Private Members' Business. - Health Boards Funding: Motion (Resumed). – Dáil Éireann (24th Dáil) – Wednesday, 27 Feb 1985

Private Members' Business. - Health Boards Funding: Motion (Resumed).

The following motion was moved by Deputy O'Hanlon on 26 February 1985:

That Dáil Éireann calls on the Government to provide the necessary funds for each health board to make good the shortfall in their 1985 budgets so that they will be in a position to provide an adequate and satisfactory level of health care for the people in their respective areas.

Debate resumed on amendment No. 1:

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

"notes that the Government has provided in the 1985 allocations to health boards sufficient funds to enable each health board to provide an adequate and satisfactory level of health care for the people in their respective areas".

—(Minister for Health).

Mr. Aylward

I welcome the opportunity to speak on this motion. I agree that an adequate and satisfactory service is not being provided at present when one considers the cutbacks and reductions that have been carried out by health boards in their finances and services over the past few years. I must admit that some years ago there was a case for cutting back on expenditure in the health service. However, these cutbacks have been implemented and many long and agonising hours have been spent by members of health boards in trying to achieve these reductions. In 1983 and 1984 huge savings were made by health boards, but there is a limit to how far cutbacks can go and that limit has certainly been reached.

I intend to speak about the South Eastern Health Board of which I am a member. The allocation to the South Eastern Health Board in 1984 represented a reduction of £3.5 million. Additional factors in 1984 called for a further reduction of £0.8 million. We all know that this included the removal of food subsidies, which cost the health boards a very substantial amount of money. When the Minister was making his allocations he did not anticipate that food subsidies were going to be cut and he made no compensation to the health boards. This resulted in a required overall reduction in expenditure of £4.3 million. The reduction actually achieved in 1984 amounted to £3.2 million, resulting in an estimated over-expenditure at the end of 1984 of £1.1 million, which had a twofold effect on 1985 figures. It represented a first charge on the 1985 allocation and it represented the extent to which expenditure remains to be reduced in 1985 arising from the 1984 allocation.

The residual effect of the 1984 allocation, together with the reduction in the 1985 allocation, resulted in an overall reduction in 1985 requirements of £3.9 million, made up as follows. There is a deficit of £1.1 million carried forward from 1984. There is an amount required in 1985 to reduce expenditure to the authorised 1984 level of £1.1 million and there is a further amount required to reduce expenditure to the authorised 1985 level of £1.76 million, making a total of £3.96 million.

The South Eastern Health Board held two meetings at which the financial position for 1985 was considered. At their first meeting they considered and approved reductions in expenditure of £1.727 million, and this was not easily arrived at. It included cutbacks in energy, staffing, transport, maintenance, reductions in overtime, medical appliances, equipment and the number of locums.

There is one matter to which I should like to refer, not with the intention to scare, but out of concern. The Minister has not taken into consideration the fire risk factor which exists in the buildings in the South Eastern Health Board area. They are all two and three storeys high. Patients are located upstairs in these buildings but nothing can be done to bring them down to ground level because there is no finance available. There are also reductions in staff and overtime curbs and there are not sufficient numbers of nurses on duty at night to cope should a disaster occur. The Minister should take particular note of this.

At their second meeting the South Eastern Health Board considered a list of recommendations from the programme committee as to possible further reductions. However, in considering these further reductions the board were very conscious of the extent to which services were underprovided. They had a list of these underprovided services which amounted to £3.5 million approximately. Such underprovisions may be attributed to the underfunding in recent years. For example, since 1980 the South Eastern Health Board allocation has been cut by a cumulative amount of £11.092 million. If the 1980 allocations were updated, having regard to the value of the punt since then, the board's allocation for 1985 would be £100.66 million instead of £83.5 million which they received this year, a difference of approximately £17 million.

Another example is the underprovision of funds to the board compared to other health boards. We are all aware that the health boards are undergoing very serious financial difficulties but I want to make a comparison showing that the South Eastern Health Board are worse off than the others. A recent survey of comparisons shows that the allocation in 1984 per head of population is £275.4 compared with the national figure of £301. If you multiply that by a figure of 394,000, the number which the South Eastern Health Board are catering for, it amounts to a gross figure of £9.7 million.

The allocation for 1985 has not only failed to redress the low allocation per head in the South Eastern Health Board region compared to others, but it has failed even to provide the same average percentage increase given to other regions for 1985. I will give further examples of the differences in this region as against the national average. In acute beds there are 3.1 per 1,000 head of population and the national average is 4.3 per 1,000 head. The average cost per bed in county hospitals is £646 and the national average is £674. A geriatric bed costs £59 and the national average is £159. The average cost in a welfare home in the south east region is £73 and the national average is £85. In regional hospitals in the south east area, the cost is £747 and the national average is £842. There are 20 consultants per 100,000 head of population and the national average is 33 per 100,000 head of population. I could go on and on. In the general medical service it costs £56 per patient in the South Eastern Health Board area and the national average is £66 per patient. These figures speak for themselves and indicate that the South Eastern Health Board are getting a particularly raw deal from the Minister. Instead of giving credit for good housekeeping, he has penalised the South Eastern Health Board.

I also wish to refer to the many completed units which are lying idle all over the country because the Minister will not approve the provision of staff and equipment. The geriatric unit in Ardkeen, County Waterford, was completed in 1984 and it lies unopened. We have the scandalous situation of the maternity unit in St. Luke's Hospital, Kilkenny, which was completed in 1983 at a cost of £240,000 and has been lying idle since. The Minister said we must provide staff and equipment from our own resources although it must now be obvious, even to him, that that is not remotely possible. I visited St. Luke's Hospital last Monday and I was shocked to see the number of beds in the corridors, end to end, with medical appliances, drips, etc., especially when one considers that there is a brand new unit lying idle.

These are some of the hardships being imposed on patients by the Minister.

This is not being said by Members on this side of the House only but also by members of the Minister's party, health board officials and concerned individuals. I appeal to the Minister to take note of what was said in this motion and to show his concern by meeting the genuine and sincere demands of the health board, particularly to protect the weaker sections of the community which his party claim to represent.

Mr. R. Bruton

One thing that strikes me about the growth of public spending is that when we have a prolonged period of growth we do not seem to get great results but when there is talk of cutbacks in spending the proposals put forward are of an extraordinary nature. Nowhere is this more vivid than in the case of the health services. We have had dramatic growth in spending in that area over the last ten years but now that there are small restrictions on the budget proposed, proposals are put forward which involve shutting down expensive equipment, the non-use of units in which there was expensive investment and the threat of the loss of life.

There has been a doubling of real resources absorbed by the health services in the last ten years and the suggestions about the effects of the cutbacks must be looked at in that context. Can we seriously entertain the suggestion that loss of life or huge waiting lists are realistic outcomes of small reductions in the allocations? The reality is that these betray poor allocation of resources within the health boards. They are unwilling to face up to decisions about priority, where money is best spent and what equipment is best used.

There are unique features about the health services. There are limitless medical possibilities of spending resources to prolong life and the decisions about the use of medical resources are not made by patients but by doctors. These have enormous implications regarding the need for health boards to have systems to channel resources to the areas where need is greatest. Health boards have failed to face up to this. There are plenty of grounds to suggest that resources are not going to areas of greatest need. I will cite some examples from documents published in the last 12 months. The NESC Report, No. 73, reveals that we have 50 per cent more acute beds than in England and Wales. That is evidence of a very high degree of concentration on the hospital resource. That is strengthened by the discovery that one in six consultations with a family doctor leads to a referral to hospital or to a consultant. That is twice the rate of the UK. These are features which are pushing our health services towards the unusually expensive resource of hospitals.

In hospitals there are many problems of resource use. For example, a recent study of the GMS service revealed that 40 per cent of short stay admissions to hospital could have been dealt with elsewhere at a lower cost. It also revealed that there is substantial evidence of excessive use of expensive diagnostic procedures by junior hospital doctors. Very many attenders at out-patient services could have been dealt with by their general practitioner. What is happening is that we have an undue emphasis on the hospital resource.

The cost of a week in hospital to the taxpayer is £1,200. That is taking into account not only the running cost but the capital cost of being in hospital. That kind of evidence shows we are using resources in a profligate fashion. By deciding where our priorities lay we could get a better health service and save resources.

As I have said, one in six persons are admitted to acute hospitals every year. Typically their stay is longer than need be and there is no proper control of the resources used in their treatment. We need to redress that problem and ensure that the resources used are used effectively and are not squandered on people who do not need them, thus denying them to people who may need them. We have tended to build up a false faith in the power of hospital to cure ills instead of realising that facing up to the problems of ill health requires a response from the community and the individual.

Instead of whining about the budgetary restraints imposed on the health boards we should be addressing the serious problems of how to get the best quality health services in a climate where the nation cannot afford to increase resources at the dramatic rate at which they were being absorbed by the health services. I am convinced that health boards can make do with less and provide the same quality of service if they face up to fundamental issues. One of the fundamental issues is that if there are beds they will be filled. The national planning board made that point fairly clear in its document. Experience in the last ten years shows that despite the fact that we were able to reduce the length of stay in hospitals we did not succeed in making hospital beds redundant. There were always people to fill the beds which supposedly were being saved by shorter hospital stays. We must ask if all our hospitals are effective and should continue to operate. They are a very expensive resource.

The Department must begin to look at the more fundamental issues of the management of medical resources. They have manfully tried to improve management practices relating to stores, the use of energy, transport and pricing policies but these, while important, are dwarfed by the real decisions which absorb resources and they are the medical decisions. We must ensure that there is ability to look at medical decisions in a management framework. Resources used wastefully on one person are resources denied to another in greater need.

There are three sectors in the health service, the primary sector, the out-patient sector and the in-patient sector. Half the population have to pay for primary care, the sector which is cheapest. The sectors which are much more expensive in the way that they absorb resources — in-patient and out-patient services — are free to the vast majority of the population. I am not saying that we should charge people for these services but there is a contradiction in saying to people that they should pay for primary care but have the more expensive resources free of charge. We must face up to that perverse incentive. It is hardly surprising that out-patient facilities are filled with people who could be treated effectively by their own doctor. As a result of the financial incentive we present to them we are telling them to go to the out-patients where they will be treated free of charge as against going to their local doctor which could cost them £7 or £8. These problems are accentuated by the effect of VHI on our health service.

Another issue we must confront if we are to come to grips with the better use of resources is that the community care organisation of health boards has failed to come up with a structured support mechanism for people who seek to be treated in the community. There are problems of non-co-operation between sections of community care. There is also the problem that community care has not a proper allocation of resources within health board budgets to make it an effective option to hospitalisation. We must address that point seriously if we are to achieve better results from the resources which, inevitably, over the next five years will be straitened.

There is no admission policy effectively operating in many hospitals. Over half the admissions to hospitals come through the out-patient clinics. Patients are not coming into hospital on a planned basis. They come in on spec to out-patient clinics and are admitted to hospital. That is not a proper way to conduct an admission policy. We need to have proper criteria to decide who gets into hospital. There must be greater screening of out-patient clinics to prevent people being admitted to hospital who could be treated elsewhere and also to prevent return calls to out-patient clinics which may be clinically unnecessary.

There is a great deal to be done by the hospitals in developing alternatives to long stays in hospitals. In the US, for example, there has developed the idea of same day surgery whereby a person can be admitted, treated and discharged on the day. However, if we are to adopt that option we must have a sensible community care programme by which we can provide a back-up service outside hospital.

We must address the issue of the lack of knowledge on our part about the treatment costs being incurred by different consultants and in different hospitals. There is ample evidence that the length of stay varies enormously from one hospital to another in respect of the same sort of treatment. That is a question we must come to grips with but we must first have systematic information about the position. I would sound a note of warning that when we are providing computer facilities we are not doing so purely for the benefit of the administrative side, in the interest of efficient transport schemes or of stores. We must provide computer facilities also for the purpose of enabling us to monitor the cost of specialist treatment. It is only when that knowledge is available to consultants that they can learn from the practice of their fellows and develop a more cost effective service. It rests with our doctors in the hospitals to develop cost effective management. They must not be tempted to hide behind professional rituals or merely to say that it has been their professional practice always to operate in such a way. We cannot afford to hide behind defences of that kind. If we do not manage our resources effectively we will be denying services to those in greatest need.

It is disappointing that the present debate about our health services has been conducted at such a politically charged level. It is no accident that that has been the case. Serious problems within the health board structure have been highlighted during the debate. One of these problems relates to the health boards not having responsibility for funding nor for decisions in relation to the use of resources. This has a very damaging effect because they devote more attention to defending budgets and to perhaps using the health boards for political purposes than to the question of coming to grips with providing a cost effective service, or of using the resources available to them in the best interests of the community.

We need also to clarify the relationship between the health boards and the Minister. It seems that the whole relationship, both in terms of finance and on policy issues is extremely murky. Publicly there are debates on the question of what precisely is over-spending or what are the shortfalls in budgets. It seems as if the Minister and the boards are poles apart, that they are not part of the same team trying to secure better results for the community. The type of ad hoc allocation of funds that has occurred between the Minister and the boards, in the absence of proper co-operation or of a proper addressing of the fundamental issues in the health services, must be ended.

I am convinced that the problems in the health services are not problems of scarcity of resources but of arranging our resources so as to put them to the best use possible. With better planning on the part of the health boards the phenomena discribed by Opposition spokesmen, whether real or threatened, such as expensive equipment being left idle, the danger of loss of life and long waiting lists, need not occur.

The motion before the House portrays a continued unwillingness on the part of the main Opposition to face up to the nature of our current economic difficulties. Government spending is 80 per cent of income. Our working population bear savage tax burdens. On another day and in another debate spokesmen for the Opposition would bring tears to one's eyes talking about the need to reduce the burden on the hard pressed taxpayer but if we are to reduce the burden we must face up to the need to reduce the dramatic absorption of resources within the health services and we must do so in a way that will not damage the health services. The Opposition must be prepared to face up to the real issues and to the way in which those are dealt with.

Mr. Allen

I support some of the points made by Deputy Bruton. I submit that the reason for the VHI contribution increases announced last evening can be traced back to the escalation in the cost of the hospital services. Last evening I heard some Opposition speakers criticise the cutbacks in the health services. They criticised the Minister's attempt to achieve savings in the system.

In November last I spoke on our policy document, Building on Reality and I criticised the level of efficiency of hospitals within the health system. I advocated that the Minister set up an agency that would have responsibility for running the hospitals, that the major hospitals be removed from the health board system and that local boards of management be set up and be responsible to the national agency. The Minister has not accepted those suggestions but he must take action immediately to deal with the problem of escalating costs. His attempts to achieve savings, especially in the southern health board area, have been made a political football. In the Cork-Kerry region we were subjected to a lot of criticism by our political opponents both within and outside the health services because of the Minister's attempts to achieve savings.

One area in which the Minister could achieve savings would be by removing some of the health care services from the hospital system. He should concentrate on ways of achieving savings in the health scheme. I wonder if those who criticise the Minister have read the report of the working party who reported last year on the general medical services and of how to achieve savings in the system. This report must be considered seriously because it deals comprehensively with the family doctor service and emphasises the importance of developing the educational and preventive role of future GPs. More attention must be given to training programmes for family doctors and we must emphasise the importance of training tomorrow's GPs to be better able to deal with the number of problems which at present are being admitted to hospitals. The current problem of over-prescribing drugs which is so prevalent in the medical profession must also be examined. However, it is not good enough to reduce the number of people in hospital because that would take people from the hospitals who would end up in the community, and present structures and resources are inadequate to cater for people in the community.

I have said previously in the House that the greatest consumers of the Department of Health finances are the hospitals. We are spending vast amounts of money on specialist services there, and we are giving scant attention to the development of structure and care within the community. Therefore, the vocational training schemes being operated for GPs in Ireland are not getting the necessary recognition they justify and deserve. Any finance invested in this type of training will give a thousandfold return. To date the help and recognition given by the Department of Health in this area is insufficient and inadequate. However, I am aware that the Minister recognises the need for a full and comprehensive GP training programme by means of finance and back-up service which have been inadequate to date.

Unfortunately, at present unless the public get consultant attention they feel they are being short changed. Routine tests are being referred to consultants at enormous cost within the hospital service, even though they could be done by the GP outside the hospital sphere. What is required is the instilling in the public of confidence in the GP service within the community which can be brought about only by the proper training of the GP which in turn can come about only by proper financial backing from the Department of Health for the vocational programmes. The attitude of the community to health care must be to keep the patient out of hospital if at all possible, and this can be done only by developing the confidence of the community in the GP by ensuring that he can give the level of service that the public have come to expect. However, in most situations the GP is being bypassed in favour of very expensive specialist hospital services at enormous cost to the Exchequer. This trend must be reversed as soon as possible. We must attack the escalation of hospital costs at once, otherwise the service will consume the full health budget.

I turn to local matters. I have referred to the position in the Southern Health Board and the political footballing that has been carried out recently concerning the £9.5 million deficit in which that health board allegedly find themselves. We advocated at the time that the Department of Health would take a more than keen interest in the affairs of that board, and I was delighted to learn that the board find now as a result of a departmental investigation that they are not in a £9.5 million deficit but far less than half of what was alleged in October and November.

Mr. Lyons

An amount of £5.6 million is not half.

Mr. Allen

Nobody said £5.6 million. I listened silently to a great deal of aggravation from the Deputy last night——

An Leas-Cheann Comhairle

Deputy Allen has one minute.

Mr. Allen

——and let him take the medicine that is being handed out now. Last night I heard references in this House to the problem about the North Infirmary. As a member of the board of management, Deputy Lyons, who referred to it, should have known that a meeting between the board of management of the North Infirmary and Department of Health officials is due to take place early next month.

Mr. Lyons

It is postponed again.

Mr. Allen

It is not postponed again, it is to take place next month. As another member of the board I feel that to play politics with the problem there will not help, and until that meeting takes place and the outcome is known, then political silence on the matter would be welcomed. We have all made our views known to the Minister and his officials privately and it should be left at that for the present. Ongoing discussions are taking place between the medical staff in the North Infirmary and the Mercy Hospital on the rationalisation of services between these two hospitals, and it is irresponsible and a disservice to the North Infirmary to give the impression to the public that all is not well with the quality of service in that hospital.

Mr. Lyons

That is an awful statement.

An Leas-Cheann Comhairle

Deputy, your time is up.

Mr. Allen

We must put the case for the North Infirmary in a logical, calm and organised manner and not in the way attempted last night.

An Leas-Cheann Comhairle

Deputy Liam Naughten and he must conclude at 7.40 p.m.

Mr. Naughten

I am delighted to have the opportunity to speak for even a few minutes in this debate. I endorse the sentiments expressed by the previous speaker. The Minister is in an extremely difficult situation in having to provide gigantic sums of money that the health service needs at present. The Minister pointed out in the House the massive increase in health expenditure in the last ten years, from £143 million in 1973-74 to £1,100 million in this financial year. Of course, we would all like to see additional finance available for the health service and every other service, but this finance can be got only by additional taxation. I find it very difficult to meet anybody today who is prepared to pay additional taxation for the services being provided. I have no doubt that the amounts of money provided by the Minister this year will be sufficient to provide an adequate standard of service. Listening to the Opposition crying about the massive reduction in the amounts of money available to the health boards etc., one could not but remember that they were the first people to put the pressure on health boards in 1982. I remember the then Government speakers who are now in Opposition welcoming the cuts introduced by Deputy Woods then.

We have one of the best health services in the civilised world, and I have no doubt that with an all-out effort at co-operation between the health boards and the Minister the standard of service and the money provided will be adequate. I regret that these cuts seem to become a political football. In the health board in my area the one reason the budget has not been discussed is politics. That is a sad reflection on the board. I have no doubt that the £110 million plus that the Minister has provided, which in effect is £370 for every person living in Mayo, Galway and Roscommon will be totally adequate to provide the services we need there.

It is important to remember the gigantic increase in the numbers of staff employed in the health service since 1973-74. At that time they had 40,000 employed whereas today they have 60,000 employed. We must face up to the difficult situation that the Government face in providing the type of service that people seem to demand. All the publicity in the national papers regarding the closing of certain institutions, particularly geriatric institutions in the Western Health Board, was just political propaganda and there is no danger whatsoever to those institutions. Each day we hear the Opposition using the opportunity of the reductions in the health service to seek more money, but in the last few months the Opposition have sought additional moneys for a whole range of things. I challenge them here tonight to say precisely where they are to get this money. They are looking for an additional £200 million to refloat Irish Shipping Limited. They were going to wipe away local authority charges which were costing another £30 million. They were going to give an additional £350 million for public service pay. They sought another £40 million for Verolme Cork Dockyard. They were going to inject £200 million into the economy for infrastructure.

This is the type of irresponsible opposition that we have not alone here in the Dáil but at health board level. If there is all-out co-operation between the health boards and the Minister we can live within our budget. I tell the Minister tonight that if this co-operation is not forthcoming he should consider seriously reverting the control of health services to the local authorities where it lay prior to 1972. I consider that very many local authorities gave a standard of health service as good as we have today. Money will not save lives. What we need is co-ordinated co-operation from everyone involved in the health services. If we have that lives will not be lost.

Mr. B. Ahern

As our time is limited I will confine my remarks mainly to the Eastern Health Board. I do not believe this side of the House have made this matter a political football. I am a member of the Eastern Health Board and I know that that board have been most constructive in their actions and have tried extremely hard to work in co-operation with the officials of the Department of Health. The members have not been political when dealing with matters of interest to the people of the greater Dublin area, of Wicklow and of Kildare. We have tried to provide as good a service as possible with the money available. Perhaps the situation is slightly different in my area because the board are directly involved in the provision of community, psychiatric and geriatric care, and with services for the mentally handicapped for some 400,000 people.

We all know that, for whatever reason, there have been cutbacks. When the Minister was in Opposition he frequently made the point that our health services were excellent and were far more advanced than those available in other countries. He often told us he did not want to undermine those services. In his contribution in the House during a vote of confidence in November 1982 he said prior to the election that was held on 24 November 1982 that a major commitment of the Labour Party was that they would not accept cutting the deficit over five or six years. The main reason according to him was that it would break the structure of the health services that had been built up by successive Governments. However, because of Cabinet pressures — I can understand them — he has lost many of the battles at the Cabinet table and he has had to implement severe cuts.

I admit that like many other services the health services had some room to manoeuvre and they had a certain amount of fat that could have been eliminated. However, that could not continue indefinitely. It is not possible to continue on a low base to cut back without running the risk of eliminating certain services and the Minister, his officials, the CEOs of the health boards and all Members of this House know that. There is not much point arguing about political footballs. The figures provide for cutbacks of the order of £37 million but I have no doubt that the gap that exists between what is available and what is required can be bridged. There is always something that can be done: it is the way Estimates are prepared. If the Minister is to be fair and honest and if he is to follow the line he has consistently pursued he must accept that there have been considerable cutbacks, whether for economic or other reasons.

In the Eastern Health Board we have tried on an all-party basis to cope with the inevitable reduction in services caused by the lack of resources in the past few years. We decided we should maintain services for those most at risk, that we should move the delivery of health care services from institutions to the community where this is possible and practicable and that we should maintain basic staff employment to the greatest extent possible. That is the position we have taken.

There are major difficulties in the Eastern Health Board to a greater extent than in other areas. The population in this area is growing at a more rapid rate than elsewhere throughout the nation and is far higher than European levels. There is a continuing and significant increase in the dependent population in the greater Dublin area — by that I mean children, those people who are at risk and the elderly. We have told the Minister that in times of difficulty those most at risk tend to come to the city for protection to obtain services and all that has put great demands on the Eastern Health Board. We have argued that we merit more assistance than others. Most of the acute hospitals in the city do not come within the ambit of the Eastern Health Board. However, the hospitals at Naas and St. Columcille's, Loughlinstown, are at a stage of development where there is a marked increase in activity and consequently their costs are increasing. It is not possible to talk about cutbacks for areas like Tallaght and Blanchardstown which are growing areas.

I am sure the Minister will acknowledge that the Eastern Health Board have tried extremely hard to cope for many years but it is not possible to expect them to take cutbacks of £5 million without substantially reducing services that are far from adequate. Waiting lists are increasing, there is a lack of community services and the services in a number of areas that were quite good are now declining. A visit to any of the health centres in the city will show what I mean. Most of the buildings of the Eastern Health Board in the city are old and they require substantial repairs. In respect of mental care, the board are trying hard to renovate their premises and to update the facilities. This applies to St. Brendan's and to St. Ita's, Portrane. That cannot be done if they have not the money. On the non-capital side there will be costs in respect of heating and maintenance of these buildings.

I plead with the Minister to try to give us the extra resources. It is not our job to say where the money should come from. I know the Minister has difficulties at the Cabinet table but that is his function. He must realise that in the past three or four years the health services have suffered more than many other areas. For instance, education has seemed not to have suffered to the same extent from the cutbacks. In this motion we ask the Minister to go back to the Cabinet and to argue for those who cannot argue for themselves. Many of those people are incapacitated or are in mental homes and many need community services. They cannot march to this House like other lobbies and they cannot come here as do other pressure groups. It is our obligation as an Opposition to fight for them and it is the obligation of the Minister to act as he has always said he would, namely, not to allow essential services to be eliminated for those who cannot pay for them.

There are many areas in which this Government have spent money and where economies could be made. Cutbacks should not be made by asking people to delay going to hospital, by allowing waiting lists to increase and by closing wards. We should not try to turn the health service into a five day week as though people did not get sick on a Saturday or a Sunday.

The situation may not be as bad as it is portrayed but it is serious. It is not good enough to say the matter is being treated as a political football. We have to fight for those who cannot fight for themselves and that is what the Minister did during his political life. He should go back to the Government and argue for as much of that £37 million as is needed to maintain these services at a proper level.

Mr. Flynn

Our position could be summarised in the following way. We believe that in a time of deep recession and falling living standards, where household budgets are being attacked every day by increased costs and prices, it is not appropriate for a Minister for Health to seek to reduce the level of services he provides to the community. The reductions and cutbacks the Minister proposes will result in very significant reductions in the quality and quantity of services people have become accustomed to. There is no doubt but that there is at present under the Minister's direction a dismantling of the fabric of the health services. These are not the words of the Opposition Party trying to score political points off the Minister. These are the words being uttered by the executive offices operating under the health boards. These people, the front line administrators and executives, are saying that there is an inevitability in what he is proposing by direction to them, that there has to be a reduction in the quantity and quality of the services being provided.

There is a credibility gap with the Minister which has to be bridged this evening and it stems from his directions at the Newbridge meeting to the chief executive officers. He made it clear in very explicit terms that there would be no additional funding this year to help bridge the gap. He also said he expected that they would comply with the guidelines laid down under the national plan. He said that these guidelines would have to be met and there was no alternative as far as he was concerned. This is a strange stand for a Minister to take in the present circumstances. He will have to accept that his public statements do not stand up when he refers to the extent and the level of the services being provided by his Department. He maintains there is no lessening of the standard, quantity or quality of the services available and no hardship is being endured by people at this time. The Minister will not acknowledge that there is curtailment of services in the health sector. He does not appreciate the staff situation in health boards and hospitals at this time. He will have to admit that, whatever he might think about the level of services the Department provide, people's expectations have not lessened over the past few years despite the fact that he would like it if there was a lessening in demand for the services. The statistics are there. They are not being brought forward by the Opposition party, but by the executives who man the health services on his behalf.

The Minister fails to appreciate the population growth over the past number of years. If there had been a decrease in population over the past ten years one might be expected to say that if fewer people are demanding the services then some cutbacks or savings might be made. But there has been a population increase and, worse still, the level of demand on the health services has increased because of the number of people who are unemployed and unable to provide the health services they require from their own resources. We have seen a further extension of that in the recent past so far as Voluntary Health Insurance costs are concerned. The effect of the increased VHI premia means that more people will not be able to meet the demands to get the necessary health services. Consequently there will be a throw-back on to the services the Minister is already reducing. There will be an increased demand from those who will not be able to fund their own requirement under the VHI scheme. This will mean that the VHI will be an exclusive club for those in the higher income bracket only. This must put increased pressure on the existing services run by the health boards. How can they meet that demand if it is agreed by the executives and by all those who provide these services that there has been a diminution in the services and that there has been a lessening in the quantity and quality of those services?

This can be backed up so far as the Western Health Board are concerned by one simple fact. This is not the first year the Minister issued a directive on cutbacks. This is an ongoing demand. Last year in the health board area dealing with Mayo, Galway and Roscommon there was a cutback of £4½ million. The board managed to get within £500,000 of that figure. One would expect that in ministerial generosity, having effected a saving of £4 million, the Minister might have made available from supplementary money at least that £500,000 shortfall so that it would not be carried on as a first charge against the services of the board this year. What was the result of the board making that exceptional effort? They were the only board out of the eight which had such a good performance, but what is their reward? They end up with a 4.79 per cent increase on the 1984 Estimate, the lowest increase granted to any health board in the country, despite the fact that the population structure in the Western Health Board area is completely at variance with the situation which exists in other health board areas — they have many people of advanced years living in unaccessible areas, living long distances from institutions and who need transport because they often live hundreds of miles from their nearest health institution.

That is the health board the Minister is threatening with dissolution. Because they made such a fine effort last year, they are condemned this year to the lowest percentage increase on their estimates.

People's expectations have not lessened. The Minister has been asked, if people's expectations are not decreasing and if there is a bigger demand on these services, what does he propose doing. He says there should be bigger involvement in community care services. May I put it to him that the budgets attached to the community care services are statutory allowances under the disabled person's maintenance allowance scheme. What he has done is to draw money from the acute care services but he has not transferred that money into providing increased allocations for community care. In other words, he is taking money from the acute services but he is not giving the community care operation a satisfactory chance to bring about a situation where there will be a lesser demand on acute services. That is the situation in the Western Health Board area. There has been an enormous cutback in the past year.

Last year medical and surgical appliances, drugs, medicines, maintenance, X-ray expenses and grants to voluntary organisations were withdrawn. We have to put it on record that the adult dental and ophthalmic schemes were suspended totally in September last. Medical wards were closed for three months. A surgical ward was closed for two months. Two gynaecological wards were closed for three months. Five units were closed for a total of seven months and an orthopaedic theatre was closed for two months; and as well as these cutbacks we have to do more this year. That is the demand the Minister is making. How can he in all honesty say that he is not dismantling the health services?

Mr. Hyland

There is no area of public administration where the social conscience of the Government is more effectively demonstrated than in the delivery of health care and in the implementation of the social welfare code. Government policy in this area should endeavour to reflect the expectations and values of the society in which it operates. Irish values and attitudes in this very important area have been to care for the sick, for the old and for the underprivileged. That unique quality in the character of the people has been reflected throughout the world in the dedication of our nurses, nuns and the medical profession generally. These expectations and values like so many of our other values have become submerged in the jungle of confusion of the so-called monetarist policies being pursued by this Government. The House will agree that this Government's attitude to our health services is in very sharp contrast to the reasoned, concerned and well informed view put forward by our spokesman on health. Deputy Rory O'Hanlon, in his opening contribution to this debate. This House would do well to listen to him. The Minister should be guided by his expertise and his great knowledge in this area. I would urge the Minister to desist from any action which will further undermine the health services. The Minister should recognise that the cutbacks of the past three years have put the health services in jeopardy and many health boards fear that in 1985 they will not be able to discharge their statutory responsibilities.

We support the Minister in his efforts to achieve efficiency. I admit that some wasteful expenditure was eliminated in the first years of the cutbacks introduced by the Minister and great credit is due to the hospital staff and administrators who assisted in this important exercise. Those committed people are now totally disillusioned as they watch the service deteriorate to the extent that hospital wards are closing, staffing levels are reduced to an extremely dangerous level in many hospitals and, indeed, in some instances essential operations have been deferred due to inadequate resources. It is wrong that people who have worked all their lives and who cannot afford to pay for operations should have to wait indefinitely for orthopaedic surgery. It is wrong for a country with such a proud record in nurse training to have understaffed hospitals and it is wrong that young students have to emigrate to get employment. The Minister has had repeated requests from health boards and hospitals to bring the staffing levels up to a standard which will at least provide reasonable services in hospitals.

In the general hospital in Portlaoise at night there is only one nurse on duty in the male ward and one nurse on duty in the female ward and if there is an emergency during the night these nurses have to deal with it. Even the Minister would agree that this is unsatisfactory. I am disappointed that the Minister in his efforts to rationalise the hospital services did not recognise the importance of the psychiatric services and the need to make sufficient resources available to keep abreast of developments and research in general hospital training which is of growing importance to many people.

It should not be necessary to remind the Minister that the level of service to medical card holders has seriously declined under his administration and that many families who are marginally outside the qualifying limit for medical cards are unable to provide for the medical needs of their families because of mortgage commitments, unemployment and so on. The Minister would be well advised to take a serious look at the position of those people. To the extent that medical cards are now the criteria for qualifying for school transport many parents now have to provide for school transport as well as for all their other commitments. We are talking about a new poor. These people are under pressure. They are proud people who never looked to the State for assistance in the past but due to the severe economic pressures on them they are now in difficulties. The Minister and the Government should take a special look at their position.

The greatest hardship of all for which the Minister and his Department are responsible is the delay in dealing with social welfare claims. I know the Leas-Cheann Comhairle will advise me that this is slightly——

An Leas-Cheann Comhairle

It has nothing to do with this motion.

Mr. Hyland

I want to make the point in passing that the Minister should try to speed up the process of dealing with unemployment assistance claims and with appeals. Many families are waiting for up to five and six months——

An Leas-Cheann Comhairle

I would appeal to the Deputy to come back to the motion.

Mr. Hyland

I apologise but this is of sufficient importance to merit a mention in the House as it is a pressing problem for many people.

The Midland Health Board were faced in 1985 with a £2 million cutback. I compliment the CEO and members of the health board on their responsible attitude in facing up to these cutbacks and in putting to the Minister for his consideration a new development programme for the Midland Health Board area. I understand that their proposal has been accepted by the Minister. I appeal to the Minister to leave no stone unturned to make the necessary resources available to the board for the implementation of this new rationalisation programme which hopefully will lead to a general overall improvement of service in the Midland Health Board area.

An Leas-Cheann Comhairle

Deputy Eileen Desmond has five minutes.

Mrs. E. Desmond

This motion put down for discussion by the Opposition has its genesis in the outcries that have been skilfully orchestrated by their local representatives in health boards throughout the country, particularly in the Southern and Western Health Boards. I am most familiar with the Southern Health Board and we have had nothing but uproar and outcry since the board were given an allocation of £138 million for 1985. That sum represented an increase of £10 million on the previous year's allocation, but that was not adverted to at all. Instead, perhaps capriciously, a figure of £9.5 million was represented as the shortfall on what was required to run the services. That figure was conjured out of the air. That £9.5 million was referred to as if it was an established fact. It was anything but that. The impossibility, we were told, for the health board being able to manage with such a shortfall has become part of the local and national lore. We have read daily about threats of wholesale job losses, of hospital closures and bed shortages, of cutbacks in services, of decisions to cut maternity leave and to interfere with student nurses' wages.

All these horrific solutions to the shortfall were trotted out. It would have been bad enough to present the frightening solutions if the problem had really existed to the extent that it was represented to exist. How much worse was it to present the problem when the shortfall was not an established fact at all? These comments were the result of a political shot in the dark. I understand that the shortfall in the Southern Health Board will be less than half the figure claimed. I believe it will be about £4 million or even less. If what I have been told is true I have very serious doubts in my mind about why such a furore was raised in the first place or what the purpose of it was. Was it an exercise to exacerbate things for the Government in an area which has suffered more than its share of job losses? As somebody not involved in a health board, I have had information only from the press and from friends who are members of the health board. It is unforgivable to use as a political football the health services on which the sick, the handicapped and the deprived depend.

Mr. Foley

I fully support the motion calling on the Government to provide the essential funds to the health boards to make good the shortfall in their 1985 budgets. The health boards this year will be short of about £40 million. I had occasion to visit Cappagh last October. I was amazed to be informed by the medical staff that they were being forced to abandon or curtail their programme for hip and knee replacements due to lack of finance. This was a big disappointment to people on the waiting list, many of whom had hoped they would have had their operations by Christmas. We have been told that Ireland provides the second lowest amount per capita for health services of all EC countries. I appeal to the Minister for Health to reconsider cuts in health service expenditure.

I wish to plead with the Minister to reconsider the provision of a kidney unit in the new general hospital in Tralee. In Kerry, patients from different parts of the county suffering from chronic kidney disease, must travel to Cork three days weekly to spend five hours on a kidney machine. They have to rise as early as 4 a.m. and travel by bus to reach Cork by 8 a.m. Regardless of sickness or the prevailing weather conditions they must reach Cork for life saving treatment, travelling over some of the worst roads in Ireland from such places as Dingle, Annascaul and south Kerry. That puts a great strain on both patients and families. The patients accept their illness with remarkable courage and the long, tiring journey to Cork is the most difficult part to accept. A kidney unit nearer home, in the Tralee General Hospital, would alleviate much of the strain and inconvenience attached to their treatment.

The Irish Kidney Association recently completed a feasibility study on the need for a unit in Kerry and are satisfied that such a unit would be in the best interests of the patients and would have the support of the medical profession. The initial cost of establishing the unit would be about £100,000. The Irish Kidney Association have established a number of sub-committees in Kerry to raise the money. Having done so, they will approach the Minister for Health to staff and maintain the unit. I hope the Minister will respond to this magnificent effort by the people of Kerry in providing £100,000 for this worthy cause. The Tralee General Hospital, which opened early last year with about 50 per cent occupancy only, was given a commitment that it would be fully operational by October 1984. It is still not fully operational, and with the financial constraints in the Southern Health Board, there is a danger that 80 beds will have to be closed which will create a number of redundancies. I hope the Minister will not allow this to happen.

Health boards can no longer provide accommodation for geriatric patients. I suggest to the Minister that a subsidy scheme should be established to help patients who have to depend on the private sector to accommodate them. In most cases their old age pensions will not cover the accommodation costs. Community care calls for a special capital allocation.

I should like to congratulate the CEO, staff and members of the Southern Health Board on the service they are providing in such severe financial circumstances. I hope the Minister will note the appeals made here tonight in regard to the shortfall of the Southern Health Board.

Dr. O'Hanlon

The contribution by Deputy Eileen Desmond highlights the difference between the Government and the Opposition. The Government are obsessed with money and its spending but we are concerned about the care of patients, of the ill, the elderly and the handicapped who are unable to look after their needs. That is what the debate is about. Deputy Eileen Desmond suggested that it was orchestrated for political reasons, particularly in the Southern Health Board area, an exercise to exacerbate things for the Government. We do not need to exacerbate things for the Government through a health debate because that has already happened through their economic policy. This debate is about the care of people who are ill and that is our concern. Last night the Minister told us that in 1982 the percentage of GNP devoted to health care was 8 per cent.

Mr. B. Desmond

The motion says nothing about the care of the ill.

Dr. O'Hanlon

Last night early in his speech the Minister told us that 8 per cent of GNP was spent on health in 1982. What is the percentage now? Even when he gave us the figure for 1982 he did not tell us that the percentage should have been corrected to 7 per cent to bring it into line with other OECD countries. We have got a very large social service element in our health expenditure. The Minister told us about improvements in facilities for the mentally handicapped but not that there are 14 units lying idle throughout the country because the Minister will not provide the money to staff them. He did not tell us about negotiations in relation to the European Social Fund which might mean a reduction of more than 50 per cent in allocations to some health boards.

The Minister told us that he would be opening units built by himself. Is this one of the reasons why there is a delay in opening Beaumont Hospital? He told us some time ago that he would start building a nurses' home in the autumn of 1984, but recently he told us that he would not do so because it is not his policy to build nurses' homes. At the same time I am told that he is going to build a nurses' home in Tallaght. He told us that he was heartened that three health boards had agreed their proposals for 1985. My own health board is one of these but they sent the following resolution to the Minister when they did agree the proposals:

Having maintained our health services with a reduced allocation for a number of years, we are concerned that there will be an intolerable reduction in the level and quality of service in the current year in this health board area.

Stocks are run down. For example, are disposable sheets available in every community care area at present? Transport services have been run down. One of my patients, an old age pensioner on a medical card, told me he had paid £28 for a taxi to attend the hospital out-patients' service. The number of fuel vouchers has been reduced each year since the Minister came into office. At a time of recession, when there is a tremendous poverty and a massive increase in the number unemployed, the services are being reduced. With regard to hospital services, wards and operating theatres are being closed down, local cover and week-end cover being reduced. Two-thirds of vacancies are to be left unfilled. Still the Minister told us last night that nobody has lost a job as a result of a cutback. It is true that nobody has lost a job, but there will be a tremendous number of vacancies unfilled which will have a most undesirable effect on the health services during the coming year. No account has been taken of the increase in population, particularly in the Eastern Health Board area.

I asked the Minister what are his priorities? He told us on a number of occasions that the health services were costing £23 million per week and we accept that. We are concerned to ensure that people who are unable, by their own means, to provide a service for themselves will have an adequate and satisfactory level of care. The Minister states in his amendment that he has provided sufficient money for that. However, if he goes around any health board area he will find that that is not the case. If he asks the people outside, they will tell him that that is not the case. It is certainly not any health board in this country that sent a resolution to the Minister that they had sufficient money to provide an adequate and satisfactory level of care, because they have not yet got that. Rather than go on radio and also tell us here that he is satisfied with the service, he should go on radio and television and tell the people that he has not given the boards sufficient money for the necessary level of health care.

I said last night that lives would be at risk, and I still believe that, directly as a result of the Government's policy in reducing the amount of money available for the health services. I appeal to Members opposite to consider the resolution seriously and to bear in mind that in 1982 when the Government were defeated on a Private Members' Motion it did not bring about the downfall of the Government. A defeat tonight will not bring about the downfall of the Government but it will alert them to the tremendous need to ensure that adequate funds are provided for health boards. Government Members who are concerned about this matter should cross the floor of the House and vote with Fianna Fáil, thereby ensuring that the Government are alerted to a serious position that is of their making but can be rectified before it is too late.

Question put.

The Dáil divided: Tá, 75; Níl, 68.

Tá

Allen, Bernard.
Barnes, Monica.
Barrett, Seán.
Barry, Myra.
Barry, Peter.
Begley, Michael.
Bell, Michael.
Conlon, John F.
Connaughton, Paul.
Coogan, Fintan.
Cooney, Patrick Mark.
Cosgrave, Liam T.
Cosgrave, Michael Joe.
Coveney, Hugh.
Creed, Donal.
Crotty, Kieran.
Crowley, Frank.
D'Arcy, Michael.
Deasy, Martin Austin.
Desmond, Barry.
Desmond, Eileen.
Donnellan, John.
Dowling, Dick.
Doyle, Avril.
Doyle, Joe.
Dukes, Alan.
Durkan, Bernard J.
Enright, Thomas W.
Fennell, Nuala.
FitzGerald, Garret.
Flaherty, Mary.
Flanagan, Oliver J.
Glenn, Alice.
Harte, Patrick D.
Hegarty, Paddy.
Hussey, Gemma.
Kavanagh, Liam.
Keating, Michael.
Kelly, John.
Bermingham, Joe.
Birmingham, George Martin.
Boland, John.
Bruton, Richard.
Carey, Donal.
Cluskey, Frank.
Collins, Edward.
Kenny, Enda.
McGahon, Brendan.
McGinley, Dinny.
McLoughlin, Frank.
Manning, Maurice.
Mitchell, Jim.
Molony, David.
Moynihan, Michael.
Naughten, Liam.
Nealon, Ted.
Noonan, Michael (Limerick East).
O'Brien, Fergus.
O'Brien, Willie.
O'Keeffe, Jim.
O'Leary, Michael.
O'Sullivan, Toddy.
O'Toole, Paddy.
Owen, Nora.
Pattison, Séamus.
Prendergast, Frank.
Ryan, John.
Shatter, Alan.
Sheehan, Patrick Joseph.
Skelly, Liam.
Skelly, Liam.
Spring, Dick.
Taylor, Mervyn.
Taylor-Quinn, Madeline.
Timmins, Godfrey.
Yates, Ivan.

Níl

Ahern, Bertie.
Ahern, Michael.
Andrews, David.
Aylward, Liam.
Barrett, Michael.
Brady, Gerard.
Brady, Vincent.
Brennan, Mattie.
Brennan, Paudge.
Brennan, Séamus.
Briscoe, Ben.
Browne, John.
Burke, Raphael P.
Byrne, Seán.
Calleary, Seán.
Collins, Gerard.
Conaghan, Hugh.
Connolly, Ger.
Coughlan, Cathal Seán.
Cowen, Brian.
Daly, Brendan.
De Rossa, Proinsias.
Doherty, Seán.
Fahey, Francis.
Fahey, Jackie.
Faulkner, Pádraig.
Fitzgerald, Liam Joseph.
Flynn, Pádraig.
Foley, Denis.
Gallagher, Denis.
Gallagher, Pat Cope.
Treacy, Noel.
Tunney, Jim.
Wallace, Dan.
Walsh, Joe.
Geoghegan-Quinn, Máire.
Harney, Mary.
Hilliard, Colm.
Hyland, Liam.
Kirk, Séamus.
Kitt, Michael.
Lenihan, Brian.
Leonard, Jimmy.
Leonard, Tom.
Leyden, Terry.
Lyons, Denis.
McCreevy, Charlie.
McEllistrim, Tom.
Mac Giolla, Tomás.
MacSharry, Ray.
Molloy, Robert.
Morley, P.J.
Moynihan, Donal.
Nolan, M.J.
Noonan, Michael J. (Limerick West).
O'Connell, John.
O'Dea, William.
O'Hanlon, Rory.
O'Keeffe, Edmond.
O'Kennedy, Michael.
O'Leary, John.
Ormonde, Donal.
O'Rourke, Mary.
Power, Paddy.
Reynolds, Albert.
Walsh, Seán.
Wilson, John P.
Wyse, Pearse.

Tellers: Tá, Deputies Barrett (Dún Laoghaire) and Taylor; Níl, Deputies V. Brady and Barrett (Dublin North-West)

Amendment declared carried.

Motion, as amended, agreed to.

Dáil Éireann díospóireacht - Wednesday, 27 Feb 1985

Private Members' Business. - Health Boards Funding: Motion (Resumed).

Tá

Níl

Dáil Éireann díospóireacht -
Wednesday, 27 Feb 1985