asked the Minister for Health whether he is satisfied with the role that the community care service have developed within the overall health service; and whether he has any proposals to develop the role of the service in conjunction with primary care.
Ceisteanna — Questions. Oral Answers. - Community Care Service.
9.
Significant progress has been made in the past in developing the services which come within the scope of the community care programme of health boards but there can be little doubt that there is still room for improvement in many areas.
One of the key elements of this programme is the community nursing service and I propose to initiate shortly a full review of the role of the public health nurse. I am satisfied that this review will lead to a more effective and modern community nursing service which will in particular be more effective in its care of the elderly in their own homes.
The personal social services are another vital element of community care and a programme of development of day care facilities, family sized hostels and sheltered workshops for the physically and mentally disabled is well advanced. I intend to introduce in the near future the first of three Bills which will strengthen the statutory framework within which professional services for children are provided.
The effective delivery of the wide range of services within the community care programme requires effective leadership and integration. A review of management structures has been completed and discussions with staff interests are at an advanced stage. This should result in improved management and control.
In a very practical way I have introduced a new programme for the development of small community care premises in an effort to upgrade our old health centres and to ensure that suitable facilities are available in each local community to cope with the developments in community services. The programme was introduced in 1984 during which year we completed 15 health centres. I hope in 1985 to provide at least the same number again within this programme. This, I might add, is in addition to our normal programme of building of major health centres.
The staff employed by health boards in the community care programme are not the only elements of a policy for community care. General practitioners are clearly a key group and I am committed to increasing the effectiveness of this service by developing closer contact between the general practitioner and the hospitals and other health facilities. I am also anxious that a new style of general practice would emerge which would be less dependent on drug therapy and the report of the working party on the general medical service provides a valuable basis for this.
Similarly, I am committed to the development of community based services for the psychiatrically ill and I have just recently published a review of the psychiatric services which I believe provides us with an excellent framework for the future delivery of community psychiatric services.
I welcome the points made by the Minister about improvements. This has gone on for a long time. Does the Minister intend to integrate the community care service with the hospital scene? Not having close links is one of the major deficiencies in making community care an acceptable alternative to hospitalisation. Does the Minister accept that services like home help and the prescribed relative allowance are extremely good value for money and that these should be put in a more effective position within the community care?
I share the Deputy's view on the latter point made by him that the home help system, the home nursing system, the visits by public health nurses and the role they play can be extremely effective, although the work structures of the public health nurses in their supporting role need to be examined. In general I agree with the views expressed by the Deputy. I commissioned a management consultancy report on community care structures. This review has now been completed and the Department of Health, in conjunction with representatives from the health board managements, are discussing its implementation with the various staff interests. Work is going ahead quite substantially. We have been building up a substantial network of small health centres in the past few years and we will go ahead with that in 1985.
The first half of the question was not dealt with relating to integration with the hospital services.
I agree that there is very little integration. We are endeavouring to integrate the community care services directly with the hospitals, but this is a two way flow of traffic and frequently hospitals do not regard themselves as being part of that development.
Apart from the improvements in the health centres which the Minister told us were carried out over the past two years, can he tell us what improvement there will be in the availability of services such as chiropody, occupational therapy and physiotherapy? Does the Minister accept that since he took office the number of persons employed as home helps and as public health nurses has fallen?
I would not accept that. One can count heads but it is the actual number of hours put in by persons and the amount of money provided in the area that really counts. We have to accept that, if we are to develop the community care side, we will have to close beds and transfer staff from the acute hospitals——
First?
——both on the psychiatric and the acute general hospitals side. There is no hope of really bringing about a transfer of resources if we maintain a very large number of beds. We have 50 per cent more beds than the average in the European Community. We have hospitals all over the country with 55, 60 or 70 per cent bed occupancy. Beds must be closed and revenue cost transferred out into the community. I do not think the taxpayer will fork out another £300 million or £400 million a year to have a massive community care programme built side by side with a massive acute hospital structure. That is the problem, but no politican is prepared to face up to the implications of that strategy even in the psychiatric hospital area where it is most manifestly necessary.
While I would accept the main thrust of the Minister's argument that there should be a transfer of resources from hospital care to community care, I could not accept that the hospital beds should be closed down first. Would it not be common-sense to ensure that the community care services can cater for these patients before they are discharged into the community?
I would not suggest that the hospital beds should be closed down first and then the resources transferred. I would suggest that they should be closed down simultaneously with the development of the community care facility. The real trouble is that everybody argues for the development of the community care facility, for more chiropodists, more public health nurses, more social workers, and more home helps.
There are fewer now.
Having built up that structure in the community, the same politicians and the same health boards say: "You dare not touch that hospital. That must stay there with all its staffing, revenue and bed implications." Unfortunately in Ireland we have an enormous capacity for trying to have things both ways simultaneously. The Deputy knows the problem. When it comes to health care the politicians are probably the biggest culprits of all because we do not give any leadership. I try to do so and I get myself into trouble every day.
The Minister has got the wrong end of the stick.
A question Deputy, please.
I am coming to that. If the Minister is hoping that the community care services will provide the role he envisages, we would all go along with that — in other words, take the pressure off the general hospital services — but is it not a fact that this will require a massive injection of capital? Contrary to what the Minister said I believe that in the initial period both these services must run in parallel. We cannot close down the general hospital services and throw that role over to community care. For a certain period of time they must run in parallel. It would require a massive injection of capital to provide the role the Minister envisages for the community care services.
The transfer might be made with a considerable saving of money. The biggest cost is revenue. There is no shortage of capital moneys. This year we have £58 million. Last year we had £57 million. The year before we had £55 million. We are spending £200 million in the four year period on hospital capital expenditure and community care.
I am not speaking of capital in the building sense. I am speaking about financing.
The real problem is the revenue cost. We have 60,000 people employed and well over half of them are working in the hospitals. I will give the example of £160 million per annum in every area including Waterford being spent on looking after 11,500 psychiatric patients. There are 6,500 staff and 7,000 more ancillary staff. About half those patients should not be in those hospitals. It is not a question of money.
Unless the Minister provides the funds for the community care services he cannot take these patients out of the hospitals. That is my point.
We cannot discuss policy any further on this question.