"That Dáil Éireann wishing to remain within the 1987 Revised Estimates for Health,
(i) notes that there is widespread public concern about the provision of health services throughout the country, notwithstanding an increase this year of £13.082 million;
(ii) condemns the failure of the Government and the Minister for Health to set guidelines for expenditure on health this year that would ensure an acceptable level of service, which failure has resulted in threats of closure of numerous hospitals, and curtailment of services in others causing inevitable deep public concern;
(iii) calls for a reduction in the size and cost of the bureaucratic machine administering the health services, including the health boards; the abolition of local Health Advisory Committees; greater accountability by consultants, and a retention of such numbers of persons supplying health care direct to the public as are necessary to provide a reasonable level of service, given the country's financial circumstances."
In the past couple of weeks the panic and terror engendered in countless homes around the country by the health cuts controversy has been scandalous and disgraceful. People waiting to enter hospital for treatment are fearful that they may not now be able to do so. People going around perfectly healthy are now terrified at the prospect of they or any member of their family falling ill. It is wrong that this should happen in Ireland in 1987. It is even worse when it is realised that there is no need for such panic to be generated in the first place.
The reasons for the present mêlée of conflicting claim and counter-claim from the Minister for Health, health board executives, doctors, nurses and trade unions in the health sector must rest squarely with the present Government. It stems directly from the absence of any coherent, thought-out policy on health. It is appalling that, in one of the most fundamental areas of public policy, the new Fianna Fáil Government have no policy. When they have begun to apply very necessary constraints on the overall health budget all hell breaks loose. Every vested interest group in the health care industry rush to defend their special interest. It should be remembered that this is now a major industry employing well over 60,000 people. Unfortunately, in the ensuing controversy, the real losers are the ordinary Irish people who are bamboozled by claim and counter-claim. Daily the latest headlines scream about more ward closures, more doctors and nurses being let go, vital services — be they sexual assault units, bone marrow transplant or heart surgery programmes — being terminated or disrupted. We have also witnessed claims by some health professionals that people, including children, will die as a direct result of the current cutbacks.
All of this stems from the absence of a coherent policy on the part of the present Government. All last week in this House the Government refused to allow a debate, demanded by the Progressive Democrats and other parties, which could coldly, rationally and unemotionally examine the facts of the situation. That too was a major failure on the part of the Government. That is why the Progressive Democrats decided to table this motion on the health cuts this week. We are glad to give Dáil Éireann and the Irish public an opportunity to have the issue debated, to force the Government to stop hiding behind procedures and bland claims, to force them to face up to their responsibility to govern in this essential area — the delivery of health care for our people.
Over the past two weeks I and other members of my party have identified and highlighted the core problem of the present controversy. It has been taken up by other parties since. It is stated simply in our motion before the House this evening, that is, our call on the Minister for Health to set guidelines for expenditure on health this year that would ensure an acceptable level of service.
In a statement I issued last week I called on the Government to agree and publish national programmes for different categories of health care, such as open heart surgery, hip replacement, kidney dialysis and transplant, care of the elderly, psychiatric care and so on, and to allocate a budget to them. That would take such priority health care programmes out of the realm of being a political football and reduce the anxiety of people in those categories.
These proposals demonstrate the absence of proper control over the health budget, vital to the public, as taxpayers, on the one hand and, on the other, as users of the health services. We might consider for a moment the crazy way health care is funded. Practically all of the enormous budget, totalling approximately £1.3 billion this year, is provided by way of central Government grant to the eight health boards, voluntary hospitals and other agencies. Yet the Government, the guardian of the public purse, retain little or no say on how that money is spent. In theory the Department of Health are the watchdog. As I and my colleagues will demonstrate in the course of this debate, not only does that watchdog not bark but he is hardly ever at his post.
Let me remind the House and the public that the Progressive Democrats are fundamentally committed to getting public spending under control. How can a Government get such spending under control if they dole it out — as in the case of the health services in the amount of £1.3 billion — and retain little or no control over how that money is spent?
One has only to observe the explosion in the health budget since the inception of the health boards in the early serventies and the advent of an unfortuante era here in which the fellow who pays the piper no longer call the tune. Since the mid-seventies, health spending here has grown tenfold and has more than doubled in real terms. Staff totals in the health boards have grown from less than 24,000 in 1971 to 57,000 today. Are we really that much healthier today as a result of this explosion of health spending? I do not believe we are.
Along the way, the massive bureaucracy of the health boards has grown up. Now vested interest groups exist who feel threatended by any change. We must cry stop to this. We must restore Government control of the health services in pursuit of the very logical maxim that if the Exchequer — on behalf of the taxpayer — pays the health care piper, then he has a right to, and must, call the tune. In this regard, I want the Minister for Health to spell out the Government's position on this matter which is compounding the present difficulties.
Tough decisions have now to be taken, but the Government and the Minister for Health cannot have it both ways. To avoid being seen to take the tough decisions, they like to point to the autonomy of the health boards' elected membership and executive and maintain that any cutbacks are their fault. But, when the health board executives do propose various cuts which are endorsed by the elected members, the Minister and the Government chastise them for so doing.
The Minister and his colleagues cannot have it both ways. The only logical stance to take now is to set proper guidelines for the delivery of health care, take direct, central control of the system and responsibility for any cutbacks or programme adjustments that must be made.
Such a policy would enable clear national programmes to be decided. It would also facilitate a programme to reduce the bureaucracy spawned by the health boards at both administrative and representative level. It would also ensure that the various vested interest groups in the health services are prevented from persisting in the scare tactics of the past couple of weeks. The plain fact of the matter is that the scale of panic and threatened cutbacks now being highlighted is out of all proportion to the adjustment in the health budget. But the Government are failing to govern. The vacuum resulting from their cowardice is being filled by the self-interest chorus of every group in this sector.
I and my party colleagues now intend to go on to demonstrate the shambles the health system has become in this country. It largely stems from the unplanned and uncontrolled system that grew up over the past 15 years. If the present Minister and his Government do not know what needs to be done, then let the Progressive Democrats tell them.
Most people in this House will be familiar with the necessity to develop proper community care and preventive health services that will keep people from becoming ill in the first place, and which will keep them out of the costly acute hospital system. But that has become a cliché because the status quo represented by the health boards, the massive hospitals network and the attendant workforce of professionals, general workers and administrative staff continue to monopolise the health budget.
Last year, only £300 million of the £1,300 million health budget went into what could be termed community services, while the general hospital services got £715 million of the budget. The bulk of that money went to health boards and voluntary hospitals and none of these is seriously accountable to the Exchequer or the Department of Health in any meaningful way. In particular the £250 million or so given out to the voluntary hospitals represents an extraordinary lack of public accountability for such a vast sum of taxpayers' money. It is a situation that must not continue.
This situation is reflected throughout the entire system. From the hospital capital programme to the implementation of computerisation in the health service, to the performance of the different working groups, most notably hospital consultants, the record is one of lack of control, mismanaged funds and inadequate accountability.
Let me illustrate further. The Department of Health have already spent over £10 million on a computerisation programme for the health services that should ultimately embrace the health boards and the hospitals. One needs little imagination to appreciate the efficiencies and savings a co-ordinated national computer programme could bring to the health service, covering all aspects of administration and doing away with many routine administrative chores at local office level. Most information would be available at the press of a button on a computer VDU. It would also be invaluable in keeping records of payments for services and would be a major check on bad debts arising.
What is the reality? There has been no cost-benefit analysis by the Department of Health on their computerisation programme. Various hospitals and health boards are at different stages of computerisation; there is no co-ordination and different agencies have adopted different computer systems. The whole thing is a shambles.
This is a programme that has been going on now since the beginning of the eighties. There is no overall strategy. This is one issue which I want the Minister for Health to explain to the Dáil and to the Irish people. It is a disgrace what has been happening to date here. When we see health board and hospital administrators concentrating solely in recent weeks on the necessity for ward closures and the curtailment of vital medical services, and no reference is made to the cost of the shambles of a computerisation programme, then we are left wondering what games are being played.
Let us move to a more basic issue, the question of catering and administration in our hospitals, many of them individually large institutions with a thousand or more people to be fed and looked after every day. You would imagine that one of the benefits that would have flowed from the elaborate administrative structure of the eight health boards and the Department of Health in the role of grand conductor, would be ensuring the best value for money when it comes to hospitals buying provisions, running their various departments and adopting the most cost-efficient in-house systems.
The reality is sadly different. Major hospitals would be major purchasers of food and other supplies. But do they operate the most efficient house-keeping systems, bearing in mind that in 1984, for instance, expenditure in the health services on food, laundry, furniture, bedding, clothing, etc. was over £55 million? Two years ago the then Dáil Committee on Public Expenditure retained the Trident Management Consultants to examine these areas in the management of the health services. They unveiled a haphazard and uneven policy of tendering for supplies of food, differing criteria for accepting tenders and the evidence is of varying prices for basis supplies as between hospitals.
Methods of preparing and distributing meals in hospitals — a major administrative task, as can be imagined — vary from the most cost-efficient downwards. According to the Trident report, ten hospitals had at the time adopted the most efficient food preparation system, but there was one notable feature. In the case of those ten hospitals, the consequential staff rota changes and the savings in weekend work and overtime, to justify the investment in the new system, were not made. Another equally disturbing, if not more disturbing, finding by the consultants was that for one large general hospital they visited, they found absenteeism among one section of the non-medical staff nearly 25 per cent and to be a major problem, according to the management.
In this short debate I do not have time — I intend to give part of my time to my colleague, Deputy Quill — to detail all the areas where savings can be effected without affecting the level of services. A further example of waste is the decision by the Department to delist several cheap drugs from the GMS resulting in doctors writing very expensive alternatives. The classic example here is Zantac and Tagamet costing the GMS over £5 million annually. Some patients need these drugs, which save very expensive surgery, but in many cases a simple inexpensive antacid would be quite adequate.
I hope now we are beginning to see a more comprehensive picture of areas needing tackling in the present budget adjustment climate. What is the Minister's response to these realities, I wonder? Moreover, I believe that these facts serve to highlight the extent to which the axe is currently being wielded in a selective way by the health board and hospital administrators to pressurise the Government of the day to cave in and give more money. But I also return to my fundamental point. If the Minister gives them carte blanche with the taxpayers' millions, can the same Minister really cry foul when they behave in this arbitrary manner?
The problems with the health system and the need for accountability and proper management do not end there. If ever one needed a single example of what is wrong with the Irish health service, one need not look beyond the role and position of the thousand or so hospital consultants. Now everybody realises the vital importance of such key health experts, and their life and death role in the system. But the question that must be asked is whether this country can go on affording the kind of conditions enjoyed by the consultant in the public health system.
The so-called common contract for the consultants, now operating since 1981, affords the specialists working conditions which are surely the envy of any other group in this country. Their contract with the voluntary hospital or health board is permanent and pensionable; with a working week of 27 or 33 hours, six weeks holidays, sick leave, special leave, sabbatical leave, rest days, travel and subsistence allowance and all telephone costs.
That is only the half of it. The contract also specifically allows consultants unrestricted leave to pursue parallel private practice inside and outside the hospital for which they are contracted to provide public medical care on behalf of the State. Their contract specifically states that there will not be any exact measurement of the time a consultant gives his public patients. He may do the 33 hours per week or more, or maybe just 13.
Nor does the contract specify the responsibility of the consultant, or set down his role as a key person in the delivery of health services. Two years ago, the average consultant's salary under the common contract for public patients was £32,000. It is a rate of pay that compares very favourably with the pay for consultants in Britain. The problems that flow from this set-up are unlimited. There is the obvious potential conflict of interest between the consultant's public and private practice. Are public patients with VHI cover encouraged to "go private"? Are public facilities paid for by the taxpayer unfairly used by consultants in their private practice?
Let me make it clear that the Progressive Democrats are fully in favour of private medicine, and as many people as possible providing for their own health care. But we also are committed to a comprehensive system of health care for those who cannot afford private care and we are concerned in the interests of all taxpayers that the latter service is delivered as efficiently as possible and is not being ripped off by any sector of workers in the service, be they porters, administrators, consultants or indeed politicians as members of health boards and local health committees — and that is something my colleague, Deputy Máirín Quill, will take up later.
In Britain, hospital consultants are restricted to earning no more than 10 per cent of their public salary in private practice. Here the correlation is more likely that consultants are doubling their public salary, at least.
It is also worth pointing out that the contract was supposed to be reviewed after five years, but my understanding is that this has not yet taken place. I want the Minister for Health to tell the Progressive Democrats and the Irish people what is the up-to-date position here. Is it true, for instance, that the consultants, through the Irish Medical Organisation, are refusing to participate in this review?
All in all, it adds another dimension to the sorry story of a health service out of control, and being exploited for the benefit of the employees of the system, rather than being organised and guided to provide the best service to the general public.
In conclusion I want to say that making our health services more cost-efficient is going to be a tough job. It is a job for the Minister for Health, and he cannot hide behind health boards, chief executive officers or local politicians. There is an urgent need now for the Minister to spell out his party's policy; to set guidelines to ensure the maintenance of satisfactory level of services and to remove the doubt and confusion that has caused such alarm and upset so many people.
The Progressive Democrats have out lined in this debate some areas of our health service where major cost savings could be effected without withdrawing essential services as is now happening. The Minister is abrogating his responsibilities and should resign if he is not prepared to spell out in detail how the finances available to him are to be allocated within the service.
As of now, he stands condemned of withdrawing essential services from severely handicapped children and extremely ill people and there are many elderly people gravely upset and feeling very insecure because of what is happening. The Fianna Fáil Party are in a sorry state when they have no health policy. The false election document has happily been torn up but the Minister, Deputy O'Hanlon, must get a grip on the situation quickly. There is plenty of goodwill and willingness to co-operate if the right approach is adopted.
Take the case of Monkstown Hospital, a private voluntary hospital in Dublin. Their 1987 allocation is a cut of 22 per cent on the previous year. Despite numerous requests, the Minister, Deputy O'Hanlon, has not been able to tell them if he plans to close it or what future he sees for it. To the great credit of the staff of the hospital, I understand they have decided to take a cut in salary of 15 per cent from the highest paid to the lowest paid in order to maintain the level of service until the Minister tells them what the future of their hospital is to be.
Such sacrifices should not have to be made but hopefully such steps, including this debate, will force the Minister to take control in planning the future health services for this country.