I move:
That a sum not exceeding £1,144,905,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1989, 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, miscellaneous grants, and a grant-in-aid.
First, I congratulate my colleague, Deputy Noel Treacy, on his appointment as Minister of State at my Department. The Deputy is very welcome and I look forward to working with him. I hope he will have a very pleasant and productive time in the Department of Health.
The exercise we are engaged in here today has, as the House will appreciate, been overtaken by recent events. I will therefore begin by addressing what actually was provided in the Estimates.
The gross non-capital provision in the Estimate amounted to £1,251.405 million. Allowing for appropriations-in-aid at £141.5 million, the net non-capital grant provision was £1,109.905 million. The net non-capital grant provision represented an increase of £39.357 million on the corresponding out-turn figure for 1988.
The 1989 Estimate included provision for an increase of 3 per cent from July in the rates of allowances for disabled persons. The provision also took account of the cost of second phase pay increases arising under the 1987 agreement on pay in the public sector.
The net capital provision made in the Estimate amounted to £32 million. Allowing for certain non-Exchequer receipts this provision allowed for capital expenditure within the year of £39 million. In addition, a provision of £3 million was made for systems development and related services in the health agencies.
The level of non-capital expenditure approvable on the basis of the subhead provisions in the Estimate was £1,256.5 million in net terms, or £1,363.5 million taking account of the direct income of health agencies. The net non-capital expenditure represented almost 20 per cent of total Government expenditure on supply services as compared with 19 per cent in 1986.
The gross estimated expenditure of £1,363.5 million was an increase of £25 million over the 1988 outturn. It comprised £850.5 million in respect of pay, £440 million in respect of non-pay and £73 million in respect of cash allowances.
The total health capital provision for 1989 was £39 million. These funds are being spent on priority projects that are designed to maintain and consolidate the physical structure of the health services. Capital provision has been made for the major general hospital projects at St. James's, the Mater, Cavan, Mullingar, Castlebar, Sligo, Wexford, Waterford Regional Hospital and Our Lady of Lourdes Hospital, Drogheda; for psychiatric units at Naas and Roscommon and for the provision of a new 34 bed geriatric unit at St. Patricks Hospital, Waterford. The planning of the new Tallaght Hospital will be continued.
I have examined the capital requirements of the health services for the period up to the end of 1994 and I am finalising the phasing of a multi-annual programme for that period, which will take account of much-needed capital developments in all programmes.
As Minister for Health I have always recognised that, given the precarious economic situation which has existed in recent years and the essential requirement to reduce public expenditure, the funding available for the health services has inevitably had to be less than I or my Government colleagues would have liked.
The acute hospital sector has been the centre of the drive to restrain public expenditure and naturally became the public focus of the previous Government's efforts in this regard. The change that has taken place in this sector has long been identified as necessary. The measures which were undertaken concentrated on achieving maximum efficiency; introducing improved methods of service delivery; and ensuring that patient care was the centre around which the delivery system must function. These objectives will continue to be necessary if we are to meet the changing health needs of our population.
We have a well developed acute hospital system with dedicated and committed nurses, doctors, paramedical and administrative personnel providing a high level and quality of service. We have a level of high technology that compares favourably with that available anywhere in the world. However I am concerned about some aspects of the service.
The number of patients on waiting lists particularly in some specialities and the variation in the numbers and period of time a person is awaiting admission to hospital in different parts of the country is a matter of concern. At present I am having a detailed and minute study of individual waiting lists carried out in a number of hospitals throughout the country.
There is a widespread public perception that patients on public hospital waiting lists can receive priority admission if they are prepared to pay. This could not be tolerated and I have directed the Secretary of my Department to contact each health board and voluntary hospital asking them to make returns to my Department indicating the number of public and private patients treated in their hospitals.
Some of the results of the measures introduced over the past three years have been an increase in the number of inpatients treated; a very large increase in day care activity and major advances in the equipping of our new major units. These success factors are very often overlooked. For a number of reasons they have been overtaken and hidden by increased demands for services. Demographic factors, AIDS and indeed advances in medical knowledge and technique have all led to increased demand.
New methods of investigation and treatment are constantly being developed and are being introduced into our system. All of these factors have placed increasing pressure on our services, as shown by the numbers on waiting lists for certain services. To alleviate this problem the present Government have committed themselves to the provision of an additional £15 million to the health services.
The additional resources are being allocated as follows: (a) introduction of sectoral accident & emergency service in the Eastern Health Board area: £1.5 million; (b) operations this year to reduce waiting lists, with priority for ear, nose, throat and hip-replacement operations: £1.7 million; (c) cessation of planned bed closures, restoration of bed weeks already lost through summer closures, and the opening of additional beds: £9.0 million and (d) the acceleration of the planned opening of new beds, including the purchase of new equipment: £2.8 million.
These provisional allocations will, if necessary, be revised within the same total provision, £15 million, following detailed discussions with the health boards and hospital authorities.
The additional funding which will be invested in the services will be allocated in a targeted purposeful manner and in a way which will ensure the best return on investment in the interests of patient care.
I moved a token Supplementary Estimate this morning on the basis that there will be an opportunity for a full discussion of the entire matter after the summer recess when the detailed allocation of the additional funding has been finalised.
As indicated also in the programme for Government, my Department will be having discussions with the Haemophilia Society to identify the specific requirements of individual claimants with a view to putting into effect through the AIDS fund a revised system of support to haemophiliacs who have contracted the HIV virus.
It is important to place on record that the Government's decision to increase the overall level of service does not mean that health agencies may set aside the spending parameters laid down by my Department. The existing cash and control mechanisms must continue to remain in force. I have stressed continually the importance of good, effective management and management which concentrates on achieving pre-set objectives. The structures through which management can operate and deliver must continually be addressed to improve efficiency.
Regardless of how services are organised in the future the requirement to have capable and productive management throughout the services will be a priority of this Government. A continuing review of the management of the system both in terms of structures, personnel and relationships will be a feature of this new Administration.
It is particularly opportune in my first address to the House on my reappointment as Minister for Health to refer to some of the major areas which will require particular attention over the next four years.
There is a tendency in referring to health to concentrate on the important and necessary services which provide treatment for illness and care for those who are suffering. However, to do so in isolation from the role of health promotion and preventive initiatives is to ignore an important element of public health policy. The House will be familiar with the health promotion structures I put in place during my previous term in office. I will continue to utilise these structures in the interests of achieving worthwhile results.
I have spoken at length in this House on the negotiations and changes that have taken place in the GMS. It is not necessary today to go over that ground again. However, let me say that discussions are continuing on possible additions to this arrangement. The duties of doctors under the new contract are specified and they include a requirement to take account of information and advice on prescribing matters agreed between the profession and management. Provision is also made for the introduction of a national drugs formulary to be operated by general practitioners. A joint working group has produced such a formulary for use in the GMS.
In recognition of the fact that general practice is undergoing significant change and that the contract itself is designed to foster particular aspects of change, the agreement provides that it should be subject to regular review, initially after 12 months and at three-yearly intervals thereafter. Provision is also made for reference to third party adjudication of matters of interpretation of the agreement which may give rise to dispute. New and straightforward arrangements are included in the contract for dealing with complaints about performance by participating doctors to ensure that the are dealt with fairly and efficiently. The agreement also provides for the establishment of a new part time post of practice support medical officer who will liaise closely with participating doctors to assist them to provide a high level of service and to identify and respond to aspects of practice which are capable of improvement in the interest of patients.
I am satisfied that this new agreement constitutes a sound basis, not only for the future of the GMS on a cost effective basis but also for the development of general practice as a whole, enabling it to fulfil its full potential as the primary core of an integrated and comprehensive health service.
The mental handicap service is an expanding service in that the life expectancy of mentally handicapped persons is rising. As a result, the level of financing of mental handicap services has steadily increased as a percentage of overall health expenditure over the past number of years. There have been dramatic improvements in the community services provided by State and voluntary agencies, but more must be done to ensure that all people requiring a service receive it in the appropriate setting. I am committed to ensuring the continued development and improvement of these services.
Much has been achieved in the past two years in developing the community based psychiatric services. There are, however, still too many people in psychiatric hospitals who have been assessed as requiring care in the community setting. I will strive to accelerate the implementation of the recommendations of the report Planning For The Future which forms the basis of my policy for these services.
The elderly are the highest users of health services. The incidence of many physical and mental conditions increases greatly in later life and dependency on medical and social services grows accordingly. The number of persons over 65 is growing as a proportion of the overall population. The growth in the number of very old — those over 80 years — will have important implications for the health services in the coming years.
The recent working party reports, The Care of the Elderly — The Years Ahead, has identified the measures necessary to provide adequate and appropriate services for the elderly, with an emphasis on care in the community. Significant progress has already been made in implementing the recommendations of the report, and improvements in these services will continue to be made.
The Government are committed to improving the lives of all children who are not receiving adequate care and protection. The Child Care Bill, 1988, had completed its Second Stage in the last Dáil and the Government propose to proceed to Committee Stage at the earliest possible date.
Some months ago, I announced my intention to introduce a new community drug subsidisation scheme for persons with limited elegibility who have a regular and continuous need for expensive medication. At present these persons pay the full cost of their prescribed medicines and must claim from the health board the balance over £28 in a given month. I recognise that this places an unfair financial burden on many individuals and families. Under the new scheme, these patients will pay only the first £28 of the cost of their drugs in a given month. The balance of the cost will be met by the pharmacist who will be reimbursed by the GMS payments board. Under these arrangements, the financial outlay of patients will therefore be kept to a minimum. Negotiations are proceeding and it is hoped to introduce the new scheme before the end of the summer.
The priorities which I have just outlined reflect some, but by no means all, of the areas in which the ongoing development of our health services will continue over the next four years in response to the ever changing demands which must be met. The basic principle underlying all of our policies will be to ensure that resources are directed to providing services for those most in need and in the appropriate setting. This inevitably will call for a continuation of my policy of redirecting resources to community care.
The House will be aware of the establishment of a Commission on Health Funding which are currently examining core issues which affect the funding, managing and organisation of health care in the future. I expect to receive their report in the near future and will study the recommendations and review the entire system of management of the health service nationally, including the health boards, to ensure an adequate and efficient public health service providing the best possible patient care. I will then submit to Government an outline of what needs to be done to meet this commitment.
The background to the financial difficulties of the VHI Board has been discussed at length in this House, so it is not necessary to detail once again the various factors which were causing the VHI's costs to escalate out of control. Suffice it to say that decisive action had to be taken to prevent the Board's insolvency and this was done. As a result, the board are no longer operating at a loss and can now begin to restore their reserves to an adequate level provided that the co-operation of hospitals and the medical profession is maintained.
In conclusion, I would like to stress again that the Government's commitment is to the provision of an adequate and efficient health service providing the best possible patient care in an equitable way.
