Dáil Éireann - Volume 348 - 01 March, 1984
Estimates, 1984. - Vote 47: Health (Revised Estimate).
Minister for Health (Mr. B. Desmond) Barry Desmond
Minister for Health (Mr. B. Desmond): I move:
That a sum not exceeding £1,021,212,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1984, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.
The gross non-capital provision in the Estimate amounts to £1,057.284 million. Allowing for Appropriations-in-Aid at £91.572 million, the net non-capital grant provision is £965.712 million. The net non-capital grant provision represents an increase of about £29.7 million on the corresponding out-turn for 1983, £936.019 million. In addition, the health services draw on Vote 50 (special grade increases in remuneration and pensions) will amount to about £30 million in the course of 1984. The capital provision included in the Estimate amounts to £55.5 million.
The non-capital expenditure on health services in 1984 is estimated at some £1,130 million in gross terms or £1,064  million taking account of income from various sources. This latter figure represents about 7.3 per cent of GNP. The gross estimate of £1,130 million comprises £704 million in respect of pay, £368 million in respect of non-pay excluding cash allowances and £58 million in respect of cash allowances.
The serious problems posed by the constantly escalating cost of providing and delivering our current level of health services is a source of major concern to this Government, and that concern is, I know, shared by all members of the House. While the quality and scope of our public health services have undeniably shown a vast improvement over the last ten years, we have now reached a point, in common with many other developed countries, where the allocation of yet more and more financial resources will not necessarily improve the actual quality of the health services which is received by individual patients. The problems which now face us in this regard are much more sophisticated than some outside commentators are wont to acknowledge.
One might point out that net non-capital expenditure on health services here in Ireland have grown from some £400 million in 1978, only six years ago, to an estimated £1,064 million in the present year. These figures represent an increase of 166 per cent. In terms of percentage of GNP, the growth over the same period was from 6.25 per cent in 1978 to about 7.3 per cent this year. It is perfectly obvious that it is no longer possible or even desirable to maintain and sustain these trends into the future, given on the one hand the maximum level of resources which will be available to Government in the short to medium term and considering on the other hand the innumerable other pressing demands which must also be satisfied by the Exchequer.
I wish to consider briefly the financial position which obtained in the health services in 1983. I think it will be accepted universally that there were no major financial problems last year. There was no need for any supplementary estimate and it was not necessary to reduce the 1983 allocations of the various health  agencies, mainly health boards and public voluntary hospitals. It is only proper that I should place on record my deep appreciation of the hard work and successful endeavour of those working in all the health agencies in coping with the financial restraints which had to be imposed in 1983 because of the serious economic circumstances obtaining in the country. As a result of their efforts, these financial restraints were absorbed without any serious impact on the excellent fabric of the services.
I know that the coming year will be more difficult for those administering and providing the services and much closer and constant attention will have to be afforded to effective cost containment if the executive agencies are to remain within the framework of their individual approved allocations. It is quite clear that most health agencies will experience difficulty particularly in the area of hospital services in containing expenditure within budgetary limits. Indeed, it is quite clear from reports which I have received to date that the overall volume of hospital services will have to be curtailed in order to secure the necessary savings in expenditure. However, I am quite well aware of the fact that there are a number of services and practices throughout the country which are by no means essential to the maintenance of a modern and progressive health service to treat and prevent illness.
There is no doubt whatever that there is still considerable scope for further rationalisation of a number of services and where necessary, for the redeployment of financial resources and personnel on an identifiable basis of priorities. It has been obvious for years that a significant minority of admissions to hospital are completely unnecessary. Indeed, the particular question of so-called “week-end admissions” which occur when premium payments to staff are at their highest and when treatment often does not commence until Monday or Tuesday, needs to be examined as a matter or urgency.
There is also the question of the indiscriminate use of publicly funded diagnostic  facilities. There has already been considerable public controversy about the gratuitous use of these public facilities and equipment by consultants in the course of their private practice. As Deputies know, I find this position quite unacceptable and officials within my Department are currently examining this entire issue. I will discuss this issue next week with the new Irish Medical Union.
We are at present working with the various health agencies in attempting to identify particular problems which may arise. All the individual agencies were notified of their 1984 allocations in mid-December last. Some days immediately after that notification, as a first step in the consultative process, I met with the chairpersons and chief executive officers of the eight regional health boards.
All of the health boards have now met to consider their position and have already adopted a range of proposals aimed at aligning projected expenditure with the level of allocation provided. Some boards have already achieved a total alignment while other boards have only partially succeeded in this task. I would now urge these latter boards to give urgent attention to the satisfactory completion of this exercise as there will be no extra funds available to further supplement the original allocation of any health agency.
The situation will be constantly reviewed in the light of reports received from the agencies on the measures they propose to adopt in order to remain within their allocations and on the implications of these measures.
In order to facilitate the health agencies in this task, I have left them relatively free to determine the particular measures which they need to introduce to ensure that they stay within their allocation. This flexibility applies especially to the question of any vacancies which may arise. It will, therefore, be essentially a matter for each agency to determine the measures it needs to adopt in the light of its own requirements.
I do not deny that the financial situation in the present year will prove challenging to many of the health agencies. I need hardly add that this will again  require the fullest level of co-operation and commitment from all concerned, be they working in the areas of medical and nursing care or administration, in either the health boards, public voluntary hospitals, homes for the mentally handicapped or other agencies.
Finally, with regard to finance generally, I might mention that I have come to the conclusion that it will be necessary to produce a Green Paper in which I can put forward for consideration and debate some fundamental issues in relation to the financing and organisation of the health services and the structure by which they are delivered. We must address ourselves to the fundamental dilemma of attempting to satisfy the ever-increasing demands for services in the face of the limited resources which our society can afford to devote specifically to health care. Some would argue for a more rigorous establishment of priorities in the health services. An informed debate on these issues is now required and I hope that the proposed Green Paper will stimulate this process of review and discussion. Work on the preparation of this document is now in progress and I intend to publish it this year.
As a society we have devoted increasingly larger amounts of our national resources to the health services. Expenditure has increased almost tenfold since 1972-73. This growth is not amenable to simple explanation or directly attributable to a single or predominant cause. It is the product of a complex set of factors, including price changes, changes in the scope, quantity and quality of services, as well as changes in the eligibility criteria for certain services.
Undoubtedly, inflation has played a major part in the escalation of costs. Real spending on the health services has increased by a factor of slightly more than two since 1972-73. Population growth and, in particular, the number of persons in the dependent age groups is another important factor. Rather than referring only in general terms to improvements which have taken place, I think it will help to put things into perspective if I mention some specific examples of the changes which have occurred in our  health services in recent years: admission to acute public hospitals increased from 389,500 in 1971 to 571,000 in 1982; admissions to psychiatric hospitals increased from 16,526 in 1966 to 27,098 in 1980; consultations under the GMS scheme grew from 5.35 million to 7.44 million over the period 1974-82.
The past two decades and particularly the seventies have seen many advances in medicine, often involving the provision of new and expensive high technology equipment and an increasing tendency towards specialisation in the practice of medicine. These advances have expanded the scope of diagnosis and care and have created a demand for additional training and new skills as well as a substantial investment in physical facilities.
Some examples of the improvements in treatment which have occurred are as follows: open heart surgery; haemodialysis; joint replacement surgery, in particular, total hip replacement; intensive care, particularly neo-natal intensive care where there have been major developments over the past 15 years.
The rapid development in recent years of diagnostic techniques has significantly increased hospital activity. New techniques do not necessarily replace existing procedures but are often used to supplement them. They are frequently labour-intensive, requiring new skills and the equipment involved is usually expensive. Some examples of improvements in this area are: computerised tomography, which was introduced in the seventies and had a major impact on the investigation of brain lesions and the detection of cancer; diagnostic ultrasound, now widely used in many specialities; endoscopy which has greatly enhanced the information available to clinicians on many internal parts of the body and laboratory investigation, the range of which has expanded enormously.
At primary care level there have been a number of significant changes over the past decade in the services provided. The introduction of the choice-of-doctor scheme in 1972 was a major advance on the former dispensary system. The past decade has also seen a rationalisation and improvement of the public health nursing  service. Both of these developments contributed to a substantial improvement in the quality of primary health care available to the community and particularly to the less well off sections of the population. Improvements in community care also favoured particular target groups, for example, the mentally handicapped and many psychiatric patients who can now be treated in the community rather than in institutions. Naturally, these improvements in the quantity and quality of the services provided have not been achieved without cost.
Additionally, the scope of the health services has widened to encompass new services principally in the community care sector. A prime example is the increasing role of the health agencies in the provision of personal welfare services in the form of financial and non-financial supports for the relief of social stress in the community.
The extension of eligibility for free hospital services in public wards to the upper income group in 1979 also marked a significant change in policy which was achieved at some cost to the public purse. In commenting, therefore, on the large increases which have occurred in spending, this range of improvements should also be borne in mind. It is not simply an escalation of costs that we are talking about, it is a health service which has changed significantly in terms of the quantity and quality of the service it provides.
One of the biggest challenges facing the health services is how best to manage its resources, whether they be staffing, financial or materials so that the best possible use is made of them. In order to evaluate how efficient the health services are and to manage them it is necessary for the Department and the health agencies to have available comprehensive and up-to-date information covering the financial and non-financial areas. It is not enough, however, to have the information. Of greater urgency and importance is the use to be made of that information and the need also for a continuing and  critical appraisal of institutional and community services.
Nevertheless it is clearly necessary for the right systems to be introduced in the first place and it is therefore heartening to record that the information available to local management will be considerably improved by the introduction of new systems in the agencies. These systems will cover a wide range of services provided by hospitals including pharmacy and patient administration. New financial systems are also being introduced which will be capable of giving a greatly enhanced quality of information. The systems are now being implemented in a number of health boards and voluntary hospitals and will add to the quality of analysis and decision taking by managers. In the past, there was a difficulty for hospital administrators for example in identifying with precision the areas where money and other resources were being inefficiently applied and by whom. With the coming of the new systems these administrators will be better able to pick our areas where wasteful expenditure is occurring and take the necessary corrective measures.
I have also mentioned the need for critical and continuing examination of services if we are to properly manage the health services. To meet the challenge of improving efficiency, particularly in the general hospital area, which accounts for about 50 per cent of all health expenditure a number of initiatives have been taken which are of considerable significance. Studies have been carried out by my Department, in some cases with the aid of management consultants, into a broad range of activities carried out by major general hospitals. For example, a report was finalised last year on the supplies function which recommended a series of good practices for use by hospital agencies in organising their purchasing and storing of supplies. Studies have also taken place of the energy, housekeeping and transport areas and there again, useful recommendations have emerged. In each of these areas the Department have written to the health agencies setting out the principles of good practice which, if they are not in operation already, should be applied by them.  There are a number of other matters which we are following up. For example, we are looking at the possibility of setting down criteria for admission of in-patients to hospitals. This examination is being carried out with a number of hospitals and is attempting to eliminate, as far as possible, admissions which are not necessary. Another area being examined is laboratory services in hospitals to see whether unnecessary tests can be reduced. Finally, the possible greater use of day beds and five day wards as means to cut down on long and costly hospital stays is also being studied. This list is not of course final. Each aspect of the health services is being continually reviewed to ensure that efficiency is present in its delivery whether it be by a health board or voluntary hospital or by any other agency receiving funds from my Department.
In addition the Department of Health are helping individual hospitals to maintain services within their existing allocations by suggesting areas where savings might be made in non-pay spending. This process is being assisted by making available to the hospitals details on how they compare with other similar institutions in terms of costs, prices, etc. Comparative information of this kind is extremely useful to the agencies in helping them to identify points of operational weakness. All the hospitals who have been provided with the cost comparisons have shown a great interest in the information.
While comparative information of this type is most valuable, I am anxious that we should have available more detailed information in the financial consequences of medical decisions.
At present our accounting procedures, whether manual or computerised, provide information under broad cost categories. I have already mentioned that new management information systems will be extremely beneficial for managers in controlling expenditure. However, I have been considering various options for new costing systems which would take advantage of the opportunities that will be provided by the health services systems development programme. Such costing methods would identify the  expenditure involved in treating an individual patient or specified groups of patients, or even particular groups of diseases. Information of this type would obviously be invaluable to health managers.
As one option, I have decided to set up a project which will identify costs by speciality within a selected hospital on a pilot scheme basis. As these hospital speciality departments are headed by a consultant it will be possible to show with some accuracy the total financial resources which are required to support each medical decision maker. We must recognise the fact that limitless finance is not available to us and it is our duty to establish exactly how our money is being spent. Equally it will be clear to clinicians that their medical responsibility inevitably involves a financial and managerial responsibility also. As things stand at present, our costing methods are not sufficiently refined to give us precise information on the cost implications of service developments or new consultant appointments.
I feel sure that the application of new costing systems, such as speciality costing, will soon fill this gap in our management information.
Those who wish to make private arrangements for services, or who are liable to pay for consultants' fees in a public ward, may take out insurance with the Voluntary Health Insurance Board. A married couple with three or more children covered by the board's Plan B will pay an annual group subscription rate of around £367 from 1 March this year. When allowance is made for deductions against tax at the standard rate this annual subscription is reduced to £239 — about £4.60 a week. This will provide cover against hospital maintenance costs and will also provide cover against fees charged by consultants on the minimum basis recommended by the VHI. Benefit is also provided for certain out-patient expenses including specialist consultation fees, general practitioner fees and prescription costs. I am sure that the VHI board will continue to play an important role within the overall structure of the health services.
 Last September I circulated to Deputies copies of the 1983 volume of statistical information relevant to the health services. The information in this is divided into sections, each of which deals with one of the main health programmes or another aspect of the health services. I think that Deputies will find this a useful aid to understanding what is happening in the health service. I will refer later to the different programmes but first I would like to refer to certain vital and health statistics which are of particular importance.
The sections of the population aged under 15 years or over 65 years are sections which make the major demands on the health services. The 1981 census of population indicated that people in this section made up 41 per cent of the population of the country. This is higher than the corresponding percentage for any of our EEC partners.
In particular the section of the population aged over 65 must be considered. The 1981 census of population indicated that there were 368,954 people aged 65 and over in the country and that 131,897 of these were aged 75 and over. These figures represent 10.7 per cent and 3.8 per cent of the total population respectively. Persons in this age group are heavy users of health services. For example, while people aged 65 years and over represent 10.7 per cent of the population, they occupy on average about 40 per cent of the beds in our acute hospitals.
The Irish birth rate was 20.4 live births per 1,000 population in 1982 during which 70,933 births took place. This is the highest birth rate in the EEC. Over 99 per cent of these births take place in hospitals.
One of the important indicators of the general state of health of a community is the infant mortality rate. This has declined from 29.1 deaths of children under 1 year old per 1,000 live births in 1962 to 18.0 in 1972 and in 1982 it was 10.5. This is a remarkable achievement.
The population is now divided into three categories for purposes of eligibility for health services.
Category 1 consists of persons with full  eligibility. These are persons who are unable to afford general practitioner services for themselves and their dependants without undue hardship. Persons in this category are entitled to the full range of health services without charge and they are issued with medical cards for presentation when services are needed. They represent roughly 38 per cent of the population.
Category II are persons, other than those in Category I, whose income in the year ended 5 April 1983 was less than £11,000. Persons in this category are entitled, without charge, to hospital services as in-patients in public wards or as out-patients at public clinics and to maternity and infant welfare services. They are also entitled to avail of the drugs refund scheme, which ensures that nobody will have to meet excessive costs for prescribed medicines.
Category III consists of those persons whose income in the year ended 5 April 1983 was £11,000 or more. Persons in this category are entitled to the same hospital services as those in Category II except that they are liable for the fees of the consultants involved in their treatment. They are also entitled to avail of the drugs refund scheme.
In effect, the £11,000 income limit is the dividing line above which persons are required to pay the fees of hospital consultants. This limit is due to be revised from 1 June 1984 and consideration is currently being given to the new limit. This limit, which will be fixed by regulations, will apply to income for the year ending 5 April 1984.
This year, despite the serious shortage of resources, the income guidelines for medical card eligibility were increased to compensate fully for the effects of inflation. The increase was about 10.3 per cent from 1 January 1984. As announced in the budget, a special age allowance is being granted to persons aged 66 years and over in assessing their income for medical cards. As from 1 July 1984 a person aged between 66 years and 79 years will be allowed an additional income of £5 per week, or £10 if married, when his entitlement to a medical card is being determined.
 Persons aged 80 years and over will be allowed an additional income of £8 per week or £16 per week if married. This allowance makes some provision for the special needs of elderly persons, their limited resources and the demands which are made on these resources arising from the infirmities of old age.
Two examples of the application of the new guidelines are as follows: A married couple with two children under 16 years paying rent of £20 per week and paying £10 per week travelling to work would normally be entitled to a medical card provided their gross income is not assessed at more than £117 per week; a married couple aged over 80 years would, taking into account the new allowance for old age, normally be entitled to a medical card if they have an income of £101 per week or less.
I should like to turn now to an aspect of health policy which has been getting a lot of publicity recently. I am referring here to the Government decision to withdraw automatic entitlement to medical cards from students and other young adults.
I should mention that the need for this restriction of entitlement arose because of the reductions on health spending which are necessary as part of the effort to get the country's finances back into shape. It was only after the most careful and detailed consideration of all the other options to achieve savings that the Government decided to withdraw automatic entitlement to medical cards from some students. The estimated saving in a full year arising from the implementation of this policy will be in the region of £2.5 million.
The position is that I have made regulations under the Health Act, 1970, restricting entitlement to free general practitioner services, free drugs and medicines, and free dental, ophthalmic and aural services. The effect of these regulations is that students and other persons between the ages of 16 and 25 who are dependent on their parents will retain their medical cards only if their parents have medical card eligibility or if they have eligibility by virtue of EEC Regulations or if they are in receipt of disabled  persons' maintenance allowance or if undue hardship would be caused by the withdrawal of a medical card.
No other services are affected by the provisions of these regulations. For example, students will retain their entitlement to free hospital services, including the services of hospital consultants. Persons with incomes over £11,000 a year together with their dependants are normally not eligible for free hospital consultant services. However, students from these upper income group families, whose medical cards are cancelled under the new arrangements, will retain their entitlement to free hospital consultant services. Therefore, students are fully protected against the risk of big bills for hospital services.
A number of important considerations were taken into account by the Government in framing this new policy. Firstly the students who belong to families in the lower income group will retain their medical cards. There are about 35,000 in this category. A large number of other students, estimated to number about 85,000 belong to families in the middle and upper income groups. Secondly, the student population is young and healthy. It has been established that persons in this age group visit their doctors, on average less than 2.5 times in the year compared to an overall visiting rate for the medical card population of six visits a year. Thirdly, even in the case of those students who are losing automatic entitlement to medical cards, they still retain eligibility for the use, without charge, of some of the major and most costly health services. Fourthly, special provision has been made in the regulations to ensure that, in cases of hardship, the required service will be made available without charge.
At a meeting I had with representatives of the Union of Students in Ireland last December I explained what was involved in this new policy. In particular, I stressed that, if the provision of any required service would cause hardship to a student whose medical card had been withdrawn, then the chief executive officer of the appropriate health board has been empowered by the regulations to make that service available without charge.
 Members of the House will be aware of the campaign which has been carried on by the students against the withdrawal of automatic entitlement to medical cards. This campaign resulted in seven persons being jailed for contempt of court following their illegal occupation of health board premises. I am pleased now to be able to set out the sequence of events which has led to the ending of this campaign.
On 17 February I had written to Mr. Joe Duffy, President of the Union of Students in Ireland clarifying some matters which arose out of the Government's decision. In particular, I explained that the issue or withdrawal of a medical card was a matter for the chief executive officer of the appropriate health board who has the authority and responsibility for interpreting and implementing the relevant statutory provisions. I also described the provisions which operate to ensure that hardship does not arise and I listed some of the factors which may be taken into account in deciding whether hardship exists.
On Friday, 24 February I was approached by Deputy Harte who inquired about the basis of the Government's decision. I wrote to Deputy Harte on the same day explaining that, while students' automatic entitlement to medical cards had ceased, students could still qualify for medical cards on the basis of their financial circumstances, including where appropriate the circumstances of their families; that on this basis about 35,000 students would retain their medical cards; that those from whom medical cards would be withdrawn would retain entitlement to a number of health services without charge, including in particular the full range of hospital services; that measures were being taken to ensure that no hardship would result from these arrangements.
On the following day, Saturday 25 February, I received via Deputy Harte a letter from Mr. Duffy outlining his union's interpretation of the regulations. Subject to two amendments, largely of a technical nature, I was able to accept this interpretation and on the same day I had a letter  delivered to Mr. Duffy stating this. As a result of this note the USI ended their protest.
The agreed interpretation of the regulations included the following elements:
1. Students do not have automatic entitlement to medical cards.
2. Students whose parents hold medical cards, or who are EEC nationals, or who hold disabled persons maintenance allowance are entitled to free medical services.
3. Other students may be assessed for eligibility, using the same criteria as other applicants, including their family circumstances where appropriate.
4. In order to avoid hardship, a student's medical card will not be withdrawn while a re-application is being processed. This will be done in accordance with normal health board procedures.
The regulations which I brought in, in accordance with the Government's budget decision, are in force. There has been no change in the regulations and no change in the implementation of the regulations. The USI now more fully understand and appreciate the basis of the Government's decision. I trust that Government policy, difficult as it is, will be implemented. I have no doubt that it is being implemented. I trust that it will be generally accepted and its merit seen by the students concerned, by their families and my colleagues on the other side of the House.
As Deputies are aware health boards are currently responsible for the collection of health contributions, youth employment levy and 1 per cent income levy from farmers. Heretofore farm income for the purpose of health contributions was determined on the basis of farm valuation and a multiplier but the High Court ruled in July 1982 that this basis was contrary to the Constitution.
In February 1983 I amended the relevant regulations to provide that farmers'  incomes will in future be assessed on a factual basis as in the case of other self-employed persons. The definition of income for health contributions is the same as that used for the youth employment levy and the 1 per cent income levy. Under the revised method of assessment farmers' incomes will be assessed on profits or gains from farming activities less expenses actually incurred in earning those profits.
The revised collection arrangements raised the question of whether health boards were the most suitable agencies to collect health contributions and levies from farmers. In April 1983 an Inter-Departmental Working Group was set up to examine this issue. In its report of 30 June 1983 the group recommended that responsibility for the collection of health contributions and levies from farmers due on or after the 6 April 1984 should be assigned to the Revenue Commissioners. I propose to introduce amending regulations in the near future to give effect to the change-over.
With regard to arrears of health contributions, I am seriously concerned about the failure of certain sections of the population, including farmers, to discharge their liabilities for contributions. In this regard I have written to the chief executive officers of health boards advising them to make full use of every enforcement procedure available to them in the collection of amounts outstanding. In the present financial climate it is essential that all persons should discharge their liabilities fully and promptly.
I now turn to changes for in-patient hospital services.
As a means of ensuring that all persons do in fact discharge their liabilities fully and promptly I propose to introduce regulations in the near future providing for a hospital admission charge of £100 in the case of persons seeking in-patient services in public hospitals who have not discharged their liabilities for health contributions. This charge will be additional to any payments for private or semi-private accommodation. These regulations will come into effect from 1 June 1984 and will apply in respect of arrears as at  the end of the previous contribution year, in effect the 5 April 1984.
It is my intention to ensure that in the coming year any person who has failed to pay health contributions will not obtain hospital services at the expense of fellow citizens who have discharged their liabilities in full. I am very hopeful that these measures will bring about the necessary improvement in the collection rate. Otherwise I will have to give serious consideration to other measures such as the imposition of hospital maintenance charges in such cases.
I now turn to the working party on the general medical services. The working party is now near to completing its task with what is hoped to be the final meeting scheduled for the end of April. The report should have a significant influence on the future development of general practice and primary health care and will, hopefully, provide a basis on which both management and the medical profession can satisfactorily resolve difficulties which have arisen under the existing arrangements.
The overall review of the organisation of community care will be concluded shortly and discussions will then commence with the various staff interests regarding the changes which my Department and the health boards consider are necessary in order to improve the delivery of existing services and provide a satisfactory foundation on which further services can be developed.
There will be two particular challenges to the effectiveness and flexibility of any organisation now put in place. First of all, the development of a good primary health care system will require adjustment of working relationships and attitudes among a wide range of those working in the community. Secondly, the significant changes and developments which will be brought about through the proposed legislation on children will require health boards to perform a wider and more demanding task in relation to the care of children. Greater team work among all of the various professions and disciplines involved will have to go hand in hand with the development of more specialist knowledge in relation to various  aspects of family and child care. We are aware from experience here and elsewhere that this is a delicate and difficult area of administration and one on which public bodies are expected, quite rightly, to perform at a very high level of integrity and professionalism.
As I highlighted during the course of the budget debate, the pay allocation for the current year in the health services represents a reduction of 2.75 per cent below 1983 pay volume. This represents a major challenge to all of those providing services as I am the first to accept that it is not easy to bring about a reduction in pay budget in a situation where many people may feel that it is more rather than less money that they have to seek.
I am encouraged by the efforts which health boards and other agencies have already made to try to achieve this difficult target and I appreciate the co-operation and goodwill that will be required from staff organisations in order to achieve a target which, because of present economic difficulties, cannot be adjusted upwards. Although the formal restriction on the non-filling of vacancies has been removed — and I know that this is a measure which is greatly appreciated within the health services — the reality is that many vacancies will have to be left unfilled and that other restrictive measures will have to be taken in order to live within the budget.
In line with the policy already announced by the Minister for the Public Service, I will shortly be notifying health boards and agencies of more flexible arrangements for the granting of special leave without pay. I hope that this relaxation will be seen as helpful to those who wish to make a career break and it will undoubtedly be welcomed by those who obtain jobs as a result of their temporary absence.
Regarding our psychiatric services programme, the psychiatric services have, unfortunately, lagged far behind other health services in terms of the quality of service and the deployment of resources. In the past I have expressed my total commitment to providing a realistic degree of State support for our mentally  ill population. Even in the present stringent financial circumstances I am determined to continue my efforts to bring our psychiatric services out of the nineteenth century and to prepare them for the twenty-first. Accordingly, my Department will be spending in the region of £159 million on the psychiatric programme this year.
I am glad to say that I have obtained a high level of co-operation from those involved in the direct provision of services for the mentally ill and there is now a fairly general recognition of the need for rapid changes and improvements in this area. Two years ago my Department commenced a planned programme for the improvement of patients' living standards in our district psychiatric hospitals. In addition to the funds provided by my Department, the health boards have been generous in contributing to this programme out of the resources at their disposal. It is the Government's intention to continue to support this scheme for some years to come and this year I am making almost £2 million available for this purpose.
Even in the short few years since the commencement of this scheme living conditions have been transformed for thousands of patients in our mental hospitals and particularly for long-stay patients who are spending long periods of time in outdated institutions. Up to very recent times services for the mentally ill have not been afforded a high priority and so there remains much scope for the improvement and upgrading of our mental hospitals. The expansion of community facilities such as out-patient clinics, day hospitals, day care centres and so on continues to be the main development in our psychiatric services. This movement towards community services will enable many people to be treated for psychiatric illness while living at home, whereas in the past they would almost certainly have had to be admitted to hospital. The availability of community psychiatric facilities also allows people to be discharged from hospital more quickly. Indeed, statistics on discharges from our psychiatric hospitals and units show that in 1980 65 per cent of patients had been in hospital for  less than one month and 90 per cent for less than three months. This trend towards short stays in hospital backed up by support services in the community is very welcome and is in line with modern developments in psychiatry worldwide.
I hope that all health boards will strive to develop services in the community to their full potential. In this regard I would like to refer in particular to the possibilities for rehousing long-stay patients in accommodation in the community. Some health boards have had remarkable success in rehabilitating patients so that they are capable of living independently or semi-independently in houses or rented accommodation in the community. These achievements did not involve major funding but were largely the result of innovative thinking and effective management at a local level.
At the end of 1981 my Department established a study group which was charged with the task of devising a planning framework for the future planning, development and expansion of our psychiatric services.
The report of this group will be available in the middle of this year and it will provide practical guidance to health boards on how psychiatric services should be developed. The report will make recommendations on the ideal format for the delivery of services and it will also lay down quantitative norms for service provision. This report will provide a set of target objectives for medical, nursing and administrative leadership throughout the country. In consequence, I hope that the present unacceptable regional variations in the range and quality of services will soon disappear and that a consistently high standard will be achieved in all areas.
Since becoming Minister for Health the need, not only to maintain the existing level and high standard but also, to develop our mental handicap services has been continuously impressed upon me. This is particularly true when speaking about the adult mentally handicapped. Despite, however, the difficult economic climate and acknowledging the special and urgent needs of the mental handicap services particularly for extra facilities for  the adult mentally handicapped, I am pleased to say that a number of positive measures were achieved during 1983.
In December, because of the serious shortfall in services for mentally handicapped people in the Eastern Health Board area, I approved the opening of the new centre for mentally handicapped people at Cheeverstown, Templeogue, Dublin 12 on a phased basis during 1984. Phase One of the complex will provide much needed day and residential places for 174 children and adults. First admissions are scheduled for 1 May 1984. The centre when completely commissioned will provide 130 residential places and 154 day care places.
In early 1983 the out-going Government's decision to exempt certain new priority projects in the mental handicap services, from the effects of the embargo on the recruitment of staff to the public sector, was confirmed, which allowed 150 staff to be recruited and enabled 14 new projects to be commissioned.
Mindful of the staffing problems that were being experienced in the mental handicap services, agreement was reached between my Department and the Department of Labour on the application of the grant scheme for youth employment to these services. To date over 250 places have been allocated to close on 30 agencies.
In September I made over £500,000 available to the mental handicap services to enable minor improvement schemes to the centres to be carried out. The money allocated was spent on urgent projects which were of direct benefit to the mentally handicapped people in the services.
Conscious of the need for a comprehensive service for the adult mentally handicapped and demonstrating my commitment to the group, I approved the construction of the new centre for the mentally handicapped at Swinford, County Mayo, which is expected to be completed by May 1987. The cost of the project will be in excess of £10 million. The centre will provide much needed places for an area which has a significantly higher incidence of mental handicap than most other areas here.
The construction of an adult day care  unit for St. Michael's House at Belcamp in County Dublin was commenced in December 1983. I expect that the building will be completed by mid-1985 at a cost of over £600,000. This facility will care for 70 severely mentally handicapped persons. As I have indicated there is an urgent need for facilities for the adult mentally handicapped in the Dublin area which will be relieved somewhat with the provision of this day care unit.
While a number of positive measures were achieved for the mental services during 1983 much remains to be done. A significant number of places for mentally handicapped people remain to be commissioned. In addition I have a number of proposals before me regarding the provision of further residential accommodation for the mentally handicapped. However, I will be looking at these projects as sympathetically as possible within the resources available to me.
While the mental handicap services are likely to be affected to some extent by the current economic difficulties nevertheless it is my intention that they will be protected in so far as it is possible from any reductions in expenditure in the health services.
I am very glad to be able to say that the long-awaited Green Paper on the disabled is now in the process of being printed. I will be laying it formally before the House within a few weeks. Traditionally a Green Paper is a discussion document and does not attempt to define a definitive response to the questions at issue. In this case I felt, however, that as many of the issues had already been the subject of reports and investigations, the Green Paper should also provide a comprehensive statement on the way in which services for the disabled might be developed in the future. The aim of the Green Paper is to provide a clear indication of Government policy in some of the main areas of concern to disabled people and to initiate a constructive public debate on areas requiring further attention and on the strategy to be adopted to meet these needs. The matters dealt with are not exclusively health in character but range  across the responsibilities of all Government Departments involved with services for disabled people.
The Government are committed to the various developments which are outlined and will ensure that sufficient support is given to the agencies charged with carrying forward the various recommendations. I am confident that the programme outlined in this paper will receive the support of the entire community and will help to ensure that the years ahead will see substantial improvements in the quality of life of our disabled people.
The past year has seen significant developments in child care services, in addition to the proposed new children legislation already mentioned. The recent transfer from the Minister for Education of functions in relation to a number of homes, formerly known as industrial schools, has effectively centralised, for the first time, statutory and administrative responsibility for all children's homes in my Department. To coincide with this transfer I have made some £1 million available for the purpose of changing the method of funding these homes from a generally unsatisfactory capitation system to direct funding by local health boards. The centralisation of responsibility combined with this new system of local funding will allow greater integration and co-ordination of voluntary and statutory child care services at local level. It will also facilitate closer liaison between homes, other child care agencies and health boards in identifying and meeting the specific needs of their own localities.
Of course our primary objective continues to be to keep children outside institutionalised care as far as possible. Health boards try to ensure, whenever appropriate and feasible, that children are cared for in a family setting, if not with their own families then with some substitute family either through fostering or adoption. Last year I introduced new regulations revising and updating rules in relation to fostering to reflect modern developments in this area. In addition to these new regulations boards will be further developing programmes, initiated last year, to improve the recruitment and  training of foster parents. I will be making moneys available to enable boards to increase the allowances paid to foster parents from a date later this year.
In the area of day care services boards will be endeavouring to keep expenditure at last year's level. In the meantime it is expected that the special committee which I have established to advise on standards and practice in relation to day care will be able to report their findings to me this year. I will be considering the committee's recommendations before introducing any detailed legislative provisions in relation to the control and regulation of day care services which is being provided for in the new children's legislation.
I come now to the legislative programme of my Department. I expect that I shall shortly be in a position to circulate the text of the new Nurses Bill. This is a very important piece of legislation which will replace the existing Midwives Act and the Nurses Act and provide for a restructuring of An Bord Altranais along the lines recommended in the report of the working party on general nursing. The new board will be more representative of the various branches of nursing and will have greater powers in relation to the control of the profession and its future development. It will also contain provision for the establishment of a central applications bureau which should greatly streamline the arrangements for entry to nurse training. I am very glad to say that An Bord Altranais has already received considerable co-operation in introducing an arrangement on an informal basis.
When introducing this Bill in the House I propose to make a definitive statement on the many recommendations and views contained in the report of the working party on general nursing. In regard to paramedical statutory registration, revised proposals with regard to the functions of the council to be established under this Bill have been circulated to the professions. I understand that we will have a response from all of those concerned by the end of March and I will then be in a position to submit proposals to the Government for their consideration.  My hope would be that this Bill would be introduced in the House in the Autumn session.
I come now to the nursing services. Speaking on the budget last month, I was glad to pay tribute to the public health nursing service which plays such an important role in the care of the elderly and the handicapped at home. Indeed we sometimes tend to regard the public health nurse as being engaged only in this sphere but a major part of her role is the prevention of illness and concern for the development and wellbeing of infants. This preventive and developmental role must not be underrated even in a situation where there may be a growing need for practical nursing services.
In regard to legislation dealing with children, my Department will within the next few weeks be circulating to other Departments the draft heads of the first of three Bills relating to children. The first of these Bills will be an extensive one dealing with the protection and care of children and will have wide ranging provisions touching on, among other things, pre-school services, residential centres, fosterage, child pornography and the control of volatile substances. The second Bill which should be ready later in the year, will provide for changes in the adoption laws based on the report of a review committee which I would hope to have about Easter.
The third Bill will deal with juvenile justice, that is with young persons in trouble with the law. I had originally intended that all the changes be provided for in these Bills would be included in the one piece of legislation. However, I find that if I were to continue to proceed in that way provisions which are urgently desirable would be held up until the whole package is ready. There is particular difficulty in drafting the juvenile justice aspects so I have decided to deal with it later, and separately. Since it is likely that comprehensive changes will be necessary in relation to adoption, I consider that this subject also requires a separate Bill.
I also hope to introduce a Bill before the Summer to extend my present powers in regard to the control of tobacco smoking.  It is essential that we give greater recognition to the hazards of smoking and to the fact that thousands of people are dying annually from cancer directly related to it. No Minister for Health can remain indifferent to that situation.
The Government has approved the preparation of a draft Bill to amend the Misuse of Drugs Act, 1977. The major changes which will be effected in the Bill will provide for
—a number of technical amendments which will make enforcement of the law easier — for example, requiring the driver of a vehicle to remain at the scene while a search is taking place and to provide for searches of lands, caravans et cetera in addition to premises.
—giving courts discretion on whether to require medical and social reports on convicted drug pushers. At present they must remand them for such reports.
—an increase in the maximum sentence for a convicted drug pusher from 14 years to life imprisonment.
—a fourfold increase in the maximum monetary penalties which can be imposed on summary conviction and removal of the penalty limit for serious offences, such as drug pushing where a person has been found guilty by a jury.
—a simplified procedure for investigating allegations or irresponsible prescribing by doctors.
—a redefinition of cannabis to capture some types of the plant which are not covered by the present definition.
In addition to these steps to tighten up the law other measures are being taken in line with the recommendations of the Ministerial Task Force on Drug Abuse. The task force will continue to monitor the position in relation to the implementation of its recommendations over the coming year.
Money has been made available by my Department to Trinity College to provide a diploma course in addiction studies. This course commenced in January and will provide specialist training for  workers who are in direct contact with drug abusers and their families. Such workers include social workers, teachers, guidance counsellors and gardaí.
Officers of the Department have met representatives of the Board of St. James's Hospital to discuss the provision of a bed facility for the treatment of drug abusers. The board has agreed in principle to providing such a facility and the details are now being worked out. A meeting has also taken place with representatives from Jervis Street Hospital about the development of facilities there and a formal submission is expected from the Jervis Street authorities in the near future.
Representatives of the Eastern Health Board and Coolmine Therapeutic Community were consulted about the provision of a suitable therapeutic model for the treatment of drug abusers from socially and educationally deprived backgrounds — particularly those in the 12 to 16 age group. The position here is that the Eastern Health Board are preparing a formal submission on this matter to the Department. £600,000 was provided specifically in the 1984 allocation to my Department of Health to pay for activities to combat the consequences of drug abuse.
I also have in mind to arrange late this year for a meeting of Ministers of Health of the EEC countries to consider the extent to which, within the Community, it would be possible to take further action to combat the effects of drug abuse.
The provision made for the drugs refund scheme in this year's Estimate requires that the threshold be increased from £23 to £28. This increase is in line, on a percentage basis, with increases in recent years. I would stress that the £28 is the monthly expenditure for a family, as a whole. While I appreciate that this amount has not been increased to a substantial degree in the past three or four years, nevertheless, it is a very useful scheme, costing at present some £6½ million, and 250,000 claims are made under it.
The general review of public dental services by the Department of Health  and Social Welfare and representatives of the dental profession is continuing. One of the aims of the review is to identify and, in so far as possible, to eliminate shortcomings in the existing services. In the long term, it will provide a blueprint for possible future developments and the rationalisation of State-funded dental services.
Orthodontics is an area which is often the subject of criticism, due mainly to lengthy delays in the provision of treatment for eligible persons. Five posts of consultant orthodontist in the health boards were advertised by the Local Appointments Commission last October and applications for these posts are being processed at present. The recruitment of consultant orthodontists to the health board service is expected to have a significant impact on the service and to quickly reduce waiting times for treatment.
The new Bill to replace the 1928 Dentists Act will be introduced very shortly. In fact, the white print of the Bill was approved by the Government in the past week, so that its introduction is imminent. In view of this, I do not propose to say more about the Bill at this state.
I have circulated to the Government the findings of my review of the operation of the Health (Family Planning) Act and against this background I expect shortly to discuss with my colleagues in Government those improvements which I feel are necessary in this Act. It is agreed on all sides of the House that the Act does require review, and on that account I am hopeful that there will be considerable consensus on the proposals which I will bring before you in due course.
As Deputies will be aware the National Social Service Board Bill has passed all stages in both Houses of the Oireachtas and is currently with the President for signature. I expect to bring before the Government my proposals for the chairmanship and membership of this board within the next month.
In drawing up this Bill, I have taken the opportunity to broaden and extend the former board's functions to give it as wide a scope as possible. In addition to its original responsibility for the support  and development of community information centres and its mandate to act as a national resource centre for the development of voluntary services, it will also be responsible for the promotion and development of statutory voluntary co-operation in the social service area.
The voluntary sector is and will continue to be a vital component of our health and social services. Every effort must be made to link the statutory and voluntary sectors in a supplementary and complementary relationship with one another. I believe that the enactment of the National Social Service Board Bill will serve that purpose by providing us with a framework within which the voluntary and the statutory sectors can work together and, equally important, within which the voluntary sector can develop and grow.
I am at present considering the composition of membership as indicated and I trust that the board will come into operation in the relatively near future. Many will be aware that during 1983 I established a co-ordinating committee of the North-Western Health Board, under the chairmanship of the Chief Executive Officer Mr. Donal O'Shea, to deal with the various problems and opportunities which arise out of the demand for Irish health services personnel from a number of countries. I have also visited two Middle Eastern countries, Kuwait and Iraq, and I intend to pay visits to a number of other countries in the near future.
Very satisfactory co-operation has been established by the Department with the National Enterprise Agency and I am very happy with the arrangements which are now emerging for the orderly development of the significant potential which exists in our health services as a direct source of “export” activity. I need hardly mention that my first priority is to ensure that the quality of our services here is not in any way diminished by this growing activity. I am equally at pains to ensure that those who agree to and go abroad do so in a secure and acceptable way and that the receiving countries are given the standard of service which they have a right to expect under contractual arrangements.
 There are still a number of problems to be resolved in this area, but I think we have made a good start in establishing the necessary mechanisms here at home to co-ordinate our activities and in developing relationships with the appropriate statutory bodies in the countries which are most seeking services from here.
This year the Department of Health's capital allocation will be £55.5 million, compared with £53 million in 1983. This increased allocation will facilitate the continuation of an extensive building programme of hospitals and a wide variety of other health care facilities in various locations throughout the country.
When I assumed office, I found a large number of very major schemes in the course of planning which would have required an enormous level of funds to provide for and many of which would, in addition, have very significant revenue implications. It was clear that there was no way that these schemes could be implemented in the foreseeable future and I was faced with the very difficult choice of allowing one or two of these schemes to proceed on a selected basis, or seek to spread the available capital resource more widely so as to remedy the major deficiencies which I found in a number of hospitals.
During the past year, I have been engaged in a very intensive review of the entire capital programme which examined closely the present and future demands which I will be faced with in the coming years. In general my approach has been to scale down a number of the major general hospital developments to meet the essential needs of the population which they are expected to serve and in a few cases I have simply had to abandon very ambitious plans and proposals which were so costly that they simply could not be justified and in any event the medical necessity for them was not compelling. This has proved to be an extremely difficult task and presented many problems. Expectations had been raised over a number of years by unsustainable commitments by some of my predecessors and it was only to be expected that individual hospitals would  not take very kindly, to say the least, to having the scale of development reduced. However, I feel that the harsh realities of the current difficult budgetary position are now well appreciated and I am glad to say that in all cases I found an understanding approach by the health boards and hospital authorities even if the decisions were painful to some extent. What has been achieved is agreement to proceed on a reduced scale on a number of projects at Castlebar, Mullingar, Ardkeen, Cavan, Sligo, Kilkenny and Wexford. I am quite satisfied, however, and have given a great deal of careful consideration to this that these reduced scale developments will meet the essential needs of the population in these areas and will provide an efficient and effective level of service which can be delivered within the context of the available capital and revenue allocations.
In the current year the capital allocation for my Department is £55.5 million and this has enabled me to ensure that work will continue or commence and planning proceed on 22 major projects this year, each of which will cost in excess of £3 million. The total cost of these schemes will amount to £32.5 million in the current year. Of course, there will also be an on-going programme of smaller developments and improvements which in their own way contribute considerably to the maintenance of standards and facilities.
I have been concerned at what, quite frankly, could be described as very sub-standard accommodation in some of our geriatric hospitals and homes. This area has been neglected very badly over the years and has contributed in a major way to the poor perception which many have of the geriatric service as a whole. This is very unfortunate since I know from personal contact that these homes are run by highly professional and extremely dedicated staff who succeed in doing quite exceptional work under what can be difficult circumstances.
It concerns me that society in general and the various medical and nursing professions seem to lay such emphasis on the development of bigger and bigger acute hospitals which inevitably drain  away resources from the geriatric hospitals and homes. I am pleased to say that I will be spending about £3.25 million in the current year on the institutional facilities for elderly patients and it is my intention to continue the level of expenditure in future years. This will go a long way towards raising the standards for these patients to an acceptable level and it is my view that if we profess to be a caring society we must ensure that we provide the facilities and services to enable our elderly to live out their lives in comfort and with their own sense of dignity.
The allocation will also provide for the continuation of the special improvement schemes within our public psychiatric hospitals, the provision of new facilities for the mentally ill and the mentally handicapped as well as the development of improved services for the physically handicapped including up-dated centres for the deaf and the blind. A special emphasis will also be placed on the development and upgrading of geriatric hospitals and facilities throughout the country for example, Saint Oliver Plunkett Hospital, Dundalk, and the Sacred Heart Home, Carlow.
I now wish to refer for the first time in the House to our ambulance services. There is little point in having an effective hospital service if patients are not transported there quickly and safely in emergency situations. It is strange that our ambulance service which is perhaps the most visible and dramatic visible manifestation of the health service in our daily lives is the one which can also command the least attention from many of us in our dealings with the health services. I am satisfied that we have a very efficient and effective ambulance service and this is due in no small measure to the dedicated staff who manage and run the service on a round the clock basis.
At the same time I am conscious that services which appear to be operating satisfactory can also benefit from close study and examination. During the year I authorised the establishment of an Ambulances Operations Committee and an Ambulance Services Council to examine all aspects of the service and I am looking forward to receiving their recommendations  in due course. One of the purposes of these groups is to provide a forum where both management and ambulance officers can come together and plan for the betterment of the service. Initially the arrangement is to run for three years but I am confident that if the people involved approach their task in a dedicated and responsible manner it can become a permanent feature from which all can benefit.
There has been a good deal of questioning in the House about meat and milk in recent years and I want to deal with these matters now. Meat and milk are particularly vulnerable foodstuffs and care must be exercised at all stages of the production process. The Minister for Agriculture and I have a shared responsibility for ensuring that only fit meat and milk is offered for sale for human consumption. Essentially the responsibilities of my Department are exercised at retail level when meat and milk are on sale to the public as a food.
The food sampling programmes of health boards include arrangements for analysis of meat and milk at retail outlets. As well as undergoing microbiological analysis, foods are analysed for the presence of chemical additives and contaminants. Systems to monitor milk and milk products for the presence of hormone residues and meat and meat products for both hormone and antibiotic residues are being developed by the regional analysts at present. Milk and milk products are already being monitored for antibiotic residues.
In view of the risk to public health from antibiotic and hormone residues in meat and milk, I am also anxious that there should be an adequate system of control in the availability and use of such drugs in animal husbandry. Under the Poisons Regulations, 1982, the sale of hormones and injectable antibiotics for animal use is confined to pharmacies, with the exception of intra-mammary and non-injectable antibiotics, which may also be sold by certain outlets licensed by health boards, provided the sale is under the direction and control of a named pharmacist or veterinary inspector. These controls are supplementary to those operated under  legislation administered by the Minister for Agriculture. Further controls are in process of introduction by that Minister which will, inter alia, restrict the sale of hormones and certain antibiotics to prescription-only sale.
In the light of a substantially increased use of antibiotics in animal husbandry following the growth of the cattle trade after accession to the EEC, and to the increasing appearance of strains of certain human diseases which were resistant to the usual antibiotics, the Department asked the Food Advisory Committee to review the position. Far-reaching recommendations have been made by the Food Advisory Committee which relate to quality, safety, efficacy, labelling and use of individual antibiotic preparations, and prescription control for all antibiotics is also proposed. Measures to monitor the effectiveness of these controls have also been suggested. These proposals are being considered in consultation with the Department of Agriculture, since joint implementation by the two Departments is involved. This series of measures constitutes an up-to-date and an effective range of controls on antibiotic and hormone residues.
The condition of slaughterhouses supplying meat for the home market has been a continuing cause of concern to both Ministers. A full survey of conditions in slaughterhouses throughout the country has been conducted recently by the Department of Agriculture and arrangements are being worked out in discussion between the two Departments for the supervision of an upgrading of conditions in the slaughterhouses and for an effective programme of meat inspection.
Milk consumed raw presents a danger to public health from such diseases as brucellosis and non-respiratory tuberculosis. Repeated efforts have been made over the years to acquaint sanitary authorities with these dangers and to encourage them to prohibit the sale of milk within their areas unless it is pasteurised or otherwise conforms to certain required standards. For the most part those areas in which raw milk may still  be sold for human consumption are in the western and less-well populated parts of the country. Efforts to encourage the extension of pasteurisation to remaining areas will be continued.
Of course, a further problem exists, even where sanitary authorities have made orders in relation to sale of milk, in so far as there is no restriction on the amount of raw milk consumed on the farm by the farmer and his family. The medical officers of health of health boards regularly remind persons consuming raw milk from their own herds to boil it before use. I would underline that. I would thank Deputy O'Hanlon for his patience in listening to this lengthy contribution but there are some other important issues I wish to deal with.
Revised instructions which issued to health boards on the promotion of vaccinations and immunisations were followed up during the year by discussions with medical officers of health. Among the matters dealt with were the maintenance of a high level of public response and the ensuring of adequate and prompt returns. Local publicity aimed at parents was backed up by a special campaign by the Health Education Bureau. These measures will be continued during the coming year and will include close monitoring of the effectiveness of the new drive.
One matter which I have been particularly concerned to highlight is the importance of maintaining an adequate level of immunity against whooping cough. Vaccinations against this disease had shown a worrying decline over the past number of years because of the publicity surrounding allegations of vaccine damage. The balance of risk from the vaccination and the disease is substantially in favour of vaccination, provided reasonable regard is had to the contra-indications.
Other specific disease which are receiving special attention by my Department at present are tuberculosis, sexually transmitted diseases and measles. As regards TB, 1,000 new cases occur consistently each year and about 6,000 persons receive treatment for this disease annually. There appears to be little scope  for reducing the incidence further under existing policies and the present programme such as BCG vaccination etc. are currently being reviewed. The review will be completed in the near future and revised guidelines should be available shortly.
It is estimated that about 65,000 cases of STD occur each year and it is apparent that the current prevention and control measures have to be modified. These measures will be updated mainly to provide for developing (a) contact-tracing services (b) treatment clinics as appropriate and (c) improved co-ordination and liaison arrangement between primary health care and community care personnel. There have been detailed discussions with health boards about these aspects. Consultation is also being arranged with the medical organisations, the Health Education Bureau and other relevant interests. I hope to have a blueprint for an up-to-date effective control and treatment system for these diseases also in the course of the year.
I am also planning provision for the introduction of a measles vaccination programme, which I hope will be launched at the beginning of next year. I am satisfied about the cost-benefit, in financial as well as health terms, of the addition of measles to our vaccination programme.
Deputies will also be aware of the extension of the rubella vaccination scheme which I arranged in recent months. All women of child-bearing age are now covered by this scheme, which is a most important safeguard against a range of congenital ailments.
Nutrition plays an important role in the promotion and maintenance of good health and the prevention of disease. There is evidence to suggest that the food supply and food consumption patterns are playing a significant role in determining the health status of the Irish population. Conditions of ill-health which may be influenced by nutrition are increasing — for example, coronary heart disease, hypertension, diabetes and anaemia. Since the national nutritional survey was carried out in 1948 comprehensive and accurate information regarding the nutritional  status of the population has not been collected. This lack of information has hampered the evaluation and planning of a food and nutrition policy for the country.
On the recommendation of the Food Advisory Committee the Department has decided to develop a food and nutritional surveillance system under which information regarding the food supply, food consumption patterns and the health and nutritional status of the population would be analysed routinely to provide the necessary baseline data for the development, implementation and monitoring of nutritional programmes such as nutrition education programmes.
The Department has asked the MSRB to develop and implement the system.
Research is one area of the health budget which receives little publicity but which is, nevertheless, of great significance. During a period of financial stringency there is always a temptation to allow expenditure on research to decline in the interest of the pressing needs of other services. I have been concerned that this should not happen and I am glad to be able to tell the House that for 1984 I have secured a real increase in my Department's allocation to research. This year a total of £2.26 million is being allocated between the two research bodies under the aegis of my Department. These bodies are the Medical Research Council of Ireland and the Medico-Social Research Board.
I readily admit that the research budget is relatively small and I appreciate that there are very many items of interest and relevance that could be studied if finance were available. However, the financial situation itself compels us to be very discriminating in what can be supported from State funds. Regard must also be had to research being done in other countries as well as to needs which may be somewhat peculiar to this country. The research budget, therefore, embraces these selected priority areas which are considered to be of greatest urgency in this country at the present time.
The Medical Research Council of Ireland is concerned with basic clinical research. It concentrates to a large extent  on the investigation of conditions which because of their origin or incidence have a special relevance to Ireland. It has already completed a study in brucellosis and is continuing its studies in alcoholism, coeliac disease, hypertension, diseases of the lung and hospital infection. This year I was glad to have been able to give them additional funding for a new study on drug treatment for the elderly. The council also promotes medical research mainly at hospital level by giving grants to suitable applicants who have a research project which the council consider worthy of support.
The Medico-Social Research Board, on the other hand, concerns itself with epidemiology or the distribution of disease in the population. Through its on-going studies, it provides invaluable information on the activity and morbidity patterns in general and psychiatric hospitals and in homes for the mentally-handicapped. The board also carry out special studies in relation to maternal and infant health. I am sure many of you will be aware of the great contribution made by the board in bringing to light the extent of drug abuse in Ireland in recent years.
In relation to both research bodies I wish to record my deep appreciation of the manner in which their management has been carried out so selflessly and conscientiously. The members of the Medical Research Council and their sub-committees and the members of the Medico-Social Research Board have invested a great deal of their time freely in this important work. I look forward to greater co-operation with both bodies in the years ahead.
As he will be retiring within the next 12 months, I wish to record particular thanks to Dr. Geoffrey Dean of the Medico-Social Research Board for his outstanding work as Director in recent years.
Despite the rapid growth and development of health services over the past 20 years or so the prevalence of conditions requiring medical attention is not diminishing — in fact, the available evidence seems to suggest the contrary.
 Yet many of the illnesses and diseases which now plague our society are in large measure preventable. Some conditions such as heart disease, cancer, alcoholism and accidents are major contributors to illness and premature death and place a severe burden on the health services and the Exchequer. The adverse effects of these conditions can in many cases be avoided by actions taken outside the realm of health services.
Within the ferment about our present state and future prospects there is one area I believe which presents itself as a focus of agreement between the critics and defenders of the health services in this country — promotion of positive health.
There are two aspects to positive health which I feel need promoting. First of all, there is the person's own behaviour. If we are fortunate enough to be born free of any major illness or disability and if we wish to maintain our good health we must not depart radically from the pattern of personal behaviour under which man has evolved, for example, by smoking, over-eating, over-drinking or sedentary living. All these things apply to politicians. Health is a limited resource and needs to be husbanded and protected by pursuing a style of life which gives health every chance.
The second and most difficult factor to control is the external or environmental conditions. Recent research would indicate that the person's health is greatly influenced by conditions outside his own control. Factors of environmental pollution, urbanisation, economic recession, unemployment, and other stresses and insecurities have as much to do with ill-health as do individual lifestyles.
These contradictions in our society must be dealt with before a worthwhile change in the health status of Irish people can take place. In promoting the concept of positive health, therefore, we will be seeking not only the co-operation of the individual but also of the various organisations and bodies which influence the environment in which that person lives. The State is obviously a major influence in this area but it is not the only one. Industry, professional organisations,  trade unions, sporting organisations, community based groups, pressure groups, multi-national companies producing and distributing consumable and other goods all have a part to play.
If the concept of health promotion is successful it should, for example, contribute to the lengthening of average life expectancy and improve the quality of life, limit early disability and enable people to use both their working and their leisure time productively in the national interest.
The concept of promoting health and of being conscious of the health implications of all our political, economic and social initiatives is a very idealistic one and will probably be slow to propagate. But it is an area which we must explore, and I hope to deal with it in greater detail in the coming Green Paper on the health services.
I wish to thank the 60,000 people who work in the health services. They are currently under enormous pressure but I have no doubt they will meet the challenges I will pose to them this year. In particular I want to thank the Secretary, Assistant Secretaries, Principal Officers and all the other grades with which I am in daily contact in the Department of Health. The portfolios of Health and Social Welfare constitute an impossible task in terms of governmental work. However, the task would be wholly impossible were it not for the outstanding co-operation, wisdom, advice and guidance which I have received from the executive and professional staff of the Department of Health in the past 12 months, advice which is available to all Members of the Houses of the Oireachtas, for which we are grateful and which is rarely acknowledged in Estimate debates.
I regret I have taken such a lengthy time moving this Estimate and it gives me great pleasure to recommend it to the House.
Dr. O'Hanlon Dr. O'Hanlon
Dr. O'Hanlon: We have listened to a marathon speech by the Minister this morning. Those who thought that there might be something in the speech ensuring that adequate health services would  be provided will be disappointed. There was nothing in the statement to bring any relief. The Minister admitted several times that there would be curtailment of services this year. Our concern is to ensure that an adequate health service will be provided. In view of the massive cutbacks for which the Minister is responsible this is not possible in 1984.
Some of the cutbacks are as follows: Mid-Western Health Board, £3.2 million; North-Eastern Health Board, £1.9 million; South-Eastern Health Board, £3.5 million; and Southern Health Board, £4.2 million. In previous years efforts have been made by the health boards to cut out any wastage. They looked at all areas of services including supply, energy, transport and housekeeping, and measures were taken to trim operations without causing any hardship. It is no longer possible to cut back on the amount of finance being made available while expecting an adequate level of service to be provided.
It is interesting that the Minister complimented those involved in administration on the manner in which they have carried out their duties. I would agree entirely. This applies to officials in the Department and at health board level. Only a few weeks ago during an RTE programme the Minister asked why the South-Eastern Health Board could not save £1 million this year when they could do so last year. That is an indication that the Minister is divorced from the reality of what is happening.
The Mid-Western Health Board held a meeting and found that the Minister's allocation would fall £0.8 million short of the amount needed to administer services in an appropriate way during 1984. They wrote to the Minister to that effect, pointing out that they needed an extra allocation. In a letter dated 24 January the Minister stated that there were no funds at his disposal which would enable him to increase the non-capital allocation for any health agency in the current year. The CEO of the board in a letter to members on 17 February stated that a reduction of this magnitude could not be met without an impact of the service, and a reduction in the standard of patient care  was inevitable. That is the result of this Government's health policy. We would not accept that it is necessary to have a reduction in the standard of patient care. It is essential to maintain an adequate level of service.
The Mid-Western Health Board decided to cut £80,000 from the ad hoc dental scheme. The Minister said this morning that he had set up a committee to carry out a general review of the dental service. He said that one of the aims of the review would be to identify and in so far as possible eliminate shortcomings in the existing services. We find that the Mid-Western Health Board have to reduce their ad hoc service by £80,000, while the Southern Health Board do not have an ad hoc dental service. The Minister should state publicly that he is not able to provide the statutory dental service which he is obliged to provide and that people should go elsewhere if they have dental cares rather than wait for the public dental service. It might be too late for dental fillings by the time their turn would come. This is a result of the cut-backs and the lack of commitment by the Government to community health care.
The Mid-Western Health Board also propose to cut back on drugs, medicines, surgical and medical appliances, dressings and bandages in the hospitals. They also propose to charge patients travelling to and from work at Shannon and they hope to raise £25,000. It will not be possible to give the increased allowances to those in long-term care. These cutbacks are in addition to those which have already been announced, such as a reduction in the amount of locum cover and temporary substitutes during periods of annual and sick leave, elimination of overtime for maintenance staff, reduction of overtime payments to junior hospital doctors, a limitation on the call-out payments to radiographers and laboratory technicians, reduction of premium payments to be achieved by reducing staffing of hospitals at weekends when medical procedures are normally scaled down, payments not to be made to student nurses for a preliminary training period of six weeks. These are the measures  being taken by the Mid-Western Health Board, and other health boards have introduced similar cutbacks.
It seems that the Minister is more concerned with statistics than with the delivery of a service. We heard about reforms, costs per patient in hospital and all the different committees. The Minister said:
For example, we are looking at the possibility of setting down criteria for admission of in-patients to hospitals.
There is only one way in which the criteria for admitting a patient to hospital can be decided, and that is on the clinical judgment of the doctor. I do not know of any other way. Unless we adhere rigidly to that method, the lives of patients will be put at risk. If we are to be presented with criteria by the Minister or the Department for admissions to hospital, the lives of patients will be at risk.
Other important reductions which are relevant to most of the health boards are in the budget. There is minimal provision for additional and replacement medical equipment. The provision for furniture, crockery and hardware has been reduced very substantially and only breakages can be replaced. I am quoting from the letter from the CEO of the Western Health Board. The provision for bedding and clothing has been similarly reduced, and maintenance of hospitals and hospital equipment has been curtailed to an absolute minimum. These are indications of the types of cutbacks being implemented as a result of the Government's budgetary policy and their health policy for this year.
In a letter to the health boards on 15 December the Minister said that the public service embargo relating to filling only one in three vacancies would apply to the health service. Wisdom descended upon him and on 6 February he wrote to the health boards — probably having realised that it was totally unrealistic to expect to fill one in three surgical vacancies or one in three nursing vacancies — and told them it would not apply in 1984 but that they will have to find the money themselves.
The hospital services will certainly suffer as a result of these financial difficulties.  The Minister has caused a great deal of confusion in some hospitals. When he closed the maternity unit in Bantry he promised that an antenatal facility would be available staffed by the hospitals in Cork. My understanding is that the consultants in Cork believe that is not feasible, that it is not practical, and that a safe service could not be provided at a distance of 60 miles. There is difficulty in providing the service the Minister promised.
In my own constituency the Minister wrote to the health board and told them they would have to close the hospital and sell it before he would sign the contract for the building of the new hospital in Cavan. He told them they would have to close the Monaghan hospital and dispose of it. Again he changed his mind and decided that we could maintain a medical and surgical service but not a maternity service. Obviously the Minister has no conception of the terrain in Cavan-Monaghan. The winters are long, with frost and a fair share of snow. We know 96 per cent of deliveries are normal, but we cannot expect a mother to put her own life and her baby's life at risk if she has to travel 40, 50 or 60 miles to a hospital in Cavan.
That is the type of policy we have had from this Government over the past year. The figures for admissions to hospital must be a matter of concern to people who need hospitalisation. In 1960, 250,000 people were admitted to hospital, and 389,500 were admitted in 1971. The figure for 1982 was 571,000. It has more than doubled in the past 20 years. That must be a matter of concern. There is no indication from the Minister that he has any radical solution to that problem. If we are to cut down the rate of admissions we must provide adequate out-patient services. The whole thrust of the Government's philosophy and policy is against any improvement in any of the services.
The Department and the Minister must realise that if we are to have the type of out-patient services which will ensure that there will be a reduction in the number of admissions to hospital they must be financed. That can only be done by  building up the out-patient services. It would be a very good investment if the Minister were to spend money on developing out-patient services but he must do that in advance of closing down hospitals or people will suffer.
The community care services will suffer this year as a result of the cutbacks. Last year the Minister told us he expected that the report of the working party on the general medical services would be available by September 1983. In June last year he expected to have it in three months. On 1 March we still have not got it. That is the story in the Minister's speech this morning. Everything we were promised last year is still coming and nothing has arrived as yet.
The general medical services give good value for money. For approximately £100 million they cover one-third of the population and provide medical services for them for 24 hours a day and seven days a week. That is a good service. Last year the Minister withdrew the general medical services from the elderly. All old age pensioners were entitled to medical cards when the Minister took office but he withdrew these services from them this time last year. Obviously he realised that was a mistake, and it was announced in the budget this year that the guidelines were to be improved for eligibility for those over 66 years of age.
It was announced this morning that that will not take effect until 1 July. Why will it not take effect until 1 July? I believe that the Government recognised that it was necessary to have a higher level of income in the guidelines for pensioners. As the Minister said, while they make up 10 per cent of the population they take up 40 per cent of the places in hospital. They are more prone to illness. If they needed a higher level of income in the guidelines for the general medical services they needed it from the day the Government decided that, and it should have applied from the date of the budget and not 1 July. This makes one wonder about Government thinking on this issue. If they believed it was not necessary to improve the guidelines, why introduce this measure? If it was necessary to introduce guidelines to ensure elderly people  would be able to provide for their illness, it should have been introduced from the date of the budget.
This morning we heard a long statement from the Minister about the withdrawal of medical cards from students. We do not believe this move will save the £2.5 million he expects, because from his figures the average number of visits per student per year is two and that will not yield £2.5 million. It is interesting to note that over the last three months, since the regulations were published, the Minister was not prepared to make any statement of interpretation of the new regulations. Seven students were allowed go to prison before he communicated with them and put his new interpretation on the regulations. The regulations clearly state that the services under the relevant sections of the Health Act shall not extend to persons between the ages of 16 and 25 years who are dependants of persons who do not have full eligibility for the services. Regulation No. 4 states that these regulations shall come into operation on 1 January 1984. This morning the Minister told us he had agreed with the students that the regulations would not come into operation until such time as they had an opportunity to apply for medical cards. Otherwise, there was no change from what he stated on 16 December when he announced the regulations. Had the Minister come into this House or met the students and told them three months ago that their medical cards were not being withdrawn on 1 January, perhaps he could have avoided the situation where the students had to go to prison.
I would like the Minister to look at the use of the general medical services cards for a variety of other purposes. This card entitles the holder not to be responsible for the youth employment levy, health contributions and the special 1 per cent levy. It entitles the holder's family to a free school bus service. Is it legitimate to use the medical card for such purposes, because obviously it is causing very serious social injustice? This morning he gave an example of a person with a wife and two children with a gross weekly  income of £117 paying £20 rent and £10 travelling expenses. He is entitled to a medical card, but if he had £118 gross he would not be entitled to a medical card, and in the present situation would not receive a medical card, even under a hardship clause unless there was chronic illness in the house. The fact that he had other financial commitments would not influence the health board because of the cutbacks. Let us take two couples each with two children living side by side in two semi-detached houses. One of them has £117 gross and pays £30 between rent and travelling expenses. In addition to free medical services, he will receive free dental and ophthalmic services for himself, his wife and family. His school-going children will be entitled to travel free on the school bus and he will be absolved from the 3 per cent levies. His neighbour with £119 gross will pay the 3 per cent levies and £150 a year for the school bus. There is no social justice in that.
Instead of reviewing the criteria for admitting somebody to hospital, the Minister should review the administration and guidelines of the general medical services. We could also ask if it is right that gross income should be considered. Why not net income? The unemployed are entitled to all the services we provide for them, but they get a net income while their next door neighbour who is working is not entitled to these services although his net income may be lower.
This morning the Minister told us the number of consultations in the general medical services had increased to five million. I would like to know if the number of visits per patient has increased over the last ten years. The Minister also told us about the three categories of eligibility — full eligibility, limited eligibility and the upper income group. He defined full eligibility, saying that persons in that category were entitled to a full range of health services without charge and they were issued with medical cards for presentation when services are needed. That used to be correct, but it is not correct any longer, because they are not entitled to free dental services or drugs they may need. For example, general medical services cardholders who  need white stomach mixtures are not entitled to them without charge because they have been withdrawn. One was on the list when the Minister took office but he saw to it that it was removed later. I should like to ask the Minister to tell the House the number of students who will retain medical cards as a result of the discussions he had with them. Will that number be increased? The Minister announced a figure of 40,000 but this morning we were told that it is 35,000. It appears that the figure has been reduced and I should like to know if the change in the number is as a result of recent discussions with students.
On the question of drugs, the Coalition partners promised that if elected to Government they would review the items removed from the GMS list. That was to be undertaken without delay and the Coalition undertook to restore items considered to be medically necessary. That undertaking was contained in their Programme for Government which stated that there would be a review of the recent removal of the over-the-counter items from the medical card scheme and refund scheme with a view to restoring to GMS patients without delay those items which are medically necessary. Perhaps it would have been better for the patients if the Government had not reviewed that list because the result of their review is that they increased the number of items removed by 233 to the end of June last. Instead of 900 items being removed, the Government removed more than 1,100 items, including such essential medicines as white stomach mixtures and certain cough bottles. Some of those were still on the list after the first list of drugs removed from the GMS list was announced.
I should now like to deal with the raising of the threshold for the drug refund scheme to £28 per month, £7 per week. That decision will cause a lot of hardship for many people. I have quoted the example of neighbours, one earning £117 per week and the other earning £119 or £120 per week. If the latter need drugs they will have to pay £7 per week. If the drugs are expensive they will have to wait up to three months for a refund of the amount  in excess of £28 per month. In a month they may have to pay out £60 or £70 but they will have to wait three months for the refund. I accept that health boards have the power to grant medical cards in cases of hardship but in times of recession and financial stringency with the Minister curtailing services the boards are more strict in the administration of services in an effort to save money. They are concerned not to exceed the allocation given by the Department. They have been told by the Minister that he does not have any more funds at his disposal to give to them. The decision to increase the threshold affects the poorer sections of our community. Families with less than £6,000 per year are being asked to pay £20 rent for a house, £10 per week for travelling expenses to work, a 3 per cent levy on income, a fee for school buses if the children must avail of that service and £7 per week for drugs. The Minister should review the long-term illness scheme. Under that scheme those suffering from such chronic illnesses as bronchial asthma or cystic fibrosis, or those who are on continuous medication, are entitled to free drugs. The Minister should review that scheme rather than tinkering with the existing system or increasing the threshold under the drugs refund scheme.
Under the community care scheme there have been cutbacks in the transport facilities available and they hit the poorer sections of the community. I am aware of an elderly man who has severe arthritis and had to forego an appointment with the orthopaedic surgeon because he did not have transport. That transport was available to him before the cutbacks. Is the Minister satisfied with the arrangements for travel that exist? Are people being sent on public transport who are not suited for it? Are young people being asked to use public transport to get to Dublin city and told to locate the hospital themselves? In those cases health boards provided transport previously. I am not against a curtailment of the old transport arrangements because I accept that some people who were in a position to provide their own transport availed of the health board service. There is nothing wrong  with eliminating that but I am concerned that the Minister appears to have gone too far and left people who need proper medical attention without the means of transport to see specialists and others.
In the budget there was an extension of the free travel scheme for certain categories of handicapped persons travelling to and from rehabilitation centres. Those people now enjoy free travel at any time of the day. The Minister should ensure that that concession is extended to all handicapped people irrespective of whether they are travelling to rehabilitation centres or not. I am concerned about a student who is blind and is attending a university in the city. That student is anxious to return home each weekend but the only bus available goes between 4 p.m. and 6 p.m. on a Friday and he is not allowed use his free travel facility at that time. Will the Minister see if he can do something for that person?
The Irish Wheelchair Association have been seeking an improvement in their residential care facilities for those who are handicapped. Will the Minister use his influence with the Minister for the Environment to ensure that local authorities provide suitable housing for handicapped persons? The policy of some local authorities is most unacceptable. They will not allocate single storey houses to handicapped people. They build them for the elderly but will not give them to the handicapped. This matter must be raised at Government level by the Ministers for Health and the Environment to ensure that in this day and age a handicapped person who wants to live in a community is given proper and adequate housing.
Concern was also expressed by that association about younger handicapped persons who are maintained in residential care institutions of health boards. They are subject to hospital discipline, and I must agree with them that young people should be given as much freedom as possible wherever their residential care happens to be. If they cannot live in the community then they should be allowed the maximum freedom possible commensurate with the proper running of the hospital.
 The Minister stated that the collection of health contributions should be transfered from the health boards to the Revenue Commissioners. That is desirable. It should never have been a function of the health boards to act as collectors of revenue. One matter at which the Minister might look is the question of standardising what is acceptable in terms of profit where farmers are concerned. Different criteria are used in means testing for general medical service cards, for health contributions, for income tax and for social welfare benefits. There are different rules in all these cases governing what is allowed and what is not allowed. I would ask the Minister to see if some way could be found to standardise what is profit and what is not profit in assessing farmers' incomes.
Capital expenditure has increased from £53 million in 1983 to £55.5 million this year. The Minister did not tell us this morning that last year the Fianna Fáil Government produced the Estimate before they left office. They allocated £55 million for capital development and then this Government on coming into office reduced that figure to £53 million. In effect there is now only £.5 million more than the original Estimate for 1983. There is grave need for a great many projects, and the Minister told us that last year there were over £600 million worth of projects in his Department awaiting sanction. When one considers the spin-off from capital expenditure in terms of building, to say nothing of the spin-off in other manufactures, such as cement, timber, paint and so on, any injection of capital into the building industry is worthy of consideration. Surely, if the Government are sincere in trying to reduce unemployment, they should increase the amount of capital available to the various Government Departments and particularly to the Department of Health. A very small percentage of capital is going to building in the community care area. It is all going to hospitals.
The allocation to the VHI is down from £3 million to £900,000 and that £900,000 applies apparently to previous years. The VHI are getting nothing this particular  year. If we look at the Minister's philosophy he wants to charge those who opt for private facilities more and more. Those over £11,000 are not entitled to free comprehensive hospital care and under what the Minister proposes he will create a situation in which there will be a massive increase in the contribution to the VHI to provide adequate cover. Now the VHI should be encouraged to provide more facilities for out-patients and community care. There is a built-in bias towards in-patient facilities in what the VHI provide. They should be encouraged to reverse that policy and provide a range of services for people who stay in the community and receive medical attention as out-patients rather than go into hospital.
The Minister referred to the use of facilities in hospitals by consultants. There is a proposal that consultants should be charged for the use of these facilities in State hospitals. We have had a preview of this in the Minister's opening statement this morning and in the newspapers over the last few days and on the radio last Sunday. The proposal to charge consultants is in my opinion a doctrinaire socialist proposal and nothing else. The Minister knows as well as we know on this side that it is not the consultants who will have to pay but the consumer. He also stated that this was a new arrangement made in 1979. My understanding is that that equipment and those facilities were always available to consultants. There were no specific charges for facilities or equipment.
There are massive cut-backs in health services. You have £24 million out of the health services. The whole idea seems to be that we should introduce this type of socialism and create a situation in which people who want to pay for their own medical care privately and so save the Exchequer should be debarred from doing so. The Minister wants to force these people who may be unable to meet their VHI commitments to use an already over-burdened health service. It will make no difference to the consultants. It will be the patients who will suffer, not the consultants. That will be the effect. If there is a fee for the use of facilities  and equipment it is the consumer who will pay. The Minister will not be able to force the consultants to pay. Many consumers, because their incomes are so reduced as a result of this Government's taxation policy, will not be able to join organisations like the VHI and will have to opt for an already over-burdened public health service with a resultant extra charge on the Exchequer. Here, in 1984, in the first two months when there are already cut-backs of £24 million the Minister tells us he will introduce this new charge to force more people into the public health service. It is estimated 175,000 patients will be affected by this decision. These are people who will already have paid their income tax and their health contribution.
An exclusive interview with the Minister in The Irish Press of 29 February carries the headline “Radical Plans for Health”. As far as health services are concerned the only radical party in this House is our party. If one looks at the legislation over the last ten or 15 years one finds the Health Act 1970, the setting up of the health boards, the Medical Practitioners Act 1978, the Abuse of Drugs Act 1979, the Family Planning Act which the Minister's own Government in the seventies were unable to introduce. The Family Planning Act was brought before the House by the leader of our party, Deputy Haughey, and was carried through the Houses of the Oireachtas and put on the Statute Book. In fairness that should gain recognition rather than the throw-away remark that the family planning legislation makes us the laughing-stock of Europe. At least it should be recognised that when the party on this side of the House decided to introduce legislation they were able to come into the Dáil, introduce that legislation and carry it through both Houses of the Oireachtas and put it on the Statute Book, which the Minister's party and the Coalition Government of the day tried to do and were unable to do. We would make more progress if recognition were given to these facts rather than the Government talking about radical plans for health.
I believe that the interview was purely  a means of deflecting attention from the day-to-day running of the service. The Minister has responsibility for formulating policy, but he has responsibility also for the day-to-day running of the services. Because the Government are not able to provide the level of care that the people expect, they are thinking up all sorts of new ideas to deflect attention, and a radical solution to the health problems of the nation is one of those ideas. The Minister is quoted as saying that he is absolutely determined that the amount of overtime being worked at hospitals will be reduced. He recognises that there is a need for more efficient outpatient services and a more controlled method of bringing people into hospitals, but there is nothing in his whole Estimate to tell us that he is going to do something to improve the outpatient services, to make them more efficient. There was nothing in his speech this morning about how we are to create a better outpatient service, which we all agree is necessary. People should not be obliged to spend three or four hours in an outpatient department waiting to be dealt with, but people will have to spend longer and longer in out-patient departments as a result of the cutbacks.
The Minister described as interesting the statistics indicating that the consumption of drugs among people under the GMS is three times greater than among the 60 per cent of the people not covered by the scheme. One cannot stress too often that the people covered by the GMS are in the more vulnerable groups in our society. He himself gave the figure this morning that those over 66 years of age while only 10 per cent of the population take up to 40 per cent of the beds. Those in the lower income groups, particularly those with large families, are more susceptible to illness. These are the people included in the GMS.
Another matter I wish to raise is the question of the number of visits to the family doctor by holders of GMS cards. In order to keep the number of visits down doctors may tend to prescribe drugs for a longer period than they would normally do so. If the visitation rate goes up  above the national average the doctor must account for it, and I understand that there is a tendency for doctors to prescribe drugs for a month when normally they might do so for only a fortnight in order to avoid bringing the patient back and so putting their visiting rate too high. The working party should look at this aspect of the GMS. If somebody gets a month's supply of tablets and then for one reason or another is chronically ill and has to go into hospital and may not need those tablets, then those tablets are wasted, and we must all be concerned about wastage of drugs.
Regarding the interview yesterday, the Minister said that he is determined that voluntary hospitals which dominate the Dublin scene will be integrated into the health board system. Again this is a bit of doctrinaire socialism and an attempt to deflect attention from the realities of the day-to-day running of the service. I wonder if the Minister has had consultations with the voluntary hospital personnel about this. I believe that the voluntary hospitals are providing an excellent level of service and have made a very valuable contribution to health care in this nation down the years, and that it would be wrong to walk in and take over the voluntary hospitals just because the Department are funding them to over 90 per cent of their needs at present. Has the Minister had consultations with the voluntary hospitals about this? I did not hear any reference to this solution from him this morning.
The Minister spoke about a Green Paper, and in last year's discussion of the Estimate he promised that we would have the Green Paper before the end of 1983. To quote his own words, when speaking on the 1983 Estimate, “before the end of the year”. This is 1 March and there is still no sign of it.
The Minister said that he will be presenting a memorandum on the National Drug Company to the Government over the next month. He went on then to the Family Planning Act. He found insulting to the Irish people — and many members of the Opposition accept this — the provision that requires people to have a prescription for non-medical contraceptives.  Generally speaking there are no ideological hang-ups on that except, it is no harm to point out, according to the Minister's statement that makes us the laughing stock of Europe. Many people, including many doctors, believe that it is in the interests of a couple that they should discuss their family planning needs with their family doctor and, having heard about the various methods available, the couple in conjunction with the doctor would decide what is the most appropriate family planning method for them. Many people who accept that as right and who see family planning as part of community health care and not as something isolated, would not consider that it makes us the laughing-stock of Europe that a couple would go to their doctor to discuss various methods of family planning and if they decide on non-medical methods of family planning they would on one occasion only get an authorisation from the doctor that would serve them for their lifetime. The Minister told us in the 1983 Estimate that he had reviewed the legislation. This morning he told us that he has circulated to the Government the findings of his review. If he had that review when the 1983 Estimates were before the House when did he circulate it to the Government? If he circulated it to the Government in June 1983 when he told us he had received it, what has it being doing since 1983, since last June? I wonder if these throw-away remarks of the Minister about the Family Planning Act, 1979 which was introduced and put through this House by a Fianna Fáil Government — a Coalition Government could not do it — are to deflect attention from difficulties within the Government on bringing forward family planning legislation.
Finally, in his interview with The Irish Press, he talked about the Children Bill. Nowhere in all of that interview was there anything radical that I could see to improve the health of the nation, no major contribution to the prevention of illness or to the promotion of health care. The only little bit of radical thinking was the doctrinaire socialism that he will move in and take over the voluntary hospitals,  although I know the Minister is not responsible for newspaper headlines.
At a time when everybody is interested in health care, in supporting the promotion of good health and the prevention of illness, it is a matter of some concern to find that the Health Education Bureau are receiving no increase in their allocation this year. They are to receive £1.25 million which is what they received last year and less than what they received from the Fianna Fáil Government in 1982. Therefore, they are receiving one-tenth of 1 per cent of the total health budget. If one examines the total amount allocated for the community protection programme it is £17.65 million out of a total budget of £1,021 million. There would have been something to be said for them having received the odd £21 million, leaving the remaining £1,000 million for the other aspects of the service. Surely the main thrust of any Government's health policy at present must be the prevention of illness and the positive promotion of good health care. The Health Education Bureau maintain that their allocation in 1978 was £1 million——
Mr. B. Desmond Mr. B. Desmond
Mr. B. Desmond: That was for Deputy Haughey's public relations exercise, spending it on horse show prizes.
Dr. O'Hanlon Dr. O'Hanlon
Dr. O'Hanlon: That was £1 million in 1978, increased by £250,000 by this Government in 1984, which is the same as they received last year. That is a 25 per cent increase during the same period that the Minister told us here this morning the cost of health services went up by 166 per cent. I would ask the Minister where are his and the Government's priorities when the cost of our health services went up 166 per cent, from £400 million to £1,000 million in that period. Yet the Minister could not give any increase since he took up office, except in fact a decrease of £250,000, from an allocation of £1,500,000 from the Fianna Fáil Government in 1982 to £1,250,000 this year. I do not know where the Minister's commitment is.
Mr. B. Desmond Mr. B. Desmond
Mr. B. Desmond: I thought they were happy enough with their budget this year.
Dr. O'Hanlon Dr. O'Hanlon
 Dr. O'Hanlon: I cannot see how they could be happy with it if they want to discharge their responsibility. And they must take note of the World Health Organisation's desire to see, as they say themselves, “health for all” by the year 2000. Surely the Health Education Bureau have a most important role to play in that goal. Surely also there are many projects in which they would like to be involved but in which they cannot because they have not the necessary finance available, for example, programmes for youth, on the problem of alcoholism, and the Minister told us here this morning that there are 45,000 alcoholics in the country. We need a proper programme to alert people to the dangers of alcohol, to the dangers of the misuse of drugs. I was glad to hear the Minister say also this morning that he hoped to introduce legislation on smoking. One would have to question the Government's commitment to an anti-smoking campaign, because always one must ask if there is a conflict of interest between the Minister for Health and the Minister for Finance who receives a lot of revenue from the people who smoke. The health boards have done excellent work in regard to health education. The Eastern Health Board have engaged in some excellent pilot projects, for example, their project on parental skills, on community pride and education for parenthood.
Certainly the most serious problem being encountered in this city at present is that of the misuse of drugs. We were told in the House recently that 10 per cent of drug addicts in the 15-24 age group are on heroine, a very dangerous drug. While I listened carefully to the Minister this morning as he told us of the plans he has in mind, apart from giving an allocation to Trinity College to set up a post-graduate course it does not appear that there has been any extra money allocated to the solution of this very serious problem. There was one paragraph of the Minister's remarks here this morning about which I would be most concerned, that dealing with sentences for drug pushers, because the intention is to increase the sentence from 14 years to life. We  cannot be sure how long a life sentence will be, it may be seven years, nine years or ten years only. Before introducing that legislation I should prefer that the Minister would increase that maximum sentence for a convicted drug pusher from 14 years to 20 years or 25 years rather than to a life sentence. To amend the law on sentencing to life would be a very serious step indeed. There must be provision to ensure that those who dispense heroine and other serious addictive drugs be punished in a way that will make it entirely unattractive for them to become involved in that sort of activity.
During the year the Minister added new drugs to those on the prescribed occupational diseases list. While this may be more relevant to the Department of Social Welfare I would ask the Minister to examine the situation of, say, somebody who contacts an occupational disease at work and who, because that disease is not on the list of occupational diseases, will not qualify for occupational injury benefit.
The main thrust of the Government's policy should be — and there is no evidence to show that they are supporting this with moneys allocated out of a total of £1,021 million — the promotion of good health and the prevention of illness. It has been said that the greatest single need in medicine in the next 25 years will be to give prevention the degree of scientific and educational attention that has been given to treatment in the past 25 years. Attention was drawn to the prevention of illness in the course of an EEC document, number 82/716 in which it was said and I quote:
Finally, more attention needs to be given to the possible ways and means of reducing the social cost of economic activity (pollution, accidents, etc.) which in the end are paid for by the social protection system in one way or another (sickness, premature disability, accidents at work). This would require a wide range of action over a number of policy fields and demand a  major effort of co-ordination within national administrations.
We should like to see a major effort towards the promotion of prevention by our administration. The Health Education Bureau have not got the necessary finance to promote a programme on, say, the correct type of lifestyle for people. The effects of smoking, excessive drinking and an improper diet should be brought to the attention of people. This morning the Minister referred to the problem of hormones and antibiotics in meat and milk. In conjunction with his colleagues in government, the Minister should consider the present situation where the local authority, as sanitary authority, employ veterinary inspectors. This should be a function of the health board rather than the county council concerned. I ask the Minister to ensure that any matter that is a health function be removed from the local authorities and placed where it belongs either with the health boards or with the Department.
We cannot have enough education on matters such as the importance of exercise and the misuse of drugs. I was surprised that the Minister said the Health Education Bureau were satisfied with an allocation that is the same as they received last year, that was £250,000 less than what they received from a Fianna Fáil Government in the previous year and which is only £250,000 higher than what they received in 1978.
I support the Minister fully in what he said this morning regarding immunisation. It is important, following the debate on the use of the whooping cough vaccine, that the public should realise that the risk from whooping cough at the moment is much greater than the risk of brain damage as a result of vaccination. People should not be deterred from having their children immunised.
The Government should also consider the whole matter of the pollution of the environment. It is necessary to ensure that we do not allow anything to happen to our environment that will be detrimental to the interests of the people. The Government have a legitimate role to play in the protection of people from  trauma and illness, but we heard nothing about it today. While accidents in the home and industrial accidents may not be the direct responsibility of the Minister for Health, in terms of promoting good health and the prevention of illness they are matters in which he should take an interest. It is important also in terms of health economics. Instead of carrying out research on some of the matters he mentioned this morning, the Minister could usefully research the cost to the health service of maintaining in hospital victims of road accidents and accidents caused to the elderly or to children because homes are not properly protected. If the Minister investigated these matters he would be doing a good service and perhaps he might find some way of reducing costs rather than simply having cutbacks. Fianna Fáil started a scheme allowing special aid for improvements carried out in the homes of the elderly, and this has continued. It has been an excellent scheme. Not alone has it improved the homes of the elderly but I am sure it has contributed to preventing accidents because the homes have been made safer.
In the Minister's speech this morning there was no joy for those who had hoped that the level of health services would be maintained. As the Minister admitted today, there will be a curtailment in the level of the services. He promised a lot of legislation, but he made that same promise last year. He told us then several Bills would be before the House before the end of 1983. This morning he told us some of the Bills will be introduced in the immediate future but others have been put on the long finger.
The Minister dismantled some of our legislation which would have made a valuable contribution to the community last year; I refer to the National Community Development Agency. That agency were not given the opportunities they should have been given. They should have been allowed a chance to show if they were going to make the valuable contribution we believed they would make when the legislation was passed in 1982. Instead, the Minister set up the National Social Service Board and he has promised legislation to combat poverty. However, the  National Community Development Agency was sufficient to fulfil their functions and they had the necessary element to research poverty and to do the work the Minister expects the Combat Poverty Agency to do.
The people do not want statistics, reviews or draconian cutbacks. They do not want the type of radical socialism that we heard from the Minister on the radio last Sunday about the consultants and hospital equipment. They do not want the taking over of voluntary hospitals.
In his speech this morning the Minister said nothing about legislation he proposed on private hospitals and private nursing homes. If he hopes to implement such measures he should consult the appropriate people who are involved in private nursing homes. They are very concerned particularly when they hear outbursts of this kind of socialism. It is important that the Minister communicate with them at an early stage and tell them what he has in mind. People expect a proper service without the risks to their health that have been caused as a result of this Government's decision to reduce the level of services by their massive cutbacks.
Mr. Enright Mr. Enright
Mr. Enright: The Department of Health are a huge Department and the policies they will pursue in the next 12 months and thereafter are important. The Minister gave us a comprehensive and wide-ranging speech this morning. Non-capital expenditure of £1,064 million is a vast amount of money. It affects the lives of everybody throughout the length and breadth of Ireland in one way or another. Both the Minister and Deputy O'Hanlon referred to some of the points and I will confine myself to a number of details. While the Minister is in the House I am anxious to make a first point which is of interest to my constituency.
I refer the Minister to the Tullamore General Hospital and the absolute necessity to have two appointments made there immediately. The hospital requires a permanent obstetrician/gynaecologist and a  permanent paediatrician. It has an excellent maternity unit with all the necessary equipment and a back-up of the necessary ancillary services, with a fully qualified nursing staff. It cannot be contradicted that it requires the two permanent appointments I referred to.
I have had the honour to represent the constituency for a number of years and I am asking the Minister to work in harmony with the CEO of the health board to ensure that a situation that occurred there last December and January will never be allowed to recur in that hospital. I will read a letter which appeared in the Tullamore Tribune on 21 January last which will bring home to the House and to the Minister the need to have these appointments made:
We wish to lodge a complaint regarding the present procedure whereby Maternity patients are ferried by Ambulance to Portlaoise during each period of time that the Resident Obstetrician/Gynaecologist is on leave and due to the fact that no effort has been made to secure the services of a Locum Obstretician/Gynaecologist for Tullamore Hospital.
We feel that it is not acceptable that maternity patients travel to Tullamore Hospital to have their babies only to be informed that the Obstetrician/Gynaecologist is off duty and that it is necessary for them to travel to Portlaoise General Hospital for delivery.
The least mothers should expect is to feel they are properly cared for at such a special moment. It is vital to be as relaxed as possible at the time of birth. How can a woman relax if she is informed at the last minute that she has to travel twenty-three miles more before she can be given expert medical attention. This news is very depressing and can give patients a most awful shock.
Surely at the best of times this travelling puts the lives of patients and babies at risk but more especially last week-end with dangerous road conditions and gale force winds and with  gardaí advising people not to travel. We only have to think of the accident at Durrow for proof of that.
One mother travelled on hazardous roads from Edenderry to Tullamore on Sunday night, in labour. Imagine her distress and shock when upon arrival in Tullamore she was put into an ambulance and transferred to Portlaoise, where she was shortly delivered. Just two hours after the birth of her baby she is ousted out of bed to get ready for the return journey. It is disgraceful that newborn infants of only a few....
The letter is signed by a number of mothers. In his reply, the CEO stated they have been trying to obtain a locum service, but this does not solve a bad situation. It is highly unsatisfactory and downright dangerous because it places the lives of mothers and children at risk. It is not good enough that it should be allowed to continue in 1984.
Therefore, I call on the Minister to have these essential appointments made immediately, and I cannot understand why Deputy Woods, when he was Minister, did not make them. Offaly is a big county stretching from the borders of Tipperary to County Meath. It is such a vast area that the present lack of a proper obstetrician/gynaecologist service cannot be tolerated.
Recently I tabled a question on this subject and the Minister said he intended to advertise for a replacement for the present consultant who has secured appointment in Wexford. The Minister also said that he would advertise for a locum pending the permanent appointment. I am concerned that the first permanent appointment should be made immediately and the second without delay.
There is a paediatric unit in the Tullamore hospital which was provided jointly by the Department and the health board. It is an excellent unit but we have not got a paediatrician to go into it. Consultants have to travel down from Dublin at considerable cost to the Department and the health board. Alternatively, children have to be transferred to Dublin. The  vast majority of the staff in the unit at present are living in Dublin. I ask the Minister to remember that rural Ireland has to be looked after as well and must be provided with hospital services, with proper maternity, back-up and ancillary services. I ask the Minister to ensure that these appointments are made and cannot overstate the importance of this to everybody concerned. Regularly mothers and fathers come to me asking for these appointments to be made, because they are unhappy with the position as it is. I put down a question recently about the appointment of a paediatrician. The Minister replied that he was acutely aware of the lack of a proper paediatric service and I was glad to hear that recognition of the problem. He went on to say that in view of the urgency of the situation his Department and the health board were at present considering various proposals for the development of adequate services. It is essential that the Minister provide a paediatrician for Tullamore General Hospital.
Many local district hospitals have a problem in that only one qualified medical practitioner has access to them. In quite a large town with a district hospital, all the doctors in the town or the surrounding area should be allowed the facilities of these hospitals, in conjunction and co-operation with the health board concerned. If such facilities were made available for the medical profession it would benefit many patients, some of whom would not have to be admitted into hospitals for treatment. The Minister should examine this question. I understand this is a matter for the Midland Health Board, but a proper Government policy should be worked out to expand this service.
One important matter referred to by the Minister this morning concerns the very serious drug problem. We are lucky that at present it is, to a large degree, confined to the cities and really large towns. However, those living in the smaller towns in rural Ireland cannot be complacent in this regard. I must place on record how seriously I view the present trend of vigilante groups who are tackling the drug problem. The majority  of those forming these protection and vigilante groups are well intentioned and have the welfare of their families and their communities at heart in carrying out these tasks, but the trend is frightening and must be of concern to all Members of this House. It clearly represents a vote of no confidence in our existing institutions — in our courts, in the Garda Síochána and in the Houses of the Oireachtas, which is extremely serious.
The plans for changes in the Misuse of Drugs Act are to be welcomed, but no Act will provide all the answers and all the remedies. One comment by the Opposition spokesman with which I agree opposed the change from an 8 year period of imprisonment to life imprisonment. However it is necessary to increase the number of years from eight to 14 or 20, instead of imposing life imprisonment. That is a wise suggestion to which the Minister and his advisers might listen.
The prevention of crime is what is important, and the prevention of the misuse of drugs is one of the most compelling tasks facing us today. The policies of the Garda Síochána, the courts and both Houses of the Oireachtas must be made more relevant to the problem. The assistance of the Garda Síochána must be made accessible to the people living in housing complexes and huge housing estates and the Ministers for Health and for Justice should have very urgent discussions with Garda policy in view. If necessary, Garda stations or Garda offices of one sort or another will have to be provided in these areas and be manned on a 24 hour basis.
I fully understand the problems faced by gardaí attached to one huge station who on occasion patrol many of these complexes. They have no real feedback or hard information about what is going on. In many instances, it is very sad to state that they are groping in the dark. This is because they are not able to keep in touch and exchange viewpoints with the people living in these areas.
The crime rate has grown in a frightening manner, serious crime particularly, and this must be seriously confronted. The Misuse of Drugs Act is important,  and I am glad that the Minister is amending it, working in conjunction with the Garda task force. In conjunction with the Minister for Justice, he will have to examine the role of the Garda in this matter. The direction of policy of the Garda under successive Governments must be closely examined. I should like it to be clearly understood that I am in no way criticising the Garda Síochána but, as is obvious with the growth of the drugs problem, in particular, the policy being pursued must be looked at, to see how it can be adapted and improved.
Many convictions have been obtained by the Garda Síochána with regard to the misuse of drugs, and I congratulate them for their fine and splendid efforts in cracking a large number of the drug rings in Dublin. Statistics for 1982 show that roughly 530,000 district court summonses were issued. Of those, over 480,000 refer to Road Traffic Act offences of one type or another. The amount of Garda man hours spent on this type of duty, on checkpoint duty, traffic duty, on obtaining details of offences, preparing summonses and so on must be examined.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: This has nothing to do with the Department of Health, Deputy. A passing reference would be all right.
Mr. Enright Mr. Enright
Mr. Enright: I have more or less concluded. I am anxious for co-operation with regard to the drug problem between the Ministers for Health and for Justice.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: If you stay on the subject of the drug problem, that will be all right.
Mr. Enright Mr. Enright
Mr. Enright: I hope greater attention will be paid to the tremendous increase in serious crime, and drugs are involved in many of these. I ask for a change in direction of policy in an attempt to combat the present frightening situation. Society has experienced some of the most frighteningly and horrendous crimes immaginable. Confidence must be restored in our Judiciary, our Garda Síochána and the Oireachtas.
The vigilantes and the protection  groups are very dangerous. A lot of these vigilante groups are gaining some respectability and that is alarming. The two Ministers concerned must put their heads together to remedy this serious problem. That is the reason why I am calling for a change of direction to get to grips with the very serious crimes we have at the moment. I am not underestimating the very important work carried out in relation to the Road Traffic Act.
The drug squad unit should be enlarged and greater training should be provided for this unit. In order to enable the Garda Síochána to enter into areas where there is a serious drug problem, the large housing estates and the different flat complexes, courses should be provided for them in youth training and leadership, sports and all types of community work. If there is a proper planned approach to this we might go a good way towards solving the problems we are facing. There are social problems and age problems to be faced in relation to the Gardaí working in this squad. Those have to be broken down. I hope our gardaí can be given regular training, not just six months in Templemore, but special sessions so that they can be trained in all the areas I have referred to. I am grateful to the Chair for allowing me to speak on these matters which are possibly more for the Department of Justice than the Department of Health.
I would like to say a few words about medical cards. We are told that once a person has an illness which is in the special type illness category that person gets a medical card as of right. Any people who apply for medical cards for children with long-term illness have a lot of problems. Children who suffer from asthma, blind children and deaf children do not get medical cards as of right. Perhaps it is a good thing that no group as of right get medical cards but there is a very serious problem in relation to the children I am talking about. The Minister should look at an extension of the guidelines for the assessment of people who are entitled to medical cards particularly in hardship cases. There should be a much more flexible method of assessment in cases like this.
 The Minister referred to the importance of nursing in relation to the whole question of medical care. The Minister should realise the large number of young nurses who are unemployed and the serious problem young girls leaving school are facing because they cannot be trained in Ireland. Many of them have to travel to other countries to qualify as nurses. I know the Minister has not an easy answer to this. I have had discussions with quite a number of married nurses recently. Many of them would be happy to retire from their jobs if there was some attractive package to encourage them to do so. The Minister should encourage married nurses to retire from their jobs by giving them some cash payment on retirement or a number of payments over two or three years. It is very sad to see the number of fully qualified young nurses who are unable to obtain employment. Many of those nurses are forced to leave the country to obtain employment. The Minister and some of his colleagues have already referred to early retirement in many spheres. I encourage the Minister to do something in relation to the early retirement of nurses.
Dr. Ormonde Dr. Ormonde
Dr. Ormonde: I am glad of the opportunity to speak in the debate on the very important Estimate for the Department of Health. As a doctor and, more importantly, as an elected member of the South Eastern Health Board I have a particular interest in this area. I am rather apprehensive because, as a consultant, I am aware that the Minister may once again make the claim that some of my colleagues and I may have a vested interest. He made this remark before when we got involved in medical cards for students. I have a vested interest in this discussion in relation to the Health Estimate and I have a vested interest in seeing that our patients receive the best possible health care from any Government.
As a consultant in a general hospital I am acutely aware of the serious consequences which the Minister's allocations have had for our health services. This is from a caring Minister for Health, from a Labour Party who demanded the Health portfolio for participation in the  Coalition Government. All these cutbacks from a Labour Party who, mark you, brought down the last Fianna Fáil Government in November 1982 on the proposed health cuts are really a case of the poacher turning game keeper. The Minister for Health was probably the most outspoken member of the Labour Party when he opposed the proposed health cuts by Fianna Fáil in 1982. Let us look at the Minister's record and at the 1984 Estimate for Health. There was a shortfall of £26 million in the allocations agreed between the Minister's Department and the various health boards last October. All the health boards have had to make significant cutbacks and this is for the third year running. Surely the Minister must realise that there is a cutoff point beyond which patients will suffer. We cannot continue to cut back and expect the same service.
Dáil Éireann 348 Estimates, 1984. Vote 47: Health (Revised Estimate).