Dáil Éireann díospóireacht -
Friday, 11 Dec 1987

Vol. 376 No. 8

Supplementary and Additional Estimates, 1987. - Vote 47: Health.

Minister for Health (Dr. O'Hanlon)

I move:

That a supplementary sum not exceeding £1,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1987, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to health boards and additional funding for the neeeds of the General Medical Services (Payments) Board.

The original net Vote for Health for 1987 was £1,168,791 including a capital provision of £57,563,000. I am taking a token sum in order to bring to account extra appropriations-in-aid which will be available before the end of this year. These additional receipts will allow me to provide for a 65 per cent Christmas bonus for persons who receive cash allowances and will also provide for additional cash for the General Medical Services (Payments) Board to alleviate their cash difficulties.

The components of the Supplementary Estimate are as follows:

	£m
65% bonus payment in respect of certain cash allowances	0.800
Provision towards additional cash requirements of the General Medical Services (Payments) Board	3.001
Sub-Total	3.801
Less:
Additional appropriations-in-aid	3.800
Net Total	0.001

As I have mentioned, a bonus payment in regard to certain benefits and allowances administered by the Department of Health was paid this month. The relevant allowances include the disabled person's maintenance and rehabilitation allowances, the infectious disease maintenance allowances, the blind welfare allowances, and the constant care allowances in respect of disabled children who are maintained at home. An estimated 33,000 recipients have benefited from these bonus payments.

The extra provision sought for the General Medical Services (Payments) Board is £3,001,000. This will bring the total provision for the board to £110,801,000 which represents an increase of about 2.8 per cent on the original provision made.

The extra provision sought is required to meet the cash needs of the payments board. It will be appreciated that the general medical services are demand-led services catering for the lower income group in the population. It is impossible, under such a system, to be completely accurate in predicting the final cash requirements of the services.

As I stated in my speech to this House on 22 October last in regard to the 1988 Estimates for the health services, the trend of increasing costs in the general medical services must be addressed. I am convinced that these trends can be arrested and a new, more rational and controllable system put in its place.

Negotiations are continuing with the Irish Medical Organisation on new methods of administering the services, including changes in the method of payment for general practitioners, in an attempt to bring this about. I am particularly anxious that these negotiations proceed as quickly as possible so that any new agreement on restructuring the general medical services is put in place in 1988.

The result of the negotiations which I asked to be activated earlier this year between my Department and the Federation of Irish Chemical Industries will provide for a price freeze on pharmaceuticals up to the end of October 1988 and will also assist in controlling costs in that year.

An increase in appropriations-in-aid of £3,800,000 is anticipated. This increase results from two sources. First, there is an irregular pattern of income from health contributions. The rate increased from 1 per cent to 1.25 per cent with effect from 6 April 1987. The additional receipts of £1,900,000 arise from increased buoyancy in the level of collections. Secondly, certain health services, in accordance with EC regulations, are provided to employed persons, self-employed persons, pensioners and dependants of such persons from other member states while they are visiting or staying in this country. The costs of providing those services are recoupable from the other member states of the European Community. The increased yield under this heading is £1,900,000 brought about largely by exchange rate fluctuations which have been favourable to us and which, of course, are very difficult to predict in advance.

I would now like to say a few words about health expenditure generally in 1987. As I have earlier indicated, the additional appropriations-in-aid now available are being used to give a Christmas bonus for recipients of health allowances and to meet the unforeseeable requirements of the demand led general medical services. Excluding these two areas, and in contrast to the experience during the previous Government's term of office, overall health expenditure this year has been kept strictly within the limitations approved in the original Estimates.

Despite this control essential services have been maintained at an adequate level and the health agencies have responded to the needs of the community, in particular, to those of the less well off sections of society. My Department have worked very closely with the health agencies in monitoring the situation, both in relation to services and spending as the year progressed and I would like to express my appreciation of the constructive way these agencies have tackled the significant problems which they faced. Everybody involved in the provision of health care has had to adjust their expectations in this period of necessary financial restraint and has had to maximise the return from the resources which are available.

The work done by the health agencies in controlling their expenditure in 1987 augurs well for a similar responsible attitude and performance in 1988. It has to be accepted that better management of financial and personnel resources is imperative if the country is to solve its serious debt problems. With PAYE revenue going largely to meet the national debt there is no alternative but to reduce overall spending. In doing so, we must ensure also that we maximise the benefits from this reduced spending and ensure that essential services are available for those who need them. I am confident that this can be done within the resources which are available for 1988.

A major event at the end of this year was the opening of Beaumont Hospital which, as well as being a significant addition to the general hospital service in north Dublin, represents a major milestone in the long term plan for the rationalisation of hospital services in Dublin. In south Dublin 1987 saw the transfer of services from Dr. Steevens' Hospital and Baggot Street Hospital to St. James's Hospital and the Meath-Adelaide group. These moves also represent significant steps in the rationalisation process as the specialities to be located in the new St. James's and Tallaght Hospitals are now located on a single site in the case of St. James's and on two sites in the case of Tallaght.

Similar rationalisation of services have taken place in Cork with the amalgamation of the South Infirmary and Victoria Hospitals and the transfer of inpatient services from the North Infirmary to the Mercy Hospital. The fact that these transfers were agreed and implemented in such a constructive way is a remarkable tribute to the spirit of co-operation which exists in the health services and which often tends to be overlooked. I would like to stress that this rationalisation is not being carried out for narrow fiscal reasons. Rather it is intended to maximise the quality and efficiency of our acute hospital services.

I might mention also that the Government have recently decided that funding of £6 million will be made available for health projects from the proceeds of the national lottery. The projects to benefit will be largely in the community area. I intend to apply this additional funding to the following areas: £2.25 million will be used to encourage the provision of community-based services for the physically and mentally handicapped with a particular emphasis on the transfer of patients from institutions to community care. The elderly will also benefit to the extent of about £900,000 again with a strong emphasis on encouraging the care of the elderly at local community level. Community based psychiatric services will benefit to the extent of about £700,000. About £1 million will be provided to enhance within a broader framework community information and development services. AIDS prevention will benefit to the extent of about £450,000. Children's services, including services for child abuse which is a growing problem, will receive about £700,000.

In seeking better use of public money to provide an effective and cost conscious service I must, as Minister for Health, be conscious of the necessity to indicate priorities for agencies when they are deciding on how their total allocations should be divided between the different service programmes. Both this year and for 1988 I have made it clear to health boards that particularly disadvantaged groups like the elderly, children at risk, and the handicapped are to be seen as needing priority attention while key services of importance to those groups such as home helps, meals on wheels etc. are to be protected as far as possible.

The fact that I was able to give the agencies their 1988 allocations in October this year should result in their being able to plan their management of resources over a much longer period than was possible this year. When I met, last October, the chairmen and chief executive officers of health boards and the chairman and secretary-managers of voluntary hospitals, I stressed to them that they should use the opportunity of early notification of the allocations to start planning for next year.

I and the Department of Health officials will be available, as we were this year, to discuss with agencies how they propose to manage their resources for 1988. I am satisfied that our common goal in maximising the use of the resources available will ensure that there will be a continuation of the co-operation already demonstrated this year and that essential services will be maintained.

Mrs. Barnes

It is a matter of concern to all of us that in a country with a young population, a homogeneous society and where we still have a great sense of community spirit that the Health Vote is so large. If it is turned around it is, in a way, a vote for non-health. At a time of stringency and rationalisation, all of us should turn our minds to that. The focus should be on the preventive area of health, thus making sure that the huge cost of health can be reduced in the most caring and compassionate way so that we will remove the areas of disease and lack of care that lead to institutionalised health services. Sometimes it takes a crisis such as we are experiencing now in our economy and with our national debt to make us realise how distorted the budget can become. Before I say anything further on that I would like to refer to the Minister's speech on this Supplementary Estimate.

The huge cost of general medical services must be a matter of concern to the Minister and to the doctors. I am glad negotiations are continuing with the Irish Medical Organisation on the huge cost of general medical services. Much of that cost must be incurred as a result of the continual return visits patients make to their doctors. There has to be a rationalisation of that. It has been said — and I am sure the Minister will understand — that we should encourage patients not to visit their doctors rather than to visit them. If the Health area were turned into a preventive one it would not alone cut back on the economic costs involved but in a more serious way it would lead to a healthier society.

The area of drugs has not been controlled or rationalised to the extent that it should be. Large multinational drug companies have incredible influence and seductive powers and the general medical services use their drugs even though they may be much more expensive than other suitable drugs. The Minister and his Department should investigate that. For quite some time there has been an overemphasis on the use of drugs as being the only means by which to treat people. It is only now that we realise that the use of drugs may not be the healthiest way to treat people. The use of drugs can lead to a dependency and a build up of resistance by some patients that have long term implications. I would like the Minister for Health and everybody involved in the health area to concentrate much more on the use of holistic medicine. Herbal and non-chemical drugs should be used by the health service. Alternative forms of medicine have been treated with scepticism and downright suspicion by the professional medical service for a long time but now in these more enlightened times we realise that they contribute far more to the development and long term health of people.

The Minister said that there is to be a rationalisation of hospital services, especially of those in Dublin. I and many other women believed when Beaumont Hospital was at the planning stage that créche and child care facilities would be part of that hospital plan, particularly because it was hailed as one of the great hospitals of the future. To my disappointment I have learned that such a facility has not been included. If we are talking about health care and health services which provide the facilities that they should, that facility is an integral part of any large hospital. In future the planning of hospitals or medical facilities where people have to wait for any length of time, and in particular women with children, should have that facility as an integral part of the planning.

The national lottery has given an injection into the health area which was desperately needed. I note that the Minister intends to give £1 million of the Department's share of the profits of the national lottery towards improving community information services. I appeal to the Minister to use the framework of the National Social Service Board which has shown its capacity, for that work. I welcome the decision to allocate £700,000 for children's services, including services for child abuse, but I appeal to the Minister to bring forward as a matter of priority for the next session of the Dáil the Children (Care and Protection) Bill. We will not know the extent of the problem in that area until the legislation is introduced. It is a matter of great disappointment that it was not dealt with in this session.

It is important that voluntary organisations, particularly the women's groups, continue to receive the necessary funding to help them prevent children, the handicapped and the elderly, being institutionalised at huge cost to the State. The Department, in their rationalisation programme, should put greater emphasis on community health care to balance the cut-backs in institutions. For every hospital that is closed down, for every community facility that suffers, there must be another form of help provided within the community to ensure that those affected by the cut backs are cared for. I accept that that will cost money and that the Minister must work within budgetary constraints but I suggest that he could save in the area of administration, visits to doctors and on drugs. Savings there should be redirected to community care.

I should like to pay tribute to health care workers. It is unfortunate that many people involved in the health services have been made redundant or forced to accept early retirement arising out of the rationalisation programme. As a result of the cutbacks health care staff must work longer hours with less support. When we are talking about the retention of essential services we must always bear in mind the importance of nurses and the need to care for patients. It is unfortunate that there has not been rationalisation in other wasteful areas.

Mr. D. O'Malley

I have no objection to the Supplementary Estimate which is for a nominal sum and which is covered by the increased amount collected. I am glad to see that the extra expenditure is covered in this way. On the question of GMS cost increases, which account for much of this Supplementary Estimate, I note that the Minister said that he is in discussion with the Irish Medical Organisation, and has been for some time. I urge him to endeavour to bring those discussions to a conclusion soon and to introduce a system of payment by capitation fee rather than fee per item of service. We have had 15 years of experience of the fee per item of service, a system which was introduced by the late Erskine Childers in the seventies in all good faith, but it has not worked out. I am sure that if he was here today he would be among those who would acknowledge that fact. We should change without any further delay to a capitation system of payment which is used in most countries and found to be most satisfactory.

The Minister made reference to the discussions he is having with drug companies and I am glad that they are taking place because that is the key to the saving of a very substantial amount of money each year without any drawback or difficulty created for patients. The failure to prescribe generic drugs, as opposed to brand named drugs, is costing the taxpayer a huge amount of money without any corresponding additional benefit to the patients concerned. That is a matter on which agreement does not have to be reached; it can be done by the diktat of the Minister or the Department of Health. He should do that without any further delay.

The Minister told the House how the £6 million from the profits of the national lottery will be allocated. They are all worthy objectives but they seem to be all part of the normal activity of the Department of Health. The idea of the lottery funds was that they should be spent on areas outside the normal remit or activity of the Department. For example, £450,000 is allocated for AIDS prevention but surely it is the duty of the Department of Health to try to prevent the spread of AIDS. That should be looked on as part of their normal activity. The same applies to other services such as community based services, services for the physically and mentally handicapped, the elderly and the community based psychiatric services. They have been part of the work of the Department for a long time. It is a pity that that £6 million is, in effect, substituted for what would be paid for out of tax revenue.

The Minister dealt briefly with the question of hospitals. When replying to this short debate the Minister should give the House some indication of his thinking, and that of his Department, in relation to the various proposals for the building or the establishment of private hospitals. There are several such proposals and there are several such hospitals operating with many more proposed. I know the Minister has had discussions with some of the promoters, or potential promoters, of private hospitals. This is a difficult matter on which one has to bear in mind the balance that has to be achieved between public and private medicine. One has to be careful, for example, not to allow this to become totally polarised as between public and private medicine. There has been a relatively successful interaction between the two over the years. They tended to be delivered in the same places and each of them benefited perhaps from that. If we are to get away from that we will have to think very deeply about it. It is important that the Minister give an indication of his view in regard to this. If the present rate of provision of private hospitals is to continue in the next number of years we will have a quite different institutional medical scene in a short time.

On the question of hospitals the Minister mentioned the changes that have taken place in Dublin and that have taken place or are taking place in Cork. I stand up here today with some sadness to talk, however briefly I am allowed, about an unfortunate change that is about to take place apparently in Limerick. The Minister announced last night in a letter to Barrington's Hospital that they are to close down. After over 160 years of outstanding service to the people of Limerick it seems inexplicable that a proposal of this kind would be referred to by the Minister in his speech as follows:

I would like to stress that this rationalisation is not being carried out for narrow fiscal reasons. Rather it is intended to maximise the quality and efficiency of our accute hospital services.

That may be the intention, but how in God's name are you improving the quality or efficiency of our hospital services by closing down Barrington's Hospital in Limerick which treats more than 50,000 outpatients a year, more than any other hospital in Ireland apart from one or two of the very big hospitals in Dublin? Where are they to go? St. John's Hospital provides no accident services and apparently refuses to provide them. The regional hospital in Limerick is already unable to cope either with inpatient or outpatient demands. People have to wait for as long as five and six hours there for outpatient service. Where are the extra 50,000 who are now going to be displaced from Barrington's to go? They are told they can go to the regional hospital. If people have to queue for five or six hours at the moment is it envisaged that they will queue for 11, 12 or 14 hours? Is that possible? The thinking of the Department for years has been that the two older hospitals in central Limerick, Barrington's and St. John's, would, in the fullness of time, be closed on the building and opening of a new hospital on the north eastern side of the city. That thinking was right. It made sense to me but obviously, that hospital cannot be built now or in the foreseeable future because of the financial constraints, and everyone assumes, particularly as fairly significant sums of money were spent in both Barrington's and St. John's in the last number of years, that these two hospitals would be retained until a new hospital was built, perhaps at the begining of the next century. It is a bolt from the blue to be told that Barrington's is to close. I will finish on this point. The situation in the midwest region — in some ways I suppose not dissimilar to some of the others — is extremely serious at the moment. The Mid-Western Health Board are debating whether to close either Ennis General Hospital or Nenagh General Hospital. If one or other of those closes, as appears to be the provision, the regional hospital in Limerick has to carry all of the inpatients and outpatients from there. It will have to carry all of Barrington's inpatients and outpatients. It is impossible. I ask the Minister before this gets out of hand and goes too far to sit back and think about it because what he has done simply does not make sense. If as he said in October, he gave an allocation for next year of £1.6 million to Barrington's — they were working on operating within that and could continue to give most, though not all, of the services they have given over the years. They are still prepared to do that. I ask the Minister to indicate in his reply that he is prepared to look again at something that is going to cause serious hardship, not just in Limerick but in the adjoining counties also.

Mr. Desmond

This Estimate in many ways masks the fact that there has been a fundamental change in the past 12 months. The Government are not yet in office for 12 months and it will be interesting to see whether they will stay in office for 12 months. It masks the fact that we are developing rapidly a two tier hospital and health care system in which those who can afford to pay, and pay there and then, will get the best treatment as quickly as they need it and at the point at which they need it. Those who cannot pay there and then must join the queue in conditions that are every day becoming more and more a national scandal. It is argued quite often that the addition of private beds to the system takes the strain off the public beds. This argument does not stand up for two simple reasons. Every private bed opened places another strain on the limited pool of medical consultant expertise that is available and involves more and more public subsidy by way of tax relief into that system and cross subsidy from the public hospitals into the private sector. For example, we have the spectacle of people going from private hospitals to public hospitals where they can have CAT scans done for nothing and then going back to the private hospitals. In other words they are having the service free of charge while it is being charged for by the public hospitals.

The fourth floor in St. Vincent's hospital is going private. There are to be extensions to Mount Carmel, to the Blackrock Clinic, to the Bon Secours hospital in Cork — a massive extension — to Brookfield, Lyndhurst and St. Monica's all in Cork and to Waterford County and City Infirmary. The latter, I am glad to say, has been turned down by the VHI. VHI charges are going through the roof. There is an increase of 8.5 per cent on plan B this year, that is three times the rate of inflation. Forget about tax relief. Your voluntary health insurance system is going out the door gradually and we have turned the country into a two tier system because there is no conscious political planning. There is departmental planning.

Dr. O'Hanlon

Blackrock and the Mater were opened in the Deputy's time in office.

Mr. Desmond

As I put on the record before, I was urged around the Cabinet table and in public to have plans B and C increased by 26 per cent but that I refused. That was the sort of increase that was being sought. People could have their own VHI D and E plans but we were not going to have cross-subsidisation for persons in Cork, Kerry and Killarney for people who wanted to go to the Blackrock Clinic. That was the way we stopped it.

Dr. O'Hanlon

Blackrock Clinic and the new Mater Private Nursing Home were built and opened in the Deputy's time.

Mr. Desmond

The Minister's own party political people brought pressure on me to change that. I will leave it at that. Once you go into any of those private hospitals you meet consultants, people who are getting up to £44,000 from the State, who do a bit of work on Monday and Tuesday mornings in public hospitals and then go helter skelter to one of the private hospitals, where they get another £60,000 or £70,000 a year, and nobody is stopping it, least of all the Minister for Health. It is difficult to meet a consultant in a private hospital today who is not also a public contractor under a common contract prepared by Deputy Haughey who, in great haste and when he wanted to become Taoiseach, gave those contracts as a gift to 1,000 consultants. Now we are landed with the system and it would require dramatic change to turn it around.

The system has gone completely skewways. It is a national scandal and it will require a huge effort, politically and departmentally, if we are to avoid having a complete two-tier system where some patients have to wait for treatment.

I spent yesterday trying desperately to get a constituent of my colleague, Deputy Liam Kavanagh, into hospital. His constituent had two slipped discs, was lying on the floor in his home but could not get into a hospital. Nobody wanted him, and least of all coming up to Christmas. I think he is still in Wicklow. If he was a private patient he would be in hospital overnight. If he had the money, he could be in a hospital within ten minutes. That is the reality.

The Minister has a different style from mine. He is closing the hospitals by gentle starvation. I came into the House and said I would close St. John's Hospital, but the Minister said he will let it die quietly. I think it should be closed. I was in favour of that, and I have no hesitation in going on the record as saying it.

Mr. D. O'Malley

Where will the people go?

Mr. Desmond

They will have a problem. Deputy O'Malley said in Business and Finance in 1986 that we should cut out public expenditure for public hospitals.

Mr. D. O'Malley

I said no such thing.

Mr. Desmond

The Deputy will have Business and Finance stuffed down his throat here and elsewhere because he produced the great apologia for public expenditure. He cannot have it both ways.

Mr. D. O'Malley

Is the Deputy saying I said we should have no hospitals?

Mr. Desmond

The Deputy said we should reduce expenditure in public hospitals.

Mr. D. O'Malley

Is that when the Deputy said I was going to close Dalkey, Dún Laoghaire and Blackrock Garda stations?

Mr. Desmond

The Deputy said we should get rid of all the public servants employed in those hospitals. Now they are going and the Deputy cannot cavil. The Minister is a member of a minority Government——

Mr. D. O'Malley

What about Dún Laoghaire, Dalkey and Blackrock?

Mr. Desmond

The Minister is implementing PD policy with a vengeance.

An Ceann Comhairle

The time is limited for this debate.

Mr. Desmond

I am gravely concerned about the institutional assistance regulations being brought in by the Minister on 1 January. Is it true that 1,000 elderly people in long stay institutional care will be charged an extra £2.5 million? The Minister says that after 30 days there will be an amendment, from 1 January 1988, to enable charges to be made on persons in long stay institutional facilities. I gather 8,000 people will be affected and they will have to contribute an extra £2.5 million. That is a scandal. Here we go again, cut, cut, cut.

I am also very concerned that there has been very little progress on the psychiatric hospital side. I would close down four or five of these hospitals before I would close any more public hospitals. We could start with a few of these hospitals in the western area, and perhaps even the south-eastern area. The Minister should do this quickly. It would save more money.

I do not accept the Minister's allegation that I had permitted excessive overruns. This year the overdraft level he approved for the health boards was £23 million and so far they have taken up £15.5 million of that amount. There are overruns and there are overruns. I permitted overdrafts in the health board areas but the Minister should stop that nonsense——

An Ceann Comhairle

The Deputy should bring his remarks to a close.

Mr. Desmond

I am glad Beaumont has been opened and I am particularly pleased that no private hospital has been established on the campus of that hospital. It is open as a public facility. Where there is a private bed, that money will go directly into the budget of that hospital. It has taken five years to do this. I was glad to see the Taoiseach, with the Minister, going around this public hospital which could have been opened three years ago. There was great political pressure and political obstruction, particularly from the Fianna Fáil Party in that area, and from certain hospitals. At long last they saw the light of day and permitted the hospital to be opened.

I am appalled that this year in all our public hospitals there are only about 300 trainee nurses and the budget next year provides for 350 student nurses. We train about 1,500 nurses each year and within two or three years there will be a grave national shortage of nursing staff. People with leaving certificates cannot get nursing training and will have to emigrate to get it. This is a national scandal. Our hospitals should be used to provide nursing training for young people — they are not even getting paid now. At least we should train them so they can have a career at international level where there is a grave shortage of nurses.

An Ceann Comhairle

I am calling the next speaker.

Mr. Desmond

The Minister should revise that policy and provide decent nursing training in 1988 for a substantial quota of young people. He should resolve this appalling problem——

An Ceann Comhairle

I am sorry, Deputy. There is a strict time limit on this debate and the Deputy's time is up. Deputies have indicated their desire to hear the Ministers reply. There are less than five minutes left. Do Deputies wish the Minister to reply?

Mr. D. O'Malley

Yes.

Mr. Carey

I cannot understand——

An Ceann Comhairle

I am obliged to put the question at 11.30 a.m. and if the Minister is to be afforded an opportunity to reply, we should agree on that. Agreed. A brief comment from Deputy Carey.

Mr. Carey

As a Clare Deputy, I cannot understand the Department of Health policy with regard to acute beds in the Mid-Western Health Board area and their proposals to close Ennis County Hospital.

Mr. Sheehan

I would like the Minister to explain the reason for abolishing the advisory health committees. This is stifling the rights of democratically elected public representatives to agitate on behalf of their constituents, and it is giving a sarcastic rebuke to representatives of voluntary bodies who are nominated to these committees. The Minister said that the elderly would benefit to the extent of about £900,000 with a strong emphasis on encouraging the care of the elderly at local community level. I fail to comprehend how that can have any effect when there is a very long list of elderly patients waiting for the replacement of artificial hips. The health boards have stated they cannot carry out even one such operation until 1988.

Mr. D. O'Malley

Are the sheep dipping committees safe?

Minister for Health (Dr. O'Hanlon)

I thank Deputies for their contributions to this very limited debate. Deputy Barnes raised the question which is fundamental to the delivery of health services in the future, that is, placing more emphasis on health rather than illness. This is an area where we have taken positive action by setting up the Health Promotion Unit which incorporates the functions of the Health Education Bureau. We will have an advisory council chaired by the President of the Royal College of Physicians and a committee of Ministers chaired by myself to ensure that policies will be implemented.

On the GMS negotiations, I am glad to say they are progressing satisfactorily. Hopefully we will get a solution that will ensure an adequate and efficient level of service for the patients and job satisfaction for those working in the service, we will be able to control the cost to the State, and we will not have to come back with a Supplementary Estimate, as we did today.

On the question of the private hospitals, I support the integrated approach because if we polarise hospital services into public and private, the specialists in disciplines in scarce supply will go to the private sector and will not be available to the public. It is no harm to stress that in Deputy Desmonds time the Mater Hospital and Beaumont — the two most exclusive private hospitals in the country — were built and came onstream. He did not do anything to stop that at the time.

Mr. Desmond

I do not get the Minister's point, Beaumont is not a private hospital.

Dr. O'Hanlon

I have not supported the building of any more private hospitals and I am satisfied there are sufficient private beds. The VHI are monitoring the position very closely and they have refused on numerous occasions to fund private beds. I do not believe there will be any polarisation into a two-tier system. Indeed, I do not understand the reference to a two-tier system because that system has been in operation for the past 60 years and 20 per cent of the people are not entitled to a free health service.

Mr. Desmond

The common contract is 15 per cent and it has now gone to 30 per cent.

Dr. O'Hanlon

On the question of the common contract, Deputy Desmond was Minister for Health for four years and he did nothing to bring about a review of that contract even though it was due. I am glad to tell the House that that review is under way at present and progressing satisfactorily.

Mr. D. O'Malley

What about Barrington's Hospital?

Mr. Carey

What about Ennis?

Vote put and agreed to.