We have circulated a proposed timetable for today's meeting which will allow for opening statements by the Minister and statements by the Opposition spokespersons. They will be followed by an open discussion on the Supplementary Estimate by way of questions and answers. Is that agreed? Agreed. I welcome the Minister for Health and Children, Deputy Martin, and his officials.
Estimates for Public Services, 2002.
Vote 33 - Health and Children (Supplementary).
I am pleased to have this opportunity to bring this Supplementary Estimate before the Select Committee on Health and Children. In doing so, I am aware that 2002 has been a relatively difficult year in economic terms. It is always the case that additional funding requirements must be justified in the context of their value for the citizen and of a well-managed system of expenditure controls. Nevertheless, the need for accountability in public funding is underlined even more clearly now, given the importance of good fiscal responsibility in underpinning the further development of our economy and our public service.
I am pleased that the major element of the Supplementary Estimate required in 2002 relates to schemes that are essentially demand-led. The bulk of the spending covered by the accountability framework of the service plans and expenditure controls set out in the 1996 accountability legislation has not, in recent years, been the subject of supplementary spending. In that period, health agencies have been particularly successful in maintaining overall expenditure within the approved levels. In 2001, for example, the overrun was just €12 million and may now be even lower, as we will discover when final auditing figures become available. This must be considered in the context of a massive €7 million to €8 billion budget.
At the same time, boards have, in many cases, not only maintained service levels within agreed plans but have also increased these levels. This pattern illustrates the effectiveness of the service planning process and indicates that the controls are robust.
Effectiveness must be measured, not only in terms of expenditure control but also in terms of how we apply the funding. Our effectiveness is illustrated in that regard by a range of achievements over the past five years. For example, hospital activity has increased by 17% while cancer treatments are up by 69%, and 26% more consultants are working in our hospitals now than in 1997. Over the same period, day cases carried out in hospitals have increased by 44%. The continuing care programmes have also benefited strongly, with a significant number of new residential, respite and day places available for people with disabilities. For example, around 840 new residential places and over 1,500 new day places have been provided in the area of intellectual disability and autism services between 2000 and 2001. It should also be noted that the ten year health strategy launched in 2001 includes all of the major recommendations of the independent report, Value for Money Audit of the Irish Health System, carried out by Deloitte & Touche.
The health services system is very complex, yet we are always mindful of the need to deliver value for money as part of the ongoing management of the system and in the context of best practice in health care for Irish citizens. Notwithstanding the success of the service planning process, issues will arise during the year that cannot be planned for and, therefore, I will move on now to the specifics of this year's Supplementary Estimate.
The gross additional spending requirement in 2002 is €169 million. Of this, €12 million is for capital, while €147 million is for non-capital. After adding a shortfall in appropriations-in-aid of €41 million, there is a net cash requirement of €210 million. The additional funding sought is necessary in order to fund adequately a number of items within the health services that have given rise to additional expenditure. As already stated, the bulk of these relate to schemes that are essentially demand-led and are provided under specific statutory entitlement. Because there is inevitably a degree of uncertainty in forecasting the actual costs of such schemes, the original Estimates may not provide fully for these costs.
Additional funding of €8 million is sought under the heading of demand-led schemes, or community drugs schemes. Expenditure on these schemes this year, as in any other year, is influenced by several factors that are difficult to predict. As always, the key variable is the number and cost of claims under these schemes and a small percentage change in any underlying trend can have a quite significant impact on the final figure. In relation to the drugs payment scheme, Deputies will be aware that there is a statutory right to relief for expenditure on prescribed drugs and medicines in excess of the expenditure thresholds that have been laid down within the scheme.
All those not covered by the medical card are eligible for the scheme, which now has approximately 1.2 million members. It has been policy to achieve maximum coverage. In addition, the cost of the scheme has been influenced by increased prescribing, combined with the fact that new drug treatments are regularly added to the common list of reimbursable medicines. These are inevitably far more expensive than existing treatments, and are patent-protected so that generic substitution is not possible.
A further factor is that the long-term illness scheme has been influenced by changes in prescribing practices in relation to people with certain conditions covered by the scheme. Those prescribing patterns not previously a feature of the scheme tend to be costly, for example, cardiac drugs for diabetics. It is also important to note that the ongoing movement of treatment from secondary to community settings means that many drugs previously available in hospitals are now provided through the community drugs schemes.
The costs of the drugs payment scheme have risen significantly since its inception in 1999. With this in mind I have, as Deputies may be aware, decided to initiate changes to the scheme in 2003. One of these is an increase in the monthly expenditure threshold of €5, bringing it up to €70, while in addition generic drugs are to be substituted for certain proprietary drugs under the scheme. There will also be procedural changes in relation to the payments to community pharmacy contractors. I believe that these changes will ensure that the scheme will deliver better value for money while continuing to deliver significant benefits to all its users. These changes are in addition to the change to the scheme put in place in August of this year, when the threshold was raised to €65. The effect of this was to generate a saving of €7 million in the current year. These savings have been offset against the €15 million funding shortfall, so that the net additional funding requirement is now €8 million.
The cost of the general medical services scheme has risen significantly in the current year. Increased costs are arising as a result of a number of factors. First, the number of cardholders has increased. The implementation of the Government decision to grant medical cards to the over 70s without means testing has contributed to a growth in the number of cardholders. The associated costs arise not only from the capitation rates paid to doctors, but also from the associated prescribing and drug ingredient costs.
In addition, inaccuracies in the health board and consequently the GMS (Payments) Board databases in relation to cardholder numbers came to light. As a result, a database-cleansing exercise was carried out on a segment of the medical card database and so far 15,200 duplicate or otherwise invalid cards have been identified. These are currently being removed from the lists. Database cleansing has now been extended to the full registration listing and health board chief executive officers have been requested to ensure that systems are put in place to manage their GMS lists properly in the future. This is part of the process of ensuring that health services funding is delivering value for those that need it.
Moving on to the cost of drugs within the GMS scheme, increased prescribing when combined with higher drugs costs is having a significant impact here also. As I have already mentioned, new and more expensive drugs, usually patent-protected, are being continually added to the common list of reimbursable medicines. Figures provided by the GMS (Payments) Board indicate that the average ingredient cost per item is projected to rise by 10.1% in 2002 over 2001. In addition, the total number of items dispensed is projected to be up 20.3% at the end of this year over 2001 - the increase in 2001 over 2000 was just 8.7%. The proposed changes I have outlined above in relation to the common list will also have an impact on the GMS scheme.
The cost of implementing outstanding agreements with the Irish Medical Organisation, IMO, in 2002 as part of the over 70s negotiations is also significant and relates to a number of issues including, among others, discretionary medical cards, asylum-seekers and non-EU residents and the practice nurse and secretaries' allowance (part-time). The overrun also includes the additional cost of the deal finally agreed with the Irish Pharmaceutical Union in respect of the implementation of the over 70s medical card initiative by community pharmacy contractors. Other elements within the overrun include an increase in activity levels by GPs, independent of any increase in activity relating to the over 70s cardholders. Additionally, some 870 community pharmacy contractors are now submitting claims electronically; contractors who make the transition from manual to electronic claims receive 13 monthly payments during the first year. Finally, an increasing number of GPs are drawing down savings under the indicative drug target scheme to develop their practices.
While a demand-led scheme cannot, as I have already said, be subject to the same sort of expenditure controls as operate in relation to service plans, governance and accountability is nevertheless of paramount importance. Following on from the issues that arose this year in relation to increased costs and shortcomings in the effective management of medical card lists, Deloitte & Touche were retained to carry out a consultancy review of the governance and accountability in the GMS scheme. A progress report covering the projected costs for 2002 has already been received and the full report is expected shortly. Additional funding of €183 million is required.
Funding is also required in relation to compensation payments and legal costs associated with the compensation tribunal to compensate persons who have contracted hepatitis C from the use of human immunoglobulin anti-D, whole blood or other blood products. Based on current trends, the pay-out from the special account and the reparations fund will be in the region of €50 million in the current year. An additional sum of €10 million is required to fully fund this expenditure. A sum of €600,000 is sought to meet the costs associated with the national drugs awareness campaign. This is part of €4 million in additional funding for the national drugs strategy that followed on from the Government decision in February of this year. The contract for this campaign, which aims to enable and empower individuals to make choices based on credible information, was awarded in November.
Savings have been identified in a range of areas to offset the additional non-capital funding required. These savings amount to €44.6 million. They include savings of €38 million as part of the mid-year corrections package and savings from the clinical indemnity scheme, statutory inquiries and certain minor bodies that were established during 2002 and for which funding in 2002 was, due to timing issues, not fully utilised. While such savings would preferably be used in service provision, they have this year been set against the funding requirements as outlined in the previous three items in recognition of the need to manage public spending within the context of the overall target set for Exchequer spending.
In relation to capital expenditure, additional funding is sought for two capital projects. These are at Cork University Hospital and at the Royal Hospital, Donnybrook. These projects follow on from a Government decision of 18 June that €18 million would be provided. A total of €15 million of this is to meet the costs of developments at Cork University Hospital in relation to the amalgamated maternity unit, accident and emergency department and day procedures unit. Service pressures made it imperative that these developments should proceed in the current year.
The second project was the refurbishment of the Nightingale wards at Royal Hospital, Donnybrook. The first phase of a refurbishment of the Nightingale wards in the hospital was completed in 2000-01. The sum provided for in the current year allows for a continuation of the programme of refurbishment to other wards. As a lower level of costs will be incurred in 2002 than had been predicted, only €16 million in total is required in the current year. This is further offset by a saving of €4 million in capital expenditure relating to the nursing degree programme, mainly due to timing of contract payments, so that the total requirement in additional funding for capital projects is €12 million.
The funding required for service provision as outlined above has been added to by a shortfall in appropriations-in-aid. My Department receives the 2% health contribution paid by employees and the self-employed and these revenues are an important source of funding in supporting service developments. Due to changes in calculating the amount payable to my Department in relation to this levy, it is expected that the income in the current year will fall short of that included in the original Estimates by €101 million. Happily, the shortfall overall has been minimised by an uplift of €60 million in relation to the appropriations-in-aid received by Ireland from the UK. These are based on the UK-Ireland healthcare reimbursement agreement.
The primary component in any given year relates to the advance payments. This funding has been used to offset the shortfall in the receipts relating to the health levy and the self-employed. The result is a net shortfall in appropriations-in-aid of €41 million, bringing the overall requirement for additional funding in the Supplementary Estimate to €210 million. It is important to note that this element of the funding requirement does not reflect additional voted expenditure.
This Supplementary Estimate will enable health agencies and the health system to meet the statutory obligations laid down as well as fulfilling the requirements of certain Government decisions. I recommend the Supplementary Estimate to the committee.
There is something a little unreal about our gathering today to authorise the spending of money that has in fact already been spent, particularly in the context of the day that is in it. Only yesterday we voted for new taxes to pay for this. The Minister has already had three mini-budgets to charge the public for this overspending. It is a statutory requirement that we meet to vote this money; I feel it is rather a pointless exercise.
Under subhead B2, the drug refund scheme, there is a €15 million overrun and €8 million is required because we have already had a saving of €7 million, according to our briefing. How can it be called a saving? It may be a saving to the Minister but it is a cost to sick people. The only difference between the €7 million and the €8 million is that sick taxpayers paid the €7 million and all taxpayers will pay the €8 million. What really bothers me about this is that in last year's Estimates this subhead budget was increased by 2% and for the current year, on which we voted yesterday, it has only been increased by 1%. Given that the same pressures will exist, can we really believe that the 1% provided for next year will somehow be enough? Granted, the threshold for the scheme has increased and the Minister will have greater savings, as he calls them, over the year but will the 1% increase be sufficient. It may be regarded as a saving in accounting terms but people will not have access to medicine. There is an inevitable danger that people will end up in acute treatment or chronically ill and dependent on even more drugs.
The overrun in the GMS systems, under subhead B3, is gigantic and is the result of one of the greatest budget cock-ups of all time. The original Estimate for the extension of the medical card scheme to the over 70s was €19 million, then €42 million, with a final Estimate of €93 million. If any chief executive officer in the private sector made a mistake of this magnitude, he or she would not survive the next board meeting. It is an indefensible mess. The excuse is that it is a demand-led scheme. It has always been a demand-led scheme and I cannot remember a single year when a demand-led scheme did not overrun its budget. That introduced an element of predictability but no provision was made for it. The numbers that would be taken in under the extension were also underestimated.
Items dispensed went up by 20%. The Minister pointed out that this is much more than in the previous year. Of course it was more when more people over 70 were on medical cards, particularly when older people require more doctors' visits and medical prescription.
The first charge in this year's budget should have been an investment in information systems. When there is poor information, poor decisions are made. This absence of solid information on which realistic budgets can be based typifies many of the problems in the health services.
The cost of implementing outstanding agreements with the IMO was mentioned. Outstanding agreements are predictable and should have been budgeted for. Their being outstanding is not an excuse. Other overrun elements were pharmacists who submitted claims electronically and, therefore, this cost more. Once the drug refund scheme was introduced it was inevitable that pharmacists would be submitting their claims electronically. There was no other way for the scheme to operate.
The final explanation is that GPs are drawing down more under the indicative drug target scheme for their practices. That was the whole purpose of the scheme. I cannot see why this is mentioned as an explanation for an overrun. It is a contra-entry and was designed as such.
I do not understand subhead G3. The explanation is based on current trends that the out-turn will be €50 million. It is December so that is not a trend, it is an out-turn. Why is it worded in this way? The provision in the coming year is double that figure. Will the Minister explain that?
Subhead K1 deals with capital expenditure and it smacks of election promises. I see Donnybrook is thrown in with design costs but the bulk of the money is going to Cork. I am not questioning the fact that it was needed but it appears that there was no pre-planning, it appeared out of nowhere in the middle of the year, directly after an election. I am not questioning the need for the investment but the reason given is that service pressures indicated there was a need for it. There are service pressures everywhere, look at Dublin. I was in St. Vincent's Hospital on Tuesday and there were people who had been on trolleys since the previous Saturday. It is not necessary to go to Cork to see service pressures. The main service pressures are in Dublin - 60% of people on waiting lists are waiting for a bed in a Dublin hospital.
I admire the Minister's presentation of the waiting list figures. It is not unique to take people from one list and put them on another to make it appear that they have decreased - it has happened in orthodontics - but there is huge pressure on hospitals throughout the State and one wonders why Cork was chosen.
The tragedy of these overruns is that so many of them were utterly predictable. Even more tragic is that it will happen again in the coming year in a more serious situation where budgetary circumstances are much tighter. I cannot see any evidence of change in the system management or IT, that will prevent such overruns from happening again. It would be more tolerable for the public if we really felt we were getting value for the €9 billion being spent.
We all understand that with demand-led schemes at this time of year there will be a Supplementary Estimate. The Minister must accept, however, that the Supplementary Estimate before us this year is an awful reflection on his stewardship. A cost of €210 million, mostly related to the GMS scheme, arose because the Minister and the Department grossly underestimated the cost of the scheme for the over 70s. They did not even know how many over 70s there were. The deal with the doctors was also mismanaged. It was highly expensive and has set down a benchmark making it very difficult to extend medical cards in any meaningful way in the future.
It is also to do with the cost and use of drugs. The drugs bill has increased as a result of pharmaceutical companies making good profits but also as a result of prescribing practice. The Minister mentioned this in his statement but he did not mention that the practice of prescribing costly drugs has been encouraged, and rightly so, by the Minister's strategies, particularly the cardio-vascular strategy. Good practice is encouraged, particularly among family doctors, in relation to drugs like statins to ensure people are well cared for and do not end up in hospital. There is a cost in that and it is important we recognise it, particularly in response to the PD approach, which seems to be that we should not be spending money on drugs, a lunatic idea if people are to stay well. We do need value for money but the reality, often, is that there is a saving if people are kept out of hospital and GPs are being encouraged to treat patients in this way.
I take this opportunity to express my sympathy to the Minister for his disastrous experience in yesterday's budget. There was nothing in it for health. Even the measures the Minister sets such store by in relation to increases in cigarette prices did not materialise. We got a relatively modest increase and cigarettes were not taken out of the consumer price index. Most notably - and an indication of a real lack of confidence in the Minister for Health and Children by the Minister for Finance - the money arising from the cigarette price increases was not ring-fenced for health.
It is estimated that the money raised through the extra taxation on cigarettes would almost pay for medical cards for each of the 200,000 people who are currently suffering at a grave disadvantage because the Government has reneged upon its election promise to them. The Minister for Health and Children has effectively lost money this year even though he made such great capital out of the idea that cigarette tax revenue should be devoted to health spending - a principle I support.
Deputy Olivia Mitchell referred to the publication of hospital waiting list figures. While it is not on the Supplementary Estimate it does have a bearing on it. I ask the Minister for Health and Children to explain the very clear contradiction within his published figures. On the one hand, he says the number of people on the waiting lists has reduced to about 23,000 but he goes on to say that there are 19,000 odd in-patients on the waiting list and almost 10,000 odd awaiting day care. I cannot understand why he is saying this or how he can work out that this is actually a reduction. A very eminent journalist like Fergal Bowers cannot figure it out either. It is important that the Minister clears up the contradiction in this statement.
The decision by the Minister to increase the threshold for the drugs payment scheme to €70 is a truly terrible one. This increase is affecting people on low incomes, families who cannot at the moment care for themselves and their children and who were promised medical cards. Instead, all they have got is increased health charges. It is a cruel decision and I find it remarkable that the Minister can deliver it so lightly. He slipped it in just before the budget clearly to try to avoid flack.
If a single person earns €133 per week and gets shingles, for example, that person will have to visit his or her doctor. A visit to a family doctor in Dublin can now cost €35 or even €40 in places. The person must then go to the pharmacist to get the treatment. That will cost another €100. The combined cost of the GP visit and the required treatment for an extremely painful condition would actually exceed his or her entire weekly income. That is inexcusable and is a reality of the change that has been made.
The type of people who attend my clinic are mirrored by people attending clinics all over the country, presumably even that of the Minister for Health and Children. They tell stories like that of the child who has asthma but is inevitably barred from the long-term illness book. People have all kinds of conditions that are not on the long-term illness book and they are finding that because their income has increased slightly, the medical card is being taken away from them. They are terrified of the consequences.
In his statement the Minister indicated his intention to require family doctors to use more generic drugs and I ask him to explain exactly how he intends to use these. There is a scheme on the GMS which is working and I find it hard to understand why it cannot simply be extended to private patients. I have raised this before and it is worth pursuing. At the moment, the Minister seems to want the generic drug approach to be used within the drugs payment scheme or the scheme in the private patients sector, but he does not tell us how it is going to be done. Will family doctors be encouraged to participate or will there be penalties? How will it actually work? I know the Progressive Democrats want to penalise doctors and patients. Indeed, the Minister has chosen to penalise doctors and patients in tightening up on what at the moment is a very small element of flexibility on the GMS scheme where somebody has moved or lost a card temporarily.
Doctors at the moment have a certain leeway. Where somebody needs treatment, the decision can be taken to care for that patient. The Government is now saying doctors have to cut this out. I find that inexcusable.
To what exactly is the Deputy referring?
In relation to the increased drugs payment scheme, the Minister, in his statement, said that he was dealing with this grey area where somebody temporarily does not have a medical card. At the moment, what happens very often is that doctors and pharmacists treat patients, and rightly so, on the basis that they will get their card. The Minister is saying that he is going to cut off that loophole. It is extraordinary when you can see people out there with lots of money——
Is the Deputy referring to the DPS?
Yes.
That is not the medical card obviously. The Deputy is talking about——
Is the Minister saying he is not going to have the GMS take effect——
It is a point about a section from my press statement about €2 million of invalid claims.
I apologise for my mistake, I thought the Minister was including GMS in that. In relation to people who have died, I ask the Minister to state now to ensure a very simple change in the registration of death regulations so that everybody knows who has died and, most important, that the health board knows who has died and can notify the GMS board. The reality is that doctors do not always know if their patients have died. If they die away from home, in nursing homes or hospitals, a family doctor is not necessarily notified. That is not always the problem but it is part of it.
I ask finally about the appropriations-in-aid. The 2% health levy has been in existence for a long time and was certainly a source of funding for the Department. I now note that there is a change in calculating the health levy, which has resulted in the loss of €101 million. This may have been part of a previous budget but I am not aware that there was a change in the calculation of the health levy that would lead to such a large reduction under the appropriations-in-aid. At a time when, for example, the trade unions are arguing for a health levy to be applied to employers, which sounds to me like a proposition with some merit, it seems a great pity that we are actually getting less from the health levy than we were before.
I am happy to have the opportunity to represent the views of the people who elected me. As a GP, I feel I can speak about what is happening on the ground. As regards the Supplementary Estimates, the decision to prioritise people over 70 years of age and automatically give them a medical card is ethically and morally very questionable and could bankrupt the GMS. The GMS is supposed to look after the deprived people of Ireland. With the €93 million that was spent on this, not alone could the Minister have brought in the additional 200,000 spoken about to the medical card scheme, he could have brought in 350,000 people.
The retired chief executive officers and bank managers among the people over 70 years of age who got the medical cards would have been quite happy to give them to people with children who probably could have used them more. That has done untold harm, not just to the haves and have nots but also among my colleagues. Doctors in Raheny will obtain four times as much to look after a 70 year old compared with their colleagues in another part of Dublin, such as Finglas, who will get only one quarter of that, so it is divisive as well.
It would make more sense to give medical cards to those people. When people go into the expensive hospital system - I have worked in it - it is difficult to get out again. If a person is seen by an SHO or a registrar, he or she is more likely to end up in hospital than if they go to see their GP. That is costly. It is as if the Minister had a choice between two machines, where one was very costly to buy and run while the other was a smaller version but could do the job equally effectively. Would the Minister not use the more cost-effective machine? What is happening at present is that a big machine is being used to do the job. It is like killing a fly with a sledgehammer. It does not work and will do more damage than good. The Minister is wrong in this regard.
With regard to the drug treatment scheme, the threshold has increased to €70. That will account for an asthmatic deciding not to use his inhaler because of €6 or €7. He will end up in hospital with an asthmatic attack. One day in hospital would pay for two patients' medical cards, including their drug costs for a year. The Department is certainly not seeking value for money.
Can the Minister confirm the reported freeze on recruitment to the public service? Will it mean that no GPs will be appointed to deprived urban and rural areas? Does it mean no more hospital consultants will be appointed? What about the three orthopaedic surgeons sanctioned a long time ago by Comhairle na nOspidéal for Mayo General Hospital in Castlebar? I started the campaign for these appointments 11 years ago. If they have been put on hold, I want to know about it now. Approximately 2,500 people travel from Mayo to Galway each year for treatment. It is about the same distance to travel from this House to Galway as to travel from parts of Mayo to Galway. How would the Minister like to travel it? People have been suffering in pain for years without the orthopaedic unit in Castlebar. However, a 33 bed ward has been lying idle for the last year, as has an orthopaedic theatre. That is reprehensible.
I will tell the Minister how to solve the waiting list problem for rheumatology. He should employ more consultants. The health strategy did not even state the number of consultants required even though that commitment was made. Surgical and medical consultants in Mayo General Hospital in Castlebar, an extremely efficient hospital, have virtually no waiting lists, but there are 5,000 older men waiting for an operation that only takes 20 minutes. They have had to get up about five times a night for up to five years and take expensive drugs in the meantime. If the Minister appointed a consultant, that problem would be solved. What is the Minister doing? He is spending the money to send people abroad to support the private health system there. That is ridiculous. It is a vote of no confidence in the public health system.
With regard to rheumatology, people are waiting four years for their first appointment. Is the Minister aware that rheumatoid arthritis in children can cause irreparable damage to joints after two weeks? However, people are waiting four years to be seen because the Minister will not appoint a rheumatologist to Mayo General Hospital. Does the Minister know how many rheumatologists there are in the west? This country has fewer rheumatologists than Croatia. The Western Health Board area, comprising Mayo, Roscommon, Galway, Clare and Limerick is covered by just one rheumatologist. I worked there 25 years ago and the only thing that has changed is the consultant. The previous consultant retired. The situation has not changed. There are 4,500 people who require this service.
I told the Minister that the women of Ireland want the BreastCheck service extended. It has cut mortality rates by 20%. Why does the Minister allow 130 lives to be lost when they could be saved? What drug can do that? The service should be extended. I promised that the women of Ireland would march on the Minister's office if BreastCheck was not provided. A sum of €6 million was allocated but the Minister has fudged the matter.
The Minister should listen to what the Minister for Finance is saying. He is telling the Minister to reform the service. What has the Minister done about the 97,000 people in the health service, 67,000 of whom are not doctors or nurses? A total of 30,000 were employed recently of whom a small percentage are doctors. There are 57 varieties of phantom beds in Mayo General Hospital in Castlebar yet up to eight people are on trolleys every night downstairs. Does that make sense? The people responsible in the health service should resign. The bottom line is that we have eight people on trolleys each night but 27 beds upstairs. That does not make sense.
Deputy Mitchell asked why Supplementary Estimates were necessary. There are inevitably Supplementary Estimates for any demand-led scheme. Otherwise, one is changing the eligibility base. If there are statutory entitlements and the scheme is used, for a variety of reasons, to a greater extent than anticipated, one must provide a Supplementary Estimate. It is not all about the over 70s. What has not been factored into some of the figures is that there will be a consequential €28 million saving on the drug payment scheme under the extension of medical cards to the over 70s. The net requirement, therefore, additional to the Estimate in 2002 is about €23 million. However, we are still seeking well over €150 million for a variety of other reasons, not least the increase in the rate of prescribing and the increase in the cost of the ingredients.
I disagree strongly with Dr. Cowley. I get angry, too, when people constantly question why we decided to give medical cards to people over 70 years of age. The argument put forward by the general practitioners and their representative organisation, the Irish Medical Organisation, was not only about equity, although that was the line they used. Dr. Cowley mentioned that up to 300,000 extra people were involved, half of whom probably would not see a GP, if we extend the scheme, something to which I am committed. One of the strong arguments put forward by the Irish Medical Organisation when it was seeking extra payments for over the over 70s was that GPs would have to see them more often than the 35 year olds if the latter were given medical cards. That is fair enough. However, if we say primary care is important and argue about the importance of preventing over 70 year olds going into acute hospitals, does it not make sense to provide them with the wherewithal to access their GPs on a regular basis, to receive ongoing monitoring and thereby assist them in avoiding the acute hospital system?
There are a number of grounds on which we can examine eligibility, one of which is the medical ground. I estimate that between 65% and 70% of the occupants of any acute hospital today are over 60 years of age. That has been the experience of most major hospitals. As people grow older they utilise hospital services far more often than when they were younger. That is a fact and Dr. Cowley knows it. People see more of the health services in the last 20 years of their lives than in the first 50 or 60 years.
We seem to have no difficulty, in other budgetary areas, extending eligibility to a range of things, such as child benefit, which could cost up to €150 million in one budget. However, there always seems to be a different approach to this issue for the over 70 year olds. It has thrown up many issues and Deputies have referred to them. Deputy Cowley talked about phantom beds, but this has thrown up the phantom medical card too.
I accept Deputy Olivia Mitchell's point about information systems. We have identified it in the health strategy. There is no argument that the database in the general health information system needs huge improvement. That was pointed out in the Deloitte & Touche value for money report and it is incorporated in the health strategy. We are formulating and will shortly publish a health information strategy which deals comprehensively with the deficiencies in the information systems. It will have significant implications.
I accept the point made by Deputy McManus about the difficulties the DPS causes for people. We had no great enthusiasm about having to increase the DPS but the scheme has increased dramatically since its inception in 1999. There has been an increase of more than 100% in the funding and a 40% increase since 2000. That has nothing to do with the under or over 70 year olds but everything to do with the cost of medication and the deals and agreements among the professionals who operate the schemes, which were in place long before I became Minister. There is tax relief available to people at the marginal rate if they go over a certain level of expenditure.
As regards the utilisation of generics, I had meetings with the national pharmo-economic unit. There are two major cost drivers of the DPS. We can look at the cost of medicines and how we approach the issue of greater utilisation of generic drugs. We are currently exploring a number of options with which we will return to the committee. The other major cost is pharmacists, who obtain a 50% mark-up on every item prescribed under the DPS. That has a significant multiplier effect in terms of the driving costs of the drug payment scheme. That agreement was arrived at after industrial relations issues were resolved and the system was then put in place. However, we should not attack the system all the time.
Is the Minister saying there is an agreement to give pharmacists a 50% mark-up? I knew there was such a mark-up.
That is the way it was.
I assume it is not an agreement.
It is built into the system. We must examine that.
How can the Minister examine it?
We will return to it because we have had discussions. We must examine it because it is a driver——
I accept that.
It is a major driver of the cost of the DPS. It has escalated dramatically in the past two or three years. That is also as a result of the fact that we have greater access. The administration of it has changed from the old drug refund scheme where people had to apply. It is now much more streamlined, a development we facilitated. There are 1.2 million people involved, which is more significant.
Deputy Olivia Mitchell also raised the issue of capital. Major capital infrastructure exists and all the projects, such as that at the James Connolly Memorial Hospital, have been planned. The Deputy mentioned St. Vincent's Hospital, but she failed to mention the fact that there is a €200 million——
That is planned and budgeted for. We are talking about unplanned projects.
It was not part of the budget. I had to find an extra €45 million for St. Vincent's Hospital the year before last because the project was €45 million more than what it was meant to be. I found that money, notwithstanding that it was not close to my constituency. It is probably closer to the Deputy's constituency.
It is in my constituency.
We did it because it had to be done. We agreed that part of the €45 million was for the extra operational theatres. Other projects included James Connolly Memorial Hospital, the hospital in Portlaoise and the new hospital in Tullamore, work on which was started. The Cork University Hospital projects, the accident and emergency, maternity and day surgical units, came in for decision after tenders were received. We had two choices. One was to defer for a year and not allow the work to commence and the other was to proceed.
It is interesting that Cork University Hospital has the third largest number of casualty attendances in the country, with an estimated 60,000 attendances last year. It is not often accepted that a Cork hospital is in that league table. If we had delayed the work by a year, the costs would have increased further. These projects were planned for some time. The maternity unit capacity is up to 7,000 births, compared to the 5,000 originally forecast. That is better value for money. The worst possible scenario would be that we would have a unit in two or three years which could only cater for 5,000 births, despite all the expenditure being used to cover the demographics of the region.
Deputy McManus mentioned the registration of deaths. We will consider that area. I have seen cases in my clinic where the Department of Social and Family Affairs does not have any difficulty writing to a social welfare recipient whose pension was overpaid as a result of an administrative error. I had a case recently where the person was overpaid by €4,000 or €5,000. The Department wanted to reduce that person's payment by €20 a week until the money was cleared. We accept there are problems with the system database. I accept the Deputy's point that GPs are not automatically told when someone dies. However, GPs know in the majority of cases if one of their patients dies. We will discuss that issue with the Irish Medical Organisation.
The health board needs to know in order to notify the GMS payments section.
I accept that.
The Minister presumes that the general practice system will always be good and accountable, yet his own systems are not right. That is a simple measure. The Minister must resolve the problem, regardless of who is to blame.
The system has facilitated investment in general practice.
Yes.
General practice covers both public and private sector remuneration and revenue. We have, for example, invested large sums of money in GP co-operatives. Expenditure in GP co-operatives in Northern Ireland does not come from the State, but from the private sector. There is a quid pro quo. Given the level of investment in primary care, I expect that people would have systems. Many GPs are developing joint practices, computer systems, etc., but many do not even have secretaries. We should not always have a knee-jerk reaction and blame the health boards and the system. We must accept criticism and take things on board, but there are two sides to the equation.
It is only a suggestion about how to resolve it. It is not about blame.
As regards Deputy Cowley's question about Castlebar, I do not have specific details with me. However, I know that capital investment in Castlebar in the past three or four years has outstripped anything in previous years. The same is true in terms of breast cancer facilities.
We are playing catch up.
We received a submission from the Western Health Board to which we agreed. BreastCheck made a submission to us. There is one key issue we must resolve with the BreastCheck board and I mentioned that in the Dáil. It relates to the fact that we have supported the Western Health Board's submission on centres of excellence in terms of the Galway-Mayo axis. BreastCheck has a policy that if we set up centres of excellence in Letterkenny or anywhere else, a person captured by BreastCheck must follow the BreastCheck system through to the end. One could have a scenario where people in the west or in Donegal would have to bypass their own centres of excellence to attend the BreastCheck treatment centres.
There are BreastCheck facilities on the east coast.
We are committed to advancing BreastCheck to the other half of the country. The only issue up to now was that the first half was to report back to us. It only reported this year on how it has worked. It has put forward what it would take to put BreastCheck in place for the rest of the country. If we sanction it this year, it will be two years before it is up and running. That is the logistical reality behind the extension of BreastCheck. There must be agreement between ourselves and BreastCheck. There must be a synergy between the roll-out of the centres of excellence on the breast systematic treatment side and what the BreastCheck board is doing. It would be ludicrous for a person who is screened in the north-west to have treatment in Dublin, despite the fact we have funded, in accordance with all the protocols, a centre of excellence in Donegal. That is an issue we must resolve before we can move forward. I will put that down as a mark to the health committees.
In reply to a parliamentary question on 21 November the Minister said that the board of BreastCheck had recently submitted a business plan to his Department for the national expansion of the programme. God help us if that is what the Minister calls a priority because the plan was submitted almost six months ago.
The Minister referred to breast cancer services in the east and the west. As a general practitioner, I know that survival rates for people on this side of the country are higher than for those living on the west coast. The cancer report indicated that mortality rates in the west are 5% higher. This is because of the lack of radiotherapy services, which the west should have.
If there are problems with the implementation of BreastCheck services on the west coast why were they not apparent on the east coast? When BreastCheck services are provided in approximately half the country, by the Midland Health Board, the North-Eastern Health Board and the Eastern Regional Health Authority, why are they not available in the west, especially if the Minister believes in the principle of equality? There is no reason BreastCheck should not have been provided nationwide when it was established in 2000. The evidence proves that, if applied, the service cuts mortality rates by 20%. What drugs will do that? People on the west coast have a greater chance of dying from heart disease, head injuries and cancer and the further they live from the centres of excellence in Dublin, the greater their chance of a poor prognosis and of dying.
That is not true.
It is.
If I recall correctly, in its instances of mortality the National Cancer Registry estimated that people in urban areas had a 10% greater chance of dying from cancer.
I wonder what that tells us.
It tells us that we should get out of here and eat decent food. Those finding are more or less definitive.
There is a lack of radiotherapy services in the west, with the result that consultants do not send their patients to the east because of the journeys involved. It means that survival rates in the east are 5% higher than in the west. There is no logic for not extending BreastCheck services. It would cost an extra €6 million. The Minister is fudging his commitment. He says he will extend them subject to the usual priorities. He should be honest and say it will not happen.
The Minister says the services must be extended on a correct basis. They have been implemented correctly in the east for the past two years. Why is it right for the east and not for the west?
When the BreastCheck services were being extended there was a need to ensure it was done correctly. It was decided to pilot the programme in half the country, namely, the east and the midlands. As the service was rolled out in the east difficulties arose, for example, in recruiting radiographers. It could not have been done on a national basis for logistical reasons because of the shortage of specialist personnel required. A good aspect of the first two years of the pilot phase is the achievement of high results in terms of standards and quality. They would have been sacrificed had the political option of extending it country-wide been exercised.
BreastCheck was launched before I became Minister. It has achieved international recognition as one of the better programmes. I accept the need to extend it to other parts of the country. However, when it was launched the Niall Higgins report, calling for the development of 13 centres of excellence, had not been published. We are now operating in a different context.
A policy issue, signalled by the BreastCheck board, has emerged. My Department is funding a centre for breast treatment in Limerick. However, as Cork will be the host area for breast screening, a patient in Limerick who produces a positive screening will have to travel to Cork. In my view that is illogical in terms of public expenditure.
We can agree to disagree on this. BreastCheck should have been implemented country-wide because international information supported such a move. The Minister's failure arose when he did not obtain the funding of €6 million required to extend the programme. He should admit that it will not be extended.
A significant increase of €30 million is to be allocated to cancer treatment services.
What about the €6 million for the extension of BreastCheck?
The Deputy should know that it is unwise to show a full hand before proceeding.
Will the Minister clarify the position on hospital waiting lists? I understand the three experts appointed by the Government to look at spending have damning things to say about health spending. They have raised the issue of means testing of the provision of medical cards to those aged over 70 years. Will the Minister indicate his views on that? It has also been suggested that there should be no further capital funding, but, without it, services requiring ongoing maintenance and current spending will not be provided. Will the Minister comment on that aspect?
We released figures two days ago which indicate that the waiting list stood at 22,718 at the end of September, representing an overall decrease of approximately 14% in numbers relative to the comparable figures for September 2001.
The Minister is not comparing like with like. When out-patient and in-patient numbers are combined the figure stands at almost 30,000. Will he clarify this?
The press release provides clarification.
There are two sets of figures. I am used to the Minister's interpretation of them.
The Deputy is not used to it.
I am because the Minister has done it consistently. He picks a date that will bear good comparison and he has repeatedly referred to it.
In 1993 the then Minister, Deputy Howlin, introduced waiting lists and he laid down guidelines on how they are to be computed. In those years some hospitals did not submit figures on day care procedures. From the late 1990s figures on day cases comprise an increasingly significant proportion of the figures. I insisted on the inclusion of these figures to provide more accurate statistics. That is why I use the term "comparable" because I will not be blamed for it if they were not included in the years 1994 to 1997. My task is to refer to like with like. In terms of the 1990s, the figures are down by 14%. Hospitals that did not submit figures on day cases will be included for the first time.
There is a need to work out a definition of day case procedures. That is why the press release advises that the figures should be treated with caution. Some hospitals include figures on diagnostic treatment involving surgical day cases, which means that minor diagnostic treatments are included. That is not necessarily a bad development. More work may be required on the day cases to ensure greater specification of categories of procedures and so on.
The good news is that, on the in-patient side, the waiting list is down to 19,000. By definition, being an in-patient involves at least one overnight stay for a surgical procedure, which is obviously more severe than a day case procedure would be. The figure to which I refer is significant. Even though we are including more figures, I would still issue a warning signal in respect of waiting lists.
The hospital treatment purchase fund is interesting from one perspective. It probably represents the ultimate test of the list, that is, if you offer a patient treatment does he or she come forward? For example, I understand that in the South-Eastern Health Board area the treatment purchase fund would have contacted approximately 600 patients who would have been on the list for a long period and 279 reported back that they had already had their operations.
Is that due to information systems?
The Deputy may say that. I am being condemned for my waiting list announcement yesterday on the grounds that it provides higher figures for the day cases. I note that the treatment purchase fund's assessment of those who are waiting longer than 12 months includes 2,000 fewer than the lists that we have received from the health boards. The ultimate way of testing these lists is by offering treatment.
We now know that 400 additional operations could have been carried out in the United Kingdom if people were referred to the treatment purchase fund, but they were not so referred. When the free telephone line was set up over the past two months, about 200 rang the number. Some 90% of those who rang in saying they would like to have an operation stated they had no difficulty in going to the United Kingdom to have their operation.
There is more work to be done on the waiting lists. The treatment purchase fund will be a significant additional help. It is not taking money out of one sector to fund another. I was told for two and a half years, since I became Minister for Health and Children, that capacity was the problem in the acute hospital system and they simply did not have enough beds for elective patients and that the overrun from A&Es, etc., were reducing the capacity of the acute sector - it was not anybody's fault - to deliver the scale of activities.
Probably the largest ever building project in terms of capacity on public hospitals in the history of the State is under way throughout the country. What we are saying, in terms of the treatment purchase fund, is that there are people who have waited for a long period and let us try to deal with them. There is plenty of work for everybody in this in terms of the numbers on the waiting lists.
There is a problem. We have not reached full capacity in public and voluntary hospitals. There is capacity which we cannot use. As Deputy Cowley pointed out, there are beds which cannot be used because of staff shortages and other reasons. Surely the treatment fund can only be of value in the long-term if you have full capacity in the hospital system, and we do not have that. We have too many long-stay patients in hospitals.
But we have capacity of 100% in some hospitals. We have utilisation——
There are too many people who should be in rehabilitation who are still in hospital.
Yes.
There are also beds that are not used. The Minister's system is so good, he seems to have completely eliminated my local hospital, St. Colmcille's Hospital, Loughlinstown. I cannot see it on the list.
I will try to find it again.
That would be nice.
On the capacity issue raised by Deputy McManus, all the major hospitals have been reporting to me that we are looking at unacceptable levels of capacity utilisation within hospitals of 95% to 100%, whereas the international norm is 85%. We have the figures to show that is the case in all the major acute hospitals. That is why we went through the bed capacity issue, why we did the bed review and identified the need for 3,000 beds and why we put in the money for 709 in the short-term.
What is the Minister going to do about taking the inappropriately placed patients out of hospitals. He could put the money in there. It would make much more sense.
We have been putting significant funding into that. The Deputy is correct. We need more——
There are still many beds which could be used.
There is still a big problem and the public private partnership model is being used to give us, within the next two to three years, about 850 continuing care beds to alleviate those pressures. In some of the major acute hospitals, there are many people who really should be in continuing care beds who are in acute hospital beds. That is my point.
In the meantime, however, the person who is waiting 15 months for an operation cannot wait around for us to provide beds for the elderly, etc. That will take time. There should be no objection to that person being offered treatment, either in a private facility in Ireland, where there isspare capacity, or, if necessary, in the United Kingdom.
I have almost forgotten my question. I accept everything the Minister said about the waiting list figures. Obviously the waiting list figures were inaccurate and in a mess to begin with, and certainly they need to be organised. The reality is, however, that if one adds the one-day cases to the number of people waiting to be admitted for more than one day, one ends up with almost 30,000 people waiting. It is irrelevant whether or not that can be compared with any figure which was ever available in the past. The point is that is the magnitude of the problem and to that extent it is useful information.
To be honest, I do not obsess about waiting list figures because, first, I know the figures are almost inevitably wrong due to lack of information systems and, second, the waiting time is the most important aspect and, indeed, the waiting time to get to see the consultant in the first place. I can definitely verify that the information on the lists is wrong. Two or three weeks ago somebody told me they had been called for their operation in Tallaght Hospital but they had actually had the operation two years ago. The person was less than impressed. The authorities at Tallaght Hospital did not even know the operation had been done at their facility.
It has been reported - I do not know from where the story came and perhaps the Minister could verify whether it is true - that there is a further €3 million which cannot be spent in the treatment purchase fund. Is that €3 million of the remaining part of this year's allocation or does it relate to next year's allocation?
It is from this year's allocation.
Will next year's allocation remain the same?
Yes, at about €31 million.
What about the €10 that was left?
They were not in a position to spend €3 million on it. The position at present is that they have capacity for about 400 patients in United Kingdom hospitals. They could have done operations on 400 patients if they had been referred.
Where is the problem? Has it genuinely to do with consultants in the health boards?
It would seem to me that some health boards and some consultants are not referring patients.
Some of them must be doing so.
Many of them are doing so. They have set a target of 1,900 at the end of this year and that will be achieved.
Unlike the Minister's target which will not be achieved.
We will see.
It is quite clear. According to the Minister's figures, he will not achieve it.
We will see. There were two other questions Deputy McManus raised which I knew we would not reach if we started talking about waiting lists. First, we will need more capital going forward in health. That is my view. "An Bord Snip" made recommendations in the context of the three wise men. In terms of the capital issue, our view is that very significant levels of capital will be required for health in the future. I support the broader thrust of having a strong fiscal base. I do not want the economy to return to the state in which it was during the 1980s or early 1990s. Therefore, I accept that the ultimate guarantor of health services is strong fiscal policy.
Having travelled around the country, I am in no doubt that significant capital funding is required, particularly in terms of the elderly, to put in place the infrastructure which will be required. There is a major capital programme already under way and it is much greater than anything we have experienced before in the health area in terms of budgets. Therefore, I do not accept the argument put forward by the committee that was established in that regard.
It is clear that the committee has a view, not only on over 70s but on all schemes. The three wise men would say that we should tax child benefit; in other words, they question all eligibility systems whose backbones are their universal nature. That is their view. The political view would be different. People have political views about entitlements and I would have a strong view that we should retain the universal nature of systems in certain areas. For example, the free travel scheme for older people has been in place for years and nobody has ever suggested that we should impose a means test on it.
We should retain universality in certain areas. For example, the free travel scheme has been in place for years for older people. No one has ever suggested it should be means tested. Child benefit is an important payment which goes directly to the parent and on to the child. It has been an important protector in the areas of child poverty. Sensible people with secure backgrounds, even some who have separated, have visited my clinic because they have little income and child benefit is important to them. I reject their broad thrust on universality systems.
I am interested in the Minister's waiting lists figures. If they are calculated using the old method, waiting lists have increased to 29,174. That is a gross miscalculation. I am a general practitioner and if I were still in my practice I would have torn out all my hair at this stage because of the difficulty of referring people into the system in the first place. Approximately 100,000 people who should be on waiting lists are not on them because it can take years to get an appointment to see a consultant and, therefore, the waiting lists are a sham.
With regard to the Minister's deadlines, the health strategy is out the window because if the public sector recruitment embargo is implemented, there will be fewer beds and consultants. The Minister still has not replied to my orthopaedic question. A young fellow with a pencil would do better. When the extension of the medical card to the over 70s was proposed, the cost was calculated using a regular person on the GMS, not an older person who would use more drugs. The calculation was wrong and it is no wonder there is an overrun in this regard.
The Minister has established 170 committees and the Deloitte & Touche report on health boards is lying on his desk. The Minister for Finance wants the Minister to give value for money in the health system. Why did he not do anything about the health boards? They need to be rationalised.
What did the report say about health boards?
It stated they should be examined.
Did the report state that anything should be rationalised or amalgamated? Let us get the truth out.
They should be rationalised because——
Let us pin down that point. I have the Deloitte & Touche report and I know what it states about health boards and everything else. It did not state health boards should be abolished.
I did not say it stated health boards should be abolished.
That is the line that has been coming out for quite a while.
No, I said it stated health boards should be examined. I am talking about rationalisation.
It stopped short of giving a recommendation. That is the problem with the report. It referred to a further review of structures.
It is not as if the Minister is a blind man. That money is badly needed. Is he aware that a machine which carries out the most basic test in Mayo General Hospital in Castlebar has been out of order for the past year? Any hospital worth its salt should be able to provide this test. It would cost €400,000 to repair and because of that people must travel to Galway. The machine was closed on the direction of the Radiological Protection Institute of Ireland yet the hospital has been waiting for the past year for sanction for funding from the Department of Health and Children.
Consultant appointments have increased by 26% over the past number of years. The issues to which the Deputy refers are the responsibility of the Western Health Board first and foremost in the context of replacement of equipment.
What about orthopaedic care?
If the demand-led schemes are left out, the Department has an incredible record by any yardstick in terms of coming in within budget or close to balance in the most expansive area of expenditure in the public sector. In 2001, €7 billion was allocated to the health boards and the overrun is €12 million in accordance with service plans. That could be reduced to €4 million or €5 million before the 2001 audit figures are delivered.
There was a great deal of hysteria and hype in August and September about the 2002 figures. I do not know how many reports I read that stated we would be €100 million in the red at the end of the year. That will not be the case and those figures will also surprise people. I accept we are committed to reforming structures under the Deloitte & Touche report. We have a consultancy in place and we are working with the individuals involved to bring forward proposals in January or early February relating to the organisational structure and they will include all health agencies.
Will the Minister confirm 25 nursing posts will be lost in Mayo General Hospital? He still has not replied to my question about whether an orthopaedic consultant will be appointed there.
All these issues can be tabled as parliamentary questions in the House and it is not appropriate to trawl through the health services in Mayo.
What is happening?
We have trawled through the services in Cork in our time.
I disagree with my colleague, Dr. Cowley, in regard to waiting lists. There are problems in certain specialist areas but there are not in other specialist areas and I congratulate the Minister on the initiative he has taken.
Tobacco and alcohol featured prominently in yesterday's budget. Does the Government want to remove them from the consumer price index? Why was that not done previously? Is there a problem in this regard? They should be removed.
I absolutely agree. Tobacco, in particular, should be removed from the CPI. The budget's impact on inflation will be an increase of 0.8%. If tobacco was removed, the increase would be 0.4%. The increase of 50 cent on the price of a pack of cigarettes distorts the CPI. Congress has a problem with removing tobacco from the CPI so that the Government would not use it as a basis for wage negotiations. Congress sees that as the removal of a significant lever for it in terms of negotiating national agreements.
IBEC has come around to the idea. I had meetings with both IBEC and ICTU last year and IBEC has issued a statement in which it felt tobacco should be taken out of the CPI. Congress has not entirely come around to that view and the Department of Finance is cautious about doing so. There might not be the same enthusiasm in that Department as there is in mine because we are driving this issue from a public health perspective. The Office of Tobacco Control estimates that the 50 cent increase could reduce consumption by 4%.
The World Bank and the World Health Organisation are clear that price is the number one weapon that governments have in regard to tobacco control and advertising is second. Price is considered number one particularly in terms of preventing young people from becoming smokers. We have raised this issue with other European governments in an attempt to reach a European-wide agreement on the calculation of inflation throughout the euro zone and the calculation of CPIs. European agreement would be equally significant.
We made pre-budget submissions seeking increases in the duties on alcohol and spirits, in particular, and cigarettes from the public health perspective. I welcome the increase in excise duty on spirits because spirit consumption has doubled over the past five years and there has been a significant shift in consumption from beer to spirits. All of us have heard anecdotally about what is happening in pubs and elsewhere in regard to shots and alco-pops. We had to move on that from the public health side. Deputy McManus and others stated that some of that money was not reinvested in health services. However, even in a tight fiscal year, the health budget will take about two thirds of the overall increase in public expenditure across the sector. Other Departments are taking decreases in their allocations. The Department of Health and Children is way ahead of other Departments because of its size, scale and the nature of expenditure.
The Minister was looking for it to be ring-fenced and we supported him in that.
I said I would love to have more of it, but I would have no difficulty with it being ring-fenced.
We will have to adjourn.
May I ask my question? I realise there is a list, but it is brief and we have a few minutes.
Will we return to the Estimate or is the committee happy to conclude it?
Could we agree the Estimate? I have a slight difficulty.
I would like to ask a brief question and forgive me if it is has already been dealt with, but I had to attend two other committee meetings. How successful has the treatment purchase fund been? Has it been an overwhelming success?
It has been successful. By the end of the year, 2,000 people will have been treated under it.
Is it not good value and should it not be extended?
Yes, it is good value.