Dáil Éireann - Volume 393 - 15 November, 1989

Supplementary Estimate, 1989. - Vote 42: Health.

Minister for Health (Dr. O'Hanlon): I move:

That a supplementary sum not exceeding £32,898,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1989, for the salaries and expenses of the Office of the Minister for Health (including Oifig and Ard-Chlár-aitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and a grant-in-aid.

The original net Vote for Health for 1989 was £1,144.905 million, including a capital provision of £35,000,000. This is a very significant provision, representing almost 20 per cent of total State spending on services and should lay to rest the perception that pervades the environment that good health services are not available to the population. This perception could not be further from the truth. We have an excellent service with essential treatment at the highest level available on demand and most elective treatment available within a reasonable timeframe. Over one million people have at their disposal, without charge, a comprehensive general practitioner and medicines service. Over 500,000 in-patients pass through the acute hospital system in a year getting the most sophisticated high technology services up to and including transplant. Over 1,500,000 out-patient attendances are serviced each year. Over 5,000 orthodontic cases are carried out and over £130 million is spent on our services for the mentally handicapped. These are not features of a negligible service, as some would have it. Rather they are features of a first rate service provided by dedicated competent people and in a most caring way.

The movement of this supplementary sum is a sign of the Government's commitment to the maintenance of this service and to the provision of funds for its improvements in specific areas and in a prioritised way as funds allow. Specifically it provides £15 million for the cost of improved acute hospital services including improvements in the sectoral accident and emergency services in Dublin; £25 million being the additional cash requirements of the General Medical Services (Payments) Board due to, inter alia, the delay in the introduction of the new GMS contract and the once-off additional cost of two months' doctors fees. It also provides £8 million being the cost of additional expenditure on demand-led schemes such as the drug refund scheme, the disabled persons' maintenance allowance scheme, the cost of the measles, mumps and rubella campaign and the hepatitis immunisation programme. It also provides £2.1 million for the cost of discharging liabilities associated with the winding up of the Hospitals Joint Services Board; £300,000 for the cost of additional expenditure on orthodontic services; a figure of £5 million to cover the cost of additional expenditure on capital services; a figure of £1 million to cover the cost of a special health cash allowances bonus payment, less £23.5 million additional Appropriations-in-Aid; less the token Supplementary Estimate taken earlier this year amounting to £2,000, leaving us now with a net Supplementary Estimate of £32.898 million.

In my Estimates statement to the House in July last I pointed out that the health services over recent years had seen [683] a number of developments which indicated that, while the services were generally successful in meeting demand, difficulties arose in some specific areas due to a number of factors. These factors included changes in the investigation and treatment of patients. I do not have to tell the House about the level of high technology available to patients at present or indeed the new developments coming on stream on a regular basis. Other facets of these difficulties were increased day surgery activity, the changing demographic picture and the major challenge of AIDS, a condition which, as the House knows, is increasing, is a very serious public health issue, constituting a major challenge to our services with the number of patients suffering from AIDS doubling every ten months. Unfortunately, this is something that will continue for a few more years.

To relieve all of these pressures the Government decided to approve the use of an additional £15 million for the general hospital sector. Those £15 million were allocated as follows. First, a figure of £1.5 million for the introduction of sectoral and accident and emergency services in the Eastern Health Board area. That included the opening of the six hospital accident and emergency departments in this city on a 24-hour basis, whereas formerly there had been a rota over the past 12 to 15 years between the three hospitals on the north side and the three on the south side. That allocation also included a figure of £1.7 million for operations this year to reduce waiting lists, particularly for ear, nose and throat complaints and hip replacements. I am glad to say that we are seeing the waiting lists being reduced. We will not be able to reduce them all this year but we shall continue to do so next year. Hopefully we will be able to bring the various waiting lists into line.

I suppose it would be no harm to mention to the House a few specific procedures. The question was raised earlier today at Question Time of the number of patients on waiting lists for some specific procedures. For example, there are some [684] 3,374 patients awaiting cataract removals; for hip replacements, there are 1,993; for heart surgery, 675, and in respect of glue ears there are 1,810. It is important to remember that these figures must be treated with caution in view of our experiences in Temple Street Hospital and with the Midland Health Board. For example, in Temple Street Hospital a consultant was appointed to carry out a review of all patients on the waiting list. To date, 171 patients have got an appointment, three telephoned to say they were not coming, 58 did not attend and 110 attended. Of those 110, it was found that 19 no longer needed a service. Therefore, it will be readily seen that approximately half the patients on the waiting lists did not need a service. That was the ear, nose and throat service in Temple Street Hospital. Despite that, the in-patient waiting list at that hospital has been reduced by some 200 since August last as a result of the intervention.

A somewhat similar position obtained in the Midland Health Board area when 470 patients were transferred to the Midland Health Board from the Royal Eye and Ear Hospital who had been on the waiting list. The Midland Health Board decided to contact each of those patients asking them whether they wished to continue their treatment. Thirty-six patients replied saying that treatment was not required and 73 did not reply at all. That reduces the figure from 470 to 361 in respect of the number of patients awaiting surgery. Of course, when examined, it may be that some of those patients will not need treatment either. That was my purpose in pointing out that we must treat such lists with caution.

Again, of that allocation of £15 million, £9 million is being provided to cover the cessation of bed closures, the restoration of beds, the opening of additional beds and a figure of £2.8 million for the acceleration of planned opening of new beds, including the purchase of new equipment.

The Supplementary Estimate of £25 million in respect of the GMS is being sought on foot of a number of factors. Firstly, the GMS is a demand-led [685] scheme. The cost of meeting patients' statutory entitlements is determined by the numbers eligible, the level of illness and the nature and extent of treatment provided by GPs. One of the principal advantages of the new GMS contract is that it introduces a greater degree of certainty into the forecasting of costs.

The new contract came into effect by 1 April last for the vast majority of GMS doctors. This was later than had been hoped for. As a result, there were a number of teething problems associated with the introduction of the new scheme, due in part to uncertainty as to when it would, in fact, come into operation. This delay has led to some increase in the original forecast of costs.

A second factor underlying this Supplementary Estimate is the once-off cost of introducing the new contract. As Deputies may be aware, payment of fees under the old GMS contract was made two months in arrears, due to the need for checking and calculation of claims. Payment of capitation is made on a current month basis. In terminating the old contract there was, therefore, a once-off additional expenditure of two months' doctors fees.

The third factor which has affected the 1989 cost of the GMS has been a significant increase in drug prices. The vast majority of our drugs are imported from Britain. Price levels there have increased significantly and this has affected our drug costs here. Under an agreement between my Department and the Federation of Irish Chemical Industries, there is a strict control on the prices charged for drugs here relative to their UK price. As part of that agreement there was, in addition, an 18-month price freeze which terminated last October. The recent increases in UK prices have significantly increased the drug Bill, both in the GMS and in the drug schemes operated by health boards.

While the agreement with the FICI proved a useful means of capping drug prices here relative to the UK, I believe that it is time to consider alternative strategies to reduce drug costs. I have given 12 months' notice to FICI under the [686] terms of the agreement and I am having a detailed examination carried out on all of the alternative options to such an agreement as a matter of urgency. I would expect that negotiations with all of the affected parties to any new arrangements on drug purchasing would commence early in the new year.

An amount of £8 million is included in the Supplementary Estimate to meet the cost of certain demand led drug schemes. Specifically £4.5 million is included to meet the additional cost of the drugs refund scheme. This requirement has arisen due to an increase in drug prices and to an increase in the number of claims.

A sum of £2.5 million is included to meet the cost of the MMR programme and the cost of immunising high risk health service employees against hepatitis B and £1.5 million is included to meet the cost of an increase in recipients of the disabled persons' maintenance allowance.

I have recently reviewed the operation of the community drugs schemes for which my Department are responsible. I am concerned that there may be some hardship in relation to the existing drug refund scheme whereby people must pay the full retail price of required drugs and await subsequent reimbursement some weeks later. I hope to introduce the new scheme shortly. We are finalising negotiations with the Irish Pharmaceutical Union whereby patients will not have to pay in excess of £28 per month for their drugs and then have to wait some months to be reimbursed.

The Hospital Joint Services Board were set up under the Corporate Bodies Act, 1961, to provide central laundry and sterile supplies to hospitals. Over the years there were some difficulties, including financial ones, and the board decided to sell their assets as a going concern by public tender. This was done and the residual debt of the board after the sale was £2.1 million which is provided for in the Supplementary Estimate.

The House will be aware that in 1981 I established a small working group under the chairmanship of the then Minister of [687] State, Deputy Terry Leyden, to review the delivery of the dental services. The working group concluded that there were many difficulties in the dental services area. As a result we decided in the current year to provide £300,000 to ensure that 500 top priority patients in the eight health boards would receive orthodontic treatment. We intend to continue this scheme to ensure that an adequate and proper dental scheme is provided for people.

The water flouridation programme continues to expand and to bring the benefits of a flouridated water supply to an increasing percentage of our population.

As part of the Supplementary Estimate I am seeking an additional £5 million for the capital programme. The need for this extra provision has arisen for a number of reasons. Many of the projects in the health capital programme involve payments over a number of years and some of these liabilities are maturing for payment in 1989 at a faster rate than was originally envisaged. In addition, considerable capital expenditure has had to be incurred this year on the replacement of hospital equipment in emergency situations and in doing necessary fire precautions work.

The need for this expenditure cannot always be anticipated but it is vital for patient safety that equipment is replaced when it becomes unserviceable and that hospital buildings are maintained to the highest safety standards.

It has also been necessary to accelerate the programme of computerising systems in the health services and this has meant setting aside a bigger than normal component of our total capital resources for this purpose.

An additional yield of £8 million from health contributions has arisen in line with the general buoyancy in income related revenue and the receipts under EC Regulations will now be £15.5 million over and above the original forecast.

These latter receipts represent the reimbursement by the UK authorities of the cost of health services provided in Ireland to UK social security pensioners, [688] to dependants of Irish migrant workers and to temporary visitors from the UK.

The gross amount necessary to cater for these increases has been reduced by the £23.5 million additional appro-priations-in-aid. Specifically the main reason for this increase is that the final accounts for both 1985 and 1986 were in fact settled and paid by the UK authorities in the course of the year and that currency rates were more favourable than expected.

I commend the Supplementary Estimate to the House.

Mr. Yates: Fine Gael will be voting against this Supplementary Health Estimate because it does not address a number of the crucial areas in which public patients are suffering under the present régime of the Minister for Health. I want to refer to one titbit I read in Back Chat in the Sunday Independent the week before last which said that the Progressive Democrats were particularly delighted at the extra cash boost for the health services over and above £15 million and that Fianna Fáil had recognised the difficulties in the health services.

What is being provided for in this Supplementary Estimate is the same service which is costing more than was anticipated. There has been a £25 million over-run in expenditure in the medical card service and a £8 million overrun in demand led schemes such as the drug refund scheme. That comes to £33 million and if we add £9 million of the £15 million which was to deal with waiting lists — on the Minister's admission tonight this £9 million was simply to prevent the closure of wards and beds in hospitals during the summer — this gives us £42 million. This is more than the total Estimate and is being provided to shore up a shabby 1989 Estimate. Not one person will be eligible for a better service, there will be no better access to services, there will be no improvements in services and none of the needs in the health service which we on this side of the House identified during the past two years have been met in any way.

It is appalling that the Minister has [689] forgotten the commitment he gave in this House during a Private Members' debate when the VHI refund scheme was precipitously abandoned. The Minister promised that he would have a drug subsidy scheme in place by August so that people could go into their chemists and be assured they would not have to pay over £28 per month for their drugs. Since then we have heard that this proposal is under discussion, it is imminent and is being given further consideration. In the meantime people with long-term illnesses, kidney sufferers, those suffering from hypertension and those with incurable illnesses are suffering great hardship. These people require heavy medication but no relief will be forthcoming for them this year despite a solemn commitment given to this House by the Minister that this scheme would be introduced by August.

The Minister is starting to play a very dangerous game in relation to waiting lists. He is starting to pick holes in his own figures. He said Temple Street Hospital or the Midland Health Board have waiting lists but when they went through them some people did not turn up and others did not want the treatment, but he forgot all the waiting lists for out-patient clinics. If I require a routine tonsillectomy I will have to wait a year and a half to see the ENT surgeon at an out-patient clinic, and if he decides I need to have the operation I will have to wait another year and a half. The Minister is referring only to the second half of the waiting list — to those people who have been approved for treatment and who are awaiting it. Only last night a GP phoned me about Ardkeen Hospital. One of his patients, having waited a year to see the ENT consultant, was told it will be a further year and a half before the operation can be carried out. All the waiting lists can be doubled because of the numbers waiting to see consultants at out-patient clinics.

My information from the Eye and Ear Hospital is that pensioners are going clinically blind while waiting for cataract operations. The timing of these operations is vital but these people cannot [690] get the treatment they need. There is a variation in the waiting lists for hip operations within counties in the health board areas. Within the South-Eastern Health Board patients from County Wexford have to wait longer than patients from County Waterford or County Tipperary, because there is more demand on certain consultants. A four year waiting list is still a reality for people hobbling around in excruciating pain with the support of walking aids and rollaters and who cannot sleep at night because the hip operations are not available to them. This is the reality of the situation. The other day an ENT consultant contacted me about a referral he had made for a cancer patient to St. Luke's and St. Anne's for radium therapy treatment. The delay for people who have no accommodation in Dublin and have to stay overnight in hospital is four to six weeks. Any oncology expert will tell you that that period can be critical to the survival of the patient. I was through that hospital very recently and it was harrowing to go through a 36 bed ward and see nothing but bare mattresses. The way to get the waiting list down is by opening these wards and not by picking holes in statistics in the House tonight.

What the Minister is doing and will do in the 1990 Estimate is to provide more money without ensuring that more people will be treated. There is no limit to the money the health services can swallow up. Earlier today we were told that the country's largest hospital sent home cancer and other patients because the very thing I feared when changes were made in the accident and emergency admissions, that there would not be an adequate bed requirement, has come to pass. People will be shuffled out of day beds and elective beds to make way for accident and emergency patients. The Minister had not thought out the accident and emergency service and thus made adequate bed provision. In the six hospitals where the new procedures have been introduced the situation has got worse instead of better. Catchment areas for each hospital were not put in place. The same tests are being done in different [691] hospitals on the same patient. More senior doctors need to be put in place in casualty and accident and emergency departments.

The Minister referred to the cost of drugs. Drugs are costing us £200 million a year between hospital drugs, the drug refund scheme and the GMS drug scheme. I cannot understand why we persist with an argument that is linked to UK prices plus 4 per cent, when prices in the United Kingdom are some of the highest in Europe, when we import 95 per cent of our drugs and when a stipulation of the agreement is that we cannot have any system that insists on using generic drugs. A generic drug is not a thrift or yellow pack drug. It is produced under licence, under the approval of the National Drugs Advisory Board to produce not a similar drug but the identical medical compound that cannot be superior or inferior to the branded product. It is the very same item at a fraction of the cost. We are told there is no money for the dental service and there is no money for adult mentally handicapped services. Why are we persisting with an agreement that is costing £20 million too much? The health commission report clearly outlines and puts down in black and white what needs to be done, but still we persist with this agreement. A 10 per cent saving on our drug bill amounts to £20 million. Such a sum of money could do much for our health services.

None of the major issues in the health services has been addressed. I will not labour on the dental service because we have gone over and over it during Private Members' time and Question Time in this House. There are 24,000 people waiting for the orthodontic service. Under the guidelines in operation two-thirds of those people will not be seen at all throughout their school life. There is no dental service for adult medical card holders, who are eligible under section 67 of the Health Act, 1970, and have a legal right to this service. There is no attempt to introduce a referral system as was there since 1979.

I have attended meetings with the aged [692] parents of adult mentally handicapped persons and they are in the most considerable anguish because they are unable to mind their 30 year and 40 year old mentally handicapped sons and daughters. They will have no one to mind them when their parents die and we need to provide adult residential places on a planned basis through the country. Their elderly parents go to the grave with the anxiety and misery of not knowing what will happen to their children, after giving a lifetime of care to them. Brothers and sisters and first cousins will not provide the same level of care for these people. We have no national plan to provide facilities for the mentally handicapped.

The Child Care Bill is before a special committee of this House, yet programme managers have not been put in place to establish referral centres or establish liaison with the school attendance officers and the juvenile justice system or to ensure that there are an adequate number of social workers to deal with the bare minimum legal requirements of access by parents to their children in foster or residential care.

The rate of increase in the number of patients contracting AIDS is doubling every seven months. No provision is being made for this catastrophe of epidemic proportions. According to the Department we have an AIDS epidemic and there is no plan forthcoming to deal with the special needs of AIDS patients in relation to their mobility, their loss of earnings, heating allowances, not to speak of providing a long-term illness card as they deteriorate. These are pressing health problems.

A very fine report was produced by a working group on the care of the elderly. It clearly outlined the need to build up services to cater for the 7 per cent increase in the elderly population between now and the turn of the century to ensure that they have sheltered housing and that they have proper access to all the facilities, such as meals on wheels, a central location to churches and proper security systems. All it would need is a [693] little bit of planning with the local authorities to put it together. Nothing is happening on the ground and in a few years we will have a crisis in geriatric care. At present subventions to nursing homes are paid on a stop-go basis, and it varies from one health board to another whether a subvention is paid or not.

This is a very confined and limited debate and it is not possible for me to go through each and every one of the complaints we have received. We have seen that this Government and the previous Government have the ability to set up commissions, committees, be they ad hoc, working party or consultative bodies. We wait patiently for their reports and when our hopes are raised by good reports we find there is no response to them.

Acting Chairman (Mr. Jacob): The Deputy has less than three minutes remaining.

Mr. Yates: We cannot go on in this way. More money is necessary — it annoys me that more money is going to provide more of the same and not improve the health services. No attempt has been made to get proper accountability in our health services. No attempt has been made to implement the decisions of the Committee on Health Funding. The health boards, and the fact that some hospitals are funded directly by the Department of Health while others are funded through health boards, are not the most efficient system. We have scores of voluntary organisations all operating in a different way. I do not believe the Department of Health are capable of dealing with the different aspects of delivery of the health care system that are necessary. We need major structural reform because the nature of medical technology is that the same service will cost more. It will cost more to provide the same health service because of the demographic structure of our population.

There are real limitations to what we can spend on health. It is not enough [694] for the Minister to mark time. It is not enough to have a fire brigade response to deal with services on an ad hoc basis, to put out the bush fire of hip replacements thus causing problems on the elective orthopaedic waiting lists. Orthopaedic surgeons have told me that they were interviewed by Department of Health personnel looking for a breakdown and details not of their management of overall trauma cases but just on hip replacement operations. One cannot pick out one segment and just deal with it. We have no hospital plan. We have no basis on which to allocate national or regional specialities, let alone speak about enforcing catchment areas. We cannot defer the major decisions that have to be taken on the health services. This side of the House will co-operate if those issues are confronted. This together with skillful spending of resources is the way to deal with the problems of patients.

The reason we are voting against this Supplementary Estimate tonight is that this is not a cash boost to the health service. It is a sham. It is a shoring up of a very faulty 1989 Estimate.

Mr. Howlin: For three years, through three budgets and three Estimates I have striven to the best of my ability to underscore to the Minister during two administrations the crisis that he has brought about week in and week out at every level in the health services. For three years the same Minister said it was not about resources; it was not about money but about management and organisation, about anything but the things for which he had responsibility. Repeatedly for those three years we were assured that adequate money was being provided and that if it could only be managed properly at board level or hospital level, if we had better administrators, all would be well.

It has taken a general election to bring about a partial conversion. We now have Fine Gael on our side. It has dawned on them that it was not about shifting around or sacking a few administrators, which was for a while the tonic they had peddled, but that it was about funding a proper health service that a civilised [695] society demands at the closing of the 20th century. Hype has been created by the Minister in recent days or by those who surround him that suddenly the crisis has been recognised. The Taoiseach looked into his heart on a radio programme during the election campaign; nobody had told him about the crisis. Obviously the discussions at the Cabinet table had never focused on the calamity that was facing the health services, but when the Fianna Fáil Party had started knocking on doors the Taoiseach had become aware of it and when he was returned to power he was going to do something about it.

What has he done about it? Have the waiting lists been reduced since he came back to office and since this Minister was reappointed? Has he taken charge to structurally change the health services? Has he provided extra money? When we are talking about money on the scale of well over £1 billion, it is easy to lose sight of fundamentals. I have sought consistently to focus on the fundamentals so that we know what we are talking about and can do some comparative analysis. That is why, when the Minister introduced the Estimate in July, the Minister who had presided over the sacking of 5,000 health workers and the closure of 4,000 beds, I wanted to focus in on what we were spending in relation to our wealth and in relation to other civilised countries.

I want to re-focus the Minister's thoughts on that now because of the much maligned former Minister, Mr. Barry Desmond on whom the Minister wants to reflect on any occasion his name is mentioned here. Let me remind the Minister that in the last year that Mr. Desmond had responsibility for the health services he expended more than £1 billion. That was the outturn for 1986. It is interesting, if we add the Estimate that was approved earlier this year — £1.144 billion — and the Supplementary Estimate of £32 million which is before us tonight, to find that the figure would be very close to the 1986 figure. But, we must ask what has happened in the matter [696] of inflation in the last three years. We are still expending at the rate at which Mr. Desmond spent three years ago and yet week in week out when the present Minister was spokesman on this side of House he berated that Minister and attacked him consistently for not spending enough money. Now we are back, after years of cajoling and after forcing the Minister to realise in the general election the extent of the problems in the health service, approaching a level of funding that was spent three years ago, with no account being taken of inflation, increased costs or increased technology in the intervening years.

The only true picture, I have said consistently, of our expenditure is the proportion of money we spend on health in relation to our wealth. In each of the years since 1985 the proportion of our national wealth that we were prepared to spend on health care has declined dramatically. We spent £7 out of every £100 on our national health services in 1985. Barry Desmond maintained that at 7 per cent of GNP for the four years he was Minister for Health. The figure declined to 6.3 per cent in 1988. The end net result of the Estimate plus the Supplementary Estimate will mean we will expend on health care about £5.90 per £100 of our national wealth. We are decreasing the proportion of our national wealth that we devote to the health services year in year out despite the fact that our dependency ratios are increasing all the time as we live longer while, at the same time, unfortunately, so many of our young people — 46,000 in the last 12 months — are forced out of the country.

The number of people who are fit and able to work is fewer in relation to the number who are dependent on health services. There is a greater demand all the time on our health services and yet this Minister and this administration are consistently reducing the proportion of our national wealth that we spend on health care. We are now in the invidious position that, as a proportion of GNP, we are one of the worst countries in the EC and will be compared not to the Germans, the French or the British but rather [697] to the Portuguese and the Greeks, on the lowest level of health expenditure.

I have said consistently that there is a consensus in this country that health care is important. In the latest submission the Minister will have on his desk from The Conference of Major Religious Superiors, Must the Poor Always Wait? they have some scathing things to say about the health services. I would like to quote these references because these people cannot be accused of being politically motivated or biased. On page 38 of their report they say:

Long waiting lists in public hospitals have become a fact of life for many poor people. The length of aftercare has shortened dramatically resulting in much hardship for the patient and his/her family ...

This is the reality that is accepted by any objective person looking at our health services. The consensus to provide an adequate health service is noted by the Justice Commission and by the report of the Commission on Health Funding which stated clearly that there is a consensus in the country to expend money on health services. Therefore why are we doing this patchwork job of putting sticking plaster on major issues?

Let us look in detail at the Estimate the Minister has brought with such hooha before us tonight. The Minister's speech was much more subdued than some of the media comment his Department and his party colleagues have generated in recent days. What is he spending money on? He is reannouncing the £15 million for improved acute hospital services — I think this is about the third time that has surfaced but at least we are passing it here. He is spending £25 million on the additional cash requirements for the GMS. That is money that has been already spent and that was not properly budgeted for.

Dr. O'Hanlon: That is what the Supplementary Estimate is for.

[698] Mr. Howlin: I remember the Government Whip saying to me that there would be no Supplementary Estimates introduced by this administration — “we do not overshoot; we do not get our figures wrong” — but quite clearly the Minister got his figures wrong. He did not provide adequate money although we told him that at the time. He is coming back here now and making a virtue out of necessity. He is implying that he is going to do great things with the £31 million he is injecting into the health service when most of it has been spent already——

Dr. O'Hanlon: We did not sweep it under the carpet like your Government did.

Mr. Howlin: ——on the hype he has created, in expecting the poor unfortunate people who are looking to the Minister——

Dr. O'Hanlon: Your Government swept £55 million under the carpet.

Mr. Yates: That is because Fianna Fáil controlled——

Dr. O'Hanlon: And you were along with them in Government.

Mr. Yates: Fianna Fáil controlled the health boards.

Mr. Howlin: These people are looking to the Taoiseach to live up to the promises he made to them during the election campaign, that the realisation had dawned upon him and that he was going to go back to the Government and solve the health crisis that he belatedly and finally acknowledged existed. What is he doing? The answer is nothing. The Minister has a responsibility to tell the people tonight that he is not going to solve the problems facing the health service because he is not committed to doing so. This Government are not going to provide the necessary resources to enable the problems facing the health service to be solved.

Once again it has been announced — this must be the sixth time this has been [699] announced — that £300,000 will be made available to the orthodontic service to enable 500 priority cases to be dealt with. During Question Time today it was pointed out there was a backlog of 24,000 cases. The Minister did not contradict this figure. All he said was he did not have the figures. Is that his response to the children who require orthodontic treatment?

Deputy Yates referred to our mental handicap services in which I have a particular interest and which I think have been sadly neglected. In this House on 20 July last I spoke about our mental handicap service and the need to provide residential places for mentally handicapped people. According to the estimate prepared by the Eastern Health Board 1,645 new residential places for mentally handicapped people will be needed by 1991. What is the Minister doing to ensure that those 1,645 new residential places for mentally handicapped people as identified by the Eastern Health Board will be provided? Residential places are required where the severity of the condition is such that the person is incapable of being cared for at home or where carers or parents are ill or aging. I made that appeal last July but to date it has fallen on deaf ears. No provision for this service has been made in the Supplementary Estimate before us.

AIDS was also referred to. During the life of the previous administration the Minister set up 22 committees one of which was chaired by the former Minister of State at the Department of Health, Deputy Leyden. However, we have not seen that report. I put down a parliamentary question to find out when that report would be published so that we would know the Government's strategy. In reply the Minister indicated that it was a private report and he had no intention of publishing it; it was for his own information. It is likely that it highlighted inaction on the part of the Government on this very serious problem. He undermined and demeaned the work done by Deputy Leyden and insulted this House by making excuses month after month [700] before finally deciding that he was not going to publish it, that it was for his private bedtime reading.

Since assuming the office of Minister for Health, he has presided over the destruction of the health service. There is one other disquieting statistic I would like to give before I conclude, which was drawn to my attention this evening, and perhaps the Minister will comment upon it. The infant mortality rate, as outlined in the journal of the Central Statistics Office, has increased from 7.4 per 1,000 live births in 1988 to 9.2 per 1,000 live births this year. With the exception of one little blip——

Mr. N. Treacy: This year is not over.

Mr. Howlin: I am quoting from the report published by the Central Statistics Office.

Mr. Yates: It is going to be worse.

Mr. Howlin: It will probably be worse.

Mr. N. Treacy: There is no point taking it out of context.

Mr. Howlin: I will let the Minister have a copy of this report. With the exception of the blip between 1983 and 1984 when there was a very insignificant increase of 0.3 per 1,000 live births, this is the only significant increase in 17 years. I wonder if this is related to the policies being pursued by the Minister and the Government?

This Supplementary Estimate amounts to another PR job by a Minister who cannot obtain Cabinet agreement to provide a health service the people agree must be provided for those who cannot pay. The Minister should not go down in history as the man who destroyed the health service, who made private medicine and who abandoned the poor and those without resources to fend for themselves or simply to die.

Mr. Sherlock: Normally one would welcome any Supplementary Estimate [701] but it is doubtful whether one can welcome this Supplementary Estimate. Because the services have been hit so badly during the past three years the question now is: how much would it take to bring them back to the 1985-86 level? We have been told that our general hospitals are very costly to run. I should mention at this juncture that we in the north Cork area are pleased that our acute general hospital is being retained. However, were it not for a judicial review in the High Court we would not have this general hospital.

Are funds being provided in this Supplementary Estimate to develop out-patient services? It is deplorable that very ill people are required to attend at out-patient clinics and have to queue for long periods. Indeed, many people who are required to attend at outpatient clinics cannot afford to do so. I believe this accounts for some of the numbers on the Minister's records who have not attended. I would like the community welfare officers to carry out a survey to find out the number of people who have appointments to attend these clinics but cannot afford to do so. I am aware that some people find themselves in this position.

As I said, our acute general hospitals are costly to run. As we can see it is not the nursing profession who have created this situation, and the stress and stain to which they are subject have been referred to. The Minister referred to the GMS contract which we in The Workers' Party have been calling for for a number of years. I fail to see why the Minister could not bring in the new contract or capitation system and why in excess of £25 million is being spent on the GMS at present.

I would now like to refer to the prescribing and dispensing of drugs. Drugs and medical supplies account for a very high percentage of health expenditure. When we are going to have a national drugs formulary? When will we put an end to the drug companies creaming off health funding? As a result of the investigation carried out by the health board of which I am a member, some very interesting facts have emerged. I hope the [702] Minister will take these into account when considering whether to establish a national drugs formulary.

In relation to dental, ophthalmic and aural services to be provided under the Health Act, it must be stated very clearly that these services are being provided on an ad hoc basis and it was never intended that these services would be provided in such a way. There is a statutory obligation to provide those services.

We also welcome the review of the common contract for consultants. There ought to be a big saving arising out of this. It is a scandal that in 1988, in a country where there are almost 250,000 people unemployed, some consultants were paid £40,000 by the health boards under the common contract and they were treating patients in their private clinics because there were no funds available to treat them within the public hospital system. This must not continue and the common contract must be reviewed as quickly as possible to eliminate the scandal. Such very generous terms must never again be given to the consultants. I hope this Minister is the man who will take on the monolith of the medical profession who seem to do whatever they like. The child health examinations of course are of immense importance and the service has been curtailed greatly in the last three or four years.

The system of determining full eligibility under the health services means that the community welfare officers who should be in the front line advising and helping people seem to take great pride and satisfaction in refusing people who are marginally over the limit for full eligibility. People find that tax or PRSI is not deductible in determining eligibility, as eligibility is based on gross income without any consideration for the circumstances of a family who may be marginally over the limit. There are many people who will go to the chemist but not to the doctor because they cannot afford to pay. That situation must end. The question is, will this Supplementary Estimate help? I say it will not.

Earlier today I referred to community [703] care in the health services. I want to see community care being developed and community welfare officers treating people with respect and dignity. They have not been doing that and in many cases, they have taken pride in refusing people because they believed that that was the thing to do while cuts were being made in the finances being provided for health.

Acting Chairman: I now call on the Minister of State at the Department of Health.

Mr. Sherlock: Did I not say that I was sharing my time with Deputy Rabbitte?

Mr. N. Treacy: You did not mention it earlier on Deputy.

Mr. Sherlock: I omitted that point. I overlooked mentioning it.

Acting Chairman: Is that all right by the House? Agreed.

Mr. Rabbitte: I will be very brief. I agree with the Minister when he pays tribute to the calibre and dedication of the staff who maintained our health services in difficult circumstances in recent years. When contributing to the debate last July I expressed the hope that the Minister would put energy into undoing the damage done to the health services in his first term of office. I would like to think that this Supplementary Estimate and the publication of the Book of Estimates which we have seen this evening is making a start in that direction. How significant a start that is can only be measured against the profile of suffering, frustration and queueing that exists in the community. Listening to my colleagues, Deputies Sherlock, Howlin and Yates, I find that there is a large measure of agreement at least on this side of the House about what needs to be done.

Seeing that we are here to debate a supplementary estimate in excess of £31 [704] million, whatever about it being to provide for an overspending, I am amazed at the reaction of Fine Gael when they say that they will vote against this Estimate, and expect us to believe that this is a normal situation. Time after time, in different capacities I have been told by Fine Gael, including their present spokesman, that there was nothing wrong with the allocation made to health and that all we needed was a more skilful allocation of resources within that budget and a more skilful managerial service at hospital level. It really takes the patrician arrogance of Deputy Yates to come into this House, having told the people for the last three years that plenty of money had been provided in the Estimate if it were only managed properly——

Mr. Yates: That is not true.

Mr. Rabbitte: ——and now that there is additional money being provided to say that they will vote against it.

Mr. Yates: The Deputy is well aware of our position during the election: we promised £60 million.

Mr. Rabbitte: During the election, yes. It does nothing for the health service or for politics that a major party released from the obligations they told us so patriotically were their responsibility from 1987 to earlier this year, come along now asking us to accept this volte face as if it were the natural order of things. I am really upset at that kind of decision.

Mr. Yates: You are very sensitive.

Mr. Rabbitte: It does nothing for politics or for the health service. The difficulty confronting the health service is about the things to which Deputy Yates referred, but it is also about funding. A myth has grown up that we are spending too much on health, that we cannot afford it and so on. We are spending 6.3 per cent of GNP on health whereas the average for OECD countries is 8 per cent. We argued before the General Election that it would take an injection [705] of £80 million to tackle the extent of the queues and to provide a free GP service.

Acting Chairman: The Deputy has three minutes.

Mr. Rabbitte: That would bring spending on health to about 7.3 per cent of GNP. Deputy Howlin outlined that taking the Supplementary Estimate together with what we already have, the allocation for 1989 is 5.9 per cent of GNP. Having regard to the demographic structure of this country, which is unique in western Europe, that money is not sufficient and the allocation tonight does not make it sufficient. Even if it was an adequate cash injecton, a cash injection alone cannot tackle the structural problems that are inherent in the health services. I agree with the other Deputies when they say that this Minister has done more to reverse the concept of a comprehensive health service in little over two years than has been done since the sixties. This has a lot to do with the Minister's explanation of his own waiting list figures, where he talks about the Temple Street experiment and what happened in the Midland Health Board. The reason for those “no shows” is that in many cases people cannot afford it. I know that to be a fact. Also, many have been forced to go private because that is the only way of being assured of speedy access to the kind of care that is necessary. That has been the cause of the acceleration of the two-tier health service under the present Minister.

I dealt at another time with the necessity to recast the common contract and to reform the VHI, two steps necessary to achieve social equity in the health service. I will not repeat that now because I do not have the time; but there is an opportunity now under the Gleeson review to tackle the common contract so that a major step forward is made whereby more consultants can be appointed though not necessarily at additional cost to the Exchequer because that can be funded at least in part by a reduction in the number of non-consultant hospital doctors, thus giving those [706] frustrated junior hospital doctors a reasonable prospect of career potential that they do not have at present.

Minister of State at the Department of Health (Mr. N. Treacy): I hope to share my time with Deputies Quill and O'Connell. I rise to support this Supplementary Estimate and to pay tribute to my colleague, the Minister for Health, on being able to get Cabinet consensus to provide almost £33 million extra for the health services this year. That is a mammoth achievement.

The past year has seen a number of significant developments in the health services. These include the approval by Government in July of additional funding of £15 million to address specific difficulties which had arisen in the acute hospital sector. Other developments saw a radical overhaul of the general medical services, a new system of financial support for those on long-term and expensive medication and in more recent weeks the publication of the report of the Commission on Health Funding.

For example, the accident and emergency services in Dublin have in recent months undergone a complete transformation with a return to sectoral organisation of these services. The additional provision, which will continue into 1990, has made a major improvement in the general hospitals in Dublin.

The operation of the general medical services has also seen major changes with the introduction from April last of the new contract for the vast majority of GMS doctors. The new general medical services scheme is the most far reaching and radical change in the operation of the community care service since the choice of doctor scheme came into operation in 1972 and will have a major beneficial effect on patient care.

As the Minister has indicated already the coming year will also see a revision of the operation of the drugs schemes so as to reduce the burden which is being carried by persons with a regular ongoing and continuous requirement for prescription medication for the treatment of long term conditions.

[707] The recent publication of the report of the Commission on Health Funding will I hope generate considered and informed debate among health professionals and the public generally. The report merits detailed examination and discussion touching as it does on the major issues facing the health services.

The report's publication underlines just how crucial the next year will be for the services as the commission's findings are discussed. I would like to move on now to a number of other important developments.

In the short time since taking up duty as Minister of State at the Department of Health I have become aware of the need to achieve a more balanced pattern of care within our health and social services. Over the years we have perhaps, tended to devote a disproportionate share of our limited resources to the high profile, high technology areas. We have tended to overlook those areas of our social services which do not attract highly vocal pressure groups but which nevertheless represent areas of very real need within our society. One such area is our child care service.

Health boards can often have a most difficult task in ensuring the promotion of the welfare of a child in an individual case. There is no simple division between the rights of parents and the rights of children.

A parent's right to the custody of a child is matched by a child's right to the company and protection of a parent. Improper interference with one means improper interference with the other.

There are occasions when the welfare of a child can only be protected by placing the child in the care of a health board, suspending rights which the parents and the child normally have in relation to each other.

It must be recognised, therefore, that a consideration of the welfare of a child must take into account the totality of rights existing between the parents and the child.

The Government's amendment to the Child Care Bill requires health boards, having taken all these factors into [708] account, to regard the welfare of the child as the first and paramount consideration.

The Bill gives power to the health boards to deliver child and family care support services in order to aid parents and prevent the placement of children into care.

I am confident that the innovative use of this power by the health boards will result in an accelerated development and expansion of community based services and facilities geared specifically to the needs of children and families.

These services will include more intensive social work support for families at risk; new counselling and advice services; home help and home-maker services; child guidance services; day fostering; family resource centres and special projects for the young homeless and other “at risk” groups.

I am also very conscious that legislative reforms must also be accompanied by the allocation of the necessary resources in terms of manpower and facilities. During the last year the Government, therefore, set aside a special sum of £4 million from the national lottery surplus available to the Minister for Education to fund a range of new services throughout the country specifically targeted at disadvantaged young people.

Among the projects being funded through the health boards are a number of developments geared for groups particularly at risk such as the young homeless, young travellers and young substance abusers. Another area which has received priority attention from the Government was the need to improve our present services for abused children. I was particularly pleased that the Government were able to allocate the necessary funds to enable new units to be established at Temple Street and Crumlin Children's Hospitals for the full multi-disciplinary assessment of alleged cases of child sexual abuse. In addition, a special sum of £500,000 from the national lottery surplus to enable similar type services to be developed in the seven health board regions outside of Dublin was made available.

The Government are fully committed [709] to ensuring that the appropriate level of further additional resources is allocated to the health boards so that the child care Bill when enacted by the Oireachtas can be implemented, in an orderly and effective manner, for the benefit of those in greatest need. The Bill has now gone to an all-party Dáil committee, which will meet on Tuesday next, 21 November, for the first time.

I look forward to working with that committee in eventually producing an excellent Bill.

The report of the working party on services for the elderly, The Years Ahead — A Policy for the Elderly, is a comprehensive review of policy and of services for the elderly which takes account of the medical and social development of recent years and the implications of future demographic trends for the provision of services.

It points to the need for a coherent and co-ordinated approach by all those involved in helping the elderly.

I feel strongly that we must ensure that elderly people receive the service they need at the appropriate time so that no elderly person is admitted to institutional care unnecessarily. As far as possible we must try to anticipate the needs of our expanding elderly population and develop the kind of services we would like to see in existence when we grow old. The emphasis must continue to be placed on community care.

We should endeavour to ensure that the elderly can lead active and fulfilling lives in their old age and live in the environment of their choice — their home. The report indicates the direction that must be taken and it indicates where resources should be invested in order to achieve its objectives. The Government have accepted, in principle, the recommendations of the report.

This House will be aware that the programme to provide immunisation against measles, mumps and rubella is currently in progress. The third phase of the publicity campaign associated with the programme has now been launched. To date, the uptake of the vaccine is in excess of 70 per cent, so that I am optimistic of [710] achieving the target coverage of 90 per cent by March 1990 among children 18 to 24 months.

I would take this opportunity to appeal to parents to ensure that their children receive this important vaccine which is safe and free and available from family doctors.

I have no doubt that, with the continued support of medical and health board staff, the professional bodies involved and the co-operation of parents, will achieve the targets we have set ourselves and eventually see the elimination of the diseases from our country.

The Control of Clinical Trials Act, 1987 came into force in December last year. As you will be aware this Act has as its objectives: to facilitate clinical research, and to protect those participating as volunteers in clinical trials.

Since coming into operation, certain difficulties have come to light which have impeded the effective implementation of the Act as a whole.

A small working party representative of those involved in clinical research and my Department was established to consider the issues and to make recommendations in relation to ways of overcoming the problems. The recommendations contained in the report of the working party have now been considered and necessary amending legislation is in the course of drafting. The Minister hopes to be in a position to introduce that amending legislation at an early date.

In July, last an expert advisory committee was set up to advise both the Minister for Health and the Minister for Agriculture on matters relating to food and to make recommendations as appropriate.

The Food Safety Advisory Committee are under the chairmanship of Dr. Fergus Hill, the regional public analyst attached to the Eastern Health Board and its membership represents a broad range of technical expertise in areas such as medicine, veterinary medicine, toxicology, microbiology, food science and food hygiene. The committee have the capability to deal effectively with the wide variety of issues on which they will be called on for [711] advice. The main subject areas which the committee will address are microbiology and food hygiene, food additives and contaminants, food irradiation, radiation contamination of foods and food legislation.

There is undoubtedly an increased public awareness of food hygiene and of all food-related matters such as the use of additives in food and food-borne illnesses. Unfortunately, comment on these important matters can sometimes be ill-informed. The food safety advisory committee will ensure that we have the benefit of expert consideration and proper advice on these matters.

This Government continue to be committed to the improvement of services for people with a mental handicap. However, some areas of weakness in the service still require to be tackled. Basic services are still inadequate in some regions. A better distribution of resources in line with local service needs is required. To facilitate this objective regional co-ordinating committees are now operating in most health board areas. Each of the committees include representatives of the health board, voluntary agencies and the Department of Health. These committees are in the process of formulating a plan for the development of services for each region and to co-ordinate the provision of services. I look forward to further progress in this area.

Progress continues to be made in developing a community-based psychiatric service as outlined in the report Planning for the Future.

There has been a considerable expansion of community based facilities such as day hospitals, day centres, hostels and community residences. At the end of 1988 there were 47 day centres and 32 day hospitals catering for some 7,500 attenders. There were also 272 hostels and community residences in existence with 1,823 places. The number of in-patients in psychiatric hospitals continues to fall and there are now about 9,000 patients in our hospitals as compared with [712] 20,000 in 1958, a reduction of some 11,000 inpatients over the last 30 years.

In the past considerable efforts have been made at developing specific care programmes for the elderly and the mentally handicapped in psychiatric hospitals which are more appropriate to the needs of these categories of patients.

In order to supplement the anti-smoking education and information programmes currently being conducted environmental controls over smoking in a variety of public places are now being put in place. The regulations are being made under the Tobacco (Health Promotion and Protection) Act, 1988, and will apply to such places as public service buildings, hospitals, health centres, cinemas and schools. The Department have completed a wide ranging consultation process and are currently considering a number of practical issues which have arisen before finalising the regulations. It has become more and more noticeable that there is considerable support among the public, both smokers and non-smokers alike, for environmental controls over smoking, which will create an environment designed to prevent young persons in particular from starting to smoke and will encourage and assist smokers to quit.

In conjunction with the National Youth Council, the Department's health promotion unit are developing a drink awareness for youth programme which aims to equip young people with the information and skills to make responsible decisions in relation to alcohol use.

Among the many activities taking place this year in the context of European Year of Information on Cancer is a training programme for teachers on the topic, being run jointly by the health promotion unit and the Irish Cancer Society. Earlier in the year a major new anti-smoking campaign got under way with special elements targeted at young people. I would like to pay a special and deserved tribute to the many and enthusiastic organisations like the Irish Cancer Society and many others for their enthusiastic commitment to their various fields of interest. They broaden the public [713] interest in various health and other matters and make an immense contribution to many people around the country. The reviews of the health services which the Minister for Health and I have given in the House this evening demonstrate the need for a fresh examination of the operation of the services to ensure that they continue to be delivered in the most efficient and equitable way. In particular the recommendations of the Commission on health funding cover a whole spectrum of policy issues arising in the services. The consultation process on the report which the Minister has now embarked upon will add to an informed discussion on the major questions to be addressed. I think it is true to say that the process of review and consequential decision making will be the most fundamental since the passing and implementation of the Health Act almost 20 years ago. In my view the health services are well equipped to meet the challenges facing us in the period ahead.

Acting Chairman (Mr. Jacob): The Minister indicated he would like to share his time with Deputy Quill and Deputy John O'Connell. I do not know how practical that is. There is one minute left. Have I the agreement of the House? Agreed.

Mr. Doyle: The Minister was not too generous.

Mrs. Fennell: It is a queer old gallop.

Miss. Quill: I thank the Minister for sharing his time with me and I congratulate the Minister for Health for bringing in a Supplementary Estimate of this magnitude. An injection of £32.9 million into the health services at this stage of the year demonstrates clearly a strong commitment on the part of this Government to bring to bear an improved and more comprehensive health service. We are seeing here this evening a section of the joint programme for Government as worked out by the Progressive Democrats and Fianna Fáil being put in place. Already £15 million [714] has been spent on improvement of the health services and that is beginning to bring about improvements on the ground. We all can be pleased with that.

However, there is a great deal of ground to be made up and I will make three points as briefly as I can. First, still far too much money is being spent on the administration of the health services. I urge the Minister to use all his energy in the years ahead to try to scale down on the amount of money spent on the administration of the health services and put that money to patient care where it is badly needed.

Also I am disappointed to see we have to introduce a Supplementary Estimate of this size to service the revised GMS scheme. I was given the clear impression when that scheme was introduced that a saving would occur. That has not occured this year, and I hope the Minister will take every step open to him to ensure that it will be brought about next year and in subsequent years. That money is badly needed and I know the Minister will work towards that. Finally——

Acting Chairman: I must ask the Deputy to be very brief.

Miss Quill: I understand and I am grateful for the time I have been given. I want to ask the Minister to work towards putting in place some proper pricing mechanism for drugs. It is ludicrous that with inflation running in England as it is at the moment we have a 10 per cent differential between prices of drugs in England and prices of drugs here. It makes no economic sense.

I congratulate the Minister on having brought in this Supplementary Estimate this evening and I support it strongly.

Dr. Lee: I thank you, Sir, for giving me the opportunity of speaking and I am going to share five or ten minutes with Deputy Fennell.

Acting Chairman: Can we have the agreement of the House for Deputy Lee [715] to share his time with Deputy Fennell? Agreed.

Dr. Lee: The moving of this Supplementary Estimate today has confirmed my deep rooted fears and suspicions that in the past few years under the harshest administration this country has ever known we are rapidly approaching and developing a two-tiered health system, one for the rich and affluent and one for the poor and downtrodden where people who, because of economic circumstances and, I emphasise, by no choice of their own, are neglected and relegated to the status of second class citizens, a country where public neo-natal services are virtually abolished. We have had proof from the Labour spokesman this evening that the peri-natal mortality rate has risen in the last years, unheard of in a civilized country especially at present. We have a country where school health services are grossly understaffed and under utilised. Surely, prevention and early detection of illnesses, as the Minister knows as a general practitioner, should be the aim of a caring and efficient health service, but the Minister and his advisers obviously do not think so. Cutbacks in real terms exist in this modern day health service. The hospital system, despite what the Minister's hyped up PR machine says, is worse now than it was one year ago.

Six months ago approximately the Minister, and especially the Taoiseach, said on TV they did not realise there was a crisis in the health service. Recently Mr. Patrick O'Neill, a paediatric surgeon and neuro-surgeon, with unique talent, unique experience and experience in the surgical management of tumours of the very young has fired what was in reality an in-hospital political row. The Minister on the Adjournment last Wednesday night informed this House that there were surgeons fully trained with sufficient expertise, technique and know-how for the surgical management of these very young and unfortunate patients. I tell the Minister his statement is untrue. I have come into possession of a sworn affidavit [716] by a senior neuro-surgeon in Beaumont Hospital. He says that the non-appointment of a permanent post, that is of paediatric neuro-surgeon, will cause major difficulties for certain paediatric patients of the hospital, notably in congenital deformities of the head, face and spine and surgery of the brain and spinal cord in infants and very young children. Their particular needs cannot be fully met by him and he is unaware of experience over and above his in these fields on the part of his permanent consultant colleague.

I am also in possession of in-hospital documents outlining four cases which deem life saving operations as a matter of urgency. I am asking the Minister, what is going on in this hospital? Who are his advisers? As a matter of urgency, I ask him to have an investigative commission set up with wide ranging powers of evidence and to reinstate this man as a matter of urgency. In conclusion, may I further state that all these services are now available for people who can afford to pay for them in the Mater Private Hospital. This is a shocking condemnation of the Department.

Mrs. Fennell: It seems to me that we are as far away as ever from resolving the grave difficulties in the delivery of health care. There is a sequence of accusations and denials, distorted statistics and a gap between reality and the Minister's perception from his office. Earlier today at Question Time the Minister of State, in a derogatory tone, accused Deputy Yates of consulting with senior hospital consultants, hospital administrators, etc. as if this was something he should not have done. Far from criticising this procedure I suggest that both the Minister and the Minister of State take a leaf from Deputy Yates' book——

Mr. N. Treacy: I think the Deputy should read the record.

Mrs. Fennell: ——and ask these people for an honest appraisal. Then they might be more tuned in to the faults and [717] get the real truth about our health service.

Mr. Yates: One cannot get dentures in east Galway.

Mrs. Fennell: I regret that this debate tonight will reflect and articulate many of the criticisms and the difficulties that have been a feature of health debates here over the last two years. We have had a general election, caused directly by a health issue.

Mr. N. Treacy: Were you not lucky?

Mrs. Fennell: During the election campaign the difficulties being experienced by people dependent on public health were aired again and again and became the central issue. Few people, not even the Taoiseach, expected that health would dominate the campaign. In response to this debate commitments were given that an allocation of £30 million would be made. Why now, six months on, are we not feeling the positive effect of this funding? The case has been well stated tonight that the damage done to the health service is so great that an injection of £30 million is not enough to reverse it. There is very little easing of distress for a number of groups. This amount of money is only a drop in the ocean and a more generous and a more imaginative approach is needed. It is now a case of us having a paler shade of crisis.

I do not intend to deal with the broad spectrum of spending but to confine my remarks to a number of areas. What will be the level of spending on the health promotion unit this year? We cannot stress enough the need for health education, to create a public awareness about the power people have to remain healthy and to influence their general well being. Is the health promotion unit getting any increase in funding this year or will it remain at £750,000?

I was one of those who were very critical about the abolition of the Health Education Bureau and the subsuming of the bureau's role into the Department. This was a shortsighted move and was [718] surrounded with suspicion, a suspicion that has been well founded. The Health Education Bureau did a good job taking all areas of health education into account. It is only when we look at the poor performance of the health promotion unit in the last two years that we realise how effective it was. The health promotion unit operates with caution, without any muscle and is making little or no impact on the public consciousness with regard to health education. Never before was there a greater need for health information and education for all ages, on such issues as diet, smoking, drinking, life style and particularly AIDS. We need a new independent public health education forum.

I question what spending will be done to build up a comprehensive corps of public health nurses. In every report and policy document public health nurse and the need for a public health nursing team are dealt with, covering the need for child care, care of the aged, care of the handicapped and care of the terminally ill. We see proposals for a better and bigger public health nursing corps all the time. There is a fine tradition of public health nursing in Ireland and these services are in great need. Spending on this service would reap great dividends.

The report of the commission on health funding found that the present staffing levels are inadequate. The home nursing service was judged by the commission to be of key importance in developing alternatives to in-patient care. As the emphasis on the health service continues to put heavy reliance on communities to care for the old, the handicapped and those discharged early from hospital, it is vital that we regard as a fundamental need the development of our public health nursing service. The NESC report No. 84 which deals with community care services states:

The domiciliary development work of the public health nurse is particularly important in those rural areas which are outside the range of developmental and child welfare clinics; in these areas the public health nurse is the key [719] person in the community care service, in the detection of developmental delays and handicap during the pre-school period.

There is no doubt that the role of the public health nurse is vital. A good well trained and well funded service could provide important and cost effective community care in so far as nurses would have the confidence of and the information about families and would be in a position to identify problems at an early stage.

I hope funding will be provided in these areas and in many other areas too. We need to inject money into these services so that patients can afford to go back to hospitals. Nobody wants the gaunt grim vision Deputy Yates painted. We need to spend in many area of health and to look at the broad needs of health services in Ireland today.

Minister for Health (Dr. O'Hanlon): I would like to thank the Deputies who made a contribution. While I would not have time to go into detail on all the contributions I will try to deal with as many as I can in the time available. Deputy Fennell was concerned about my knowledge and that of the Minister of State and said we should talk to more managers and people who are involved on the front line. She need have no fears for either of us. We both keep in close contact with what is happening in the service. She also commented on the health promotion unit and said she is concerned about it. I would like to ask her, and indeed other Deputies, what efforts they have made to acquaint themselves with what is happening in the health promotion unit because the feedback I am getting suggests it is very successful, much more successful than the Health Education Bureau ever was. One of the reasons for this is that it has the Government clout behind it when it wants to do something. The clean watch campaign on food hygiene was a major success. The measles, mumps, rubella campaign was also a major success. The [720] anti-smoking programme, the AIDS education programme and now the drink awareness programme, which is being presented is quite an achievement, plus all the leaflets that are available, special stands——

Mr. Howlin: Where is the AIDS education programme?

Dr. O'Hanlon: The AIDS education programme is there. There is a pilot scheme in 12 schools. AIDS education is available to all second level pupils before they leave school.

I was particularly interested in what Deputy Lee had to say. He accused me of telling an untruth but started with telling one himself, claiming that the Taoiseach said he did not know there was a crisis in the health service. The Taoiseach said no such thing; he never mentioned a crisis in the health service. The crisis in the health service is in the imagination of people in Opposition. Then Deputy Lee went on to say I had told an untruth during the Adjournment Debate last Wednesday night.

(Interruptions.)

An Ceann Comhairle: There is a time limit to this debate.

Dr. O'Hanlon: Deputy Lee stated that I told an untruth in relation to a consultant in Beaumont Hospital and he gave as his reason that he had a sworn affidavit by a consultant to some effect in regard to the services in Beaumont. A sworn affidavit by a consultant does not mean that I was telling an untruth in this House. Other very good expert opinions are available to me. I stand over what I said on the Adjournment Debate and I will stand over it outside this House.

Mr. Carey: I gave a case to the Minister a full week ago but he has not replied.

Dr. Lee: I am surprised at a man of the Minister's experience.

Dr. O'Hanlon: Deputy Yates said he [721] could not see any sign of a better service. I do not know where he has been. He might not know that last Friday I opened a £40 million hospital with 300 beds and the finest facilities in the world for public patients. The coronary care unit in the Mater Hospital is without parallel in any private or public hospital.

(Interruptions.)

An Ceann Comhairle: I must insist that the Minister be heard without interruption in his concluding remarks. All I am seeking is fair play in the matter. If any Deputy persists I shall ask him to leave the House.

Mr. Farrelly: The Minister is inviting interruptions.

An Ceann Comhairle: Please desist.

Dr. O'Hanlon: New facilities have been opened at the Mater Hospital and at St. James's Hospital, where £10 million has been spent on X-ray equipment. Waiting time for major cardiac X-ray investigation has been reduced from four months to four weeks at St. James's Hospital. Six accident and emergency units have been opened in the city. Regarding waiting lists, I should like some facts from Members of the Opposition on individual patients.

(Interruptions.)

Mr. Farrelly: I can give half a dozen cases.

Dr. O'Hanlon: A Deputy told me that a patient waited two and a half years for an appointment but in fact the patient's name was put on the waiting list on 24 April 1989. I was able to tell him that in the House and he did not deny it.

Mr. Howlin: The Minister is able to rewrite the facts.

Dr. O'Hanlon: Deputy Yates talked about no catchment areas for the accident and emergency services. We do not want [722] catchment areas; we want to make sure there are vacant beds available, not like what happened at St. James's Hospital.

(Interruptions.)

Dr. O'Hanlon: He also stated that the cost of drugs was £200 million, whereas the actual cost was £140 million. One cannot dismiss the figure of £60 million. He asked why we should persist with the FICI agreement. It was brought in by the Labour-Fine Gael Coalition and expired in July this year. We notified the Federation of the Irish Chemical Industry that we were not renewing that agreement.

(Interruptions.)

Dr. O'Hanlon: Services for the mentally handicapped have been protected and there have been numerous developments. It was claimed that 1,600 places are necessary in the Eastern Health Board area. That is not true. They need 360 places.

Mr. Howlin: Is the Minister saying it is not true?

An Ceann Comhairle: Please desist, Deputy.

Dr. O'Hanlon: A total of 51 new hostels have been provided for the mentally handicapped and 71 new centres. Reference was made to subventions for the elderly. We dealt today with the increased number of bed days available to patients in the EHB area. Deputy Yates has told us many times to abolish the health boards. Fine Gael councillors around the country are passing resolutions at county council meetings to bring back the advisory health committees. They want some sort of devolved administration but then they tell us to do away with the health boards. They should get their act together.

Mr. Yates: The Minister does not know what he wants to do.

[723] Dr. O'Hanlon: Deputy Howlin praised Deputy Desmond for what he spent. We all know what he spent and the people of this country paid the penalty.

Mr. Howlin: He was savaged for four years.

Dr. O'Hanlon: I do not blame Deputy Desmond since he was a member of the Fine Gael-Labour Coalition. I blame both parties. There was overspending of over £55 million in two years and the unfortunate people had to pay the penalty, yet Deputy Howlin advocates following the good work done by Deputy Desmond.

(Interruptions.)

Dr. O'Hanlon: I am very proud to be a member of a Government who will say what the facts are.

An Ceann Comhairle: Deputy Howlin should have some sense of fair play.

Dr. O'Hanlon: We will stand over the facts on behalf of the taxpayers.

Mr. Carey: That is the standard required of every Minister. This Minister is no different.

Dr. O'Hanlon: Health care is important. That is why we have put money into the Mater Hospital and why we opened Beaumont as soon as we came into office. We have provided a modern, first-class service. Improvements have been made at St. James's Hospital and we will be opening a new accident and emergency service there before the end of the year.

Mr. Howlin: The Minister is in cloud cuckoo land.

Dr. O'Hanlon: Deputy Howlin made a virtue of the percentage of GNP Deputy Desmond spent on the health service. In 1986 the cost of the health service was £1,176 million. In 1989 it was £1,339 million and next year I am glad to say it will be over £1,400 million. We can stand [724] over it and we do not have to sweep £55 million under the carpet to deliver it.

Mr. Yates: The waiting lists are being swept under the carpet.

Dr. O'Hanlon: We will be spending 21.3 per cent——

An Ceann Comhairle: The shouting down of any Member in possession is a truly deplorable thing.

Mr. Rabbitte: I think we need a crèche facility.

Mr. Carey: The Minister heckled well when he was on this side of the House.

An Ceann Comhairle: Deputy Carey was allowed to make his speech without interruption. Members will be allowed to make their speeches without interruption, devoid of any disorder.

Mr. Lawlor: They do not like the medicine.

Dr. O'Hanlon: Deputy Sherlock raised a point about the common contract. The Government referred the question of the remuneration of medical consultants and their other terms and conditions to the Review Body on Higher Remuneration in the Public Service and any final decisions in relation to the contract will have to take account of their deliberations.

Deputies are aware that the accounts of the VHI for the year to the end of February 1989 have recently been published.

Mr. Yates: They are virtually bankrupt.

Dr. O'Hanlon: These accounts are now eight and a half months out of date. The recovery plan had an immediate impact. It was put into effect at the beginning of this year and there was an improvement of £2 million by the end of February. Indications in recent months are that the [725] plan is working well. The factors giving rise to losses have been corrected and the board can now begin their return to a secure financial position.

I thank Deputies who contributed to the debate. We will take on board the positive comments made. I would ask Deputies to recognise that we have a first-class health service which compares [726] favourably with any service in any developed country. The coronary care unit for public patients at the Mater Hospital compares with any similar unit anywhere in the world. I challenge any Deputy to say where there is a finer unit. That is an indication of the level of service we intend to provide.

Question put.

The Dáil divided: Tá, 66; Níl, 62.

Ahern, Bertie.

Ahern, Dermot.

Ahern, Michael.

Aylward, Liam.

Barrett, Michael.

Brady, Gerard.

Brady, Vincent.

Brennan, Mattie.

Brennan, Séamus.

Briscoe, Ben.

Browne, John (Wexford).

Burke, Raphael P.

Calleary, Seán.

Callely, Ivor.

Clohessy, Peadar.

Connolly, Ger.

Coughlan, Mary Theresa.

Cowen, Brian.

Cullimore, Séamus.

Daly, Brendan.

Davern, Noel.

Dempsey, Noel.

Dennehy, John.

de Valera, Síle.

Ellis, John.

Fahey, Frank.

Fitzgerald, Liam Joseph.

Fitzpatrick, Dermot.

Flood, Chris.

Gallagher, Pat the Cope.

Hilliard, Colm.

Hyland, Liam.

Jacob, Joe.

Kelly, Laurence.

Kenneally, Brendan.

Kitt, Michael P.

Kitt, Tom.

Lawlor, Liam.

Leonard, Jimmy.

Lyons, Denis.

Martin, Micheál.

McCreevy, Charlie.

McDaid, Jim.

McEllistrim, Tom.

Molloy, Robert.

Morley, P.J.

Nolan, M.J.

Noonan, Michael J.

(Limerick West).

O'Connell, John.

O'Dea, Willie.

O'Donoghue, John.

O'Hanlon, Rory.

O'Keeffe, Ned.

O'Kennedy, Michael.

O'Rourke, Mary.

O'Toole, Martin Joe.

Quill, Máirín.

Roche, Dick.

Smith, Michael.

Stafford, John.

Tracy, Noel.

Tunney, Jim.

Wallace, Mary.

Walsh, Joe.

Woods, Michael.

Níl

Ahearn, Therese.

Barnes, Monica.

Barrett, Seán.

Barry, Peter.

Bell, Michael.

Belton, Louis J.

Boylan, Andrew.

Bradford, Paul.

Bruton, John.

Bruton, Richard.

Byrne, Eric.

Carey, Donal.

Cotter, Bill.

Currie, Austin.

[727]Higgins, Jim.

Higgins, Michael D.

Hogan, Philip.

Howlin, Brendan.

Kavanagh, Liam.

Kenny, Enda.

Lee, Pat.

Lowry, Michael.

McCartan, Pat.

McCormack, Pádraic.

McGahon, Brendan.

McGinley, Dinny.

Mac Giolla, Tomás.

McGrath, Paul.

Mitchell, Jim.

Moynihan, Michael.

Nealon, Ted.

Deasy, Austin.

Deenihan, Jimmy.

Doyle, Joe.

Dukes, Alan.

Durkan, Bernard.

Farrelly, John V.

Fennell, Nuala.

Ferris, Michael.

Finnucane, Michael.

Flanagan, Charles.

Foxe, Tom.

Gilmore, Eamon.

Gregory, Tony.

Harte, Paddy.

[728]Noonan, Michael.

O'Shea, Brian.

O'Sullivan, Gerry.

O'Sullivan, Toddy.

Owen, Nora.

Pattison, Séamus.

Quinn, Ruairí.

Rabbitte, Pat.

Ryan, Seán.

Sheehan, Patrick J.

Sherlock, Joe.

Spring, Dick.

Stagg, Emmet.

Taylor, Mervyn.

Taylor-Quinn, Madeleine.

Timmins, Godfrey.

Yates, Ivan.

Tellers: Ta, Deputies V. Brady and Clohessy; Níl, Deputies J. Higgins and Howlin.

Question declared carried.