Estimates, 1992. - Vote 41: Health (Revised Estimate). – Dáil Éireann (26th Dáil) – Thursday, 28 May 1992

Estimates, 1992. - Vote 41: Health (Revised Estimate).

Minister for Health (Dr. O'Connell)

I move:

That a sum not exceeding £1,534,327,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1992, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards and miscellaneous grants.

I apologise to Members that copies of my speech have not yet arrived. I did add some extra comments for the benefit of Members which were incorporated before I left to bring my statement up to date. That is the reason for the delay but copies are on their way. I would ask Members to please accept my apology.

Mr. Farrelly

Has the person bringing them the right to travel?

Dr. O'Connell

The gross non-capital provision in the Estimate amounts to £1,713,417 million. Allowing for non-capital appropriations-in-aid of £220.090 million, the net non-capital vote provision is £1,493.327 million, of which £28.806 million is national lottery-funded. The net non-capital provision represents almost 22 per cent of total Government spending on supply services in the current year and shows an increase of £177.014 million of 13.4 per cent over the original 1991 Estimate.

On the basis of the subhead provisions in the Estimate, the level of non-capital expenditure approvable amounts to £1,720 million. When account is taken of the income generated directly by health agencies, the total projected expenditure for 1992 amounts to £1,846.6 million.

Last year £28.135 million national lottery money was spent mainly on services for the elderly, child services and services for the mentally and physically handicapped. The 1992 national lottery allocation is £39.8 million of which £11 million is for the hospitals building programme. A sum of £6 million is for the payment of compensation to haemophiliacs infected with the AIDS virus. Substantial assistance will continue to be provided from the national lottery to services for the elderly, child care and services for the mentally handicapped and the physically disabled. A total of £1.6 million will be allocated to the health boards for distribution by them to local voluntary agencies operating within their areas.

The 1992 capital provision is £43 million. This allocation provides for all contractual obligations and other priority commitments. Provision is being made for the continuation of the major projects at Ardkeen Hospitals, Waterford, Sligo General Hospital and the Rotunda Hospital and for the commencement of construction at St. Luke's Hospital, Kilkenny, the development of the laboratory and psychiatric unit at the Mater Hospital, Dublin and the bone marrow unit at St. James's Hospital, Dublin. Provision will also be made for the purchase of urgent replacement equipment and for a number of fire-precaution and asset renewal schemes.

In line with the recommendations contained in the report on the development of the psychiatric services Planning for the Future, the policy of targeting resources in the area of community psychiatric services will be continued in 1992. Hostels, day hospitals, day-care centres and other community facilities are being planned. A new mental health centre will be built at Longford in 1992. Construction will also commence on a new centre for autistic persons at St. Vincent's Hospital, Fairview.

The 1992 capital provision for physical disability and mental handicap will also be concentrated on the provision of community-based services. A capital contribution is being made towards the cost of the new Cheshire Homes at Monkstown and Sligo. Funding is also being made available for an acute unit and new residential facilities for mentally handicapped persons at St. Vincent's, Navan Road, Dublin. Funding will also be provided for a number of projects in the child care area, including the provision of a group home for children at Shanakiel in Cork.

An Bord Altranais are currently conducting a comprehensive review of the nurse training system. Such a review in respect of the training of any discipline would be significant but it is given added importance by the pivotal role of the nursing profession within the provision of health services. The review process is itself a complex issue and is, I know, being pursued in a thorough and comprehensive manner. I look forward to studying the outcome and I shall sympathetically consider the recommendations that will emerge in the context of available resources.

My Department have commissioned a nursing requirements study which is being undertaken by management consultants. This study will draw together on a scientific basis a detailed picture of projected nursing skill deficits and the measures necessary to deal with these. Taken together with the results of the training review, the resulting data will provide a sound base-line from which to address any existing or potential imbalances in nursing manpower which could otherwise have an adverse effect on services.

The nursing profession is one area of the health services upon which there is a particular impact arising from the harmonisation of training criteria in member countries of the EC. I am pleased to report that we have made good progress in making the necessary arrangements to ensure full compliance with the Directive on general nursing.

A further aspect of current initiatives in regard to nursing which I would like to mention is the 1985 Nurses Act, which is the governing legislation in respect of nurse training and registration. I know that some dissatisfaction has been voiced from within the profession regarding the structures and procedures put in place by the 1985 Act. My own view is that there is considerable merit now in reviewing the operation of the Act given that it has been in place for a number of years. I am now in the process of initiating such a review in consultation with interested parties.

I would like to refer briefly to the issue of pay determination. In line with the provisions of the Programme for Economic and Social Progress my Department, together with health service employer and union representatives, are presently exploring the potential of the local bargaining provision of the programme in the context of various pay claims which have been lodged by the staff side. The debate on this is taking place against a background in which the public service pay bill has increased very significantly in recent years and will again in 1993, taking account of existing commitments.

I would not wish to pre-empt the outcome of these discussions but I would like to stress that the policy the Government must adhere to in the health services, as elsewhere in the public services, is that any future special concessions in relation to pay or other conditions of employment will have to be funded on the basis of tangible productivity measures. The mechanism provided in the programme gives both sides a unique opportunity to look at all aspects of health services employment so as to optimise the output of the health system while providing for staff a secure and rewarding career structure. If approached in a positive frame of mind this process can open the way to a more constructive approach to the whole conduct of industrial relations in the health services. While the debate on this is at an early stage, I have every confidence that with some determination and ingenuity, solutions will emerge which will address the realistic aspirations of staff and give a fair deal to the ultimate paymaster — the taxpayer.

With regard to services for the mentally ill, the Government have decided to publish a Green Paper on mental health, which will consider policy issues and propose new mental treatment legislation. The printing of the Green Paper is under way and it will shortly be published and circulated for consideration. I am conscious of the need to provide those who wish to offer suggestions on improving the delivery of services to the mentally ill an opportunity to put forward their opinions.

The fundamental shift from an institutional to a community-oriented model of care for the mentally ill is now established in each health board area and resources will be allocated to ensure that this direction in the delivery of care will be maintained. More community facilities for the care of the mentally ill, such as hostel accommodation and day care facilities, were provided in 1991 and notable achievements were the opening of new 30 bed psychiatric units attached to Roscommon and Naas general hospitals. Work on the provision of an acute psychiatric unit at the Mater Hosptial, Dublin, has commenced and will be completed by the end of this year. Planning of the psychiatric unit at the Mercy Hospital, Cork, is ongoing.

I am particularly anxious to ensure that the alternative community-based services should be of the highest quality and I am asking the inspector of mental hospitals and his staff to pay particular attention to this aspect of the service at this vital stage of development and allocation of resources.

This year I have been able to continue the considerable developments started in 1990 and 1991 for the elderly in community based and hospital services. The objective of Government health policy, as set out in the report of the working group on services of the elderly, The Years Ahead, is to support the care of dependent elderly people at home for as long as possible and to ensure that, when the elderly can no longer be cared for at home, there are appropriate specialist and extended care facilities to meet their needs.

The priorities of service development at present are to strengthen the capacity of the health services to care for the person at home, to provide more specialist facilities in acute hospitals and to meet the needs of the increasing numbers of elderly mentally infirm. Significant progress has been made towards implementing the recommendations of The Years Ahead. In the past two years £8 million has been made available to the health boards. This funding has enabled the health boards to expand home nursing facilities, to provide day centres and hospitals, to increase the number of physiotherapists and speech therapists in the community and to develop services for the old with dementia.

This year I have provided funding to both the Meath and Mater hospitals to establish special units for the elderly and these units should soon be fully operational with consultant and back-up staff in place. With the additional £1 million made available in this year's budget. I intend to provide more extended care places for the elderly, particularly in the Eastern Health Board area where there is the greatest need for such places.

The drafting of regulations to implement the Health (Nursing Homes) Act, 1990, is at an advanced stage. These regulations will be discussed with interested parties in the nursing home sector in the near future with a view to their implementation as soon as possible.

One of my priorities in the current year is to expand facilities and services for people with mental handicap and their families to keep abreast of the needs of the growing and ageing population. This said, however, direct funding to agencies for the mentally handicapped is now 56 per cent higher than it was in 1986, and expenditure by the health boards has also increased significantly. A total of about £170 million was spent on services for people with mental handicap in 1991. The additional funds allocated in 1992 represent the single largest annual investment ever in these services and I am very pleased to have been able to achieve this.

The past three years have seen a consistent effort by the Government to expand and improve services for people with mental handicap. All Deputies agree this should be done. In 1990 the Government made a special allocation of £2 million available for the development of mental handicap services. In 1991 the Government provided a further £1 million to continue the expansion of services. Funding was provided to open 20 places in Cheeverstown House and 27 places in Aras Attracta, Swinford, County Mayo, as well as additional respite services in each health board area. This year an additional £5 million of revenue funding and a further £1 million capital has been made available to develop a range of new services, which will include additional residential places, day places and increased respite care facilities. Provision has also been made for the establishment of a genetic counselling service at Our Lady's Hospital, Crumlin.

I have referred to the provision of the commissioning of additional places at Cheeverstown House. The impasse which prevented the opening of these additional places has been a matter of some concern on all sides of the House and I would like to avail of this opportunity to pay tribute to those who contributed to the resolution of that dispute. I am happy to report that both the Eastern Health Board and the board of Cheeverstown House are now working to the agreement negotiated by the federation of bodies providing services for people with mental handicap.

I would like to refer here to the report of the review group on mental handicap services Needs and Abilities, which confirms the correctness of many of the principles which underlie the present provision of services for people with a mental handicap. It indicates that with adequate support services, the overwhelming majority of people with a mental handicap can live in the community. It attaches great importance to the early identification of children with delayed intellectual development. If the abilities of these children are to be developed, their needs must be identified as soon as possible. I am glad to say that the Government have accepted in principle the recommendations of the report and are committed to their implementation under the Programme for Economic and Social Progress.

A special allocation of £3 million was made available in the 1991 budget specifically for the development of dental and orthodontic services and the 1992 allocations to health boards retains the special provision enabling the boards to provide for the continuing development of these services.

As Deputies will be aware, there is a continuing high level of demand for orthodontic treatment. Cases requiring treatment have been categorised depending on the severity of their condition in accordance with guidelines issued by my Department. I can make copies of these guidelines available to Deputies who wish to see them. Approximately 12,000 children are currently receiving specialist orthodontic treatment and it is estimated that a further 4,000 children are receiving treatment at primary care level. Following a review of the salary and conditions of the post, a number of health boards have been successful in recruiting consultant orthodontists. This will allow for further improvements in service levels. I am urgently looking at ways in which the services can be further developed in a manner consistent with the cost-effective use of resources.

Policy reviews have been carried out in recent years on the services for people with a mental handicap and for those with a mental illness. The development of these services has benefited considerably from the debate generated by these reports. There has been no similar initiative in relation to services for persons with physical disabilities. Since taking office I have been concerned that services for people with physical disabilities have not been receiving the attention they deserve. There is a need for an in-depth examination of this area. Accordingly, I am at present finalising the establishment of a review group to make recommendations for the expansion and improvement of services for people with a physical disability within the framework of the commitments in relation to the physically disabled contained in the Programme for Economic and Social Progress.

As a result of discussions with the Irish Medical Organisation on the recently submitted report, Community Medicine and Public Health — The Future, the Hickey report, I have agreed in principle to the establishment of a regional public health function in all health boards to be headed by a director of public health who will be a member of the health board management team. It is intended to open discussions with the relevant staff organisations in relation to this matter in the near future.

A committee on cervical screening were established in 1988 to review the cervical screening service. This committee have produced a very constructive interim report which was circulated to all the relevant hospitals, organisations and individuals. I will gladly make a copy of the report available to Deputies. I reconvened the committee in accordance with the undertaking given in the Programme for Economic and Social Progress and they will be meeting shortly. One of the major items to be included in their terms of reference will be a review of the operational efficiency of the test notification procedures. I can assure the House that I am fully committed to ensuring that the service available is both comprehensive and effective.

The Estimate provides for a wide range of important service improvements in acute hospital services, throughout the country. I should like to refer briefly to a number of these items. The commissioning of phase 1C in St James's Hospital was completed in January this year. The theatres, recovery area, burns unit and ward blocks, 279 beds, are now open. I would advise Deputies to visit the hospital to see these facilities which I believe surpass those available in London hospitals. These facilities replaced substandard accommodation on the site. In addition, I have announced the provision of capital funds to begin construction of a new oncology-bone marrow transplant unit to be built.

I have made special provision this year for the development of a medical genetics service at Our Lady's Hospital, Crumlin in line with the recommendations for a medical genetics service in Ireland made by a special committee. Funds have also been provided for the appointment of an additional consultant cardiologist. The recently opened oncology unit will also be brought up to full strength in the near future, with the appointment of a second consultant oncologist and some 15 support staff for the unit. Provision has also been made to enable Our Lady's Hospital to continue to train medical and nursing staff associated with the new national liver transplant centre. Special funds have also been allocated to enable the hospital to provide services for children affected with the HIV virus and AIDS related complaints.

A specific provision has also been made for the liver transplant programme at St. Vincent's Hospital to allow the current arrangements with King's College Hospital in London to continue with a view to returning the programme to Ireland later this year. Special funding has been set aside to enable the establishment of a joint department of anaesthesia serving all the hospitals in the south Dublin area. Funding has also been provided for further development of the oncology service at St. Vincent's Hospital with the appointment of a further consultant oncologist.

Funding for ultrasound equipment to carry out cordocentesis, a procedure to detect blood flow within the foetus and to identify blood vessels from which to take samples, has been provided in the National Maternity Hospital. This means that babies who previously had to be referred abroad for the treatment can now be treated in Ireland.

To date no public hospital has acquired it own magnetic resonance imaging facilities. MRI scanning has been available to public patients only through private hospitals with the fee being paid by the referring hospital or health board. Agreement was recently reached with the Northern Ireland health authorities on a joint purchase arrangement for MRI equipment and, as a result, MRI facilities are to be located at the Royal Victoria Hospital, Belfast and Beaumont Hospital, Dublin. The provision of the equipment, including building work at Beaumont Hospital will cost approximately £2 million and it is expected that commissioning should be completed before the end of 1992.

Deputies will be aware of the Government decision announced last September to prepare legislation to provide for a single new authority who will be responsible for all health and personal social services in the Eastern Health Board area. Because of the range and complexity of the services, and their vital importance to the community, I have to be satisfied that any changes will be based on the most careful, thorough and informed study of all the relevant issues. The process began with the work of the Commission on Health Funding. Following publication of their report, the Dublin Hospital Initiative Group and the Hospital Efficiency Review Group were set up to examine the specific problems in the Dublin region and in the acute hospital sector. The failings identified in the existing system included the lack of co-ordination between hospital and community-based services, the resultant over involvement of the Department of Health in the management of individual services and the lost opportunities for achieving efficiencies through greater cooperation between agencies, both statutory and non-statutory.

An Ceann Comhairle

I am sorry to interrupt the Minister but the Chair is bound by the decision of the House this morning with regard to the amount of time available to the Minister and the other spokespersons. I am sad to say that the time available to the Minister is exhausted.

Dr. O'Connell

How many minutes have I left?

An Ceann Comhairle

None.

Dr. O'Connell

Finally, I wish to say that the new authority will take over the present functions of the Eastern Health board as well as some of the functions of the Department of Health. I referred earlier to this point. The Deputies have copies of my speech and if they wish to raise any questions my officials will be glad to be of assistance to them.

An Ceann Comhairle

As the Irish saying goes, ní fhanann an t-am ná an taoide le héinne.

Mr. R. Bruton

I am sorry the Minister did not have the opportunity to finish his speech. Nevertheless, I availed of the opportunity to glance through it. I should like to congratulate the Minister in the sense that this is the first formal Estimates debate in which he has taken part. I wish him well in his work. If most of my comments are somewhat critical it is principally because of the time constraints. I welcome some of the measures announced by the Minister, for example, the special attention being paid to public health as an element of health care.

First, I wish to express the sympathy of the House to the family of the Raheny man, Noel Murphy, who died because he could not get a heart transplant. This is a reminder to us that we do not have an effective donor system. The Minister should push for the introduction of such a system. For my part, I intend to sign a donor card which is no bigger than a cheque card and can be kept in a wallet. This card commits a person, in the event of an accident, to donating their organs. It costs nothing and it should be encouraged.

This year we plan to spend a sum equivalent to £750 for every household in the country on health services but, in many instances, basic needs are not being met. We have to consider the Government's priorities in relation to health. I took the time to look at the spending plans for the past five years to see where the money was spent. In the past five years an overall cut of 2.5 per cent was imposed in the health budget. We can learn of where the most severe cuts fell in today's Estimates. They include: for people with a handicap, a 7 per cent cut over the five year period; on home nursing services for people needing care and support in the community, a 6 per cent cut; on psychiatric services, a 19 per cent cut and on preventive medicine, an 11 per cent cut. Fine Gael believe that those are priority areas that should have received extra funding rather than being singled out for the most severe cutbacks. If the Minister does the calculations he will find that which I have outlined is correct.

Priority does not lie in relentlessly increasing the drugs budget, which has been a feature of Government spending in the past five years. That does not address the problems in the health services. Sadly, basic needs are not being met. People with a disability are denied even basic rights such as the rights to education, therapy and a place for care as well as the right to avail of training and obtain gainful employment. We have seen in the newspapers in recent weeks reports of 24 children who have no place to go. If those children were able bodied they would not be in this position. After receiving expensive training they will have to revert to doing nothing in their homes. More than 1,000 people are waiting for residential places. While the Minister's allocation this year is welcome, the overall services have been declining and do not provide for the escalating requirements in this area.

The country's 66,000 carers are struggling, with little or no support. They have to provide care 24 hours a day, seven days a week, 52 weeks a year without a break and many are strained to breaking point. There are four times as many people with chronic illnesses being cared for at home as are being cared for in hospitals or in residential care, and the resources needed to support them are not available. The budget for public health nursing, home help service and therapy in the community amounts to less than £10 per week per person cared for at home. The total sum is less than the cost of running one good sized hospital. This is the area in which the most severe cuts were made under the Government's ruling.

People find it impossible to provide a public health nursing service because they are being constrained in their ability to travel to patients and so on. If the State had to provide care for the many people being cared for in their homes it would cost at least £450 million. Yet carers are given no proper support. The cost of caring is not recognised in the tax code. The carers' allowance is derisory and an insult to the people. As the Minister knows, only 3 per cent of carers receive the allowance. It is available only to people who are effectively on the breadline. A married couple on £100 a week would not qualify for the carers' allowance.

In the area of disadvantage there is a definite link between illness and poverty. In deprived areas of Dublin the death rates are double the norm. The incidence of major illness for an unskilled or unemployed person as shown in the recent ESRI study is two-and-a-half times that of a professional and the incidence of psychiatric illness for an unskilled person is ten times that of a professional. Yet patients in disadvantaged areas suffer most as a result of the restrictions in recent years. I do not need to tell the Minister that the people in Tallaght, where there is a population of 250,000, have, for 12 years, been waiting for a hospital. These people got a firm promise in the 1989 general election from the Minister's party that work on the hospital would commence in 1990, but that did not happen. Many of the most deprived sections of the community live in that catchment area and those people are missing out on services that we know they should have. This is not an insuperable financial challenge. Last year the Minister provided £15 million in the Estimates to Ardkeen Hospital in Waterford which was needed, but all that is required in Tallaght is that a similar amount be provided each year during the period of construction of the hospital. That is not an unreasonable request.

Public patients still have to wait for an intolerable period for basic services that would transform the quality of their lives. I refer specifically to cataract removals, hip replacements and heart surgery. These are core services that should be an integral part of the health services. Many patients were very concerned at the cavalier way in which the Minister suggested that heart surgery is a fashionable operation. People who are in pain have been told by professionals, who hotly dispute the Minister's claim, that they need this operation. Such a claim suggests that the Minister's actions might result in waiting lists becoming longer. It is sad that in many cases it is only when patients suffer trauma and are brought to a casualty department that they receive care. That is unacceptable. The Minister should guarantee a maximum time for which a person would be expected to wait for surgery in those important areas. Guarantees of that nature are integral to a patient's charter.

There have been reports in recent weeks of difficult children who become homeless in our towns and cities being left without help. The Minister will have read recently about a young child who was sleeping rough and was prey to the obvious hazards of substance abuse, prostitution and crime. A basic service is not being provided in that area.

Elderly people who have given a lifetime of service to this country are not receiving a proper service. Many of us know of cases of elderly people who fell and broke a limb being released from hospital prematurely and having to go back to homes where there was no support service available. Public health nurses and therapeutic services should be provided in these areas, but that is where the severest cuts are being made. Since 1988 the Department of Health were preparing legislation on nursing homes and an Act was passed, but four years later no regulations have been made to implement the provisions of that Act. Some nursing homes are not up to standard. In most parts of the country no subvention is available and even in the Eastern Health Board area where the subvention is provided it is inadequate, with the result that many people are living in penury.

If one spouse goes into a nursing home the other is left on subsistence levels, after the subvention. That is the way the system works. It is not acceptable. There are far too may gaps in these services. I cannot accept that the Department, who have had four years to think about this, are still struggling with the writing of regulations. It strains credibility beyond any level. I am glad the Minister has made a commitment to resign as Minister if this is not in place before the end of this year.

Dr. O'Connell

Within 12 months.

Mr. R. Bruton

I will have to check the record. My interpretation of what the Minister said was that it was 31 December 1992. We will have a new year election.

Mr. McCormack

There will be an election anyway, before that.

Mr. R. Bruton

The Government's spending priorities have not been designed to address these problems. Many of the problems have got worse because of the Government's approach. I was very disturbed at the Government's decision to reject the Health Commission's proposal for a common waiting list for four hospital services. That was the key to providing equity in access to health care. The principle they expounded, that access to health care would be on the basis of medical need, was thrown out by the Government. Instead, we are to have a policy of separate treatment, access and waiting lists which will copperfasten a two-speed health service. It is quite clear from the Minister's announcement of the allocation of beds in public hospitals that we will not have any equity in access to care under the Minister's new regime. The Minister overlooked the fact that there are substantial private beds in private hospitals that greatly outweigh the bed availability for public patients. There is no equity in what the Minister is offering to us.

A stack of legislation is not being implemented. The Child Care Bill, for instance, has been in gestation for at least seven years, if not longer, and still substantial sections of it have not been activated, even though they have passed into law. There have been many false dawns. The Programme for Economic and Social Progress was to mark a decisive watershed in the health services. An extra £190 million was to be provided for community care. We thought that at last the Government had recognised that community care in Ireland should not mean that the family would have to bear the burden, and that there would really be support services. All sorts of services were to be funded. There was to be speech therapy available, carers were to have access to nursing support and respite care and so on. Within seven days of the signing of the Programme for Economic and Social Progress we saw the reality in the details of the 1991 budget, when not one whit was allocated to this programme promised to the social partners. By this year's budget, all pretence at honouring those commitments had been abandoned.

In the past 12 months we have seen a catalogue of unacceptable attacks on the few services that trickle down to patients. The drugs refund scheme was cut to such an extent that for a family who were just over the medical card limits, it was virtually abolished. We had the ludicrous rota of the accident and emergency services due to cutbacks. At the end of last year the Minister finally recognised the lunacy of this and that it did not even save money. We also had a totally unacceptable measure to grab £3 million from VHI reserves which had been set aside for the future health needs of VHI members, who are paying their full health levy of £250 a year and who are not availing of public health services to which they are entitled. Under our Constitution, revenue should not be gathered by taxing groups of people in that way. It is not in the common good which is the fundamental principle of our Constitution.

This Government have been very strong on promises, and I worry that the Minister will add to those promises. The Minister has on numerous occasions talked about solving all sorts of problems, but we have not seen the action. The Minister was to tackle the urgent need for modern family planning legislation, but only last week the Taoiseach told us that he had not even circulated the proposals to his colleagues.

I am seriously concerned about the management of the Department of Health in the last few years under the stewardship of a series of Fianna Fáil Ministers. The most basic element of management is being able to calculate how much is needed to provide a service. In 1990 the Minister overran his budget by £56 million, 4 per cent of total spending and in 1991 the Minister overran his budget by £104 million, 7½ per cent of the Health budget, even after the mid-year cutbacks. That is clearly a breakdown in the ability of successive Ministers to manage that Department. If that was repeated in every other Department it would double our borrowing requirement and we would be in economic crisis. In the general medical services area the overrun in two years was 23 per cent despite the introduction of a system of capitation which the Minister claimed was designed to get a tighter control over spending and make the GMS more cost effective.

There is a serious lack of strategic thinking about the provision of care for people. Decisions are made on a hand-to-mouth basis and that was very evident in the mid-year cutbacks in 1991. Health targets have not been set and there are no quality of service indicators in our health services against which hospital managers can be judged. Health promotion and preventive medicine have been the Cinderellas of the service and have been subject to the most severe cutbacks. The Department are still no closer to allocating budgets for health providers on the basis of the services they make available. Efficient managers are not given the reward for excellence and the incentive to develop cost effective procedures. Despite persistent declarations by Ministers for Health that their priority is to shift the focus away from acute hospitals into the community, we have seen the opposite. The hospitals now control 73 per cent of the general Health budget and this share has been growing in the last four years. If we judge from last year's capital programme we will see that 95 per cent of that went to hospitals, building up the dominance for the future of the hospital budget.

The focus should be on community care, on primary care and on the GP service which could be the focus to develop many more services. General practitioners have the capacity to diagnose and treat many chronic illnesses effectively in the community, but their progress in developing those services has been arrested by the Department, who have not given out any grants under the scheme that was to encourage this development.

The AIDS crisis was not mentioned in the Minister's speech. I know that the Minister cannot mention everything but that is an enormous priority. The Minister again announced that another consultant was to be appointed. That announcement was first made above five years ago and still the appointment has not been made. Events have overtaken the Minister. He will have before him the Comhairle na nOspidéal report on AIDS which says that the consultant requirement for AIDS treatment is four now, and that this will need to be reviewed in a few years. That is only an example of the lack of attention to this problem. General practitioners in the inner city are trying to provide care for patients with AIDS on a budget of about £18 per year, not per week. That is ludicrous.

Mr. Howlin

Since the Minister's party returned to office in 1987 I have spoken many times in health debates, on Health Estimates and various health matters. Today we have a new Minister, the third Minister for Health whom I have addressed in this House. I hope there is an opportunity to redress some of the mistakes of past years. I mentioned 1987 because it was a very significant year. It saw the launch, subsequent to a general election in which the health services figured largely on billboards across the country, of a policy which had a fiscal core but did not have a health strategy. The devastation caused by the series of decisions made in 1987 still has resonances in the health services which people have to endure.

It would have been my earnest hope that I could use the opportunity of this debate to congratulate the Minister for Health on progress made in respect of a wide variety of problems that we all know exist in the health services. The Minister came to office with a reputation as an activist and he has certainly talked up a storm and indicated willingness to grapple with issues which have been largely ignored for some years. So far there has been a lot of talk and very little action. Most, if not all, of the problems that he could readily have identified from his background in medicine and as a backbencher in this House are still in evidence. In short, the crisis in the health services that dominated the general election campaign in 1987 and particularly in 1989, when Ministers and the Taoiseach finally acknowledged that there was a problem, still remain to be addressed. There are still queues and bed shortages and a difficult working environment in which we asked the best and most committed health workers to struggle to maintain decent standards of patient care. There is a crisis in morale and very little has changed since the Minister came to office. The problems may have slipped off the front pages of newspapers and out of the focus of television programmes, but that is because we get weary of the same stories. The evidence in regard to health services is known to every Member of this House and is a feature of our clinics and our relationships with constituents. Nothing has been done to generate any fundamental improvement in the people's health service since the most recent change in Government personnel.

The same is true in relation to a number of more specific areas such as Tallaght hospital, the Adelaide hospital, the situation in regard to carers, the whole area of administrative reform and the issue of AIDS, which was a crisis a few years ago. It is as if that crisis has passed.

Dr. O'Connell

We are taking care of it.

Mr. Howlin

Unfortunately the Minister has not taken care of it. That is a complacent attitude but the reality is that we have one of the fastest growing AIDS problems in the world. It is small now but potentially devastating. We need to keep the focus on AIDS, yet it did not merit a mention in the Minister's speech. These are just a few of the major issues which have yet to be tackled and in respect of which there is no clear policy from this Minister.

In the legislative area the Minister has failed to address a number of important matters. The issue of the Health (Family Planning) (Amendment) Bill has reached the stage of farce. In the light of all that has gone on in recent days, one would have thought that this major measure would not have presented any great difficulty for the Minister but we still have no Bill. This morning on the Order of Business the Taoiseach could not say if the Bill is to be enacted or to be withdrawn. Where are we going if we cannot get basic answers to these fundamental questions for which this Minister is responsible?

It would be unfair to say at this stage that the Minister is in any way a failure but he ought to be on notice that his actions are being carefully watched by this House and by the people and if he does not soon begin to deliver on the words that are strong and promising we will become agitated and we will campaign again for him to move on. In relation to this Minister's performance, the jury is out and it is time for him to deliver.

I have only 20 minutes and rather than attempt in that short time to address in any clear way an analysis of all areas of health expenditure, I want to focus on a few areas. I hope the Minister will respond by giving his views. First I refer to the on-going crisis in Beaumont Hospital. Early in April I made a number of remarks in this House and elsewhere about the critical situation there. Those remarks were critical of the board of Beaumont Hospital. I called for a public inquiry into the situation there. Since then both I and other members of the Labour Party have received a number of letters from the board, all of them couched in overbearing and somewhat threatening language and all of them basically demanding retractions or repudiations of the Labour Party comments. According to the board, my comments are the source of "much public disquiet" about the hospital. I understand that similar tactics were employed by the board to try to silence media comment about the situation in the hospital also.

I have refrained from further comment in the matter up to now, partly at least because there is a statutory inquiry going on into one aspect of the affair, and also because a pending inquest will have a bearing on one other issue involved, but it would be remiss of me not to refer to the issue in this debate.

The events that have surrounded Beaumont Hospital in recent years include the dismissal of two senior staff members, the suspension of another, a series of Medical Council inquiries based on serious allegations made within the hospital, a number of expensive court hearings, numerous letters to the papers making strong allegations of all sorts, a statutory inquiry, and an inquest. There have been at least two independent medical reports into some of these issues, together with a report which was apparently an attempt by the two independent experts involved to reconcile their original documents. Considerable sums of public money have been eaten up by all these matters. Patients and the public are deeply concerned and anxious about all these matters.

None of these events was instigated by me or by the Labour Party. The problems of Beaumont Hospital originated within the hospital itself, and not as a result of any outside agitation.

The position of the Labour Party has been clear from the outset of this whole affair, and I wish to reiterate it here. I will continue to reiterate that, despite any threats from the board of the hospital — that is what a public representative must do. We have not taken any side in the affair. We have called for a public inquiry to clear the air, and to provide necessary reassurances to the public who pay the hospital's bills and depends on its services. I hope the Minister will give a clean indication of his proposed actions to resolve these problems.

There is public anxiety about the situation. Wishing to have it go away will not have the desired effect. Instead of trying to silence criticism by publc representatives or by journalists the board of Beaumont Hospital should long since have called for the establishment of an independent inquiry to clear the air once and for all.

I wish now to turn to another issue, one which I consider to be of paramount importance in the health services — there are very many issues I could address — the situation of the mentally handicapped in Ireland. Recently, the Minister for Health, in answer to questions in this House said he wished to make it his number one health priority. On that occasion I offered him my support and that of my party to do just that. I meant it then and I mean it now. The crisis in mental handicap is not just a health crisis, it is also an education and a training crisis. The Government's recent policy document on needs and abilities, not only calls for substantial increased funding for the whole area of mental handicap but also called for a much better co-ordination of and the delivery of services, particularly between the three Government Departments involved Health, Education and Labour.

Two salient facts underpin the present dilemma: first, the Government are already £25 million behind the financial commitment called for in their own report and, second, not only has there been no attempt to improve the co-ordination, deemed to be vital between the Departments concerned, but it appears that the Departments of Education and Labour have been specific and vigorous in regard to such co-ordination.

We have known for some time of the existence of huge shortfalls in the provision for residential needs of people with a mental handicap. That shortfall continues to represent a source of tremendous fear and insecurity for the parents and families of all the people involved and a major impediment to the goal of an independent life for as many people as possible with a mental handicap.

There is now emerging a second crisis area — the area of training and employment. Because of the underprovision over many years by the Exchequer, virtually all training services for people with a mental handicap are entirely dependent on finance from the European Social Fund. Quite frankly, many administrators in this area spend more of their time too-ing and fro-ing to Brussels to secure that funding than administering the services.

It is a basic condition of all ESF funding that the training provided must be geared towards employment in the open market. That condition has been ignored and to some extent abused by some of the agencies in recent years. As a result, administration and control of the finance has been increasingly centralised in the hands of the National Rehabilitation Board.

The net effect of this has been that many young people, leaving special schools at 18 or 19 years of age, now face two levels of assessment before they can be guaranteed a training place. They have to be assessed first — as they always had been — to determine the extent to which further training will contribute to their development and the kind of training most appropriate to their needs. There is a new level of assessment now to determine whether or not, as a result of training, they are likely to secure employment in the open market. This newer assessment is becoming an annual feature. Young people with a mental handicap who embark on a three-year training programme can be told at the end of the first or second year that there is no longer a place for them or that they are no longer suitable for that particular type of training.

This, in turn, can have two further effects. First, a considerable number of young people are now sitting at home with their parents or their guardians, deprived of any training whatsoever because someone has determined that the training will not give them a job at the end. Second, the quality of the training has been effectively downgraded to try to fit the open market employment requirements.

As a result many people are being trained in boring and repetitive tasks which have no therapeutic or developmental value, but which have some commercial value. There have always been employers even in the public service, who will hire cheap labour to do casual work, for example, pack bags, sweep floors, sort washers or something equally trivial. Considerable amounts of EC money, and smaller amounts of Exchequer funds, are being spent at present to train people with a mental handicap for that sort of life and that is not good enough.

There is another consequence, too, of this whole approach. Because of the condition I referred to earlier, EC funding is not availalbe for sheltered employment. The Exchequer is unwilling to spend a penny on sheltered employment. The result is that many of the agencies which offer sheltered employment facilities, some in high quality surroundings, are in a state of bankruptcy.

There is no future for many young people with a mental handicap unless they are provided with training geared to their real needs and with a decent prospect of sheltered employment subsequently. In recent years the Government have turned a blind eye to this fundamental reality. They have talked instead — and we heard it again today from the Minister — about concepts like integration of the mentally handicapped into the community.

Integration should be a choice which is open to the person with a mental handicap. Instead, I regret to say, it has become a code word for doing things on the cheap. Unless this issue is addressed at the most fundamental level — that means Irish taxpayers' money and not European money — I predict that within five years we will all see and become aware of the appalling and deplorable conditions which face many young people with a mental handicap.

The tragedy is that a community filled with goodwill towards people with a mental handicap are unaware of this reality. I can promise the Minister that if he means what he said in the Dáil, when answering health questions a week or two ago, about making mental handicap his number one priority he will get all the support he needs from us. It is the only true mark of a caring and civilised society that it is prepared to pay special attention to the needs of these citizens who have no voice of their own.

I wish in the few minutes remaining to turn briefly to a couple of other areas. Instead of commenting I shall ask questions of the Minister. I know I should do this at the end but it may give the Minister and his officials time to consider their replies. Since the commission on health services funding reported in September 1979 we have been promised fundamental reorganisation but what we got was a series of committees. I should like to know the Minister's intentions. It is not good enough for the Minister to talk about giving the most careful, thorough and informed study of all the relevant issues. We are sick to the teeth of hearing about careful studies. There are so many reports in the Minister's office I am surprised there is room for himself. More committees have been established by him and his two predecessors than in any other Department. At one stage 22 different committees were sitting in the Minister's Department. It is time to act. Can the Minister indicate to the House today his intentions in relation to the administration and organisation of the health services? Has he rejected the notion the executive authority of the commission put forward? What are his priorities? Does he accept the notion of health being a right? That is what the commission recommended and they said it was also the view of the Irish people. What is the Minister's attitude in relation to the Health (Family Planning) Amendment, Bill? Will he accept the issue of ment handicap and make it the number one priority in his Department?

Acting Chairman (Mr. Wyse)

I would ask the Deputy to conclude.

Mr. Howlin

What improved resources would he make available to carers? There are a number of issues I wish to raise at the conclusion of this debate. Our people are a caring people. They are willing to pay and support a Minister who will provide a health service that will look after all our people. I hope this Minister, new to his brief, will prove to be that.

Minister of State at the Department of Health (Mr. Flood)

I welcome this opportunity to take part in the debate on the 1992 Health Estimate. This year will see steady progress in the development of the health services both in the community and institutionally based services. My colleague, the Minister for Health, has already referred to a wide range of the developments which are taking place this year. I would now like to focus in particular on developments in the areas of child care services, public health, AIDS/HIV and drug misuse.

With regard, first, to child care services a number of important developments are taking place in this area in the wake of the enactment of the Child Care Act, 1991.

The Act represents the most comprehensive reform of the law in relation to the care and protection of children since the foundation of the State. It provides a secure legal framework for the future development of our child care and family support services. It envisages a fundamental change in orientation from a system rooted in charity and crisis management to one in which the emphasis is on prevention, participation and welfare rights. The principles enshrined in the new legislation will shape future policy developments in this area.

The Act contains a wealth of new and improved provisions designed to promote the welfare of children. These range from granting health boards new powers to provide child care and family support services, the introduction of new legal procedures to enable the health boards and the Garda to intervene where children are being neglected or abused, to new legal controls on pre-school services and children's residential centres.

Given the scale and complexity of the new legislative provisions, it has always been recognised by all sides of the House and by the various interest groups that the Act would have to be implemented on a phased basis over a number of years. The implementation of the Act will require a sustained programme of investment to provide additional community care staff, to develop new and improved residential and community facilities and to evolve locally based responses.

This is acknowledged in the Programme for Economic and Social Progress which contains a specific commitment to gradually increase the number of community based child care specialists and home support services for problem families over the period of the programme.

The Government are committed to providing the additional resources needed to bring the Act fully into operation as soon as possible. As a first step, a sum of £1 million was set aside in last year's budget to fund essential service developments preparatory to the implementation of the legislation.

Among the new developments approved during 1991 were: 30 additional social workers; new hostels for homeless youth in Dublin, Galway, Sligo and Athlone; new residential services for adolescents in Dublin Cork and Limerick; new child psychiatric services in the North-Eastern, South-Eastern and Mid-Western Health Board.

As the House will be aware, the Minister for Finance announced in the budget that a special allocation of £2 million is being provided in 1992 to enable further developments to take place in the child care services in accordance with the commitment in the Programme for Economic and Social Progress. This is in addition to the £3 million already in the system and brings our investment in the Act this year to almost £5 million. The additional moneys will be used to give effect to a number of important provisions of the Act. These will impose a statutory duty on health boards to: promote the welfare of children who are not receiving adequate care and protection, provide accommodation for homeless children, provide or ensure the provision of an adoption service in their area, and to establish a Child Care Advisory Committee to advise and assist them in the performance of their functions.

The additional moneys will enable health boards, in association with the voluntary sector, as provided for under the new legislation, to begin to develop a comprehensive range of child care and family support services, to recruit additional social workers, child care workers, child psychologists and child psychiatrists and to develop family resource centres and other special initiatives for families facing particular difficulties.

Over the past two months, there have been significant developments in relation to our approaches to the management of AIDS and drug abuse.

Last year, the National Co-ordinating Committee on Drug Abuse, which I chair, produced a comprehensive set of recommendations which form the Government Strategy to Prevent Drug Misuse.

In view of the link between intravenous drug abuse and HIV in Ireland, the objective of the strategy and drug misuse were further consolidated by the establishment of the National AIDS Strategy Committee.

We now have available to us two comprehensive, interdependent strategies which will enable us to approach the problem of drug abuse and AIDS, in a co-ordinated and integrated manner. I am also pleased to inform the House that almost £3 million has been allocated towards the implementation of both strategies.

To date, a total of 272 cases of AIDS have been reported. Of these 108 have died. The voluntary HIV-testing service indicates that over 1,200 persons are actually carrying the virus in Ireland. With the natural history of the infection, more persons will, regrettably, be progressing to full AIDS and will require on-going care and management.

AIDS/HIV are matters deserving of the closest attention and consequently comprehensive plans have been prepared to deal with the many social and medical challenges presented by AIDS and HIV. The implementation of these plans will draw on the combined efforts of the health services, voluntary organisations and other areas of the public sector, such as the education system.

Government policy is to ensure that all persons with HIV/AIDS should receive the care and management appropriate to their needs. In view of the nature of the HIV infection, care and management of individuals will be required at all levels of the health services from primary care services through to hospice, palliative and respite care facilities. Our strategy is, therefore, to ensure that such a framework of services is available appropriate to the needs of the individual. This approach is in line with the recommendations of the Care and Management Sub-Committee of the National AIDS Strategy Committee.

Towards this end, a total of £315,000 has been allocated to the Eastern Health Board to establish, by 1 July 1992, two satellite clinics for the care and management of persons with HIV/AIDS. These clinics, which will be run by general practitioners, will operate closely with the community drugs teams which are also being established by the Eastern Health Board, and will provide the required range of risk-reduction services, aimed at preventing the further transmission of the HIV virus. These services will include methadone maintenance, the provision of condoms, needle-exchange, HIV-testing and counselling.

I have also allocated additional funds to the Southern and Western Health Boards totalling £75,000 to enable them to develop their services for AIDS and drug abuse and have asked each health board to implement, as appropriate, the recommendations of the National AIDS Strategy Committee. The Department will be discussing the implementation of the strategies in their areas, with the other health boards very shortly. A total of £50,000 has also been allocated to the voluntary sector in Cork and Galway.

The committee also support the conclusions and recommendations of Comhairle na nOspidéal on the management of AIDS at consultant level and in particular the creation and appointment of an infectious diseases consultant in north Dublin. The process of appointing the infectious diseases consultant for the north side of Dublin has begun and I am confident that the service will be fully operational shortly. When operational, this service will relieve, significantly, the pressure on St. James's Hospital. This hospital has been at the forefront of the AIDS problem for many years now and I am glad to have been in a position to allocate additional funds to the hospital recently to enable it to meet the increasing service needs associated with AIDS. I would like to take this opportunity to thank the St. James's board, the management and the many categories of staff who are involved, for the pioneering work which the hospital has done in developing services for patients with AIDS. I know that it has often been very difficult and I want the hospital to know that their work is much appreciated.

I can assure the House that both the AIDS and drug abuse strategies will be kept under close review to determine the nature and scope of possible further measures required to minimise the difficulties which these problems bring both to the individuals affected and to society in general.

In the course of the year there has been an acceleration of work on EC measures designed to complete harmonisation of controls by member states in the food and drugs area in anticipation of the completion of the internal market at the end of this year. Ireland must be seen to contribute fully to the evolution of the necessary proposals and administrative actions which are required for this purpose.

In the food area, a wide range of regulations has been introduced to give effect to internal market directives. Among the most important of these was the Health (Official Control of Food-stuffs) Regulations made towards the end of 1991. These regulations implement the terms of a general EC Directive which aims at the creation of standards of inspection, sampling and training across the Community. A special allocation of £500,000 has been made to the health boards for recruitment of extra staff and improvement of public analyst laboratory facilities.

A further directive is proposed which will lay down quality standards for laboratory practices and provide for a community inspection service. A draft food hygiene directive is also proposed which will, inter alia, provide for codes of practice for different sectors.

In the field of medicines control, four EC Directives have been adopted this year and four further measures are under examination. The measures adopted to date relate to such matters as advertising, labelling and consumer information, prescription classification and regulation of wholesaling. To a substantial extent, Ireland's national legislation already conforms to the standards agreed. The most significant of the proposals still under consideration at Community level is aimed at the establishment of a European system which will significantly reduce duplication of scientific assessment while at the same time ensuring that all relevant safeguards are maintained to protect public health.

My colleague, the Minister for Health, has already made reference to the significant level of resources which the Government have made available for the health services this year. The Government have been anxious to meet the needs of all our client groups and to maintain the momentum with regard to the development of community services as set out in the Programme for Economic and Social Progress within the constraints of overall resource limits. The developments which I have just referred to in the areas of child care, AIDS-HIV and public health clearly demonstrate the Government's commitment to the provision of a comprehensive health service of the highest quality.

Mr. Byrne

To try to cover all of the issues I should like to cover in the ten minutes available to me is asking too much. If time permits, the issues I should like to address are: the Minister's directive to build a central clinical waste disposal incinerator on the site at St. James's Hospital; the incredibly damaging and real prospect of the closure of the only Protestant teaching hospital in Dublin, which would have consequences for the Protestant minority in our society, because of the ongoing bungling about the Tallaght hospital; the ever-worsening plight of the parents of patients and the patients suffering from mental handicap because of severe underfunding and particularly because of the underfunding for the provision of adult day places and adult residential places; the outrageous policy as initiated by the Minister in privatising public beds in our public general hospitals, a policy that would continue to give private patients priority over public patients with its two distinctive waiting lists — one for private patients and one for public patients; the continuing discrimination against public patients by which, for example, in the three private hospitals in this city — the Blackrock Clinic, the Mater Private Hospital and St. Vincent's Hospital — there are magnetic resonance imager scanners but none of the public hospitals has a scanner comparable to those.

It is about the outrageous treatment of women in health, from family planning services to the lack of a genetic counselling service, that I shall make my initial comments. In the light of the public debate that is raging now and has raged for several years, how can this Minister threaten, in an almost sectarian manner, to allow the Adelaide Hospital to close? I have received quite disturbing correspondence from the chairman of the board of the Adelaide Hospital, Dr. David J. McConnell, and I hope that the Minister will pick up that correspondence and respond to it in a progressive manner. The significance of the Adelaide Hospital lies in its distinct and unique ethos and medical ethics. That would disappear with the closure of the hospital. Many Catholic men and women are extremely happy with the ethos and medical ethics of the Adelaide Hospital, and in fact, for very many Catholics in this city that hospital was their first choice.

The Minister has responsibility for the scandalous and out-of-date family planning legislation, which forbids condoms, coils, the pill, IUDs and so on from being prescribed under the general medical services system. I ask the Minister to explain to me what sort of a hypocritical nonsense is it that one cannot prescribe the pill under the general medical services system in this country yet the fourth highest drug prescribed is the pill? Mind you, the pill is not being prescribed for family planning purposes — because that is outlawed — but as a "cycle regulator". Doctors prescribed the pill under the code name "cycle regulator" no fewer than 398,823 times in 1990 under the general medical services scheme.

Would the Minister tell the House, and tell Irish women in particular, where a pregnant and often distraught woman with a history of genetic problems in pregnancy can have an amniocenteses test carried out? The Minister, as a doctor himself, would realise the peace of mind often afforded women who have a history of difficult pregnancies and particularly those who have faced genetic problems. Why is there no genetic service in this country. Why have thousands of our citizens had to go to the Royal Victoria Hospital in Belfast over the years for an amniocenteses test?

On the delicate issue of abortion itself, what has the Minister to say about his so-called patient's charter to the Methodists in Ireland for example, or to Protestants in general, particularly in the light of the threatened closure of the Adelaide Hospital and its ethos? In The Irish Times, under the heading “Methodist Notes”, “The Church supports limited abortion” this delicate issue was addressed. I should like the Minister to respond. The Methodist Church state that when the mother's life is at risk, their first concern would be for the mother, whose first concern must be one of commitment through her own continuing life to her family responsibilities. Their second point is that the limited abortion option would be supported when there was a risk of grave injury to the physical and mental health of the mother, especially if she has family responsibilities, and also in the case of rape or incest. The fourth instance in which they cite support for limited abortion is that of gross abnormality of the foetus, for example, when a reliable investigation indicates that the foetus would be born without a brain or would not long survive birth. In cases of lesser abnormalities, they say that each decision should be made with extreme caution.

Whatever about a united Europe and European union, how can we address the problem to the one million Protestants living on the other side of the Border? How can we assure them that their ethos would be protected if there was a unitary State? I ask the Minister to rise to the challenge and show them, and the rest of us, that he does not believe in the extension of the confessional state to Northern Ireland.

What is the Minister going to do for all of those Irish women who have opted to travel to England for abortions? Irrespective of the future outcome, be it constitutional or legislative, Irish women will continue to seek abortions as a solution to their predicament. Would the Minister agree that because of the lack of access to information on appropriate aftercare, many women fail to have the important check-up after six weeks? I am sure that he knows that the lack of that check-up may leave minor infections undetected and put women's gynaecological health at risk. These are our citizens, these are our Irish women. Does the Minister, as Minister for Health, have an obligation towards them?

Why must we leave the care, the welfare, the sympathy, the understanding and the education of the medical position affecting those women in the hands of groups such as the Womens' Information Network, who provide non-directive counselling? Equally, the network provide an emergency telephone help-line service which offers non-directive pregnancy counselling and information on abortion. For the record, in case there is any unfortunate citizen of our State now requiring such counselling, I advocate that she should ring the following telephone number, which would give her access to the Women's Information Network; 6794700.

Mr. Callely

Is the Deputy looking for coverage?

Mr. Byrne

That telephone number is available in the telephone directory.

Acting Chairman (Mr. Wyse)

Deputy Byrne, you have exactly one minute left. Time is running out and I am trying to facilitate as many speakers as possible. I shall be strict as regards the remaining one minute.

Mr. Byrne

I should appreciate it if the Government Members stayed quiet for a moment so that I could make my point.

Why does the Minister believe that the people in the catchment area around St. James's Hospital should have to put up with the potential pollution caused by the building of a central clinical waste incinerator on their doorstep? Would the Minister assure the House that he will issue a directive cancelling the proposed project for the St. James's Hospital site?

Acting Chairman

The Deputy must conclude.

Mr. Byrne

I am concluding now.

Mr. Callely

The Deputy is fuelling the concern.

Mr. Byrne

In conclusion, would the Minister not agree with me that it would be completely wrong for all the clinical waste of every hospital and home, including the three private hospitals, to be deposited on the doorstep of our constituents living around St. James's Hospital.

Acting Chairman

I must ask the Deputy to resume his seat. Before calling on Deputy Fitzpatrick, I wish to inform the House——

Mrs. Fennell

On a point of order, I oppose the order of speakers. I came into the House with a script——

This was not raised on the Order of Business.

Acting Chairman

There is nothing more the Chair can do in that respect. I wish to inform Deputy Fitzpatrick that he has five minutes and that at 12.15 p.m. I will be calling on the Minister to reply.

Dr. Fitzpatrick

I seek the permission of the House to share my time with Deputies Callely, Burke and Roche.

Acting Chairman

Is that agreed? Agreed.

Dr. Fitzpatrick

I would like to refer to the dental service. Let me make a few quick points. The first is that the problem in the dental service is one of management. We have staff but there is a problem about money. It, therefore, comes down to a question of how the available staff should be deployed and it is up to the Minister and the Dental Council to resolve it. I believe, however, that the Dental Council are engaged in restrictive practices.

It was accepted in 1963 that the Dental Hospital was unsatisfactory. Successive Governments made promises both to the hospital and the public that a new dental hospital would be provided but 30 years later we are still waiting for one even though the present hospital is a potential fire hazard and will have to be vacated within five years.

Finally, I call on the Minister, the Eastern Health Board and the Irish Dental Association to provide an emergency dental service at weekends. It is virtually impossible for anyone with a child in pain to find a dentist on a Saturday, Sunday or bank holiday Monday. As we approach a long weekend, I know that many families will go through a weekend of misery because they will be unable to find a dentist who will provide a service to relieve pain.

Mr. Burke

I welcome this opportunity to contribute to the debate on the Health Estimate and to thank the Minister for issuing approval recently for the Swords Health Centre.

I am sorry, Deputy, but I seek your co-operation on this. We must have brief questions.

Acting Chairman

Dr. O'Connell

I should inform Deputy Richard Bruton that the Supplementary Estimate provided over £50 million, including £1.5 million for capital expenditure. There was no question of its being £104 million, as was suggested by the Deputy.

Deputy Richard Bruton referred to the sad position obtaining because of lack of organ donors. I accept the need to intensify public support for organ donation. I will take a special look to ascertain how we can best support the statutory and voluntary organisations engaging in that campaign in order to make people more aware of the tremendous contribution they can make by becoming organ donors.

Deputy Richard Bruton referred also to resources for community services. I have to say to the Deputy that one cannot just close mental hospitals; one cannot just shake out all the staff from hospitals and say one will provide community services. It does not work like that. It would be great if it did.

Mr. R. Bruton

One could fund public health nurses.

Dr. O'Connell

One cannot close all large mental hospitals; one can do so only on a phased basis. Indeed, I am having costings carried out in regard to how we could close our large mental hospitals over the next four years; to ascertain whether, by selling the land, we could provide the necessary community services. But one cannot just do it and get rid of 4,000 or 5,000 staff. There are funds needed annually for mental hospitals and, whether we move towards providing greater community services, staff must be paid. Therefore it is not as simple as the Deputy maintains.

Deputy Howlin referred to the difficulties being experienced in Beaumont Hospital. I fully accept what he said; it is a difficult, delicate position — he and I know that — but we must allow the current inquiry to proceed. I would ask Members to believe that I have been earnestly endeavouring to have that inquiry completed. As Members will appreciate, these difficulties are undermining the morale in the hospital which is not in the best interests of patients. I would appeal to the hospital authorities and staff to do everything possible to reassure patients. It is a wonderful hospital and we are spending a lot of money on it and we want to ensure we get an adequate return. However, many patients have come to me saying they received first-class treatment and care there. It would be my earnest hope that the inquiry be brought to a satisfactory conclusion before long. I might suggest that Deputies Richard Bruton and Howlin and I sit down together to ascertain what we can do in this respect. I would ask them to consider doing so.

Deputy Howlin referred to the reorganisation of the health services. At present we are receiving submissions from the group which are almost complete. Over 100 submissions have been received to date. I promise the House I will report back to them as soon as possible on that matter.

I should stress that I have not forgotten many of the things I said when I first assumed office but, like everything else, it is very difficult to get matters moving. Indeed, when one presents a ten-point plan, the first thing one must do is have it costed by the Department of Finance, which is what is causing the delay.

If Deputy Richard Bruton wants to examine the details of the Supplementary Estimates we will provide him with the necessary information with regard to apparent lack of control of expenditure on the part of the Department, but the position is not as he stated. He also held the Government responsible for the growth in expenditure on drugs. I should remind the House that new, sophisticated drugs emerge every year. They are costly, patented drugs. What happens is that one puts a patient on a costly, new drug keeping him or her out of hospital. We do not cost savings in that way. We are now able to treat severe, malignant-type cases, normally hospitalised and in need of constant care, on an ambulatory basis. The same applies to other diseases affecting the gastro-intestinal system, respiratory complaints and so on. These patients can now be treated without being hospitalised but it is costly.

Mr. R. Bruton

But only 5 per cent generics.

Dr. O'Connell

These are demand-led schemes because we cannot predict or say tomorrow that only so many people can become ill. We have no control over that, so whenever more people become ill, it involves greater expenditure. That is what is happening. We are still endeavouring to control costs. There is an interdepartmental examination of the cost of drugs and their report will come before Government very soon. But we do examine every possible way of controlling costs. Indeed, I might point out that the savings apply to the Department of Social Welfare, not the Department of Health, since people are restored to health and enabled to work again.

I wrote down the points Deputy Richard Bruton made. For example, he claimed there has been a 19 per cent reduction in the allocation of funds to psychiatric services. In fact there was an 8 per cent to 10 per cent reduction — in real terms 8.4 per cent, information which was given in reply to a parliamentary question on 13 May. The Deputy may not have been furnished with the full details but it was an 8.45 per cent real decrease in revenue and a 9.92 per cent reduction in revenue and capital.

I wish to thank all the Deputies for their positive contributions.

Mr. Byrne

The Minister gave no answers to anybody.

Dr. O'Connell

I hope to work more closely with all Deputies and should anybody want more information, it is my intention that the Department of Health should provide it. That is the way we should operate, and we will.

Acting Chairman

Thank you, Minister.

Dáil Éireann díospóireacht - Thursday, 28 May 1992