I welcome this debate as an opportunity to consider in a constructive way how the health services are being developed and how the main problems are being addressed. The Government is very clear about what it is trying to achieve through the health services. It has adopted and is seeking to implement the 1994 health strategy statement, as updated this year in my Department's statement of strategy. It has also set out its specific priority objectives in the programme for Government and is making steady progress in achieving these. Contrary to what is sometimes claimed, there is a clear and coherent programme in place for the improvement of the health services.
The Government has committed significant additional resources for the improvement of health services in areas of greatest need and I shall be describing these in more detail later. It is devoting more resources to the non-capital and capital areas; the latter has enjoyed a significant increase and further large increases can be anticipated.
Planning, management and control are essential in implementing the longer-term strategy. The Government will use the 1996 legislation to control non-capital expenditure within the limits agreed by Government and approved by the Dáil. It will ensure that available resources are distributed as objectively as possible, consistent with real needs, and it will not allow the agenda to be dominated by those who are best placed to make the loudest noises about their needs. It is not an unplanned or rudderless service. It is far better integrated than many health systems and is acknowledged by the OECD as an efficient, well organised service.
In regard to the statements made by the Opposition last week and yesterday in the Dáil on the infamous £32 million, I do not intend to return to this matter in any great detail. For the record I will say one more time, there is no reduction in spending on the health services this year. There is an increase in overall expenditure. The allocations to the agencies have not been reduced and will be increased by the Supplementary Estimate when it is taken soon. The Opposition appears to be demanding that I effectively ignore the accountability legislation which it brought before the House two years ago. I can only say that its principles were quickly overturned by the first real choice it had to make as an Opposition in supporting its own legislation. It should know — I have no doubt it does — that the health services must have genuine planning for the future and that playing politics will destroy the foundations of accountability, planning and management set down by the legislation of 1996.
This Government has, since it took office, shown its determination to invest in the health services so that key areas will benefit from the continuing and welcome growth in the economy. The Health Vote has increased by over 9 per cent this year over the outturn for 1997. The increase for 1999 over the expected outturn for 1998 will represent a figure of 9.5 per cent. Given the Government's commitment to holding public expenditure at an average increase of 4 per cent per annum, it can be seen that the Government is funding the health services as a top priority.
In regard to capital, I have negotiated a three year programme. This is the first time any Minister for Health has been in a position to work with such assurance in relation to capital developments. This will be of immense benefit to the system as my Department and the agencies can plan on a much more orderly basis. The actual amounts for each year of that programme are: £147 million in 1998, £155 million in 1999 and £165 million in 2000. Over that three year period the total amount of extra investment over the original 1997 figure of £108 million will be a total of £143 million. Indeed, the figure for the year 2000 represents an increase of 53 per cent over the 1997 original figure introduced to the Oireachtas by former Minister Deputy Noonan.
All of this reflects the Government's recognition that the health capital programme has not been adequately resourced in the past. The 1999 letters of determination from my Department to the agencies will set out budgets for the replacement of priority equipment, maintenance backlogs and fire precaution works, and it is my intention to continue this process in the years ahead so that the agencies will be in a position to plan for the medium term in regard to better maintaining their infrastructure. It has been a matter of great satisfaction to me that I have been able to greatly increase the capital investment in services for the mentally handicapped, the elderly and those requiring psychiatric care. I am confident that I will, in due course, be able to announce for 2001 a further greatly enhanced level of funding for capital.
The acute hospital sector consumes about 50 per cent of total expenditure. This sector is getting its fair share of resources having regard to the need to meet other priorities, many of which have been relatively neglected until recent years. The hospital system continues to expand with more patients being treated every year. This year alone has seen an increase of 9 per cent in day work with a 1 per cent growth in in-patient activity and with an overall average increase of over 3 per cent.
While the acute hospital sector continues to receive the largest single share of the funding devoted to the health service, the benefits of this funding are clear. In recent years, the acute hospital system has treated a steadily increasing number of patients. A recent study by the OECD has shown that the Irish hospital system has become more productive and efficient. The average length of a hospital stay has declined. Better management of hospitals has resulted in increased occupancy levels. Hospitals have taken advantage of developments in medical practice to increase the level of day care in Irish hospitals almost four-fold since 1986. The impact of these improvements can be seen in the fact that the number of patients treated in acute hospitals has risen by 3 per cent a year since 1987. In the 12 months to the end of August 1998, 539,900 patients had been discharged from our acute hospitals, almost 17,000 more than in the same period last year.
The continuing improvement in output in the acute hospital sector is underpinned by a commitment by this Government to provide additional funding, facilities, equipment and staff to the acute hospitals. In this year alone, the Government has provided an additional £44 million to improve acute hospital services. As a result of this funding, new hospital developments are being brought onstream, including those at Temple Street children's hospital, Longford-Westmeath General Hospital and the Mercy Hospital in Cork. Additional medical and nursing staff are being employed to improve services for patients in important areas such as the accident and emergency service. The cancer strategy provides for the appointment of additional consultants in the specialties of oncology, haematology and palliative care and the development of services for cancer patients in regions where the need for such services has been clear for a long time. The funding and services which have been put in place this year have gone some way to addressing the problems in acute hospitals which the Government faced on coming into office. The recently published Estimates for 1999 again provide evidence of our concern to provide for the development of the health services. I will continue to work throughout 1999 to further improve the acute hospital service.
I announced yesterday an increase in charges for private rooms in public hospitals. Let me make it absolutely clear again that I have no apologies to make for this increase. The increase still leaves a gap between the charges and the cost of providing services to private patients in public hospitals. As Minister for Health and Children, am I expected to allow these charges to be frozen and thereby continue with subsidies for private practice or should those charges not reflect the realistic cost of providing services? There are already considerable subsidies in place for the private sector, including tax breaks, and I will not allow a situation to continue whereby the taxpayer must pick up an ever increasing proportion of hospital costs while the private sector does not meet its fair share.
The total amount earned by the State from private patients in 1997, in respect of private accommodation in public hospitals, is estimated at about £68 million. It is also estimated that the cost to the Exchequer in 1997-98 was £64.5 million in respect of income tax relief on private health insurance premiums and about £20 million in respect of unreimbursed medical expenses. There is massive investment in public hospitals by the Exchequer, including building, equipment and staff training. Public hospitals also provide the accident and emergency services. Health insurance companies avail of these facilities and they must make a contribution towards those services. There are many reasons for cost increases for insurance premia, including the charges made by private hospitals and medical consultants. It is estimated that the last increase of 9 per cent in January 1998 in private accommodation charges contributed only 2 per cent of the 9 per cent increase in private health insurance premia introduced by VHI in September 1998.
On taking up office as Minister for Health and Children, one of the priorities I set was to tackle the problem of unduly long waiting lists and waiting times, as pledged by the Government in An Action Programme for the Millennium. I immediately examined the situation and saw the need for organisational changes in the way the waiting list initiative was being implemented. I took a number of initiatives in 1997 aimed at improving the efficiency and effectiveness of the waiting list investment. These were the much earlier notification to each hospital of the level of funding to be made available to them under the waiting list initiative — hospitals received details of their waiting lists funding in December 1997, whereas in previous years the funding for waiting lists tended not to be allocated until around July; an increased focus on waiting times as well as on waiting lists, so that we would not lose sight of our major concern — that is to reduce the length of time patients must await treatment on a public waiting list.
As regards the waiting list initiative, I allocated £12 million for waiting list work this year, which represents an increase of 50 per cent over the funding made available by the previous Government in 1997. The additional funding will result in an extra 15,000 procedures being carried out during the current year. I took these initiatives against the background of a significant increase in waiting lists during the period 1995 to 1997.
When the Fine Gael-Labour-Democratic Left Government took office in December 1994, waiting lists stood at 24,000. When that Government left office in June 1997 waiting lists had increased to over 30,000. They rose to 32,000 by December 1997 due in part to the allocation by that Government of just £8 million for waiting list work in 1997. This represents an increase of 33.3 per cent during the lifetime of the previous Government. With the reduced funding provided by the rainbow Government waiting lists rose by one-third. This suggests that for the foreseeable future we need more significant funding to address the problem of waiting lists and waiting times and I am addressing the question of additional funding requirements as part of the budget process for 1999.
I caution against adopting a simplistic approach to dealing with unduly long waiting lists and waiting times. Ireland is not unique in having long waiting lists and waiting times for acute hospital procedures. They are a problem for the health services in many countries and no country has yet managed to wipe them out or to have them reduced very quickly. The quick-fix solution of simply throwing money at the problem is not the answer. What is required is a structured, co-ordinated and multi-disciplinary approach to dealing with waiting lists and times. Fundamental to this is the establishment of the underlying causes of unduly long waiting lists and waiting times. Towards establishing these causes and, by extension, a strategy to deal with them in a planned way, I established the expert review group in April 1998 to look at the problem.
The report of the review group sets out a logical and structured means of addressing waiting lists and waiting times. It has recommended that efficient and effective action to tackle waiting lists and waiting times will require developments at each level of the health care system, in particular in relation to care of the elderly. By their very nature, the measures recommended by the review group will take time to put in place to yield their full potential.
As a first step, I am making the organisational arrangements necessary to ensure a structured and planned programme to deal with the waiting lists and waiting times is implemented in each acute hospital as a matter of urgency. In addition to increasing the number of elective procedures during 1999 and achieving an overall reduction in waiting lists and waiting times, I will be putting in place arrangements necessary to manage the waiting list initiative, at national and hospital level, in a more efficient, effective and consistent manner than heretofore. This will involve shared responsibility between management and consultants for the management of waiting lists in a manner which respects the relative roles and responsibilities of both and which has, as its ultimate objective, the implementation of waiting list programmes in each acute hospital, where every person who requires an inpatient surgical procedure receives that procedure within the target times specified.
There has been much recent debate and criticism about the levels of funding for services for persons with a mental handicap. I am pleased to have another opportunity to reiterate my record in this area. Since my appointment as Minister and despite the many competing demands on the resources available to my Department, I have consistently identified as one of my top priorities the provision of the additional residential, respite and day services outlined in Services to Persons with a Mental Handicap — An Assessment of Need 1997-2001. In the past 12 months or so, I have allocated an additional £25 million to these services. This is more than double the additional funding allocated by the previous Government in 1997.
I have also put in place a £30 million national capital programme, to run over four years in tandem with the assessment of need, to provide the infrastructure necessary to support these services. This is the first time such a programme has been provided and it allows for multi-annual planning in developing services.
My recent announcement of a £13 million capital project for St. Ita's Hospital, Portrane, funded jointly by my Department and the Eastern Health Board, is of particular satisfaction to me. I am proud to be part of a Government that is not only the first to fully appreciate the need for this development but is also providing the necessary funding to ensure this development becomes a reality.
The level of additional funding provided to date has given clear and concrete evidence of this Government's commitment to meeting the needs identified in the assessment of need. This commitment, together with the multi-annual budgeting framework, will facilitate a significant development of services for those with a mental handicap in a well-planned and orderly way. This will represent a huge improvement on the ad hoc“stop-go” approach to such development in the past. I have clearly demonstrated my commitment and that of the Government to meeting the identified needs in this area and this will remain a top priority.
The rights of our older citizens to appropriate support in their homes and easily accessible services, when these are required, is also a major issue which needs to be addressed. The need for action is clear from the demographic changes taking place, which will result in significant increases in the number of older people over the next 15 years.
The National Council on Ageing and Older People, in a recent report, highlighted a number of key service areas which need urgent attention. These include the home help service, respite care, support for carers, day care, paramedical services, social work services and services for older people with mental health problems. Having examined the report and discussed the issues with various groups who represent the interests of older people, it is clear the greatest need lies in the provision of better community-based services, particularly care in the home, including support for family carers.
In 1998, we provided an additional £7 million to provide new services for older people and to improve existing services such as specialist departments of medicine of old age attached to general hospitals, together with community nursing units which provide a wide range of services for older people, including respite and day care, day hospitals and day centres. The additional money has also allowed staffing in existing extended care hospitals and in the community services to be improved. An additional £1 million has been provided this year to develop a specialist mental health service for older people, while over £6.5 million was provided in late 1997 to enable health boards to provide greater support to older people in private nursing homes. On the capital side, I have more than doubled the level of capital resources previously made available for health facilities for older people by bringing that figure to £14 million in the current year.
The areas of child care and food safety are key priorities on the Government's agenda. The importance of these areas was underlined with the appointment of Ministers of State, Deputy Moffatt and Deputy Fahey, to take day to day responsibility for making progress on the Government programme. Both Ministers of State will speak later in the debate and outline developments in these areas.
I have set out some of the key policies receiving attention at national level. However, for those policies to impact at ground level they must be built upon by local management. The health strategy and the accountability legislation have placed a key emphasis on the delegation of authority to local levels. In return for such delegation, it is reasonable to expect that best practice should apply uniformly across agencies.
I now turn to the key tasks of governance and management and set out the level of performance I want to see achieved throughout our services. Everyone accepts that health management is a complex and difficult task. It has perhaps been the focus of most public debate in the acute hospital sector. One area which has received insufficient attention to date is that of governance. No manager, however skilled and well supported by clinicians, can deliver appropriate and effective services without clear directions from his or her board. There is an absolute need for every health agency to be explicit about the values and principles which underpin the service it delivers and by which it will measure itself and those it employs.
The accountability legislation brought a sharper focus than ever before to the issue of governance as it now affects health board members and management. This year my Department has embarked on a general programme of governance development with a number of the major voluntary hospitals. This is long haul work but I am certain it will be a vital part of our future success and our continuing ability to deliver quality services within defined budgets.
As we all know from managing our personal finances, budgeting is not easy but it must be done. A failure to live within one's means may be possible for a short period, provided the degree of deviation is modest. However, this cannot be sustained for long without serious consequences.
The managers of health service agencies must also live within their budgets. I accept that the management of acute hospital services poses significant and difficult challenges. The activities to be managed are largescale and complex. The acute demands that may be made on the system are unpredictable. However, none of these demands are new. We have been here before and we have managed these problems.
There is a degree of predictability in what faces each acute hospital every year. The surge in demand for acute services in January and February of each year is a well observed phenomenon. The drop off in demand for elective services in the summer is also well known. The fact that facilities have to be taken out of commission for maintenance or refurbishing is known. At the beginning of each year it should be possible to devise a plan which matches known available resources to these demands. However, a plan drawn up in December or January cannot simply be put on a wall or a shelf and left there to gather dust.
What is the role of clinicians in this process?
We know that clinical decisions and clinical activity drives the vast bulk of spending in the acute hospital sector. We also know and appreciate that expenditure driven decisions have clinical implications. It is, therefore, obvious that clinicians should be involved in the management process in our hospitals. They already are in many hospitals and I will launch an initiative on 27 November to roll this process out to the entire hospital system. I do not claim now, and I will not claim then, that this alone is an answer to some of the difficulties we have seen in recent weeks. The process of implementing this will not be easy and it will pose major challenges to doctors and managers. It will not lead to easier decisions, but it should lead to better ones.
There is a need for partnership in the health services. This partnership lies not just in delivering services but in working together to resolve problems. Two of the most pressing problems requiring attention are medical and nursing manpower. Frameworks are in place for both but if partnership is to work, it cannot work on the basis of Department or management proposing solutions which are then examined or criticised, perhaps rejected, because they represent a change in how things get done, even if doing them differently would represent a better deal for the patient.
We must put the patient at the centre of the system, even if that means changing the type of contracts people have, the hours they are required to cover, the ways in which they interact with other service providers and the processes through which work is done. Those responsible for governance must assure themselves that the service is good and safe and is seen as such by the patient. Management must provide the environment and the infrastructure through which people are likely to give of their best, as well as complying with their statutory obligations and those delivering the service must show flexibility and responsiveness in a dynamic and necessarily rapidly changing service.
Whether in governance, management or delivery, in every part of the service, we must identify and spread best practice. Whether one is receiving or seeking a service in Donegal, Dublin or Kerry, the response should be equally good. I am making this a matter of the utmost priority and I will return to this theme regularly in my discussions and contacts with all parts of the service.
I thank the House for its attention and invite Deputies who may wish to do so to contribute to this debate. I will try to respond comprehensively and constructively either today or subsequently in writing.
I have tried to set out the principles which I, as Minister for Health and Children, must work from and the performance we should work towards achieving throughout our health services. I have secured significant extra funding for hospital services, the mentally handicapped, the elderly and other services. For 1999 the increase in the gross health vote will be about 9.5 per cent or £356 million. This, by any standards, must be regarded as a large increase. I have obtained significant extra resources for the capital programme for the hospital and non-hospital areas and ensured that the programme will be well resourced over the 1998-2000 period. I am confident I will soon be able to announce further significantly enhanced capital funding in the year 2001.
It cannot be denied that this level of increased investment must be balanced by a commitment to govern and manage in a planned way through efficient and effective application of resources. There is a clear responsibility on all of us, whether in this House or involved in service provision outside, to ensure that the principles set out in the legislation two years ago are accepted by everyone and implemented. I appreciate that Deputies are impatient to see early progress in a number of areas and I am equally anxious to advance as quickly as possible. The overall strategy I have set out here builds on the work of previous Governments in the health strategy and the accountability legislation. If the signals we send out to health agencies and the public are to be consistent, it is imperative that all sides of this House support this overall strategy.