Tuesday, 1 June 1965
Dáil Eireann Debate
That a sum not exceeding £11,488,900 be granted to complete the sum necessary to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1966, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.
The Estimate which we are now discussing is not that which is printed in the Book of Estimates, but the one in substitution for it which was circulated last week. I hope Deputies will not find this confusing. The purpose of the substitution is to show the reduction, from £1 million to £500,000, in the provision for the Grant-in-Aid to the Hospitals Trust Fund in Subhead K. This reduction follows the Budget adjustment of the capital programme. The opportunity presented by this substitution has been taken to show, in respect of last year, the effect of the adjustments made by the Supplementary  Estimate taken in March last, after the printed volume of Estimates for 1965-66 was prepared.
I am grateful to the House for facilitating me in taking, in conjunction with the main Estimate, the Supplementary which was introduced only this afternoon and which, I understand, has now been circulated to Deputies.
On the details of the Estimate which we are discussing, and on the work of my Department, I do not intend to speak for very long. I have only recently taken up office as Minister for Health and it would be inappropriate that I should review in full detail, as is usually done, the work of this Department during the past year. I have, instead, arranged to let Deputies have tables of the most important statistics which were customarily referred to in the Estimates speech. These, I hope, they will find useful.
Neither do I propose on this occasion to speak to the House on future plans for further developments in the health services. Since taking up office I have devoted a large part of my time to reviewing, comprehensively, all aspects of the services. I have had preliminary discussions with certain interested organisations and am arranging to meet others. When this review is completed, I hope that the House will have an opportunity of debating the future of the services and I hope that you will bear with me if, today, I do not deal with this issue.
Without taking away from what I have just said, there are a few matters which I feel I should mention specifically. The report of the Commission of Inquiry on Mental Handicap is one of the most significant of these. This report was presented to my predecessor at the end of last March, and is at present being studied. The various organisations providing services for the mentally handicapped, and other interested bodies, have been asked to submit their views. The Government's intentions with regard to the recommendation in the report will be announced at the earliest possible date. Those Deputies who have read the report will, I feel, agree that it is a monument to the diligence and public spirit of the members who devoted so much  time and energy to work on the Commission.
Mental handicap is a vast problem. In recent years, it has evoked a tremendous upsurge of public interest, manifested in the activity of voluntary associations. These can play a highly important part in moulding public opinion, in assisting the work of special institutions for caring for the mentally handicapped and in the provision of material benefits for the institutions and the patients. We must hope that, whatever Government action is decided on as a result of the report, these bodies will not reduce their efforts as, in this field, voluntary helpers activated by charity can very often do more than public bodies.
Action on improving the services for the mentally handicapped is, of course, continuing, while we are completing our study of what should be done on the basis of this report. We have more than trebled the accommodation in special institutions for the mentally handicapped since the Department was established in 1947. There are now over 3,000 beds in these institutions and a further 700 are being provided or are being planned at the moment.
In the past, tuberculosis has been one of the salient topics referred to in the Estimate speeches of the Ministers for Health. This disease is not such an outstanding cause of death as it once was, but it is important that the public should not lull itself into believing that the dangers from tuberculosis have disappeared, or virtually disappeared. On 31st March last there were still 1,326 beds occupied by tuberculosis patients in hospitals and, in 1964, the number of deaths from the disease was 366. A detailed analysis of these statistics shows that the rate of fall in the numbers of tuberculosis cases aged 45 and over has been relatively slow in recent years. People in the upper age groups are forming an increasingly higher percentage of the total number of tuberculosis cases. This may, in part, be due to an assumption on the part of the public that tuberculosis is a young person's disease and to reluctance on the part of older people to take the necessary steps to guard against it. In particular,  it is the experience that people over 45 are slow to present themselves for periodic X-ray. I am advised that if it were possible to get every adult to come for X-ray annually, and thus ensure early and rapid treatment when the disease is found to be present, tuberculosis would very soon disappear entirely as a major public health problem.
I would make a special plea for full response to the mass X-ray community surveys. These surveys, which aim at a complete coverage by X-ray of everyone over the age of 12 years in the areas selected, are a most important element in the programme for the elimination of disease and they cannot be regarded as a success unless the response is close to 100 per cent. The response has been far from this in a number of areas. I hope that, for the future, we will see better use being made of this service, as, indeed, of all the other available preventive and curative measures in relation to this disease.
Early this year, it was decided, following consultation with the Medical Research Council, to substitute oral vaccination against poliomyelitis for the earlier vaccination by injection and to offer this oral vaccination free for everybody in the age group from six months to 18 years, which is the most vulnerable group.
I am glad to be able to report to the House that the response to this new scheme has been excellent. The full course of oral polio vaccine consists of three “feedings” on a lump of sugar or in a spoon of syrup, given at intervals of some weeks. The scheme commenced in March and, of the million or so children eligible, over 80 per cent have received their first feeding. However, there are still 20 per cent or so of all the children in this group who have not commenced the course. I would appeal to the parents of these children to arrange, without delay, for them to do so during the current public sessions, or by special arrangement with the chief medical officer for their area or their family doctors.
 I would also urge those parents whose children have commenced the course to make sure that they complete it, and thus secure the full protection against this disabling, and often fatal disease. The second feeding commenced within the last few weeks and, so far, over half a million children have had this feeding.
There were 28 deaths in 1964 arising directly out of maternity. While this represents a considerable improvement on the position even a few years ago, the death of a mother in child-birth is especially tragic, and the occurrence of even this small number of maternal deaths is a source of considerable concern to us all. A while ago, the Irish Medical Association, after discussion with my Department, set up a Committee of the Association with the object of investigating, if possible, every maternal death in this country. I have recently been presented with a copy of their report for 1964 and my Department has commenced, in conjunction with the Irish Medical Association, an examination of the lessons to be learned from it with a view to reducing, still further, the deaths from this cause. It is clear, by comparison with neighbouring countries, that there is still scope for reduction.
In the field of mental health, we are awaiting the report of the Commission on Mental Illness—due later this year —before making any comprehensive plans for changes or developments in the services. However, here, again, I would not like the House to think that work on improving the present services has slowed down. Desirable changes, particularly when we can reasonably assume that they will not be at variance with what the Commission might recommend, are proceeding all the time. For example, an interim suggestion from the Commission of Enquiry that psychiatric in-patient units should be established at General Hospitals has been taken up and I am glad to say that the Waterford Health Authority, who were approached in the matter, have readily agreed to establish such a unit at Ardkeen General Hospital. Some staff difficulties delayed the opening of this unit, but these have now  been resolved and the unit will be opened for the reception and treatment of psychiatric patients in the present month.
The Galway County Council were approached with a view to establishing a similar unit in Galway. Progress has not been so good there but I am not without hope that it will be possible to arrive at a satisfactory solution soon.
The mental health services in Cork have been the cause of great concern, both to the health authority and to my Department. There are about 2,300 patients in the Cork Mental Hospital, and there is considerable overcrowding in substandard accommodation. In these conditions, it is impossible to provide anything resembling a proper therapeutic environment in which the patients will have every opportunity to be helped—and to help themselves—to overcome their disabilities. There is now general agreement as to the lines of an interim solution to the pressing problems in this area and it is intended that steps will be taken urgently to improve the services.
Early this year, the Hospital Sterile Supplies Board was established under the Health (Corporate Bodiés) Act, 1961 to provide, on an effective and economical basis, the supply of packaged sterilised requisites, initially to the Dublin hospitals and later to hospitals throughout the country. The board has been actively engaged in making the necessary arrangements to obtain premises and staff and I understand that they hope to start the service in a matter of months. This undertaking is the outcome of most welcome co-operation between hospitals and will, I hope, lead to other desirable forms of joint effort. One of these which is at present under consideration is the establishment, in the interests of efficiency and economy, of a central laundry for the voluntary hospitals, or for a number of them, in the Dublin area. The views of these hospitals on this proposal are being sought. Hospital costs are increasing at such an alarming rate that hospitals must make every effort to cut out waste and overlapping.
The numbers availing themselves of  the protection given by the schemes of the Voluntary Health Insurance Board against the cost of hospital treatment continued to grow. Subscribers and their dependants now total about 230,000.
The Voluntary Health Insurance Board have been studying the incidence and extent of expenses relating to illness, incurred otherwise than in relation to in-patient treatment in hospital, to which the Board's schemes are at present limited. They have carried out amongst subscribers a survey of expenses on treatment outside hospital and have obtained much valuable statistical information. I understand that, in the light of the results of this survey, the Board are examining the possibilities of extending their schemes to provide some protection in relation to the cost of illnesses treated outside hospital. I should say that I would personally be very much in favour of such extensions, if they are found to be practicable, and I am myself studying the scope of the services provided.
Before passing from the Voluntary Health Insurance Board, I would like to take this opportunity to pay a tribute to the late Mr. Noel Burke, who was General Manager of the Board since it was established. He was also Chairman of the National Organisation for Rehabilitation since it was founded in 1955. Mr. Burke's energetic and dedicated devotion to the successful development of these bodies was widely recognised. His untimely death was a loss not only to those organisations but to public life generally.
This year has been designated by the Irish Red Cross Society as the Old People's Year, with the object of focussing public attention on the problems of the aged, of encouraging voluntary charitable organisations to co-operate, so that a more co-ordinated service will be provided for old people, and of directing into practical channels as much as possible of the great good-will which exists but remains non-effective at present. The care of the aged is undoubtedly one of the great problems of our time. It will be dealt with in the general review of the health services which I am at present undertaking, but there are a  few observations I would like to make on the matter on this occasion.
Health authorities are playing a considerable part in dealing with the problem by maintaining old people in institutions, mainly the county homes. Substantial progress has been made in recent times in the improvement of the accommodation for the old in county homes.
There is a matter, which is not in my brief, to which I should like to refer at this juncture. It is a matter of tremendous importance to me as I am sure it is to all Deputies. In regard to the matter of county homes, I should like to mention a change which I propose to make in the arrangements for collecting contributions towards maintenance for those receiving institutional assistance. A person is now allowed to keep out of any income he has a sum for personal use—for the purchase of tobacco and similar requirements. The minimum sum which a person is now allowed to keep for this purpose is 10/- a week. I propose to make regulations providing that this minimum will be increased to £1 a week from next August and that, in addition, he will be allowed in all cases sufficient to meet any commitments he may have for fixed charges, such as rent or hire purchase payments.
Mr. O'Malley: However good or comfortable an institution may be, the best place for an old person is at home. The substantial increases in old age pensions announced in the Budget will make it possible for many to remain at home who otherwise, through economic necessity, would have to look for institutional assistance. So, also, in time will the provisions for special housing of the aged in the Local Government housing code, particularly when supplemented by increased attention by health authorities to the medical and nursing needs of these old people who remain in the community.
Certain local authorities have shown commendable initiative in reviewing their functions in regard to the old  people on the basis of a very broad approach. They are taking comprehensive steps to make sure that the aged in their functional area are not regarded merely as a health problem, or a housing problem, or a social welfare poblem, but as members of the community who need certain services and certain assistance which the local authority, in its widest aspect, can command and bring to bear as representatives of the community, supplementing but not supplanting the effort of individuals and of charitable groups alike. This comprehensive approach by local authorities has as yet developed in only a few areas, but where it has been done, it has shown that the local authority, when it approaches this problem in this broad way, can play a very important part in succouring the aged.
Having mentioned what has been done by some local authorities, it is but fitting that I should here pay public tribute to what is being achieved, in this field, in Kilkenny, through the initiative of Most Rev. Dr. Birch, Bishop of Ossory, even though the Kilkenny scheme is not directed specifically to the care, in the community, of the áged, but embraces all underprivileged groups. As far as I personally am concerned, the care of the aged will be an urgent priority.
The statistical tables which I have circulated show the main features of developments in the building and reconstruction of hospitals during the past year. I do not, at this stage, intend to discuss any details of the various projects which are under way or which have been planned, but I do propose, in the near future, to have a look at our hospital building programme as a whole, with a view to seeing whether it is necessary to make any changes in it, or to see whether any special projects might be pushed ahead at this stage. However, I think in this respect we must remember that it is not practicable to set out a real list of priorities until we know what the capital requirements for mental treatment might be after we have had an opportunity to examine the report of the Commission on Mental Illness.
To turn to the Estimate itself, I am  sure that Deputies will not wish me to explain, in detail, each of the variations in the figures under the various subheads since last year. I propose merely to refer to some of the more important aspects of the Estimate. The total amount of the Estimate has increased from £14,688,051 for the year 1964-65 to £15,308,900. Most of this increase comes under Subhead G, which is the large subhead containing provision for grants totalling £13,722,000 to health authorities in respect of their revenue expenditure. This is attributable mainly to revisions of remuneration of local authorities' staffs and the staffs of voluntary hospitals, this latter being reflected in increases in the capitation rates paid by the local authorities to those hospitals.
This increase does not, indeed, represent the final picture. There are certain further adjustments of remuneration still in train, and it is expected that when they are completed there will be a further increase in the expenditure amounting to, perhaps, £1,000,000, and in grant to nearly half that figure. It will be necessary for me to introduce a Supplementary Estimate later in the year to cover this increase. That Supplementary Estimate will also include provision to cover the increases announced in the Budget in Disabled Persons (Maintenance) Allowances and Infectious Diseases (Maintenance) Allowances which will be payable from August next. Adjustments in salaries have also accounted for the increase under Subhead A, which covers the salaries of the staff of my Department.
The Supplementary Estimate circulated today is to make provision for paying grants to health authorities, during the current financial year, to cover 50 per cent of the capital cost of their fluoridation programmes. The ordinary day-to-day operating cost of fluoridation already reckons for recoupment from the health services grant. Until now, there was no provision for grants towards capital equipment. I have received representations from a number of local authorities for some relief towards meeting the initial cost of their fluoridation installations.  Bearing in mind that local authorities may obtain from the State a substantial subvention towards the cost of new public water schemes, and that fluoridation is essentially an improvement to the public water supply, I have felt that I should come to the assistance of local authorities in meeting the extra capital cost of fluoridation. The Supplementary Estimate provides accordingly and covers not only expenditure which will be incurred in the present year but also capital expenditure incurred in previous years. The rate of recoupment will be 50 per cent of approved expenditure.
Finally, in introducing this, my first Estimate as Minister for Health, I should like to say that, having had some opportunity of seeing the complexity and the range of the services which my predecessor, Deputy MacEntee, administered for over seven years, I have the highest admiration for the tremendous work which he did. I can only hope that I will succeed in achieving the same high degree of administrative competence as he showed.
Mr. D. Costello: We appreciate why the Minister did not wish to take the opportunity at this stage to outline his proposals for the future development of the health services. I hope he will appreciate why we wish to take the opportunity to do so. In fact, we have considered in very great detail the whole operation of our health services, and we have published in great detail the radical reforms which we think are necessary in our health services if we are to give the services to which our people are entitled.
I hope the Minister will pay attention to the suggestions we have made in the consideration which he will be giving to the future development of our health services. He can expect from us complete co-operation in the reforms which we think necessary, but if, on the other hand, in carrying out the review which is to be made, he brings forward proposals which are merely palliatives, or which amount to mere tinkering with the problem, he can expect from us only our vigilant criticism. I should also say that if he  attempts to stop reforms, or to block reforms, in the rather callous way his predecessor did, he need not expect any co-operation from us at all.
On many occasions we have reiterated what we think are the glaring defects in our present health services. Those defects are known to anyone in the lower income groups who has had the misfortune to come up against the services and they should be known to every Deputy and every public representative.
The criticisms of the means test which have been made over the years are, I believe, fully justified. In many cases the application of the means test is carried out in such a manner as to be degrading to the applicant for the blue card. In its administration there are considerable delays, and delays occur in the renewal of medical cards which involve the unfortunate patient in uncertainty, distress and worry. As is generally known, there is great inequity in the assessment of entitlement to the blue card in different parts of the country.
Figures given by the Minister's Department to the Health Committee during the previous Dáil show that 11.9 per cent of the population of Dublin city are covered for free treatment. In Waterford city 56.6 per cent are covered, and within Waterford county, 52.9 per cent are covered for free treatment. Across the border in Tipperary, South Riding, only 32.1 per cent are covered. Certain discrepancies in the figures can be explained by a difference in the standard of living in different parts of the country, but the disparity is so great that different standards of living are not the only reason for these disparities. It is obvious that different standards are applied in different parts of the country, and that, in fact, people do not get fair treatment. It is obvious that as the system is operated, it is not operated equitably.
Of course, very high administrative costs are involved in the operation of the means test. Those costs are not only to be found in the local authorities and the Department of Health but  also in the hospitals themselves, who have to maintain quite a large staff to fill in the many forms and operate the many regulations in the required manner.
Apart from the indignities and inequalities involved in the means test, there is the glaring fact that under the present system 30 per cent of our population have no choice of doctor at general medical practitioner level. The lower income group now covered by the 1953 Health Act is roughly 30 per cent of the population and for these people there is no choice of doctor. I am sure every Deputy is aware of cases where people have lost faith in their local dispensary doctor, not perhaps through any fault of the dispensary doctor but because human nature being what it is, people, particularly sick people, can easily lose faith in a doctor and for these people there is no alternative but to pay for medical services and, in addition, pay for the drugs which may be recommended. In fact, this is happening very frequently. There are poor people who have to pay for medical services because they do not for one reason or another avail of the dispensary services made available for people in the lower income group.
While the criticism I am about to make does not apply so much in the city of Dublin, undoubtedly in the country districts dispensaries are placed in positions inconvenient for those who may wish to avail of them. People may live on the borders of a county or dispensary district and find themselves within a short distance of a dispensary they might like to avail themselves of but are prevented from doing so.
I believe these criticisms of our health services are fully justified and any scheme which would assist in remedying them should be carefully considered. The criticisms of the workings of the Health Act apply not only to the lower income group but to the middle income group which comprises the majority of wage earners. We are the only western European country except Finland who make no provision in our public health services to cover the expenses of general medical practitioner care for the bulk of our population. The position at the moment is  that the vast majority of our wage earners have to face, in the case of illness of themselves or their families, heavy bills not only for general medical practitioner care but for hospitalisation as well.
As is well known, there is the curious situation that if a person needs treatment in the out-patient department and if he is in the middle income group, he has to pay for it. He has to pay for any surgical appliances that may be advised by his doctors and for any operations that may be undertaken in the out-patient department and this happens very frequently. The result of this situation, I believe, is that there is gross overcrowding in our hospitals because in fact a great many people are brought into hospitals who do not need to go there. They are brought in out of the kindness of heart of the hospital authorities who say that if they are treated in the out-patient department they will have to pay for the appliances and the drugs but if they are treated in the hospital, they will get specialist services and appliances free.
This happens also in the sphere of voluntary health insurance and the result is that a great many people are in hospital who need not be in hospital. This is one of the effects of the operation of the Health Act and it involves very heavy extra expenditure not only for the hospitals but for the local health authorities and, ultimately, the Department. There are other anomalies in the health services which I hope the Minister will carefully consider. There is the position of old age pensioners who will not get benefit if the income of the family is such as to disentitle them to it.
There is another area crying for reform. It is the school medical examination which is, to a very large extent, a farce at the moment. A child is examined three times in its school life. There are no proper facilities for the examination; there is no privacy in the examination; there is no guarantee a child may be ill when the examination takes place; and, as everybody knows, the health authorities are grossly understaffed and the examinations carried out do not in fact represent a proper service.
 I have touched only on the areas where I believe the defects are so obvious and require remedies. In the consideration which Fine Gael gave these matters, we believe there was one solution which would remedy these defects and we have suggested an extension of the idea of national insurance in the sphere of health and have recommended the establishment of a comprehensive national health insurance service.
It is to be strongly regretted that our proposals were criticised in the heat of the general election in the way they were. I sincerely hope the Minister, in his review of the health services and of the way in which reform can be made, will forget the ill-considered criticisms made. The Taoiseach and the former Minister for Health criticised our suggestions and used the nonsensical phrase that the health insurance proposal amounted to a poll tax.
There is only one way we can extend the health services to give the people what they need, that is, through health insurance. They have done it in other countries. There is no way in which we can bring about the necessary reforms unless we use health insurance and I give the Minister a guarantee, not only on my own behalf but, I feel certain, on behalf of all my colleagues, that we shall forget what the Taoiseach and the former Minister for Health said about the insurance principle and shall not refer to it again if in fact he accepts this principle and brings it in because there is no other way of doing it, taking into account the standard of health of the country, our system of payments to the health authorities and the general level of taxation.
If the Minister adopts this principle, he will get our full co-operation. The suggestions we have made would in fact get over the defects, the crying deficiencies, in our present system. If we had a system of health insurance, it would mean there could be a free choice of doctor for all. It would mean there would be free treatment in hospital for all insured persons. It would mean giving a free general medical practitioner service.
 When I say “free,” of course I know Deputies will understand exactly what I mean. We have never said the services can be provided otherwise than by health insurance and have suggested that the people would willingly accept the need for weekly contributions in respect of the services they would be given in return. We believe this is practical and that it can be worked so that the poorer sections, the social assistance class, may not have to contribute and that farmers with poor law valuations of under £15 may contribute nothing.
So, too, in the realm of child welfare, we believe very radical reforms are necessary. At present the health authorities are obliged to provide clinics only in towns with populations of over 3,000. There are many areas where there are no proper child welfare services. We have suggested and advocated the establishment of child welfare clinics for all children, from birth to the age of 16, and which should be available not just for children in national schools but all children, including those attending vocational and secondary schools. Such clinics could be staffed by the district nurse, a social worker and medical personnel, and reference could be made, when necessary, to local doctors from the clinics, or to hospitals as the case may be. We have also suggested that this country is suitable for a service, which has operated in other countries, particularly France, of mobile welfare clinics, because there are many outlying areas from which mothers cannot bring in their children without great hardship to themselves and the children. The system of a mobile service is working well in France and could be operated here without too great a cost and in areas where the need is most great.
The Minister in his opening remarks referred to the work being done in Kilkenny under the auspices of the Rev. Dr. Birch. This is remarkable work. We have in fact suggested an extension of the idea being undertaken there to the whole country. This is why we have suggested this domiciliary  welfare service which we believe is so urgently needed. The case of old people is of course one of the prime needs of the present time. There are a little over 32,000 people over 65 living alone. Such a domiciliary welfare service could operate a home help service for these people. This has been developed in Northern Ireland but it has not been developed in this part of the country at all. It is not an expensive service to operate but it would require skilled social workers such as we have suggested in the domiciliary welfare service which we think should be introduced.
The Minister referred to the Commission of Inquiry on Mental Handicap and I think the thanks of this House and of the public generally are due to the members of this Commission who have reported so excellently and thoroughly on this very important problem. This report clearly indicates the urgent need for immediate action. It is not possible to ascertain the exact number of mentally handicapped people but carrying out a review of conditions on the most scientific basis possible, the Commission have indicated that as a target we must produce for our mentally handicapped people facilities based on the following figures: for severly handicapped, all ages, 2,750; for moderately handicapped children, 1,400; for mildly handicapped children, 5,000; and for moderately and mildly handicapped adults, 8,000. Our facilities fall far short of these figures and it is common knowledge to many public representatives, apart from members of the medical profession or of local authorities, that there are children living at home who should in fact be in institutions, who are in need of care and of expert help which they are not getting at present.
How are these services to be organised? Voluntary organisations—and by that term, I mean the lay as well as the religious organisations—have, with one exception, been responsible for providing facilities for the mentally handicapped in this country. Only one health authority has in fact provided a service, and an excellent service it is. Apart from that, all the services either  in the form of residential care, or in the form of day-centres, or five-day residential centres, have been supplied by the voluntary organisations. We have got to face the fact that the provision of services for the mentally handicapped will require active co-operation between the State and the voluntary organisations, that the voluntary organisations without the assistance of the State cannot provide them. We must also realise that the State must provide the services in areas where the voluntary organisations do not do so.
This is an important principle which we must accept and it is one which the Minister's Department and the Minister's predecessor have not accepted up to the present. In the memorandum which the Department sent to the Select Committee, dated September, 1962, it was stated in paragraph 31:
As indicated at paragraph 22 all the institutions caring for the mentally handicapped are run by voluntary organisations. This has been found to be a satisfactory arrangement and while there is no legal barrier to prevent a particular health authority from setting up an institution of its own for the mentally handicapped, the Department would favour an extension of the activities of the voluntary organisations.
It was clear from this that the health authorities were not going to build institutions. This is a principle which we cannot accept. This is not an area where we should get into matters of principle and talk about the value of voluntary organisations and the iniquities of State institutions. What is involved is a question of a partnership between voluntary organisations, doing excellent work, on the one hand, and the State, on the other. There is an obligation on the State to provide the services where the voluntary organisations cannot do so. If in fact this view that was expressed to the Select Committee prevails, we will not get the expansion of the services which the Commission so clearly indicated was necessary.
Part of the difficulty of providing the services for the mentally handicapped has been the considerable  diffusion of responsibility for this problem. Is this a health problem? Is it an educational problem? Is it a problem of social welfare? The White Paper produced by the Department entitled The Problem of the Mentally Handicapped indicated this disparity of view as to whose responsibility the provision of services was. At paragraph 16, after referring to day-centres for ineducatable children, it states:
Because of the type of service they provide, these last-mentioned enterprises, providing centres on the basis of attendance for portion of the day, do not clearly fall within the ambit of the functions of the Minister for Health. Neither could they be said to be educational establishments and, as such, to come within the responsibility of the Minister for Education. It could tenably be argued that, as the centres provide care for mentally handicapped children many of whom cannot be educated or trained, and thereby provide relief for the parents of the children, they should be considered the concern of the Minister for Social Welfare. The Minister for Health has, however, accepted responsibility (under the Ministers and Secretaries Acts) for somewhat similar groups such as senile and infirm persons and unmarried mothers and their children; it might, therefore, be appropriate for that Minister likewise to accept responsibility (ministerial) for these day-centres on the grounds that they fall more nearly within the ambit of his functions than elsewhere.
But this lack of responsibility is not just merely an academic point to be made in a debate; it works in real life in the services not being provided because in fact persons connected with the voluntary organisations know full well what happens.
They know that you negotiate with the Department of Education for your teachers' salaries and for the provision of teachers and for the transport costs, and you negotiate with the Department of Education for the building costs of a new school or the repair costs of an existing school. You are then concerned with the Board of  Works for the planning. You go on the next part of your rounds to get help through the local authority or to get assistance in the way of the medical or nursing staff involved. In Dublin, you deal with Dublin Corporation for school meals. In fact, a great amount of time, talking in terms of years, has elapsed before these negotiations bear fruit. I do not want anything I say to be regarded as any reflection on public officials who have to deal with these problems because I think it is the general experience that nothing but understanding and sympathy is obtained from these public officials, both in local authority and Government Departments, who are concerned with this problem. But the fact is that the whole system is such as to bring about delays which are unnecessary and which, in fact, result in the provision of services being so long delayed that in some instances they are not supplied at all.
We made reference to the problem of sheltered workshops. They have in Cork an excellent sheltered workshop started by a local organisation. What authority in Dublin is responsible for the provision of sheltered workshops? Is it the health authority, the Department of Education? The Department of Health cannot do it. Is it Social Welfare? Nobody takes responsibility, and the sheltered workshops are not put up. If, in fact, the local associations concerned with this problem set out to do something, they do not know which Department to go to.
This brings me to what I believe to be a very necessary reform in our whole setup in regard to mental handicap. We in Fine Gael believe there should be established a special statutory body charged with the responsibility of providing, or alternatively seeing to the provision of services for the mentally handicapped. Such a statutory body would co-ordinate the existing services: it would avoid the administrative delays that exist at present. It would establish services in areas where voluntary organisations at present are unable to do so. The Commission in its report indicated the necessity for co-ordination and suggested that an institution for the mentally handicapped be established. It  seems to me it should have gone farther and that what we need is a statutory authority responsible for the provision of services because the present setup and the diffusion of responsibility between health authorities, the Department of Health, the Department of Education and the Board of Works, with the Minister for Finance behind them all, means that services are not now being provided.
Such an authority would not, in fact, usurp the powers of voluntary organisation, either clerical or lay. It would work as health authorities work at present and provide the services which it is statutorily obliged to provide through the medium of voluntary organisations where they exist and build institutions where they are needed and do not exist. Until this whole situation is rationalised, we shall not get the progress which is needed.
On the subject of mental illness generally, the Minister's predecessor last year described it as one of the most pressing health problems we had. There are over 19,000 people in our mental hospitals. We need better accommodation and more out-patient clinics. The present staffs of out-patient clinics that do exist are grossly overworked and the clinics are understaffed and overcrowded in practice. We need more trained psychiatric workers. This is a matter we have referred to in considerable detail in our policy document. There are only two people in the country with a PSW qualification compared with 30 in Northern Ireland. Undoubtedly the trained psychiatric social worker would help, to a significant degree, in getting over the grossly overcrowded conditions that exist at present.
We have a record in respect of mental illness of one of the highest ratios in the whole of Europe per 1,000 of our population in mental homes. A great many people are in mental homes who should not be there and it is partly because we have not got out-patient clinics and partly because we have not got trained PSWs. These workers are, in fact, able to prepare families for the return of the patient, prepare the patient himself when his illness is cured or almost cured, and also able to prevent breakdowns  when the patient has left hospital. This is one cause of the deplorably high number of people in our institutions.
There are areas for reform in practically all aspects of the Minister's Department and none more glaring than in the area of physical disablement. Under the regulations at present, the health authorities have power to pay maintenance allowances for persons undergoing training for vocational rehabilitation. The present weekly rate is totally inadequate but apart from that, there is a rigid means test. What happens to a disabled person who has to undergo rehabilitation training in an institution is that his social welfare payment is taken into account in deciding the amount of the maintenance allowance paid to him. In fact, it ends up that a person who may have got a serious injury in an industrial accident and may at the same time be getting social welfare insurance, instead of getting £4 per week—the maximum under the regulations—ends up by getting £4 17s. 6d. on top of the social welfare payment.
More serious still, is the lack of uniformity in the standard of rejections on medical grounds. In fact, throughout the country very different standards are applied to determine whether a person should get the maintenance allowance and undergo the training which is available. One of the serious aspects of this problem is the long delay involved. It can take from four to six months, for a person who perhaps has had a disabling disease or perhaps an industrial accident and is fit for rehabilitation from the medical point of view, before he is declared entitled to the maintenance allowance. I know of cases of people who had to stay in hospital at an extraordinarily high expense to the State because of the long delays involved in getting them a maintenance allowance. There is a training fee under the Disabled Persons Rehabilitation Regulations of £4 a month which is completely inadequate and which I trust will be increased when the increases referred to in the Budget come to be implemented.
We have already referred earlier in  the debate to the position of people in receipt of disablement allowances and have indicated our determination to see that people will not have to suffer a reduction in disablement allowances, or home assistance as the case may be, merely because they get an increase in the social welfare allowance. The Minister's predecessor did not agree with this point of view. On 29th January of last year he expressed the view in the Dáil that he was against giving double increases to persons and was against giving them an increase in their disablement allowance as well as an increase in social welfare allowance. That is bad logic, apart from being a very poor form of charity. It seems to me that if a person is entitled to a social welfare allowance and also to a disablement allowance because of serious disablement, in fact, there should be no reduction because of the increases in the social welfare code.
In this area of rehabilitation it seems to me that there is great need for more decentralisation. There are, of course, certain types of rehabilitation, such as the care of paraplegics, which do need a central organisation but it seems to me that there could be developed to a much greater extent rehabilitation centres on a regional basis attached to the large hospitals throughout the country. We should also develop in this country a scheme for the homebound, disabled persons who are at home, unable to go out but who can, in fact, work in their home and lead useful lives. Such schemes are being operated in other countries such as Denmark but are unknown in this country. They could, in fact, be developed in association with the domiciliary welfare service which we have proposed.
The Minister should seriously consider the establishment of a national register of disabled persons. That would facilitate assessment of disabled persons and would also facilitate their placement in employment. In this connection it seems to me that we have got an obligation to endeavour to educate employers. Many employers, of course, are very alive to the desirability of helping disabled persons and many employers give employment to disabled  persons, but not all. I know of one case of an employer who had, in fact, employed a disabled person, a mentally handicapped girl, and, when the 12 per cent increase in wages came, the girl's father was sent for and, instead of being told that she was to be given an increase in her small weekly wage, he was told that her wage was going to be reduced because costs had gone up. It would be a source of scandal if I were to give the name of this particular employer and I shall not do so but, in fact, this has happened. It seems to me that we have got to educate employers to their responsibilities in this connection.
It is now generally recognised that the necessity for a hospital building programme is on a very vast scale. It is sometimes thought that we have enough hospital beds in this country and people who are inclined to indulge too much in the Guinness book of records and other forms of statistics are inclined to be misled by the fact that we have so many hospital beds per thousand of the population. These statistics cloak the reality and there is great need for a very considerable drive for more hospital accommodation, improvements in county homes, the improvement of mental institutions and the improvement of general hospitals, maternity hospitals and the institutions for the mentally handicapped.
This, unfortunately, was not the view of the Government. It was, unfortunately, not the view of the Government in its First Economic Programme because the First Economic Programme stated that social investment in the past had given us an infrastructure of housing, hospitals, communications, et cetera, which is equal, in some respects, perhaps, superior, to that of comparable countries, and it was suggested that social needs would soon be overcome.
We have criticised this view in the realm of housing and we have pointed out how wrong it was and we have pointed out that the Government acted on it and that there was a decline in housing. It happened also in the sphere of hospitalisation and if we have a big  backlog in the sphere of hospitalisation now it is because the Government took this view in its first economic programme and carried it out. In spite of what was said in the first economic programme the Minister's predecessor, last year, in the course of his introductory remarks, at column 135, Volume 127, said:
In 1964, it was recognised that we had a staggering outlay to face in respect of our hospitalisation programme and yet the programme, of course, was permitted to decline under the first economic programme and this resulted in the very serious situation which we have in so many new fields of health, physical and mental, throughout the country.
I should like to join in the tribute which the Minister paid to the late Noel Burke and to express on behalf of us on this side of the House our very deep gratitude for the many years of work which he did on the Voluntary Health Insurance Board, in the National Organisation for Rehabilitation and many other fields of public service in which he gave so unstintingly. I do not think it is exaggeration to say he lost his life because of the work he did for the public good and we should extend to his widow and family our very deep regrets.
The Minister, as I have said at the outset, has got now the task of preparing for improvements and reforms in our health services. We believe that these reforms are necessary. We believe that radical reforms are necessary. We sincerely hope that the Minister will not adopt the attitude of his predecessor, will not pretend to this House and to the country that he is interested in reform and stifle any efforts at reform in the way he did.
I believe, looking back on it now, that Fine Gael took a wrong decision in deciding to work on the Health Services Committee. With the benefit of hindsight, it is now possible to see  that the Health Services Committee was a front to do nothing, to hide inactivity and that we would have been better off making known to the public our views, views which we proclaimed again in the course of the last general election. It is past history now. We are going to continue to press our views. It was not without cost, let it be said, because the propaganda against us was to my own knowledge successful. A canvasser in my constituency was put out of a house because, he was told, they were against a Party in favour of socialist medicine. Another canvasser was told that Fine Gael were Communists and to go about his business. The propaganda against us was not without success. As I have said, we are prepared to forget the criticisms that were made, prepared to forget the line that was taken against our proposals for a national health insurance scheme, if, in fact, the Minister is prepared to adopt it. If he does, he will have our whole-hearted co-operation and all our people will benefit from it.
Mr. Kyne: I should like to congratulate the Minister on his appointment as Minister for Health. It is time we got a fresh young mind in that Department, a man who is in touch with the public and in touch with the problems of the ordinary people, whether they be old age pensioners, workers or disabled people. In the past he has had active contact with them and I am sure he knows their problems as well as, if not better than, most other Deputies and that with his guidance the Department will show a new life and a new sympathy on this vital matter of health.
The Minister's first action, as he announced today, in deciding to increase by one hundred per cent the amount of money that old age pensioners and other such people in our institutions will be allowed to retain for personal use, is an excellent beginning. That is the beginning I would expect from the Minister and I hope that when he comes to announce the proposals for an amended health services scheme they will bear touches like that showing active sympathy for the problems of the old, the sick and disabled, enabling them to retain £1 of  their income for personal use, for such things as tobacco and insurance. Keeping up with insurance is a very big problem for all old age pensioners who want to ensure that when they die they will at least receive a proper burial and not be buried at State expense in a way they would not wish. I congratulate the Minister on his decision.
This Estimate is of the utmost importance to the people. In fact, it is a matter of life or death to them, particularly the working class people who have to depend mainly on the dispensary service. I do not propose to speak on the health services with any special medical or nursing knowledge. I speak rather as one of those who could be called a consumer. I represent and I am myself the type of person who receives the medical service. It is because of that I feel I can speak of the defects I have come across and which have been brought to my notice. The Minister quite naturally as any Minister in a Department would do in putting forward an Estimate, tried to show up the health services in as rosy a light as possible. That I can accept; in fact, I would accept it as being the duty of the Minister to do that. Equally, it is the duty of a Labour Deputy in Opposition to show up any defects he sees there, and I hope the Minister will take steps to remedy them as soon as possible.
I was interested to hear Deputy Costello's statement that the Fine Gael Party have produced a contributory health scheme. We all know that but those of us in the Labour Party also know that in 1959, five years before the Fine Gael health scheme, the Labour Party produced a health scheme, and the differences between the ideas in the schemes are very minor ones. It could almost be suggested that the Fine Gael scheme was a copy of the 1959 Labour policy.
Be that as it may, we welcome the fact that Fine Gael and Fianna Fáil would adopt Labour ideas on health. It has always been our view that a contributory scheme paid for by the workers while they are employed, so that they may have the services when they are ill, is what the people need. We are tired of the degrading means  test and in the most up-to-date health policy we have issued from the Labour Party we are suggesting there should be no lower income group, no middle income group and no higher income group, but that the people of Ireland as such should be treated as a unit and have, by right, the health services of this country available to them. It is true that it would be necessary to provide that certain sections such as old age pensioners and others with low incomes would not be required to contribute either at all or as much as people with higher incomes.
When the Fianna Fáil Government introduced the Health Act of 1953 the Labour Party agreed with Fianna Fáil that that legislation was a step forward. We still believe it was a step forward on a national scale and we voted with the Government on that occasion because we felt anything was better than the old Poor Law system which existed before that. Unfortunately, all the advantages of the 1953 Health Act were gradually whittled away by Ministerial orders and regulations.
In the 1953 Act, for instance, it was clearly stated that a boy or girl having reached the age of 16 years would be entitled to a medical card provided his or her income did not exceed a certain amount. By ministerial regulation that same boy and girl have since been deprived of a card because of the pooling of the total income of all the people of the house. In that way many a deserving person who normally should receive free medical attention has been deprived of it irrespective of the fact that, while sons and daughters earn certain wages, parents receive very little if any of these wages and have no authority to force from their children the amount of money that the health services investigator decides should be contributed by the children to their parents. Because of decisions of the investigator in this regard, many a father of a family has been deprived of a medical card to which he was justly entitled. I am quite sure the Minister knows about these cases as  well as I do but I felt it was my duty to draw attention to the fact that many of the ministerial orders and regulations made since 1953 have taken most of the good of the Health Act from it.
One of the main defects of the system of the medical card for the lower income group is the humiliation involved in making an application. One must publicly confess and publicly prove that one is unable to provide certain medical services. One must fill in a form. That form is confidential and I am sure it is treated as such. One must also produce proof from one's employer in relation to wages, and not alone one's own wages but the wages of other members of the family. On receipt of that information, the investigation officer goes to the respective employers and queries the amounts stated on the form, queries whether these people earn overtime or have any additional remuneration over and above their basic wages. That is humiliating. Medical services given on that basis should not be tolerated.
There is then the question of delay. A medical card is applied for and, in many cases, it takes anything up to three or four months before a decision is reached. That may be the fault of the local authority concerned. Public representatives are often approached with an appeal to get an early decision. I cannot understand why such long delays should occur. Again, when application is made, a printed circular is sent to the applicant: “You are not eligible for the service”. No reason is given. It does not say that the income is too high thereby giving an opportunity to the applicant to produce further evidence in support of his application. Refusal is based on the report of the local assistance officer. His word goes and there is no right of appeal. The refusal bears the signature of the county manager. There is no appeal from the decision.
Local representatives have succeeded on occasion in having cases re-examined, but all that is very degrading for the applicant. He should not have to seek the aid of a local representative. He should not have to put his case to him: “I am in a pitiable way.  I cannot pay the doctor. I have a child sick at home and I just cannot get medical attention.” That local representative has then to go along to the assistance officer, the secretary of the health authority, or the county manager and endeavour to get justice for the applicant. Very often there is proof that the case was badly investigated or dealt with in such a manner that a right decision could not be reached. Very often public representatives succeed, on re-examination, in pointing out facts that should have been obvious to the investigation officer in the first instance.
The biggest defect in the medical card system is the fact that medical card holders are tied to one doctor. During the discussions that took place in 1953 on the health services there was a good deal of talk about the importance of doctor-patient relationships. What doctor-patient relationship can there be between a dispensary doctor and a medical card holder? It is quite on the cards that a local dispensary doctor may be at variance with a patient or with some member of the patient's family, due to no fault of either the doctor or the patient. Where such a position exists a patient might easily be suspicious of treatment. Again, the doctor would not be happy in treating the patient. I am confident that the doctor would endeavour to give the best treatment he could but I am also certain that neither he nor the patient would have that all-important relationship upon which such stress is laid by the medical profession. I believe that, unless a patient has absolute confidence in his medical attendant, advice and treatment will not have the desired results. I cannot advocate legislation on this Estimate, but I earnestly appeal to the Minister to consider this aspect. If he succeeds in overcoming this defect he will be taking a tremendous step forward. This is a defect that every group coming before the Select Committee pointed out and all emphasised the need for remedying it.
There are, too, difficulties inherent in the dispensary service from the point of view of certain drugs not being stocked in certain dispensaries. It is well known  that dispensary doctors often give prescriptions to medical card holders, telling them: “That is what I believe you should have. If you can procure it at your local chemist and pay for it out of your own pocket I believe it will do you a great deal of good, but I am not allowed to supply it to you because it is not kept in stock in the dispensary and we have no permission to prescribe it. We can prescribe a substitute.” In the opinion of some doctors at least some of the substitutes are not what they would prescribe for a private paying patient. Medical services should not be based on ability to pay rather than on need. Need should be the governing factor. If a drug can relieve, improve or cure a patient then, irrespective of cost, the doctors working under the Department of Health should be in a position to supply their medical card patients with that drug.
The facilities in our dispensaries are in many cases disgraceful. Patients have to queue for prescriptions, very often under the gaze of the public passing by the doors. They may have to wait at hours which are quite unsuitable to them. Very often they have to await the convenience of the chemist. That type of medical service is just not good enough. Medical card patients should be free to go to any pharmacist who is willing to provide services for these people by agreement with the Department of Health. I am sure such agreement could be obtained. Prices could be fixed for the various drugs. There should be a choice of pharmacist and a choice of doctor. In that way these patients would get the treatment they need without the humiliation of lining up at the dispensary at prescribed hours.
I am not sure if the Minister has announced his intention of increasing the ceiling from £800 to £1,200. Perhaps that is the position in regard to social welfare contributions but, if the Minister is thinking along those lines, he should remember that it will be necessary also to raise the ceiling in the case of medical card holders. I am aware there is supposed to be no fixed limit for medical card incomes and that it is a matter for the county managers. But we are all aware that the County  Managers' Association have laid down certain regulations giving so much to a single man, so much extra to a married man and so much for each child. With the changes in wages over a number of years past it is ridiculous to think that a married man with £7 a week and no children should be expected under present-day conditions to provide medical attention for himself and his wife. A visit from a doctor to a home in most country towns and rural areas costs from £1 to £1 10s. per visit. Very often the doctor's prescription will also cost from £1 to £1 10s. That could mean that one visit a week could cost £3 a week. Either that man has to afford that and keep himself and his wife on the remainder or else he cannot afford to receive medical attention at all.
Great hardship is being inflicted on borderline cases, people just slightly over the amount laid down by the County Managers' Association. They are deprived of medical cards. I know of one such worker who told me he could not afford to become ill. He suffered from blackouts and was in need of regular medical attention. Because he did not qualify for a medical card he had to go without the medicines and drugs necessary to keep him in employment. The result was not a saving to the Department but a complete loss. That man fell ill, had to be removed to hospital and detained there from six to eight months. If the income levels are to be increased, special attention should be given to ensuring that the upper limits of the lower income group are considerably increased.
All the hardships do not lie on the medical card holders. There are some difficulties for the middle income people also. Again, there is this degrading means test. When a person in this group is moved to hospital the question arises of how much a day he will have to pay, anything from a shilling up to the full 10/-. Personal questions are asked. Again, the local relieving officer visits homes and employers. He visits the employers of the sons and daughters of the person in hospital. He is endeavouring to find out whether  or not the form completed by the person in hospital is correct. It is a most degrading exhibition. Anybody going to hospital would abhor and detest it.
I know, because I put down a Parliamentary Question to the Minister some years ago, that the charge per day, be it one shilling or ten shillings, results in a sum so small that it scarcely offsets the cost of administration and collection. Very often the case has to go before the courts. The person cannot afford the money and the local authority must for audit purposes show they did everything possible to get it. Very often local authorities have incurred considerable legal expenses endeavouring to collect money they could very well have done without. This charge could be wiped out and these middle income people could rest in hospital instead of worrying how they are going to meet the hospital charges. Of course, these people can go to the local authority or the manager and make a plea. Very often the cost is reduced considerably. But all that is degrading, and people in hospital should not have to worry about it. Medical services should be paid for by the State, the employer and the worker. Those who are ill should be completely free from the financial worries that accompany the health services at present.
Then there is the case of the people in the higher income group. It is true that my sympathy does not lie too much with them. But the people in the income group over £800 up to £1,000 are in a pitiable position. They contribute by way of rates and taxes to the health services but they receive simply nothing from them. I feel a person in that income group is in need of consideration. I have had experience of a person with an income of just over £800 who went into hospital recently. Admittedly, he went into a semi-private ward. He was charged £2 19s. 6d. a day for his maintenance. That is an extraordinary amount of money—almost £21 a week. You could not afford to be sick. It would be cheaper for you to die than pay that and then pay the doctor's fees on top of that. They are never reckoned in pounds, always in guineas, and could  run to 60 guineas or 70 guineas for an operation, and not even a very major one. I am aware there are men in this country almost in the millionaire class. They need not worry. If the health services were extended to cover them, they would not avail of them. They would prefer to have a private place, to go to their own doctor, not even stay in Ireland at all but go to Zurich or some place else where people have the name of being very special physicians or surgeons.
One problem for the middle income group people is this. When they are ordered to hospital they are so confused or worried that they take no notice of where they are being sent. The doctor rushes them into hospital and the next thing is that they find themselves in a semi-private ward. It is no good proving you are in the middle income group, that you are under the amount for the middle income group, and that you are now in a semi-private ward without your knowledge and without any action of yours you have been moved in there. Very often the person is moved into a semi-private or private ward for the convenience of the hospital authorities but when it comes to the notice of the health authorities that a middle income group person is in a semi-private or private ward he is immediately classified as outside the group. He is, therefore, charged the full amount of money.
That is something which should not happen. If a patient is put in a semi-private or private ward by error or without any direct request being made by him for his transfer to such a ward, I do not think he should be called upon to suffer for a mistake made by somebody else.
Mr. Kyne: I know that is so but very often it does not happen. Sometimes the man, who does not know the local representatives or does not know the value of local representatives, just tries to pay. That is what happens very often. There is another point I  should like to mention and that is the matter of dental services. We find in Waterford, anyway, that adults can get out as many teeth as they like provided they have a medical certificate. Teeth are pulled freely. In fact, there is no problem about extractions but we certainly have a problem when it comes to dentures. Very often we have people on a waiting list as long as three, four or five years. It is ridiculous that a man or woman aged 30 or thereabouts should have all his teeth extracted and then have to wait so long for dentures. Very often the person will be left waiting for five or six years. As a result, he gets stomach disorders of a very serious nature. He is unable to chew his food properly. It is true that when a woman becomes pregnant or a person gets ill and gets a certificate from a doctor to say that there is a danger to that person's health, an effort is made to give priority. That very often means that the person may have to wait six months short of the three years instead of getting immediate attention.
Surely it is possible to get impressions taken and dentures made in a much shorter time and surely it is not necessary that dentists should do this job? Surely it is not dentists who have to make dentures? Surely dental mechanics do this job? I am quite certain that there are highly skilled and qualified people in Ireland well able to do that job if they were permitted to do so by law. The Minister should have a look at that matter. I know this has been done in some of the northern countries. I understand it is done in Norway, Sweden and other Scandinavian countries. Those countries have permitted such people to fit dentures. Surely this job is no more complicated than the fitting of artificial legs and you do not need to be a doctor to do that job? Such work is done by some of the outfitters who supply these things.
I can see no reason why hundreds or thousands, if we take the whole of Ireland, of adults are without teeth simply because they have not the money to provide the entire cost themselves. The local authorities say they  cannot get it done because they are not able to get enough dentists to meet the demand. That seems extraordinary.
There is another point I should like the Minister to deal with, when replying, or he can deal with it privately by letter. I should be glad if he would indicate whether the Waterford Health Authority have any proposal for the establishment of a maternity hospital at Dungarvan. I am aware that as long ago as 20 years such a proposal was considered. It seems ridiculous to me that up to 200 or 300 mothers have to travel to Ardkeen or some other place from Dungarvan which is at least a distance of 30 miles away from their homes. They cannot be visited by their husbands or children because of the distance and because of the great expense to the family due to the high cost of transport. If relief was available for visiting them that would be a practical solution.
There is no reason, because of the size of Dungarvan town, why a maternity hospital should not be established there. I know there are two or three or maybe six beds in the old county home section of the local hospital. I know it is an excellent county home and I do not want to cast any reflection on the services provided or the cleanliness of the hospital but it is a fact that the title of county home does not rank very high on any man's tongue anywhere in Ireland. It would look so much better on the birth certificate of a child that it was born in Dungarvan maternity hospital rather than in Dungarvan county home. That fact alone would justify the establishment of such a hospital even with the services being equal. I would press on the Minister the need to examine that position. If the Waterford Health Authority have not formulated proposals I shall have to put pressure on them to see if I can get them to initiate such a scheme. I would then hope to get the consideration and the help of the Minister to having such a hospital established. It is certainly the wish of the people of the town that such a maternity hospital should be built there.
 I was interested in Deputy D. Costello's figures in connection with the medical card ratio in Waterford compared with Dublin. I think the figure he gave of 55 or 50 per cent medical card holders was exaggerated. He stated he got them from figures supplied to the Select Committee. I remember there were figures supplied earlier in the deliberations of that unfortunate body which were later changed. I think it was found that some wrong figures had been supplied in connection with Waterford. If my memory serves me right, Waterford is one of the best counties for providing medical cards. I think the figure is roughly between 25 and 30 per cent for the combined city and county, not 50 per cent which was given by Deputy Costello. I simply make that point because it might seem unusual, if practically all Waterford people had medical cards, why I am up here complaining, when I come from that constituency.
Mr. Kyne: Perhaps, I misunderstood what the Deputy said. I just thought I would try to clear up that point in justification of my own speech here this afternoon. There is one thing I very strongly agree with Deputy Costello on and that is the question of schools treatment. A medical examination is held in the schools about once a year. That is the case in both the city and county of Waterford. Unless it is discovered that a child shows signs of having an appendix, bad eyesight or ear trouble at that examination a schoolchild cannot avail of the special Act for schoolchildren. But if that doctor does not go there every year, and the defect is there, the fact that he does not go deprives that child of the service it would normally be entitled to get and would have got if the doctor had gone. If we are to be so strict that the child may not be sent to the school's doctor and we do not decide whether or not the pupil is qualified  to receive treatment under the Act, then at least there should be much more frequent inspection of children in the schools and I know that, with the staff available, that is impossible at the moment. Therefore, I suggest that it would be a help if the parent of the school-going child could get the school's doctor to issue a certificate free but he will not do that unless the child is inspected in the school. It is a ridiculous position. As Deputy Costello said, the law should be investigated to see if any alteration can be made in it.
Another point struck me when Deputy Costello and, indeed the Minister, paid a tribute to the work being done for old people. I am very well aware of that work. In my town, we have a voluntary group called The Friends of Saint Martin. Without any direction from the Government or the local authority, and out of their own pockets, too, the members arrange outings, film shows, dances and entertainment for all the old people of the area. Last year, they proposed, and indeed they did it, taking a group of from 70 to 80 old people to the beach at Ardmore, a distance of about 14 miles from Dungarvan. They hired buses for the old people and paid for them out of their own pockets. Actually they take care of old and lonely people, not necessarily all over 70 or anything like that. People who live alone and are inclined to be recluses are also encouraged to come out. It was suggested that they be given a meal. The men and women members of that group prepared two meals, a dinner and a tea but the point I want to bring out in this connection concerns co-operation. It was suggested by one of the members that they should approach the civil defence unit which has a mobile canteen in attendance at all their parades and combine in the preparation of a meal to be given by The Friends of Saint Martin for what could be refugees in a time of Emergency but were in fact the old people of Dungarvan out on a friendly excursion. To our amazement, the local civil defence officer informed The Friends of Saint Martin that it is contrary to regulations that any part of the civil  defence equipment should be used on such an object.
Mr. Kyne: Exactly, but maybe he will be able to talk to the Minister for Defence: one never knows. Anyhow, it will not do the Minister for Health any harm to know that that is the kind of co-operation that exists. He is asking local authorities to co-operate in helping the old and the lonely. Certainly, private people help all they can. The Minister should consider asking his colleagues in other Government Departments to co-operate likewise.
I think I have said all I can usefully say on this Estimate. I should like to conclude by promising the Minister for Health, on behalf of the Labour Party, our fullest co-operation should he in his wisdom see fit to introduce a contributory scheme. We shall, of course, examine it and criticise it if we feel there is something wrong with it but we shall certainly give the Minister the benefit of our constructive criticism, our advice and our votes in this House if we feel it is a scheme in the interests of the people.
I am sure the Minister will do an excellent job in the Department of Health. He is bringing a fresh mind and a new outlook to this Department which is the most important one for the people of this country.
Mr. Booth: I should like to comment on just a few points made first of all by Deputy D. Costello. Deputy Costello criticised the Minister's predecessor and the Fianna Fáil Party generally for what he believes to be a lack of clear appreciation of the need for increased health services. He quoted from the first Programme for Economic Expansion in alleged support of his view. I think at least it is correct to say that Fianna Fáil have always been careful, in proposing legislation, to ensure, first of all, that the funds will be available to finance it. This has invariably been a source of criticism from Fine Gael, in particular,  though I think the Labour Party have been rather more realistic in their approach to the question of financing health services.
When the first Programme was being drafted, the position was that the first priority was, I am quite sure, that the economic state of the country would drastically be improved so that funds could then be made available for worthwhile purposes—and under the heading of “worthwhile purposes” I would include health services as well as industrial and agricultural development schemes. But we were at that time, in 1957, faced with an economy which was in grave difficulties and that was no time in which to indulge in grandiose plans for expenditure of public money on social services. It was a time when, to our great regret, we had to pull our belts in and try to soldier on for a little longer until the economy got back on its feet again.
I can never understand this criticism that Fianna Fáil are not anxious to improve health services when nothing could be more popular than to be able to give better health services to one and all. We should all like to seek popularity in that way, if we could, but we knew that any promises which we might make at that stage could not be honoured immediately or even in the near future.
Deputy D. Costello then went on to deal with the principle of insurance as a basis for a new health scheme but here again we have an illusion that insurance is the answer to all our problems. If it were such an easy answer, we should have jumped at it long ago but the facts simply do not confirm that view.
Mr. Booth: I am not Deputy MacEntee but I am grateful for not being Deputy T.F. O'Higgins either. One of the troubles with the Select Committee on Health Services, from the Fine Gael point of view, was that the facts did not correspond at all with their theories. That, above all, was the  reason why the Select Committee was allowed to grind to a halt and finally break up.
Let us deal for a moment with the question of insurance. Evidence was given before the Committee which showed some interesting figures. If we assume, for instance, that there are 500,000 persons who would normally have insurable employment, for every shilling per head, there would be raised a sum of £1,300,000 per annum. That means one shilling per week of course. But £1,300,000 is a comparatively insignificant figure when set against a total expenditure of something in the region of £15 million, or an even larger total of about £18,500,000 if we are to take into account hospital deficits.
If we were to consider an insurance scheme, the obvious thing to do is to look across to Great Britain and see how it works there. In Great Britain the weekly rate at the moment is £1 6s. 2d. for a male worker. That is the total contribution of worker and employer.
Mr. Booth: It is a general comprehensive social welfare benefit. The contribution here was 11/10d at the same time and that makes a difference of 14/4d. There is a difference in income rates of course between the two countries but, even if we did come much nearer to the British rate, we would be very far short of our target. But the real illusion is that the British health services are paid for on an insurance contribution basis. In actual fact, in Britain 12½ to 14 per cent of the cost of the health services comes from insurance contributions. Of the remainder, about 11 per cent comes from local authorities—that is, rates—and the balance of 75 per cent comes from central revenue. That is the so-called national insurance scheme but, even in Great Britain where it has been tried out over a number of years, and even with very high insurance contributions, the Exchequer still has to find 75 per cent of the cost of the health services.
 No wonder Fine Gael started to lose interest in the Select Committee on Health Services when facts like those were produced before them and could not be contradicted. Let us forget, altogether, therefore, any suggestion that it is possible, purely by insurance contributions, to finance a national health service. It has never been done anywhere else, even in countries which have a far higher rate of industrialisation than we have, and where accordingly the collection of compulsory insurance contributions would be very much easier than here.
Let us consider, too, what the situation would be in Ireland, where there is such a high proportion of self-employed workers. How can their contributions be worked out? Will they be worked out purely on the basis of the same rate as that applicable to an employed worker, or will they have to pay the contribution both of worker and employer? If not, how will we finance the scheme at all? Are we prepared in such a scheme to deny health services to anyone who is in arrear with his insurance contribution? To my mind, it is unthinkable that a person in need of medical attention and unable to pay for it should be denied that service by reason of being in arrear with an insurance contribution. But, at the same time, if the service is not to be denied to those who are in arrear, everyone will be in arrear. That, I think, is fairly obvious. I do not know what the answer to that is, except to say that we must find some way of financing our health services that will be fair and just to all classes of the population. The principle of insurance is certainly not the answer.
Reference has been made also to the desirability of a free choice of doctor. It has been claimed that we should get away from the degrading dispensary system because cases may arise where a patient falls out with his dispensary doctor and wishes to go elsewhere. Here again, the evidence before the Select Committee on Health Services was most unhelpful to the Opposition Parties on this point, because it was clearly established that for the great number of people in rural Ireland the  local dispensary doctor is the only available medical practitioner.
Mr. Booth: Deputy T. F. O'Higgins will have an opportunity of coming in and giving an alternative version, if he wishes to do so. It is a fact which cannot be contradicted that over a wide area of rural Ireland the local dispensary doctor is the only medical practitioner. That is because the population is far too scattered for an ordinary general practitioner to build up a remunerative practice, and it is essential, first of all, to have a dispensary doctor who is paid a fixed salary and who is also allowed to have a private practice.
Let us take the position in Great Britain again to see to what extent this free choice of doctor is actually so attractive. I have a brother living in London at the moment and his description of the system leaves me far from enthusiastic about it. He did go on the panel of one doctor who gave satisfaction for a limited period and then began to lose interest in my brother and his wife. He was not giving proper attention to them. They had the right to go and choose another doctor.
First of all, they found it acutely embarrassing to try to break away from the doctor to whom they went in the first place. He made it as awkward for them as was conceivably possible. They did find another doctor who would accept them on his panel. They found a doctor who was very well recommended, and they managed to get his consent. They went to their first doctor, and then the row began. They nearly had to fight their way out of his clutches before they could get on to the second doctor's panel. On the second doctor's panel, they got satisfaction, again for a period,  but the second doctor was too good. He was too popular, and his panel was getting too big. After a very short time only, he began to work on the team principle, and to bring in another doctor to work for him on that panel. As soon as that happened, he retired to a sort of consultancy role, and my brother was no longer able to see the doctor of his choice. He could only see one of his assistants. That is inevitable, and we had plenty of evidence of it at the Select Committee, too. This free choice of doctor is an illusion in very many cases.
I was delighted the Minister paid so much attention in his speech today to the question of the care of old people. With modern medical knowledge, the expectation of life of the whole population is rising steadily, and the proportion of old people is, therefore, rising and presenting a problem. I agree entirely with the Minister—and I think most of us would—that the proper place for old people is at home, and not in an institution. We must do everything we can to facilitate people who are prepared to repay to their parents something of the debt they owe to them. The modern jargon on the point is that we cannot allow old people to prejudice our whole lives. We thereby forget that we, in our turn, as children prejudiced the lives of our parents, tied them up, and restricted their liberty, their freedom of action, their freedom of expenditure and everything else.
The least a child can do is to care for his parents just as they cared for him when he was very small; but there are cases where the old people may be childless, or the children may no longer be resident in the country or the area, and this presents a problem for the whole community. There are various ways in which we can care for these people. We can, as the Minister said, care for them in improved county homes but that, I feel, is far from being the ideal solution. We can, and I think we should, grant very considerable State aid to Church bodies who may set up old people's homes, because the religious orders or  churches who do this work are doing it from a very deep sense of vocation and they are, therefore, in the main, setting up institutions where real love and care are given to those who make use of the service.
I have a horror of institutional life, and I feel it must be a terrible deprivation for old people suddenly to find that they no longer have any privacy. I know that in large and well-equipped old people's homes it may be possible to give them a nice bedroom, and, perhaps, to have a nice community lounge, but always there is the feeling of being just one of a crowd. I would hope that further attention will be given by the Minister, and also by his colleague in Social Welfare, and possibly in Local Government, to the new conception of old people's homes, with small houses built specially for old people, small houses built around a community centre where there would be readily available catering facilities for at least one meal in the day, and where there would be a resident nurse, and possibly a resident doctor, who could be readily summoned by simply pressing a button to look after anyone who was in need. If these old people could be accommodated in small chalet-type residences where they could go into one or two rooms, close the door, and feel they were in their own home— preferably with some of their own furniture in the rooms—it would make their declining years very much happier.
No one wishes to live in a sort of boarding house or hotel atmosphere, and nothing is as comforting to old people as to have some of their own very personal belongings close to them, so I would hope that in this matter the Government as a whole will try to work out some co-ordinated policy for keeping old people happily in their own homes if possible, and, if not, in special small residences where they can have some sort of home life of their own, as well as the benefit of the help which would be made available from some community centre.
I appreciate that the Minister is not  yet ready to give a very full account of his proposed revision of health legislation generally. From what he has already said to us today, I feel we can look forward with confidence to some really adventurous thinking on these lines, but this adventurous thinking will be realistic. It will not be a piece of airy thinking such as the mere adoption of an insurance principle, or the adoption of the inherent right of free choice of doctor. Those, I do not believe, are by any means the main features of the proposed revision. I for one have the greatest confidence that the Minister will find a much better solution, and that he will be able to devise much better health services now that the funds are becoming available to finance them.
Mr. T.F. O'Higgins: Our point of view in relation to health policy and this Estimate has been fully and effectively stated by Deputy D. Costello. I have not very much to add to what he said, but I think there are some things which should be said at this stage in this new Dáil.
I noticed that some of the morning papers today expressed, in terms of comment on this debate, the view that the Minister would indicate to the Dáil today the terms of a new scheme for health services. He has not done so and perhaps in the generosity of the House, one feels he is a new man in a new job and he has not yet had time to do it. We shall go along with that view for the moment but I think it is relevant to remind the Minister and the House, despite the fact that with the disappearance of Deputy Booth, there will be only one Fianna Fáil Deputy in the House——
Mr. T.F. O'Higgins: ——that this 18th Dáil was sent here largely because there was public concern, public dismay, in relation to the standard and quality of our social services, and while the Minister, in the three or four weeks' time that he has had available to him as Minister for Health, has not been able to produce some plan or programme for the future, I hope he  understands that we expect from him in the course of the coming 12 months evidence, concrete and definite, of new thinking in relation to health services.
What is there at the moment just will not do. What is there at the moment represents, from a national point of view, a very black mark on our social policy. What is there at the moment divides more accurately than Partition itself the people who live on this island into two categories or classes of people—those living in six of our counties enjoying an adequate standard of health services and those living within the Republic enjoying a remnant from the Victorian age.
If, as a country, we are to be sincere in our views, to be true to ourselves, if we contemplate ever a reunion of this country, we must at least be making plans now to have and to offer in a united Ireland a standard of health services at least as good as is now obtaining in the Six Counties. Again, if we are serious in our oft-repeated protestations about marching into Europe by 1970, with our chests out and our heads up, we must now be laying plans and arranging and ensuring that the health services our people enjoy will be at least as good as those enjoyed by the people in the rest of Europe.
The dismal fact is that today, 1965, some 12 years after the passing of the Health Act of 1953, we now enjoy as a country a standard of health services which is just a plain disgrace. We do not provide in the slightest any medical services for the vast bulk of the population and we have Deputies like Deputy Booth who appear to be complacent and rather happy at the measure of what we are doing. We just cannot afford this if we are to retain our people, if we are to solve the problem of emigration, if we are to operate in a competitive world in any serious way.
We must look to the social conditions which we operate and among those social conditions the most important, in my view, is the standard and level of the health services. So, while we excuse the fact that the Minister is not in a position today to announce Government plans for the  future, we want him to understand that we expect concrete evidence in the coming months that there will be a drastic reform of our health services and a definite plan radically to improve them.
Deputy Booth talked here about the Select Committee on Health Services. I should like to be able to enjoy the happy frame of mind Deputy Booth obviously possesses. He is very pleased with himself, with Fianna Fáil, with everything they are doing, but I doubt if Deputy Booth could have attended the Select Committee for any number of meetings. If he did, he went in wearing blinkers and earplugs because I cannot understand how he came to express here opinions and comments on the evidence heard by that Committee.
I hope that evidence will be published in the near future and I hope that people will be able to read the volume and nature and breadth of the views expressed at that Committee during the years the Committee were in being. Suffice it for me to say that, in my view, the evidence established without doubt a general, widespread, profound dissatisfaction with our present health services—widespread, profound and general, from doctors, from nurses, from social workers, from the trade union movement, from representatives of all kinds of organisations. They were all of the view that what existed at the moment was unsatisfactory and did not measure up to what was required from a national point of view.
There was also in the evidence given to the Committee a general and widespread view that it was essential in any properly operating health services that there should be a free choice of doctor and that those availing of the services should be entitled, as any free citizen should be entitled, to go to the doctor of choice. Deputy Booth has said he does not go along with the idea that a free choice of doctor is a preeminently important thing. He is not entitled to that viewpoint, as I am glad to see—perhaps because of the heat of the election campaign—that at least the Leader of Deputy Booth's Party, the Taoiseach, conceded in the final days of the election campaign that  whatever shape or form the new health services should take, there would be included a free choice of doctor. We shall expect and hope to see the nature and form the free choice will take.
I am sorry at this stage in the debate to make some remarks about a Deputy who is not here and who, in my view, should be here, Deputy Seán MacEntee. Deputy MacEntee was elected to this Dáil as the outgoing Minister for Health. He is not here at this debate and accordingly what I have to say in relation to him I must say in his absence. I cannot avoid that because I find it necessary to call attention to the fact that just before the people voted in the last election, in the newspapers of 6th April last, Deputy MacEntee, as Tánaiste and Minister for Health, published in the daily press a letter dealing with the record and activities of the late lamented Select Committee on Health Services. I shall quote from the Irish Press of 6th April, 1965:
On 12th February, 1964, the Select Committee, having heard 180 witnesses, whose evidence ran to over 350 pages of closely-printed text, decided, on the motion of the chairman, that it was in a position to make a report to Dáil Éireann. In pursuance of this, I submitted a Draft 3rd Interim Report on the 12th March, 1964, proposing that the Committee should inform Dáil Éireann that:
It seems desirable to the Committee that it should prepare a report describing the General Medical Service and the General Institutional and Specialist Services and the submissions and evidence tendered in relation to them, and outlining, without prejudice to its considerations of the system of health services as a whole in its final report, the Committee's conclusions in relation to possible changes in these services.
It is perfectly true that the then Minister for Health, Deputy MacEntee, as such, did propose that the Committee should go to Dáil Éireann with that interim report, describing what was there and indicating that at some time in the future something else would emerge from its deliberations. The letter goes on to say:
This attempt on my part to have the Committee report on the two most important branches of our health services was blocked by Deputy T. F. O'Higgins, who, on April 6th, 1964, urged the Committee not to accept my proposition. This ruse succeeded and the work of the Committee was brought temporarily to a halt. In putting forward his blocking proposal, Deputy O'Higgins made many sweeping and baseless statements....
Now, Deputy MacEntee, as Minister for Health, or as ex-Minister for Health, or as a Deputy, is entitled to any view he likes to express but I am entitled to reply to him and I intend to do so now This letter was published in the Irish Press of April the 6th, not on the 5th, nor on the 4th, nor on the 3rd, nor the 2nd nor the 1st; it was published at such a time as to prevent any possibility of an effective reply before the people went to vote on the following day. The facts to which Deputy MacEntee refers in that letter are certainly not in accordance with the record. Deputy MacEntee said that I put forward a blocking proposal at the Health Services Committee. The fact is that on behalf of my Party I put forward, and I had circulated prior to 9th April, 1964, a comprehensive, detailed proposal relating to the complete re-organisation of our health services, confined in that document to the general medical services. That memorandum was the result of considerable work and research and covered the  entire field of the general medical services.
After it had been circulated, the Committee met, on 9th April, 1964, and this is how the Minister for Health, Deputy MacEntee, described my proposal at that meeting—there was not a general election at the time and it was not necessary to write letters to the papers—and I quote from the official minutes of the meeting:
That is a very strange way to describe a memorandum which on 6th April, 1965, the day before the people went to vote, he referred to as a ruse and a blocking proposal. On 9th April, 1964, he said at the meeting of the Committee that he thought the Committee should congratulate and thank the Deputy who had put forward that proposal and then proceeded to say that he would put forward a counter-proposal and that he hoped the memorandum and the counter-proposal would be considered on their merits. I hoped so too and so did every member of the Committee who was working on that Committee in the interests of the evolution of a better health service. We met on 9th April. We heard some other evidence at two other meetings but for the record let me say that no meeting was ever convened by the chairman, the Minister, or anybody else, at which my proposals could be considered on their merits by the Health Services Committee, nor did the Minister for Health ever circulate any counter-proposals or any suggestions contrary to my memorandum.
The fact is that 12 months went by and then in the month of March, 1965, the Committee broke up out of sheer frustration, after the Taoiseach had, on the Vote on Account in the Dáil, proceeded to criticise the memorandum which I had submitted before it was ever considered by the Health Services Committee. I mention that for the record. I know that in relation to health and policy generally there is, and always will be, I suppose, a manoeuvring for position, an endeavour  to paint oneself and one's Party in a particularly favourable light. These things must happen; they are part and parcel of the hard facts of politics.
Personally, I felt that the Select Committee idea would not work out. It appeared to me impracticable that political Parties could sit down together to work out a common policy, if in fact they had strong views of their own. We had strong views in relation to health policy, views in which we sincerely believed. For us to go into the Select Committee as we did meant that we fought for our point of view or otherwise surrendered our convictions. We went into the Committee and we did fight there for our point of view, and not only that but we went into it and acted constructively throughout all the meetings with all the evidence there which our Party sifted and examined carefully and in the end we were the only political group in that Committee to sit down and work out a plan. We did that and we did it because we sincerely believed that the Committee, having been set up and having gone into operation, would result in something worthwhile.
The fact appears to be that whatever we were doing or endeavouring to do was not going to be taken seriously and was not taken seriously. We have now the situation in which the then Minister for Health, Deputy MacEntee, can write to the newspapers criticising what was done inside that Committee while the minutes are sealed as confidential, while the public do not know what is going on. That, to put it mildly, is unfair. I hope this Dáil will be moved, as it was proposed the last Dáil should be moved, by a motion ordering the release to Deputies of the minutes of the Select Committee and of the different submissions made to it so that those who may be interested can examine fully what took place inside the Committee and can see for themselves what part the different Parties played in the proceedings of that Committee. At present all I can say is that I believe the record of the Fine Gael Party on the Committee is a sound and  proud one. I am extremely glad that I and my colleagues having gone on the Committee—although I had, as I indicated, my own misgivings in so doing—set about our role in it in a constructive way and put forward proposals which we believe in, and I think our record has been a good one.
Deputy Booth also referred to our health policy in so far as it related to an insurance scheme. I do not want to go into that now: we have had a surfeit of discussions on these matters in the course of the last election and perhaps prior to it. Deputy Booth is certainly entitled to any opinion he cares to express or to any reservations he says he holds as to the success of an insurance scheme. I believe it is feasible and practicable and I am certain that if it had not been rejected in such an out-of-the-way fashion by Deputy MacEntee, as Minister for Health, there would now be considerable progress towards operating it. In my view, there is no other way in this country having regard to how we are distributed, the nature of our internal economy and the type and nature of our population, to provide here a general medical cover except by insurance. I know efforts can be made to do a whole lot of things, to give a little bit more in addition to what is there; to alter in a variety of ways the present dispensary system; to find, for instance, some absurd solution like a choice of dispensary doctor—all these add up to nothing.
Mr. T.F. O'Higgins: No, I said “choice of dispensary doctor”. The Minister need not talk to me about a choice of doctor. I think I have been advocating it a long time before the Minister thought he would be Minister. But what is needed here, and nothing else in my view will meet the situation, is the provision — I use the phrase “bulk of the population”: you could use the phrase “entire population” if necessary; it does not  matter—of general medical services for the bulk of the population covering the services of a doctor in the home and assistance, at least, in relation to the provision of drugs and medicines and medical appliances. That is what every other country in Europe provides.
Can we do it? We can, of course, do it without difficulty provided people are rational and do not close their minds. We can do it by insurance; I do not believe we can do it otherwise. It was unnecessary, and I think politically unsound, for the Minister's predecessor to endeavour to intimidate and frighten people by picking figures from the skies and saying: “This is going to cost £34,000,000 or £35,000,000.” Of course it will not cost that. The need and the object of these proposals is to provide a cover in relation to personal health services, that is the services of the individual outside hospital when he is sick, nothing more than that. The present cost of the dispensary system is, I think, around £3.5 or £4 million on the Estimates. That is what should be covered. Nobody contemplated or suggested that the hospital services should be run on insurance lines— perhaps that will come in time—but it was not part of, or in any way concerned with, the proposals we made. Our proposals related to personal health services and we can cover these and extend them and improve them on the lines of insurance. If we do not do it that way we will not do it at all.
I hope the Minister when he comes here with proposals will have the political sense to grasp this nettle firmly. Whatever is gone by, let it be part of the bygones and let us face the fact now that if we are to provide a standard of health services for our people we must do it on the basis of a contributory scheme of some kind.
I can understand that at the height of an election or in the immediate proximity of an election any proposal that the other side puts forward is condemned out of hand. The Taoiseach condemned our proposals prior to the last election. He said they constituted  a poll tax as if that was some phrase which was supposed to end all further discussion. The fact is that every social welfare scheme imposes a poll tax of one kind or another. Every worker who pays a weekly premium for his social welfare stamp pays a poll tax. Up to this it was not regarded as anything reprehensible but the Taoiseach said our insurance proposal in the one limited field of health must be rejected because of this poll tax and that in itself would be regressive. That, again, is a point of view and I trust the Taoiseach will now reconsider his views in that regard. So far as we are concerned we can see that under a health insurance scheme one can have a premium which, if necessary, can be a percentage of the wage packet; it need not necessarily be a uniform or standard figure if that is thought socially undesirable: it can be a percentage of the weekly income and there is no difficulty in doing that.
The Taoiseach, in some remarks he made on the Vote on Account here last month or in March said: “What about the farmers?” There is no problem whatever about collecting premiums from farmers. Premiums can be collected twice a year with the half-yearly rates demand. There is no difficulty about that. People are not being bona fide when they pick up details of that kind and blow them up as if they were an insurmountable problem. There is no problem about it.
Deputy Booth asked what about the man who does not pay his weekly premium? Are you going to let him in sickness die? Of course not. He must be provided for and after he is provided for and looked after, he will be sued and will be made amenable for payment of his contributions the same as any worker now who fails to measure up to his social welfare commitments is liable to be made amenable in the courts. There is nothing new or difficult about that. I have more faith in people, obviously, than some other Deputies, at least. I believe that the percentage of people who would fail to pay a small weekly sum which is going to represent health cover for themselves and their families  would be very small indeed. I am certain that a person who failed to honour commitments of that kind would not have the good wishes or the goodwill of his neighbours or even of his own family. I do not regard the failure to pay premiums as being in any way a difficulty.
I started by saying I did not intend to discuss details of health insurance but I fear that, having got launched, I found myself doing it. I merely wanted to answer what Deputy Booth had urged as if these were accepted insurmountable problems. They are not. Deputy Booth talks about the fact that in England only some 25 per cent of the cost of health services is funded from insurance premiums. That, of course, is so, and so it would be here. We do not suggest that in our present circumstances, whatever the future might hold, we could cover with insurance premiums the hospital services or the specialist services inside hospital. The big bulk of health cost will still have to be paid for through rates and through the Central Fund and that has always been clear in our proposals. Deputy MacEntee, for his own purposes, used to imagine otherwise but, at least, at that time I was the person entitled to talk on Fine Gael health policy, not Deputy MacEntee, and our proposals in that regard have always been clear. They are related to personal health services. As I say, it might be possible under a broader scheme and at a later stage to develop in a different way but, at least, at the beginning we should aim at covering personal health services.
I do not know what plans the Minister may have in mind, what consideration or thought he has given to these matters. I am certain he has given or will give considerable thought to them. There is a general expectation that a new and profoundly altered health service will emerge. What is there at the moment has been, in my view, demonstrated to be unsatisfactory and people want a great deal more. Whatever course the Minister decides to embark upon, I hope that he will not  come into this House eventually with some little alteration or modification of what is there, that he will not start plastering over cracks or making adjustments in what has already proved to be unsatisfactory because, if he does that, he will not, in fact, be facing up to his responsibilities.
I notice the Minister said the other day that he had as an interim measure instructed local authorities not to send statutory requests for the filling of vacant dispensary medical officer posts. I was very glad to hear the Minister say that. When I occupied the position of Minister for Health in 1954-55, 1956 and the early part of 1957 there were a number of dispensary posts vacant in Dublin city. I had the intention to use those vacant posts for the purpose of initiating a pilot scheme in the large built-up areas of this city, providing for a choice of doctor amongst doctors in general practice. I hoped to do that administratively and to see how it would work out, to start off by modifying the dispensary system in that sense and to get doctors in general practice in Crumlin, Ballyfermot and places of that kind, where they were available, to provide the service for those entitled to avail of the general medical services.
In fact, it was not done and immediately after the change of Government Deputy MacEntee, as Minister for Health, decided to have all these posts filled. They were filled and an opportunity to have a worthwhile experiment disappeared. It is for that reason that I was extremely pleased to hear that the Minister is seeking now, I hope, to create the same situation in which an experiment, at least, can take place. I wish him luck in that. I hope the experiment will turn out to be successful and that it may be possible to inch towards a situation in which such services as this Dáil feels should be provided for our people should be provided by doctors in general practice and that we shall not have a named doctor, being the State doctor—call him dispensary doctor: it does not matter—being the only doctor that a patient may go to. We have outlived that system. It is outmoded. It is part  of the last century and we should get away from it.
I know that, as Deputy Booth mentioned, there are places in the country where it will always be necessary to pay a doctor to stay there, areas in which the population is small, sparse and widely distributed. We cannot do anything about that and in areas of this kind, of course, some form of subsidy must be provided to enable at least one doctor to be there. A choice of doctor will not be possible in many areas of the country but it should be possible in the centres of population; it should be possible in Dublin, Cork, Limerick, Waterford; it should be possible also in many of the larger provincial towns and I hope that we will see progress towards that end.
May I say one other thing? I did not hear the Minister but I was very glad to read his reference to the late Noel Burke. I, perhaps, more than any other Deputy, at the initial stages of the Voluntary Health Insurance Board saw evidence of the manner in which the late Noel Burke took up the task of getting the new idea of voluntary health insurance into operation and getting it known and accepted by an important section of the people. He certainly gave to that task tremendous energy and tremendous ability. The success of the voluntary health insurance idea was in large measure due to the personality of Noel Burke as the General Manager. The tribute paid by the Minister to his memory and the sympathy which he expressed with his family were indeed proper and very well due to the man concerned.
Mr. Moore: First of all, I wish to extend my congratulations to the Minister on his appointment to this most important post, perhaps the most important post in the Government. He has a formidable task ahead and I wish him God's blessing in the work he is about to do with the vigour we all expect from him.
I should also like to pay tribute to the work of the former Minister, Deputy MacEntee. During his many years as Minister, he was much  criticised and I regret to say that this evening the two Fine Gael members I heard speak spent a good deal of their time, not in criticising the health services on their merits or demerits but in criticising Deputy MacEntee. It is very easy to criticise the health services or any service but the people who are most critical of the health services, when they received the authority to amend them, did not produce such brilliant results. I do hope that in discussing health there will be less emphasis on personality and more emphasis on what should be done to give the country the health services it needs and deserves.
Health, perhaps more than any other topic of national importance, lends itself to the use of clichés. People talk about a free-for-all mother and child scheme, and so on. It makes me recall a poem written by Goldsmith about forms of government which could be parodied to apply to the health services: “Our forms of health services let fools contest; whate'er is best administered is best.” That brings to mind a recent happening which goes to show that people do not know what is available to them under our present scheme. A few weeks ago the chairman of a voluntary body made a statement that the parents of mentally or physically handicapped children did not have to pay for treatment. To test this out, I wrote to the Dublin Health Authority and asked them if it was true. They wrote back to say that as far as they were concerned the parents of a mentally retarded child had to pay for treatment, provided they were not on the general medical register, the same as any other parent. Here we have a responsible man making a statement believing it to be true, but the health authority differ from him and the parents go on paying. I hope the Minister, when he brings forward his comprehensive scheme, will ensure that the people will be made aware of what they are entitled to and what they are not entitled to.
Good housing is the basis of good health and we could tie in the housing programme with our general health services in order that one wing of our  services will not outweigh the other. If we are to have a healthy community, we must ensure that the houses people live in are conducive to good health. The same applies to hospital buildings. I serve on the board of one of the oldest voluntary hospitals in the city. It has a remarkably good board of governors, people who come from various strata of society and who agree on nothing but their devotion to this hospital. They raise vast sums of money each year voluntarily in order to help the hospital but this old building is forever being patched—a new roof this month, new floors next month.
The Minister in his programme for hospitals should scrap these old buildings and erect modern buildings which would be temporary: all the time medical science is developing and the building of today must be completely out of date tomorrow. We should not build for one hundred years but for 20 or 25 years at the most. We should sweep away the old buildings which were built many years ago when medical science was in its infancy. We would save money on that type of programme and we would save the hospital staffs a great deal of heartbreak in trying to care for sick people in a building like the one I know of which is practically falling down. Due to the generosity of Deputy MacEntee as Minister in making State funds available, the building I have in mind is still standing and wonderful work is being done there for people who need help.
One matter with which I hope the Minister will deal in a realistic and effective way is the payment of disability allowances to retarded people. I have in mind the case of a girl—I call her a girl although she is in her thirties —who is mentally retarded. She has the brain of a child of about two years of age. Her parents are dead but she is fortunate in that she is cared for by other members of the family who have almost dedicated their lives to ensuring that this girl wants for nothing.
The Dublin Health Authority on one occasion made this girl a grant of £1 a week. Her sisters by hard  work improved their positions in the business in which they were employed and their income went up. The Health Authority said: “You are earning too much”, and they took back the £1 from that girl. If her sisters were not so dedicated, they could have said: “We will refuse to keep you”, and she would be taken away to some institution where it would cost more than £1 per week to keep her. These are blots on our scheme of health services and yet they could be remedied so easily.
The cost of giving every mentally or physically handicapped person this allowance of £1 a week would be trivial compared with the amounts we spend on less worthy objects. Because of the mentally handicapped state of this girl, there could be no question of trying to get money for nothing. One would not need to be a doctor to realise that this girl is beyond hope of ever becoming a normal citizen. I do hope the Minister will show that we on this side of the House believe in justice for people, whether they have all their faculties or not. Every retarded person should be recognised by the State. Their families should be helped to keep them from the institution, to keep them within the home which, in most cases, is the best place for them.
In Dublin there is the system of the blue card and when the holder's name is entered on the general medical register, he is entitled to free medical treatment. Here again we must be generous and make this facility available on a personal basis. Even if the family, generally speaking, is well off, we should give the card to the person who is aged or ill. In that way such a person would have a certain sense of personal independence instead of a feeling of dependence upon relations. I do not advocate that the family should, of course, abdicate its responsibilities and that the State should take over. My approach is help through the voluntary groups, with the backing of the State.
This evening I thought a Deputy on the other side of the House was rather inclined to criticise the voluntary organisations. I may have misunderstood  him, but I think it a pity anyone should criticise these bodies. Most of us who are members of Dublin Corporation also serve on some hospital board, or some other organisation, and we know the tremendous help given by these voluntary organisations to the handicapped. This help is not given at State expense. It is given because we believe in the philosophy that all men, including the handicapped, are our brothers and we must care for them out of our own resources or through the medium of the taxation levied by the State. As I said, there should be greater liberality in relation to the blue card for people in need of medical or hospital treatment so that they will not live in the constant fear of not being able to afford the attention of a doctor. Eventually they become so ill they have to be removed to hospital and then someone has to pay for them, either their own people or the State. The expense is greater then than it would have been if they had had a medical service of which they could avail for an early diagnosis of illness and a cure of that illness in its early stages.
I am not one of those who think we can provide a free-for-all health service. That is a myth. Someone must pay either through taxation or in some other way. If it is done through taxation, the burden will fall heaviest on those who can least afford to bear it, on those whom we should protect. They may suffer most in the end under a free-for-all health service. I tire of people who point to Britain and other countries and the services they have there. There is one European country renowned for its social services; in it one is looked after from the moment one is born until the day one dies. That country has one of the highest suicide rates in the world. In fact, I understand there is now an approved method of committing suicide. It is designed to cause the least amount of trouble. Here we have different beliefs. By all means, let us look at these other countries and take what is good from them, but let us not slavishly follow these so-called progressive countries which are completely  materialistic in their outlook, and which leave a great deal to be desired in relation to those things we hold sacred.
I should like to make a plea now for a new deal for hospital nurses. Go into any teaching hospital and there you will find nurses doing as much as 12 hours' duty at a time. We are very proud of the Irish nursing profession. Irish nurses in Britain and elsewhere have demonstrated that they have been bred in a country which holds things sacred that are no longer held sacred in other countries today. These dedicated women care for our sick, working 12 hours a day in some cases. Most of them are members of a trade union. I am a member of a trade union. If these nurses followed the normal pattern, they would not work 12 hours a day. There would be the usual threat and ultimately the hours would have to be reduced. We should give our nurses a proper deal. We should show that we appreciate their services. We should show them that we are proud of them. Lipservice is not enough. We should give them a new deal with the best possible pay and conditions.
Mr. O'Malley: Might I intervene at this stage to make a correction in the figure which I quoted in moving this Estimate? It has been brought to my notice that I was supplied with a wrong figure. I ask the permission of the House now to correct it. The figure of £11,488,900 which I gave should have been £11,223,300.
Mr. P. Hogan: (South Tipperary): Deputy O'Higgins referred to the Select Committee of which both he and I were members. I can elaborate on what he said. When he submitted his memorandum to that Committee, Deputy MacEntee expressed his appreciation of the submission and intimated  to us that he would study it and probably submit a counter-proposal himself. All during the sittings of that Select Committee Deputy MacEntee favoured, as far as I could gather, the preservation of the dispensary system. He said it had the great virtue of being cheap, and of course it had. As a general medical practitioner system, it is probably one of the cheapest in the world. Perhaps “cheapest” is the operative word.
In last year's Estimate salaries and wages came to about £1 million, drugs came to about £500,000 and a little more than that was provided for dispensaries. The total sum came to something like £1,650,000. Deputy MacEntee was therefore quite correct in saying that the service is cheap. The bulk of the expenses are institutional. Deputy MacEntee also said that the system had the great advantage that the doctors appointed had to be chosen by the Local Appointments Commission and people were therefore saved from the great danger that existed in other countries where a doctor could put up a plate and start to practise without supervision by anyone. That was rather a naïve approach because every medical practitioner has to pass a qualifying examination and be duly registered. With all due respect to the Local Appointments Commission, many doctors who fail to secure appointment having appeared before that body have in practice been superior, as I well know, to many of the successful candidates. Deputy MacEntee also thought the system excellent in that he had strong disciplinary powers under it; he could easily sack the doctor. I will leave it to the House to decide whether that is an advantage or a disadvantage.
During the operations of the Select Committee, the former Deputy Dr. Browne resigned. He felt the deliberations of the Committee to be rather unrealistic. It was in the nature of a front calculated to delay. I personally was not at the time quite sure one way or the other. I thought we should give the Committee the benefit of the doubt and in this House I advocated  the continuation of the Committee. I said we should not be asked to report too precipitately. However, following on the submission of Deputy O'Higgins's memorandum in April of last year, no further meetings of the Select Committee were called. It was not until the Labour representatives in disgust handed in their resignations that things came to a head. The final meeting was called. I did not go to it. I do not know if it was even held. I do recall that Deputy O'Higgins in this House, at Question Time or during the Supplementary Estimate—I forget which—adverted to the fact in a cross-conversation with Deputy MacEntee that no meeting had been called from April to the following February. Deputy MacEntee's reply was: “You know the reason quite well. There was no place to call it.”
I ask any reasonable person anywhere if it is not possible for this Oireachtas or for the Government to find in any part of the Dáil Chamber, in the Seanad, in any Government building, in any hotel in Dublin, Cork, Limerick or Waterford a room where 12 men could sit down and hold a meeting? It was the most childish retort I ever heard delivered in this House. It was the final conviction, as far as I was concerned, that there was a completely unrealistic approach to this whole question of the Select Committee. That reply by Deputy MacEntee convinced me at least that he was not really very bothered as to whether the Committee held its meetings regularly or not. As Minister for Health, he was not very much bothered as to what report they would make and when they would make it. Ultimately, during the last election we were told Deputy MacEntee would seek re-election but would not take ministerial office.
That announcement as regards ministerial office was first made by the Taoiseach. We can all recall that on the eve of the election, under election pressure, the Taoiseach came to the microphone and said he would provide a free choice of doctor. In the House the other day I asked the present Minister whether he thought he could, within the framework of the present  dispensary services, provide a free choice of doctor. He told me the matter was under examination. He was not in a position to give me a reply. I can appreciate that. He has not yet settled into office and has not, I presume, had an opportunity of giving it the study necessary to give a reply on such an important matter.
There is a matter which has not been referred to so far during the debate. It is something of importance to the people of Dublin and Cork. It deals with the question of hospital costs from now on. The Minister has made a few adjustments in this Estimate. I have not been quite clear as to their significance. I did note that £500,000 has been taken off the Hospitals Trust Fund. As we are all aware, over a number of years the Hospitals Trust has been meeting the deficits that normally arise in the running of our voluntary hospitals in Dublin, Cork and elsewhere. From 1957 that figure has progressively increased.
I have here a reply to a parliamentary question of mine some time ago. It shows the sums advanced in the form of payments to the voluntary hospitals towards revenue deficits. In 1956-57, £701,000; 1957-58, £1,250,000; 1958-59, £900,000; 1959-60, £1,200,000; 1960-61, £1,500,000; 1961-62, £2,140,000; 1962-63, £1,900,000; 1963-64, £2,400,000. I may mention that during the same period grants to voluntary hospitals for capital projects decreased precipitously. In 1956-57 they were £2,363,000, the next year £945,000 and so on to 1963-64 when the figure was £694,000. This shows a complete alteration in the policy at the level of 1956-57 in the matter of capital grants for voluntary hospitals and health authorities. In that aspect alone it contradicts Deputy Booth's statement that the Government were always prepared to provide generous funds for hospital capital purposes.
My main concern at present is the question of the payments to the voluntary hospitals by the Hospitals Trust. We all noticed recently in our newspapers statements to the effect that the Department of Health were now pressing the voluntary hospitals to charge a  more realistic figure for their services; in other words, they were not to be so dependent on funds from the Hospitals Trust. I do not know what the average cost of a bed is in a voluntary hospital. It would depend on whether or not it was a teaching hospital. However, I presume it would take from £15 to £20 to maintain some of the beds in our institutions. If this annual disbursement from the Hospitals Trust is to be seriously lowered, as is now foreshadowed, it will mean a substantial increase in the cost of living for every man, woman and child in this city and other cities throughout the State who have to seek medical services in their local voluntary hospitals. I do not know whether these costs are ever reflected in the cost of living index figures, but they certainly will be reflected in the pockets of the average citizen. We may call it another little budget. I want to draw attention to that because I think it has so far escaped the average person; but he will find out to his cost in the months ahead if he seeks medical services that the bill will be substantially greater than he anticipated.
There is another matter on which I would like some information from the Minister and that is the question of national health insurance levels. It has been mentioned that there is a possibility that the income level for national health insurance will be raised from £800 to some higher figure, say, £1,200. Some years ago the figure was raised from £600 to £800 and automatically the level for qualification for the middle income group was correspondingly raised. I do not know whether that is legally obligatory or not. I do not know whether that is something which must be carried out or whether the Minister makes a separate decision on it. However, I, as a medical man, would point out to the Minister the position that may follow from this.
At present, doctors working in voluntary hospitals give their services free, or at some nominal figure, to the lower and the middle income groups. About seven or eight years ago, as I said, the figure was raised from £600 to £800. As far as I know,  there were no compensatory measures taken to put the doctors right as regards their income. That manoeuvre must have lowered their income. If, again, the figure is raised from £800 to £1,200 the main livelihood of junior surgeons and junior consultants generally in our voluntary institutions will be seriously affected. I would like the Minister to take cognisance of that fact. If that eventuality is likely and if he is prepared to consider the position of those affected, I should like him to try to meet their case.
Mr. O'Malley: When the Minister for Social Welfare introduces his measure to increase the insurability limit for non-manual workers from £800 to £1,200 a year, then automatically, without any legislative measure, that will bring the limit under the Health Acts for insured workers up to that figure.
Mr. P. Hogan: (South Tipperary): They are paid some retainer fee on the number of patients or beds. I do not know exactly how the details are worked out but if they have not beds they will be particularly affected by alterations of that sort.
Mr. P. Hogan: (South Tipperary): If he has no beds, he has no fee to get. Some of them have no beds at all and other members of the junior staff have only two or three beds. The Minister will find that bye-and-bye representations will probably be made to him in respect of some of the people who find themselves affected by alterations of that nature. I hope, if such a case is made to him, that he will adopt a generous attitude towards them.
General medical practice is carried out by two types of doctors. We have the dispensary medical officer or DMO and the private general medical practitioner. There are over 600 dispensary doctors in the employment of the State and there are about the same number—I think the figure is slightly more—in the case of general medical practitioners.
The dispensary system in this country is about a century old and was designed to provide medical services for the very poor people. At present, it caters for what is termed the lower income group, 30 per cent of the population, 800,000 people. One of its main defects is that there is not free choice of doctor. We consider, apart altogether from medical consideration, that it is socially unsound to segregate one-third of our population in an apartheid-like manner for no other reason than that they are poor. These people are compelled to go to a State-appointed doctor at a public dispensary at State-appointed hours for their services whilst those who happen to be a little more affluent can make a private appointment to suit themselves and their doctor. They can go to his  private house and to the local chemist to get their prescription filled. As far as I know, that system does not obtain in any other modern community. The dispensary system which still exists down through the years has largely been departed from.
The panel system in England was introduced over 50 years ago and it gave a free choice of doctor to all sections of the community. There are many defects in our system when you come to examine it. The inequality of the case load is a particular defect which has not been mentioned here. The dispensary boundaries have proved themselves to be very rigid things and all down through the years there has been very little attempt made to bring the dispensary boundaries into conformity with population trends. The Minister, on the few occasions on which he tried to do something about this, invariably encountered so much trouble that he was very cautious about making a second or third attempt. I do not know how these dispensary boundaries were originally laid down. Some of them are completely outdated as regards modern population distribution.
I put down a question here on one occasion to try to establish the inequality of case load. I may mention that in our sister island the greatest care has been taken for years under the British health scheme to establish a reasonable equality of case load. It is a matter that is under continual review. No corresponding efforts have been made here, so much so, that, taking our counties alphabetically, we find, for instance, that in County Carlow—and I mean the number of persons covered by medical cards, holders and dependants— one dispensary doctor has responsibility for a potential patient population of 3,781 while another doctor in the same county has a case load of 538. Yet both of these doctors are paid the same salary.
If we pass to the county of Cavan, we find one dispensary doctor there with a case load of 1,769 while another doctor in the same county has a case load of 407. In Clare, one doctor is  expected to look after 2,440 dispensary patients while another doctor there, on an equivalent salary, has a case load of 357.
In Donegal, there is one dispensary doctor with a case load of 1,457 while another dispensary doctor there has a case load of 282—and so on from county to county. I shall not weary the House in giving the extremes of discrepancy for every county in the State but there is this amazing discrepancy of 200 or 300 patients in the charge of one doctor while in an adjoining dispensary area, a doctor has many times that number. In County Waterford, a dispensary doctor is supposed to look after 8,000 people—a part-time officer looking after a class which represents, on an average, one-third of the population. Clearly, in one case you have a medical man who is in the happy position of being paid full salary for a relatively small amount of work and then you have the unfortunate dispensary doctors with a case load to which they cannot properly give service.
I am not concerned with the doctor-who happens to have a small number of health cards on his panel. That is his good luck. I am concerned with the situation whereby a doctor qualifies as a part-time officer and is expected to look after 5,000, 6,000, 7,000 or 8,000 people. Clearly, that is not a service, and while Deputy MacEntee may say it is a very good service because it is so cheap, the answer is that these people are going to private doctors and paying directly— and the State is pretending it is giving them a free service.
I do not think it is very easy to alter that position. I admit at once that there are population discrepancies between town and country districts  but the extreme discrepancy is revealed when the case load of each dispensary doctor in each county is analysed and shows an absolute negligence down through the years. I am quite sure the Department have been well aware of this difficulty for a long time. I am equally sure that it is not a matter that can easily be rectified within the framework of the dispensary district.
I asked a question on one occasion as to the number of dispensary boundaries altered in the course of rationalisation down through the years. One could count them on the fingers of one hand. An odd place now and then was altered. If two or three doctors die simultaneously, and their dispensaries are left open, then and only then can the Minister come in and alter the boundary of a dispensary. I know from personal experience that whenever such an alteration is mooted, one doctor is pleased while the neighbouring doctor is displeased. I offer, as a very cogent criticism of the dispensary system as it exists, the inequality of case load with the inevitable insufficient service which doctors who are overloaded must of necessity give to the lower income group and the relative impossibility under the existing dispensary system of rectifying it.
There are other discrepancies which are equally inexplicable—at least I have never heard an adequate explanation for them. Take, for example, the percentage of health cards issued as between one health authority and another. As the House is probably aware, the issue of health cards is entirely a function of the county manager. It is an authority which has been delegated to him completely by the Minister for Health. He issues health cards on the advice of his home assistance officers. Without reflecting upon home assistance officers in the country—I suppose they could hardly be described as trained social welfare assessors, but they do their best—the position has arisen that the percentage of health cards issued from county to county shows an amazing  and indisputable discrepancy. Let us take, for instance, the two neighbouring counties, Leitrim and Longford. Leitrim is, I suppose, the poorest county in Ireland. Longford, I would say, is a relatively wealthy county. Yet, we find that over 23 per cent of the people in Leitrim have been deemed eligible for health cards, while in the neighbouring county of Longford, 46 per cent are deemed eligible for health cards. The test of eligibility, according to the 1953 Health Act, is that a man must be unable through his own efforts or by other lawful means to provide for himself.
I find it hard to reconcile the discrepancy in those two neighbouring counties. One would expect the position to be somewhat the reverse. For example, in the county of Dublin, the percentage of people deemed eligible for health cards is 10.3, whereas in the relatively wealthy county of Limerick, 36.4 per cent of the people are deemed eligible for health cards. As one looks at the figures from county to county, it would seem that indeed in many cases it is the poorer counties which have the smaller percentage of health cards.
Mr. P. Hogan: (South Tipperary): I think that is the reason. If we come to examine the per capita payment of public assistance, for instance, we will probably find the same position obtaining—the poorer counties which need the assistance most are least able to pay. Similarly, the poorer counties not able to put up the money will not issue health cards. When they issue health cards, they have also to provide free medicines. That costs money and, therefore, I presume there is a tightening up in the issue of health cards in the poorer counties, so there may be something to be said for those who are advocating equalisation of funds and grants. That is my second criticism of the dispensary system in relation to the health cards.
I need not mention, of course, that the obnoxious means test is associated  with the health cards and has caused considerable distress among the poorer section of the community. We are all subject to a means test, of course. When the income tax man comes round to us, we all have to put up with these unpleasantries, but it is particularly obnoxious when the very poor are subjected to a means test with regard to the issue of health cards.
It is, I understand, legally obligatory to re-assess means annually. That, of course, is not done. It would be impracticable and very expensive. But perhaps an intriguing method has been devised in Dublin. There, the numbers of health cards are published periodically and people are asked to re-apply for them. If they do not re-apply, they do not get a card. That is in lieu of the annual means test which, apparently, they are legally obliged to carry out and in practice cannot.
One of the difficulties which the dispensary system presents is in relation to boundaries. It is difficult enough to have a county boundary but it is quite ridiculous to find a dispensary patient having to travel miles to see his dispensary doctor when across the street another dispensary doctor lives. Yet, the patient cannot go across the street to the neighbouring dispensary doctor because he is not in his dispensary district and sometimes a patient is forced to travel miles to see a dispensary doctor who is allocated to his geographical area. There are numerous cases where this causes considerable hardship. The boundary system attached to every dispensary district is completely irrational and would automatically disappear if there were a choice of doctor.
It has been suggested that free choice of doctor could be provided by a regrouping of the dispensary districts or rather by an amalgamation of these districts. If you take, for example, the city of Limerick, you will find seven dispensary medical officers there. For argument's sake, let us say we will abolish the dispensary boundary and will pay them their salary and let the people in the special dispensary areas have a free choice of doctor. Immediately you will be faced with a difficulty;  the doctors are paid on a salary basis and not on a capitation basis, or on a free choice basis and, inevitably, it will happen that the popular doctor will be overworked to such a degree that he will no longer be able to give adequate medical service and the less popular doctor who likes to take things easy will be able to spend his afternoon playing golf. Human nature being what it is, on the fixed salary basis, a free choice of doctor system cannot be instituted in a practical way.
Again, as regards the dispensary system, the element of free competition, which is as vital in the medical world as in the commercial world, is sadly missing. Every dispensary patient is conscious of the fact—much more conscious of it indeed than is the dispensary doctor—that if he did not call to the dispensary at all, the doctor would be just as well pleased, whereas a private patient or a patient who is paid for by the State on a capitation or other basis in which there is an element of free choice, feels and knows he is always welcome in the doctor's surgery.
The dispensary patient often calls to the dispensary with that subconscious feeling, which may be, and in most cases is, completely unwarranted. He feels that because he is not paying a fee directly, because his visit does not mean any monetary recompense for the doctor, he is only a second-class citizen, that he is merely tolerated. That introduces a bad relationship at the beginning, and it is something which the doctor cannot in any way wipe out. It is an in-built part of the dispensary system. Dispensary doctors all say to me that one part of the Health Act, 1953, which they thought was successful was the maternity section which gave free choice of doctor to the expectant mother. They all agree there was always a better relationship and a better feeling between patient and doctor than obtained in many cases under the compulsory element which is inherent in the dispensary system.
Again, dispensary hours are fixed hours. Very often they are held in the forenoon, and sometimes in the afternoon. They often entirely cut  across the working hours of the lower income group. Sometimes people who have to get health cards are prepared to go and consult a practitioner privately rather than hang around for half a day at the dispensary and lose a day's work. I also think the dispensary system is dishonest. It is dishonest where a huge number of patients are apportioned to a particular doctor, such a large number of patients that he cannot give an adequate service. It is dishonest on the part of the State to pretend they are giving a reasonable service to the lower income group when they are quite prepared to allocate 5,000, 6,000, 7,000 or 8,000 people to the care of one unaided doctor, who is graded as a part-time officer.
I may be asked: Why do people look for health cards if there are so many defects in the dispensary system? First and foremost, let me say at once that I have been amazed that the dispensary system has worked so well for so long, largely due to the dedicated services of the medical profession throughout the country down through the years. People look for health cards for two reasons. The first is that drugs have become very expensive. Some of the modern and popularly used drugs are amazingly expensive. Less well off people find their chemist's bills a burden now, and not their doctor's bills. While they might like to go to see the doctor of their choice privately, they are deterred from doing so by a fear of the large chemist's bill they will have to meet when the doctor writes his prescription. Consequently many of them are compelled to remain with a dispensary doctor in whom they may not have great confidence, because they find their chemist's bills so onerous, and many of them look for health cards in order to get some of the modern expensive drugs free.
The second reason why people look for health cards is that if they have to go into hospital for treatment for an operation or an investigation, they believe that if they have a health card,  they will be provided with this service free. The very fact that there is such a demand for health cards should not in any way be taken as indicating that it is a fine system and that everyone is rushing to get into it.
A further objection which can be offered against this dispensary system is in the field of social justice. As I mentioned in the beginning, we have over 600 dispensary doctors in our society and over 600 private general medical practitioners. They both do the same kind of work. The dispensary doctors do a little extra work of a public health nature, but by and large their work is similar. At one time dispensary doctors were paid a very low salary, something around £200 or £240 a year, out of which they had to provide, as now, for their travelling expenses.
The remuneration of dispensary doctors has improved considerably, particularly in the past decade. In days gone by, dispensary doctors vis-á-vis local private practitioners were almost on level pegging. The dispensary doctor had a small extra income from his dispensary. By and large, there was equality of opportunity. Things have now changed. The dispensary doctor is now in receipt of a substantial salary. In the meantime, the State has encroached considerably on several fields of private practice. Drugs have become prohibitive in price; there has been an increasing drift towards the hospitals; the dispensary doctor has superannuation and pension rights as well as his salary. Therefore the position as between the dispensary doctor and the general medical practitioner has become increasingly difficult for the private medical practitioner.
Many of these men have given the greater part of their lives in service to the community. They have paid their taxes. They should have equality of opportunity in the exercise of their profession. The position is that the dispensary system has led to the evolution of a privileged class. In fairness, there should be equality of opportunity as between dispensary medical practitioners and ordinary private medical  practitioners. There was relative equality of opportunity many years ago. That equality has now become inequality and I offer it as another objection to the present dispensary system. If justice is to be done, men in private practice, many of whom are finding it increasingly difficult to make ends meet nowadays, should be given similar or nearly similar opportunities to those available to their more fortunate colleagues.
We on this side of the House are therefore advocating the abolition of the dispensary system. We advocate free choice of doctor so that any patient may be entitled to go to any doctor. When we say free choice of doctor, we admit at once that it is a relative term. Free choice of doctor presents no difficulty in large centres of population such as Cork and Waterford. It presents graver difficulties as the population thins out. However, there is free choice in Northern Ireland. It is in operation in Scotland where population distribution cannot be so very dissimilar from our own.
While we may have a choice of several doctors in the larger centres of population, in most parts of this State there is within seven miles a choice of at least a second doctor. The Department of Health have gone into this and they report that if we exclude the more remote parts of the western seaboard, under existing general practitioner distribution, there are two doctors available within seven miles of each house in the country; and in Leinster, Munster, Cavan and Monaghan there are more than two.
It should therefore be possible to give a second choice of doctor to at least 90 per cent of the population who are prepared to travel up to a maximum of seven miles. Of course it will be necessary still to subsidise or pay extra to doctors who live in remote areas. Northern Ireland, Scotland and England have what they call a loading system—subsidisation of doctors to live in sparsely populated areas. There is no reason why some similar system should not be put into operation here.
 In the various submissions made to us at the Select Committee on Health Services, I think I am safe in saying that there was predominant acceptance of the notion that a free choice of doctor was highly desirable. I have listed here for the Minister the various objections to the dispensary system as I see it. I have asked him whether he believes he can preserve the dispensary system and still provide free choice of doctor. I do not think it is possible. In my view, we shall inevitably face the fact that the dispensary system will have to be abolished if we are to introduce a modern system of general medical services.
Deputy Booth seems to have completely misunderstood the position as far as we are concerned. In his statement today, he seemed to suggest we had proposed an insurance system which would provide a complete cover for general medical services. He pointed out that even in Britain, where there is a completely nationalised service, insurance payments cover only a percentage of the total cost. What we are advocating is an insurance system to cover nothing more than the general practitioner services. We have never said we should attempt at this stage, or in the future, I presume, to finance the entire range of general medical services on an insurance basis. When you consider that our general practitioner services approach only £2 million a year, while the total bill for health now is around £30 million, it becomes clear that Deputy Booth has a completely wrong approach when he suggests, as apparently he believes, that we propose to finance the entire medical services out of insurance.
I listened to the Minister's speech and I did not, as I had anticipated, hear anything about his ideas or plans for a future health service. He drew attention, properly so, to the incidence of tuberculosis, particularly in older people. I would add one point to his remarks on that, namely, that particular attention should be paid to the old chronic bronchial, the old man who goes around in every town, into every pub, coughing and puffing.  Many of these people are clinically tubercular characters and a potential danger to the community. They do not die from it themselves—they are immune, or relatively immune — but they are potential spreaders of the disease. We should all use our good offices so far as we can to try to get these old gentlemen to some medical man to be examined or, preferably, X-rayed.
I was glad to see the Minister's approach to the establishment of psychiatric units in hospitals. I have always been averse to the notion of specialist hospitals. It is a good thing that our mental hospital specialists should be brought again into the stream of living medicine and should not be segregated or boxed up in a watertight compartment as they have been for years without medical or social contacts with the other members of the medical profession.
The Central Sterilising Agency should be of considerable value not alone to this city but to the country at large. It is in operation in many other cities and considerable preliminary work was done on that concept of things by the Nuffield Foundation in Oxford.
I regret that the Minister did not make any mention of a national formulary. This is something which I mentioned a year or two ago. It is generally considered that a national formulary is a reasonable and economic method of dispensing and prescribing drugs and I would ask the Minister to have another look at the question of introducing a national formulary.
A Parliamentary Question here the other day elicited the reply from the Minister for Health that he had difficulty in filling a vacancy for a diagnostic cytological service for the diagnosis of cervical carcinoma. There are 200 cytologists carrying out this work in Great Britain and there are 75 in training. It seems rather strange that we cannot get even one here. If the Minister has been reading his Hansard he will have seen that Lord Taylor said that it has been estimated that they require 1,000 such technicians in Great Britain for every 50,000 of the population. On the basis that  every woman of over 20, at risk, should be examined on a three-yearly basis, then on the calculation that one technician would do 20 specimens per day we would require perhaps 50 such technicians here to provide a comprehensive service. It is rather ridiculous if we need 50 that we cannot get one. I do not know where the Minister advertised but if he contacts the British Medical Association they may be able to help him if he finds difficulty in filling this type of post. I take it that it is purely a technical post under the control of a pathologist but certainly he seems to have considerable difficulty in securing somebody for the post.
I asked a question here some time ago about what services were provided here for testing drugs which are in circulation. I cannot lay my hands on the Minister's reply at the moment but I have never been completely satisfied that our system of control particularly over biological preparations and our method of biological assaying is completely watertight. To give an example, in Britain recently tetracycline pediatric drops imported by Intercontinental Pharmaceuticals Ltd. were found by a research chemist in Birmingham City analytical laboratory to be seriously deficient in potency although it was claimed that these drugs were up to full standard when they were issued by the manufacturing house in Italy. I believe that at the moment new legislation has been suggested in Britain for a more adequate control over the quality of drugs in circulation and I recommend to the Minister that he should get in contact with his counterpart in Britain (a) as regards the more adequate control of drugs being imported into this country from the continent or elsewhere and (b) as regards more adequate methods for analysing drugs in circulation.
Some of the tests involved in the examination of these drugs are of an extremely complex nature. There was a time here when in every hospital and in every dispensary, when a new supply of drugs arrived, the doctor was supposed to forward three bottles to a laboratory in Dublin. We all know that in relation to examining these specimens in any worthwhile fashion  laboratory facilities did not exist. It is one matter to have a sample analysis made of the fat content of a specimen of cod liver oil. It is quite a different matter to have cod liver oil examined for its vitamin E content which is really what matters and which means far more elaborate tests. I do not know if that custom still obtains in the Custom House but most people regard it as rather a joke. However, the public authority accepted it and everybody was very happy.
Modern drug testing, testing of vaccines and sera and biological preparations is a highly-complex and expensive business. The number of laboratories capable of providing all-round facilities of that kind is limited and it is quite possibly true that for many biological preparations we have not got facilities in this country to carry out an adequate investigation. For that reason, I think the Minister should examine the entire question of control of drugs, particularly as to their biological potency, and he should seek the co-operation of the British authorities in this matter.
On the question of the mentally handicapped, as some speakers have already said, this seems to be a noman's land. Is the care of the mentally handicapped a health problem, an educational problem or a problem for the Minister for Social Welfare? Of course, there are medical aspects of it and it is in respect of these that I mention it. Educational training in the care of the mentally handicapped is a matter for the Minister for Education but in the care of the mentally handicapped in many cases, quite a complex medical investigation is necessary—only a minority—but I suggest to the Minister that he should endeavour, where such services are not available, to provide the necessary diagnostic facilities and have diagnostic centres where you would have a consultant pediatrician and a pediatric psychiatrist. I think that would be the nucleus of diagnostic centres which should be provided throughout the country, certainly in places outside Dublin and Cork, where there may be already a necessity to provide these services.
 It may also be necessary for the Minister to consider if it is desirable to introduce legislation to deal with this particular problem for as far as I know there is no special legislation already formulated to deal with the mentally handicapped. It is my business here merely to deal with the medical aspects of mental deficiency as this is a Department of Health Estimate. I stress very strongly that in some of these cases quite a complicated medical investigation may be necessary on a purely physical basis. I think that before mentally deficient children are segregated for day schools or residential schools, it is highly desirable to have a clinical medical examination performed in all cases with suitable referring facilities for consultative opinion where the local practitioner considers this desirable.
I asked the Minister a question the other day and I ask him again now: in the event of there being an overhaul of the dispensary system, what measure of compensation will he put into operation for existing dispensary doctors who have a contract of service with his Department? I should like him to express his views on the system of payment he would prefer under a State service. Does he advocate a salary basis, a capitation basis or a fee per service basis? That will be a matter, possibly, for long and difficult negotiation between the Minister and the medical profession in the future.
We have complete medical reciprocity with Great Britain and I remind the Minister that unless a reasonable income is forthcoming here to medical men, the standard of medical practice will deteriorate because the men will emigrate. The estimated gross remuneration for 1955-56 in Great Britain for unrestricted general medical practice, the offical figure of capitation and loading payments, is £3,580. There are various other payments to be added so that a general practitioner's average income in Britain for the coming year will be £4,600. I give these figures to the Minister so that when he comes, as he may have to come, to negotiate with the Medical  Association or the medical union, he will have an appreciation of the level of salaries obtaining elsewhere. Where there is free movement of doctors between one island and the other, if the Minister feels that he must retain a good type of medical practitioner here, he will have to bring his salary commitments up to something on a par with those obtaining in Great Britain.
There is one small point I want to make to the Minister. The general practitioner scheme which the Fine Gael people have been advocating covers 85 per cent of the population. I do not know how precisely that figure was arrived at but it was presumably on the basis that the lower and middle income group constitute 85 per cent of the population. Under the present health system, people of the middle income group outside hospitals have to pay for their doctors and for their drugs. When members of that middle income group, which constitutes 1,600,000 persons or 85 per cent of the population, go into hospital they cannot be charged more than 10/- per day and that 10/- is subject to appeal, not alone appeal to the local manager but, unlike holders of the medical card, the persons concerned can appeal directly to the Minister and in most cases the appeal is sustained and in practice only a minority pay the full 10/- per day. There are small initial fees of 2/6 for an X-ray and 5/- for a consultation.
Consequently, there is here an abnormal drift towards institutions. When people find that they have to pay for the doctor outside and they do not have to pay in an institution, very early on they ask for an admission ticket to a hospital. The doctor is placed in the invidious position that if he hesitates to issue such an admission ticket he leaves himself open to the interpretation that he is holding on to the patient in order to get a fee out of him and consequently all doctors complain that under the existing system there is a drift towards institutions by people whose complaints  do not necessarily demand institutional treatment.
A similar position arose some few years ago under the Voluntary Health Insurance Scheme. As Deputies know, the Voluntary Health Insurance Scheme does not provide for domiciliary service but it covers institutional service or hospital service or nursing home service and the practice apparently arose that persons who had taken out voluntary health insurance were unduly inclined to seek nursing home or private hospital services for complaints which could reasonably be well treated outside. The Voluntary Health Insurance Scheme is not State-aided. It has no other funds except what it gets in the form of annual subscriptions and a leading article was written in the Irish Medical Journal urging the doctors to use what influence they had to try to restrain voluntary health insurance patients from seeking unnecessary hospitalisation and pointing out that if that practice continued the Voluntary Health Insurance Scheme would break down and they could not certainly provide any increased amenities in future.
People who take out voluntary health insurance are, I suppose, the top drawer income class of society here and, if they were prepared to do that, is it not likewise reasonable to expect that the middle income group under £50 valuation and with an income of £800 a year would do likewise? The present medical services as they work here at the moment clearly lead up to that and may be one of the reasons why we here have got more beds per thousand of the population than any other country in the world and if we increase our beds by 10 or 20 per cent tomorrow morning they still will be all occupied as long as you do not charge the occupants an economic fee.
That may be one of the reasons why the Fine Gael Party thought it desirable to provide a free service, an insurance service, covering 85 per cent of the people. If there were no direct passage of money between patient and doctor outside institutions as well as  inside institutions there would be less tendency for patients to be bombarding hospital doors for admission and Deputies will appreciate that it is a far more expensive method to treat a man for a cold in a nursing home than it would be in his own bed.
Mr. Corish: I want to be very brief on this Estimate. In the 1961 election one of the main topics was the health services. In the election just past it was an even more important issue. Because it was such a hot topic in October, 1961 the Government agreed to establish a Select Committee on the Health Services on the understanding that the Committee would report to the House and make a recommendation within a matter of months. The various political Parties in the House gave their utmost co-operation at first and for a long time in trying to correct what they regarded as an inadequate health service and in trying to improve it and to do so in a reasonable time.
I never think there is much use in going too far back into the past. A post mortem on the Select Committee on the Health Services will not serve any useful purpose because what Deputies want to see is a change being made. That Select Committee was a pure waste of time and my only regret is that when we considered it initially, that was, about two years ago, we did not decide then to direct the members of the Labour Party to resign from the Committee because it seems that the action they took early in the Spring was such that brought home to the Taoiseach the futility of the Committee that had been sitting for three and a half years and was not making anything like a report and certainly was making no recommendations for the improvement of the health services. So much so that, I am sure without consulting anybody, not even the then Minister for Health, the Taoiseach here in a few sentences in a debate on the Vote on Account abolished the Committee with a wave of his hand. It was only then that he understood the  futility and the waste of time there had been over a period of three and a half years.
The members of the Labour Party and, I suppose, the members of the Fine Gael Party and the backbenchers of the Fianna Fáil Party were prepared to give this Select Committee a chance in October, 1961 but that chance was abused to the extent of three and a half years, a period during which certain members of the Committee were determined that nothing would be done.
I did not expect that, today, the Minister for Health would go as deeply even as Deputy Hogan went into the health services. I do not think anybody expected him to do that, but we expect action from the Minister. I do not know what is in his mind. I believe he will be much more liberal in his approach than previous Ministers for Health but we are not going to give him three and a half years or even one year. I think it would be reasonable to expect from the Minister for Health a White Paper in broad terms within a matter of months. I do not know what other people's conception of a White Paper is but to me it is an outline of the way in which the Government want to proceed generally in regard to the health services. We will not hold any Minister for Health to every single sentence that may be included in a White Paper rather but we should engage in this House in a discussion of a White Paper rather than have presented to us Bills which give details of health services, and details which Ministers, unfortunately, have been reluctant to change in many respects.
Therefore, as far as the Labour Party are concerned, I want to assure the Minister—and he knows more or less what is in the mind of the Labour Party in regard to health services— that we will be tolerant for a while but if no general plan or general intention is announced within a reasonable time he will be subject to much more criticism than his predecessor, Deputy MacEntee, was in the last three and a half years because he was hiding behind the fact that the Select Committee was sitting.
I want to refer to page 2 of the Minister's  speech where he said he has had preliminary discussions with certain interested organisations and he is arranging to meet others. That was the downfall of the Select Committee on the Health Services. They received evidence, as Deputy Hogan will tell you and as I am sure the Minister knows, from every organisation in this country, whether it had anything remotely to do with health or not. There must be a mass of evidence in the Department and I pity the Minister for Health if he intends to go through that mass of evidence again.
I object to the abuse of the functions of this House by Governments and by Ministers. Governments are prone to discuss proposals and to discuss legislation with outside bodies rather than have them discussed here in Dáil Éireann. The members of Dáil Éireann are representative of the people. I am amused and sometimes annoyed, to hear, in reply to parliamentary questions or in speeches by Ministers, that they are consulting this organisation or that organisation. If Ministers of this Government or any other Government were to listen to the views expressed here by Deputy Hogan, by members of the Labour Party or the Fianna Fáil Party, they would get much more information. They would also get much more support by having regard to the views, ideas and opinions of those who are elected by the ordinary people. I would, therefore, suggest to the Minister, in view of what has happened over the last three and a half years and the evidence that was sent up to the Select Committee, that he should not spend too much time talking to these organisations. I am not objecting to consulting major bodies like the Employers Federation, in this case the Irish Medical Association, the Trade Union Congress, bodies like that, but the Select Committee interviewed the most insignificant people. I am confident that with his energy and what I believe to be a liberal outlook on the part of the Minister, we can get a good health scheme.
There has been talk here about a free-for-all scheme and it has been decried on some sides and  it has been advocated by the Labour Party. The Minister read our policy document which, I will be the first to agree, was not in great detail; it was in some deatil. It did not advocate the introduction of legislation, say, in three months' or six months' time which would give a free-for-all medical scheme. The attitude of the Labour Party is that we should gradually work towards a free-for-all scheme, and it is not so frightening as it was five or ten years ago. This scheme could be regarded as a mass insurance scheme. If we have to contribute by way of insurance, by way of taxes, by way of rates, surely we can contribute to a fund in order to see that everybody is insured against ill-health? Every insurance operates on the same basis. I do not complain because I have not had an accident, even though I pay £30 or £40 into an insurance fund every year. I regard myself as being lucky and I do not think people should have cause for complaint in contributing to an insurance scheme so that everybody would be covered for health purposes. Anything other than that would be a covetous attitude.
There is no point at this stage in going into details on this Estimate because all these things are known or should be known to anybody who has been a member of Dáil Éireann or who has been in public life since 1953 when the Health Act was passed here. We could go on ad nauseam about medical service cards, the difficulty there is in getting them, and so on. It is a messy system which—and I say this having voted for the 1953 Bill—after the experience we have had, should be completely abolished. Let us then work gradually towards a free-for-all medical scheme.
Some of the conservatives in this House do not appreciate the cost of ill-health. One gets tired in 1965 of the cliché that fathers and mothers of families should generally be able to provide for themselves. That is all very well in theory but in practice it does not work. I hope I will be able to fend for my own family of three children but it made me think when one of them was sick in the last couple of weeks. It was some sort of a bronchial  infection, what is known as spring fever. The doctor attending the child gets £1. He writes a prescription which costs 30/-. For persons who have not a medical card, for persons who cannot afford that sort of thing, how difficult it must be when, because the parents are concerned about one of their children and want to make sure the illness does not develop into pneumonia or that the child's chest is not affected, they have to pay £2 10s. when they call in a doctor.
Action is needed and needed quickly because people can be crippled with hospital bills and doctors' fees. The doctors have increased their fees in recent times, and I would suggest that as far as Deputy Hogan and his surgeon friends are concerned they are well able to look after themselves. However, it is different for ordinary people who cannot get these medical cards, who are not in the lower income group. In my county the man who has £12 a week and a family of two children does not get a medical card. Take the man with £15 a week and four or five children; he does not get a medical card. A tremendous conflict must rage in that man's mind when any member of his family falls ill. What does he do? Does he say: “We will not send for the doctor to-day because it would cost me 15/- or £1 and, if he writes out a prescription, it will cost me another £1.” That is the question and that is a down-to-earth aspect of health services to which previous Ministers unfortunately did not seem to pay much regard; but the present Minister has sincerely interested himself in health matters in the city of Limerick. I know that from reading the reports of meetings of Limerick Corporation. Because I believe he is close to the people, I also believe that he can give this House in the near future the bones of a scheme. Let us cover the skeleton afterwards.
With regard to the new Health Bill, I would say to the Minister that he should not come in here having his mind made up that his Bill must be passed with the support of the members of the Fianna Fáil Party. I am  one of those who do not believe in playing politics in this House. Sometimes it may appear that we do that, but I do not want to play politics. We will get a good health scheme only if the Minister comes in with an open mind and is agreeable to formulating a scheme which will satisfy Fine Gael, his own Party, the Labour Party and any Independents who happen to be in the House. If he does that, his Bill will get an easy passage. I appeal to him to act quickly. The less discussion he has with too many outside bodies the better it will be. The people best able to advise him are the representatives close to the people, the members of the Dáil, a big proportion of whom are also members of local authorities.
Mr. Andrews: Like the Leader of the Labour Party, I, too, shall keep my contribution brief. Having listened to Deputy Declan Costello's contribution on health and, more particularly, his excellent contribution in relation to the mentally handicapped, I now make a suggestion to the Minister in this regard. I would ask him to ensure that there will be a co-ordination of services which will include the mentally handicapped. I disagree with any suggestion of the setting up of a separate body for the purpose of dealing with the mentally handicapped. I believe these people should not be set apart from other forms of disability. Subject to whatever safeguards are necessary, they should be included in the other groups of handicapped persons requiring rehabilitation or long-term care. An association for the care of the mentally handicapped is already in existence. There are associations, too, for other forms of disability. To set up a special institute for the mentally handicapped would focus attention, in my view, upon a specific disability, and that in an undesirable way. It would be wrong, I believe, to do that; it would be a very bad thing to highlight a difference that ought not really to exist. Every effort should be made to avoid setting apart in the public mind the mentally handicapped. The formation of a special institute would  tend to increase this undesirable cleavage, as it were, rather than reduce it.
The Minister dealt with the incidence of tuberculosis and appealed to us not to be complacent. The figures he gave up to 31st March, 1964, were 1,326; deaths in that particular year reached a figure of 336. I suggest that one of the contributory causes of tuberculosis is the overcrowded living conditions in some areas. If these conditions are remedied, the figures will decrease considerably. Indeed, the Minister for Local Government in his new housing drive will do much to remedy this very serious situation. While tuberculosis is on the wane, cancer is increasing. I think the Department of Health should issue to local authorities pamphlets to be circulated to the people telling them what precautions to take. As a matter of urgency, every individual should be advised to undergo medical examination at least once every year. That would be in the individual's interests, apart from any other consideration.
In common with other Departments, the Department of Health has an obligation to let people know what their entitlements are. One of the great drawbacks today is the lack of information available to people. Here, again, pamphlets would help to remedy the present unsatisfactory situation.
This is “Old People's Year”. Attention is being focussed on the problem of our aged. The major problem in relation to old people is loneliness and boredom. The Minister says, and rightly, that, however good and comfortable an institution may be, the best place for an old person is his or her own home. I quite agree. Increasing the old age pension has done something to mitigate the problem. Nevertheless I feel more can be done. I think the answer is the provision of State grants to families helping to maintain an aged father or mother, or both. I would ask the Minister to examine this suggestion.
Institutions have been mentioned. In his proposed survey the Minister  should take a look at one institution in the constituency I represent, the home at Roebuck run by the Little Sisters of the Poor. In it there are 400 or 500 old people living in the most extraordinarily happy conditions. They help one another. This is an important aspect. They can do things for one another which they could not do if they were living individually in some room or hovel.
The Minister is to be congratulated on the way he presented his Estimate. He did not presume to have all the answers but he did show his awareness. He showed his recognition of the many and varied problems which exist in relation to health. The Minister, when he studies, for example, the report of the Commission of Inquiry into Mental Handicap and considers the many other recommendations before him and when his surveys are completed, will implement all these matters in the interests of the nation.
Mr. Lindsay: The atmosphere in which this Estimate is being discussed is a very agreeable one. It has been developed from the very beginning by the manner in which the Minister for Health approached this Estimate in his opening speech. I want to wish him success in this Department. In doing so, I am convinced that I am not surrendering anything politically because it has been my firm view long before I came into this House that the health of the young, the middle-aged or the aged should not be the plaything of political Parties or a means of scoring off one another. It is all very well for strong and healthy people such as politicians to engage vigorously in defence of their respective principles, but the care of the sick and the aged should be the concern of us all in common. As Deputy Corish did, I expect action from Deputy O'Malley as Minister. We shall demand it of him because we feel that an ever-present challenge will make him give of his best. Therefore, it will be our duty to be as vigilant and as necessarily vocal as we can in that regard.
The Minister, quite understandably, has refrained from going into detail on this Estimate. He has not had a long  time in which to go into the details of what must be the great complexities of his Department. One thing I would advise him at the beginning is this. By all means, study all of the reports that are available up to now, but from now on forget about committees and commissions. It is not any remedy to the suffering ill to read in the newspapers that a committee has been set up to inquire into the methods by which they can best be made to recover. They will die while these committees sit. Many people died while the Select Committee sat here for the past three and a half years. Many people died during the consultations on previous occasions. If there are to be any more of them, the step would be retrograde instead of forward. I agree with Deputy Corish that this is the place to discuss matters of health, whether affecting people who live in large urban areas or rural districts. We are all here from such areas and, being here, we should be able to make the appropriate and relevant contribution regarding the matters that affect the health of our people in these areas.
It is commendable that such attention should be given to the mentally handicapped. In that regard one cannot pay too great a tribute to the voluntary institutions that have been carrying on this work silently and devotedly down the years. One has only to visit some of these institutions and see the care, devotion and love shown by every member of these communities to these creatures God, in His wisdom, has chosen to deprive of some faculty or other in whole or in part. No small credit is due either —and I say this completely non-politically—to Deputy Declan Costello for his tremendous work in this field of health activity and to the people he has gathered around him to help him in forwarding that work. I am glad to see that the State, through the Department of Health, is equally vigorous in pressing the claims of these unfortunate afflicted.
It is to be noted that the incidence of tuberculosis now appears to be in the upper middle-age group. They, of course, are the people hardest to get at. I can appreciate the difficulty of the medical people in trying to get  people of that age to submit themselves voluntarily to examination and subsequent necessary treatment. It is easy to get parents to bring their children to the appropriate clinic. But when people are on their own there is a great tendency to put off the necessary examination or appearance at the clinic from day to day, from month to month, or even from year to year. The consequent mortality must be high and, more tragic still, may not be attributable to the particular disease.
The care of the aged is described by the Minister as one of the great problems of our time. It is not the care of the aged, put that way, which is, in my opinion, one of the greatest problems of our time. It is the want of care of the aged, the lack of devotion now being shown, and the tendency among people with whom old people live to have them driven into institutions because they appear to them either a nuisance or an economic hardship. We are living in that way in a most materialistic age. We are living in the age when the family unit—and by the family unit, I mean from grandparents to grandchild—has suffered considerably in this matter of inter-generation affection. People are thrust into county homes and other institutions now by unthinking sons and daughters. It is not sons-in-law or daughters-in-law who are to blame; in many cases it is those of direct blood.
These are the things we have to fight against. In the west of Ireland, with which I am most acquainted, where there is a low marriage rate, people tend to grow old alone. Where the younger people are wont to emigrate at an early age, the care of an old person then becomes a genuine hardship on the person living alone and probably minding young children while the head of the house is a migrant himself, earning money temporarily in England or some such place. This is a problem relating to the rural communities, the cities and large towns. It is a problem to which the Department should address themselves.
I remember the night Mr. Harold  Wilson was interviewed on television when he became Leader of the British Labour Party. He was asked by one of the interviewers what thought was uppermost in his mind at that moment when he became responsible for the fortunes of that Party. The very first thing he said was: “My thoughts go to old people living alone.” A cynic would regard that as probably a political gimmick. Well, I accepted that. I believe it gained for him great assistance and great support from the British people. How he has implemented that is another matter. I consider the care of the aged is a very serious matter for the Health Department in this or, indeed, in any other country. Every effort should be made before care of the aged becomes essential that, by all the advocacy we can command, or we can get others to command, we should make our people have the same regard for their old and infirm as they were wont to have in the not so distant past.
Dispensary doctors have been dealt with at great length by Deputy Hogan of Tipperary, and I do not propose to say very much about them. The dispensary doctor system is the same one that existed in the pre-telephone era and when the only means of transport the doctor had was on foot, by horse, by pony and trap and probably by bicycle.
So much has been said on the question of the free choice of doctor that it is unnecessary to say anything more. I think, however, that free choice of doctor would tend to re-establish the very necessary relationship that exists between the doctor and the family he has attended over generations. Remuneration in this regard is important because it is necessary, in my view, that the family doctor, if possible, should settle as early as possible in the dispensary district which he is fortunate enough to obtain. If the remuneration is satisfactory, if the housing is satisfactory and the doctor has the necessary vocation, which, indeed a doctor needs very much, then I believe that continuity will endure  from generation to generation, even in one doctor's lifetime.
There is no doubt but that there are great complaints about chemists' bills. People rush for medical cards in order to obviate this difficulty. I believe that to be very true but there is another very great expense which, in my view, is incurred unnecessarily in health. I do not know whether the Minister can do anything about it or not. I refer to the absolute discretion which the county manager has either to insist on payment of the bill or, on representation, to have it wiped out altogether or reduce it so considerably that it becomes insignificant. I am all for the needy and the hard-pressed receiving the full measure of support that the State can give them but I am totally against people, who can afford to pay their bit, being allowed off in order that some public representative either at national or local level may be regarded as the local powerful man. This has succeeded in increasing the rates which we are all deploring as having reached unbearable proportions. Unless some steps are taken in that regard the level will rise still higher.
I have been looking over the comparative tables of the principal diseases issued by the Minister. There is an improvement in comparison with previous years but I am particularly disturbed by the fact that moneys are allocated in this Estimate to particular places. I want to speak simply about County Mayo. I see Castlebar is to get a new maternity unit and a new admission unit and in the county home they are about to provide new ward services, and build staff blocks and instal central heating. All these services are very necessary under the existing system but we have an excellent hospital at Ballina. We have an equally excellent, if smaller, one at Belmullet.
When I was in this House before I asked for some kind of surgical service for Belmullet and certainly a permanent surgical unit for Ballina District Hospital. I was told that these things would cost money but money spent on the saving of life and the preservation of health is money well  spent. One could mention a whole list of things on which money is wasted or certainly invested in projects which are no more than political risks. Health is never a risk unless it is neglected. It can never be a risk if it is well looked after.
During the last two days, owing to the lack of surgical equipment at the Ballina District Hospital, an unfortunate mother of five, about to be delivered of her sixth child, was sent in an ambulance from there to Castlebar. All they could do in the district hospital, where they have excellent medical services and excellent doctors and all the know-how but nothing in the way of surgical equipment, was to see that the last Rites of the Church were administered to her before leaving the hospital. It was fortunate they did so because she died on the road to Castlebar. How different that would have been if the Minister's predecessor, Deputy MacEntee, had not told me in reply to parliamentary questions and on his Estimate that the expenditure of the money required for such surgical equipment at Ballina District Hospital was not warranted or justifiable.
I consider no amount of money is too great to save the life of the mother of five children or any other number of children. It is because of the cynical approach to the spending of money on the surgical equipment in the district hospital that there is in my constituency today a home saddened by the loss of a mother and a husband who is bereaved and children who do not yet know of the loss of their mother. I hope the Minister—I believe he will—will look into the matter and ensure that there is no recurrence of that in the future. Infant mortality and maternal mortality are things about which something can be done and I am sure the Minister will see that they are done.
I want to say a last word on voluntary health. I regard the Voluntary Health Board as one of the greatest bulwarks against the expense that arises from ill-health. The tribute paid by the Minister today to the late Noel Burke is, to my mind, twofold, Firstly,  it was deserved and, secondly, it is, I believe, indicative of the Minister's liberal approach to the whole question. The Voluntary Health Insurance Scheme can be subjected to abuse and I take particular exception, from my own experience, and from the experience of others, to hospital authorities inquiring before you leave the admission unit how many units you have for surgical treatment and how many units you have for maintenance. The only purpose of that question, so unashamedly asked, is to be able to charge the maximum that one's policy can afford. That, I think, is a wrong approach on the part of some of these institutions and is in utter conflict with the spirit in which the Board was set up.
These are some of the views I hold on health. I shall not talk any further on it or on any other aspect of it this evening. The reason I refrain from doing so is that I expect that some sort of plan, scheme, Bill or White Paper will be in existence very soon on all of these matters. As I said at the beginning, it is to be hoped that there will be no further committees, no further reports, and that when it comes to this House, we shall be able to regard the subject of health as something vital to all our people. I should hate to think that my life or the life of anybody belonging to me, or indeed the life of anybody in this House, was dependent upon whether or not we were implementing a Fianna Fáil scheme, a Fine Gael scheme or a Labour scheme. On this big question, we must have agreement.
Not so very many years ago, when a Civil Liability Bill was before this House, a Select Committee was set up in which substantial agreement was obtained on all matters. If that could be done on the legal side of civil liability, why can this whole House not go into Select Committee and hammer out, however long it might take us, a plan, scheme or Bill culminating in an Act that would put health for all time on the pedestal of treatment it deserves and take it away from the political platforms so that no longer would we go up and down the country fighting elections on two matters in particular—how we  can make you live, paying you most and you working the least, or, how we can have you sick and keep you more comfortable than the other fellow can.
Mr. Ryan: I have raised in this House on a number of occasions during the past year the question of the intolerable delays many citizens have to suffer in the out-patient department in Dublin hospitals. This problem is not peculiar to Dublin. It has been faced and overcome in many cities throughout the world by adopting a simple procedure of having appointments made at particular times. But, here, the Department of Health acts in ostrich fashion and refuses to recognise the urgency of the problem and we have had successive Ministers for Health refusing to go to the trouble of making even casual inquiries into the extent to which this problem exists.
Deputy Corish and others spoke of personal experience in the course of this debate. It is not necessarily a good thing to argue from the particular to the general. I have had the experience of being in the out-patient department of a hospital—deliberately not making my public status known, in the knowledge that if it were known, special treatment would be afforded to me—and of having to wait 2½ hours or almost 3 hours for a simple medical service to be discharged, and, on learning of my public status, receiving profuse apologies which I brushed off as I considered the apologies were due not to a reasonably able-bodied man but rather to the mothers of young children and the working men who could not afford the time off but who were obliged to attend for two, three and four hours on a number of days a week to receive necessary medical attention. That is what is happening and it is a disgrace. That is what the Department of Health refuses to do anything about.
It is not entirely the blame of the voluntary hospitals or of their out-patient departments who are trying to carry on without sufficient money and with inadequate facilities. It is a crying shame that that should be so and I  demand that this intolerable situation be cured at an early date. It is relatively simple. Instead of calling on all people to be there at 9 a.m. or certainly to be present before 10 a.m. if they are to get attention at all, it would be much better that a number of people be asked to attend at 9 a.m., and others at 10 a.m., 11 a.m., 12 noon, and so on.
It is well known that one of the ways of avoiding these delays is to try to contact one of the Governors of these voluntary hospitals or to use some other approach or influence to receive special attention. That should not be necessary in this day and age. It is a disgraceful situation which could be solved speedily and humanely if the Department, as the co-ordinating body for the health services which it is intended to be and should be, took the initiative and endeavoured to have a system of appointments in order to avoid these appalling delays which are inflicted on people at the present time.
It may be that the Department has a sense of guilt because many people who are entitled to the general medical services have, in some of our Dublin suburbs, to wait for hours in the local dispensary before receiving medical attention. This is not the fault of the dispensary doctors who are discharging a herculean task with Christian devotion. However, where doctors are asked to look after as many as 2,000 patients, they cannot possibly get through the work in a short period of time.
It is entirely wrong that people requiring necessary medical attention should have to attend anywhere for two or three or four hours to receive that attention. Mothers of young families in Dublin suburbs such as Ballyfermot and Finglas who have some children attending school—the girls attending the girls' school and some boys attending the boys' school —and infant children at home cannot properly feed and care for them all and look after a sick child as well if they are required to wait, as they often are, for several hours in these overcrowded dispensaries. That this should exist in this day and age is  an appalling reflection upon our society and that the Fianna Fáil Party should have set up a Select Committee three and a half years ago deliberately to prevent any improvement in that situation is, I think, unforgiveable.
There has been a tendency in recent times to pick out individuals in the Fianna Fáil Government and to put the blame on them for certain matters but there ought to be such a thing as responsibility in the Government. If the Fianna Fáil Party means anything, it means that it is responsible for the actions and inactions of the Government. The purpose of the last Committee which sat for three and a half years was deliberately to delay and to prevent any improvement in the health service, lest it cost any additional money. I said that from this seat three and a half years ago. When, later, I was asked to sit on the Committee, I refused because I said, in opposition to its establishment, that I felt it wrong that this House should deliberately create a false situation and give the impression that it was attempting to improve services when in fact it was deliberately setting about creating an institution which would prevent any improvement and which would, at the same time, discourage people from any discussion of the health services.
The Committee achieved its purpose. It was entirely successful. I think Deputy Corish and others are wrong in condemning the last Select Committee on the Health Services. That Committee achieved what it was created to achieve—a delay in the improvement of the health services in this country. It was entirely successful and I congratulate Deputy MacEntee and every member of the Fianna Fáil Government and the Labour Party who joined with the Fianna Fáil Party on the success they conferred on that Committee after setting it up in the first instance. Never has any committee set up for a purpose been so successful for the purpose for which it was set up. It is a disgrace that so many Deputies could go into the lobby and establish a committee for that fraudulent purpose. We in Fine Gael voted against it. I am sorry Deputy Corish is not here to hear me express my personal irritation at his  remarks when he gave the impression that the House was unanimous in its support of the establishment of the Select Committee on the Health Services and that they in the Labour Party alone saw through this fraud.
The fact is that the Committee was set up for one purpose, to delay improvement in the health services at the time Fine Gael had tabled a motion in this House asking the House to adopt the Fine Gael programme for health reform. It was done because the Fianna Fáil Government were in an embarrassing position. The small quota of Independent Deputies were obliged in conscience to support the Fine Gael motion, unless a way out was found. The Select Committee was to report in three months; then the period was extended to six months; then a year, and ultimately forever. Then came the general election of 1965 in the course of which the Taoiseach, hardpressed in the country before the election and feeling that the social conscience of the nation had been aroused by the Fine Gael Party, made a tremendous announcement that he was thinking—and I suppose we must be grateful for small mercies—it might be possible to have a social policy running alongside an economic policy.
I am appalled to think that it is only when they were hard pressed in the course of an election campaign the Government in power now for some eight years, have any pricking of their conscience regarding the discharge of their social obligations. I suppose, even at this late hour, it has dawned on them that the medical services in this country are far from what they ought to be.
One of the most deplorable things about the present health services is that nobody knows what assistance can be made available to people in particular circumstances. It would appear that, if the health services are worthwhile, and if they are intended to be of assistance to people, the people ought to know what services are available but no Deputy can say with certainty whether a particular applicant for the general medical services is eligible or not for those services. The decision as to eligibility will  be taken by some faceless official who, presented with a similar set of facts in relation to two different applicants, may come to entirely different decisions. It certainly creates a great sense of injustice.
How often must the Minister for Health and others in this House have heard people remark that those who can afford to pay for medical services have the blue card, and many of those who cannot afford to pay have not got it? One knows the natural tendency of jealousy and the feeling that a person who is undeserving gets something. This feeling is so widespread in the country that it underlines what we say about the present health services—that they are entirely unsatisfactory and they lead to an appalling amount of dissatisfaction.
Deputy Corish spoke of abuses on the part of officials and the public in relation to the health services. Many of these things cannot be pinpointed but I think it is well known—certainly in the urban areas—that some holders of blue cards make their cards available to people who are not holders of the blue card. In a large urban area, where a dispensary doctor may have as many as 2,000 people to look after, he may not know all the families and all the individuals coming to him and the bearer of the card must be taken at his, or her, face value. There have been cases in which people have received treatment, drugs and medicine on the cards of other people. This may be a widespread abuse. If it is extensive, it means that making our health services universal may not be as costly as many people believe it may be. We on the Fine Gael side of the House will not tolerate any further delay in so far as the health services are concerned and we shall not hesitate to introduce a motion in relation to the Fine Gael policy, and we shall wait and see what subterfuge may be presented in regard to the health services so seriously required in this day and age.
I asked the Minister for Health recently to amend the rules that apply to the registration of births and deaths.  It is not a matter for legislation but for ministerial action; it is a question of amending regulations. The regulations at the moment require that people must attend in person and hand in the particulars on the form to the Registrar. I suppose the purpose of this is to prevent fraud or incorrect registration. That may be valid in rural Ireland in a small dispensary district where the medical officer, who is the local registrar, is familiar with the families who dwell there and with the appearance of individual members of any family in a large urban centre but it is absolutely idiotic to require that people whose relatives die in a city hospital, or whose children are born in a city hospital or nursing home, should have to attend in person to register a death or birth. It does not strengthen for one moment the veracity of the registration to require the personal attendance of the relation of a deceased person or newly born child. It defies all reason in this day and age to require a person, in distress owing to the death of a relative or busy because of the birth of a child, to go to a dispensary and join a long queue of people who are seeking one thousand and one medical services and wait for a few hours, perhaps, on a doctor who never may have known him and whom he may never meet again in order to say that John Murphy died or was born on a certain date.
The Minister for Health has a reputation in another Department for sweeping away the cobwebs and some of the rust that got into the State machine. This is a simple operation which he can readily and quickly perform and I hope that he will do it with all possible speed. It amazes me that one can make claims for money on the State by simply signing a form, forwarding it to a Department and getting payment on the basis of a written document without appearing personally, while you cannot discharge the simple duty of registering one of the facts of life without attending in person.
Deputy Booth mentioned that the expectation of life is rising steadily. I  feel that the vital statistics available to the Department of Health prove otherwise. It is a myth that the expectation of life is rising steadily. Strangely enough, it did rise for a short period of years, but at present a decline is taking place, if anything. All that we mortals can be hopeful about is that if we get over the age of 20 we may live for the normal span of life. There was a time when the rate of mortality of people in their twenties and thirties was higher than it now is. What is known as the expectation of life is not significantly greater now than it was 50 or 100 years ago.
The reason why we may have a larger number of older people in the community is not an increase in the expectation of life, or an increase in medical skills, because I think the sad and sorry experience of humankind, and the medical profession in particular, is that skilful as the medical profession may become in the treatment of one disease, another disease, or some other ailment, catches up on and replaces their hard-won victory over a particular disease or complaint. We must not despair. I have no doubt that we will continue to strive to combat all the diseases and all the afflictions of mankind. We must organise our society and see that the various techniques which are available to society to help the less fortunate in the community are developed in this country too, and see that no one is denied medical services or ancillary services simply because of lack of means.
That happens here at present. There are many families in this city in which the parents particularly deny themselves medical attention in good time because they have not the means to pay for it. They may not, perhaps, deny it to their children because the love of a father and mother for their children is greater than any statutory prohibition, and every sacrifice will be made by most parents to provide the medical care which is prescribed for their children. In many cases mothers and fathers refuse to consult a doctor because they fear they may require hospitalisation or expensive medical care, and they are not in a position to pay even 10/-a day for it. Consequently, they are doing themselves harm additional to  the medical deficiency that may already exist.
We cannot hope to ameliorate that situation until we have an open and generous national health scheme, whatever the cost. We in Fine Gael will never quibble over the cost of the introduction of such a scheme, provided it is not based upon antiquated Victorian laws or antiquated administration. If we try to graft a modern 20th century scheme on to an 18th century medical service, the cost will be prohibitive and the administration will be inefficient. We must wipe out the old dispensary system and replace it with something worth while.
I am glad Deputy Hogan referred to the question of compensation for dispensary doctors who may not be retained in their present offices in the event of an amendment of the dispensary system. I was appalled to hear of a dispensary doctor in this city who has always supported Fine Gael in the past and who voted for Fianna Fáil on the last occasion, not because he was satisfied with the dispensary system, but because he was afraid that the election of a Fine Gael Government would lead to the abolition of his post without compensation. Deputies know of the statutory rules and regulations which govern the payment of pensions and other emoluments of people whose public office is terminated under the existing system. If those posts were abolished under the Fine Gael health scheme they would be more than adequately remunerated for any loss or seeming loss of income. No dispensary doctor who is giving proper attention to his patients, and no doctor in general practice, has anything whatever to fear from a national health service. In fact, he has everything possible to gain. People will go to the doctor who attends them and they will not go to the doctor who neglects them. That is as it should be.
I was really disappointed to hear Deputy Booth today asking the House not to provide free choice of doctor because the effect would be that people would go to the best doctor and would not go to the doctors who were not giving them the attention they thought they ought to get.
Mr. Ryan: Perhaps his time will come. There may be changes, and the fact is that he represents a significant element in the Fianna Fáil Party. Certainly, the former Minister for Health was of the same mind as Deputy Booth, and he was not where he was, for so long as he was, without substantial support from his Party. One can be certain that when that Party meet to consider whatever proposals are put before them by the Minister and the Government, Deputy Booth and his element within the Party will certainly endeavour to prevent the necessary improvements from coming about. For all we know, it may well be the view of the Minister, too, that we should not give people this freedom in the choice of doctor. If we are not prepared to give them a free choice of doctor, we may as well abolish democracy altogether. If people have freedom in the choice of who represents them in this House, they should certainly have freedom in the choice of the doctor who attends to their urgent bodily needs. We may as well say that we have no choice in the selection of the confessor who deals with our spiritual needs and that that is not as natural a right as the choice of a medical man.
Mr. Ryan: These things are terribly important. If a person has not confidence in the person who gives them medical attention, half the good of that medical attention is gone. There should be entire confidence between doctor and patient, and that confidence certainly does not exist between all dispensary doctors and their patients. In many cases that may not be the fault of the doctor. These are human problems and they do exist. There is certainly no justification in any urban centre for requiring people to go to a certain doctor.
The dispensary system can also be criticised on the ground that, when doctors prescribe medicines for patients, in many cases the prescriptions  are altered by non-medical people who provide substitutes for what has been prescribed, or else there is such a delay in the provision of the prescribed drugs or medicines that the person's health condition has changed between the time of the writing of the prescription and the delivery of the goods. Some years ago I saw what I thought was a walking skeleton coming to see me. I was amazed to learn that the man could walk at all. He had been brought down by a kindhearted neighbouring taximan. I went up as fast as I could. The reason why that man was a human skeleton was that the Dublin Health Authority were not making available to him the drugs and medicines which had been prescribed. They were giving him substitutes. Within three weeks he was an entirely new man and when next he came to see me he did not need the services of a well-disposed taximan.
That is only one man who suffered ill-treatment because of the inhumanity of our dispensary code. All this must be swept away. I hope it will be done through the unanimous decision of all sides of the House. We shall not accept any half measures in this respect. We in Fine Gael, as well as Deputies in the Labour Party, have continuously criticised the efforts Fianna Fáil have made in relation to medical matters because we were not satisfied they were doing the right things in the right way. What we hoped was that what they would do would not cost too much and do too little. It will not do the nation any good to see the same system operating in another decade. Therefore, we shall not delay the Minister any longer from getting down to his homework.
Mr. Barry: It is not my intention to delay the House any longer than five or ten minutes. I do not normally do so. I should like to begin by congratulating the Minister for Health on his promotion from Parliamentary Secretary. As a Minister man and as a Cork neighbour of the Minister, a Limerick man, I wish him the best of luck in his new capacity. I  should like deliberately to repeat what has been said by other Deputies during this debate, that health matters should be taken out of politics.
I should like the Minister to know that, genuinely and sincerely, as far as I am capable I shall give him every help he requires from this side of the House in his efforts to improve the health services and their administration. That goes for any Minister for Health, whoever he may be. I was afraid, when the Taoiseach and Deputy Cosgrave began swapping pleasantries across the floor of the House, that it was not a good sign. The Department of Health and the work they do must at all times be kept out of politics. I sincerely hope that will be done.
I was rather disappointed, listening to the Minister's speech, that he did not indicate any significant changes in the operations of the Department as I have known them during the past eight years. It may be, and I accept it, that the Minister has not had time to shake up the Department in the way I believe he will do and is capable of doing. My duty now is to bring to his attention some of the things I think are necessary to shake up that Department.
The Minister knows as well as I do that among all the people in the country there is general dissatisfaction with the health services and the treatment provided for the sick. We all know that the present burden of the cost of the health services is much heavier than the people are prepared to bear. It may be they would be prepared to bear that burden cheerfully if they could hope for better services in the future.
All Deputies, especially those who are members of health authorities, will agree that the greatest proportion of the increasing burden of rates is due to higher health service charges. When rates throughout the country continue to increase annually by anything from 5/- to 15/- in the £, it is time that those of us entrusted with the responsibility to look after the interests of the people who sent us here should pause and take cognisance, should ask  ourselves what is faulty in the administration.
More than once, as a member of the Cork Health Authority, I have made this statement knowing very well it would be unpopular. More than once I have drawn attention to the fact that the cost of administering the health services at national and local levels is astronomical. I, therefore, appeal to the Minister for help for the people who must foot the bill. He was a member of a local authority and he will, therefore, more readily understand what I say when I appeal to him to take serious notice of this problem.
With a full sense of responsibility I say that the greater proportion of the vast amount of money spent on the health services has been going in administration costs with very few benefits accruing to the people who are entitled to them. The Minister must agree that the cost of administering the health services has been one of the greatest single factors responsible for the increasing rates throughout the country, particularly during the past three years.
The Taoiseach admitted in my presence, in The Square in Tuam during the recent by-election campaign some months ago, that he realised the burden of rates was a national problem which should be tackled immediately. I suggest that the Taoiseach, with the Minister for Health and other members of the Cabinet, should examine the problem with the utmost urgency. I further suggest that much of the pruning and saving that could and should be done could come from the health services administration.
Only an hour ago, Deputy Corish referred to the number of Commissions that had been set up. He referred specifically to the Select Committee on the Health Services which sat for more than three years and got nowhere. He revealed the disappointment of the Labour Party at the fact that absolutely nothing had come of the work of that Committee. I could not agree more with Deputy Corish. The great tendency in Government lately has been to hand over all those things  to Commissions and now, if I read the papers rightly, there is a suggestion that we will have another Commission to look into the health services and the Minister will ask other bodies and people to advise on this matter. Could the Minister contradict that suggestion?
Mr. Barry: I am glad of that. I expected that the Minister, being a big man as he is, would do that here and now. While all of us, especially those unfortunate people who are handicapped, either mentally or physically, are looking forward to the Minister's administration and a more practical and realistic approach, could the Minister, having assured me on this other point, now assure me that he will bring in a Health Act in the next six months?
Mr. Barry: When you are bringing those submissions to the Government I hope you will keep in mind many of the practical suggestions made from different sides of the House this evening. I just want to make a suggestion in regard to the medical card system. It is a system I abhor and I hope when you are bringing in your suggestions——
Mr. Barry: When the Minister is bringing in his suggestions to the Dáil, I hope he will take into account the plight of unfortunate people subjected to the rigorous examination of a man or woman, now called a home assistance officer, who might be in good humour today and in bad humour  tomorrow. By reason of their humour varying the chances of those people obtaining a medical card varies also. I hope the Minister will find some way over this when he brings in his new proposals. This is an annoying and vexatious inquisition not only into the individual's own means but those of his family, in Limerick, in Cork, in Birmingham, in London, in America and in Australia. It is high time in a Christian society such as I hope we now have that all this victimisation should be stopped. We are living in an age when, thanks be to God, it cannot be said that hunger exists anywhere and we all depend on one another to tell at least most of the truth if not all the truth when asked simple questions by officers appointed by the State.
The Minister should use his good offices in regard to another matter. It is a very good thing that mental illness is now regarded in the same way as any other illness. A few years ago if there was any question of mental illness in a family that family was regarded as “taboo” and unfit to associate with their neighbours. The Minister should endeavour to ensure, now that mental illness is regarded in the same way as any other illness, that no stigma will attach to the unfortunate member of a family who happens to be a victim of mental illness.
In conclusion, may I assure the Minister that we are all behind him in any proposals he may have for improving the Health Act and its administration and for improving the care and consideration for those who require medical attention. Deputy Hogan of Tipperary made one of the best speeches I have heard since I came to the House ten years ago. Much of the information he gave the House was news to me. A man like Deputy Hogan, who is prepared to take an interest in these things and to state his case, is to be admired. Any Minister for Health must take cognisance of what such people say. I am sure that Deputy Hogan and the Minister have something in common and I hope that between them we will get a proper health service. I wish the Minister well in his attempt to produce this.
Minister for Health (Mr. O'Malley): At the outset, I should like to thank the Deputies on all sides for their very encouraging remarks on the occasion of the introduction of my first Estimate. Deputy Corish made a very wise observation. We do not have to consult with the various bodies again. We are here in the Dáil as public representatives and we have a knowledge of a fair cross-section of the problems of the people we meet every week of our lives. When I met the Irish Medical Association on two occasions recently, and such bodies as the Irish Nurses' Organisation. I did so to get further information for my own education, so to speak, and they were certainly of great assistance to me. I asked them certain questions, having pointed out beforehand that my asking questions did not imply that my decisions had been taken by the Government. I made it quite clear that I could not commit the Government in any way and that any proposals I would make would be subject, naturally, to the ultimate approval of the Government. However, I would be less than honest, and I think I owe it to the House, if I did not mention that I was a member of a local health authority myself and that anomalies do exist. We all know that the greatest trouble is the uncertainty and lack of uniformity throughout the country as to the position that will obtain in one county vis-à-vis another. The minds of the people, too, to a great extent, are clouded as to what their rights are. That defect should be remedied. Some local authorities have a lot to learn and it is about time that some of them began to adopt a more humanitarian outlook. It is time, too, to stop seeing people as statistics and faceless ones——
Mr. O'Malley: ——to be filed and catalogued and forwarded in due course to my Department. Not all complaints can be avoided entirely but certainly many of the hardships imposed could be greatly lessened by a more sympathetic approach and understanding in certain instances of which I am sure we are all aware. It is true that I am examining all facets of the  health services and every constructive suggestion made here today will be examined by me in great detail. Such suggestions have been made on all sides of the House.
Criticism has been made of the Select Committee on the Health Services. I do not want to go into too much detail about that, but personally I have got invaluable assistance from the submissions, the evidence and the comments of members of that Committee. It has saved me the task of having to consult quite a lot of the bodies who gave oral and written evidence before that Committee. This has been of very great assistance to me. It is true that I am enamoured personally of having a choice of doctor where this is practicable. I think it is inevitable and that it would further improve the services. I also think that there can be great hardship for the middle income group in the very high cost of drugs and medicines. I do not think a high percentage of people even with comparatively good wages can easily afford them. This also is under very careful consideration.
On the other hand I had an interesting meeting last Sunday with a member of an Order that is doing great work in domicilary treatment in the south. She told me: “If you like to come along with me next week I shall take you into three or four houses and show you some cupboards with expensive medicines in them but in many instances it is not drugs or expensive pills that are needed but nourishment.” We must, therefore, examine this problem in all its aspects and not in a glib manner.
I agree with suggestions that any proposals we arrive at should have a certain amount of elasticity. Certainly, whenever any proposals of mine are being discussed in the House I shall be quite amenable to further suggestions. Everything, of course, depends to a great extent on the provision of finance. People say: “Can we afford this?” My answer is and my personal opinion is: “Can we afford not to do certain things which are crying out to be dealt with?” That is why I was so  impressed with some of the evidence given before the Select Committee which supported what I and other Members of the House, as public representatives, ourselves know, that these anomalies, injustices, and hardships are not unique in our own city or locality but are fairly widespread throughout the country.
We speak of income limits: a man may have £1,500 a year and be under very heavy and continuing medical expense. That would be a greater hardship on him than it would be in the case of man with £10 a week and, perhaps, one child, especially if the man on £1,500 a year has eight or nine children. For such as these cases, the application of the hardship clause must be examined very carefully.
I was very glad to see the unanimous approval of the priorities which I intend to give in regard to the treatment of old people. Certainly, the public require to be educated in this regard as I have been educated myself. I met a body of nurses last Friday and I interviewed a very fine type of woman, a responsible public health nurse, and she gave me an account of the set-up in her own area. She told me they had set up a register of the aged and had obtained valuable information in regard to the care of geriatric cases. The register for that area was started in November, 1963, and there are now 1,000 persons on it. I do not know if this is typical, but this public health nurse found—and this in an area, which I shall not name, which was held up to me as a good area for health services;—that about 20 per cent of those on the register lived alone. Some were discovered living in very serious, if not appalling conditions. This nurse told me that she went in with the American Expeditionary Force to Belsen and she found conditions in her locality almost as difficult to deal with. She is not a person given to hysterics. The principal problem she found was loneliness. I think Deputy Andrews also referred to that. Some of the old people lived alone, many fields away from the road. They had no neighbours. Many suffered from defective sight, poor hearing and  lack of dentures. In some cases, the visit of the public health nurse was the only contact they had with humanity. Consequently, her visits were eagerly welcomed and the old people sought to keep her with them as long as possible. In view of the number on the register, and also because these nurses must attend to dispensary duties with a doctor and give injections and other services, it is obvious that the domiciliary care of the aged is a matter which will have to activate minds in my Department very much and very quickly.
We should be grateful to Deputy T. F. O'Higgins for removing some of the wrappings from this personal health insurance scheme, as he describes it, and for having explained to us what his scheme would cover. He was very candid and made it very clear. It seems now clear that it would mainly be intended to cover a general practitioner service, as he says, with choice of doctor and so on. His scheme would replace the present dispensary service, but the hospital services, the mental health services, the mentally-handicapped services and so on would not be covered by this insurance scheme.
I should like to get the Deputy's scheme in perspective. In the present year the dispensary service is costing approximately £1,860,000. Those figures are given in the Estimates. I should like to correct Deputy O'Higgins because he was in error when he mentioned £3.5 million to £4 million. The cost of the services, other than dispensary services, is estimated at £27 million. Am I right in assuming that this cost would not be greatly affected by the Deputy's proposals and that it would be necessary to meet it as at present, half from the Exchequer and half from the rates? If this is so, then, as the cost of the dispensary service represents about 6½ per cent of the total cost of the health services the way in which most of the cost is met would be unaffected.
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