Thursday, 21 May 1987
Dáil Eireann Debate
Mr. Keating: I want to take this opportunity to make four main points in relation to the general question of public policy regarding health. It is important that we should bear in mind that this discussion is not just about financing the health services.
First, there is the underlying mistake that has permeated the discussions all this week, that throwing more money at the health service is synonymous with having improved standards of health care, or indeed improved standards of general public health. That is a simplistic and somewhat blinkered approach to the issue. It does the kernel of the problem a disservice. The kernel is not so much the level of resources we use but how we use them pursuant to policy. The assumption is based on a very artificial notion about our health services. That notion is that we have a health service. I submit that we do not. I believe that we have a sickness service, one which deals with illness and does not deal with education towards good health and the prevention of those problems that create ill-health.
Secondly — and to me this is fundamental and I would really appreciate if the Minister could address it — there is the need to change from the present system of disbursement of public funds in the health service, a system which is loaded with built-in vested interests at every level, where all involved receive payments, grants and disbursements based on the amount of service, the frenzy of activity rather than the quality of results or the absence of illness. How can we seriously expect a system to be efficient if it depends for its financial benefits, in terms of who receives them, on there being more illness, more beds, more wards, more hospitals?
Thirdly, there has been a great deal of unjustified, unsustainable and irresponsible comment during the last week about the funding of the health service. The bottom line is that this year, as every other year, there is more money being spent on the health service than last year. That is in keeping with what happens  each year when the amount spent is greater than that for the year before. But it is never enough and there are people in this House who will always ask for more. They have no responsibility and no prospect of having responsibility as to where it comes from. I have no doubt that in years to come we will look back at this era and in view of the incredible pressure and ferment of criticism that has developed over the last number of weeks, we will perhaps come to the conclusion that we have had the worst of all worlds, that we have had all of the controversy, the vilification of the Opposition and the political shenanigans arising from the health cuts but, unfortunately, we have not had the economic benefits of genuine constraint in the health services.
My fourth point is our absolute lack of confidence in the present capacity of the Department of Health, to some extent by virtue of the statutes which affect them, either to shed new light on improvements in the health care generally, or indeed in the specific context of financing health, to be adequately accountable for taxpayers' money. There is ample evidence of that.
The simplistic approach that our sickness service demands more and more money, that if it does not get more money we will naturally have a decaying service is fundamentally wrong and based on a false notion of what good health is about. We have an acceptance that it is essential that everybody be bombarded with a campaign to buy more drugs, to attend hospitals more often, a whole approach which is about making profits, about generating business. The health services as they operate now are essentially a business, not a social service. I will quote from a book called Holistic Health by a writer called Lawrence LeShan who said:
There is a tremendous amount of propaganda from drug companies and their advertising agencies to the effect that our bodies do not work and are constantly in danger of decomposing from one thing or another. We must, we are warned, keep a large variety of drugs available, or we will certainly be  overcome with everything from dandruff through haemorrhoids to athlete's foot. Not a single system of the body (excluding those like the lymphatic that the lay public does not really believe exist) is exempted from the threat that it cannot function well by itself or recover unaided if it becomes disordered.
He develops that theme that we need constant pepping up, sedating down, medical attention, trips to hospitals, and prescribing. I doubt if there is a house in the country that has not one or two boxes of outdated unwanted drugs in a cupboard somewhere. This is about business, not about good health. Good health should take into account the fundamental need to have on our schools curriculum a programme for education for health which embraces the issue of diet, physical and mental exercise and a whole range of issues which have nothing to do with a drug-addicted society, a whole positive attitude towards the fact that the body is self-healing given reasonable opportunities. That is a fundamental approach to redressing what we have assumed to be the way to good health.
The second thing which arises logically from that is that we have a system which is permeated by the profit motive. That profit motive extends right down to the health boards. It is a preposterous notion that the health boards should have on them members whose incomes depend on how they disburse public funds. Do we really expect them to do what is necessary in the public interest? It is asking too much to think that they will never succumb to the temptation to make a profit. That profit motive permeates every level.
There are other societies where those engaged in medicine are rewarded in direct ratio to the amount of time they are not called upon, implying that if they are doing their job well they are not active. A system that allows people to be paid in relation to the number of calls on them is nonsense and inevitably people will be tempted to use the opportunities  for maximising their income. That is fundamentally wrong. It is wrong when we see it at health board level, where the people involved are at least open to the suspicion that consciously or otherwise they are developing an environment in which they can maximise their own incomes and where if there are cutbacks they affect those at the cliff face, and that is what we are witnessing. George Bernard Shaw summed it up relatively well when he said that any sane nation having observed that one could provide for the supply of bread by giving bakers a pecuniary interest in baking, and should then go on to give surgeons a pecuniary interest in cutting off one's leg is enough to make one despair of political humanity. That sums it up well enough.
If I were politically cute, I would keep my head down and say nothing, but the allocations this year surely do not justify the headlines we have seen saying that the health services are in chaos and the particularly emotive, offensive and exploitative programmes which have used old people for the purpose of putting pressure on this House to obtain more scare resources, a highly questionable procedure. Those allocations, limited and constricted as they may be, do not justify that kind of heat and steam. Those allocations show that in the case of every health board except one, there is this year a greater allocation than last year. I would be the first to admit that in areas there might not be enough. Nobody has ever had enough yet. The reality is that we are living way beyond our means and it cannot continue. Those who cry and bleat for more should say where it is to come from.
The one health board did not get more; it got £600,000 less which I am sure is a matter of discomfort for them but it should not result in the closure of hospitals and hospital wards in sensitive areas relating, for instance, to child assault and rape, unless there is a deliberate policy for some reason. Those who are at local and middle management level who administer these allocations in a selective way are being deliberately selective for reasons that have nothing to do  with the wellbeing of those who attend those hospitals.
Over the past number of years the health services have expanded dramatically. Since the mid-seventies the health service has grown tenfold, and more than double in real terms. Staff totals in the health boards have grown from less than 24,000 in 1971 to 57,000 today and yet some people ask for more. It is not a question of more resources, it is a question of making better use of existing resources. There are no more resources and there will not be any more resources. The miracle is that these resources are available because most of them are borrowed. The sad part about the use of the resources is that it is very difficult to have confidence in the way they are overseen. The Comptroller and Auditor General in his report, Appropriation Accounts 1981 in paragraph 72 under the Health Estimates said:
The accounts of certain Voluntary Hospitals are audited by Local Government Auditors whose reports are made available to me. One such report examined by my officers in the year under review related to the audit of the 1979 accounts of a Voluntary Hospital which in that year had 94 per cent of its running costs financed by grants from this subhead. In 1981 grants paid to this Hospital amounted to £7 million approximately.
In his report dated 28 July 1981 the Local Government Auditor referred to a number of deficiencies in internal control and accounting procedures. These included erroneous and inconclusive bank reconciliations....
The Accounts of the Health Boards are audited by Local Government Auditors whose reports are made available to me. In his report dated 16 August 1982 on the audit of the accounts of the Eastern Health Board for the years 1979 and 1980 the Local  Government Auditor drew attention to a number of accounting and control deficiencies as a result of which he was unable to satisfy himself as to the accuracy, reliability and completeness of the Board's accounts and records and was unable to form an opinion as to the fairness of the results and financial position as presented....
The Board's expenditure in the three years totalled approximately £71 million ... As control deficiencies such as those referred to by the Local Government Auditor can lead to an increase in the Board's grant requirements I asked the Accounting Officer what action was being taken by the Department of Health to ensure that such deficiencies are rectified.
The deficiencies he was referring to were his inability to obtain “satisfactory audit evidence of the proper receipt, issue and custody of stocks of such goods including medical supplies and equipment”. He said that the value of such items purchased in 1979 was £3.3 million.
A concerted attempt had been made to charge expenditure incurred in 1982 to the 1981 accounts and that the measures employed to achieve this included, inter alia, the alteration of the dates on suppliers' invoices....
To my way of thinking that would be a criminal activity. He went on to develop the same theme in 1985. Those reports are available annually to the Government. What has been done about those systematic deficiencies and distortions? The former Minister for Health, Deputy Desmond, said he had told the health boards they could not spend what they had not been allocated but they did so while he was Minister and continued to do so.
There are many other issues one could raise in the context of these anomalies but this boils down to our inability to have confidence in that accounting procedure.  For example, we have not heard a word from any side of the House about the fact that on average it costs more than twice as much to provide a hospital meal for staff in hospitals than the charge made for it and that the menu is different from that for the patients. What about that subsidy? We have not heard any suggestion about the fact that it costs four times as much to issue a birth or death certificate than the charge made for them. Could that be corrected? We have not heard any suggestion about the failure of the Department of Health to deal with their statutory obligations in a number of areas relating to the provision of services or in regard to a list of matters some of which I referred to in a written question today. What about the significantly higher level of doctor visitation and prescribing to GMS patients over private patients? That cannot be explained away by the supposed inferior health status of medical card holders. We have not heard anything about the virtual non-existence of a dental service for medical card holders although that is a statutory entitlement.
The confusion, costs and duplication in the system of inspection of food and food premises by the Departments of Health and Agriculture has not been referred to. The Minister has failed to insist on up to date audited accounts. It is preposterous that every year we allocate to these health boards moneys where they have not shown — in some cases they have shown with certain unhappy overtones — that they have used wisely or well previous allocations. I suggest that we should insist on an annual report and accounts for the previous full year prepared to an acceptable standard and laid before the Dáil at least 90 days before any budget which includes an additional provision for them is considered by the Dáil.
I asked the Department of Health a long time ago to answer questions about Jervis Street Hospital but the hospital refused to give that information. I am not saying that the Department of Health get sufficient money or that discomfort and  distress is not being caused but some attempt to redress the imbalance is appropriate. A lot of the over-reaction engendered this week is unjustified. In all fairness the general thrust of the Government's policy should be supported although I wish they scrutinised general guidelines on how the cuts are to be adopted.
Minister for Education (Mrs. O'Rourke): I hope Deputy Mac Giolla, and those anxious to contribute, get an opportunity to do so. I am glad to have an opportunity to contribute to a debate which has been conducted in a calm way, particularly in the aftermath of what has been a stressful time for those in the health services and, in particular, the Minister and his officials. The approach which the Government have taken to the funding of the health services in 1987 must be seen in the context of the economic situation in which we find ourselves. The very survival of the country as an independent society requires that firm action be taken to rectify the imbalance in the public finances. It is almost universally acknowledged that this crisis can realistically be tackled only through a reduction in levels of public expenditure. The level of expenditure in recent years has reflected an unrealistically high rate of activity in the public services.
It is a basic principle for the effective development of health services, and one which is maintained by the World Health Organisation, that services should be  effective and delivered at a cost that can be sustained. It is not a realistic option for a community to plan for a level of public services, including health services, which ultimately undermine the very productive base which enables such services to be afforded. This strikes me in my Department. There is a natural aspiration by people towards a greater delivery of services as they expand but sometimes people lose sight of the fact that the only way they can be expanded is through a productive base in the country. If that gets out of hand a halt has to called. The Government are trying to maintain a balance in public expenditure to allow for a modest growth and the maintaining of essential services in all Departments.
The Government are pleased that this prudent approach to public expenditure is already beginning to show results in generating an environment which shows growth and investment. The recent fall in interest rates is merely the first indication of the new situation. In association with prudent economic management the Government have embarked on a comprehensive programme of development to ensure that the productive sector develops in such a way as to improve living standards and the viable public services which are essential for a humane society. We are involved in a complex balancing act between how far we can go in the containment of public expenditure while at the same time running in tandem with that trying to achieve growth in areas that will allow an upturn in economic activity.
In tackling the level of public expenditure the Government are determined to ensure that an adequate level of health care will be provided for the public. They are satisfied that this can be done within the level of resources provided for the health services in 1987 — a sum of £1,300 million which shows an increase on that provided in 1986. The Government would, of course, wish to be in a position to provide a higher level of funding but this simply is not possible. I believe that the majority of Members share this view. What is important now is that the  resources available are managed in the best possible way to ensure an effective and efficient health service for the Irish people.
When Deputy O'Hanlon took office two months ago he advised the various health agencies of their allocations for 1987, allocations which should have been issued by the former Minister. The fact that he did not do so meant that health agencies had less time than they would otherwise have had to make the economies necessary this year. Their task has therefore been made more difficult.
The suggestion that guidelines were not issued to health agencies by the Minister for Health on how they should frame their budgets must be refuted. Nothing is further from the truth. Specific guidelines were issued and elaborated upon at meetings held by the Minister for Health with the chairman and chief executives of all health boards and voluntary hospitals.
Tribute should be paid to the very open manner in which the Minister met immediately with all the agencies involved. There was no skulking in his office. He met them openly and discussed their problems and is doing so even at this moment. He has shown remarkable courage in the way he has faced up to the difficulties he has had to encounter. I take grave exception to the way in which the Minister has been depicted in the newspapers, both pictorially and verbally. The newspapers are not to blame because they only report what they see and what is put in front of them. Panic has been engendered among the public at large and this is not a reflection of a caring attitude towards the sick and those who are in need of services. The fact that one person has been singled out for public odium is reprehensible because the decisions for which he is blamed were taken by the Cabinet as a whole. All 15 Cabinet members played their part. It is crude and clumsy to blame one person who happens to hold the portfolio at a particular Department. This is a point of view I always held during my four years in Opposition. The matter on hand should never be personalised. One may attack  Government policy but never a particular Minister.
Mrs. O'Rourke: I never engaged in a debate in this House with Deputy Barry Desmond. The Minister made it quite clear to the health boards that community care services were to be protected as far as possible, including services for the old and house-bound, services for the mentally handicapped and child care services. He asked the agencies to secure the necessary economies as far as possible in the institutional area and in particular in the acute hospital sector where we have higher bed capacity than we require.
I would also make some observations on the personnel issues surrounding the implementation of Government policy within the health service. Because of the particular manpower structure required within the health services, the instructions issued by the Minister allow a significant degree of flexibility to local management. While individual health agencies are required to reduce numbers employed by a given quantum, there is discretion to provide that key posts becoming vacant may be filled so as to maintain essential service levels. In addition, and where possible, local management will be given a high degree of autonomy in arriving at the appropriate staff mix within their areas of responsibility.
I now refer to the blatant attacks which have been made on those health service staff who work within the clerical and administrative stream. The unwarranted attacks on people in that sector bear no relation to the amount of work these people put into the system. They are being used as a convenient scapegoat by groups who say on the one hand that they support the prudent management of health resources but want on the other  hand to make a public show of apportioning blame. Today they blame the Minister, tomorrow they blame the Department and the following day they blame the administrative staff. They want to be seen by the public at large to be financially prudent and aware of fiscal rectitude because they know it is the plat du jour, but they need to find a scapegoat whom they can blame in their constituencies.
Mrs. O'Rourke: The administrative and nursing personnel and all the people engaged in the maintenance and domestic work make a very important input to the smooth running of a hospital or community care centre. How would Deputies opposite react if they found that their letters of representation could not be answered because of cuts in the administrative and clerical staff?
An Leas-Cheann Comhairle: The Chair can hardly appeal to the ladies for gentlemanly behaviour but they will get the point that the Chair is not impressed by the succession of interruptions and I would ask the ladies to desist.
Mrs. O'Rourke: But may I continue? The Chair is referring to the other ladies. The hype created by the PDs and certain other people in relation to these staff is at best misinformed and at worst malicious. To someone not directly involved with the health services, it smacks of taking an easy and simplistic option. The delivery of health care is a complex task requiring a full range of expertise incorporated in a single team. The clerical person who makes the appointment, collects the charges, pays the allowances and assesses eligibility services, the doctor who provides the treatment, the nurse  who provides the care and the domestic and maintenance staff all have a vital role to play in the efficient and effective delivery of the services. It is quite odious to “ghettoise” a particular group and say that if they were wiped out overnight there would be no trouble in the health service.
Clerical and administrative personnel account for only some 10 per cent of all health service staff and some four-fifths of those who are engaged in the direct delivery of services to the public. They are the people who make the appointments, operate medical record systems, provide reception facilities and act as secretaries to medical consultants, as well as providing the other administrative support services, including the collection of charges, payment of allowances, etc. The remaining very small portion of clerical and administrative personnel function in the headquarters of health boards and other health agencies.
Since the issuing of the allocations, officials from the Department of Health have met the management of each health board and voluntary hospital and they are currently engaged in the co-ordination of the plans of the various agencies to ensure the coherence of the service being provided across the country. The Minister stated earlier that the hospital services division of his Department, with the assistance of Comhairle na nOspidéal, will start further consultations in each health board area next week and that the results are to be considered globally in the Department to ensure that adequate services are provided regionally and nationally. It is difficult to see what more can be done by the Minister to ensure that the actions taken by the various agencies are fully integrated.
Mrs. O'Rourke: I am coming to that. The impact on services should have been  obvious for some time, and it was emphasised by the previous Government in their January Book of Estimates which the lady Deputies opposite wish to forget. Unfortunately, for whatever reason, that Government failed in their duty to take the necessary remedial action both in relation to this year and in relation to the control of expenditure for their previous four years in office. This has placed the present Government in an intolerable position. It is perfectly obvious that the Deputies opposite were part of a Government who wished to impose upon medical card holders a prescription charge.
Mrs. O'Rourke: While the Government have mitigated much of the hardship which would have resulted from certain of the measures proposed by the previous Government, they were never going to be in a position to satisfy all of the demands on the health services. I am under no illusion about the difficulties which face providers of health services in the current year, difficulties which have been caused largely by the mismanagement of previous years. The very tough measures which are required will require tough action by health boards and hospitals but I am satisfied that, despite the economy measures necessary, the level of funding provided is sufficient to ensure an effective health service can be provided and I am heartened by the constructive approach adopted by my own board area who have always managed their own affairs in a very good way.
Mrs. O'Rourke: Everybody is in favour of rationalisation in principle. However, it is clear from some of the contributions made in this House in recent days that many members of the Opposition can cope with rationalisation only in the abstract. Everybody is in favour of having dump sites but not in their neighbourhood. Everybody is in favour of rationalisation but please, Sir, not in their health board area. Once flesh  is put on a proposal they are unwilling to accept the consequences. Was this the reason the Fine Gael Government when they were at that long, secret meeting for six or seven weeks failed to issue the allocations to the health boards? They wanted to run away from what they had to do.
Great credit is due to all concerned for the early publication of the new provision in the VHI scheme. I think it will be taken up by a great many people and will continue to be utilised. In all large organisations potential cost savings can be found through increased efficiency, as Deputy Keating mentioned. The organisations within each structure may need assistance in identifying and implementing these.
Mrs. O'Rourke: With regard to the Sexual Assault Unit and the Child Treatment Unit I was very pleased to hear the Minister for Health this morning — whom Deputy Flaherty seems not to have heard — make very careful reference to the very valuable service which they provide. I have had many discussions with him and I am satisfied that Deputy O'Hanlon as Minister for Health working through and with the health board officials and the various agencies will come to a very satisfactory solution to the problems in that area. However, I find it extraordinary that some of the people involved in that valuable service choose day after day to highlight its problems deliberately when they know clearly that there will be a satisfactory solution to them and the Minister will refer to that here this evening.
Mrs. O'Rourke: Go raibh maith agat.  I want to say one word. I had thought before the advent of the women Deputies into the House that this debate was very constructive and open. I hope this debate today will highlight the fact that the Government's health allocations for this year exceed those provided in 1986. Nothing can take from that.
An Leas-Cheann Comhairle: I indicate to the House now that there are 15 minutes remaining. Ordinarily I would be moving to the Fine Gael spokesperson. The Ceann Comhairle indicated to Deputy Mac Giolla — unfortunately he could not be present this morning — that he hoped that he would be called. Deputy Donal Carey has indicated that he is anxious to speak. Let me indicate that of the 15 minutes remaining, you will have five minutes each. Is the House agreeable to five minutes each?
Mr. Abbot: My understanding is that earlier today the Ceann Comhairle mentioned he would consider Government speakers with considerable leniency having regard to the fact the he opened out the debate when he came back into  the House and I am coming down in response——
Mr. Naughten: It is a pleasure to have the opportunity to say a few words in this debate. I regret the time has to be so short because one could say so much about this important subject. We have been talking here for the past three days about the reduction in the health budget. I have just listened to the Minister speaking and I am shocked at her final comments pointing out an increase in the health budget this year over last year. Of course there was an increase, but we are talking about 3.5 per cent inflation and we need an increase of 3.5 per cent to keep on par.
The increases in my health board, for example, are £200,000 in a budget of £107 million. I heard the Minister say that her health board had come to grips with the difficult situation they face. Let me point out that hers was one of the health boards that got the lion's share of that increase in that they got the second largest increase in the country. That is what has other health boards in a very difficult situation including the Western Health Board of which I am a member. The Western Health Board are faced with the prospect of cutting 470 jobs just now and with depriving vast numbers of people of a medical service in the next few years. I appeal to the Minister for Health to ensure that health boards get an increase in allocation. It is impossible for the health board of which I am a member to survive. We are faced with massive closures in Castlebar, in the Regional Hospital, Galway, in Merlin Park, Galway and the total elimination of services at Roscommon County Hospital. In Roscommon 130 beds are being closed down, 130 nurses and medical staff are  being let go, surgical services are being transferred to Castlebar, medical services are being transferred to Galway Regional Hospital and the surgical hospital is being closed down. Neither I nor other members of the Western Health Board can tolerate this because 55,000 of the population served by the Western Health Board will be left without service. Unfortunately no individual in that catchment area of the health board lives nearer than 50 miles of the Regional Hospital in Galway; some would live up to 100 miles. The Minister has allowed a disgraceful position to obtain within the Western Health Board. I note that the Minister of State at the Department of Finance, Deputy Noel Treacy, is present to seek an additional allocation for the Western Health Board.
Mr. Naughten: If we do not get such additional allocation it will mean that the Galway and Roscommon delegates to the Western Health Board meeting tomorrow will be fighting for the limited resources available. The Minister of State and I know that.
Mr. Naughten: We all know the disastrous effect the closure of Roscommon County Hospital will have on the whole of the Roscommon region, I should appeal to the Minister of State to use his influence with the Minister for Health, between now and tomorrow, to ensure that we are given an additional allocation. Our allocation has been reduced so drastically it will be impossible for us to maintain any level of service within the Western Health Board area. The structure of the services will be totally dismantled. If we do not receive this additional allocation I am afraid that people in Roscommon will die through lack of services because beds will not be available in other institutions in Mayo  and Galway to cater for the population of Roscommon.
I would appeal to the Minister to use his good offices to ensure we are given this additional allocation. He is from the west himself and knows the devastating effect lack of funds will have on the health services there. I know also that the Minister of State, Deputy N. Treacy, is a man of the people. I appeal to him to do likewise.
Mr. Carey: I thank you, a Leas-Cheann Comhairle, for giving me an opportunity to contribute to this important debate. I spoke in this House on the budget and complimented the Minister on being open about his proposals. However, in my contacts since with the local health board I had considerable difficulty in ascertaining what alternatives there were to the Minister's proposals, whether there were any choices available, or how such decisions had been arrived at. I am utterly disappointed that the decision of the chief executive officer of our health board is to close four hospitals in County Clare.
When we were in Government I listened intently on two or three occasions to the present Minister for Health talk about the problems being encountered in Ennis County Hospital. Indeed I was harassed on numerous occasions when I spoke of my support for that hospital. The Mid-Western Health Board now propose to reduce the number of beds in this hospital from 130 to 80. Only last year there was a major investment in this hospital. In addition there was a mammography unit, an ultra-sound machine and other equipment installed in that hospital. There is grave disquiet generally in County Clare about the way these proposals are being handled. Anybody who has seen correspondence about proposals to the Minister will readily appreciate that alternatives or choices have not been considered. In the case of the closure of psychiatric beds in County Clare, had the Minister or the health board offered the relevant institutions to  the private sector to continue the services, then there would be some type of alternative available to the people of County Clare who are appalled at the ham-fisted manner in which these matters are being conducted.
I would appeal to the Minister, who is a member of the medical profession, to take some note of his fellow practitioners who sent me a petition on behalf of the Irish College of General Practitioners. They expressed their shock and disbelief at the proposed cuts in the health services in the Clare area, contending that they are haphazard, unplanned with little consideration having been given to their consequences. That document was signed by the chairman of the Clare branch, Dr. Feore, by its treasurer, Dr. Michael Harty and its secretary, Dr. Michael Kelleher, who incidentally is a member of the Minister's party. He was brave enough last Sunday to hold a collection for Fianna Fáil in Lahinch. At the same time he has appeared on protest platforms all over County Clare indicating his opposition to the closure of Ennistymon Hospital.
The proposals of the Department of Health to contain expenditure in the Clare area has not been thought through. There should be full exposure of the relevant plan and any alternatives so that the public might at least get to grips with some of the difficulties confronting them. For example, a Leas-Cheann Comhairle, if four hospitals were to be closed in your constituency what would be the reaction of the local population? One can readily appreciate the feelings in County Clare with the proposed closure of the St. John of God's maternity unit. As Deputy Ahern said earlier today, the provision of this maternity service in Ennis has been on the cards since 1968. At present some people have to travel 70 miles to Ennis; they will now have to travel 90 miles. The reason for the proposed closure of this unit is beyond me. There are contractual obligations between the Mid-Western Health Board and the Sisters in St. John of God's unit in Ennis which oblige them to provide that service for  ten years with a three-year option of closure. In a submission of the Mid-Western Health Board to the Minister as recently as yesterday they say they will terminate this gynaecology service in Ennis and transfer it to Limerick. There has been no estimation of the cost or any consideration of the obligations involved. The Sisters tell me they will take every penny they can, contending that the Department of Health and the Mid-Western Health Board put them in their present position of being severely in debt. I would appeal to the Minister to have his officials examine the matter of the St. John of God Hospital in Ennis before the Mid-Western Health Board tear it asunder.
An Leas-Cheann Comhairle: I did indicate to Deputy Mac Giolla earlier that I thought he would have five minutes. The Order of the House requires me to call the Minister at 4.40 p.m. Perhaps the Minister would agree to cede two minutes of his time so that I could call on Deputy Mac Giolla.
Tomás Mac Giolla: The Workers' Party have always held — this was contained in a document seven or eight years ago— that the medical services were wasteful in expenditure, that we could have a free, comprehensive health service for the percentage of gross national product we spend on our health services at present. Even if the powerful and wealthy interests entrenched in the system were taken on politicially, if patients were put first, we could have a free, comprehensive service for 7.5 per cent of gross national product.
We believe that the real purpose of the £10 charge is to dismantle the general hospital scheme, replacing it with an insurance-based hospital service for 60 per cent of the population. The Tussing report did propose such a £10 charge for hospital services. At the same time they recommended that there should be a free-for-all general practitioner service introduced. That would encourage  people to go to their general practitioner rather than availing of the provisions of the expensive hospitals scheme. The people who must now pay this £10 charge are those just above the poverty level, beyond eligibility for a medical card, but in receipt of an income of less than £15,000. These are the same people who pay the health contribution of 1.25 per cent of their salaries. Those in receipt of incomes above £15,000 do not pay it. This means that those who pay this 1.25 per cent contribution get less service and now will have to pay the £10 charge as well. People with incomes in excess of £15,000, contributors to the VHI scheme, will have that charge paid for them by the VHI without any increase in premium.
It should be rememberd that health contributions are not collected from the farmers and the self-employed. There are millions outstanding in that respect, with no interest having to be paid on such outstanding amounts whereas interest must be paid on arrears of income tax. We maintain that the 1.25 per cent contribution should be payable on all income. Furthermore, we contend that interest should be paid on outstanding health contributions with a more vigorous pursuit of defaulters. We point out also that there is £33 million tax relief on premiums payable to the VHI, £1.5 million of that relief now being devoted to the care of the élite in the Blackrock and Mater Private Hospitals being borne by the taxpayer. This relief on VHI should be abolished and at the same time eligibility to consultants' services should be extended to all. The £35 million which would be saved by the abolition of tax relief on VHI would be more than enough to pay the consultants for any extra work involved.
I will refer to the fee per item system which we have constantly harped on during the years. It is a blank cheque for doctors and medical practitioners. Doctors themselves have said so. It encourages over-prescribing and should be replaced by a capitation or salaried system along the lines suggested in the report of the Irish College of General Practitioners.
 In regard to drugs we have called for a national drugs formulary. This would be an agreed list of generic drugs — there are about ten brands or more of every drug — prescribed within the health service in order to keep prices down. In regard to the drugs refund scheme, at present in the GMS the State will pay the pharmacist the wholesale price of the drug plus a prescription charge for each item. Under the drugs refund scheme after the initial £28 per month is paid by the patient the State pays not only the wholesale price and the prescription charge to the chemist but also the 50 per cent mark-up price. Therefore, in some instances the State pays the pharmacist more under the drugs refund scheme than it would pay both the pharmacist and the doctor if the patient had a medical card and was entitled to all free services. That is a total waste of money. Before closing hospital wards or axing jobs the Minister should deal with this scandal in the GMS and with the drugs refund scheme because it is in that area that the real savings can be made.
The percentage of GNP on health should be frozen at its present level. The general medical service and the drugs refund scheme should be reformed. Health contributions should be extended to all income levels. There should be a vigorous pursuit of defaulters with regard to health contributions and interest should be made payable on all health contributions. Tax relief on VHI premiums should be abolished immediately for the Blackrock Clinic and the Mater Hospital and eventually, with proper planning, it should be abolished for all hospitals. Rational planning and democratic control of the health services is essential. All these much needed reforms can take place within the present budgetary position. All we require is for the rich to pay their fair share of taxes and health contributions and for the Government to reform the structures of out health services so that they begin to serve the community rather than the private powerful interest groups embedded within the present structure.
 I wish to refer to a document I received by post this morning. It is an extraordinary document, a photocopy of a letter to a Minister — I do not know which Minister — from the Taoiseach outlining the need for further significant cuts in expenditure on the basis that the public sector debt continues to be a burden on the economy. It asks the Minister to identify specific programmes where further expenditures and cuts can be made immediately, as early as this summer. I do not know if that letter was addressed to the Minister for Health but it is calling for further cuts in expenditure in that area. If the Minister for Health has been asked to make further cuts on top of the ones already being made we would like to know what they are.
Minister for Health (Dr. O'Hanlon): First I should like to thank all the Deputies who contributed to this debate today. There is general agreement that we cannot go outside our allocation for this year. That was also highlighted in the debate of the past two nights when both the Progressive Democrats and the Fine Gael Party included in their proposal and amendment that we would not exceed our allocation for the current year. Any disagreement that exists is basically on how the allocations have been made to the health boards and to the voluntary hospitals and the manner in which any savings are being made. It is important that I say again at his stage, because there seems to be some doubt about it, that we gave very strict guidelines to the agencies as to how we expected savings to be made. It is also important to point out that the reason they have a difficulty is because of the £55 million over-expenditure in the past two years. It is accepted by everybody in the House that there was an over expenditure of £55 million; £36 million over-expenditure in 1986 and £19 million over-expenditure in 1985.
Deputy Dukes laid the blame on the health boards which, he said are dominated by Fianna Fáil members. I lay the blame fairly and squarely on the Coalition Government, because section 31 of the Health Act is available to the Minister  to ensure that there is no over-expenditure by the health boards. On the one hand, Deputy Dukes lauded that section and pointed out that the Minister had the power to control spending. I would like to ask why section 31 was not implemented when he was in Government. He maintained that the overruns were due to Fianna Fáil dominated health boards and at the same time he recognised that the Government of the day had the power to control the spending of health boards. he was Minister for Finance for part of that Government's period in office but section 31 was not implemented and therefore we have this overrun of £55 million. That is the basic problem. People come into this House complaining about various cuts in the number of hospital beds or in staffing arrangements but the responsibility lies fairly and squarely on the Government who allowed the over-expenditure of £55 million.
Dr. O'Hanlon: I listened to Deputy Carey speaking about County Clare. In that county no agreement has been reached to date on how savings are to be effected because the health board have not yet finally decided their budget. I met a deputation from the Mid-Western Health Board yesterday and I hope that at their next meeting they will agree on a budget. No decision has been made on what hospitals should be closed in County Clare and therefore we are speaking in a vacuum in regard to what might happen following the meeting of the Mid-Western Health Board.
Dr. O'Hanlon: We will come to that in a minute. The guidelines we issued to the health boards were quite clear and specific. They were to protect community care services, the services for the elderly, the handicapped——
Dr. O'Hanlon: ——and home help services. They were also to ensure that any savings that would be made would be made across every discipline and would not affect just the frontline staff. We were anxious to protect the frontline staff and to make sure that savings would not be made in that area only.
A suggestion has been made that no savings are being effected in regard to administrative staff. From the information I have with regard to the health boards the effects of the allocations and savings are being applied fairly in each area. It is important to point out in regard to the administrative staff that many of them, although not directly in contact with the patient, provide an absolutely essential service. The community welfare officers who are administrative staff are in direct contact with the patients.
Dr. O'Hanlon: Secretaries who are responsible for arranging out-patient appointments, for sending reports of X-rays, typing and sending out reports of tests in hospitals and consultants' reports, telephonists in the hospitals, the persons who process claims for medical cards, the persons responsible for the payment of disabled persons' allowances, all these people are administrative staff but everybody would agree that they are not the people we want to get rid of because, if we did we would not be in a position to deliver this very essential part of the health services. We are monitoring what is happening in the various health board areas but on the information I have at present, I am satisfied they are effecting savings across the board and that each discipline will be treated in the same manner. Every health board received a larger allocation this year than last year.
Dr. O'Hanlon: I accept it was not much larger, but every health board received a larger allocation this year than they did last year. The voluntary hospitals did not receive as large an allocation because of the £55 million shortfall which had to be taken into account. The health boards received a larger allocation this year in order to protect the community care services because that is fundamental——
Dr. O'Hanlon: It was less than they spent because the Coalition Government allowed them to overspend £55 million. We accept that. We have been saying that for the last month. This is the cause of the problem. They got a larger allocation from this Government than they got last year.
Dr. O'Hanlon: The health boards made the decisions where the savings should be effected and I defend my decision to allow them to decide how these savings would be effected. Let us take the South-Eastern Health Board. I think it was much more appropriate that elected public representatives and persons representing those working in the service — medical, nursing, pharmacy, dentists and so on, all these go to make up the health boards — should decide what the priorities were for the South-Eastern Health Board rather than a Minister. If I were to go over the heads of the South-Eastern Health Board — which I would not have the right to do because they have statutory responsibility in this area — and made that decision, I would be told I was being dictatorial and that I was not taking account of the needs of the local people.
Dr. O'Hanlon: I make no apology for defending the fact that the health boards  were given the opportunity, and took it, to decide what their priorities were in their own area. It is the health boards who decide policy.
Dr. O'Hanlon: ——a team of senior officials from my Department went to every health board and all 52 voluntary hospitals to discuss how they intended to effect the savings which were necessary this year. They brought all that information back to the Department and have prepared a report which I am studying at the moment. I have to ensure that we have an adequate and proper health service in place and that there are no gaps because of the way the voluntary hospitals decided to effect the savings.
For example, if all the voluntary hospitals in Dublin decided to close the ear, nose and throat departments we would not have an ear, nose and throat service and this would be entirely unacceptable. We are examining how each agency and health board intend to effect their savings and if there are gaps we will look at them to ensure that a proper medical service will be available.
We are waiting for the Western and Mid-Western Health Boards to finalise their budget arrangements. When that is done I will send a group of senior officials to those areas to bring together in a consultative process the health boards and the voluntary hospitals and create an opportunity for the voluntary organisations and the staff interests to make their input into how they see the money should be spent in that area. We want particularly to bring together the health boards and voluntary hospitals to ensure that there is some rationalisation in the  services they administer. I am sure everyone will agree that it is essential that we get value for money, and that process will be starting almost immediately, probably next week.
Following that we will have a national conference on the health services. We know exactly what has to be done. I have already announced that we are setting up a review body to look at the funding of the health services. Everybody must agree that the Exchequer is not in a position to provide the necessary funding to ensure that all the services people wish for will be in place. I will be announcing the names on that committee within the next ten days.
Dr. O'Hanlon: Concurrent with that review, we will be looking at the rationalisation of the acute hospital system and we will be making a decision on that. The primary health care services, health promotion and preventive services and the managerial arrangements at all levels in the system need to be improved. All this appeared in our programme for national recovery. There is nothing new there. Anyone who read our document before we went to the electorate will have read all about this. I listened to Deputy Dukes this morning and he said I had not said anything about looking at the structures of the health board and how the services were managed. There it is in our election document.
Dr. O'Hanlon: This morning Deputy Dukes suggested we should reduce the number of health boards. Yet when Deputy Desmond, in Government, brought forward a plan to reduce the number of health boards, he got no support from Fine Gael. I believe it is appropriate to ask why they have changed their mind now.
I believe we need a devolved administration in the health boards and I am prepared to look at the structures within the health boards to see how management can be improved. I have always had a reservation about whether there should be strict demarcation between the programme for community care and hospital care. I believe if you are serious about shifting resources from hospital to community, there should be an integrated programme rather than two separate compartments. These are the types of areas we will be looking at.
Deputy Kemmy raised the question of consultants and the common contract. I have already spoken to the IMO and intimated our desire to see the review of a common contract commence. Deputy Desmond suggested their might be a select committee of the House on the health services and I will consider that suggestion. Whether in Government or in Opposition we all try to ensure that we deliver the highest level of health care for the people we represent. The Government are providing £13,014 million this year for our public health services. With the numbers of people working in the health service — up to 60,000 — we will provide a proper and adequate service. The people have no need to fear. In spite of the hype which has been causing anxiety to patients and their relatives, I am satisfied we will provide a proper level of health care this year.
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