I was very appreciative of the calm and helpful way in which Senators approached this Bill. From the contributions that have been made here and in the other House, it appears to me that there seems to be no dispute about the increases proposed. It has been the normal practice since the Health Contributions Act, 1971. It has been described by the Fianna Fáil Party as being a tax, but it was introduced by my predecessor, the late President Childers, in his own words, to supplement the financing of the health services. That is exactly what is being done here today and, as I said, people accept that in view of movements in wages and in inflation generally it is a justifiable increase.
There were references to cutbacks, which I referred to as economies. There has been a fair amount of scaremongering over the last two months since the allocations were notified to the health boards. It is a field in which there can be scaremongering and in which political mileage can be gained, whether deliberately or not is a matter for the individual who makes the contribution. The area of health is a sensitive one. and it is because of that that people become emotional about it. People who speak in public tend to play on the emotional aspect of health. The amount of the increases do not seem to worry Senators; they were not a worry to Deputies in Dáil Éireann either—the increases are reasonable and were accepted.
The measure gives people scope to talk about the health services in general. Senator McCartin summed up the matter when he said that we had done pretty well so far as finances were available. It would be no harm for me to give an idea of what we have been spending on the health services in recent years. I am particularly concerned with my own three years as Minister for Health. Expenditure has grown by 144 per cent in the last three years. No other Department could claim that the money allocated to them showed an increase of anything near 144 per cent with possibly the exception of the Departments catering for the Garda and the Army. This increase has been modified because of rapid inflation over the last three years but so far as expenditure on health services is concerned there has been an improvement in real terms of 16 per cent. The Exchequer is contributing £242 million this year, compared to an Exchequer contribution of £67 million in 1972-73. That represents an increase of 261 per cent. So far as the allocation for health is concerned, there is an all-time record in 1976 as opposed to the criticism that has been made. It is the highest percentage of gross national product ever allocated to the health service. That in itself is a tribute to the Government who make the decisions as to what moneys should be allocated. In terms of gross national product, in terms of Exchequer contribution, it is an all-time record as far as health services go.
People are concerned about medical cards and I can understand their concern. The criticism we have heard tonight and over the last few weeks, generally with regard to the health services, would be criticisms and queries that would be made and put even in times when we were in a position to give more to the health services. As far as the lower income group are concerned, I would say that as far as the issue of medical cards is concerned they have greatly benefited. When I came to office in March, 1973, 28 per cent of the population were covered by medical cards—that is, holders and their dependants. At present that figure is 36 per cent. Therefore, there is an increase from 28 per cent to 36 per cent.
I will remind the Seanad that some of that is accounted for by reason of the fact that we have a number of extra people who are unemployed. But, taking that into account, there has been a gradual increase in the issue of medical cards over the last three years.
There are complaints now that medical cards have been taken from people. That is true. They have been taken from people at various times since the general health scheme was introduced ten years ago. We will always have the person who believes that he or she should have a medical card. The chief executive officers lay down the guidelines. I provide the money for them. They have to adhere strictly to the guidelines laid down. When I came into office I discovered that there were various guidelines in the various health boards. In some cases there was allowance for travel, allowance for children, allowance for rent and various things like that. In others there were not. In others there was a mixture. On the first or second occasion that I met the CEOs, as a result of our discussions they decided on a uniform scale of guidelines which have now been applied over the whole country.
There are hardship cases where people may exceed the guidelines or the limits from time to time, but it has been found that the health boards have not been ungenerous to people who can plead hardship even though they do not qualify for a medical card. It can apply to an individual in a family or for a temporary period in a family where there is long illness.
Apart from the standardisation of the guidelines in the last two years there has also been a review of the guidelines with regard to inflation and increases in wages and so on. These reviews take place every six months. A not inconsiderable improvement in the health services is demonstrated by the fact that in 1972-73 there were 42,000 people employed in the health services and today there are 47,500, an increase of 5,500. People might criticise and say that this is what is wrong with the health boards, we have too many employees in them, but they seem to assume that there are too many administrators, there is too much top brass. This is not the case. The bulk of this increase of 5,500 is in relation to those who actually work on the ground, the doctors, nurses, welfare officers and all those who are directly concerned with the provision of good health and the curing of people.
This increase has led to an improvement in the quality of the whole range of the health services. In addition in the last three years there has been an extra 1,760 institutional beds of all kinds provided since this Government took office. In general hospitals the figure is an extra 400 beds. In psychiatric and mentally handicapped hospitals the figure is 900. People referred here to the plight of the psychiatric patients and those who are mentally ill and mentally handicapped.
We try to provide within the resources we have had over the last three years the maximum amount possible in order to ensure that those people who needed to be treated in institutions would have a better chance than they have had heretofore. As far as homes for the aged are concerned the target was something like 40 welfare homes of which 24 have been provided up to date. It has been pointed out that such development is not possible during 1976.
In the case of the blind, an extra 160 beds have been provided. Other improvements were made, such as additions to the list of long-term illnesses in respect of which drugs and medicines are supplied free of charge regardless of income. A constant care allowance in respect of severely mentally or physically handicapped children was also introduced. That was a most welcome innovation by the Government. It cost the State something in the region of £1 million.
There was the generous attitude of the Government towards thalidomide children, responsibility for which was not taken and would not be taken by the previous Government. Possibly if they had stayed in power longer they might have come around to the point where they would have felt some sense of responsibility, but to the credit of this Government they were very generous with such children. At the same time they introduced the constant care allowance of £25 per month.
I know the general hospital plan has not been welcomed in various places. I wish to assure the House that the selections were made by me in accordance with the guidelines that were laid down by Comhairle na nOspidéal and in all cases in accordance with the recommendations of the eight health boards. I know I have disappointed people in Monaghan, I know how disappointed people are in Tullamore, in Manorhamilton and various other places like that, but we accepted the principle of the establishment of bigger and better equipped hospitals throughout the whole country, and this was the result.
Efforts were not made by the last Government to evolve any sort of a hospital plan. The Fitzgerald Committee were established and they came up with recommendations which did not appear to be accepted by anybody in public life, either in the Dáil or the Seanad or in the public bodies. I was very critical of the plan they produced. I said so and gave my reasons. I was not necessarily happy, because Wexford town was left out of it. It was something that was not acceptable to the Fianna Fáil Government of the time. The late Mr. Childers, who was Minister for Health, ignored it. He hoped it would die and that people would forget about it. When I came into office I decided we would have to evolve some sort of a plan because it appeared that many of our county hospitals were badly in need of repair, could be described as third class hospitals, even though the personnel in them gave a very long and efficient service. Now the plan means that in the areas that have been picked we will have hospitals that will be able to cater for a majority of the population in the various provincial or rural areas.
Planning is going ahead in respect of hospitals. It is a tedious process. It is going on in Letterkenny, in Tralee, in Cavan, because it is recognised that Cavan deserves perhaps not absolute priority but some sort of priority.
I am concerned about the training and employment of the handicapped. If people look at the record and the results they will find that as far as this Government are concerned the training and employment is a priority. As a matter of fact, there was an established working party on this and the report on the training and employment of the handicapped has been received and has been implemented as quickly as possible. Community information centres were also established, something that was clamoured for quite a long time.
What I am saying in essence is this that we are spending an enormous amount on the health services. The Government do not begrudge the amount of money that is being spent but, as I said, it is an all time record. But it is not sufficient just to shovel money into the health services unless we are satisfied that the money is being spent in the right direction and that we are getting the most beneficial results.
Therefore, there must be an evaluation of health expenditure. This is absolutely essential particularly, as I said in my opening remarks, because 18 per cent of non-capital expenditure goes to health as against 10.5 per cent in 1971. It is essential that we evaluate the ways in which we spend the money. I also believe that it is essential to ensure that the scarce resources which we have are devoted to the most valuable programmes. It is essential to ensure that money is not wasted. On this matter, the Opposition like to refer to the cutbacks, that is the reduction, in their estimation but I call them economies and I challenge anybody in this House or in the other House to go into hospitals throughout the country to see not deliberate waste but waste that could be obliterated. I am trying to ensure that this will happen in 1976, that there will be an evaluation of the expenditure, that there will be a positive search into the matter of spending money in the right direction. There is evidence of waste in many of our institutions and this we must eliminate because otherwise hospital administration will go merrily on in the knowledge that the State, the Exchequer or the Department of Health, will take up the bill, as against the time when the health services will be funded differently, and we are awaiting that, thank God, in accordance with the promise we made when we formed the Government, when 40 to 50 per cent of the health expenditure was provided by the ratepayers and members of county councils and health boards were much more careful in their demands to their executive officers. Now that their contribution amounts to something like 1.2 or 1.8 per cent, I am not saying they wilfully do it, but they have not the same responsibility as I have as Minister for Health to ensure that moneys devoted to the health services are spent in the proper way and that the right amounts are provided as well.
We must evaluate our administrative structures to see that the services are administered effectively and economically. Senator Killilea made the same sort of criticism last year as he did this year. He doubted the efficiency of the health boards and seemed to infer that they did not give the same return as far as health care was concerned as the old system under which the counties themselves were responsible for the health services. There is need for a programme evaluation and a whole review of the administrative system. All these administrative and economic problems are not just peculiar to this country. This sort of debate is going on in many parts of the world, in Britain and in Europe and in the world generally. I am trying to improve the procedures in these areas, in administration and in programme evaluation.
Towards that end, in 1973 an organisation unit was established that would take up the task of improving the administration in the Department of Health itself, and that is a rather revolutionary idea. The unit has also undertaken work with the health boards to improve their financial control and budgetary arrangements and to ensure that money is spent in the best direction and with the best results. This organisation unit has also undertaken pilot studies on hospital administration schemes. This has been started in St. Finbar's in Cork which is one of the health board hospitals, and it also commenced, in association with the Mater Hospital, a study to see how their financial control and budgetary methods can be improved. If we can learn from these two studies and if we can apply them to the other hospitals, the voluntary and the health board hospitals, we will be on the way to ensuring what I hope will be the result of ensuring that money will be spent in the right direction.
There are also the individual services, apart from the general hospital administration, and there is a growing awareness in all our health agencies for a need for a shift of resources, meaning that some of the resources that now go into hospitals would be shifted to community care because it has been pointed out here that the cost of a stay in hospital now is extremely high due to various reasons such as inflation and wages and salaries.
These are the things we must think about when considering economies because the State, no matter how much money it has at its disposal, will always find, as Deputy Markey said, that there is a need and a seeking for more and more. The demand for health services is limitless, but unfortunately the resources are not.
There was criticism, by Deputy Killilea in particular, about the health boards and there was a suggestion that there is a need for a review of the whole system. As I explained to the Dáil last night, I propose to establish a review body, but before I go on I should like to correct an impression that there are enormous bureaucracies at the top of the health boards. This is not so. There are 50 who could be described as top management and they would include people like the CEOs, programme managers, accountants, personnel officers, planning officers, apart from the typists, the clerks and others who are not directly engaged in the health sphere. Due to the fact that we will be spending £165 million in 1976, nobody could suggest that top management in eight health boards to the extent of 50 is excessive. There were 50 in the beginning. There was an addition of two posts established in 1970.
We should not assume that because health expenditure has gone up since the health boards were established that this is necessarily a consequence of their establishment.
Much of the increased expenditure has been due to rises in pay rates and, of course, to inflation and development policies over the year, particularly during the last three years. As I said in the beginning, the improvements in the health service in the last three years was represented by an increase of 16½ per cent. If the health services are to be re-organised, and if the health boards are to be re-organised, there are only three methods by which this can be done. The first one would be a reversion to the county system. I do not believe that we should revert to a county system. This is my personal point of view. My party are in favour of regionalisation of these health boards. Somebody said on one occasion that we could unscramble the scrambled egg, and that is what it would mean. I believe that if we reverted to the county system next year or the year after, or in the near future, we would have many more problems than we have at present and that expenditure would be greater. I am doubtful whether we would get the personnel or whether we would get the county managers to re-take responsibility for the administration of health. There could be an entirely new system or we could consider improving the present system.
I believe that the most practical and wisest thing to do would be to improve the present system. McKinsey who came in on the establishment of personnel for the health boards after the health boards had been established in accordance with the decision of the two Houses of the Oireachtas suggested that there would be a review after five years. That five years is up. I think it is only natural that a review should take place. As I said to the Dáil last night, this certainly is not meant to be, nor would I want it to be, a reflection on the staff, on their competence or on their dedication. I do not believe we should have a witch hunt. There is far too much loose talk at present, particularly with regard to expenditure in the health services.
To review the health services and their administration, we have to decide how that review will take place. There could be a special team from the Department of Health with outside consultants. There could be an investigation by a team of outside consultants. There could be an all-party committee of Deputies and Senators, that is, a committee of the House or a select group of all parties could represent us from the professions, from the Department of Health, the consumers and the trade union movement.
I just mentioned these as options. I have not made my mind up yet except to the extent of saying that there should be a review. I do not know what will come of this. I do not think we should be too optimistic as to the outcome particularly when those of us who were in the Dáil at that time remember the select committee that was established on the health services and which met between 1961 and 1965. The results of their labours — it may not have been their fault — did not bear much fruit.
I indicated in my opening speech — I do not know whether Senator Killilea was here or not — that I intended to extend the limits and I hope to put regulations before the Dáil and the Seanad in a reasonably short time. The proposal would be to raise the limit of £2,250 to £3,000 and in the case of the self-employed pensioners and so on from £1,600 to £3,000 because when the last change was made the people in the £1,600 bracket were forgotten. That will be corrected when the new regulations are introduced.
I do not want to prolong my speech but I should like to correct some of the allegations that have been made with regard to cutbacks. I should like to compliment the members of the health boards in the various parts of the country. I have not seen in any of the newspapers any effort by them to seek medical capital. Whether they were reported or not, I do not know. I cannot remember reading any of the wild allegations which were made in other places.
The members of the health boards have acted responsibly and have attempted to make reasonable economies without affecting patient care. I would like to stress here that in their consultations the various health boards and the Department of Health decided that any economies that were made would not affect patient care. That is the important thing as far as I am concerned and I am sure it is the important thing as far as the Senators and the Deputies are concerned as well.
We did have some scare stories which did not do the morale of the personnel in the health services any good and certainly seemed to be designed to frighten our unfortunate people who have to have recourse to the health services. There was a suggestion, for example, in respect of free milk to children that the age would be reduced. This was not decided. It was not considered by me and there was no truth in the world that this was going to take place. Even though denials were made in respect of that allegation, they continued to be made and I suppose, will be made in the coming weeks as well.
It was also suggested that the welfare allowances would be cut. Instead of cutting the welfare allowances, as Senators know, an increase of 10 per cent will be given in all these allowances during this year from the 1st of April. Again, there will be a review in October.
It was also suggested that a means test for constant care allowance would be reduced. There is not a scintilla of truth in that. Again, even though these allegations were denied, those who made them in the first place will continue to make them.
It was also alleged that the routine child examinations would be done away with. There is no truth in that. It was refuted but people still continue to repeat it. It was also suggested that 50 beds would be closed down in three major Dublin hospitals. I inquired about that and gave an assurance that this was not so but still the allegations are made. There were doubts as to whether the general medical service would be maintained on the same level as 1975. Again, I gave an assurance that that would be so. In order to ensure that there would be no slip-up in respect of the operation of the general medical service for those who would be in the lower income group, the Health Boards allocated an extra 19 per cent to the general medical service section of the health service as against the overall increase of 13.5 per cent in respect of the Estimate as a whole.
I am as conscious as anybody about the expenditure on drugs. A number of points were made in the debate about this. I shall like to inform the Senators who mentioned this matter that a working party was established a short time ago of representatives of the Department, the health boards, the doctors, the pharmacists and the pharmaceutical industry: "To look into the issue of economic and responsible prescribing within general medical services." Their terms of reference are broad enough to ensure that expenditure on drugs would not be as high as it is and that there would not be what appears to me to be an abuse of drugs in very many cases. I am certainly not suggesting that there should be any diminution in the quality of the drugs; far from it. It appears that some people have an idea that a cheap drug is as good as a dear one. However, all these matters, like overprescribing and people holding drugs in their own homes, will be investigated because the drug bill in our health service, as in health services all over the world, appears to be pretty big indeed.
I think I may have covered the individual points made in a general way. I do not think I am expected to go into detail on this short Bill. I have assured Senator Dolan about the issue of medical cards and the planning of the hospitals, and what we are doing in that respect in particular areas where the situation is bad. I share his concern about the dental service. As resources become more readily available we will try to make further improvements in the dental service. I take all the points he made, points which I made when I was in Opposition and for years before it.
I have covered the general points, maybe not specific ones, but I commend this short Bill to the House. There does not seem to be any opposition to the direct proposals contained in it.
