed in relation to that issue. Not only did they row in behind their Coalition colleagues but they even went before the people to declare their great deeds.

This motion states:

That Dáil Éireann condemns the cutbacks in the Health Services and calls on the Government to take immediate steps to provide the necessary financial assistance so as to restore the standard of general medical services and of patient care to the levels which have hitherto prevailed.

I sometimes feel that this Minister is suffering from delusions of grandeur. He seems to regards himself as a surgeon, certainly in relation to the cutbacks he is making at present. More specifically, he is asking the health boards to implement these cutbacks and he has managed to avoid facing the public in relation to any of these cuts. He is expecting the health boards to do the entire job for him. I can assure the Minister that the South-Eastern Health Board will not do his dirty work. He can do it himself.

Mr. Donnellan

The Deputy is making as big a political issue of it as he can.

Dr. Ormonde

Last week the Minister did a PR job in meeting the health board representatives in Newbridge. What did he hope to achieve at this meeting? The health boards had been given their financial allocations already.

Mr. Donnellan

They had not received official notification.

Dr. Ormonde

We knew our allocation at the meeting of the South-Eastern Health Board last Thursday. All the health boards knew about their allocations before the meeting. I am at a loss to understand what the meeting was about. As a PR exercise it failed rather miserably because the headlines on Saturday's edition of The Irish Times stated “Cutbacks Threaten One Thousand Jobs”.

(Interruptions.)

Dr. Ormonde

The reality is very much different. That figure is very short of the mark. In the South-Eastern Health Board the situation is even worse. Vacancies are not being filled, temporary positions are unfilled and the CEO in an effort to achieve further savings has suggested that we abolish locum cover. In the document presented to the chairmen of the health boards last Friday this proposal was also mentioned. The Minister has consistently said that there will be no cutbacks and no deterioration of service but surely any normal intelligent being must understand that if you refuse to provide cover for one of the two surgeons or physicians in county hospitals the service must suffer. It means that the one person remaining will be on duty 24 hours a day, seven days a week. In effect he can provide only an emergency service. Is it the Minister's intention to provide only an emergency health service? Certainly he will not be in a position to provide anything else.

Mr. Donnellan

Is the Deputy talking on behalf of the patient or the doctor?

Dr. Ormonde

Obviously on behalf of the patient. A doctor cannot work seven days a week for 24 hours each day. That is what he is being asked to do.

Mr. Farrelly

Politicians have to do it.

Mr. Power

Do not interrupt the doctor during his diagnosis.

Dr. Ormonde

Patients must suffer. Operations will not be performed. Waiting lists will become even longer. The Minister will achieve further savings but at the expense of the poor, the needy and the sick.

Then there is the other proposal concerning the five-day syndrome. Obviously one can be sick only on five days of the week because the wards will be closed at weekends. Certainly one could not afford to be sick on a Sunday because we could not afford double time.

The meeting on Friday was a useless PR exercise because the allocations had already been made to the health boards. We had a meeting of the South-Eastern Health Board last Thursday and we knew our allocation then. Our shortfall this year is already £1.8 million and as this is the first charge on the 1985 allocation our shortfall for 1985 will be a massive £5.4 million. I cannot speak for the other health boards but there was a suggestion in last Saturday's Irish Independent that there would be a total shortfall of £37 million. I believe it will be far in excess of that figure. The Government and the Minister made no provision for the additional costs last year for which the boards were not responsible. I refer specifically to the halving of the food subsidies. No provision was made for this, yet the health boards had to pick up the tab. We are working on an inflation rate of 5.5 per cent but in reality the inflation rate in 1985 is much more likely to be 7 or 7.5 per cent.

According to the Secretary General of the IMO in April this year the proportion of Irish GNP represented by health spending stopped rising in 1980 and dropped gradually over the next few years before falling sharply this year. There had been an increase of 11 per cent in the Government's overall budget spending this year but health spending only increased by 3 per cent. Apart from representing a severe cutback in the real level of health spending this meant that the Government cutbacks were totally unequal and health suffered the brunt. It is strange that all this comes from an outspoken Minister for Health who promised to look after the health of the sick and the needy and was committed to them. The country's eight health boards were expected to save a total of £24 million this year. We all knew that they could not possibly achieve this and the shortfall will be the first charge on 1985, meaning in effect that if they could not achieve the savings in 1984 the shortfall in 1985 would be at least double that because the same savings will not be achieved in 1985.

The Mid-Western Health Board were asked to achieve cuts of £3.2 million in their spending this year. The latest reports suggest that their deficit at the end of the year will be something in the region of £1.5 million. In 1985 it will become £3 million as well as the other shortfalls which will be included in their present allocation, which means that the deficit will probably be in the region of £4.5 million.

The Southern Health Board were faced with a shortfall of £4.6 million at the start of the year and after most stringent cutbacks and closing of wards — for example, the new hospital in Tralee has only opened two-thirds of its beds — they seem set to have a deficit of £2.6 million. When you consider that in terms of 1985 prices you are probably talking of about £7 million shortfall.

The Midland Health Board will have a deficit of about £400,000 this year and their CEO says that this is partially due to the Government's decision to cut food subsidies. The health board will have to take up these additional costs. This is the situation for 1984, so you can imagine what it will be like in 1985. Units which have cost more than £7 million to build are lying idle because the Department have refused to provide the money to open or staff them. What kind of economic madness is this? Will they do as they did in relation to Irish Shipping and send in liquidators to the health boards also?

The maternity unit in Galway, so dear to the Minister's heart, which cost over £4 million to build remains unopened because funds have not been provided although I understand that there was an attempt to open it recently as a PR exercise even though it is neither equipped nor staffed. The new 30 bed maternity unit at Cahercahill near Ennis, costing £750,000, lies idle because of lack of staff. A 14 bed gynaecology unit at St. Luke's Hospital, Kilkenny, built at a cost of £25,000 has been idle now for two years despite severe overcrowding at St. Luke's Hospital.

A geriatric assessment unit was built in Ardkeen Hospital approximately six months ago which also lies idle because the Minister refused to staff it. This was done in spite of the pious platitudes contained in Building on Reality which states that it is the Government's intention to make provision for the needs of the increasing number of elderly people. We are told that there will be improvements in the many institutions which provide for geriatric patients. They are lovely sentiments, but the reality is different. This all comes from a Labour Minister for Health who is committed to catering for the sick, needy and the aged. Money has been spent on providing paediatric facilities in the general hospital in the midlands but these cannot be opened because there is no money available to appoint consultants and other staff. Money has been earmarked to provide badly needed orthopaedic facilities in the midlands at the District Hospital, Athlone, but now the Minister says that the Midland Health Board will have to find the money within their allocation to fund these posts. I have bad news for the Midland Health Board because when we were faced with a similar situation in the south-east we managed to fund additional funds from within our allocation to provide for two casualty officers and a radiographer but we were then told by the Department of Health that, because we would have a deficit for 1984, these funds had to go to correcting this deficit. Therefore, even if you manage to find the funds within your allocation, you still lose out.

Wards have been closed during the year at a number of voluntary hospitals including the Meath, the Mater and the Adelaide. Faced with a deficit of £1 million this year, the authorities at St. James's Hospital, Dublin, were forced to withdraw tinned fruit and ice cream from their patients. How low can we get?

In Building on Reality it states that in order to raise additional revenue it is proposed to raise the fees for private and semi-private accommodation by — I thought 15 per cent — but I discovered tonight that they propose to raise them by 20 per cent. This means that many patients who at present opt for this accommodation through the VHI will now be priced out of that organisation and will have to revert to an already overstretched and overcrowded public hospital service. They cannot cope with the demands on them at present and now the Minister is preposing to add to their problems. I wonder if the Taoiseach and the Donnybrook set are aware of the implications of this decision.

(Interruptions.)

Dr. Ormonde

I have a letter from the sister in charge of St. Vincent's Private Nursing Home concerning the implications of the Minister's decision in relation to semi-private and private accommodation. She recognises the dangers in increasing the cost of this accommodation and has asked the Fianna Fáil Party to intercede and to prevent the recommendations from being implemented.

With regard to the outlook for 1985, the financial allocations of last week suggest that the health services will gradually grind to a halt as they cannot possibly continue with a shortfall of at least £37 million. We have had our allocation since last Thursday——

(Interruptions.)

Dr. Ormonde

It indicates a shortfall of £5.4 million in the south-east. The North Eastern Health Board got their allocation yesterday. There is now another proposal from the Department of Health that they will introduce discriminatory funding, with the bigger hospitals receiving more money than others. This could lead to a huge gulf in Irish medicine with a small number of hospitals properly financed and well equipped while the remainder struggle with inadequate funding and outdated equipment. I thought the Minister for Health would be present tonight and I was going to appeal to him and other Labour members, especially Deputy Seán Treacy, in view of his statement in November 1982, to reverse this decision. If the Labour Party have a conscience and hope to retain credibility they should support our motion. They were set up in relation to food subsidies and they should not let that happen again with regard to the health of the sick and the needy, the people they claim to care for. If they do, they will not be thanked by the electorate.

Debate adjourned.