Social Services Minister Dr. Clarence Terceira told the House of Assembly yesterday.

He said: "Most effort at reform has focused on controlling costs and also on access to health care.

"The Island's health care system is changing and facing a number of pressures withing the system.

"These include an ageing population, substance abuse and AIDS amongst them.'' Dr. Terceira was speaking as he put the massive Health Care Review -- which runs to 250 pages -- up for debate by MPs.

He said overuse of King Edward VII Memorial Hospital's emergency department, an increase in medical malpractice actions and advances in technology all contributed to rising costs as well.

In addition, rising expectations in a better-informed community added extra pressure on cost and resources.

He said: "The consumer and the provider should in fact assist in trying to control costs, but also they have the difficulty of an increase in expectations and technology as well as the need or request for continuing tests which, of course, escalates the cost of health care.'' He added: "The system is somewhat fragmented -- we need to pull these fragments together and have a better understanding of what these parts are and try and do away with as much duplication as possible.'' Dr. Terceira added: "The consensus that Government and the community cannot continue to provide unlimited health care is certainly a challenge.'' And he said: "The present system is of a high standard -- but then we found areas which are fragmented and not coordinated.

"But there is no doubt there should be, if possible, quality care at affordable prices. That has to be the priority of any health care system.'' Dr. Terceira said increased education aimed at healthy living could cut the need for medical care -- especially a programme aimed at the elderly, who are expected to be a major contributory factor to the cost of medical care over the next few years.

He added a major conclusion of the review was that a Bermuda Health Council should be set up to help control costs and regulate the health care system.

But he said one of the failings of an "excellent'' report was a failure to tie the Health Council in with Government.

Dr. Terceira added 75 percent of Bermudians had major medical insurance cover -- but that usually ended at retirement and the insurance industry was currently examining that problem.

He added it had been recommended that the subsidy for the elderly should be increased to 100 percent from its current maximum of 90 percent for after the age of 75, while removing the subsidy for the young -- but gradually increasing parental premiums.

Dr. Terceira, however, said he would like to see free health care from birth to the age of two to continue because, although young people were generally healthy, if there were serious problems they would generally show up before the child's second birthday.

Shadow Health and Social Services Minister Renee Webb said she did not think Bermuda had a first-class health care system.

She said it was a "good community-type'' system on a par with a small town in the US.

And she added that there was a "negative public perception'' of health care on the Island -- which was part of the reason for the review being undertaken in the first place.

She said: "We would like to make it first class and the report is trying to do that -- but I don't think we are there yet, which is what the report points to.'' She said Bermuda, at nine percent of gross national product spent on health, fell between Britain, at six percent and the US at 12 percent.

But she added that the cost of care on the Island had gone up by one percent from eight percent between 1993 and last year.

She added there was an artificial element in pricing, with the high cost of over-utilisation of the KEMH emergency department being used to offset care for indigents.

And she pointed out that tight controls on pricing and a Bermuda Health Council with wide-ranging powers would not necessarily be welcomed by health care professionals.

She added that over one period, the cost of living index went up by around 10 percent while the cost of healthcare went up by 42 percent.

Laws were needed to govern people setting up in para-medical practices and charging high fees after completing "only two week courses'' abroad.

And she said: "There have been a few horror stories about some of the goings-on in some of the rest homes in Bermuda.'' She also noted the low cost of care in rest homes and said many elderly people would prefer that or a home care environment.

Ms Webb said Social Assistance cover should also be considered for full-time caregivers in a family home setting.

She added that effective preventative programmes were vital in ensuring a healthy population less likely to suffer serious illness as a result of bad practices.

Extending health care insurance to retirees was an "excellent idea'', but she questioned whether insurance companies would welcome such a scheme.

Concluded on Monday Dr. Clarence Terceira