Friday, 20 June 1980
Dáil Eireann Debate
That a sum not exceeding £541,860,000 be granted to defray the charge which will come in course of payment duting the year ending on the 31st day of December, 1980 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 certain grants-in-aid.
I propose to combine the original Estimate and the Supplementary Estimate, which I will move later, for the purpose of explaining the financial provisions. The two Estimates combined provide a gross amount of £650,350,000 for non-capital requirements and £27,500,000 for capital purposes. The combined capital and non-capital provisions, totalling £677,850,000, are offset by appropriations-in-aid which are estimated at £42,800,000. The net provision sought between the two Estimates is thus £635,050,000.
The gross non-capital requirements amount to £650.35 million. This compares with a gross non-capital out-turn of the Health Vote of £498 million for 1979—an increase of 30.6 per cent. This increase of £152.35 million may be explained broadly as follows.
Increase in pay costs account for £124.8 million, that is, over four-fifths of the total increase. Budgetary increases in the rates of cash allowances account for £5.8 million, that is £1 million in respect of the extra three months cost in 1980 of the increases in rates approved as from  April 1979 and £4.8 million for the 1980 budget increases. The balance of £21.75 million is attributable to extra costs in 1980 arising from improvements and developments of services in 1979, including changes in entitlement to services as from 6 April, 1979, the commissioning of new units of accommodation in 1979 and 1980 and provision for price increases in 1980.
Appropriations-In-Aid are estimated to produce £42.8 million in 1980 as compared with £35.8 million for 1979. The increase of £7 million is due largely to extra income which is expected to be realised from the scheme of pay-related health contributions which was introduced from 6 April, 1979.
The Supplementary Estimate accounts for £93.19 million of the increase in Vote requirements between 1979 and 1980. A total of £88.39 million of this is needed to meet the cost of pay settlements for nurses and others. The balance of £4.8 million represents the estimated cost of adjustments in rates of cash allowances provided for in the 1980 budget.
As I have mentioned, increases in expenditure on pay for health services personnel account for £124.8 million of the increase in the non-capital Vote requirements between 1979 and 1980. Of this total, £36.4 million is due to the extra full year cost of pay increases approved in 1979, including pay adjustments associated with the national understanding. Recent pay awards for nurses will give rise to grant requirements of £76.3 million in 1980 and the balance of £12.1 million is required to fund health agencies in respect of the cost of pay awards for certain medical, para-medical, non-nursing and administrative grades.
The overall capital allocation for health services amounts to £28 million for 1980, of which £27.5 million is being provided under subhead K of the Health Vote. The capital allocation for 1979 was £27.5 million. I will refer later to some of the projects on which this money is being spent.
In a year in which the Government  have had to take many difficult decisions in relation to public expenditure generally it was inevitable that some financial constraints would have to be imposed in the health area giving rise in turn to difficulties for those involved directly in the provision of services. Health services are labour intensive and have been subjected for some time now to considerable demands for improvements in conditions of service for personnel. The figures which I have given show how big a proportion of the extra money we have this year will go to meet these demands.
The health services are there to meet needs which are of great importance to individuals and we are continuously under pressure in attempting from available resources not only to maintain existing levels of service, but also to make improvements to cover perceived gaps. They create new demands which can often be very expensive to meet. The phenomenon of rapidly increasing costs and the demands for increased levels of service is not peculiar to our country. It applies internationally and the resultant financial problems cause concern in countries with far greater resources than are at our command.
Despite the difficulties of the economic situation the Government have made available a reasonable share of overall Exchequer resources to finance health services in 1980. Before we take account of the large sum provided for in the Supplementary Estimate which I will move, about 20 per cent of the total non-capital Exchequer requirements are allocated to health. This compares with 18 per cent in 1975.
When account is taken of the very sizeable additional expenditure which has to be faced in 1980 to meet the cost of special pay claims, such as those provided for in the Supplementary Estimate which I will move, it will be appreciated that the Government have agreed to a commitment of a very sizeable share of national resources to meeting the cost of health services in 1980—indeed the greatest share that has  been provided in any year up to this point of time. This must be accepted as a positive demonstration by the Government of an acceptance of the need to provide the best possible services that can be provided from our national resources.
I would now like to turn to the services themselves and deal with a number of recent improvements and with policies for the future. I will commence by reflecting on some of the groups who require and deserve our special attention. First, the elderly. At present, there are over 350,000 people aged 65 and over living in this country. Some 13,000 elderly people are in long-stay care. That means that most of our older people are continuing to live in their normal environment.
My policy for the elderly is to encourage them and to help them to stay in their own homes and in their own communities, to help them remain healthy and independent, and to encourage them to use their talents for their own and other people's benefit. Voluntary organisations in association with the health boards play the vital role in the provisions of these services.
While much valuable work has been done and continues to be done, I am in no way complacent about the services for the elderly. There is still, in too many cases, too wide a difference between the quality of life of the elderly and those who are in the working population. Many people on retiring from work are not able to cope with the change and this affects their health. Many of our old suffer from isolation and loneliness and many do not use the services which are there to be used.
We need all the time to review the role of our elderly in the community as a whole. With the structure of families nowadays the traditional cherished position of the old person has been steadily eroded and I am afraid that we have not been very successful in coming up with alternatives ways to make sure that a person does not become stigmatised and written off purely because of the number of years he or she has spent in this  world. I would hope, therefore, not only to improve services where this is necessary but to bring about a somewhat different attitude to old people, both in their own perception of themselves and in the perception which others have of them.
During this year I will be establishing a National Council for the Aged. I hope that this body will not only draw together the many groups who are working with and for the aged but will help to put a new perspective on how we can help the elderly to cope with their problems and to take the opportunities which their leisure time affords them.
During this year also the Health Education Bureau will be publishing a booklet which will reinforce the positive aspects of ageing and give very useful advice to people on how best to maintain their health in their older years. This book emphasise that being old does not necessarily mean being dependent.
My Department and the Health boards are carrying out a review of the effectiveness of two services which have great significance for older people, that is home helps and meals-on-wheels. The objective of this review is to ensure that the service being provided is relevant and that it is done in a way which is both effective and acceptable.
Next year will be the International Year for Disabled Persons. There will no doubt be many opportunities over the next year-and-a-half to discuss this whole problem and I do not intend to dwell very long on it here today. However, I sincerely hope that through all of our efforts the process of accepting and integrating the handicapped person into our community will be considerably advanced as a result of what happens during the year. I will shortly be setting up a national committee to co-ordinate and promote the objective of the International Year for Disabled Persons. The committee will give a consderable amount of attention to considering how our attitudes to the handicapped can be improved so that the normalisation which the handicapped greatly desire  will come closer to realisation. I expect to be in a position to announce the membership of the national committee within the next two weeks.
I have recently reconstituted the National Rehabilitation Board, which has a key role to play in furthering the well-being of the handicapped person in the community. I hope that the board can function as an effective co-ordinating body, as a setter of standards, and as a catalyst in improving the quality of life of the handicapped person.
Finally, in relation to the handicapped, I acknowledge the major contribution being made to the improvement of our facilities by the moneys made available from the European Social Fund. In the current year, we have been allocated £8.2 million. This represents an increase of £2.1 million over 1979 and brings the total amount we have received to £25 million. It has been particularly gratifying to see community workshops developed throughout the country, bringing to reality a concept which is particularly geared to the needs of the rural community.
Since 1974, my Department have exercised a lead responsibility in relation to services for children. In 1975 the Task Force on Child Care Services submitted an interim report. The implementation of the recommendations of that report is now almost completed.
In anticipation of the final report of the task force, and to prepare for the major work that remains to be done in this area, the Government have strengthened my Department both at ministerial and official level. Deputy Tom Nolan, Minister of State, has been assigned a special responsibility for children and family services. As soon as the Task Force on Child Care reports we will be in a position to respond quickly and to prepare the new Children's Bill which has been long awaited. I have no doubt that the implementation of the task force report will also involve a strengthening of the services both in the community and in residential facilities. I assure the House that the Government will continue to give this task the very highest priority.
 It is generally agreed that any health services which can be provided in the community should be provided there rather than in hospitals or other institutions. For one thing, the cost of institutional treatment continues to grow and anything which can be done to minimise the impact of this cost is of course desirable. The cost factor is not, however, the only one nor even the most important. It is now generally accepted that it is in the individual's interest to be treated in the community where this is possible, and I am continuing to approach the problem of the provision of services by strengthening so far as possible the community care services which will enable treatment to be provided outside institutions.
With this in mind we have recently started a review of the organisation within the health boards for the delivery of community care services. This review, which is under the direction of a steering committee comprising representatives of my Department and the health boards, will begin with a review of the existing organisation by a firm of consultants. They will be reporting on the effectiveness of the present organisation of community care services, on how this is functioning and will involve discussions with the staffs providing the services to obtain their views on the manner in which it is working.
We are also undertaking at present a review of the general practitioner maternity and infant care service. It is appropriate at this stage to re-examine this scheme, which has been in operation since 1956, and to establish whether there are improvements which could be made in its operation.
Medical card holders and their dependants have for a number of years past been entitled to dental services. However, it proved difficult to recruit sufficient numbers of dental staff in the public dental service to meet the expanding needs and to enable a satisfactory service to be provided for the eligible medical card holders and their dependants. During 1979 a working party,  representative of the health boards, the Irish Dental Association and the Department of Health, examined the existing dental services and made representations about the manner in which they might be improved.
Arising from this report a scheme was introduced in November 1979 under which the health boards referred eligible persons from their waiting lists to private dental practitioners who had agreed to provide services under the scheme. The scheme operated successfully for some months, but the Irish Dental Association have in recent months indicated that they do not wish to continue with it until certain matters concerned with fees under the Social Welfare scheme are brought to a conclusion. I have put proposals to the association and I hope that these matters can now be resolved quickly and that the association will be willing to participate fully again in this scheme, which has been extremely effective in reducing the lengthy waiting lists for dental treatment which had existed in almost all health board areas.
In September 1979 a new scheme was introduced providing for sight tests for medical card holders and their adult dependants. Formerly such persons had to attend at health board clinics to have their eyes tested. Under the new scheme sight tests can also be obtained, at the patients' choice, from ophthalmic surgeons or ophthalmic opticians in private practice. The new scheme has been very effective in reducing the waiting lists for ophthalmic services, which were until then common in all health board areas.
At the same time new arrangements were introduced for the supply of spectacles. Previously these were obtainable only from contracting opticians, generally one per county. New spectacles can be obtained readily from any practising optician who is in the scheme. These new arrangements are proving very acceptable, particularly to elderly and other patients who find it difficult to arrange travel to central clinics for fittings, adjustments or repairs.
The general medical service currently provides a choice of general practitioner  for the 1.2 million people who are eligible for this service. It is a service which operates effectively and I receive very few complaints about it either from those for whom it is provided or from the doctors who are actually providing the service. It is estimated that it will cost £54 million in 1980, of which about £25.5 million is accounted for by the cost of drugs. The high cost of drugs continues to be a matter of concern to me and I am perhaps more concerned with the excessive and increasing recourse to drugs by the population as a whole. This has serious implications for health and welfare. I will be asking the Health Education Bureau to pay particular attention this year to the area of drug consumption.
Expenditure on drugs in the health services is at a relatively high level—estimated to total £50 million in 1980. This is the subject of detailed investigations at present and I will be pushing for measures aimed at reducing the high costs which we have to meet.
We are continuing to expand the facilities available to enable community health services to be provided effectively. Seven new health centres are expected to be completed during the current year and the planning of 17 others is in hand. Attention is also being paid to the provision of accommodation for community care teams so that these will be capable of effectively delivering services.
In relation to hospital services, the total sum provided in the public capital programme for hospital and other health projects in 1980 is £28 million. As I indicated earlier, £27.5 million of this will come from the Exchequer, the balance coming from the Hospitals Trust Fund. The total of £28 million compares with £27.5 million in 1979, £21.5 million in 1978 and £16 million in 1977.
The allocation of £28 million for the current year was fixed having regard to the general constraints on public expenditure this year and made it necessary to review activity on the capital side generally and to impose a degree of constraint on the overall hospital and health building programme. However, despite  these difficulties I am satisfied that considerable progress has been achieved in our hospital development programme.
In the last three years the implementation of the programme of general hospital development gathered new force and saw the Government's policy of providing as rapidly as possible the most modern hospital service for our people proceeding with vigour. During that time the construction of the new hospitals at Beaumont in Dublin and in Tralee was begun and is now very well advanced, as is the construction of the major development of Letterkenny General Hospital. In other parts of the country the planning of the development of general hospitals has reached the final stages in many instances.
Construction of the developed Mater Hospital and St. James's Hospital in Dublin will commence this year. The planning of the hospital projects at Cavan, Castlebar, Mullingar, Sligo and Ardkeen in Waterford is at an advanced stage. At the same time the planning of the development of Galway Regional Hospital and Wexford and Kilkenny hospitals is being pursued. Planning is also going ahead for the provision of maternity units at Limerick Regional Hospital and at Our Lady of Lourdes Hospital, Drogheda, and for a new medical department at Tullamore hospital. Preliminary planning for the development of James Connolly Memorial Hospital, Blanchardstown, and Portlaoise hospital has also commenced.
Therefore, despite the current financial restraints, the momentum gained in the implementation of the programme of general hospital development has been maintained and will continue until our agreed aims are fully achieved.
This year, following consultation with all the bodies involved, I made the necessary order for the establishment of the board which will plan, build and administer the new hospital at Tallaght. The board will include representatives of the Meath and Adelaide Hospitals in Dublin, the Eastern Health Board and the University of Dublin. I am now  about to appoint the members to the board so that it can begin its work without any further delay. Agreement has also been reached with Dublin Corporation and Dublin County Council for a suitable site which would be made available at Tallaght.
The matter is complex and I have decided, to enable the views of the hospital authorities providing services in the area to be taken fully into account, that examination of the matter could best be undertaken by a group comprising representatives of my Department, the Eastern Health Board, and the hospital authority for St. Columcille's, Loughlinstown, St. Vincent's Hospital and St. Michael's Hospital, Dún Laoghaire. I expect the group to commence its work shortly.
Another area in which final decisions were outstanding was the future organisation of specialist services in Cork city. With the opening of the new Cork Regional Hospital at Wilton in 1978 it was essential, to ensure the proper future rationalisation and development of general hospital services in the area, that a detailed study of the specialist services required and how they should be provided and organised should be undertaken. Consequently, a group representative of my Department, the Southern Health board, the Cork Voluntary Hospitals Board, Comhairle na nOspidéal and University College, Cork, was established late last year to carry out this task. This group has now reported to me, setting out its recommendations for the short-term and long-term development of the services in the area.
I believe that the recommendations contained in the report will make for an effective and comprehensive service in Cork city in the future and in the mean-time will allow the existing services to be developed in a rational manner. I intend  to have copies of the report made available to interested Deputies shortly.
Apart from the major hospital developments already outlined other significant improvements have been undertaken in hospitals throughout the country over the past three years. Time does not permit me to refer to these in detail but the projects were decided on following consultation between my Department and the hospital authorities and are generally in accordance with the priority afforded by these authorities.
During the period 1961 to 1978 the number of patients treated in our acute hospitals rose from 266,000 to 512,000, an increase of 92 per cent. This increase cannot be attributed to the increase in population as this was 19½ per cent over the same period. There is no sign of a levelling off of these figures and, while the position has been contained to some extent by a reduction in the average length of stay in hospital, many hospitals have to cope with problems of regular overcrowding due to pressure on beds.
The general hospital development programme will help to relieve pressure on hospital beds by providing improved accommodation in many areas. However, it would be unrealistic to believe that we can continue to provide and pay for additional hospital beds and facilities without any financial limit. Other developed countries are also faced with a similar problem.
I have initiated a study by officers of my Department to try to find out the reasons for the rising rate of admissions and what measures could be taken to relieve the position—for example, whether greater emphasis needs to be placed on use of day-beds or five-day wards and the provision of treatment on an out-patient basis.
Some months ago I circulated to all hospital authorities copies of two booklets published by my Department which were based on the report of a working group set up by my predecessor to consider the information needs of hospital patients and the arrangements for receiving people in hospital out-patient departments. The main purpose  of the two booklets is to direct attention to the need to provide all necessary and useful information to hospital patients before admission and the importance of receiving them courteously and helpfully. I might add that the issue of the booklets is not to be taken as a reflection on hospital managements but rather as an encouragement to improve still further the arrangements for receiving and furnishing information to hospital patients and their relatives.
Since 6 April 1979 everybody has eligibility for hospital services other than the services of hospital consultants. Hospital services are now free of charge in a public ward or at a fixed charge in a private or semi-private ward of a public hospital. Subsidies are paid towards the charges made in private hospitals.
For the services of hospital consultants an income limit operates. Persons below this income are entitled to get these services without charge. Persons with income above the limit are liable for the fees of the consultants concerned. I have recently increased this limit to £7,000 based on income for the year ended 5 April 1980. Approximately 85 per cent of the population are within the limit and are entitled to full hospital services without charge.
The remaining 15 per cent of the population can for a small premium insure against the cost of consultants' fees with the Voluntary Health Insurance Board. Consequently, we have in effect a comprehensive hospital service. I have given some further data to Deputies in a hand-out and these are available to them for their comments on the Health Estimate.
Mr. Boland: It is perhaps indicative of the entire performance of the Department of Health and the cut-backs they have suffered this year that the Minister in the time allotted to him was not even able to deliver his 21-page speech, managing only to get to the top of page 17. The Minister did not circulate any statement for the information of Deputies. He circulated a script which he was unable to read——
Mr. Boland: It is a script of what the Minister did not say. Presumably, in his concluding remarks the Minister will complete his introductory remarks, which again is typical of the performance of the Department of Health over the past year.
There has been a great interest in the health area among those who are in the health field and who are unfortunate enough to be called to the Department in this year of severe and stringent financial cut-backs. The words of a children's song have become a common joke among the health boards and hospital board managements in the health services. The old song said: “When you go down to the woods today, you're sure of a big surprise....” That is the only thing they are sure of when they go to the Department today or any day this year—a big surprise when they discover by how much the Department are insisting on the level of existing services being cut back, on hospital patients being cut back in the actual diet being provided for them, in starvation of capital funds.
There is an increase of £500,000 on last year on an Estimate of £27.5 million, an increase in capital services in the health field of 1.8 per cent. That is the increase in money terms. Official figures now show inflation running at over 20 per cent. Those with any experience in the building field know that since last January building costs have increased by 15 per cent and the Minister has given the health services an increase of 1.8 per cent against an inflation rate of 20 per cent.
Professional staff engaged on the forward planning, about which the Minister spoke so proudly, have had to be dismissed. Work has ground to a halt. As far as I can see, in the capital field as regard health services, it is all planning and no action, no building. We know that capital means building, provision of jobs and provision of facilities for extra services. That has been torn up and scrapped by the Government this year.
 Each day the health activities of the Government become worse. That is a poor boost for a new Minister when that complaint can be made to him six months after taking office. Let us not forget that he took over from the man who is now Taoiseach and responsible for the overall economy. The Minister was handed a Department in a situation where even if he wished to introduce improvements—I have no doubt that he would—he is unable in any way to introduce any real improvements in health services this year. Things have been reduced to the ludicrous level, as we heard in the House some weeks ago, that the diet of patients in psychiatric hospitals in the Southern Health Board area has been cut. The total contribution of the present Government and the new Minister for Health, as far as patients in the Cork psychiatric hospitals are concerned, is that they can no longer be given apples and oranges—not exactly what one might consider a luxury.
Let us have a look at the non-capital services. The Minister pointed out that the increase on last year's expenditure was £152 million, of which salaries and pay costs accounted for £124 million. That left a total net increase in the non-capital services, the day-to-day running of the health services, the health boards and the community services, of £28 million or 5.5 per cent. Official figures show an inflation rate of 20 per cent and an increase in money terms of 5.5 per cent. The result is a cut-back in the services being provided for the general population, a cut-back in the services being provided for inpatients and outpatients, loss of personnel, failure to appoint people to existing vacancies and a turndown in the health services generally.
We have seen a situation which I never believed would happen in this country. In the course of the last year of the previous Minister for Health and in the first year of the present Minister for Health the one group of people I never believed would take militant industrial action, and who always expressed the view that the last thing they wished to do  was to engage in industrial action which might affect their patients, were forced by the recalcitrant attitude of the two Ministers for Health and the Government to take industrial action. I am speaking about the nurses. There have been many debates in the Houses over the last three years about the need to improve the pay, working conditions, employment opportunities and training of nurses. The previous Minister for Health was warned by me that he was living dangerously with the nurses and that he was sitting on a powder keg which was likely to blow up in his face. It blew up because we engaged during the last three years in a policy in the health field of putting on the long finger anything which was unpalatable and adopted as a short priority anything which obtained a high publicity aspect.
The high publicity is gone and the previous Minister for Health is gone. The present Minister is left with the sweepings. There is not a lot of high publicity emanating from the Custom House these days. There are not a lot of promises or great undertakings these days. There is not a lot of talk about the undertakings reported in the Irish Independent last January as having been given by the present Minister for Health that there would be not cut-backs whatsoever in health or social welfare. He denied this undertaking in the House on 5 June last and his statements that day and today were clearly fallacious.
Let us look at some of the promises which were given by the previous Minister for Health and by the Fianna Fáil Party in their election manifesto of 1977. We do not hear about this document very often these days and it is not quoted very often by the other side of the House. One of the undertakings given in that document was that an all-party committee of the House would be set up to advise the Minister for Health on health matters. In volume 302, column 1065, of the Official Report for 8 December 1977, the former Minister for Health said:
The Minister actually refused to set up that committee as a committee of the House but a year later he appointed an all-party informal committee which was to advise him. If we want any better indicator of the real degree of interest, we have only to look at how often that committee have been convened by their chairman, the Minister for Health. In the three years the Government have been in office that committee had one meeting, which was the inaugural meeting at which no other business was conducted except the insistence by the former Minister for Health that he be appointed chairman. The committee have not met since and there is no indication when they will meet. According to the Directory of officials in the public service, a full-time officer in the Minister's Office is secretary to that all-party committee. That is that man's official title, but the committee have not met now for one and a half years and had not met during the previous one and a half years.
That is a far cry from the undertaking to completely reorganise the mental health services and it is also fallacious. The greatest shame in the health field under successive Governments is that the level of services for patients in psychiatric hospitals has been and continues to be abysmally low and there has never been any real effort or commitment on the part of the Department of Health to separate the psychiatric and the mental handicap services. Until that is done proper standards cannot be achieved in any of our psychiatric institutions.
 In one of the largest psychiatric hospitals less than half the patients are receiving any form of therapeutic care. We are told that a reasonable degree of comfort is being provided for the patients. Patients from St. Ita's hospital in Portrane used to be brought to a house donated to them in County Wexford for a holiday but this year they are denied their holiday because the Department of Health refused to sanction the payment of wages to the nurses who must accompany them. That is the achievement of this Minister and of the Government in 1980. The mental handicap long-stay patients in St. Ita's hospital, Portrane have been denied the one thing they have been looking forward to for a year—a week's holiday in County Wexford—because the Government are broke.
For two years now we have been promised a new Bill on mental treatment. It has not appeared yet. If the Minister had got an opportunity to read all of his speech he would have told us that it is to be circulated next week. His predecessor promised it early last year, the middle of last year and late last year. Since the present Minister took up office he has also been promising it. I hope when it is circulated that it goes some way towards dealing with the problems of the mental handicap services and it deals with the question of setting up separate services, separate directors of mental handicap and psychiatric services. I hope it provides a real level of service, comfort and therapeutic care for people in long-stay mental institutions. I want to assure the Minister that if it does not provide those things it will receive a very stormy and lengthy passage through the House. If it is circulated next week it will not be discussed until next session. I want to assure whoever is Minister for Health when this Bill comes before the House that if it does not contain the areas which I referred to it will receive a very stormy and rough passage through the House.
Another promise given was that the Government would encourage the development of a Voluntary Health Insurance  Scheme by substantial taxation allowances. We have had three budgets up to now but we have not heard of that promise again. Perhaps the Minister will give us some indication of the situation in relation to that undertaking.
The most time taken up by Deputy O'Connell, by the former Minister for Health and by me in this House in the health field last year was the debate on the Government's Family Planning Bill. That Bill was passed a year ago and was signed by the President 11 months ago. But it is not yet in operation because the present Minister and his predecessor have not the courage to make the regulations to bring the Bill into force, because the entire Bill and its concept was, as the Minister's predecessor said, an Irish solution to an Irish problem. The Government's solution to the Irish problem is, having spent many hours delaying this House in discussing this Bill, not to make regulations to implement the Bill and consequently not to bring down upon their shoulders the criticism of all of those who would be affected adversely by the provisions of the Bill.
It is not a very realistic way of approaching government. It is not a great way of showing respect for the House and for the intelligence of the electorate, but it is certainly an Irish solution to an Irish problem. Having applied the solution to the problem, you then do not implement the solution so that you cannot get yourself into any further trouble. Perhaps the Minister will let us know why after six months in office he has not yet managed to sign the regulations to bring that Act into force, or perhaps he will tell us whether he is going to make those regulations or whether that Act is to lie on the Statute Book inoperable for the lifetime of this Government.
The last debate in this House in which the Minister's predecessor participated was on the needs of the physically disabled. It was pointed out at that time that 1981 had been designated as the international year for the physically disabled. The Minister managed to get as  far in his script as referring to the physically disabled. He announced that he was setting up a national committee to co-ordinate and promote the objectives of the international year for disabled persons. Since December 1979, when the House last discussed the position of disabled persons, there has been no real progress in most fields in relation to the ten points which I suggested were all achievable, many of which did not cost money. I am going to reiterate them, despite the fact that once again we are in a situation where we are confined to 25 minutes to discuss the activities of one of the major Departments of Government. That same situation applied last year and there has not been in this House in the three years since this Government took office a full debate on the Estimate for the Department of Health because of the refusal of the Government to allow time for that debate. I am still going to take the additional time to speak about the needs of the disabled. At that time in December I suggested that there was a need in ten areas which could be achievable. They are as follows.
(1) Local authorities should be asked to prepare an indication of the number of physically disabled people on their housing lists, the number of specially designed houses in course of construction or planning for them and the number of modifications which they had carried out on existing dwellings.
(2) There should be a time limit established after which all public bodies would receive, if necessary, a financial cutback if they had not carried out modifications to their public buildings so as to make them acceptable to the physically disabled.
(3) A date should be set after which all transportation authorities would have financial restrictions imposed if they had not carried out modifications to their trains, boats, buses and planes so as to make them easily accessible to the physically disabled.
(4) All public bodies should be set, and made to achieve, an employment  target so that they would employ a certain proportion of physically disabled persons in their organisations. I see in yesterday's papers that there is some move in that regard in one small part of the public sector but not throughout the public service generally.
(5) The Department of Health, and the Government through their other Departments, should ensure that there are no excessive delays in the payment of the special grant for modification of private dwellings so as to allow them to be used by the physically disabled.
(7) Ordinary schools should be modified so that children who are partially disabled and who at the moment are obliged to attend special schools would be able to participate fully in the life of their community and attend ordinary schools which they are so anxious to do.
(8) There should be some reasonable amount of spending money given to physically disabled people who are living in long-stay institutions and whose physical needs are catered for but who are left penniless and unable to participate in any way in their community as a result.
(10) The Department of Labour rather than the Minister's Department, whether he realises it or not, are the employment agency for the physically disabled and the Department of Labour should be assigned that function rather than the Department of Health who clearly are unable to carry it out.
Perhaps an indication of the Government's concern or otherwise for the physically disabled is best examplified when I remind the House that last July I  attended a very pleasant function in the middle of my constituency which was the turning of a sod for the building of a new rehabilitation unit shelter workshop for the disabled in Swords, County Dublin. The sod is still turned and there is a sign on the site and we will celebrate the first anniversary of that sod-turning next month. There is a different Minister. He might like to come out and re-turn the sod. Nothing further has happened since the day the Minister for Health had his photograph taken, his script circulated to the newspapers, his publicity achieved and we all went home happy. The Government have an interest in the physically disabled. Let them get on with the rehabilitation site shelter workshop for Swords which they started 12 months ago.
Let us look at the cut-backs in real terms. Yesterday's newspapers tell us that the Southern Health Board have had a cut-back of £.5 million this year, the North-Western Health Board a cut-back of £1 million and the South-Eastern Health Board a cut-back of £1.5 million in their need for the running of their day-to-day services. Virtually none of the health boards has been given an allocation for the carrying out of any new capital works whatsoever. Only yesterday at Question Time I asked the Minister when it is proposed to sanction the extension to the school for handicapped children at the Dominican Convent, Cabra. The Minister's answer was, “While I am sympathetically disposed towards the project, I am not in a position to indicate at this stage when the building work can commence. I will keep the matter under review”. The Dominican Convent, the handicapped children and this House do not want the Minister's sympathy. They do now want the Minister's review. They want the extension built.
On June 5 I asked the Minister whether he would sanction the additional moneys to enable stage 2 of the programme for the Coolmine therapeutic community to be established properly. The Minister's answer was, “I regret that it will not be possible for me  to make resources available in the current year to enable the Coolmine Lodge therapeutic community to commence fully this year”. The House does not want the Minister's regrets. The House wants the Minister's action. If the Minister is unable to obtain from his colleagues in Government sufficient money to carry on adequately the existing level of health services, never mind the improvements planned or the additional physical building and the additional facilities and services spoken about over the years, if the Minister has not enough muscle to get the money to have the existing level of services maintained, then there is one short of action open to him and it should be very obvious to all.
It would be better if the Minister was to seek to get sufficient moneys to run the services rather than have carried out by his Department these insidious campaigns against the hospitals like St. Columcille's where every effort is being made to denigrate the services of that hospital and to run down the level of services being provided for the people of south and south-east County Dublin. That is not acceptable. If the Minister has work to do, let him do it in getting sufficient money to have services maintained at present rather than endeavouring to close down existing services. Let the Minister look at the operation at the out-patients' department which are urgently in need of attention. Let the Minister remember that in 1970 when McKinsey recommended the setting up of the eight health boards he also recommended that their progress be reviewed after five years from the point of view of cost, effectiveness and efficiency. They have been in operation now for ten years and no attempt has been made by the Minister's Department to carry out an investigation into the health boards, never mind into some of the other hospitals. Let the Minister realise that one of the greatest social problems in our developing areas is the lack of health centres and the fact that health centres are arriving five and ten years after new communities with young families are in  those areas. Let him realise that day centres are needed for the elderly and that no attention whatsoever has been given to the area of the pre-school play groups with no standard and no training set down for the teachers in those groups.
Let the Minister look at the area providing services for school children in the 12-16 age groups and let him provide the service which by law he is committed to providing in the infant welfare and school inspection services in rural Ireland. Many children never receive that service which the Minister is obliged by law to provide. Let us realise most of all that the Minister said, “As Minister for Health I have very little influence over many of the factors which affect health”. At least he is truthful.
Dr. O'Connell: The £635 million which has been allocated to the health service this year represents over £190 a year or over £3.50 a week for every man, woman and child in this country. Since 1978 expenditure on health has risen by 86 per cent. We now have 7.3 per cent of our GNP allocated to the health service. That is a statistic which places us among the big spenders on health care in the EEC.
The question we should ask ourselves is, are we getting value for money in our health services? Has this massive expenditure resulted in a corresponding increase in the quality of the health services and the health of the population as a whole? In short, has more money meant more health? Unfortunately, I would say no. We have spiralling health expenditure co-existing with deteriorating health services, and the standard of health among the general public has remained static for the past ten years. It is almost like throwing paper into a furnace. The more we spend, the less we are getting in return for it. Despite this massive expenditure, we still have a very high incidence of mental handicap with over 4,000 people in dire need of proper institutional care. We have the worst record on dental health anywhere in western Europe. We still have 1,200 deaths of infants under the age of one  and we have a further 800 stillbirths a year. Many of our hospitals are Victorian ruins with staff having to put up with working conditions and overcrowding which no trade unionist would accept. The conditions in some of our psychiatric institutions are appalling and they constitute a violation of basic human rights.
Of course we can point with pride to the fact that 90 per cent of our population are entitled to free hospitalisation and 36 per cent to free general practitioner care. However, a massive waiting list for everything from hip replacement operations to basic dental care indicates that all too often these are merely paper entitlements. They may exist under the Health Act, 1970, but they do not exist in practice. The simple point I am trying to emphasise here is that the benefits of massively increased health expenditure have failed to percolate down to the consumers of health care. I do not envy the Minister for Health his task. It seems that what we pour into it is not going to the consumer of health care, to the ordinary person in the community. There are a number of reasons for this, such as medicine relying on advance technology and highly skilled labour, both of which are very expensive. Extension of medical care also leads to more demand for that care and this also leads to ever-increasing costs. The priorities of health care have centred largely on hospitals and other institutions where costs are very high instead of on a proper system of community care and health education which seeks to cut down costs by keeping people out of expensive institutions.
In 1979, 46 per cent, almost half the health expenditure, went on general hospitals alone and that is an enormous amount of money. We have to look very carefully at the whole situation of health care and we must have a radical overhaul of our health services if we are to produce the health in our community that we are aiming at. It will call for a Minister with great dynamism who will be able to bring about the necessary  radical reform in the health services that will benefit the public as a whole. The State at the moment is costing itself millions upon millions of pounds by its failure to develop community care services, particularly for the elderly. It is a shortsighted policy to cut back on services such as public health, nurses, home helps and meals on wheels, the very services which can keep our elderly people out of institutional care, where costs range from £60 to £100 per week.
The Government should be aiming to increase the prescribed maintenance allowance to a level which would encourage families to keep their parents out of these institutions. We have the anomalous situation where the State pay £11.75 to a relative to keep an old person out of a home whereas if they let them go into the home it would cost from £60 to £100 a week. One of the radical changes required is a proper £20 to £25 a week prescribed relative's allowance, to encourage people to keep their parents out of these institutions.
Community care services for the mentally handicapped are also being neglected. A number of day centres have been forced to abandon their services through lack of funds. This is causing a severe strain on families who are trying to cope with mentally handicapped people at home. The community care idea also remains underdeveloped at the level of the local health centre. These facilities should be developed as a halfway house between the home medicine cabinet and the hospital—a place where routine first aid and diagnostic services should be available without having to hospitalise people.
I realise that the Minister has moved to streamline the out-patient facilities in hospitals. This is an area of importance, but my point is that the basic concept of community health care and preventive medicine remains untried in this country. There is nothing in this Estimate to show differently, with the exception of some increases for the health education bureau.
The issue I wish to concentrate on in the relatively short time available to me  today is the neglect in the area of services for the mentally handicapped. The question must be raised in this House as to whether these people's basic human rights are being catered for in our health services at present. The mentally handicapped stand out as a prime example of this neglect. Health planners have failed totally to take account of the fact that mentally handicapped people are living longer now than they did in the past and are requiring services and facilities for their care.
The recently published Report of the Working Party on Services for the Mentally Handicapped states that there are 2,300 mentally handicapped persons in the community and that these are in need of residential care and an extra 2,500 mentally handicapped being kept in institutions where they do not belong—in psychiatric hospitals and geriatric hospitals which are totally unsuitable for the care of the mentally handicapped. There is an immediate need of well over 4,000 places in proper residential care for the mentally handicapped. The report argues that there is a large number of mentally handicapped people displaced, many people with mild conditions being cared for in homes who could be cared for in the community and a large number with severe handicaps who should be treated in residential centres. We could not just switch over and take those mentally handicapped people out of homes because we have not got the necessary community services for them. These services are not adequately developed. You could not therefore do a magic trick with these figures. There are a minimum of 4,000 mentally handicapped persons who require suitable care and we are not allocating the necessary funds for these facilities to be built.
The situation regarding our mentally handicapped is being allowed to deteriorate to such an appalling extent that basic human rights are being violated. This is particularly so with regard to the 2,500 mentally handicapped persons being kept in psychiatric hospitals in conditions to which a farmer  would not subject his cattle. If I may read from the report of the Association for the Rights of the Mentally Handicapped, as a result of a visit to one of these psychiatric hospitals, this is what they had to say:
They sleep in a long, bare dormitory. The beds are old, mattresses sagging and the bed clothes did not look clean. Next to the dormitory there is a day room with bare furniture except for forms arranged around the walls. The floors were very dirty, particularly near the walls where we noticed that the floor boards were rotting... The dining hall was a similar room. Rat holes were clearly in evidence... The stench of ancient urine-soaked floors was palpable... The urinal regularly overflows and floods out onto the floor.
That is a report on St. Ita's Hospital by the Association for the Rights of the Mentally Handicapped made in February 1979. One could be excused for wondering whether that should have been 1879, because conditions in so many of our institutions for psychiatric patients are a throwback to that era.
The most depressing aspect of all is that successive Governments have lacked the political will to come to grips with the problem and provide the necessary facilities for mentally-handicapped people. Let us face it, the mentally handicapped are the last in the queue for Government funds when economic times are good and the first in the queue for the government cuts when economic times are bad. They have no political clout. They are not organised. They hardly represent a significant electoral block. In short, given the way political economic priorities are established in this country, they do not count.
Last year a paltry 144 new residential places were created for the 4,000-odd mentally-handicapped people in need of proper residential care. It would take over 30 years to meet the existing need for facilities for the mentally-handicapped were we to continue at this present rate. So we can forget about  plans, reports and predictions. We must talk about performance. With a mere 144 new residential places created last year we can tell a parent with a child who is mentally-handicapped and needs residential care that we just might be able to accommodate him some time around the year 2010.
The record on the community care side is even worse: 115 hostel places only were created for the mildly-mentally-handicapped capable of being catered for in the community. At this snail-like pace it is absolutely inconceivable that a significant number of places can be opened up for residential care by removing those who can be cared for in the community because the facilities do not exist. The Department of Health say they expect to create 240 residential places in 1980 and an extra ten hostel places, a target which still leaves services for the mentally-handicapped 20 years behind schedule. I admit that this Government are not alone to blame. I am not here attempting to score any political points. But, if past Governments must share the blame, it is the present Government which must bear responsibility for action at present. Because of that I appeal to the Minister to make the needs of the mentally-handicapped a very special priority. Unless a Minister for Health does so at some point, these people will continue to be condemned to enduring a shadow existence, to lives which are a mere reflection of what living could and should be.
The other area of the health services to which I should like to refer is the long-neglected question of psychiatric services. I am regularly receiving disturbing reports about conditions in St. Loman's, St. Ita's, St. Brendan's and other institutions throughout the country. Psychiatric nurses working in St. Loman's Hospital had occasion to describe that institution as little better than a Victorian workhouse. There are different categories of patients, from geriatrics, to acutely disturbed persons, to alcoholics, all lumped together in the same ward. Conditions are so overcrowded that a billiard room had to be requisitioned  as a ward and a storage closet as a recreation room.
Another result of the overcrowding at that hospital is that patients have to be shifted from one bed to another, which means that a patient may find himself being taken out of his bed at 6.30 to 7 o'clock in the morning to make room for another patient moving in to have electro-convulsive therapy. That is happening at St. Loman's Hospital at present. And, with one bath only for up to 40 patients, even basic hygiene is difficult to maintain. St. Loman's Hospital has a mere 179 beds in adult wards and only 110 fully-trained staff to look after these inmates. The situation is chronic. The staff shortages are so severe that on occasion school leavers have been left to look after seriously disturbed patients.
Conditions at St. Ita's are little better with patients still being kept in wooden huts built over 80 years ago to house construction workers. I have been speaking about these huts and the conditions at St. Ita's for the last ten years and I have found very little change.
What can I say about St. Brendan's other than that it is literally falling apart? An engineer's report warned that the main building as well as units L, M and N must be evacuated and demolished. It is a crying shame, and indeed an indictment of the inspector of mental hospitals that he inspected that hospital and ignored the dangerous conditions existing there. When I went up to inspect it I could not believe that he could pass a hospital like that, where on one occasion four stone of ceiling fell in on a patient who was transferred to another hospital. The whole place is falling apart. I was appalled to think that these, the most defenceless people of all, were being herded into places like this.
 Rightly so, and I commend him for those sentiments. But, while I am in favour of community care for psychiatric patients, I must sound a warning. Community care does not mean that we literally throw these people back into society after years and years of life in an institution because they simply would not be able to cope. The only way in which they could be returned to the community is if there are proper services provided, half-way houses, to meet their needs. These psychiatric patients whom we have institutionalised require support. To throw them back into the community without the appropriate back-up services to give them that support would be totally irresponsible. This message must be borne in mind as we debate the future of St. Brendan's. Community care must not be used as a justification for running down our present residential psychiatric services. What I am saying is that we cannot justify the appalling conditions in our psychiatric hospitals on the grounds that we are wasting money by keeping these institutions in proper repair. We cannot do that. We put these people into these institutions. The very least we owe them is a basic, minimum standard of care which respects their decency and dignity as human beings.
I brought to the attention of the Minister for Health reports to me from psychiatric nurses at St. Brendan's Hospital. To give the House an idea of what conditions are like I might read some of their remarks: They say that harmless patients are being kept in the high security unit while dangerous patients are being dispersed to other wards. After 5 o'clock in the afternoon there is one junior doctor only on duty, this also at the weekend, when there is only one senior doctor on call, who may be as far away as Dún Laoghaire from St. Brendan's. The meals provided are not sufficient to maintain even a basic resistence to disease among patients. Breakfast consists of two slices of bread, porridge and weak tea. These patients get nothing after 5 o'clock in the afternoon, nothing at all. The problem is that many of these patients may require  electro-convulsive therapy which is not administered until 12.30 to 1 p.m. the following day. Therefore they are forced to fast from 5 o'clock in the afternoon until approximately 1 o'clock the following day. That is appalling and something must be done to treat them as normal human beings.
Again these psychiatric nurses reported to me that in one female unit at St. Brendan's Hospital, Unit O, young psychopaths are being kept with geriatric patients who literally fear for their lives. These are psychiatric nurses at the hospital who feel they want to have conditions improved, who want to help the patients but who feel they do not get the necessary leadership. They do not know to whom they should refer their complaints. Another example of what I am talking about is that patients are drinking tea out of soup bowls. These psychiatric nurses want improvements effected. They are demoralised by the situation obtaining. In a letter to the Minister I appealed that something be done about those conditions as a matter of urgency. I am dwelling on this question of the mental health services because I feel something must be done about these most defenceless people in our society.
I should like to refer now to the question of medical cards. An enormous proportion of our health expenditure goes to general hospitals. We are encouraging this situation by cutting down on the entitlements to medical cards. The present limit of eligibility for the medical card are totally unrealistic in the present inflationary age.
There is gross discrimination against certain sections of the community, mainly those living in urban areas. In the west and north west 50 or 60 per cent of the people are entitled to medical cards while in Dublin city 14 per cent are entitled to them. This is due to the two methods used to determine eligibility—the notional system for farmers and the gross income for people in the urban areas. As a result, people in urban areas are suffering tremendous hardship. This accounts for the fact that  so few people in the Dublin area are entitled to medical cards. Last night ten people came to me because they had been deprived of their medical cards due to the changing guidelines.
If we spent more money on the family doctor service we could keep people out of hospital and save money. I am not advocating that more money be spent on the health service. I am against that. We could do more for our people by providing a proper health service without destroying the economy by devoting more money to primary health care. This would call for a dynamic Minister and radical changes. I hope the Minister will take into account the points I have raised.
Mr. O.J. Flanagan: In view of the fact that under the rules I cannot make a full speech, may I direct the Minister's attention to the continued development of three hospitals—Portlaoise, Tullamore and Mullingar. Will the Minister be prepared to sympathetically consider a new approach to the provision of hospital and health services for the people of Longford, a growing and progressive town? Over the years I often wondered why the people of Countries Carlow and Longford have been so patient when they do not have up-to-date hospital services.
I want to talk about cancer. While we are debating statistics here there are hundreds of people dying in hospital of cancer. What are we doing about educating the people about ways of preventing this disease? What are we doing about cancer research? What are we doing to provide sufficient publicity to educate people about cancer? We should teach them that cancer is curable. We do not have screening facilities or the proper approach to this matter. Throughout the world 17 million people out of 50 million people die each year from cancer and this figure will continue to rise. What are we doing to educate people about preventative cancer measures and early diagnosis?
In the interests of the thousands of  people who are walking around and do not know they have cancer, what action will be taken to reduce the number of deaths from cancer? This can be done by organisation. A special section of the Department should deal solely with preventive cancer measures. I intend making a speech on this Estimate and devoting it to one theme, that is, the practical steps to be taken in cancer treatment, the provision of early diagnosis and educating the people about cancer.
The Minister will be contributing to this cause generously if he takes a courageous and practical approach to this disease. Some people regard it as the death knell. This is the wrong approach. Let us take the advice of the experts: cancer is curable.
I pay tribute to the cancer experts who are doing a marvellous job. They need more co-operation and should have closer international contacts with experts in the rest of Europe and the United States. If the Minister tells us he will do something about this serious problem, I will fell that my contribution, however brief, was worthwhile. He will have the deep gratitude of many thousands who are likely to fall victim to this serious disease. I hope on a future occasion I may have the opportunity to deal more fully with this serious problem which needs to be courageously tackled.
Minister for Health (Dr. Woods): I would like to thank Deputies for their comments. I want to point out that the arrangements for the timing of this Estimate debate were agreed between the Whips. I would be happy to debate this for whatever time is allocated. Because of the time restriction I made available to Deputies a script in case there was not time to read it through. As Deputy Boland asked a number of questions I will cover some of the points dealt with in the last pages of my script.
In relation to capital expenditure on improvements to mental hospitals and the provision of new units, in the past three years 14 major schemes to improve conditions were completed. An  additional 14 schemes are at present in progress or nearing completion and 22 schemes are in various stages of planning. There are over 300 capital projects under way at present. It could be misleading to follow the views put forward by Deputy Boland and I would be the first to admit that I am anxious to have further capital money.
Concerning the development of community psychiatric services, since this Government assumed office such facilities have been increased by 100 per cent. In 1977 there were 30 hostels catering for 300 patients. Today there are 600 patients living in over 60 hospitals.
The text of the Health (Mental Services) Bill, 1980, will be circulated to Deputies early next week. The Bill, which I believe to be fully in accord with the most modern developments in psychiatry so far as the detention and treatment of persons suffering from severe mental illness is concerned, will provide in an up-dated way for the registration and supervision of the operation of centres for the mentally ill, the control of admission and discharge procedures and will include safeguards against the unnecessary detention of patients. The Bill will be circulated next week. This means Deputy Boland will have plenty of time to discuss this and to bring forward next autumn the views he has threatened. I am making this Bill available now so that he can give it his maximum attention and come up with constructive suggestions. I hope other Deputies will do likewise.
On mental handicapped services, I totally refute Deputy Boland's reference to a lack of development. Steady progress continues to be made in the provision of additional residential and day accommodation for our mentally handicapped children and adults. In the last three years an additional 420 residential places came into operation and it is expected that a further 240 residential places will be completed during the course of this year. At present there are about 5,000 places in our special  residential centres and hospitals, while a further 8,000 places are available in a variety of day-care facilities, including schools, special classes, care units and sheltered workshops. I am conscious however, that much remains to be done before our total needs in this area are met. The most acute need in this service relates to the provision of extra facilities for adults and in drawing up the programme for capital development, priority has been given to those projects which will make extra adult places available.
I am also particularly concerned about the promotion of positive good health. Deputy Boland quoted me somewhat out of context in saying that as Minister for Health I have very little influence over many of the factors which affect health. That was in the context of the positive development of health. As I have said, as the member of the Government with a particular responsibility for health, I have the information and expertise available to me to make other decision-makers and people of influence in the community aware of how they can either damage or sustain their health by what they do or omit to do.
I am very concerned about the extent to which the abuse of alcohol is causing major social problems. There is clearly a will in many parts of the community to do something about curbing excessive drinking, particularly among young people. What has not yet been agreed and will have to be settled soon is the means which should be adopted in order to do this. There is no single easy way of doing it. There is no way that the Government on their own can do it, and it is a matter in which we all have an interest and a part to play.
I referred earlier to the proportion of overall national resources which the Government provided for the health services in the Estimates for 1980. I pointed out that at 20 per cent it compares more than favourably with the 18 per cent allocation made available by the previous Government in 1975. The share provided in the Book of Estimates for 1976 stood again at 18 per cent. The  Government's commitment of resources in the current year is increased appreciably by the need to provide a further £93 million by way of Supplementary Estimate. All fair-minded people will admit that the Government are playing their part in helping the health services to cope in a difficult period.
I have been asking health boards and other health agencies to pursue energetically the question of finding all economies which can be secured through efficient management of available resources. Nobody wants to see the curtailment of any service which is vital to the well-being of patients. On the other hand the sources of any possible waste or extravagance should be eliminated and the best possible use should be made of available manpower. All opportunities for achieving economies in the use of energy and in general management expenses should be examined. I particularly appreciate Deputy O'Connell's remarks in this respect.
I have twice met the chairmen and chief executive officers of health boards to discuss their problems and have been greatly encouraged by the spirit of co-operation I have found. They have, of course, referred to the difficulties they are experiencing, particularly because of the present rate of inflation. I will be meeting them again in another month or so for further discussions when information is available as to the level of savings being achieved through the implementation of the economy measures on which they have decided. Positive and useful proposals for economies have emerged from these meetings.
The situation as regards voluntary hospitals and homes for the mentally handicapped is being monitored regularly. There is a need to base projections on the rate of success which is being achieved through the programme of economies which managements have introduced. Some but not all of the managements envisage difficulties, especially in cases where growth in service levels over 1979 has resulted from the appointment of additional consultant  staff and increased admission rates and utilisation of services. The general situation will be kept under constant review to see what can be done.
Opposition Deputies will, no doubt, recall that the position now is in many respects similar to what occurred in 1976 when the then Minister for Health had also to deal with the inevitability of economies in expenditure. I will not dwell unduly on this because I am sure Deputies will be familiar with these facts.
Our strategy today is, predictably, based on securing economies through efficient management and on the avoidance of reductions in essential services. We may be faced with some problems as the year passes and we will have to see what can be done to ease any situation which presents a major difficulty, but not necessarily through the allocation of additional funds which in present circumstances are not available. Nevertheless, it will be noted that we are continuing to develop new facilites throughout the country as resources permit. We also have an opportunity to assess our present services and likely future needs so that we may be prepared to develop quickly when national and international circumstances permit.
Several comments have been made in relation to St. Brendan's Hospital. I visited it very recently and have seen the particular building to which Deputy O'Connell referred. I should like to point out that over £1 million has been spent on improving conditions in the past year and over a number of years many areas in the hospital have been brought to a very acceptable level of accommodation. It is very important that Deputies recognise this. I accept that there is a great deal to be done in that area but it is equally important that we recognise the work which is being done. A meeting has been arranged to take place in my Department next week between my officers and officers of the Eastern Health Board to resolve problems in relation to the transfer of patients from wards seven and eight.
Deputy O'Connell also referred to St. Loman's Hospital and I found this particularly  interesting. I recently made a speech at the opening of a day hospital in Kilcock and I emphasised the need to keep our friends, relatives and neighbours in the community as far as possible. This is an excellent example of a day centre being provided with community participation. This has had the effect of relieving some pressure in St. Loman's although this is just one part of the problem there. However, it is an indication of the direction in which we wish to see these services going and this is why I have given it so much attention. I might add that St. Loman's Hospital is a modern building and could not be described as Victorian in any sense.
Dr. Woods: Deputy Boland referred to St. Ita's and made a point about a summer holiday programme being upset. This would come under the management of the Eastern Health Board and I will take up the matter immediately with them. He also mentioned the all-party committee on health services. It is only fair to point out that Deputy Boland expressed serious reservations about participating in that committee.
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