Dáil Éireann díospóireacht -
Friday, 13 Dec 1991

Vol. 414 No. 7

Supplementary Estimates, 1991. - Vote 41: Office of the Minister for Health.

Minister for Health (Mrs. O'Rourke)

I move:

That a supplementary sum not exceeding £50,438,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1991, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that office, including grants to health boards, miscellaneous grants, and a grant-in-aid.

On 26 February 1991, my predecessor Deputy O'Hanlon outlined to the House the Government's policy regarding the management of the health services in 1991. The policy, as outlined in February, was based on a number of key principles, including: the maintenance of services at a level not less than that which was approved in respect of 1990; the provision of assistance to health boards in meeting the cost of demand-led schemes where these proved to be higher than initially anticipated; and the pursuit, by health agencies, of all possible opportunities to maximise the use of available resources prior to the consideration of additional funding. We remain committed to those principles.

Given the current economic situation it is vital that all sectors of the public service contribute to the containment of expenditure at levels consistent with our economic targets. To this end, a package of corrective measures was introduced in July of this year. This Supplementary Estimate is net of savings achieved as a result of that package of measures. Despite the acute pressure on the public finances the Government are honouring fully the commitment which they made in relation to the funding of the health services in 1991.

I would now like to refer briefly to the main elements of the Estimate before the House. This year, for the first time, the cost of all the schemes, generally regarded as demand-led, has been included in one subhead of the Health Vote-subhead G.2. This subhead provides for expenditure on: disabled person's (maintenance) allowance; disabled person's (rehabilitation) allowance; capitation fees to vocational rehabilitation centres; mobility allowance for handicapped persons; infectious disease (maintenance) allowances; blind welfare allowances; long term illness scheme; drug refund schemes; domiciliary care allowances for handicapped children, and maternity cash grants.

The boards are statutorily compelled to meet the costs incurred by every person who establishes eligibility under the various schemes. In addition, changes in the manner in which eligibility for the disabled person's maintenance allowance is assessed coupled with the changes in the social welfare code have led to an escalation in the cost of this scheme. These schemes have, therefore, put a lot of pressure on the resources of health boards.

Expenditure under the disabled person's maintenance allowance has increased due to an increase in the number of recipients. This has arisen mainly from the introduction of the equality legislation in 1989 and the outcome of the Healy case which established the right of spouses to claim the allowance in their own right. The effect of these combined, has resulted in a greater number of spouses claiming DPMA both at the full and reduced rates. The number in receipt of this allowance has increased by some 5 per cent over 1990 levels.

Prescribing trends in the drug schemes have shown an upward trend during 1991 resulting in higher than anticipated costs in these schemes, notwithstanding savings which have been achieved through changes in the drug refund scheme. The expenditure trend of the long term illness scheme has been influenced by the drug prescribing patterns evident in the general medical services scheme. While the number of persons covered has increased by some 3 per cent to about 47,000 persons, the main factor responsible for the increase in the cost of this scheme is the increase in the cost mix of drugs prescribed, from less expensive items to newer, more costly, items.

The drug refund scheme has been affected in a similar way by a change in the drug prescribing mix. In addition, the drug cost subsidisation scheme, which was introduced in 1990 to alleviate the circumstances of patients requiring medication for an extended period, now covers some 19,500 persons compared with 12,000 on commencement of the scheme.

Because of the increased expenditure on these schemes and to make provision for the bonus payments in December, an additional provision of £8.6 million is being made available to health boards. I am pleased to be in a position to provide this assistance to the health boards, thus avoiding the need for health boards to reduce expenditure on other services in order to meet these costs. This is a significant development in the arrangements for the funding of health boards and eliminates one of the major budgetary uncertainties which have affected the boards in recent years.

A feature of modern health care is the increase in the range and scope of medical conditions amenable to treatment. A number of these treatments are highly specialised and it is not always feasible to provide them in this country. We are continuing to support hospitals in keeping abreast of medical developments, as in the case of liver transplants. Nevertheless, the need to send patients abroad to receive specialised medical care has increased considerably in recent years, although the overall numbers are still relatively small. An additional provision of £1.3 million is being made available in order to meet the costs incurred in 1991.

Earlier this year, following a series of discussions with the Irish Haemophilia Society regarding the plight of those haemophiliacs who had contracted the HIV virus, the Government decided to provide further financial assistance for haemophiliacs. The House will recall that a sum of £1 million was allocated by the Government in 1989 and this sum was disbursed to individuals and their dependants through the HIV-haemophiliac trust.

This year the Government approved the provision of further assistance of £8 million. Certain aspects of the Government offer required to be cleared by the High Court. This has now been done and I am pleased that, as agreed with the Haemophilia Society, the first payments are being made this week. The balance is due to be paid early in 1992. A total of 102 persons and/or their dependants will benefit from the settlement. Under the arrangements agreed with the Irish Haemophilia Society and its legal advisers, the £2 million to be paid this year, which is provided for in this Estimate, will be divided equally among the claimants. The balance of £6 million will be paid early next year.

This Estimate makes a provision of £1.5 million from lottery funds in respect of capital expenditure on essential equipment replacement. It will be used to fund a range of top priority items, including the provision of a replacement cobalt unit and major X-ray equipment at Cork Regional Hospital. Following the failure of the cobalt unit at Cork Regional Hospital earlier this year, it was necessary to make immediate arrangements for the ongoing treatment of some Cork patients at St. Luke's Hospital in Dublin. Arrangements are currently in place for the provision of this specialised treatment and additional funding will be available to cover the cost to St. Luke's. The commissioning of the new cobalt unit in Cork will bring a welcome end to this necessary but somewhat difficult arrangement for patients from Cork. I am, of course, very grateful to the staff of St. Luke's for the care and dedicated attention given to those patients. The capital provision in this Estimate will also be used to fund the purchase of operating theatre and anaesthetic equipment in a number of hospitals. I am very much aware of the need for additional funds for the purchase of new and replacement equipment and I hope to reflect these priorities in the allocation of capital in 1992 and subsequent years.

An amount of £17 million is included in the Supplementary Estimate to meet the additional expenditure of the general medical services scheme. This will bring the provision made for this purpose in 1991 to £172.712 million. This compares with an initial provision of £155.7 million.

The major contributory factor to the increase has been the continuing escalation in the cost of drugs prescribed. The cost of drugs has continued to increase, despite the price reductions which resulted from the agreement with the Federation of Irish Chemical Industries, negotiated in August 1990. The major cause of this increase in costs is the prescribing of newer, more expensive drugs, rather than an increase in the volume. There are several reasons for the increase, including accelerating advances in treatment therapies and the diffusion of sophisticated drugs and medicines from tertiary hospitals into the community. Despite this trend, we are still relatively low prescribers when compared with other EC countries, but we must continue to identify and realise opportunities for savings in the total drugs bill. In the February review of the GMS scheme several of those opportunities were identified and they are now being implemented.

The National Therapeutics Advisory Committee have been established, a particularly important initiative. The committee, representative of hospital doctors, hospital pharmacists, general practitioners, community pharmacists and management, are charged with examining all factors involved in influencing prescribing; advising on mechanisms to bring about greater co-ordination and offering professional advise to doctors on cost-effective prescribing. I ask everybody involved to work together to make the best use of the resources available. The Government are considering other initiatives in that respect.

The major commitment given by my predecessor on behalf of the Government last February related to the maintenance of services in acute hospitals at the level approved in respect of 1990.

The additional provision being made in this Estimate for acute hospital services is £15.458 million, which is made up of the £7.713 million contained in subheads G.1 and G.4 and the freeing up of £7.745 million in subhead G.1 as a result of the provision of additional lottery funds under subhead G.9. The health boards and hospitals have been able to maintain their bed levels, as I said earlier in reply to a Dáil question——

Mr. R. Bruton

What does "freeing up" mean?

Mrs. O'Rourke

It means freeing up. I shall answer the Deputy when I reach the issue under subhead G.9. I consider the term to be a very simple one to understand; the Deputy does not understand it.

In addition to maintaining the level of service which was promised at the beginning of the year, it has been possible to effect some improvements in the range and quality of the service.

I shall now refer to what the Government have been able to do. It may seem a little odd that I have to rush through my contribution, but I am told I have only 20 minutes available to me.

An Leas-Cheann Comhairle

That is correct.

Mrs. O'Rourke

That is why I am galloping; I would much prefer to speak more slowly.

Work on the new hospital in Waterford commenced in 1987 and is due for completion in 1993. I would love to dwell on this rather good subject. Improvements have been effected in Waterford, Wexford, the Mater Hospital in Dublin and work is under way at the Rotunda Hospital. In south Dublin in 1991 phase 1C of the development at St. James's Hospital was commissioning.

In relation to the Mid-Western Health Board, resources were made available to enable the planning of much-needed developments at Limerick General Hospital and appointments to Ennis General Hospital. Provision has been made for the development of a consultant-led geriatric service and the accident and emergency and physiotherapy services at Ennis have also been improved.

Members will notice the modesty of the Midland Health Board. In August of this year approval issued to the Midland Health Board——

(Interruptions.)

Mrs. O'Rourke

——for the planning of two new theatres at Tullamore General Hospital.

In this short review of acute hospital services in 1991 it is appropriate to refer to the work of the Dublin Hospital Initiative Group, chaired by Professor Kennedy. The House is well aware of the group's excellent work and the various reports they issued. There were three reports: the first report contained a series of recommendations in relation to the implementation of "best practices"; the second report dealt with the organisational structures in Dublin and the third report dealt with out-patient services, the management of in-patient waiting lists, referrals of patients and geriatric services.

Professor Kennedy was subsequently invited to chair a new advisory group, who have already met and who will oversee the implementation of the recommendations of the Dublin Hospital Initiative Group in relation to acute hospital service issues, particularly regarding out-patients and waiting lists. The group will also advise me on other matters relating to the future development of hospital services in the Dublin region. I am very pleased indeed that the group have been set up and have held their inaugural meeting. I thank them for agreeing to act and I wish to keep in touch with them in relation to their various reports. I pay tribute to them for the work they have done.

The Estimate provides £170,000 for consultancy services. That expenditure arises in the finalisation of the work on hospital efficiency which concentrated on hospitals in Dublin and Cork. The recommendations made in the report are being implemented through a high level steering group with the assistance of the consultants who prepared the report.

Particular emphasis has been placed this year on the necessity for health agencies to achieve greater value for money individually and collectively. I am glad to be able to inform the House that the health boards and hospitals have responded very positively to the initiative. The concept of value for money now forms an inherent part of the management culture of the health services.

The steering group established by my predecessor are continuing to work closely with hospitals and will also work closely with the recently established Mercy/Charity Healthcare Company, and I am satisfied that in general this co-operation and collaboration will continue to move forward in this sphere.

The health board value-for-money coordinating committee established earlier this year have met on a regular basis. They aim to achieve better purchasing power in many fashions and I understand that the purchasing performance of health boards is improving. The committee will continue to receive the support of the Department.

I am also pleased that the concept of collective action has been adopted by the Federation of Voluntary Bodies Providing Services for People with a Mental Handicap through the establishment of a pilot study group comprising four organisations.

Cross-Border co-operation continues to be a priority in our efforts to maximise efficiency through collective action. A series of initiatives is being pursued with our colleagues in Northern Ireland, notably in the area of equipment purchase. That is a very interesting development. I know my predecessor, Deputy O'Hanlon, enjoyed a fine relationship with his opposite number in the North of Ireland. I have heard from Mr. Jeremy Hanley and hope to meet him shortly. When I held the Education portfolio I enjoyed a similar relationship with Dr. Mawhinney and later with Lord Belstead. In the wider political sense and in the narrow health sense, it is very important that the contacts and ties continue.

The lottery provision is being increased by £9.745 million. As I already explained, £7.745 million of this amount enables my Department to free up an equivalent amount under subhead G1 towards the cost of acute hospital services under health boards. It does not mean that there are additional funds now available in 1991 for grants to voluntary welfare agencies. It is a substitution of lottery for Exchequer funding.

In addition, £2 million is being provided from the lottery in respect of payments to be made to haemophiliacs. I have already dealt with that matter.

The Estimate also includes a provision of £4.5 million in respect of a shortfall in appropriations-in-aid of the Health Vote which results from a lower than anticipated level of receipts from health contributions. This does not, of course, increase the gross level of expenditure which can be incurred under the Health Vote in 1991.

I am pleased to recommend the Estimate to the House. It is clear evidence of the Government's determination to meet fully the commitments made to the health services and to cope with the difficulties which have arisen for the services during 1991. I know that it has been a difficult year for those managing and delivering the services and I hope they will see in the Estimate a very clear expression of the good will and concern which informs the Government's policy in relation to the health services.

Although I have had occasion to deal with health matters in Private Members' Business and replied to Dáil Questions in relation to the Health portfolio, on this formal occasion I pay tribute to my predecessor, Deputy O'Hanlon, for his four years and eight months' dedication to the cause of health, for the service he gave the country and for his commitment to the provision of high quality health services.

I should now like to speak briefly on one other matter, although it does not exactly form part of the Estimate. Since the beginning of September, as the House will know, the accident and emergency services in the six main Dublin hospitals have been operating under a rota system whereby each hospital is off call after 5 p.m. for one week in every three. At the introduction of the new rota a firm commitment was given that the effects of the new arrangements would be monitored closely by my Department in consultation with the Eastern Health Board steering group on the accident and emergency services.

This steering group is made up of the chief executives of the hospitals concerned and their accident and emergency consultants. A detailed report on the operation of the new rota has been submitted recently with the unanimous recommendation that all six hospitals revert to the 24-hour on-call arrangement because of the difficulties that have emerged under the new rota. The group have stated that while overall activity levels were maintained, difficulties emerged in maintaining satisfactory levels of service because of peaks in attendance during the on-call weeks. Furthermore, elective, that is planned, hospital admissions and out-patient clinics have been affected in hospitals during their on-call weeks. In the light of the experience of the arrangements introduced in September 1991, the Government have decided that there should be a reversal to a 24-hour on-call arrangement for all six hospitals. My Department will be meeting the six hospitals to discuss their service plans and priorities having regard to their financial allocations for 1992. Of course, the hospitals will be required to live within their overall allocations for 1992 and, in this context, they will have to address the relative priority and balance between their emergency services and the level of the other services they will provide. I will be asking the Eastern Health Board Steering Group, to which I have referred already, to review the operation of the revised accident and emergency arrangements and to report to me at the end of March.

I commend the Supplementary Estimate to the House.

Mr. R. Bruton

As this is her first formal Estimate I should like to welcome the new Minister to her office. However, if she were to ask today how we are doing in the Department of Health, I am afraid I would have to say that the present year she is reviewing has been one of disastrous mismanagement by Government of the health services.

It is a year in which the Government have lost their grip on the management of this crucial sector. One need only revert to the January budget when the then Minister, despite the protestations of all of the health agencies under his charge that they did not have sufficient money to keep their basic services going, denied that that was the case and insisted on under-budgeting the services. As predicted, by July the health budget had gone completely off the rails and the Government then reponded with a completely reckless programme of retrenchment.

The House will recall that the Government launched an illegal dawn raid on £3 million from subscribers to the Voluntary Health Insurance Board, virtually dismantled the drug refund scheme, as a consequence of which many low income families who sustained an illness found they would have to spend up to £180 on drugs without any refund of those costs. In effect, this scheme not only created hardship but deepened the poverty trap about which the Government so frequently say they are endeavouring to do something.

The worst decision of all was their mindless policy of closing two of Dublin's major hospital casualty departments every night. I am glad to note that the present Minister finally acknowledges this was a disastrous decision that did not save any money and brought admissions in Dublin hospitals to a virtual standstill.

I would have to say to the Minister that it is serious when her Minister of State came into the House not one month ago and assured the House that elective admissions were up, that everything was running well as a result of that change. To treat Members of the House to that sort of padding and misleading information is just foolishness on the part of the Department and the Minister of State. We are not children; we know the problems. If one is taking a new approach to health the first thing one should do is have a little honesty with people as to what is happening.

Mrs. O'Rourke

Excuse me, I have now been accused of dishonesty.

Mr. R. Bruton

No, I did not accuse the Minister at all of dishonesty.

Mrs. O'Rourke

I want to put that on the record.

Mr. R. Bruton

I refer to a reply to a parliamentary question on 12 November 1991 by the Minister of State, Deputy Flood, in which he——

Mrs. O'Rourke

That is different.

Mr. R. Bruton

——indicated, if the Minister would only listen, that the overall level of elective admissions had been maintained and improved.

Mrs. O'Rourke

Will the Deputy get to his dishonesty remark.

Mr. R. Bruton

That is dishonest. The Minister came into the House today and told us that the elective schedules had been completely disrupted.

Mrs. O'Rourke

I came in today and said I had the report of the steering group——

Mr. R. Bruton

——which had reported then. On 12 November the Minister of State said; as reported at column 1250 of the Official Report:

The Minister for Health recently received a report on the operation of the Dublin accident and emergency service since the introduction of the revised rota on 2 September, 1991.

Mrs. O'Rourke

Which I have now had an opportunity of studying.

Mr. R. Bruton

Sir, may I have the facility of continuing my speech without interruption from the Minister?

Acting Chairman

I am going to ask the Minister not to interrupt the Deputy, but I ask the Deputy also not to use what I might describe as unparliamentary language, such as dishonesty, lies.

Mr. R. Bruton

I am only quoting from something——

Acting Chairman

Before the Deputy continues to quote, perhaps he would not use the word "dishonesty". Will the Deputy continue with his speech?

Mr. R. Bruton

Those are two flatly conflicting statements on the part of two members of the Government.

I should like now to pass on to the present position in the Department and their approach to the management of these services. It is very disappointing that the Department appear to have lost any real knowledge of what is taking place in the services themselves. I have tabled a series of parliamentary questions to the Minister's Department: for example, seeking the number on waiting lists, when the Department were unable to provide that information; whether the Department would outline the level of capital spending on facilities for those with a mental and physical handicap, when the Department were unable to outline the information; a question about the capital projects assisted from the 1991 public capital programme, the projected cost, the allocations made, asking what work remained to be done on these projects, when the Department were unable to provide the information. Again, I sought information on waiting lists classified in different procedures when the Department were unable to provide the information. Another had to do with one of the big issues facing our health services at present, that of medical liability, when the Department were unable to provide the relevant information.

This is becoming a growing feature of Departmental attitude to parliamentary questions in this House, it is a very disturbing one. I wonder whether it is that the Department do not know or do not want to let on because earlier this year the Government were willing to indicate detailed figures with regard to waiting lists. In April I recall they indicated a number of 1,700 people awaiting hip replacements, 2,500 awaiting tonsillectomies, 3,000 for cataract operations, 1,000 for heart by-pass operations, all hard figures we were able to debate in the House. Now the Government will not provide those figures. The reality is that the Department are shying away from the financial and service realities created as a result of the 1991 budget.

What has happened in real terms in 1991 is that the health boards and agencies under the Minister's control were given an extra £40 million, that is the health boards and various voluntary hospitals, to run their services. They had absolutely no chance of maintaining their services with that sum. For a start they were committed to normal pay increases to their staff of £45 million — that was an increase in pay they had to meet which alone would have absorbed all of their allocation — but, in addition, they were committed to £30 million in special pay increases. Before one even begins to allow for the rising costs elsewhere in their non-pay elements, the health boards and agencies were down by a sum of £35 million. That was a real cut in their services provision of 5 per cent. It is no wonder we are seeing growing waiting lists, the special care institutions with growing lists, the community health services being subjected to increased strain with no opportunity or possibility of developing these to meet the rapidly emerging needs such as the AIDS crisis.

Those are the hard facts the Government have attempted to conceal. For example, the Government announced they would maintain the level of services in hospitals but when one examined what they meant it transpired that what they meant was that they would keep on paper 12,000 beds in the system. They ignored the fact that prolonged seasonal closures were to be a feature in all those health agencies. Those prolonged seasonal closures reduced the ability of hospitals to deal with their elective waiting lists.

I will take just one example, that of the Mid-Western Health Board which, in the second half of this year, took out of their system 10,500 patient days, thus increasing their waiting lists — giving that the average hospital stay is five or six day — by approximately 2,000 patients. That is in one of the shortest lists where the waiting time for hip replacement is two and a half years. The same is true of every other health board. These waiting lists are often being concealed. People who want an assessment for surgery have to wait longer and longer before they can see a consultant and have the possibility of joining the end of a waiting list.

The Government have repeated year after year that they are committed to providing resources to develop community care. They have not done so this year. The Programme for Economic and Social Progress refers to real increases in spending of £90 million over the next seven years and a gradual shift of resources from in-patient institutions to community services. The year 1991 saw a real decline of £25 million in the provision for community care, a dramatic reversal from the target. Contrary to the Government commitment we saw a decline in the share of health spending going to community services as against acute hospital services.

That is the reason that a growing number of persons with mental handicap are in urgent need of residential placement. The list in the Eastern Health Board area has grown by 50 per cent in less than a year. Carers rightly feel neglected and bitter at the failure to provide resources. They have to provide care day after day, well beyond normal breaking point. There are literally thousands who have been deemed in need of residential care which is not available for them.

The voluntary agencies have been badly treated this year. Not only have their budgets been cut but the health boards have adopted the practice of delaying payment of their cheques for up to six months. This puts a huge strain on voluntary agencies and on suppliers, who face the same delay. The consequence is that next year suppliers when tendering will build into their estimates substantial increases because they know they will not be paid for six months. It is storing up a problem for the coming year. The national lottery has sucked £50 million out the budgets of voluntary agencies by depriving them of their fund raising capacity and it has put back a mere £3 million. It is idle to talk of charters for these voluntary agencies when this is their experience.

During the election campaign in 1989 the scales finally fell from the Taoiseach's eyes with regard to the crisis in the health services. The same message is waiting for him and for the Minister if they care to listen. A very insidious development in the way we are funding our health service is the notion of special allocations from the national lottery. The health boards have been bearing real cuts for a number of years in their overall provision but then on budget day a few million pounds is given by way of special allocation. These sums do not go a tiny fraction of the way to honour commitments made or to compensate for the cuts. The Government are trying to get praise by splitting the cuts and making a small allocation after the budget. Far worse is that the health agencies cannot plan on the basis of these sorts of allocations because they do not know from year to year if they will continue. They are trying to develop a long term plan which will see a gradual build up in community care, but that is not possible under these special allocations. It conflicts with good management of our health services.

Another foolish decision this year was the extension of care to the top 15 per cent of income earners. These people never asked for public care. It was really an effort to get an extra £20 million in health contributions but it did not contribute to a better health service. It would have been much better to concentrate on the existing public waiting lists. It was a shame that the Government took this decision. It involved this House in much needless debate which did not get to grips with the problems of people waiting for cataract operations, hip replacements and cardiac surgery. It was a hollow gesture which did nothing for the health services.

The Minister's Department have been very strong on rhetoric and the Programme for Economic and Social Progress made pleasant noises about the way our health services should develop. I said in a debate earlier this week that it took only seven days for the Government to renege on the commitment to persons with disability set out in that document. All those other commitments are gradually unravelling. Nurses, particularly those employed on a temporary or part-time basis, have been expecting some recognition of their services. They went to the Labour Court and got a commitment that they would be given recognition and an opportunity for some sort of incremental scale which would give credit for their skill and experience. Now the Government are trying to talk them down. The nursing staff are in the front line trying to deliver services to patients, often in very difficult conditions. It will be a retrograde step if they have to suffer a cutback in their income, which is often very small. They are among the low paid in the health services who are having to bear the brunt.

The Minister remarked that drug costs are out of control. The Government budgeted for a £7 million drop in the drugs bill in the GMS and in the drug refund scheme but there was no coherent policy underlying it. It is not surprising that huge sums have to be put into the GMS to compensate for the foolish undertaking in the original Estimate to bring about dramatic cuts. There was no policy to achieve it. We must consider the fact that drug companies are spending £35 million promoting their products. There is the place to start making savings. That money is not getting through to any patients and it is probably encouraging doctors to prescribe drugs in the most recent brochures.

This has not been a good year for the health services and the outlook for the coming year is probably worse. Deputy Rabbitte will probably speak about the problems in Tallaght where the long suffering people are waiting for their hospital. That is a typical example of our problems. I hope the Minister will take her Department by the scruff of the neck and institute a better management system and a much improved delivery of services to people who wish her well in her job.

Mr. Ferris

The Labour Party are opposed to this Supplementary Estimate because we do not believe it is sufficient to meet the increasing, legitimate and proven demands of the health services.

In the debate on the motion put down by Fine Gael last week I maintained that the area of disability has been shamefully neglected by the Government and I said the Minister for Health should make it a priority to remedy this situation. I have some confidence that the Minister can and will improve the position of handicapped people. In order to do this the Government should increase the resources available in the forthcoming Estimates and next year's budget to implement the recommendations in the report entitled Needs and Abilities which is at present before the Minister. I also said they should provide the minimum capital and revenue resources to meet the needs which have been identified in that report, together with additional resources to make up the shortfall in funding in 1990 and 1991. This shortfall has not been taken into account in the Supplementary Estimate.

The Labour Party have identified that over the three years starting in 1992 the Minister will need approximately £12.7 million in capital funding and approximately £15.9 million in current funding for mental handicap alone. As I said in the debate I mentioned earlier, the major agencies involved in the provision of services for people with a mental handicap — I will communicate the names of the agencies to the Minister — are practically bankrupt and will be seeking urgent meetings with the Minister. I understand from reliable sources that one of these agencies is located in the Dublin area while another works in the western and midland area. These agencies have to deal with a major crisis in funding and are virtually unable to meet their day to day liabilities.

The acute financial difficulties experienced by these agencies have been caused by a starvation of funding from the Department of Health, and indirectly by the Department of Finance and the Government. Each year since 1987 these agencies have been subjected to more and more cutbacks. It has now reached the stage where most of them can no longer manage to maintain their existing services, let alone meet any increasing demands.

The Minister has given a commitment to maintain services at the agreed 1990 levels. However, one cannot run a health service based on statistics. If, for some reason outside our control, there is an epidemic next year and more people need to be hospitalised how will this demand be met if funding is maintained at the 1990 level? This means that, statistically, people cannot get sick. How can one run a health service on statistics like that? The Minister admitted that a mistake was made in relation to the major hospital accident services in Beaumont Hospital and other hospitals in Dublin and has reverted to the original arrangement; we asked her to revert to that arrangement and I am glad she is now doing this.

The position of families who have to care for a person with a mental handicap has greatly deteriorated in recent years, as the report before the Minister graphically demonstrates, there has been a stand still in real budget terms while those with a mental handicap and their families have grown older and their demands more pressing. The same applies in terms of the services provided by the health board. As Deputy Bruton said, all the health agencies and programme managers have been in contact with us about this problem.

There is an article in today's The Cork Examiner written by Eamon Timmins entitled “Health Board Shock”. It states that health boards have debts of between £50 million and £60 million over and above the normal deficits in their current accounts. The problem is so bad that some hospitals have experienced difficulties obtaining the normal deliveries. Small firms in my area rang me to say they are sorry but they cannot supply the hospitals in my area as they are unable to pay their bills. Normally suppliers like to have contracts with health boards who are regarded as good customers who pay their bills when they became due, but because health boards are unable to pay their bills, small suppliers are being put under incredible pressure. These small suppliers are unable to subsidise the cash flow problems of health boards.

This point was taken up in the article by the chairman of the Small Firms Association, Mr. Faulkner, who said that this practice is unacceptable and unethical. That is an extraordinary statement from a person who is responsible for small firms. Surely it is unacceptable from the point of view of the State that major agencies have to issue post-dated cheques which may bounce. This represents gross mismanagement by health boards and the Department of Health from the point of view of patients who at the end of the day, are the people who will suffer.

Reference has been made to waiting lists for essential treatments. It is sometimes forgotten that the people who get to the top of the queue may find it impossible to get a bed in a hospital. This problem is getting worse by the day. It is particularly bad in respect of long-stay patients who need geriatric accommodation. This morning I was contacted by the distraught relative of a person who is being discharged from a district hospital. As no bed is available for this medical card holder in a geriatric hospital, they are being forced to look for a bed in a private nursing home. The Minister's predecessor failed to introduce the necessary measure which would enable health boards make payments to private nursing homes to subvent the cost of looking after old people with medical cards who have given a lifetime of service to this country. Because the State has abdicated its responsibility to these people, their relatives have to go around the country trying to find private nursing homes to take them.

Hospitals are being forced to cut back on bed linen, cleaning, hygiene, nutrition and heating, all the items which make a stay in hospital a little more bearable. Increasingly patients are put anywhere space can be found for them. In some cases non-ambulant patients are put in beds on second or third floors of dilapidated buildings. It is only a matter of time before these patients are put at extreme risk from fire and other hazards. I hope the Minister will take it upon herself to visit some of these institutions which are starved of cash and cannot meet the requirements laid down by county council fire officers and her Department.

There is only one reason the proportion of national wealth spent on health care has been reduced every year since Fianna Fáil came into office in 1987; the proportion of national wealth spent on health care is estimated to be approximately 6 per cent but this figure has failed to take account of the significant growth in GDP. The figure is even smaller now. Since the 1987 election the Government decided to take 4,000 health workers out of the service; introduced charges for services to which people were previously entitled under PRSI; closed 3,000 beds — 2,000 of which were acute beds, 300 geriatric beds and 700 psychiatric beds — closed 24 hospitals, some of which were in my health board area and one in my own town, Tipperary — St. Vincent's Hospital. That was a tragic decision which had been proposed by Fianna Fáil members of our health board. They promised to reintroduce an ambulance station but that promise was never fulfilled.

In a reply to a question the Minister stated that health boards had been given mobile cardiac care units in five or six health board areas but only one was put into operation, in Sligo. In the south east region one such unit was parked in a shed for two years despite the generosity of the Irish Heart Foundation. They are the problems we are faced with. Those statistics are unpleasant but they are facts. Some of the hospitals that were closed have been put to other use. I compliment St. Vincent's Hospital, in my constituency, which is now a very useful day care centre. That is fine but that centre was supposed to be erected on a new site in a new purpose built building before the closure of St. Vincent's Hospital.

The net effect is that £200 million less has been spent on health in the past few years. This Supplementary Estimate will not even cover over the cracks as far as funding the health boards is concerned. It will not stave off the potential bankruptcy facing many of the health agencies or allow for the heating to be turned up in any of our hospitals as we approach the cold weather.

Another matter to which I would like to refer is the fact that the medical council have run out of funds and are unable to continue functioning. To some extent their funds have been exhausted by the long running and very complicated inquiry they are conducting into certain matters in Beaumont Hospital. They may not even be able to complete that inquiry. The Minister will agree that the medical council are a very important body responsible, ultimately, for professional standards in medicine. The point has now been reached where the medical council are unable to do their business. That will result in a crisis in standards which will inevitably be accompanied by a crisis in public confidence. We do not want that. Against this background one of the most nonsensical and even nauseating provisions in the Supplementary Estimate is that of £170,000 for a so-called hospital efficiency review. That is being done at a time when the medical council are in difficulty because they are carrying out an investigation into certain matters in Beaumont Hospital. If one had any relationship with hospital administrators, consultants or matrons who are so committed to the health services one would realise there are very few areas that can be run more efficiently.

The health services are deteriorating before our eyes. Our nursing profession have been shamefully treated to a point where the majority of nurses work under conditions of great physical and emotional stress. In most health boards, and this is well known, nurses have been forced to take unofficial action and work to rule simply because they are unable to cope any longer with the ever-increasing demands made on them. That resulted from the voluntary redundancy offered to the 4,000 health workers in 1987. Those who remained in the services were committed to staying. Because of the inability of health boards to fill vacancies or create jobs in the nursing service, nurses who are left must face extra stress. That will lead to more difficulties unless the Minister addresses the issue of health funding as a matter of priority.

I compliment the people directly involved in the health services, the nurses and doctors, who are extremely committed and who work under tremendous stress and strain. This is the level to which the Fianna Fáil-Progressive Democrats Government have brought our health services. The Estimate provides for a sum of £40 million from the Exchequer and £10 million from the national lottery which will do little or nothing to alleviate the crisis in our health services. I have no doubt that, if and when the Government have the courage to publish the Estimates for 1992, we will find that the picture is even more bleak. We are warned about the doom and gloom of the public finances by every media source, on television, radio and in the newspapers.

I urge the Minister to fight within the Cabinet to ensure that her Department are given priority over other Departments. She should not allow further economic stringencies to be placed on her Department. That is the reason we will be calling a vote on this Estimate. It is clear that the Government have already forfeited the trust of the Irish people in so many other areas and that was confirmed in last night's television opinion poll. If that is the case, they cannot be trusted to look after the health of our people. There is an element of distrust and absolute abdication of any sense of responsibility in health, education, housing and other priority areas.

I look forward to the Estimates honouring commitments given to Tallaght in the past, an area which I had the privilege of visiting with my colleagues, the Minister's predecessor, and the Minister of State. There is an £8 million hole there which is supposed to represent the start of a new hospital complex to service the wider Tallaght area. I look forward also to some improvements being carried out at St. Luke's Hospital, Kilkenny where, because of overcrowding, patients are in the corridors. That could be taken as an underhanded way of ensuring that we do not appoint more nurses.

If we saw the level of nursing care in other countries, within and outside the Community, we would be ashamed of what we have done to some of our people and with what the Government have been allowed to get away with. In February the Minister's predecessor — and rightly so — committed himself to additional funding for disabled persons maintenance allowances, drug refunds and other matters. The problem is that until recently, the Department of Health have failed to reach an agreement with health boards, chief executive officers and chairmen and that has created a cashflow crisis. The health boards are required by law to pay out funds to people who qualify for disabled persons maintenance allowance, drug refunds and so on. They have no control over these issues. We spent eight or nine months arguing with them as to the levels of over expenditure and I am sorry it has created a cashflow crisis which has affected other services and led to a cutback in overtime rates and other problems.

I will not continue to itemise the problems, but I hope the Minister will continue his commitment to this Department. This Estimate does not give me any cause for pleasure or reassure me, but I accept that the Minister has not been there long enough to put her stamp on the Department of Health.

An Ceann Comhairle

I am sorry to interrupt the Deputy, but the time available to him is well nigh exhausted. I would be greatful if the Deputy would bring his speech to a close.

Mr. Ferris

We will oppose this Estimate on the basis that it is insufficient. That is unfortunate because throughout the year we have been asking for money but unfortunately the Minister never answered the call.

Mrs. O'Rourke

I was not here to answer.

Mr. Rabbitte

I congratulate the Minister on her appointment to the Department of Health. I do not know if this Ministry is the most difficult chore that faces the Minister in the New Year, but in any event I wish her well in it.

Before referring to the acute hospitals service I will take up a point made by Deputy Ferris concerning his plea that the traditional neglect of the mental handicap area be addressed by the new Minister. Every Member of the House will agree that this problem in Irish society has been hidden for too long and that eventually the parents of mentally handicapped people were forced to organise themselves, to go onto the streets, to picket this House, to hold meetings adjacent to this House and meetings in the Mansion House attended by almost 1,000 parents, all with harrowing stories to tell about the neglect of the mentally handicapped in our society. They were forced to do this because of their difficulty in dealing with the health agencies, the Department of Health and successive Ministers for Health. I will not relate as anecdotal evidence the kind of stories told at those meetings and I am sure the Minister shares the human sympathy that exists for people dealing with these problems, but it is an area where parents have been left to look after their mentally handicapped offspring or relatives without respite every day of the week. There have been inadequate institutional day relief services and so on. The problem was exacerbated in my part of the city by the long term scandal of the under utilisation of places in Cheeverstown House. That problem seems to be nearing a solution now. It was disgraceful that that facility was only half used for so long.

I agree with the general remarks made by Deputies Bruton and Ferris about the under-provision of resources for health services. I am not arguing that the solution to all our problems in the health service is to throw more money at it, but having regard to the problems that are again manifesting themselves, especially in the acute hospital services, it is clear that we still have a crisis. I hope that if we have a general election, and one seems to be imminent, the Taoiseach will not be able to tell the people that he only learned of it during the course of the general election campaign.

I would draw the Minister's attention to the provision to alleviate the problems in the acute hospital service. Deputies Bruton and Ferris dealt at some length with some of the difficulties, especially the inordinate hardship imposed by the fall back to a rostering system for the accident and emergency services in this city, which was disgraceful. If the delivery of and access to services in the acute hospital system is serious in the areas dealt with by Deputies Bruton and Ferris, can the Minister imagine what it is like in the part of Dublin which I represent where there is no acute hospital? I cannot see how any Minister for Health could, for example, announce a plan to streamline and reorganise the delivery of services under the aegis of the EHB, create five new district areas, each related to an acute hospital, and here we have a population of almost 250,000 people without an acute hospital. How one can reorganise the EHB so that a new district health area is supposed to have as its focus an acute general hospital of any kind, I do not know. When the former Minister announced that plan he did not make any provision and did not explain how it was supposed to function.

Indeed, the air is thick with rumour and comment on scandals in politics and in business, but there is no scandal to compare with the neglect of the people I represent in west Dublin, north Kildare and west Wicklow. This is an ongoing saga. I have the prospectus which was issued at the announcement of the conclusion of the competition for architectural design for the Tallaght Hospital in 1981, ten years ago. It makes very interesting reading in the context of the Minister, Deputy O'Hanlon, explaining to the House that the cost of the project is now envisaged to be £118 million. It was £64 million according to the document I have in my hand at the time when we were supposed to turn the sod. The longer we push it into the future the more difficult it will become to climb that mountain. The helpful prospectus was laid out in question and answer form. The first question was "when will the hospital open?" and the answer was that planning for the hospital started in earnest in 1981, that the various stages of planning and building take a total of ten or 11 years and that therefore the hospital would open in 1992. The Minister's colleagues in the constituency were not happy with that at all, especially when there was a different Coalition Government in power, and they published an advertisement in June 1989 which sets out a very specific commitment.

An Ceann Comhairle

I would be grateful if the Deputy would not display any object.

Mrs. O'Rourke

It has become very fashionable to display one's photographs.

Mr. Rabbitte

I accept the strictures of the Chair. I merely wanted to validate that in that election of 1989 the local Fianna Fáil TDs promised to bring forward the construction of the hospital to 1990. They were not satisfied with it starting, as scheduled, in 1991 and they undertook to bring it forward to 1990. The advertisement stated that the chairman of the Tallaght Hospital Board, Professor Richard Conroy, and the Minister for Health, Deputy O'Hanlon, had agreed to accelerate the development programme and that "it is now hoped that work will be under way in about 15 months time".

One can imagine the boost that was to an area that has been so under provided for. It was a big factor in that election and people's hopes and aspirations were greatly boosted by that undertaking.

This is not just a question of a badly needed medical facility in my part of the constituency but it also holds out the prospect of some 1,800 people being employed at the new hospital. I know well that there will not be 1,800 new jobs but nonetheless it does contribute to developing an economy within the Tallaght area which is so badly needed.

Another question on that prospectus was as to what size the hospital would be. The prospectus stated that it was planned that the first phase of the hospital which would open in 1992 would contain 450 beds with full supporting outpatient services, full accident and emergency service and all of the support departments such as pathology laboratory, X-ray departments, operating theatres, physical medicine, physiotherapy, dialysis department, pharmacy, chaplains, a social work department and so on.

What kind of hospital would it be? The hospital would be a major regional teaching hospital serving the people of Tallaght, west Wicklow and south Kildare. It would be associated with the Trinity Medical School and have a full nurse training school with post graduate medical facilities in all disciplines.

What would the hospital mean to the community in the area? It would provide the most modern and sophisticated medical facilities in the country, a centre of learning for medical research and a meaningful liaison between community medicine such as family doctors and other community health professionals through the use of a post-graduate medical centre designed specifically for that purpose.

Where would the hospital be? We know where the hospital will be in due course.

When would building start? Building was scheduled to start in late 1988 or early 1989.

How much would the hospital cost? The budget price set by the Department of Health on 1 January 1984 was £62 million for the total project.

How many jobs would be provided? There would be some 1,600 employees in the new hospital.

The Minister will readily appreciate how major a project that is for the people of south west Dublin. It is not just the 90,000 people in Tallaght, it is the 50,000 people in Clondalkin and the people of the adjoining small areas of Rathcoole, Newcastle, Saggart, Brittas, Walkinstown right down to west Wicklow and part of Kildare. It is a major catchment area, the most densely populated and fastest growing in the State, almost one quarter of a million people, and yet we are now told that this is being put on hold.

Let me compare it, as I have done before in this House, to the situation in Limerick where there was a political dispute a few years ago about the closure of one of three hospitals in that city, a city that is smaller than just the Tallaght portion of the catchment area I am talking about. One could, for example, compare it with Galway, where they have the Regional Hospital, the Galvia Hospital and Merlin Park, three hospitals in a city of 40,000 to 45,000 people compared with this area of almost a quarter of a million people.

I have to urge the Minister to try to give this some priority because it is a major issue in the delivery of health care in my area. I notice that in a recent statement from the Secretary of the Hospital Board, Mr. Des Rogan, he talked about his hope of work being enabled to start next summer, and my understanding is that it would cost about £6 million to allow work to start. The Minister sitting here today must know whether she has found that £6 million to enable work to start.

Mrs. O'Rourke

No, but you know because you always hear from your friends in all sorts of Departments what is going on.

Mr. Rabbitte

I do. That is true.

Mrs. O'Rourke

Do you remember the regional college that you claimed was not going to go ahead?

Mr. Rabbitte

One cannot put patients in the regional college but since the Minister mentioned that, she is right. I know, too, how successful the Minister was in her previous ministry in finding £6 million when it was needed to provide a badly needed education facility in south Dublin.

Mrs. O'Rourke

Do you remember the regional college project in Tallaght, when you told everybody it would not go ahead?

Mr. Rabbitte

I campaigned very assiduously for that college and I am delighted that the Minister managed to deliver a commitment that had been given during the previous ten years.

Mr. Byrne

Will she surprise us twice?

Mr. Rabbitte

However, this is the Health Estimate and I was merely complimenting the Minister on her success, against all the odds, in finding £6 million for the purchase of Carysfort.

Mrs. O'Rourke

It was £15 million for Tallaght.

Mr. Rabbitte

I hope the Minister can find a similar amount — it is a coincidence — to allow work to start on the Tallaght Regional Hospital next summer. I hope we will not have any argument, and the junior Minister would seem to suggest that we will not when, at one of the flood of public meetings, if you will forgive the pun, that took place throughout the constituency he assured the people that "the management structure will not hold up the hospital." He did not say, to be fair to him, that the financial problems might hold it up — I do not want to misquote him. I would like to hear the Minister reiterate that commitment, that the management structure will not hold up the hospital, because, for a number of reasons, I would hate to think that the debate about the ethos of the hospital would be revived. It would be unhealthy that we should have the sort of divisive debate that happened a few years ago.

Whatever about the history of the three hospitals that are to comprise the new Tallaght hospital, all of us in this House would agree that for a great many years now the Adelaide Hospital has had an inclusive ethos. It is quite wrong to refer to it as having a protestant ethic or for the Minister to want to impose a Roman Catholic ethic. I sincerely hope that debate will not be given a new lease of life by any temporary dispute that may have happened between the three hospitals, because the preponderance of people who have reason to be grateful to the Adelaide would agree with the view that the ethos obtaining in that hospital has been an inclusive one.

The wish expressed by the Church of Ireland to maintain a direct relationship with a major teaching hospital is, I submit, a perfectly understandable one. I am aware that the Church of Ireland Bishops, for example, met the Taoiseach on two occasions and, according to my information — I subsequently met some of the same people — they were very pleased with the Taoiseach's understanding and appreciation of the importance of this dimension.

Mrs. O'Rourke

If the Workers' Party had their way, he would not meet anyone.

Mr. Rabbitte

I think, a Cheann Comhairle, that the Minister should not provoke me because I am likely to take up that provocation.

An Ceann Comhairle

The Chair takes the view that this friendly banter is symbolic of the season of peace and goodwill and would wish very much that it would continue.

Mr. Rabbitte

I shall continue in that mode by complimenting the Taoiseach on what I understand was the broad minded approach he took at that meeting towards the representations made by the representatives of the board of the Adelaide Hospital and of members of the clergy of the Church of Ireland. It is critically important that we maintain an even keel, that we do not allow any divisive issue to be introduced into this and that, above all, we do not use it as an excuse for not proceeding with the hospital. It is not an issue that provokes the slightest dispute within Tallaght. The people of Tallaght demand that the hospital be constructed.

It is interesting to note that the Catholic Clergy have been very active in the campaign to have the hospital built——

An Ceann Comhairle

I intervene to advise the Deputy that his time is well nigh exhausted. Perhaps he would bring his speech to a close.

Mr. Rabbitte

Let me say very quickly that the Catholic clergy issued a circular, in all the parishes of the constituency, in which they expressed their concern at the postponement of the Tallaght hospital project and pleaded with the public representatives of all parties to make representations to the Minister for Health to make sure the project went ahead.

I wish the Minister well in this difficult Department and plead with her to put the construction of the Tallaght hospital back on the priority list in the Department of Health. Even at a time when resources are scarce, the provision of £6 million should not be an insurmountable barrier having regard to the scale of the problem.

An Ceann Comhairle

The time has come to call another Deputy.

Mr. McCartan

At the outset, I would like to thank Deputy Byrne for allowing me to make a brief contribution at this stage. I understand he will wind up the debate on behalf of The Workers' Party. I also wish the Minister well in her new portfolio.

I understand that in an aside — I will be corrected if I am wrong about this — the Minister in her contribution announced that, having considered the position in relation to the accident and emergency service in the Dublin area, the hospitals will revert to the system which obtained earlier this year under which all the six major hospitals will be on call 24 hours a day, seven days a week, from now on. If that is so, I am very pleased. While Deputy Rabbitte holds a certain view in relation to the position in certain areas of the city, those who have to rely on the general accident and emergency service provided in our hospitals will be very pleased with this announcement.

When I raised this matter in the House on 24 October with the then Minister for Health, Dr. O'Hanlon, I asked him whether he would be prepared to act on an interim report on the operation of the accident and emergency service in Dublin but he indicated he had only received the report and was not in a position to make any comment. When I pursued the matter with him I came to realise very quickly that he did not seem to appreciate the nature of the problem. He proceeded to tell me that people living in rural areas — he gave Belmullet as an example — had to travel up to 50 miles to get to their nearest hospital whereas in Dublin people only had to travel six to ten miles at the maximum to get to a hospital. I explained to him, however, that a person from Belmullet would not be obliged to pass a major hospital on the way.

While I appreciate that people living in rural areas have to travel great distances to get to a hospital for people in Dublin it can be a major problem to get from one side of the city to the other. For example, people living in my own community on the northern fringe of the city and close to Beaumont Hospital could not always go to that very fine institution in the event of an emergency or accident. They were sometimes obliged to find their way to other hospitals, such as Blanchardstown, using the public transport system which, incidentally, does not operate after 11 p.m.

The reason I raise this matter is that in the week gone by Beaumont Hospital was on call. However, because of the demand for the service in the accident and emergency department, by 8.30 p.m. on a number of evenings they had been inundated with cases and had to divert all callers after that time to the other hospital on call. Therefore, even when it was on call it simply could not carry the workload. For those reasons, I am very pleased with this announcement that a comprehensive service will be available. No doubt it will be stretched during the winter months.

I ask the Minister to indicate if the Department have any proposals — I note that this matter was not dealt with by her in her speech — in regard to the disposal of waste from hospitals in the Dublin area. We have now reached crisis point. The environmental health section of Dublin Corporation recently carried out a survey of the 27 major hospitals in Dublin city and its environs by way of questionnaire. Ten of the hospitals, two of which are responsible to the Department of Health, failed to respond. I do not want to name any of the hospitals concerned because it was indicated that excuses had been tendered in the case of some of them. It is incredible, however, that the environmental health officer did not receive the full co-operation of the health institutions concerned. The picture painted is extremely worrying.

When Beaumont Hospital was constructed, an incinerator was installed to dispose of all waste on site but it has not been used since the hospital was opened because it does not meet the standards laid down. When we went after the English contractor who installed it we discovered he was no longer in business. Beaumont Hospital, therefore, has a very expensive — but now valueless — piece of equipment on hands. As the result it has to dump its hospital waste in a landfill site on the north side of the city. This is not a satisfactory method of waste disposal.

There is no incinerator in Dublin city which matches the standards laid down by the EC and the Department. All of the incinerators available to the hospitals in Dublin, therefore, are not up to standard or are inadequate. This is a major problem. The matter was highlighted in a recent report of the environmental health officer of Dublin Corporation in which he underlined the urgent need to provide an incinerator to allow hospitals in the Dublin area dispose of their surgical and other waste.

Other speakers have referred to the services for mentally handicapped persons but, as this issue was dealt with in an adequate and comprehensive manner in the debate during the week, I do not intend to go into it now. While I appreciate the Minister has been asked by Deputies on this side of the House to deal with matters urgently, I put it to her that her Department should respond in the near future to the question of the disposal of hospital waste.

Mr. Byrne

I thank my colleague, Deputy McCartan, for being brief, thereby giving me the opportunity to contribute.

This is quite a large Supplementary Estimate — in excess of £50 million. I am often amazed that Departments' budgets are so much out of line that Ministers have to seek the approval of the House for extra money. People in the health services feel that the Minister has an obligation to provide more money and the Opposition can only support such a Supplementary Estimate. Although we support this allocation it is inadequate and therefore we will be opposing the Supplementary Estimate. I ask the Minister why more money is not being provided for this area because quite clearly this amount is not enough.

During the 1989 election the Taoiseach pleaded ignorance about the state of the health services. The Fianna Fáil Party had obviously lost touch with the grassroots and the public. Everybody was amazed that the Taoiseach would state that he did not know the health service was in such a bad state. I remind the Minister that it is still in a desperate state. This Minister will not have the opportunity to make the excuse that she is not aware of or is not in touch with people who suffer as a result of the chaotic health services.

The Minister is new to this post and I have already welcomed her to it. Although I am not The Workers' Party spokesman on Health, I periodically stand in for my colleague, Deputy Sherlock. The Minister is a fast learner and she will know of the crisis in the hospital service, particularly in the accident and emergency services. She will have heard the pleas of carers of people with mental and physical handicap. I am sure she is aware of the huge numbers of men, women and children on waiting lists for admission to hospital, and of the trauma they suffer as a result. The Minister will have heard of the crisis with the care of the elderly. She should be aware that there are at least 50 geriatric patients at present occupying beds in the Meath Hospital because no beds are available in nursing homes. This hospital is bursting at the seams with patients, many of whom are inappropriately located there.

The Minister will know of the huge problem with the care of the elderly. Some groups are successfully engaged in political lobbying and the Minister is aware of the problems of the people they represent. For example, she is aware of the problems facing the mentally handicapped because of high profile lobbying in that area, but I will devote a few minutes to the care of the elderly, who do not seem to have the same degree of political lobbying behind them. Statistics show that people are living longer due to modern medicine and better care. Therefore the present crisis in caring for the elderly will get progressively worse as time goes by. There is nothing as tragic as people suddenly realising that an elderly father or mother is in need of hospital or nursing home care. They are shocked at how difficult it is to find a nursing home with a vacancy and then at the cost of nursing home facilities. Many of these families are ill equipped to meet that cost and the health boards cannot satisfy their needs due to an inadequate number of beds. I hope the Minister will take action in this area.

The Minister will be aware that due to the huge waiting lists for acute hospitals, general practitioners request their patients to use the accident and emergency services to gain entry to these hospitals. There are thousands of people waiting for elective surgery. The Minister spoke earlier about the accident and emergency services. She should look into the reason general practitioners use this system as a way of getting patients into hospitals.

I congratulate the Minister on reintroducing the 24 hour accident and emergency service in the six acute hospitals in Dublin city. What amazed me was the way her predecessor, in trying to save £750,000 or £2.25 million, depending on which report you read, arbitrarily introduced a rota system. However, no money has been saved and, quite rightly, the accident and emergency units in the six acute hospitals are being opened again on a 24 hour basis. While the maximum 12,000 bed facility will be retained, because general practitioners and others are using the accident and emergency system as a means of gaining access to hospitals, I appeal to the Minister to consider major reports, such as the accident and emergency report.

I am told there are reports sitting on the Minister's desk gathering dust. If those reports were implemented it would help solve some of the problems with the accident and emergency services. This is quite a complex problem which will not be solved just by opening the accident and emergency units on a 24 hour basis. Much more needs to be done. Although I welcome the reintroduction of this service on a 24 hour basis, unless the hospitals are allowed to open wards that have been closed, to bring on stream more hospital beds so that the people who are on waiting lists receive treatment, general practitioners and others will continue to use the accident and emergency services to gain admission to hospital.

I am not surprised that the Minister has reverted to opening the six hospitals to deal with accident and emergency cases. A number of hair-raising incidents occurred over the past number of weeks, including the Beaumont incident. Whatever about adults having to wait, it is disturbing to hear that because of staff shortages in Crumlin Children's Hospital children have had to wait for 12 hours to see the appropriate doctors in the accident and emergency unit. We also had the case that because of excessive demands on the Meath and Beaumont hospitals accident and emergency cases had to be diverted to other hospitals. It was inevitable, therefore, to revert to having six hospitals on call.

The Minister has to make a serious decision to use her political determination to ensure that there is an injection of sufficient funds into the health service to make the services for the care of the sick more acceptable than they are at present.

The Minister has announced that six hospitals will remain open on a 24-hour basis to provide an accident and emergency service, but that they must do this out of their existing resources. Presumably this will have a cash implication and I would like the Minister to confirm whether the hospitals have sufficient resources to provide the accident and emergency service so that people will not have to wait 12 hours to be seen or be left lying on a trolley in hospital corridors or waiting rooms. It is one thing to instruct the hospitals to provide an emergency service, but what will happen if there are not enough beds? It is a chicken and egg situation. While one can demand that six hospitals remain open on a 24-hour basis, if additional beds are not provided, there is no real improvement in the health service.

I would like to think that some of the moneys being provided in this Supplementary Estimate would go to implementing the recommendations of the report of the review group on services for the mentally handicapped. If the Government have made a policy decision to accept the findings of this report, money is needed to implement its recommendations. I will not get involved in a re-run of the debate on services for the disabled; nevertheless it is important to put on record that people caring for the intellectually disabled have a tremendously difficult life to live. For many parents or family members, it is a 24-hour difficult task every day. One could become emotional about the experiences of some mothers as they struggle to care for their intellectually disabled offspring. Christmas is often not a happy time for carers of the intellectually disabled. Because of the constant demands being made on them and the need to give 24-hour constant care to the handicapped person, every day is the same, Christmas day included. The Minister has the power to make it a real Christmas for the carers. I appeal to her to use her power at Cabinet to activate a plan for the implementation of the recommendations of this report.

During Question Time I tried to get the Minister to agree to accept the findings of the arbitration board on the IMO's claim for a 40 per cent increase in fees under the GMS. Over 1.25 million people depend on the GMS scheme. The IMO have threatened to take strike action and withdraw the services of their members from the GMS. The Minister must realise that the withdrawal of services from so many vulnerable people would be catastrophic. Without a shadow of doubt if the threat was carried through and services were disrupted it would result in death, injury, misery and a further deterioration of patients' health. Clearly there is a case to be met in regard to the doctors who are exclusively servicing the needs of the GMS patients. The IMO have a legitimate case, although I might have reservations about a claim in excess of 40 per cent at this time. Although there was a threat of a possible bus and rail strike, CIE agreed to go to arbitration and agreement was arrived at. I ask the Minister to commit herself to accepting the findings of an arbitration board on the claim now being pursued by the IMO. It is better that an amicable solution be found without disrupting the service to medical card holders.

I know that the Dublin Dental Hospital is not solely the responsibility of the Minister for Health. However, a site has been acquired in James Street for a new dental hospital because the existing buildings have been condemned by the fire officer, time and time again. The Dublin Dental Hospital makes an invaluable contribution, particularly to the marginalised section of the population, medical card holders, prisoners, haemophiliacs, and AIDS victims. The staff are working in unbelievable conditions. The Minister should liaise with her colleagues to ensure that the proposed building of the Dublin Dental Hospital proceeds.

An Ceann Comhairle

I intervene to remind the Deputy that he has hardly a minute left.

Mr. Byrne

Again let me ask the Minister to look at the waiting lists. In the Eastern Health Board region there are 7,000 people seeking orthodontic treatment for which the waiting time is four years for treatment. There is also a growing waiting list for the treatment of varicose veins, which is a relatively simple operation. Increasingly, people are finding difficulty in having that relatively simple operation carried out.

I shall leave it there for the moment and hope that the Minister will find an opportunity to answer some of the questions raised.

Mr. J. Mitchell

I wish to avail of this opportunity to raise several matters which in my view defy logic and cost the State money.

The Minister wants increased resources for health. There are practices imposed by her Department and by others which, if changed, could lead to a saving of money. The saving of such money could result in the Minister being able to extend medical card benefits to those who need them and could allow us revert to the system whereby medical drugs costs are paid on a monthly rather than on a three monthly basis.

I wish to talk specifically about means testing. There may be as many as 20, or even more, different means tests applied by the State. Means tests are operated by the Departments of Health, Social Welfare, Environment, Justice and Education. For at least four years I have been pressing in the House for the provision of a single national eligibility test. I hope that I am not straying too much from the main Estimate but I do want to highlight the anomaly that thereby arises.

If somebody becomes unemployed, for instance, he or she has to go through the hoops seven, eight or nine times at least to obtain the benefits to which they are entitled. They go through all these different means tests in just as many different public offices, taking up the time of the same number of public officials. Very often those means tests are set to different criteria and applicants are confronted by all kinds of traps and anomalies.

I have been arguing strongly for one national eligibility test so that the humiliation, degradation and inconvenience caused to the poor is stopped; so that people do not have to go through the hoops eight or nine times. If people are subjected to an eligibility test for a medical card and are successful, they should be granted a certificate of means, which certificate should be accepted without further question for all other State means tests. That practice would save a great deal of official time as well as eliminate much inconvenience, humiliation and degradation caused to people who become less well off. Could the Minister please say why there is not one single national eligibility test for all State services?

Mrs. O'Rourke

That would not be a matter for me alone but it is a fair point.

Mr. J. Mitchell

I have raised the subject on several occasions in relation to the Department of Finance, the Department of Health and the Department of Social Welfare. An interdepartmental committee were set up by the former Minister for Finance, now Commissioner MacSharry. That committee were to report within a year, and that was four years ago.

The anomalies continue and I shall go into them in a moment. Not only that, each budget in the past four years has worsened the anomalies. The Government are spending money, trapping people in poverty and worsening public service.

Just this morning, for instance, I was confronted by the case of a separated wife with two children who was not in receipt of the deserted wife's allowance or any supplementary welfare because her older child was working and she was assessed on that child's income. Of course the older child was not handing in that income.

An Ceann Comhairle

I have allowed Deputy Mitchell some latitude but the matters to which he refers impinge on the responsibility of other Ministers. They are not the sole responsibility of the Minister in the House.

Mrs. O'Rourke

I am interested, and I would be glad to listen.

Mr. J. Mitchell

My point is that in order to get a medical card, the provision of which is the responsibility of the Minister for Health, that lady had to have her older child leave home. The mother was not getting the income of her older child, though it was included in the assessment. When the older child left home the mother not only got a medical card, she received supplementary welfare and rent assistance; she qualified for everything. By pushing that child out of her family home an enormous additional cost accrued to the State. Such an occurrence is not unusual, it is happening all the time because the means of children are taken into account in these cases.

In another case with which I am dealing a mother of a large family has valiantly, despite her own poorish health, struggled to keep a disabled child at home. Again because of the aggregate means of the family, that mother is deprived of the carer's allowance. She does not want the carer's allowance for herself, that money is needed because of the extra requirements of the disabled child. The mother will be forced to put her child into an institution—I can see that coming within the next few months — because she just cannot cope any more. Again because of family means the mother is also denied a medical card. What will happen is that her child will end up taking a costly place in an institution. The child will be away from the family and will cost the State perhaps as much as £500 a week.

Means testing must be reformed urgently because the system is riddled with anomalies that cost the State money. The biggest anomaly is the creation of a great poverty trap. If a couple with two or more children live on social welfare they are already poor — and I want to emphasise that point — but if the husband or the wife takes up a job and earns the average industrial wage or less, because means testing is taken from gross pay and not net pay and because of tax, social insurance and so on, the family will be worse off. That is the classic poverty trap. Instead of becoming net subscribers to the Exchequer, such couples are trapped in poverty and become net drawers from the Exchequer.

If the system of means testing were changed to assess workers for medical cards, differential rent, higher education grants and so on, on net pay rather than gross pay then the large part of the anomaly would be removed. Having workers' means assessed on gross pay when it should be assessed on take home pay is costing us money. Since 1984 assessments for everything in the United Kingdom have been taken from net pay. The means of a worker cannot be assessed on gross pay which is never received. Workers should be assessed on the money they get into their hands. So long as that very unfair anomaly against workers remains the poverty trap will be tied in and will continue to cost the State extra money in the Health Estimate as well as in other Estimates because people are forced to take alternative steps. Deputies deal with such circumstances every day of the week.

Anomalies such as occur in the cases to which I have referred cost the State money and they also infuriate the people in the street, who learn of the anomalies and wonder what we, as elected representatives, are going to do about them. When people become unemployed they experience the humiliation of being put through all of the different means tests at different offices, offices that are often located at the end of an expensive bus run — an expensive bus run that they cannot afford.

In respect of all State services, whether within the Department of Health, Social Welfare, the Environment, Education or Justice — with regard to matters like criminal and civil legal aid — I propose that individuals should be able to go to their local health centre, not entailing an expensive bus ride, and have their circumstances ascertained by way of an eligibility or means test. In addition, I propose that any certificate issued should obtain for all other services and should last a year, even if their circumstances were to improve within that year. Otherwise we are spending a lot of money, not on administrative duplication, trip-tuplication or more, very costly triplication or more, very costly administration, and very humiliating inconvenience for citizens while, in the meantime, the services deteriorate.

I am not going to go into the hospital health services today. Others have gone through their inadequacies, the waiting lists and so on. I want to talk about those who are not in hospital but who may have to go to hospital because of poor out-of-hospital services. In particular I want to refer to the medical card. I appeal to the Minister to ensure that that change is effected for 1992, that medical cards would be granted to workers on the basis of their take-home pay, the money they get into their hands, not on their gross pay.

The recent changes in relation to claims under the drug refund scheme which mean that one must expend so much over three months before obtaining any rebate should be reversed. I know it is State money but it was a mistake, is very unfair and is an added burden on those families already penalised by sickness. I do not know what are the savings, but I am quite sure that, in a full year, they are a lot less than was made in some recent property transactions in this city. That is tremendously important.

This debate is taking place at a time of unparalleled unemployment. Even in recent months we have seen reports of the connection between unemployment and health; there is a very real connection. Indeed, it is not just psychological health that is affected but physical health as well. Unemployment adds enormously to the health problems of a family because of the pressures it creates. We should not add to those pressures by humiliating people when they become unemployed, by putting them through these several hoops. Because of the additional health problems created, not merely for the unemployed themselves but among their families, we should not be adding to their costs by saying they must spend so much more in three months than had been the case previously before they get any refund. I appeal to the Minister to endeavour to help people remain at home.

I know there are three other speakers wanting to contribute but when we have the full debate on the Health Estimate in the coming year I hope I will have more time to spell out my concerns and suggestions.

Mr. Taylor

In deference to other speakers wishing to contribute, I too shall be brief. In the circumstances I intend to confine my remarks to one aspect of the Supplementary Health Estimate rather than range across the whole spectrum.

I want to refer to that most important question in my constituency, the failure of this Government to provide, in this Supplementary Estimate, for the construction of the Tallaght Hospital. This disgraceful position has been adverted to in this House on many occasions. Yet, here is a Supplementary Estimate introduced for £50 million without any indication that the Government intend to fulfil the commitment given in this House going back over a period of years. Tallaght is now a town of 90,000 plus people. Plans for a hospital were laid out and a commitment to its construction given by this Government.

I might refer now to a motion in Private Members' time introduced in this House on 6 December 1988, in particular to the Official Report of that day at column 47 when the Labour Party gave up their Private Members' time to a debate on the development and needs of Tallaght. That debate was responded to by the former Minister for the Environment, Deputy Flynn, when he said:

The new hospital at Tallaght will be one of the major general hospitals for the Dublin area and will, together with Naas Hospital, serve the population of south-west County Dublin, the western portion of County Wicklow and the southern portion of County Kildare.

At the bottom of the same column the Minister had this to say:

This Government are committed to the Tallaght Hospital project and approval has recently issued to the board to proceed to stage 4 of the planning process. It is anticipated that if the present rate of progress is maintained construction work will commence in mid-1990.

We have seen how almost £9 million of taxpayers' money has already been expended on this project. Year on year this House voted moneys towards the continuation of that project, its development, the drawing up of designs, plans and so on. Perhaps twice-yearly I tabled parliamentary questions to the Minister for Health on this project. For example, on 18 July 1989, I asked the then Minister for Health if he would make a statement regarding the present state of development of the proposed new hospital for Tallaght. The Minister replied as follows:

Planning for the provision of the new hospital at Tallaght is at an advanced stage. It is anticipated that if the present rate of progress is maintained construction work on the first phase of the development will commence in 1990 and should be completed in 1993.

What do we find? We find a complete abdication of the responsibilities and commitments, freely expressed by this Government, to the needs of the people of Tallaght and the surrounding areas for their hospital. The people from Tallaght have to travel great distances to St. James's and the Coombe Hospitals incurring transportation expenses they cannot afford, incurring risk to life and limb as a result of delays in having to go there. Indeed, we know that the existing city centre hospitals Tallaght Hospital is intended to replace are old and past their period of economic and proper usefulness. The Meath Hospital has wonderful staff, they do a magnificent job, but the buildings are more than 200 years old and crumbling. It is not acceptable in a modern world that such buildings should continue to be used.

The Government introduced a £50 million Supplementary Estimate for health but the £10 million required in 1991 and 1992 to get that project at least moving, does not appear in this Supplementary Estimate. No way can the Labour Party support that. It is a sell-out of the people of Tallaght. It is an absolute disgrace that, having given the House their firm commitment, having used up £9 million of taxpayers' money, the Government now abandon those £9 million and are not prepared to say that, in 1992, they will commit moneys for Tallaght for that much-needed hospital for the people of the area to enable them get that project under way.

The board of the Tallaght Hospital was set up years ago comprising tremendous expertise, doctors, nurses, specialists and politicians — I served on it for a while myself; they met on 104 occasions. Can you imagine the number of man hours these experts gave, voluntarily, to draw up those plans and designs for the Tallaght Hospital, being thrown out the window? It is a matter of indifference to this Government that all that work and all that money have been ploughed into this much needed essential facility which was promised. What is the response? The response has been a brick wall, nothing, no interest, no care, no appreciation of the needs of the men, women and children of Tallaght. That speaks for itself.

The Labour Party will oppose and vote against this Supplementary Estimate.

Mr. Garland

I will endeavour to be brief to allow Deputy Belton to contribute. On behalf of the Green Party, Comhaontas Glas. I am opposing this Supplementary Estimate. The cost overrun for this year amounts to no less than £50 million or nearly 4 per cent of the original Estimate. The fact that public expenditure on Health this year has reached £1.4 billion is an appalling indictment of the state of the nation's health. The Minister's Department should be called the Department of Illness. Their response is always reactive rather than progressive. They see people who are sick and say they must be cured. That shallow, short term attitude to the nation's health is reflected in this enormous expenditure. The attitude of the Department should be holistic and preventive. They should ask why people are ill in the first place. In fairness, in the past two or three years there have been some signs of movement and consultants are talking about the stress factor in heart disease and cancer. We must ask the basic question — why is stress such a factor in our health profile? I am sure it was not so 30 years ago.

The pollution of our cities by coal and motor vehicle emissions is a major factor in the nation's health. It should not be forgotten that while considerable progress has been made in Dublin in reducing air pollution levels due to the ban on the sale of bituminous coal, serious problems still exist in other large cities such as Cork, Limerick and Waterford and smaller provincial towns. No proper monitoring is taking place in these cities and towns. In money terms alone the cost to the taxpayer of maintaining people with respiratory problems in hospital is enormous. Now that pollution from bituminous coal has been substantially reduced in Dublin, attention must be paid to car emission levels which can be a major health hazard. Drastic reorganisation of Dublin transport is needed to get cars out of the city centre.

Drugs are a major cost factor in the health services and, although there was an apparent price reduction during the year, the cost of drugs seems to increase all the time. Again, the stress factor and the lack of a holistic approach to curing patients manifests itself. Whereas the Department of Health are quite rightly attempting to effect price reductions in drugs, the Department of Industry and Commerce are doing the exact opposite by their promotion of the Patents Bill which extends the life of patents from 16 to 20 years. The effect in the pharmaceutical industry is to maintain the high prices charged by patent drug companies for a further four years. I am surprised the Minister did not refer to this. Any further cost cutting in this area will be extremely difficult.

Hospital accident and emergency services are appalling, particularly in the Dublin area where it is not unusual to wait hour upon hour for attention. A nation which allows this to happen has its priorities wrong. The ever-lengthening queues for operations are another manifestation of this. The hospital services are undoubtedly at crisis point.

While in Opposition Fine Gael are most vociferous in their call for greater health expenditure but while in Government they pursued Thatcherite economic policies, to the great disadvantage of the poor and the underprivileged. Many middle-class families suffer from health cuts, yet at elections they vote for reactionary parties like Fine Gael or either of the Government parties.

Most distressing is the inadequate provision for the mentally handicapped. Surely every Member accepts the need for a realistic budget in this area.

The Green Party are very concerned at the cost of running the health services and in the long term we would like to see costs considerably reduced by the adoption of a less stressful and more healthy lifestyle. Great savings can be made by treating the symptoms of the disease, be it diet, the living and working environment or the whole economic insecurity of Ireland today, before the symptoms become a debilitating illness.

Mr. Belton

I will deal with issues relating to the Midland Health Board region. The Minister referred in her speech to Tullamore General Hospital and the orthopaedic services there. This matter has been a major problem for quite some time and the consultants called together all the local politicians, emphasising their anxiety about the lack of services in this hospital. These surgeons are under extreme pressure and the waiting lists are huge.

Some people in County Longford have been waiting 18 months or two years for treatment. I spoke to a man at a function recently who has been taking pain killers for the past month and his prospects of a hip operation in the near future are almost nil. I welcome the reference to two new theatres at Tullamore Hospital in order to increase the services in the orthopaedic unit and I hope this project will be undertaken quickly. Coming as she does from the midlands, the Minister must be well aware of the problem.

The orthodontic service in County Longford is nil. There is a waiting list but nothing is happening. There is absolutely no service for primary school children.

The Minister is aware of all the good work which has been done at St. Christopher's in Longford. They are awaiting funding for a residential home there and at Granard and I hope the Minister will see to it that the Midland Health Board can provide the necessary funds for that worthy project.

The casualty unit in Longford is not all that we would wish but it is providing a service. Some anxiety has been expressed about it and I want to emphasise how important it is. We were hoping to have a new unit built and the Minister might consider that matter.

Mrs. O'Rourke

I thank all Deputies who have contributed to this debate. The speeches were interesting and informative and I agreed most heartily with Deputy Garland who wished to see a less stressful and more healthy lifestyle, thereby reducing the Health budget. Would that it were so simple. It would be lovely if——

Mr. Belton

There is no stress here.

Mrs. O'Rourke

He is a very nice Deputy but sometimes one would think he is living in fairyland. He seems to think that everything would be lovely if we all adopted an outlook similar to that of the Green Party.

Deputy Bruton raised several points. He made accusations about incompetence in my Department. I have only been there a short while but they seem to be entirely competent. He also said they appeared to be unwilling to supply information. I do not accept they are unwilling to supply information. I will pay assiduous attention to any parliamentary questions put down by the Deputy from now on to ensure that he gets the information he wants. He referred to payments to health agencies. All these agencies will get the appropriate pay increases in addition to what they have got. It was mischievous of the Deputy to say they had to make savings in their estimates to pay costs.

Deputy Bruton also said the Government had made an illegal raid on the VHI. I accept that in the Dáil we speak under privilege but I should like to put it on the record that I am sure no illegal raid on any organisation was made by my predecessor, by the Government or the Department of Health. The word "illegal" seems to be the "in" word for some Deputies.

Mr. R. Bruton

It was certainly unlawful.

Mrs. O'Rourke

Illegal was the word used.

Mr. R. Bruton

What is the difference?

Mrs. O'Rourke

I will be making further announcements in 1992 about the development of the AIDS programme. All areas of health are vital but AIDS is one area to which we have to give very great priority. The Deputy also asked about the freeing-up of money. As I said, there will be a freeing up of £7.745 million in subhead G.1 as a result of the provision of additional lottery funds under subhead G.9.

All Deputies referred to services for the mentally handicapped. I accept their bona fides in this respect. People who speak on this subject usually know someone with a mental handicap. As I said last week, I intend to develop a coherent plan for the provision of services in the mentally handicapped area.

Deputy Ferris referred to the problems being experienced by certain health agencies due to a lack of finance and he went on to talk about the Medical Council. I dealt with that matter during the week and I was rather alarmed by what he said. He implied we should pay for some of the expenses incurred by the Medical Council. As the House will be aware, they are the regulatory body for the medical profession, are self-financing and are responsible for the investigation of issues such as the one which arose in Beaumont Hospital. The Deputy went on at some length about this issue. The position in regard to this council is as I have outlined. Naturally I regret the events in Beaumont Hospital.

Both Deputy Rabbitte and Deputy Taylor referred to the Tallaght Hospital. The Minister of State, Deputy Flood, and I have discussed this matter and I have read most of the brief on it. I hope to shortly meet with a representative group——

Mr. Taylor

I hope the Minister will do for the hospital what she did for the regional technical college. She promised a regional technical college and she delivered on that promise.

Mrs. O'Rourke

I thank the Deputy for his kind comment. However, I should point out that there is a big difference in the cost.

Deputy Byrne said that I was a fast learner. I do not know what to make of that comment. Nevertheless, I am always delighted to get a compliment of any kind. He referred to the needs of the elderly, to the Meath Hospital and the acute hospital services. As I said, I hope next year to consider the establishment of geriatric assessment units. He also spoke with feeling about the mentally handicapped and the disabled.

Deputy McCartan referred to the problem of waste disposal in Dublin hospitals. This matter was raised in an Adjournment debate in the Seanad some time ago and a very detailed answer was given to it. This is a complex issue and it needs to be properly addressed. There is no point in adopting a short term solution to the problem. I accept that this is an issue to which I must address myself. My ex-constituency colleague, Deputy Belton——

Mr. Belton

I could be the Minister's constituency colleague again.

Mrs. O'Rourke

Yes, if there is another census before the next election. However, I do not think that will happen. I should like to thank Deputy Belton for contributing to the debate. He referred to the Midland Health Board area, with particular reference to Tullamore, and the casualty service in the Longford Hospital. As I said, the Midland Health Board occupy a very modest space in terms of the other health boards. Somebody said it will not always be like that and we should wait to see the estimate for the Midland Health Board next year. If I increased their allocation I would be accused of being partisan. I have to take into account all aspects of my brief.

I want to refer to the word "cutback". I do not have the figures with me but the expenditure on health this year will amount to approximately £1.4 billion. This represents an increase of approximately 11 per cent on the start-up figure at 1 January last year. One can never spend enough on health or education. People need the services provided in these areas and the requirement for these services increases each year. How one can call an increase of approximately 11 per cent a cutback is remarkable. One can never give enough. Every country is experiencing the same difficulties in the provision of education and health services.

I am not one bit daunted by the challenges facing me and I look forward to dealing with them and to hearing the many fine ideas which will be put forward during debates on health in the House. I look forward, in particular, to working with all the agencies in the health area.

An Leas-Cheann Comhairle

The question is, "That the Supplementary Estimate be agreed to." Is the question agreed?

Mr. Taylor

No. Vótáil.

An Leas-Cheann Comhairle

In accordance with the order of the House made yesterday, the division in question is postponed until 6.45 p.m. on Wednesday, 18 December 1991.

The Dáil adjourned at 4 p.m. until 12 noon on Tuesday, 17 December 1991.