Substantial funding has been provided and not just the 40 per cent increase in the ordinary allocation to the agencies catering for mental handicap. A sum of £2 million was provided in the budget in 1990 which provided 179 new residential places, 442 day places and respite care for 200 persons with mental handicap. Not alone was that £2 million repeated this year but a further £2 million was provided to allow further development in the services, particularly in Cheeverstown House and in Áras Attracta in Swinford.
With regard to planning, not alone did we re-establish the co-ordinating committees in the health boards but we produced the report of the working party Needs and Abilities. That outlines the needs, and within the Programme for Economic and Social Progress we will provide the new services necessary. We all accept that it is necessary to develop services for people with mental handicap.
With regard to cutbacks, it is time we stopped talking about cutbacks in the health services in this House and faced reality. Over the last two years there has been in increase of 3,000 people working in the health services. There are now just 60,000 people working in the health services. That is an indication of the development that is taking place. There are also 1,000 more hospital beds open now than there were two years ago. There has been quite substantial development in the health services.
With regard to waiting lists, I inquired today with regard to Cappagh Hospital and I was told that there are 11 consultants in Cappagh Hospital and nine of them have waiting lists of less than four months for hip replacements at the moment. I asked if we had sufficient facilities to eradicate waiting lists. I am told that that is possible in regard to hip replacements, but I hasten to add that when we have all the hips replaced and repaired we then, as one hospital did last year using the increased allocation which they got, get into knee joint replacements and elbow replacements. It is very encouraging that we are up with the very best and most modern technology in the world and that we are moving into other new joint replacement operations.
However, my main purpose in the House this evening is to discuss the Estimate for my Department. The gross non-capital provision in the Estimate amounts to £1,510.366 million. Allowing for appropriations-in-aid at £194.053 million, the net non-capital grant provision is £1,316.313 million, of which £11.8 million is national lottery funded. The net non-capital provision represents over one-fifth of total Government expenditure on supply services and represents an increase of £40.247 million over the corresponding out-turn figure for 1990.
Health cash allowances have again been increased at a rate significantly in excess of inflation. The rate of disabled person's maintenance allowance has, for example, been increased by almost 6 per cent. The Estimate also provides for the cost of certain special pay awards which fall to be paid in 1991.
On the basis of the subhead provisions in the Estimate, the level of non-capital expenditure approvable amounts to £1,511.100 million, of which £1,045.527 million is in respect of pay, £377.684 million is in respect of non-pay and £87.916 million is in respect of cash allowances. When account is taken of the income generated directly by health agencies, the total projected expenditure for 1991 amounts to £1,630.500 million, which is a substantial sum of money.
The House will be aware of the very valuable contribution the national lottery has made to the development of community health services in recent years. Last year more than £10.5 million lottery money was spent on providing a wide range of services, including services for the elderly, child services and services for the mentally and physically handicapped. In 1991 the lottery allocation will be £16.89 million, of which more than £5 million is for the hospital building programme and £5 million is to assist with the implementation of the recommendations of the working party report The Care of the Elderly — The Years Ahead. The balance will be used to assist projects similar to projects in previous years and includes special allocations for the mentally handicapped and for child services.
From 1990 the procedure for the distribution of national lottery funds was changed. While the Department continue to retain control of funding for national based projects such as child services and services for the elderly, grants to local voluntary agencies are now a matter for the relevant health boards. The amount allocated to the health boards for this purpose in 1991 is £1.5 million.
The total capital provision for 1991 is £41.330 million. Of this, £27.240 million is being provided by the Exchequer, £5.090 million by the lottery, and a further £9 million is being provided from external sources. Despite the difficult financial situation which has obtained in recent years, considerable progress has been made in improving the physical infrastructure of the health services. Major improvements in the acute hospital sector have been made, particularly at Beaumont, the Mater, St. James's Hospital, Cavan Hospital, the International Missionary Training Hospital, Drogheda, Castlebar and Mullingar. This year, I am making funds available to complete the commissioning of the developments at St. James's Hospital and funding is also being provided to continue work at Sligo, Wexford and Ardkeen. Provision has also been made in 1991 for construction work on important hospital improvement schemes at the Rotunda, Monaghan and Kilkenny. Progress continues to be made in the improvement of the capital stock of the psychiatric service, services for the elderly, services for the physically and mentally handicapped and child care services.
Significant capital developments have taken place in recent years, despite limitations on capital funds, and I recognise that much remains to be done. In relation to capital, I am endeavouring to take a view of what must be done over the next five years or so. We already have significant contractual commitments which will dominate the next few years. Beyond that, we must try to ensure that the existing system is maintained at the right level of efficiency, safety and effectiveness. We cannot contemplate embarking on further developments unless we are satisfied that this additional draw on resources will not hinder our ability to maintain existing services at a high level of efficiency. I am particularly conscious of the demands which must be met in relation to fire precautions, maintenance and the replacement of equipment.
The programme of information technology of the health services made good progress over the last year. Increased funding has been provided and over the two years 1990-91. Almost £9 million in special capital grants is being made available. Every health board, and many of the large hospitals and other health agencies, have received grants in support of a wide range of projects. The programme is concentrating on the provision of information in support of the management of patient care and of resources. Modern hardware, software and networking technologies are being installed. Particular attention is being given to ensuring that the agencies have the capacities to extract full benefit from these developments through involvement of users of the systems in their selection, training, the development of systems expertise locally, and so on.
Despite the continuing tight budgetary position, some of the most important developments in the health services in recent years have taken place in 1991.
The conclusion of the Programme for Economic and Social Progress represents a significant milestone in the development of community based services. As the House is aware, there was a debate in the eighties about where new moneys coming on stream should be spent in the health services. There is now a consensus that new moneys should be spent in the main in the community for the development of community services. This is not the view just in this country; it is also the view in other countries in the developed world. I am very pleased that that is recognised in the Programme for Economic and Social Progress and that a very comprehensive programme spells out in clear detail where developments will take place within the next seven years.
Subject to the overriding consideration that we continue to live within the fiscal parameters set out in the programme, substantial capital funding will over the seven year period be allocated to services for the elderly, the physically and intellectually disabled, the psychiatricially ill, child care, dental services and health centres. In addition, the Government will significantly increase current expenditure on these services.
We have already made progress in this regard. This year's budget included additional funding for specified community-based services. I emphasise to the House that the Government will not be prepared to allocate these additional resources without ensuring that value-for-money is achieved and that the planned developments in services actually take place. Indeed, the monitoring arrangements for the programme will ensure that resources are used for the specific purposes for which they were allocated and that their impact will be assessed.
The recent enactment of the Health (Amendment) Act, 1991, represents yet further progress in our efforts to simplify and streamline the operation of the health services by establishing just two categories of eligibility. The Act will ensure a much fairer system of access to public hospitals. Under the new admission arrangements which are being introduced on a phased basis, all non-emergency patients will be obliged to make an explicit choice between public and private care, including accommodation and consultant treatment. This will result in improved access to public beds for public patients, since public beds will no longer be occupied by consultants' private patients. I believe that, in adopting this approach, we will greatly improve the services available to all persons in public hospitals, whether they choose public or private care.
This year I have placed a major emphasis on the health service as a whole achieving greater value for money throughout each area of activity. I am pleased to report that the service has responded very positively to this initiative. My Department are providing agencies with every support possible in the pursuit of this objective.
The concept of value for money has now been firmly established within the structures of health boards and major hospitals. Particular emphasis has been given to the promotion of greater co-operation among health agencies. I am glad to say that there has been a ready and rewarding response.
Late last year I received the report of the Hospital Efficiency Review Group who examined in detail the efficiency of seven major hospitals under a wide range of operational headings. We are currently implementing the main recommendations of that report.
I have established a top level steering group to work closely with the chief executive officers of the participating hospitals on the implementation of those efficiency recommendations contained in the report which are amenable to immediate action. Particular attention is currently being focused on savings which can be achieved on the pay side; public utility contracts; materials management, including purchasing, and pathology costs. I am confident that as the year progresses, this initiative will continue to show very positive returns. This is being done in the context of an incentive-based policy which provides for the agencies concerned to retain the benefits of the economies generated.
Conscious of the need to maximise performance the chief executive officers of the health boards, as well as taking the initiative of assigning a senior officer to the development and co-ordination of value-for-money programmes at board level, have also at national level established a value-for-money co-ordinating committee under the chairmanship of the chief executive officer of the Eastern Health Board.
In addition to these measures a number of very important initiatives have been pursued directly by my Department this year. Examples include the introduction of a computerised price index system on a pilot basis in seven sites to provide monthly comparisons of prices, brands and usage on a range of over 900 products. The system has the added benefit of providing valuable comparisons with the United Kingdom health authorities. I may say in that context that when I came into office I established a cost containment unit. We discovered that in some instances the hospitals which were using the largest number of certain items, say, disposable gloves, were paying a higher price than hospitals which were using a lower amount. By keeping an eye on the prices paid by the various agencies and keeping in touch with the supply officers of the hospitals and agencies we were able to achieve substantial savings through the cost containment unit. We have developed this further through our value-for-money programme.
The area of income generation has been reviewed and agencies have been advised to pursue more vigorous collection methods in, for example, the collection of road traffic accident income. A number of improved income generation schemes are also in the process of being established at present to ensure that agencies maximise the use of all available assets and resources.
Arrangements are being put in place to ensure a more co-ordinated approach to the procurement of equipment. We are in contact with our colleagues in Northern Ireland concerning the purchase of an expensive piece of equipment, a magnetic resonance machine. They are purchasing a similar piece of equipment and we have adopted a joint approach in the tendering process to obtain a better price.
A detailed examination of professional indemnity insurance costs has been undertaken. Arrangements have been put in place to facilitate increased take up of European Community intervention schemes by health agencies. Greater co-operation between the Dublin children's and maternity hospitals is being promoted. A series of initiatives have been pursued with our colleagues in Northern Ireland in the non-pay and equipment purchasing areas. I have referred to one such initiative already.
In recent years there has been growing public awareness of the scandal of child sexual abuse. The growth in the number of reports of child sexual abuse and the number of cases in which abuse has been confirmed has been most disturbing. As recently as 1982 there were only 37 confirmed cases of child sexual abuse known to the health boards. In 1989 the total number of confirmed cases of all sorts of child abuse known to the health boards was about 1,300, of which the number of confirmed cases of sexual abuse, was about 500. These figures represent a four-fold increase in five years. The Department have not yet completed the collection from health boards of statistics in respect of 1990, but on the basis of the returns that have been made to date all the indications are that the total number of cases in 1990, including child sexual abuse, will show a further increase. In response to this appalling development. I have approved the establishment of specialised units for the investigation, management and treatment of children suspected or being victims of child sexual abuse. These units are at Temple Street and Crumlin Children's Hospitals and are composed of multi-disciplinary teams, including a paediatrician, psychologists and social workers, with psychiatric support where necessary. Outside of Dublin, services for the investigation and treatment of the victims of child sexaul abuse have been set up by each of the health boards.
The growth in child sexual abuse clearly illustrates the need for effective legislation to protect children who are at risk. This is the major objective of the Child Care Bill. The Bill has recently completed its passage through the Dáil and Seanad. The purpose of the Bill is to update the law in relation to the care of children, particularly children who have been assaulted, ill-treated, seriously neglected or sexually abused or who are at risk. The Bill aims to achieve these objectives through the strengthening of the powers of the health boards to provide child care and family support services; to allow immediate intervention by health boards and Garda where children are in serious danger; and other measures designed to promote and preserve the welfare of children.
Implementation of the Bill will necessitate major expansion and new investment in our child care services. In the Programme for Economic and Social Progress the Government have given a commitment to making the necessary resources available to enable the Bill to be fully implemented over the seven years of the programme. Already a good start is being made this year in preparing to implement the provisions of the Bill.
In developing our service, special regard will be had to the most vulnerable groups — to children who are unloved and unwanted, to children whose parents are unable to care for them, to the plight of young Traveller children living in Third World conditions and to the tragedy of the homeless children. The plight of young homeless people and the dangers which they face is an issue which the Government take very seriously. As the House is aware, the Taoiseach recently gave the Minister of State at my Department, Deputy Flood, special responsibility for the co-ordination of child centred services. One of his first tasks is to expedite a number of projects which will provide additional accommodation for homeless young people. A number of initiatives in this area have recently begun to come on stream in Ballymun and Tallaght and negotiations concerning a number of other projects are at an advanced stage. I have asked the parties concerned to make every effort to expedite this process and would hope that most of the additional places would become available during the summer. A number of other longer term projects are also planned, some of which should come on stream towards the end of the year. I will be keeping the situation under close review and can assure the House that the Government are committed to doing all that they can to bring an end to the plight of young people sleeping rough on our streets.
I am delighted that the legislation dealing with the recognition of foreign adoptions has been enacted as the Adoption Act, 1991. This legislation sets out new statutory procedures for the recognition in the State of adoptions effected abroad. While the legislation was framed primarily with the Romanian adoptions in mind, the provisions will apply to adoptions granted in countries throughout the world.
Given the scale on which Irish people are travelling abroad to adopt children, it is clearly desirable that the law here should be clear and explicit with regard to the circumstances in which such adoptions are entitled to recognition. It is equally important in the interests of the children concerned that there should be proper procedures to regulate the adoption of foreign children by Irish residents. Children involved in inter-country adoptions are particularly vulnerable and those countries where the adopting parents reside have a special responsibility to protect the welfare of the children by ensuring the suitability of the proposed adopters is properly assessed beforehand. I believe that the new legislation achieves these objectives and that it provides a secure legal framework for the adoption of foreign children by Irish residents.
The problem of drug abuse is one which is a matter of deep concern to all of us. I am determined that every effort should be made to ensure that this problem is controlled in as effective a manner as possible. Past responses to drug misuse problems have tended to concentrate on supply reduction through a range of legislation provisions and stricter enforcement measures. While these efforts have to a large extent been successful in limiting supply and frustrating the efforts of organised suppliers of illicit drugs, they can only be fully effective if operated in tandem with comprehensive demand reduction policies based on education, treatment and occupational rehabilitation.
When I reconstituted the National Co-Ordinating Committee on Drug Abuse in May last year I asked them, as a matter of urgency, to develop a set of recommendations which would form the basis of a national strategy to prevent drug misuse, covering all aspects of the problem and in particular demand reduction. The recommendations of the committee formed the basis for the Government strategy to prevent drug misuse. The strategy recognises that there are no easy or instant solutions available to us in our struggle against drug misuse, and recognises existing deficiences. It sets out realistic and achievable targets in relation to data collection, demand and supply reduction, including education and increased access to treatment and rehabilitation programmes, underpinned by a co-ordinated structure, at both national and regional levels, geared towards their effective implementation. It involves much greater emphasis on community-based services and introduces, for the first time in Ireland, the concept of community drug teams, drawing on the expertise of general practitioners and other health and social services professionals working in the targeted communities with serious drug misuse problems, in addition to proposals on strengthening the legal provisions available in the area of supply reduction.
The health status of this country leaves much to be desired. The folowing examples provide graphic illustration of this point: 12,000 deaths annually are as a result of coronary heart disease or stroke. Many of these deaths are premature and preventable. The number of deaths from coronary heart disease and stroke for males in the age bracket 30-69 is 336 per 100,000 — the corresponding figure for Italy, Spain, Belgium and France is under 150; 63 per cent of adult male and 48 per cent of the adult female population are overweight and 5,000 deaths annually are attributable to smoking.
The Irish lifestyle is implicated in many of the poor status indicators to which I have just referred. A major focus of health promotion policy is the development of pilot health promotion projects which form part of a national plan for health promotion intended to ensure that the Irish population has a quality and quantity of life on a par with the best health status in Europe.
Significant funds have been invested in the development of the lifewise programme. This programme is a health education programme for adults aimed at promoting healthy behaviour and providing individuals with the skills, information and motivation to develop a healthy lifestyle. The programme has been piloted in the Mid-Western Health Board area, and because of its success to date, a number of other boards, along with the Irish Countrywomen's Association, have asked to be party to the programme. A national structure to oversee the development of the lifewise programme and to ensure its quality is being developed.
Alcohol abuse, particularly among young people, continues to be a major source of concern. The recent report of the psychiatric hospital services indicates that 25 per cent of admissions are due to the abuse of alcohol. Unfortunately many of the people admitted to hospital because of the abuse of alcohol are young people. I was pleased last year to launch a drink awareness programme for young people. This programme is a joint initiative between my Department and the National Youth Council of Ireland and it aims to provide young people with personal and social skills necessary to make responsible decisions regarding their use of alcohol. A nationwide training programme for youth leaders and other persons involved with youth is now under way and 350 people have been trained to date.
A number of other initiatives in alcohol education are also being pursued. However, a broader focus is required to tackle the problem of alcohol abuse. Measures necessary to address the problem are multi-factorial and are encompassed within the remit of a number of Government Departments and statutory and voluntary agencies. In pursuance of a broadly based policy on alcohol, the Government decided that the Advisory Council on Health Promotion should develop a policy which will address broader economic, social, educational, cultural, and health factors which impinge on alcohol use, including the problem of underage drinking. The council have recently commenced a major consultative exercise in pursuance of the formulation of the policy. I hope to receive a draft national alcohol policy by the end of the year.
Reducing the number of people who smoke and especially preventing younger people from taking up the habit remains a priority in my Department. On Shrove Tuesday I launched the 1991 anti-smoking campaign. The campaign includes a multi-media advertising campaign which highlights the dangerous and disgusting nature of the smoking habit, particularly in relation to young people, a schoolbased information campaign, and a general practitioner-public health nurse pack which will be developed during 1991 to assist such professionals in their practice to adopt a more focused anti-smoking approach. In addition, I am confident that the Government decision to increase the price of a pack of 20 cigarettes by 10 pence in the January budget will help significantly in reducing the number of people who smoke.
The recovery plan introduced in January 1989 by the Voluntary Health Insurance Board has been a success and reserves are now moving back towards an appropriate level. The principal nature in the recovery plan were subscription increases; some reductions and restrictions in benefits and cost containment measures, particularly hospital cash limits. From 1 March 1991 the VHI introduced their new full cover system under which, in return for increased fees, participating consultants agree not to charge additional amounts to patients.
The present position in regard to participation in the scheme by the different consultants is as follows:
radiologists — 78 per cent are participating
physicians — more than 50 per cent are participating
pathologists — 99 per cent are participating
anaesthetists — negotiations are not yet concluded
surgeons — 15 per cent are participating.
The VHI expect that the numbers of participating consultants will continue to rise and they will persevere with their efforts to boost participation.
I am confident that following the positive trends inherent in VHI's affairs in the past 18 months, VHI, with my support, will continue to offer at reasonable cost and on equitable terms, health insurance to all those who wish to avail of it. Private health insurers in other countries, in contrast, do not offer health insurance cover on equitable terms but rather, operate on a principle of charging older and more vulnerable subscribers higher premia than the young and healthy low risk categories.
The proposed liberalisation of the insurance market, including health insurance, in the move towards the EC Single Market by January 1993 could have implications for VHI operations. In view of the serious consequences for Irish health services generally, my Department have made a submission to the EC outlining the particular circumstances of the Irish health services and seeking to maintain community rated health insurance, that is the type of schemes operated by VHI, as the only type of health insurance available on the Irish market. I am hopeful that we will be successful in this regard.
I made reference last year to the commencement of the first review of this contract for GMS doctors and to the unique opportunity it provided for an assessment of its operation. The review has been completed, under the chairmanship of Mr. John Horgan, former Chairman of the Labour Court and his report has been considered by both the Irish Medical Organisation and the management side. The report contains a number of recommendations both in relation to the interpretation of specific clauses within the contract and to the operational aspects of others, as they affect the overall effective and efficient operation of the scheme. I am satisfied that the review recommendations are a fair interpretation of the manner in which the contract was originally intended to operate and, taken as a package, will serve to strengthen the commitment of all those involved in its operation to develop the full potential of general practice.
I am particularly pleased that a satisfactory arrangement has been agreed on the matter of establishing a tax effective GMS pension plan. It is expected that the scheme will be in operation very shortly. The resolution of this matter has allowed the Irish Medical Organisation to complete their consideration of the review report.
I have previously mentioned in the House my concern regarding the need to control costs within the GMS scheme and, in particular, my disappointment with the growth pattern in the volume of prescribing medicines.
The total expenditure on drugs in 1989 was £107, million, an increase of 15.9 per cent on the previous year. The total ingredient cost of drugs rose by 18 per cent, of which approximately 6.5 per cent was due to price rises and 11 per cent was due to volume increases and substitution of dearer drugs. When analysing previous years' figures it was found that a similar rate of volume and substitution increase has been a constant feature of the scheme.
The total expenditure on drugs in 1990 was £114 million, approximately an increase of 6.1 per cent on the previous year. The total ingredient cost of drugs rose 6.3 per cent over the 1989 figure. The latest figures available for 1991 indicate a continuance of this upward pattern in prescribing.
Having regard to the very serious position now reached in relation to prescribing patterns within the GMS scheme, I have recommended to Government that the drug strategy outlined in the GMS review report be implemented without delay.
I am conscious that the strategy involved close co-operation between general practitioners and the health boards. I am confident that this co-operation will be forthcoming from both parties.
The strategy proposed is designed to produce significant drug savings in 1992. I have already introduced some elements of this strategy including the launch of the National Drugs Formulary and the introduction of a repeat prescription facility to the GMS scheme to help curb this growth in the prescription of drugs.
The strategy envisages the establishment of a national therapeutic advisory committee, which will give independent authoritive advice in relation to prescribing both in hospitals and the community. The aim is to encourage the highest standards of treatment through appropriate, safe, efficient and cost-effective prescribing. Other elements of this strategy which I intend to implement with the co-operation of the Irish Medical Organisation and the profession include: enhanced educational measures on drug use and prescribing focused on the general public and on doctors; greater co-ordinating between hospital and community prescribers; improved analysis of prescribing data; better information flows, including those to general practitioners in relation to their own prescribing patterns and costs; better support structures and greater involvement of health boards in the management of prescribing.
Another element of the Government's strategy in this area relates to drug prices. In this regard I am glad to report that the agreement between the Government and the Federation of Irish Chemical Industries completed last August led to a decrease in drug prices of approximately 10 per cent on average in the first year. The significant feature of this agreement is the breaking of the link between Irish and UK pharmaceutical prices. In future price movements in Ireland will be linked to movements in prices in certain EC countries and this will result in a significantly lower price adjustment in August 1991 than would otherwise have been the case.
In 1990 a special allocation of £3 million was made available in the budget for the development of dental and orthodontic services. A similar amount was made available as a special allocation in the 1991 budget. This additional funding has brought about much needed improvements in the adult dental services provided by the health boards and has also enabled improvements to be effected in the orthodontic services. About 24,000 adults benefited from the improvement availability of routine dental treatments in 1990, bringing to nearly 42,000 the number of adults who received routine courses of dental treatment during 1990, while a further 34,000 adults received emergency treatments. The accumulated backlog has been greatly reduced especially for people waiting for dentures.
Two and half thousand children began their courses of secondary orthodontic care in 1990. It is estimated that health boards will be able to provide up to 2,000 new starts in orthodontic treatment in 1991. Priority in orthodontic treatment is being given to children in the most handicapped categories in accordance with guidelines issued by my Department in 1985. Recently the conditions and salary attached to the post of consultant orthodontist with the health boards have been revised by my Department to make the post much more attractive. Vacancies in the health boards were recently advertised by the Local Appointments Commission and I am very hopeful that a number of suitable candidates will come forward. Appointments to those vacancies will enable further improvements in the orthodontic services to be carried out. As well as the recruitment of consultants, a number of dentists in health boards are being trained to treat the less serious orthodontic patients under supervision. This will also help considerably in reducing waiting lists.
The increased level of funding for dental and orthodontic services provided in 1990 and 1991 has brought about significant improvements in the dental services. Dental care provision for handicapped persons is a priority area. The creation of the new full-time post of consultant in dentistry for handicapped children and young adults — centred in the Dublin area, but which will provide a national service — will result in great improvements by making specialist level treatment more widely available and by training other dentists and dental students to treat these special patients. The newly created grade of dental hygienist will make a significant improvement to the amount of dental care available for eligible children and adults. I am also engaged in discussions with the Dental Council concerning the creation by the council of a grade of denturist who may legally supply dentures to members of the public.
Good dental health requires that there be a combination of preventive and treatment programmes available to the community, the mix depending on the amount of dental disease already present. Where effective and efficient preventive programmes are in place there is less reliance on expensive treatment programmes. I might mention here that a number of studies show that across a wide range of parameters there has been a steady improvement in levels of oral health. Goals set in 1984 for the year 2000 will have to be revised as a number of these goals have already been exceeded for some age groups. Nevertheless, much remains to be done. Careful planning is required to maximise the resources available. My Department are currently preparing a dental plan which will set goals for oral health for each age group in the population to be achieved over the next decade.
The fluoridation programme continues to be a cornerstone of our preventive programme. This programme is carefully monitored at health board and at Department level. About 65 per cent of the population are served by water supplies which are flouridated. While there has generally been a significant decrease in the level of dental caries in children, surveys show that this decrease has been most significant in children who had been lifetime residents of fluoridated areas. Some of the plant dates from the setting up of the fluoridation programme over 25 years ago and the need for replacement is constant. A sum of £200,000 was provided in the 1991 Budget for the provision of new plant and for the replacement, as necessary, of existing plant.
I have already referred to the services for mental handicap and the very substantial improvements that have taken place. When Deputy Ferris raised the issue I responded to it. I have referred to the fact that we now have in place a very good programme and I referred to the report of the working party and the provisions in the Programme for Economic and Social Progress.
Our psychiatic services have continued to develop along the lines recommended in the report Planning for the Future. This report recommended a service which was comprehensive, community oriented, sector based and integrated with other health services. The implementation of the policy outlined in Planning for the Future has involved a fundamental reorganisation of our psychiatric services from the traditional institutional approach to one where the emphasis is placed on treating people to the greatest extent possible in local community settings without the disruptive effects of hospital admission. It is encouraging that the hospital population has reduced from 30,000 in 1958 to fewer than 8,000 at present and there has been a very substantial reduction in the last five years of 4,000, from 12,000 down now to 8,000.
I am glad to be able to report that health boards are continuing to make progress in providing community psychiatric facilities. Since Planning for the Future was published in 1984 the number of day hospitals and day centre places has tripled and the number of hostel places more than doubled.
In the past year substantial progress has been made in integrating acute psychiatry with the general hospital system. Acute psychiatric units have been opened at Cavan and Tralee general hospitals and it is intended to open similar units at Naas and Roscommon hospitals later this year. A new community based psychiatric service is being developed by the Eastern Health Board at the Mater Hospital for north Dublin city and as part of this service it is intended to open a new psychiatric unit in the Mater in 1992. Other significant service developments this year include the development of a community psychiatric service in Roscommon, Kildare and north Tipperary and the improvement of facilities at the Central Mental Hospital.
As I indicated to the House on 26 February last, the Government are committed to assisting health boards and agencies to continue to maintain bed availability of 12,000 beds in 1991.
While special earmarked funds were allocated at the end of 1989 to effect improvements in the average waiting times for identified "blockspot" areas, for example, orthopaedics, children ENT services, open heart surgery, the overall strategy of the Department is to concentrate on getting the maximum return from every pound invested and rigorously seek efficiencies where they can be found. Only when this has been achieved should the question of additional funding be considered to finance needs and not demands.
The third report of the Kennedy Group which I have recently received contains a number of very important recommendations regarding in-patient waiting lists and out-patient services. It does not accept that it is merely a question of allocating more resources in an undirected manner to either or both of these problems. Rather it makes a series of detailed recommendations on a lengthy number of steps which should be taken by each hospital before it is in a position to demonstrate that it cannot provide an adequate service with the resources already available to it.
In relation to waiting lists, the report recommends that initially all waiting lists be validated. Each hospital should maintain comprehensive, standardised information concerning the numbers and types of patients awaiting admission. Validation to establish reliable waiting list data should be adopted as a firm policy in each hospital and such policies should ensure that appropriate management and clinical action is taken on foot of such reviews.
Hospitals should also immediately carry out a bulk postal review of patients who have been on a waiting list for more than an agreed period of time. On completion of this comprehensive review and validation of current waiting lists, formalised regular arrangements should be made by each hospital for the ongoing review and validation of lists. This approach is not standard practice in all hospitals at present and until it is, data relating to waiting lists should be treated with great caution.
The report further recommends better scheduling of activity to reduce waiting times, analyses by hospitals to establish whether their activity levels, having regard to case mix, are broadly comparable with the productivity levels of similar services in other locations, a systematic review of the scope for increasing levels of day surgery for appropriate conditions, development of appropriate information technology and better information to general practitioners with regard to the average waiting times for admission. While the Kennedy Group's recommendations were based on their analysis of the hospital services in Dublin, they have equal validity for other areas of the country.
The third report of the Kennedy Group also makes a number of important recommendations with regard to the organisation of out-patient services. It highlights the need for better appointment systems for out-patient clinics, for a policy for dealing with non-attenders, and for reducing the level of unnecessary return attendances. It makes recommendations on better patient information and it highlights the need to match staff to the particular demands of providing a high quality out-patient service.
These recommendations do not come from a group representative of any single discipline. The group which was chaired by David Kennedy was a broadly based group drawn from all the major agencies in Dublin, including representatives of the managements of the hospitals, their consultant staffs and the general practitioners. The Department will be working closely with hospital managements and staff to implement the recommendations made. Many of these will be applicable in all hospitals.
The Department remain committed to the delivery of a high quality service to patients. Following a detailed analysis of the problems which arise in the delivery of care, the report of the Commission on Health Funding in 1989 recommended greater responsiveness to patients' needs, including an appeals system and the specification of maximum waiting periods. A "patients' charter" specifying a hospital code of conduct covering the information to be given to patients before, during and after treatment is being developed, with a patient feedback mechanism within each hospital with the aim of improving communication and the quality of services within hospitals.
A considerable amount of work has been undertaken on these issues within individual hospitals and it is hoped to progress these matters further, building on the specific range of detailed recommendations made recently by the Kennedy Group.
This will link in with the measures announced in the Government's Programme for Economic and Social Progress to minimise waiting times for patients, to provide comfortable waiting areas with appropriate amenities and to provide patient information leaflets. The programme also refers to the development of the “patients' charter”; based upon the following principles: the right of access to services in accordance with need; the right to considerate and respectful care; the right to privacy; the right to information; the right to confidentiality of all medical records; the right to refuse to participate in research projects; the right to respect for religious and philosophical beliefs; and the right to make a complaint.
In recent months, an extra ten beds were opened in the Mater Hospital so as to bring back heart by-pass activity rates in line with previously agreed target levels. My Department are examining as a matter of urgency ways and means in which to increase this activity further.
My Department entered into a formal agreement with Camberwell Health Authority in March 1991 which provides that all patients referred from public hospitals in this country requiring liver transplantation will be operated on at King's College Hospital, London. Under this agreement, Irish medical staff will be seconded to King's College Hospital to receive appropriate training and experience to enable a liver transplant service to be re-established in Ireland as soon as circumstances allow. The circumstances are not related to funding but to the fact that it is necessary that a certain number of patients need transplantation — approximately 50 patients per year — in order to have a viable transplant programme. As soon as the numbers who need transplantation — unfortunately the numbers are increasing all the time — are sufficient, a programme will be re-established in this country.
A working group representative of the Department, the Southern Health Board and the voluntary hospitals in Cork have been established to draw up a plan for the development of hospital services in Cork city and county for the next decade.
The function of the working group is to seek a consensus on the role of acute hospitals and on the priorities for development. The terms of reference of the group are as follows: 1. to examine the present organisation of acute hospital services in Cork city and county and assess the existing services; 2. to draw up a plan for the development of acute hospital services to include: a definition of the role of each of the acute hospitals in relation to national, regional and local specialties as appropriate; recommendations for changes in the organisation of services to provide a more efficient and effective service for patients; maximum co-operation and sharing of facilities where appropriate between Cork hospitals; identification of priorities for service development; a management development programme for each hospital and the hospitals collectively.
The provision for the health services in this year's Estimate reflects this Government's continued commitment to the provision of a first-class service for our people. Inevitably, while the level of service provided has increased over the past number of years, demand will always outstrip the level of service which we are in a position to provide. This has been the experience in health services in all parts of the world, and Ireland is no exception. This Government's prudent economic policies have played a vital part in the progress which we have made over the past number of years. In the current economic climate it is more vital than ever that this prudent approach be maintained. In such circumstances it is unlikely that it will be possible to meet the all but insatiable demands on the health services — indeed it would be irresponsible to attempt to do so.
As I have said, there are problems not alone in our own country but also in all developed countries in the world, including Britain, France and the United States. I want to assure the House that this Government are committed to a continuing policy of achieving maximum return from the public funds invested in the health services and of measured progress in the development of our health services. There has been very substantial improvement and development in our health services in the last couple of years, and I have already referred to that. We want to continue to provide a high quality service that will respond to the needs of our people.
