Dáil Éireann díospóireacht -
Tuesday, 26 Feb 1991

Vol. 405 No. 6

Private Members' Business. - Health Services: Motion.

Mr. R. Bruton

I move:

"That Dáil Éireann condemns the Minister for Health for his failure to undertake structural reform or to engage in coherent planning of the health services; and, in particular, for his failure to make adequate financial provision in 1991 to maintain existing services, the result of which will be deteriorating conditions falling most heavily on the handicapped, the elderly and those on public waiting lists for hospitals; and calls on the Government (1) to allow Health Boards run limited overdrafts pending a reassessment of resources needed by them to maintain and develop services in 1991 and (2) to introduce a proper reform plan for the health services based on numerous studies now available on the need for structural reform.

With the agreement of the House, I will divide my time with Deputy Bernard Allen.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. R. Bruton

After four years of management of the health services by this Minister, we are once again in 1991 back to a health crisis. The health boards have been left short of funds necessary to just maintain their level of services of last year. They are an estimated £20 million short. The result of this thoroughout the country will be fewer admissions to hospitals for elective-surgery with the inevitable lengthening of waiting lists. In one health board, for example, there will be up to 7,500 fewer admissions this year, there will be fewer residential places for those who can no longer cope at home, there will be extra strain on nursing care and there will be fewer support services for those in the community.

Similarly in the voluntary hospitals we are facing a crisis once again as exhibited by the recent situation in the Dublin hospitals where the accident and emergency admissions system has run into complete chaos. We have as a result — it has been documented — inadequate supervision of patients who are being left unattended on trolleys, often overnight in humiliating circumstances, and many are forced to stay for very long periods.

We are looking at the position in 1991 where the existing chronic waiting lists for services for mentally handicapped persons will worsen. Hundreds are already without service and thousands are facing inadequate service levels for their needs. The reality is that the cuts which the Minister for Health is imposing this year are unplanned and poorly thought out. They are a stab in the dark and a hope that the consequences will not be too bad, when the reality is that they have scant regard for the families who will have to cope with the consequences of longer waiting times and the early discharge which is an essential consequence of these budgets.

There are very notable examples in the various health boards of what will happen. The South-Eastern Health Board report that they will be reducing admissions by 7,500 patients this year compared to the levels which the Minister is forcing them to cut back to. This will result in their waiting lists growing again after a short period when there was a slight decline.

In the Southern Health Board two hospitals will see 1,700 fewer admissions. In the Midland Health Board 70 long-stay geriatric places will be closed and 20 staff will be let go, although the chief executive officer told the board there is a very strong case against this loss of staff. Again in the South-Eastern Health Board we are told of the release of psychiatric patients into the community, although they admit there is not the required development of back-up services to cope with these admissions in the community. Every board reported that they will not be able to develop any new community care services. This comes at a time when the Minister has declared his priority for the development of community care. No improvements will occur in 1991, outside the small number of areas where the Minister has offered special budget provisions.

There is a supreme political irony that this Minister for Health who, in 1989, shielded the Taoiseach from the reality of the health crisis should again, in 1991, a local election year, choose to squeeze out of the service the small improvements he has allowed since the last election which were wrung out of him by the political reality of what was facing patients. Perhaps later this year we will see a drawing realisation about the health crisis.

Some of us looked to budget day as a day we thought there would be some breakthrough in the health allocation. I know many social partners who looked to the health budget to see of very substantial sums made available, were treated to what I would regard as a complete sleight of hand on the part of the Minister that fooled no one. He announced on budget day, and sought applause, for an extra £8 million for dental care, care for the elderly and care for the handicapped. However, when you read the small print of this year's Budget Statement you discovered he was actually taking £4.5 million out of the health services, he was taking £2.5 million in economies which he refused to specify, he was taking £5 million in unspecified restructuring of borrowing — which again he refused to specify — and he was taking £5 million in extra public contributions for health that were being pocketed by the Exchequer.

We are really back to the old days of creative accounting, phantom efficiencies, putting off the evil day where debts are paid, and taxation by stealth. That was the essence of this year's budget announcement in the health area. Even some of the announcements were fraudulent. We heard that another £3 million for dental services was being allocated but the reality is that that was only restoring an equivalent cut that was built into the Estimates given to the health boards.

Since budget day the Minister has shrugged off the reports from the health professionals and contemptuously dismissed their appeals for a reassessment of their funding requirements. Only last week we thought we saw a chink in his armour, that perhaps he was having a change of heart, we heard that maybe he was going to restore £10 million to the health boards. I am extremely sceptical about the reality of this because from what we have heard the Minister's plan is that the money is to be found elsewhere in the health budgets. I cannot look to any year in the health service and see where the Minister will find these savings.

The voluntary hospitals, the other major area of spending, are in deep trouble. In the last few weeks we have seen total chaos in the accident and emergency departments of those hospitals. We have seen detailed reports from professionals in the Mater Hospital of the inadequate supervision, of the inability to monitor patients appropriately and of the chronic overcrowding in cubicles — of more than one to a cubicle — and where patients have to remain overnight on trolleys. As that report indicated this is humiliating treatment for patients at a time when they are at their most vulnerable.

Last year the Minister commissioned a special committee under David Kennedy to report on this. They reported urgently in the middle of the year on what needed to be done. They indicated the lack of adequate observation wards, the need for a greater allocation of experienced staff, the delays in the turn around of results from diagnostic tests, the cumbersome assessment procedures, etc. All the problems were listed. The Minister was to see that the necessary changes were in place by 1 October 1990 at the latest. Clearly the Minister failed to deliver on this as in so many other areas.

Catering for the accident and emergency departments is not marginal in the business of a hospital, that is the essence of their job. Almost half of all admissions to hospital are coming through the accident and emergency departments. This is the time when people are at their most vulnerable. It is not acceptable that the Minister permits a situation where a short cold spell can throw the system into complete chaos, as we have seen in recent weeks.

The tragedy is the way this Minister has presided over our health services where sacrifices have been squeezed from patients, but these sacrifices have been in vain. We have had four years of persistent savings, but in that period the Minister has failed to undertake any fundamental reform that could hold out the vision for people of a better health service. In every area the Minister has refused to act. He refuses to specify health service targets which the health agencies could aim for and against which we could judge their performance. He still uses crude cash controls that fall most heavily on the front line services, and have the consequent effect on patients.

Budgeting for our hospitals and other health agencies remains entirely divorced from their actual achievements in the provision of service. We have seen the two speed health system become more entrenched in the period of this Minister's care for the service. The Minister has even failed to get to grips with the efficiencies that can be achieved easily from the system, in areas like energy, management and the use of drugs.

It is depressing to see that this Minister consistently refuses to put forward plans for the restructuring of our health services. He persists with the cumbersome system of administration from eight health boards which has resulted in a system that is over-administered but under-managed. This failure could be forgiven if the need for action was unknown, but the reality is that the Minister's own Department signalled the direction of reform quite clearly in a document published in 1986, Health, The Wider Dimensions. The Minister inherited a charted course on his desk as to the reforms that were needed. In every area that document indicated the reform in the system needed but the Minister has not moved in any of these areas. Instead of taking action he has piled up more and more consultancy reports. The names of Fox, Kennedy and the Review Group on Mental Handicap trip from his lips as if the mere mention of their names meant that there was reform, change and a better service. These are just more in a long string of reports and the only thing which extinguishes them is that they have not yet had the opportunity to gather dust on shelves.

The Minister expects a gullible public to believe a new display of rhetoric, the pledge in the Programme for Economic and Social Progress that he will develop community care services. The reality is that there are very shallow foundations to the Minister's declared priority for the development of such services. A promise was made in that document that a sum of £100 million would be invested in community care facilities over seven years. However, none emerged in 1991. On the contrary, several requests by health boards for urgent new community care developments were turned down.

On day-to-day spending, the Minister imposed cuts on the budgets of community care providers which were much tighter than those imposed on hospitals. The major hospitals got an increase of over 10 per cent in their allocation, whereas most of the community care services have to make do with virtually unchanged budgets in 1991, despite escalating costs. This makes a nonsense of the Minister's often made claim that he will make extra moneys available to community care rather than to hospitals.

The cruellest cut of all has been reserved for the parents of mentally handicapped children where the Minister halved the allocation in the budget for their needs. The parents of mentally handicapped children have had to take to the streets to highlight the crisis they are facing. As I said earlier, hundreds of mentally handicapped children are without any service and thousands of them are inappropriately placed. Nationally there is an immediate need for 800 extra residential places and 1,000 extra day places. The cost of this runs to about £23 million. It is against this background that we must judge the Minister's allocation of £1 million in 1991, the first year of the much vaunted seven year programme. This sum is an insult. Waiting lists will get far longer for the mentally handicapped and their carers this year. The treatment being meted out to the carers of the handicapped is shameful and a major blot on a society that regards itself as caring.

Many aging parents who have to care for their handicapped children are driving themselves into the ground trying to cope, with far too little help. Many have not had a break in years and they face huge uncertainties in the future. Even the basic support services which one would expect should be provided for people caring in the community are not available to them. For example, only 155 respite places are available, as documented in the recent report by the NRB. This means that fewer than half of the parents of mentally handicapped children can get a break from caring. A similar situation exists for those parents caring for physically handicapped children.

The carers' allowance is a sick joke. It is only paid to parents who are on the bread line, that is, if they earn less than £100 per week, below the minimum income level dictated by the Commission on Social Welfare as constituting a subsistence level. The mentally handicapped do not have automatic eligibility for free doctors' care and they face rationing on essential items such as nappies. Specialist services like speech therapy, occupational therapy and physiotherapy are hopelessly overstrained and the Minister does not have any long term plan in this area. He did not indicate in the PESP any service targets which would be achieved and gave no commitment as to how the service would develop over the years.

That document also raised a new issue, the change in eligibility for hospital services. The Minister proposed that the top 15 per cent of income earners in our community should now be eligible for so-called free services in the hospitals. The reality is that the cost of these services has been significantly increased for those who depend on them. I am very sceptical that this change will bring any improvement to the lot of public patients.

This action is not in accord with what the Health Commission recommended, despite the misleading impression given by the Minister. The commission favoured the abolition of restricted hospital entitlements for the top 15 per cent of earners, but their key recommendation was that all necessary services should be available on the basis of medical need and not ability to pay. This recommendation was to be implemented by a "commmon waiting list for both public and private patients from which cases would be taken on the basis of medically established priority." This, in turn, was to be backed up by regular publication of criteria for admission to hospital and of maximum waiting periods for access to specific procedures. None of these fundamental recommendations made by the commission have been implemented by the Minister. He has ignored the notion of a common waiting list.

On the face of it, it seems absurd to answer the chronic waiting times for public patients by the extension of the service to a further 15 per cent of patients, especially when not a red cent is being provided by the Minister to meet the extra demands which might emerge. The Minister argues that public beds will be freed by excluding private patients from them. Many dispute this but what is most extraordinary is that the Minister does not know how many private patients have been using public beds. He is engaging in what seems to be a major social experiment about which no one knows the outcome, least of all himself. Yet, the Minister confidently announced to hospital consultants that he sees no reduction in private practice resulting from his changes. There can be only one reason why this will be so — the Minister will continue to ensure that the public system is sufficiently starved of resources, that waiting times will continue to be unacceptably long and people will not opt to take up their entitlements. The Minister has steadfastly refused to offer any guarantees about maximum waiting times for treatment in public care. This is why people have been willing to join the VHI.

The abandonment of the idea of a common waiting list held out by the health commission bodes ill for those who have to depend on public provision. The Minister is institutionalising the two speed health service for the first time instead of tackling its causes which were the essence of the Gleeson approach to setting consultants' remuneration. It is sad that we have to come into this House after repeated debates on the issue of the health service and refer again to the failure of the Minister to deal with his responsibilities. This is the reality and the Minister and his party will sadly discover this later during the year.

Mr. Allen

We have the most overreported and under-planned health services in all of Europe. At this point in time the Minister for Health has been in power for four years, yet during that period he has not made one single decision regarding the fundamental problems facing the health services. He set up a commission on health funding and during the two years of their deliberations he used their existence as an excuse for doing nothing and not making decisions.

When the commission published their report the Minister invited submissions from interested groups, another excuse for not making decisions. He then set up a series of committees. We had the Fox report, the Kennedy report and in the Southern Health Board region we are waiting a further report, the Kenny report. These reports cost an enormous amount of money. It is an absolute scandal that at a time when children in our schools cannot even get dental treatment the Minister would spend approximately £350,000 on the Fox report — I garnered that information from a reply to a question I put down to the Minister on 19 February. Expenses to date in dealing with the Kennedy report are running at £30,000 and the final costs are not yet known. The Kennedy report and the Fox report have been completed, but the Minister has not released the details of them. The health boards which are affected by the Fox report are unaware of its contents. I am calling on the Minister to publish the details of the Fox report and the Kennedy report which he received last Friday and contains five chapters dealing with out-patient services, in-patient waiting lists, services for geriatrics and the question of referrals from outside the Eastern Health Board region. The latter report extends to 208 pages. The tax payer, and the public, who are long suffering are entitled to know the contents of those reports.

The Minister for Health is frozen by indecision. He is not prepared to take the hard decisions that could bring about improvements in our health services. We have eight health boards, each of them bureaucratic monsters out of step with each other and some of them are havens of political patronage. I have come to the conclusion that that is one of the reasons the Minister does not consider the existence of eight health boards, in a country whose population is three million people, as superfluous.

The health boards, despite their unwieldly structures and inadequacies are striving as best they can to deliver a health service to the public. However, they are failing miserably. They are failing to give a service to the public, a service to which they are legally entitled. Our hospital services are in turmoil, with long waiting lists and delays in essential surgical procedures because of equipment breakdown. For example, only this week I received a letter from the leader of the consultant group in the Cork Regional Hospital and which stated:

Cork Regional Hospital is a multidisciplinary hospital containing local, regional and sub-national specialties. In recent years there has been a serious undermining of its role as a result of deterioration of equipment, fabric and morale. In spite of this, services have been maintained and, indeed, in many areas increased. A further decrease in the allocation for the hospital for this year is now envisaged and this could have serious implications for the delivery of services to the public as the year progresses.

This is a matter of grave concern to us and we wish to alert you of the situation.

An unprecedented meeting will be held between public representatives and the staff of Cork Regional Hospital next Friday because of the crisis there. The Minister has been warned of the position. Submissions have been made to him by the Southern Health Board regarding the need for a capital allocation for equipment, but he has ignored those submissions.

Despite major problems facing the health services perhaps one of the greatest and cruellest con jobs in recent years has been the Minister's pathetic attempt to pretend that a full, comprehensive and free hospital service will be available to all our people in the foreseeable future.

In other words the Minister is trying to pretend that despite the long waiting lists of sometimes up to two years for ear, nose and throat operations and orthopaedic and cardiac surgery and despite the profiteering involved in private practice in our public hospitals, evidence of which the Minister received months ago and did nothing about, despite the fact that patients who are seriously ill are being denied entry to hospitals, despite the widespread chaos and suffering because of inadequate facilities, the Minister is trying to use the big bluff, the political stroke, and he tells us he is going to provide free hospital services for all within a number of months.

To all this chaos the Minister is going to add a further 200,000 potential patients to the health services, and he is trying to tell us he will be in a position to treat all who require treatment. Shame on the Minister. He is either out of touch with reality or, worse still, is attempting one of the cruellest political strokes ever here just because of the impending local elections. It is shameful that political stroking can come before the wellbeing of the patient in such a sensitive service.

The local elections are coming in June and already we are hearing the political promises. These promises will be as numerous as the patients on the waiting lists before June. We have already heard a number of these promises. The Minister last week indicated that there may be more money for health boards, without saying where the money will come from except that it will come from internal sources. I would like to know where the money is coming from and how much will be provided. We are to have free hospital services for all our population, and everything in the garden will be rosy, again because of the June elections.

I repeat, this surely must be one of the most pathetic and cruellest political strokes of all time, and we have had a lot of them in recent years. If the local elections can produce suddenly from nowhere extra finance and promised improvements in our health services surely the greatest tragedy of all must be the needless deaths and suffering in recent times. Now we are being told they could have been avoided. I hope the public will not be fooled by the Minister's and the Government's trickery.

I ask the Minister to say where the money will come from for all the improvements suggested in recent times, either promised by the Minister or leaked by Government sources. I would like to quote from an editorial in the Irish Medical Times headed “Where Will The Money Come From?” It states.

The news that agreement has been reached between Dr. Rory O'Hanlon and the hospital consultants concerning remuneration for lost earnings consequent on the extension of the free hospitalisation scheme is of course welcome.

But any settlement along the lines proposed is going to be costly. Whatever the final expense, and substantial compensation is being quoted, more money yet again is going to be needed for health. Yet we have been told by way of the budget and the budgetary estimates that while there is more for the health service than last year the increase is likely to be swallowed up by existing expenses.

The article states in conclusion:

What is worrying about this whole business is that it lends substance to the widespread view that more than at any time previously it is the Department of Finance rather than Health which is effectively deciding policy for health. If we are wrong then all the Minister has to do is make plain that the extension of free hospitalisation is one of the lynch-pins of his policy.

The problem that remains is that money is going to have to be found to compensate disgruntled consultants and the likelihood is that it will be found at the expense of the very people the extension of free hospitalisation was meant to benefit — those paying tax on incomes over £16,400 a year.

Health, social welfare, education and housing should be the cornerstones of any nation's social policy. Here there is no housing programme despite the glossy presentation made by the Minister for the Environment, Deputy Flynn, in recent weeks. Health is in a shambles. We have a Minister for Health who is out of touch and not in control of the system, and the Minister for Finance, Deputy Reynolds, and his Department are calling the shots purely for cosmetic reasons because of the Programme for Economic and Social Progress. The Minister for Health is obviously all at sea at present on health issues and there is an urgent need for direct intervention.

There is urgent need for direct intervention by this House because the lives of our people have been sacrificed in some cases and in other cases they are increasingly being put at risk. I am tonight calling on the Minister to set up an all-party Dáil committee on the health services because horrendous things have been happening up and down the country. We must, as elected representatives, face up to our responsibilities and deal with the problems directly because the Minister has run away from his responsibilities.

I reject the allegations made by the Minister some weeks ago in this House that TDs are scaremongering in the Dáil. The Minister has been provided with plenty of evidence in recent weeks to prove my allegation. Last Thursday the Minister of State received evidence of medical cardholders being harassed by a health board and this has not been dealt with.

Lip service has been paid to community care in recent years while, at the same time, the service deteriorates. There has been widespread withdrawal of medical cards, harassment of medical cardholders — as I said last Thursday in the House — and medical cardholders who cannot get ophthalmic or dental treatment. The comprehensive community care programme about which the Minister spoke is a figment of his imagination. It is pathetic that health boards cannot provide a cardiac ambulance service in some health board areas. Doctors will tell you that people are dying on the streets because ambulances do not have defibrillators or monitors to deal with cardiac arrests on the streets of our cities outside Dublin. This scandalous situation must be dealt with.

Our spokesman for health dealt with the pathetic way our mentally handicapped children and their parents are being treated at present. This House must not leave the running and the workings of the services to the Minister, his Department, the Foxes and the Kennedys, who are just producing reports and making a fair bit of money from the services which should be going directly to the patients who are suffering. There have been enough reports, we now need action. If the Minister will not act this House should refer the health services to an all-party committee. This House should monitor the performance of the Minister from now on. We represent the people, an all-party committee should monitor the situation because the Minister is out of touch.

Minister for Health (Dr. O'Hanlon)

I move amendment No. 1:

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

Recognises the substantially increased financial allocation provided for our health services in 1991 and commends the Minister for Health for the initiatives he has taken and is taking to radically reform our health service in the light of the recommendations of various studies now available to him and in particular for the action he has taken to enable the increased level of service to be maintained by our health agencies.

The speeches of Deputy Richard Bruton and Deputy Allen could have been made by members of The Workers' Party. They advocated moving more to the left and spending more and more money. I will deal with some of the points raised and the Minister of State, Deputy Flood, will deal with the remainder tomorrow night, including the contradictions. One of the Deputies said there was no more money in the service but later he said more money could be provided by reducing the cost of drugs. Indeed, Deputy Allen made the same speech four years ago when he was spokesman for health for his party.

Mr. Allen

I wish the Minister had acted on it.

Dr. O'Hanlon

It was scaremongering as was the case again tonight. There is nothing new in the motion, nothing that we have not heard every time that the health services are mentioned by Fine Gael spokesmen in this House. There are, however, clear signs of regression, a return to hankering after something which is not available to the health services — soft money.

I will deal with that particular phenomenon in more detail later, but it is a matter of surprise and disappointment to me that the party's new spokesman on Health, Deputy Bruton, should be prepared to advocate further expensive borrowing. It would seem that little has been learned by the main Opposition party in the last four years. The suggestion that it is necessary to become involved in further borrowing at this stage of the year is, to say the least, precipitate.

I am pleased to be implementing a practical programme of reform, to provide those services that are needed at costs we can afford. I intend to remind Deputy Bruton, his leader and his colleagues, not only of the detailed plan which already exists for the maintenance and development of the health services, but, more particularly, the steps which are being taken and will continue to be taken to implement that plan effectively and efficiently.

I have little doubt that, in truth, it is a source of political disappointment to Fine Gael that steady progress has been and is being made. Conditions in the health service are not deteriorating: reform and renewal are taking place and there will not be any end to this process under this Government.

The motion before the House today completely ignores the real progress made by this Government in strengthening and developing our health services. We have attracted much criticism from Opposition parties for not implementing or responding to the various expert reports published on individual aspects of the health services in recent years. This, as I will show, is totally without foundation. Indeed, on occasions we have also been criticised even for establishing these groups in the first place, amid claims that they are a substitute for Government action. This is patently untrue.

The motion is based on the assumption that existing services will not be maintained during 1991 because there has not been sufficient financial provision made. In dealing with this aspect of the motion let me first outline the provision which has been made and level of expenditure which health agencies are authorised to incur during 1991.

The post-budget figures for health services show a total gross provision of £1,543 million, the largest amount ever provided. Capital grants account for £32 million of the above. A further £9 million will be made available from non-Exchequer sources, giving a total capital availability of some £41 million. The gross non-capital provision is, therefore, £1,511 million.

The level of provision which has been agreed for 1991 is considerabe, particularly when viewed in the light of overall Government expenditure. An examination of the post-budget net non-capital figures shows that almost 22 per cent of total spending has been allocated to the health services in 1991. Never, over the last decade, has the health share of total resources been this high. Since I came into office, this share has increased in each successive year which is in stark contrast with the decline which occurred when the Opposition were in Government.

The motion speaks of the alleged inadequate financial provision this year for the health services. I will give more figures: between 1982 and 1986, the amount of money provided in real terms went down by .5 per cent and, in the last four years, it increased by 6 per cent in real terms under this Government. The reality is that the 1991 allocations which issued to the health boards and voluntary hospitals are, on average, almost 7 per cent greater than the comparable allocations last year. It should be understood that the additional expenditure approved for health boards and voluntary hospitals in 1991 represents a considerable investment by the State in the public health system. Indeed, since 1989 I have provided about £116 million extra for the health boards and, by any standards, these are significant levels of investment by the State in the health system.

The motion also refers to the effects of the allocation on the handicapped. However, the fact is that the voluntary organisations providing care for the mentally handicapped have received from my Department a level of financial resources for 1991 which is 9.7 per cent in excess of the 1990 figure. Such an increase again underlines this Government's commitment to protect the handicapped and ensure that services provided for them by their organisation will continue and, indeed, will be developed.

Most of the discussion concerning the adequacy of the financial provision has tended, as usual, to centre on the extent to which acute hospital services will be affected. The Government set the approved number of acute hospital beds at 12,000 in 1990. Apart from the normal seasonal closure, this level of bed availability will be maintained during 1991.

Deputies

Rubbish.

Dr. O'Hanlon

The Government will assist health boards and agencies to maintain this level by supporting an enhanced value for money programme.

My policy is, and has been, that we must not just maintain the level of service but enhance it. One way of addressing this issue is the pursuit of greater value for money at all levels throughout the service and the Government have laid great emphasis on this strategy for 1991. The way forward in the hospitals sector has been set out in the Fox report. Similar strategies are now being applied to all other major agencies, including health boards.

Achieving greater value for money will not happen overnight. Indeed, I believe that many agencies have operated very efficiently for a number of years. By value for money I mean greater efficiency, economy and effectiveness, doing the right things; doing things right; and eliminating waste.

One example is in the area of the management of consumables. For too long little attention has been paid to the management of usage, product selection, warehousing and stock management and, indeed, to purchasing itself. Good examples of progress in this area are the development of computerised up to date price information by my Department and the reorganisation of the procurement function in the Eastern Health Board with the establishment of their professionally developed purchasing unit.

However, value for money will not be maximised unless there is greater co-operation between the various health agencies, working together and with the VFM unit of my Department. I am very pleased to report that the senior management of the agencies have responded to my requests in this regard. We now have in place in each health board a senior official with specific responsibility for VFM. The health boards collectively have established a value for money committee under the chairmanship of the chief executive officer of the Eastern Health Board. Furthermore, an action programme to follow up the main findings of the Fox report is being developed by a steering group including two assistant secretaries of my Department and Mr. Noel Fox. This group are working closely with the six main Dublin hospitals and work has already commenced on such functional areas as energy, pay, supplies, pathology — all major cost areas.

Let me say for Deputy Allen's benefit, that while we will be publishing the Kennedy report the reason we are not publishing the Fox report is that when Noel Fox and his group went into hospitals they were given freely information it would not be appropriate to publish in fairness to the hospitals concerned. I assured that, as far as the Southern Health Board and Cork Regional Hospital, are concerned——

Mr. Allen

The health board would like to have it published.

Dr. O'Hanlon

——they will get all the information relative to their own department.

Mr. Allen

Is the report an embarrassment to the Minister?

Dr. O'Hanlon

It is not.

An Leas-Cheann Comhairle

I thought that after the initial reactions to the Minister things might have abated. The Deputies know that if any of them is not happy with the Minister's medicine, they have the alternative, and I will guarantee to all sides of the House that they will have an uninterrupted presentation.

Mr. Sheehan

I am afraid——

An Leas-Cheann Comhairle

Deputy Sheehan, if you are not happy and you want to do justice to the importance of the debate, you know the alternative. I do not want to have to impose it, but I will.

Mr. Sheehan

I am afraid the Minister's medicine is out of date.

An Leas-Cheann Comhairle

I will not repeat myself. If we have a continuation of interruptions I will ask the Deputy in question to leave the House.

Dr. O'Hanlon

One final example of progress in this area of VFM is the initiative I took last week in the launch of the National Drugs Formulary which will make a substantial contribution to the control of drug costs on a national basis and at the same time expand the list of drugs available under the GMS scheme to include analgesics and antacids.

The Deputies may be aware that the review group who looked at the GMS suggested a figure of £8 million for savings in changing over to generics for patients. Of course, I always underline that the important thing is that the patient receives the drug appropriate to his need, but there is an obligation on the prescriber to use a cheaper drug as long as it is equally efficient and effective.

I have no doubt that as the year progresses VFM programmes will generate additional resources which will not be clawed back from the service. Much work has been done in changing attitudes but unless we build in adequate incentives, such as allowing retention of savings and providing the proper motivation to improve value for money, the optimum level of savings will not be achieved.

It is not enough to initiate VFM programmes on an ad hoc basis but to build it into the structure of the service. I see my Department's role not just in encouraging VFM but in assisting agencies in the development, implementation and measurement of VFM strategy. It is in this spirit of co-operative action that I have decided to establish the performance audit unit within my Department so that we can not only facilitate the transfer of good practice throughout the service but actually measure and be seen to achieve best value for money while ensuring that resources are allocated in the most equitable way possible between the various components of the service.

Surely no one can argue against prudent management on the basis I have outlined. It is only when all such possibilities have been fully implemented that one could properly consider the need, if any, for additional funding. Certainly now is not the time to come to conclusions on this issue.

A Deputy

Nonsense.

Dr. O'Hanlon

The costs of certain schemes, such as the drugs subsidy schemes, are very difficult to control. They have, in recent years, put a great deal of pressure on health boards. I have, on a number of occasions, indicated to this House my concern about this growing problem, most recently during my statement on the budget on 6 February. It has now been decided that these costs will be identified in a separate subhead. The full cost of meeting these schemes will be funded from the Exchequer, relieving the boards of the necessity to make savings elsewhere, if the costs prove to be higher than initially estimated. This should be of major assistance to the health boards in maintaining services during this year.

Containing activity and unit costs at agreed levels throughout the year will require careful management controls in health boards and hospitals throughout 1991. The Government will honour fully all commitments: the message I want to give to the House and to the public is that services will be maintained at not less than the levels approved for 1990. There simply will not be the deterioration in services this motion talks about.

As I said at the beginning, I am surprised and disappointed that Deputy Bruton should advocate an increase in health boards' overdrafts as a means of solving a problem which, as of now, does not exist. As I remarked during my budget statement to the House on 6 February, it is difficult to know where Fine Gael stand. On the one hand, they say we are spending too much money and, on the other, they come in here regularly and say we are not spending enough. In this instance, they seem to be hedging their bets. We should, they say, allow health boards to extend their credit with the banks despite the fact that we may not require this credit later in the year.

It is a remarkable proposal but one which bears all the hallmarks of the party's approach to the financing of the health services when they were in Government. Because of that approach we find ourselves still grappling with an uneconomic level of bank debt. It is certainly not my intention to add further to our problems by accepting the terms of this motion.

A Deputy

The Minister forgets when he was in Opposition.

Dr. O'Hanlon

Let me now return to the accusations that have been made on many occasions that recommendations of reports on the health services are not being implemented. I established a number of working groups in recent years to advise me on priorities for the development of individual services; my predecessors have done the same. In a service as complex and costly as health, such examinations will always be necessary. In this respect, we are no different to all other developed countries. It would be inexcusable if, when allocating £1.5 billion of public money, we failed to engage in fundamental reviews of individual service areas.

I was very pleased with the important work done by such groups as the Commission on Health Funding which I established. They reviewed the entire structure and funding system of the health services. The reports of the Working Group on Health and Welfare Services for the Elderly, the Green Paper on Services for the Disabled and the Study Group on Psychiatric Services, Planning for the Future have been enormously helpful in plotting the development of services.

Contrary to claims that these reports have been ignored, the Government are engaged and have been for some time in a careful and structured implementation of the key recommendations in each case. The implementation process began with the action plan which I announced to this House in February 1990. It received a further major impetus with the conclusion of the Programme for Economic and Social Progress between the Government, trade unions and employer groups. The progress which has been made in implementing the recommendations of the Commission on Health Funding is a good example. I will briefly highlight some of the main recommendations.

As regards eligibility, the commission's key recommendation has been accepted and will be implemented with effect from 1 June 1991. As regards administration and management, a major detailed preparatory work has been completed and, as indicated in the Programme for Economic and Social Progress, the Government will announce their proposals during this year. So far as information and evaluation are concerned, the action plan which I announced in February 1990 is being implemented. In relation to drug costs, the FICI agreement is in place, the National Drugs Formulary has been launched and a special unit has been established within my Department to concentrate on all aspects of drug procurement, usage and costs. Further developments will arise from the recently completed review of the GMS. In relation to the provision of appropriate services, the options open to carers in planning the right mix of service for each patient will be considerably broadened by the enhancement of community based services in line with the service and financial commitments contained in the Programme for Economic and Social Progress.

I will return to some of these matters later. It is, however, clear from this brief summary that, contrary to what is implied in the Fine Gael motion, there is a plan and reform is being implemented.

Policy implementation is proceeding in a coherent way and is based on a substantial body of research and analysis of priorities. Only in this structured manner can we ensure that we achieve value for money and the best possible services, given the resources available.

I have been concerned, since becoming Minister for Health, about the importance of ensuring an adequate availability of key services in the community, including those for the elderly, the physically and mentally handicapped and children at risk. The Commission on Health Funding stressed that it was not sufficient to expand these services in an undirected way. A proper evaluation of the needs of specific target groups, and an assessment of the best means of meeting these needs, was required. Accordingly, the action plan which I presented to this House in February 1990 allocated extra funds to carefully selected areas. We spent an extra £5 million on services for the elderly, an additional £3 million on dental services and a further £2 million in the area of mental handicap.

I am pleased to say that, following on the success of these extra allocations, we have been able to take a similar approach under the new Programme for Economic and Social Progress. The funding involved, however, will be substantially greater. Over a seven year period we have committed ourselves to allocating £100 million of capital expenditure to community based services for the elderly, mentally and physically handicapped, psychiatric services, child care, dental services and health centres.

The extra capital funding will be an important contribution to developing our community based services. Up to now I have been particularly constrained in the capital funding available; the bulk of it has had to go, in the past, towards our in-patient services.

In addition, I would remind Deputies that we will also be allocating significantly increased levels of current funding to these community based services. By the end of the seven year plan, we will be spending £90 million above the present annual level of current expenditure in real terms. The Government are committed to providing additional funding in each year's budget and a start has been made in this process in 1991.

In my budget speech last week I dealt with many of the aspects of the Programme for Economic and Social Progress. I will not go over them now, but I will move on to other aspects of the programme, for instance, eligibility which was mentioned here tonight. To ensure the greatest possible equity in the availability of health services, new arrangements for eligibility for public hospital services were announced in the Programme for Economic and Social Progress. These measures were recommended by the Commission on Health Funding and by the National Economic and Social Council and were sought by the Irish Congress of Trade Unions in the context of the programme.

In brief, the principal changes are the abolition of the income limit for Category 2 eligibility so that all patients will now be entitled to public consultant services, free of charge and the modification of the present arrangements for admission to public ward accommodation in public hospitals.

The removal of the income limit will rectify a number of anomalies identified by the commission which arise in determining eligibility for a hospital services card, while the new admission arrangements will contribute towards equity of access to public beds. Under the new admission arrangements the availability of public beds for public patients will be increased by requiring private patients needing other than emergency treatment to avail of private or semi-private accommodation. Emergency cases will continue to be admitted to whatever bed is available.

The abolition of the income limit will take effect on 1 June next and the new arrangements for access to public beds will be phased in gradually over the next couple of years.

In improving the position of public patients, the Government will also ensure that the public hospital system continues to cater adequately for the needs of private patients. The Government also recognise the crucial role played by voluntary health insurance. In introducing the new system the Government will be sensitive to the need to ensure that the public hospital system caters adequately for the requirements of private patients and that the important role and contribution of voluntary health insurance is not diminished in any way.

The decision to continue full tax relief on health insurance premium illustrates the Government's commitment to this principle. The introduction of the new eligibility arrangements follows upon the very detailed analysis of the Commission on Health Funding and the National Economic and Social Council. Once again, it is an illustration that the Government are ensuring that the changes necessary for a more equitable and efficient health service are carefully researched and identified and then implemented in a planned manner.

The current negotiations with medical consultants cover a number of vital issues, including the implications of the change in eligibility. Agreement on matters such as pay, accountability and the management role of consultants is central to the future orderly management and delivery of a high quality service that must have regard to available resources.

We have been fortunate in this country to have such a committed and highly qualified medical staff who can be justly proud of the quality of service which has been achieved. I would like to put on record the Government's commitment to achieving an agreement which will do justice to the interests of the patients, the consultants and the taxpayer.

A major review of the organisational structures of the health services is in progress. The purpose of this important review is to establish how our health services can be better organised to achieve greater efficiency and effectiveness from the very substantial resources being provided by Government. That review began with the analysis of administrative structures prepared by the Commission on Health Funding in chapter 9 of their report. The report analysed, in broad outline, the weakness and strengths of the existing structure. It identified the lack of integration of related services and inadequate accountability within the existing structures as major shortcomings which any solution must address.

Following publication of the commission's report I announced an action plan in February last year to provide a pragmatic strategy for the implementation of major improvements in identified areas of the health services which I regarded as priority areas. A central pillar of that action plan was the establishment of the Dublin Hospital Initiative Group and the Hospital Efficiency Review Group to advise on the detailed strategy to improve efficiency within the health services. I now have the recommendations of both groups in relation to organisational structures particularly in the Dublin area. Both groups have concluded that services could be delivered more effectively if mechanisms were developed to co-ordinate services better and improve resource management and have made a range of very detailed proposals.

In the Programme for Economic and Social Progress the Government have set out their decisions on the principles upon which the organisation of the health services should be based. The principles are based on the findings of the expert groups which I have already mentioned. As promised in the programme, the details of the Government's proposals will be announced during this year.

This issue is of fundamental importance. It calls for time and care and it will get the time and care this issue requires. I am satisfied that the time and care given to preparing our proposal is more than justified. I also see it as appropriate that those proposals should be announced in the context of a programme which provides for major investment in the development of our health services and especially community services. I am also working on a patient's charter about which I will be saying more in the future.

Waiting lists are a feature of all health systems. Better health care with ever increasing demands on services, the needs of our growing elderly population and even the development of new forms of treatment, such as hip replacement surgery, have all had effects on waiting lists.

In 1989, certain areas were identified as requiring special attention and additional resources were targeted for these areas. I have placed strong emphasis on tackling waiting lists in general and waiting lists for hip replacement operations, ear, nose and throat surgery and cataract surgery in particular. I am pleased to have this opportunity to report on the progress made with regard to these procedures. The waiting list for hip replacement operations has decreased by over 12 per cent since April 1990.

With regard to ENT, in the Deputy's area of Cork, last year there was a reduction of 45 per cent in the waiting list and a reduction of 55 per cent in Temple Street.

(Interruptions.)

Dr. O'Hanlon

The Deputy does not know anything about it. Progress was also made in relation to cataract operations where there was a 12 per cent reduction in the waiting list.

I have now received the final report from the group which David Kennedy has chaired. I was very pleased to attend the final meeting of the group last Friday and I intend to publish that report in the very near future. I will ensure that all the recommendations, most of which relate to best practice, will be fully and quickly implemented.

Mr. Sheehan

It is all reports and no action.

Dr. O'Hanlon

I would like to take this opportunity of publicly thanking David Kennedy and all who worked with him in producing such a significant and helpful set of recommendations.

Mr. Allen

He got well paid for it.

Dr. O'Hanlon

I will also be announcing further details of the medical card——

An Leas-Cheann Comhairle

The Minister has three minutes left. The Chair regrets that the ether that had been applied earlier seems to have disappeared.

Dr. O'Hanlon

I will be saying more about the medical card appeal system which we will be establishing in the very near future. I have referred before to the information technology recommended by the commission on funding: we have a special provision of £4 million for that this year and very substantial progress has been made in a number of hospitals around the country.

Health agencies the world over always seek additional funding partly because of the complexity of the services and partly due to the demand-led nature of so many of the services they provide. I as Minister for Health must distinguish between demands and need and fund the latter. To do otherwise would mean that a disproportionate and unjustified amount of public money would be committed to the health services. Indeed, it would be true to say that the entire gross national product of any developed country could in time be consumed by the health services if every pressure group were to get its way. I could not stand over such an approach, nor could any responsible Minister for Health. A far better strategy is to work at getting the maximum return from every pound invested and seek efficiencies where they can be found. Then, and only then, should the question of additional funding be considered to finance needs and not demands.

Mr. Allen

In the meantime people die.

Dr. O'Hanlon

It is very important to make a distinction between cutbacks and not meeting increasing demand. While demand is increasing here as in every country, it should be recognised that rather than cutbacks in service in the last two years there has been a substantial increase in the level of service being provided throughout the country.

Mr. Allen

The Minister sounds like Ben Dunne, the supermarket tycoon, talking about value for money.

Dr. O'Hanlon

Almost a thousand more beds and 2,500 more staff in the last 18 months; that is progress.

Mr. Sheehan

We cannot open the geriatric ward in Bantry Hospital.

Dr. O'Hanlon

I am very concerned at the alarmist and untrue statements about our services, and we heard plenty of them here tonight from Deputy Bruton and Deputy Allen, which create fear and concern in patients and their relatives. Deputy Bruton referred to a deterioration in the services for mentally handicapped. That is grossly untrue. There will be no deterioration. They got a very substantial increase: they got £2 million in last year's budget which has been repeated in the current year, plus another £1 million. He referred to accident and emergency as being in chaos. There is no chaos in those services. I have always respected constructive criticism and recognise the need for continuing development in our health services.

Mr. R. Bruton

Listen to the parents of the mentally handicapped who were in the Mansion House last week. They will give constructive criticism.

Dr. O'Hanlon

However, it is true to say that we have a quality service and that is due in no small measure to the caring, committed and dedicated staff we have, to our nurses, doctors, para-medical and administrative staff. We can be proud of the caring staff and the high quality of service we have in this country. It is my intention, not alone to maintain services at their existing level but to continue to implement improvements where needed and as resources allow.

Mr. Sheehan

All talk but no action.

Mr. Ferris

I wish that all speakers so far in this debate would realise that there is an element of disbelief out there about what is really happening in the health services. I do not think the Minister has for one moment addressed what is a major problem. This sense of complacency was indicated by the Taoiseach even last week when he said across the floor of the House in the budget debate that he did not know what was the matter with the health services, because in real terms there is real money available. The Minister has now confirmed and continued that attitude. Does the Minister not realise that there are also increased costs in real terms in the health service? Because of that, there are areas in which the boards have no control whatsoever over expenditure, like the GMS and, indeed, the hospital activity that has been increased over the years. These are increases and hidden charges in reduced estimates or estimates with which they are unable to maintain their services.

An Leas-Cheann Comhairle, I should at the outset have requested your permission to share some of my time with Deputy Howlin tomorrow night. I hope the House will agree.

An Leas-Cheann Comhairle

It is a matter of formally asking the House. Agreed.

Mr. Ferris

Thank you. There are problems in health areas because of these deficiencies that are outside their control. I am surprised at the original motion from the Fine Gael Party which we are now discussing. It does not go nearly far enough to analyse the short term crisis in our health service and in proposing the solution.

Frankly — and the Minister has touched on this — I find it extraordinary that the Fine Gael Party in particular, the party of so-called fiscal rectitude, should be proposing here that a rational solution to the crisis in our health services would be to allow health boards to increase their already substantial overdrafts. Fine Gael have never been able really to face up to the truth of the crisis in the health service. It was the budget of 1987, it should be remembered, that led to the start of this crisis. It was the present Leader of Fine Gael who introduced that budget. Since then, that party have begun the process of starving the health boards of resources and they have been unable to admit that the problem is simply and almost exclusively a shortage of financial resources. That is why every time a solution is proposed they have always stopped short of saying that what the health services need should be paid for by the Exchequer. That is the kernel of the problem. People are entitled to the service and if this Government and this Dáil do not provide the resources, we are doing a disservice to the people we represent. The closest that Fine Gael have ever come since the 1989 election was their proposed to allocate funds out of the national lottery, as if that was a reasonable basis on which to plan the health services — based on gambling. We should not be gambling with people's health care.

It is a statutory responsibility on us all to ensure that this Dáil provides sufficient funds to provide health care for our people. It is neither sensible nor practical in the light of experience — and I have many years' experience on a health board — to attempt to address the problems by encouraging health boards to increase their existing overdrafts. Experience has shown us that that simply defers the problem for another year. The Minister accused health boards previously of doing this, at a time when the Minister's members were on health boards advocating the increasing of overdrafts. The Fine Gael Party, as well as everyone else in this House, know it well. We should be honest and responsible in demanding an increase from the Exchequer and we should do so immediately. They know that that would leave their leader with egg on his face, having regard to his record in the area of fiscal rectitude, and that it would make a nonsense of what has passed for a philosophy for some time in the recent past.

The immediate crisis in the health service arises in two areas. First — and this is the real crisis — is the shortfall in health board allocations. This has been confirmed by all the health boards. Some of them have rejected it, some of them have had to go back, under threat of abolition under section 31, to cut back services in spite of the Minister's request not to do so. These shortfalls to health boards will inevitably lead to cutbacks in elective treatments and to longer waiting lists. Second, there is the acute shortage in provision, both current and capital, in the area of services for people with mental and physical handicap. There have been increases in those two areas but nothing like what is required to give the services that people with mental and physical handicap need.

Debate adjourned.