In accordance with the order of the House of today, the Minister for Health and Children will now take questions on the health services.
Health Services: Statements (Resumed).
I wish to raise with the Minister for Health and Children the extraordinary approach taken earlier today by the Minister of State at his Department. I presume the Minister is aware that the Minister of State, Deputy Fahey, when discussing the state of waiting lists and the difficulties experienced by hospitals, referred to everyone playing a part in the difficult decisions that often go with trying to match immeasurable demands with measurable resources. Regardless of differences which exist between us, I am sure the Minister will agree that, in the context of the health area, to some degree there will always be demands which cannot be met.
Is the Minister in a position to reconcile the fact that the Minister of State can state one thing in the House and something different in his constituency? It appears that Deputy Fahey roars like a lion in his constituency and squeaks like a mouse when in the House which is a phrase used by the late Deputy Kemmy to describe another Member of the House on a different occasion. Has the Minister seen the Connacht Sentinel of Tuesday, 10 November which carried the rather elaborate headline “Fahey tells meeting: ‘Hospital cuts fault of top management’”? In dealing with the situation in Galway, is he aware that the Minister of State is quoted as saying that the closure of two wards and a theatre would only save £200,000 and that this would not solve the problem——
I draw the Deputy's attention to the fact that it is normal practice for Members to stand during their contributions.
I beg the Chair's pardon. I had assumed the rules to be less formal, given that we are involved in a question and answer session. Is the Minister aware that the Minister of State at the Department of Health and Children, Deputy Fahey, criticised Billy Moran, chief executive officer of the Western Health Board, by stating "The closure of two wards and a theatre are only going to save £200,000. This is not going to solve the problem. I am satisfied it was not necessary to do it this way." The Minister of State also said that he would ask Mr. Moran not to proceed with the closure of the two wards and the theatre.
Will the Minister explain how the approach taken by the Minister of State in his constituency can be reconciled with what he told the House earlier about playing a part in the difficult decisions to which he apparently wishes to be a party in this House but placed apart from when outside it? Will the Minister discipline Deputy Fahey for his attack on a public servant who was not present to defend himself? Will he also indicate to the House the steps Deputy Fahey, as Minister of State, has taken within the Department to try to ensure that beds do not close in Galway and to ensure that the theatre which has been closed for the past three weeks will be reopened?
It seems we will spend the next hour playing political games. Deputy Shatter wishes to make a personal attack on the Minister of State at my Department, Deputy Fahey, and I understand such attacks were made earlier by Deputies McCormack and Ulick Burke.
That is not true.
The Deputy should allow the Minister to continue. He will have an opportunity to ask questions later.
If the Minister of State said the same thing in his constituency and in the House he would not be the subject of criticism.
That is the Deputy's view and obviously he has political reasons to state it. Let us stop playing games. Additional funding will not be provided for the hospital services. Since last December, everyone was aware of the nature of the outlined strategy and the purpose of the accountability legislation. Members will be aware of this because several of them, including Deputies McCormack and Shortall, have served on health boards. I have no problem explaining that we will not go back to the situation that obtained up to recently when we had to plan and develop health services on the basis of allocations made long after the start of the financial year and deputations trooping into Ministers mid-year to bid for more moneys because expenditure was above what was targeted for. In the interest of greater transparency and accountability, the policy of successive Governments since 1993, when historic deficits, totalling £120 million, were eliminated, has been to bring forward prompt payment legislation to ensure small suppliers to the health services do not have to wait ten or 12 months for payment because budgets in the health sector are way out of line. That legislation had the support of everybody in the House and everyone accepted it had to be done. We introduced the Health (Amendment) Bill, 1996, the purpose of which is to make sure we deal first with situations where people get allocations and letters of determination prior to the start of the financial year, to give an opportunity to the health agencies to draw up a service plan, not three or four, during the year, based on the allocation made.
The purpose of these legislative frameworks is to bring some semblance of planning into the health service. Now they are on the Opposition benches, the Deputies opposite say we should not mind that, but put more money into the health service willy-nilly and we will have a better health service. If that were the case, we would have a better health service, because that is what has been done up to now. That does not work. I have made a political decision, with which people in this House may wish to disagree. It has been my contention since I became Minister for Health and Children that the capital base, valued at more than £4.5 billion, the infrastructure which we use to try to deliver a health service, requires major capital investment. We cannot have a situation where equipment is replaced only if it breaks down, paid for with money taken out of revenues. We have to put forward a designated capital budget for that purpose. I have decided on a £10 million re-equipment budget every year to bring more capital investment into the health service so that we can improve morale in the service which has not seen a capital investment programme worth the name for years. Those are the facts. If we want to improve morale in an organisation perhaps we should put more money into the physical environment in which people work. The only way to do that is to enhance the capital programme. If people say this is being done at the expense of day-to-day expenditure in the health service, my reply to that is that last year the increase on day-to-day expenditure was 9 per cent and in 1999 it will be 9.5 per cent. Leaving aside our political differences for a moment, if we all agree there is a finite amount to be spent on the health service during a year, how can we plan for the development of the health service if we then say the service plan drawn up at the beginning of the year means nothing. That makes no sense.
On a point of order——
Tell us why the Minister of State is saying different things in Galway from what he says in this House.
I said the same things.
Is there a limit on the time the Minister can spend waffling.
The Chair has no control over the Minister.
So he can waffle as much as he likes. We cannot get our questions answered if he deliberately waffles.
Deputy McCormack accuses me of waffling. I will tell the Deputy the definition of a waffler — a man who supports a Government which did not provide a brass farthing for the improvement of the hospital he claims to be the protector of——
This is filibustering.
——a Government that decided the amount of capital it would invest in 1997 would be £103 million.
Will the Minister give way to Deputy McManus on a point of order?
Will the Minister answer the questions he is asked?
The difference between us is simply that the last Government refused to draw up a capital investment programme worth the name for the health service and put money on the revenue side. I have decided on a much increased revenue allocation — 9 per cent this year, exceeding £3 billion for the first time on day-to-day expenditure, and 9.5 per cent next year on the revenue side. I have an enhanced capital programme to deal with the underlying problems. The underlying cause of the difficulty in delivering a quality health service is that we have not had a capital investment programme worth the name for years.
The last Government sent cardiac surgery patients to Dublin and spent £60 million in Limerick.
There are escalating waiting lists and the Minister is closing a theatre and putting 45 nurses out of work. It is a disgrace. The Minister of State is not brave enough to say the same thing in two different parts of the country.
Deputy Shatter and the Minister of State, Deputy Fahey, should not interrupt across the floor. Let us try to have an orderly question session. The purpose of question time is to elicit information. If Members do not want to ask questions, that is fine. It is a matter for the Members. I will hear Deputy McManus now.
In that spirit, I wonder if it is in order for the Chair to ask the Ministers to be succinct in their replies in the way he is asking the Opposition to be succinct, and to be equally favourable to the whole process of a question time.
Unfortunately over the years the Chair has had no control over the length of reply a Minister gives.
I am not asking for control. I am asking for courtesy.
I have three questions for the Minister. The first relates to the legislation he has been citing and which I believe he is hiding behind. That is particularly the case in relation to the Minister of State, Deputy Fahey. Will the Minister confirm that there is nothing in the 1996 Health (Amendment) Act which precludes him from making additional funding available to health boards?
Second, in relation to the allocation, the Minister makes much play of the fact that health boards draw up their service plans, the budget is provided and they have to live within that. I do not deny it makes absolute sense to have clear legislation in place which obliges health boards to live within budget. The point I would make is that we are in a unique situation this year.
If at the end of Question Time Members have not had an opportunity to ask questions, it is because people are making repetitive statements. This morning we had statements from Members. This is Question Time. While I would like the Minister to give Members an opportunity to ask questions and curtail his remarks, the Chair has no responsibility or control over the Minister. The Chair does have control over Members, and I will insist, because there was an opportunity for statements this morning, that Members ask questions. There are a number of Members offering, and I want to ensure that as many of them as possible have an opportunity to do so.
Does the Minister accept that in a time of plenty, when we have a budget surplus in excess of £1 billion, it makes sense to invest a proportion of that huge surplus in our health service to relieve the huge pressures that exist, and that if we do not do that in a time of plenty, we will never do it?
My third question relates to the increase in the gross health Vote of 9.5 per cent. How much of that 9.5 per cent is likely to be taken up, first, with medical inflation and, second, with pay increases already agreed?
I will answer the questions as briefly and as quickly as I can. In relation to the Health (Amendment) Act, 1996, we are introducing a Supplementary Estimate precisely to put more money back into the health boards, for example, in relation to demand-led schemes. If the question specifically asks whether I will use Supplementary Estimates to put more money into the hospitals, the answer is "no". The reason suggested in the statements of Labour Party speakers this morning — the idea that section 5 provides an automatic bail-out at any time——
An additional allocation, not a bail-out.
I am giving the Deputy an answer. She can ask another question if it is not clear enough.
I am not talking about a bail-out, I am talking about using Exchequer funds to deal with a social problem.
If the Deputy is not satisfied with the answer, she can ask another question.
The Minister should not twist what I said.
The Deputy suggested that the legislation asks that a serious effort be made to work within budgets. It does more than that, it places a statutory obligation on agencies to work within their allocations. It is not a question of making a serious effort and reverting half way through the year to the old system under which they were bailed out if they were over budget. That is the implication of what the Deputy said. The purpose of the legislation is to provide for better planning and financial management to build a better health service. It does not ask that agencies make their best shot at it or state that extra funds will be made available by way of a Supplementary Estimate if problems arise. If that definition was accepted——
That is not what I am suggesting.
There is nothing to stop the Minister reviewing the position in the middle of the year and recognising the need for an additional allocation. The Minister constantly misrepresents what was said.
I have not misrepresented anybody.
The Minister should answer the question.
I am.
I ask Members to refrain from interrupting. I have two choices, I can ask someone to leave the House or I can suspend the sitting. The Minister should be allowed to reply. Members will have an opportunity to ask questions.
My position is consistent and clear. No one was under an illusion at the meetings I had with health boards, including the one of which Deputy Shortall is a member, before the letters of determination were issued. It was made clear that service plans should be implemented in accordance with the terms of the legislation. Because of increased resources they were in a position to provide for increased levels of activity. Leaving aside the question of whether more money should be provided——
That is the crucial question.
This is the first year in which more than £3 billion has been provided. Because of better financial management of the economy we can plan improvements in public services next year. A total of £920 million will be available for this purpose, of which £354 million will be allocated to the health service. The Deputy is suggesting that some of this money should be spent this year. That nullifies the purpose of the exercise. The service plans for 1999 will provide for these improvements. The pay-related elements account for £200 million of the figure of £354 million.
Does the Minister agree that where income exceeds expenditure the excess should be spent on the provision of treatment for those in urgent need of an operation? Income from the health levies exceeds the amount included in the 1998 Estimates. This is under-standable because of changed conditions. In such circumstances people find it difficult to understand that wards are being closed and patients have to wait for major surgery.
I do not agree with the Deputy. The health service is funded from two sources, the Exchequer grant and Appropriations-in-Aid. It has been suggested that if there is buoyancy in Appropriations-in-Aid, one is off the hook and can increase the level of expenditure.
I did not say that.
It is irrelevant whether the funds are provided by way of the exchequer grant or Appropriations-in-Aid, health agencies have to operate within the authorised level of expenditure. For reasons of political mischief, the Opposition is continuing to suggest that £32 million is being held back from the health service but, as things stand, the authorised level of expenditure will be exceeded. It is nonsense to suggest, therefore, that money is being held back, even allowing for buoyancy in Appropriations-in-Aid.
It is a question of priorities.
The priorities were set at the beginning of the financial year. Economic policy provided for a net increase in public expenditure of 4 per cent. The Department of Health and Children was granted an increase of over 9 per cent. It has been granted an increase of over 9.5 per cent for next year. The reason for the increase is that I have been able to negotiate an enhanced capital programme to deliver the quality of service the people are demanding. It is estimated, as things stand, that the £3 billion barrier will be breached this year.
What about patients' needs?
It is irrelevant whether the funding ratio is 90:10, 89:11 or 88:12 because the authorised level of expenditure remains the same for health agencies.
Patients' needs are something about which the Minister has forgotten.
The Minister has made a virtue out of his consistency. Does he accept that the approach he is adopting only confirms the public's view that we have a hospital service governed by the concerns of accountants rather than of patients? Does he accept that there is an inconsistency in his approach to hospital budgeting and budgeting in the Department in the sense that a Supplementary Estimate is being prepared to provide for extra spending of £75 million? The public find this difficult to swallow. Does he accept that there is an inconsistency also in relation to the commitment in the programme for Government to tackle waiting lists?
Does the Minister agree with the Minister of State who appears to think that there is no problem in patients accessing consultants at an early stage on the pathway through the acute hospital service or does he agree with me and Professor Muiris Fitzgerald, an eminent consultant, that there is a major problem which is creating difficulties for him in spending money to reduce waiting lists?
I asked the Minister by way of a parliamentary question regarding the level of increased hospital activity, which the Minister periodically promotes as positive, especially the increase in inpatient and day services, what proportion of that increase had been directed towards private and public patients. It is an important question because there is a danger of a streamlined service being provided for private patients and of public patients being pushed further down the queue.
First, none of the Supplementary Estimates is for my Department. They are for drugs schemes administered by the health boards, for PRSI and superannuation overruns, etc. Second, the Deputy's view of what the Minister of State, Deputy Moffatt, said is different from mine. Deputy Shortall suggested non-consultant hospital doctors were examining patients without consultant cover. In the interaction which occurred in the House for which I was present, the Minister of State suggested there was back up in terms of senior house officers and registrars. That was his only contribution. He did not suggest there was easy access to consultants. He simply made the point that, in instances where non-consultant hospital doctors examine patients and must make medical decisions, a back up service is available from senior house officers and registrars when the consultant is not present.
Which does not work.
That is what the Minister of State said. What the Deputy suggested he said is not correct.
I will address the point that the hospital service is being run by accountants. I will introduce an initiative shortly to try to bring clinicians into management. With the type of high technology hospital service available as we approach the 21st century and the regional and tertiary centres being developed around the country, a greater partnership is needed in the management process. The old hierarchical system and stereotypical view of how hospitals are run — the general surgeon and the administrator and a case of never the twain shall meet — is an unfair assessment of how matters stand. However, that is not to suggest we do not have a sufficiently integrated service in terms of management. In some hospitals, such as St. James's and Cork University Hospital, I have seen multidisciplinary teams of executive management and clinical directorates working together. That is in line with best practice and is needed throughout the hospital system as it would benefit both managers and clinicians. The idea would be that clinicians would be in charge of budgets as well as patients. That brings its own disciplines and challenges and both sides have their reservations. However, everyone involved in the pilot schemes agrees it is a better system of management and that they would not revert to the old system. That is in train and should be accelerated in the interest of good patient care, if nothing else.
I do not accept the hospital service is being run by accountants for the reasons I have given and because of the thrust of our policy. If we revert to the historical position of deficits and allow budgets for health services to become irrelevant, the logical conclusion reached — and quickly because of the costs involved — is that hospitals will not be able to deliver core services. That is the reality if there is no reference to budgets. I accept management of the health service is a difficult process because a huge number of personnel is involved. We provide a very good service compared to many. It has many problems but we will continue to work to solve them. However, the experience of the late 1980s and up to 1993, when the historical deficits were cleared, showed that such deficits in such difficult years seriously arrested the development of the health service. This was because of the overhanging debt on health boards and the consequent debt repayments which had to be contended with. This was at a time when health boards were already working on tight budgets and when there was less economic growth and strength.
We are now in a position to plan the service and successive Governments have annually increased its funding. A significant difference in my approach is that I insist on an enhanced capital programme. If the position is adopted that budgets do not matter in the hospital system, although they account for 52 per cent of the health budget, and it is allowed persist, with more being paid than was agreed, other services will be placed at the back of the queue, such as those for the mentally handicapped and physically disabled. If there is a finite amount of money and hospital services are sui generis within the system, other community based services will suffer if budgets are not adhered to because their allocated budget will be eroded. We cannot have it every way.
I am trying to ensure the message is sent to all that everyone plays on the same pitch, that service plans are drawn up in line with allocations and that, on the basis of working with that budgetary discipline, there will be an enhanced capital programme of investment in areas where historically there was none, for example, district hospitals and community-based hospitals where the elderly are cared for. I have been in such places and many of them have not had walls painted for years. There is a need to deal with psychiatric services and inappropriate placement in mental hospitals. I am proud that St. Ita's in Portrane is proceeding. We are making that a priority and providing £13 million for it to provide a service for those people. No general hospital in the country has to contend with that. It has been a priority of the Eastern Health Board for 30 years.
Does the Minister intend to give an answer to my question? I tried by way of parliamentary question and was unsuccessful. Who is benefiting from the increased activity in procedures in acute hospital services? People are not on a level playing pitch and the Minister knows that. Poor people are not getting treatment.
I will give the House an example to answer that question. From 1995 to 1997 the social, progressive, left wing, flavour of the month Government of which the Deputy was a member allowed public hospital costs to increase by 13 per cent and private patients using public beds did not have to pay extra. I increased private patient contributions by 9 per cent last year and by the same amount this year. What effort was made by the rainbow Government to give public patients greater access to public beds? None.
There was another initiative important to public patients called the waiting list initiative. The amount of money allocated to it by the rainbow Government was reduced while waiting lists rose by one third.
There has been an increase of 10,000 in waiting lists in the past 18 months.
I will not take a political lecture from members of that Government.
When I give the Minister a lecture——
I will know about it.
Let the Minister conclude, Deputy McManus.
I want the record to show that the Minister would not answer my question.
Deputy McManus should resume her seat.
I withdraw the remark. It was not a lecture. However, I will not accept the point. The rainbow coalition Government did nothing to redress the imbalance——
Who is lecturing now?
——and allowed a situation to develop where a greater subsidy was given to private patients in public hospitals than is the case now.
Answer the question.
That is an answer. It is a fact.
Not to the question I asked.
A Leas-Cheann Comhairle, our patience is being tried.
A question please, Deputy. Perhaps if the Minister was not interrupted so frequently we would have more time for questions.
I did not interrupt anybody. Will the Minister accept that for health boards to stay within their budget, the budget would have to be adequate in the first place? Will the Minister further accept that he can legally introduce a Supplementary Estimate if he had the will to do so? I do not want rhetoric. During Question Time yesterday the Minister acknowledged he had the £32 million and said he would not return it to the Department of Finance. Is he aware that less than 3 per cent of that £32 million would keep two wards and a theatre open at University College Hospital, Galway, and prevent 45 nurses being laid off? Judging by his performance here today, does the Minister intend to ride rough shod over this crisis, in the hope that it will go away, at the expense of hospital patients and those on waiting lists throughout the country?
When the Deputy was supporting the then Government at the end of 1996 I do not recall him saying that a budget of approximately £39 million for University College Hospital, Galway, was inadequate.
It was 1.5 per cent in the Western Health Board.
I am answering the Deputy's question.
I did not ask about that.
The case could certainly be made that it should be more — every hospital in the country could make that case — but unfortunately we have finite budgets and we must allocate on the basis of the total allocation. I do not recall the Deputy stating with any degree of conviction that it was inadequate. As a defender of the Government at the time, he probably stated it was more than adequate. The following year the allocation increased by £5.4 million on the original allocation.
That is not correct.
On the outturn it was up £1.3 million.
That is misinformation.
Deputy McCormack should allow the Minister to reply.
Under this Government it increased by £5.4 million on the original allocation.
The total budget was 1.5 per cent.
I am simply explaining the position to the Deputy.
Deputy McCormack should allow the Minister to respond.
When I became Minister for Health I visited Galway and I was surprised to see that the Deputy's efforts in regard to providing a capital programme for Galway hospital had come to nothing.
That is a lie. It is untrue.
I think £8 million was made available.
The people of Galway see through the Minister.
Do not interrupt, Deputy McCormack, in fairness to your colleagues who want to ask a question.
I assure the Deputy that I have since approved a total of £120 million for what will be practically a new hospital for Galway. It is important the Deputy takes note of that because along with a capital investment comes increased revenue implications year on year which will address some of the problems he is seeking to resolve. Because of an enhanced capital programme there will be an increased revenue stream coming into that hospital. We will provide a greater range of services.
With closed wards.
Indeed, life-saving surgery will be available to people in the west who were told they had to go to Dublin if they needed a heart by-pass operation. The political decision was taken to provide that service in Galway because we wanted to ensure that the health strategy objective of regional self-sufficiency is respected for the benefit of those in Deputy McCormack's constituency and in the west generally. That was not recognised or understood by the former Minister when he brought forward a cardiac strategy——
The theatres are closed.
——which did not contain any reference to Galway. Deputy McCormack's view of life seems to be that the louder he shouts, the more he will get.
I am not shouting.
That is rich coming from the Minister.
The Deputy can shout from now until midnight but an exception cannot be made in his case because other people worked within their budgets.
Answer the question I asked.
The answer to the question is that the budgets are adequate given the fact that the Deputy supported the previous Government when it allocated £5.4 million less. The Deputy should not come into the House to play games for the local population. He is trying to suggest he will be the saviour of the hospital.
No.
The people who will fund the hospital in Galway are on this side of the House. They provided the money. They negotiated the capital programme to ensure Galway had the type of hospital it deserved.
They closed the wards.
I am not from Galway but it became clear to me when I visited the city that it deserved a hospital.
I am in favour of that but the wards must be kept open.
If the outgoing Government did not think it was worthwhile to provide it, we will.
The Minister did not answer any of the questions I asked.
He did not get much of an opportunity to answer them. I call Deputy Gormley.
I have three brief questions for the Minister which are inter-related. Does the Minister accept that closing the Adelaide, Harcourt Street and Meath hospitals in my constituency of Dublin South-East was a major mistake given the demographic change and the fact that more young families and children are living in the area? Will he accept we need more acute hospital services in the south inner city? Will the Minister confirm that accident and emergency admissions at Tallaght Hospital are 30 per cent ahead of the aggregate of the three hospitals to which I have just referred? Finally, when will the Minister publish the Deloitte & Touche report on Tallaght Hospital?
I answered the Deputy's last question yesterday during Question Time. I realise the Deputy cannot be everywhere at one time. In relation to the accident and emergency service at Tallaght, a matter raised by the Deputy earlier today, I would remind him that of the three hospitals Tallaght replaced, only the Meath Hospital provided adult accident and emergency services. In planning for the move to Tallaght, it was estimated that adult accident and emergency attendances at Tallaght would be greater than at the Meath by up to 40 per cent. In fact, accident and emergency attendances at Tallaght have not reached this level of increase. Accident and emergency attendances increased by approximately 19 per cent between the opening of the accident and emergency department at Tallaght in June and the end of August. In September and October, adult accident and emergency attendances were up by 17 to 18 per cent as against the comparable 1997 figures for the Meath Hospital. Significant additional resources have been supplied for accident and emergency services at Tallaght, including the most modern X-ray facilities in Europe, on-site laboratory facilities which were not available at the Meath Hospital, additional staffing and the newest accident and emergency department in the country. Accident and emergency admissions at Tallaght show an increase over the rate of admissions at the Meath, but these admissions are still at a rate below that of other comparable hospitals.
Filibuster.
Furthermore, since the move to Tallaght, 35 non-acute beds have been provided for the exclusive use of Tallaght at the old Meath Hospital. These beds are provided by the Eastern Health Board and do not impact on the resources of the hospital in Tallaght. I do not agree that the move should not have been made.
Will the Minister agree, in the context of his acknowledging that there has been a dramatic increase in the waiting lists, that closing 912 beds in December at a loss over the next six weeks of 16,000 bed days makes no economic sense and, in the context of patient care, is indicative of a lack of insight into the needs of patients? Will he confirm that when it comes to bringing a Supplementary Estimate before the House, the Minister, at his discretion, has available to him the possibility of making whatever financial decisions are necessary in the context of what he regards as an essential priority? Will he acknowledge it is an essential priority to keep these beds open in December in the context of the estimated waiting list at the end of the year being in the region of 38,000 patients?
I have a simple question for the Minister. What advice does he have for the patients currently on those waiting lists? I refer to those in need of heart surgery and others who have been on waiting lists for two, three or more years?
Deputy Durkan, I want to give the Minister time to reply.
The Minister's reply will be short. What advice will he give those patients now? Must they wait for another two or three years until the necessary resources are provided to deal with the problem?
I want to return to the central question about the adequacy of the allocation. In a time of major economic buoyancy we are simply not spending enough on our health services. What is the Minister's view of the fact that we are close to the bottom of the EU league in terms of spending on health as a percentage of GDP? This is the kernel of the problem.
Is the Minister still intent on closing two wards in University College Hospital, Galway and, following the breakdown in talks yesterday, is he aware that administrative and management staff will force patients out of St. Mary's and St. Pius's Wards and transfer them to other overcrowded wards? Does he intend to allow a spectacle never before seen in the country to develop? In view of the ongoing negotiations in Portiuncula Hospital, Ballinasloe, will the Minister recommend that the Western Health Board take over that hospital? Will he comment on these matters?
The Minister used the expression "we can plan" and I presume he is planning for 1999. In the Mid-Western Health Board region the waiting list for ophthalmic treatment has increased and an application has been made to the Minister for an increase in theatre costs associated with the three ophthalmic surgeons. Do the Minister's plans include one to bring this list under control in 1999?
Will he comment on the phenomenon of the invisible waiting list?
On Deputy Shatter's point, one way to bring about greater efficiency would be to deal with the 150,000 bed-days where there are inappropriate placements. This would give us the opportunity of dealing with some of the problems being discussed today.
Why does the Minister not deal with that problem? Why are there empty nursing homes? The Minister should resign.
That is Deputy Shortall's view. Personal insults mean nothing to me. I assure Deputy Durkan that far more resources will go into the waiting list initiative than did under the Rainbow Government. There are fewer on waiting lists for cardiac surgery than when I came to office.
Did the Minister's accountants tell him that?
The negotiations in Portiuncula Hospital are between the health board and the hospital. The Department is not involved. However, they are at a very early stage and the Deputy should communicate any considerations he has to the relevant authorities.
All activities in the hospital services which were planned at the beginning of the year are being completed.
There has been no improvement in waiting lists. That is some plan.
The question of pegging health spending as a proportion of GDP has been raised. While I appreciate that the suggestion was made in a constructive spirit and I do not dismiss it out of hand, it has some important drawbacks which have received insufficient attention. One need only recall how routinely economic forecasts are shown to be inaccurate to realise that economic growth is difficult to predict over the medium term. Variations in economic growth would lead directly to swings in the level of resources devoted to health over a number of years. If health spending is pegged as a proportion of GDP, what plans do the Opposition have to avoid serious dislocation of services during a downward economic cycle?
What should we do in an upward cycle?
We have put in place an enhanced capital programme to provide the nursing homes Deputy Shortall wishes to see.