Committee on Finance. - Vote 48—Health.

Tuesday, 14 March 1967

Dáil Eireann Debate
Vol. 227 No. 4

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Debate resumed on the following motion:

That the Vote be referred back for reconsideration. — (Deputy Ryan.)

Mr. S. Flanagan: Information on Seán Flanagan  Zoom on Seán Flanagan  Deputy Ryan also raised the question of preparing people for their retirement. This, of course, is a very wide issue, having social implications of a far-reaching nature. I accept that many people are unprepared for retirement but I have often wondered at what stage in one's life should one begin to prepare for retirement. Is it the age of 35, 40, 45, or when? In any event, this is one of the questions on which the Commission [558] on Mental Illness made certain recommendations. I shall be considering them carefully in conjunction with the Commission's general report.

In regard to old married couples in county homes I fully share Deputy James Tully's concern that people who have lived all their lives together should be separated at the end of their lives in county homes. I am not sure exactly how many couples are so affected but it is not very large in terms of numbers. The same consideration applies here as that in regard to mentally handicapped children in mental hospitals, namely that the problem is not one to be dealt with as a mere problem of numbers. I propose to take positive steps to try to ensure that all married couples will in future be able to stay together during the last years of their lives, in county homes if they have to be there.

The next matter I should like to refer to is the district nursing service. I thank all Deputies who paid tribute to this service because I regard the service as being perhaps the single most important service provided in the country for the community; and I regard the expansion of the service, which is going on fairly rapidly at present, as being of fundamental importance. Some Deputies, including Deputy James Tully, said the service is not being expanded rapidly enough. While this may be so, the fact is that considerable improvement has been achieved to date and most local authorities have fairly enthusiastically responded to the circular issued by my Department some months ago.

As a result, 68 additional post of public health nurses have been approved and proposals for the creation of 43 further posts are being considered. The fact that this expansion has not occurred at the speed some of us would desire is due to difficulty in obtaining suitably qualified and trained nurses for appointment. As the House knows, An Bord Altranais are holding courses leading to certificate examinations. I had the pleasure some months ago of declaring open the first such course, attended by 34 trainees, and I shall also have the duty of presenting the necessary [559] certificates to these charming ladies in the very near future. I am told that some of them were present in the House at an earlier stage today and only regret they are not present now so that they could hear my complimentary references.

Deputy Corish, I am afraid, has stolen their hearts by the references he has made to the undesirability of these ladies having to disguise their crowning glory, their hair. These courses will be continued until the requirement laid down in the White Paper of 600 district health nurses is fulfilled. The only thing I wish to add in regard to this is that I believe the tour of local authorities which I undertook late last year had some effect on those local authorities who were dragging their feet in the matter of co-operating with my Department in steps to improve the ratio of public health nurses to the population, as set out in the White Paper.

As regards Deputies' references to district medical officers who are not availing of the service of public health nurses, this is a difficult personal problem on which all I can say is that I hope the number of doctors about whom this can be said is steadily diminishing. I am aware of instances where doctors have not cooperated; I am aware of instances where doctors have regarded the nurses as being more or less personal secretaries and who have, to some extent, impeded them in the discharge of their duties as nurses. I deplore that, in the few instances it has occurred, and should hope that the motivating factor will be, as it ought to be, the service of the people and providing for their needs, not the matter of the personal convenience of either the doctor or the nurse.

Another matter, mentioned by Deputy Kyne, was the provisional medical cards. He said he thought there should be a system of appeal from decisions of the managers of health authorities. I have given a great deal of consideration to this matter. I can certainly see force in Deputy Kyne's argument, but, at this stage, I feel we should not take any steps to [560] provide appeal machinery. I am concerned by the fact that there are considerable divergencies, as between managers, in the application of the existing law, with the result that persons earning a certain amount of money per week qualify for medical cards under certain health authorities and do not qualify under others. The fact that the county health authority system is shortly going to be replaced by a regional board seems to me to obviate the necessity for creating appeal machinery at this time.

Secondly, there is the proposal in the White Paper to standardise the means test and to publicise an agreed formula in such a way as to achieve, as far as possible, the level of standardisation that is desirable in this regard. With the creation of the regional board, at least as I envisage that board operating, there will be a built in machinery for appeal from whatever local officer carries out the initial examination to the board itself. This should provide a fair system of appeal, without creating any appeal machinery, as is suggested by the Deputy. In other words, what I am trying to say is that I agree with him that uniformity of application of the means test is desirable. I agree with him that anomalies should be removed. I agree with him that some form of appeal machinery is desirable, but I believe that to create it at this stage would be undesirable, because, other things apart, it would be expensive to do so and when regionalisation is a fact, some machinery will exist in any event.

I now come to another point which Deputy Kyne raised, in regard to the interview I gave to the Irish Medical Times. Here I must also refer to what Deputy Ryan said because he suggested that I gave that interview with an eye on the medical profession and gave my replies with a view to pandering to the conservative elements of that profession. Might I say to Deputy Ryan that if he really thinks that, he might have said this in his article to the Irish Medical Times in which he dealt with my interview. He had an opportunity then, of which he did not avail.

Mr. Ryan: Information on Richie Ryan  Zoom on Richie Ryan  The space was limited.

[561]Mr. S. Flanagan: Information on Seán Flanagan  Zoom on Seán Flanagan  I accept it as so. I do not think Deputy Ryan believes I was pandering to the conservative elements of the medical profession when I said that it is not envisaged that the lower income group will be substantially increased from the 30 per cent odd it is today but I take Deputy Kyne's point seriously because it is a serious matter. He quoted paragraph 51 of the White Paper and suggested if the limits were prescribed in accordance with that paragraph, the proportion of eligibility for medical cards would likely be as high as 50 per cent and said this was not in accordance with what I said in the interview. He asked me to clarify this.

I am glad to do so. What is said in the White Paper is what we intend to do. Of course, it is clear that already in certain parts of the country the proportion of people who have medical cards is already at, or even higher than, 50 per cent. There are parts of the country where the proportion of medical cards is as high as 60 per cent, those obviously being the poorer rural areas. What I said to the Irish Medical Times was simply this. It is not envisaged that there will be a substantial overall increase in the number of people who will be entitled to medical cards, but I am not tying myself. I did not then and I do not intend to do so now. What is said in paragraph 51 is what we intend to do. When one combines with that intention the other intention of regularising the method of assessing eligibility for medical cards, the proportion can then take care of itself.

I do not believe, having regard to all the considerations that will have to apply, including increasing affluence, increasing wages and salaries and so forth, that there will in the end be a substantial increase in the proportion of people over all the country who will be entitled to be included in the lower income group, although, of course, there will always remain certain isolated, remote areas where people are poor and where the proportion will be higher. There will also be richer urban areas where the proportion will be very substantially lower.

[562] On the question of eligibility, Deputy Esmonde, somewhat, to my surprise, made the suggestion that home assistance officers do not deal fairly with the people and that instead they try to save expense by refusing medical cards to people who should be granted them. As I say, I am very surprised that he said this because he is a Deputy for whose views I have considerable respect. I can only say I find it very difficult to believe. I should point out that home assistance officers do not refuse medical cards at any rate. All a home assistance officer does is to go along and investigate the means and circumstances of the applicant and report his findings to the health authorities, who in turn make the decision. Therefore, it is not strictly accurate in any sense to say that home assistance officers refuse applications for medical cards. On the other hand, there may be the casual instance where the home assistance officer sends in a report which could be regarded as harsh or unfair. I believe and hope that the number of cases in which this would apply is very small. If the Deputy or any other Deputy can give me instances I will be happy to have them re-investigated but on behalf of the home assistance officers, I should say that they are, in the main, doing a difficult job and doing it honestly and well.

I come next to complaints made by Deputy Treacy about dispensaries in County Tipperary, and also complaints by Deputy Coogan. This question of the condition of the dispensaries, and indeed the provision of dispensaries throughout the country, must be considered in the light of the proposal to change from the existing dispensary system to one in which there will be choice of doctor. I am aware that so far as Tipperary is concerned, if I may take it first, that it was the intention of the authority there to replace the dispensary premises at Ardfinnane, Ballingarry and Kilsheelan but the health authorities were asked to review the proposal to put up new dispensaries in these places in the light of the declared intention to introduce the choice of doctor system instead. As the House is aware, under the new proposed [563] service, eligible persons will attend their doctor, not at a dispensary premises but at the doctor's private surgery. Generally speaking, health authorities would not be obliged to provide dispensary premises at all, though, of course, an exception will always have to be made for those special areas in the country requiring special consideration.

Since Deputy Treacy made his remarks, I have had certain inquiries made of the county manager in Tipperary, especially with regard to Ardfinnane. I am advised that in an effort to remedy the position there, the authority have advertised recently for the purpose of acquiring alternative premises for use as a dispensary, pending the implementation of the choice of doctor scheme. They have also undertaken to examine the position in regard to the other dispensaries I have mentioned, with a view to effecting any essential improvements required at any of these centres.

The proposal mentioned to introduce a choice of doctor has also affected the provision of dispensary facilities in the Mervue area in Galway city mentioned by Deputy Coogan. A premises will have to be provided in any event for child welfare and other services and a suitable site has been purchased by Galway Health Authority. I hope there will not be any undue delay in the erection of the premises on this site and that that will remove the cause of the Deputy's grievance.

Deputy Ryan also had some adversely critical things to say about the pharmacy service at some of the Dublin dispensaries. I agree that the service has defects but I should not like to think that it is quite as bad as the Deputy would have the House believe. He says it is not uncommon for patients to call three or four times with prescriptions before they are filled in. I have made inquiries from Dublin Health Authority and they assure me that this is not so, nor is it so that a chemist or his assistant will give a patient a drug which has not been prescribed by the doctor, that is, where the originally prescribed drug is not [564] available. I understand that the practice is that if the prescribed drug is not available, the pharmacist or his assistant contacts the doctor first and obtains his permission before supplying any alternative. I accept that in some of the larger dispensaries, where anything up to a half-dozen doctors are in attendance, there may be a wait of an hour or two, sometimes a few hours, for medicines. This is a matter of concern to me. It is also a matter of concern to the health authority. I believe that the fact that it was raised here will encourage the health authority further to keep this situation under constant examination.

Deputy Ryan again mentioned the matter of the supply of surgical appliances as relating to the Dublin Health Authority area. I say “again”, because it was the subject of a Parliamentary Question to me some months ago. Perhaps this is an appropriate time to refer to a little skirmish between the Deputy and myself this afternoon, arising out of a Parliamentary Question. The point I was trying to make then was that I do not know that I approve of asking Parliamentary Questions in general terms when the Deputy merely has an individual instance in mind. I have no objection whatever to Deputy Ryan continuing this practice. I do not regard it as an abuse of the parliamentary process and I would be the last person to take umbrage at the Deputy or anybody else in his Party putting down Parliamentary Questions even on the most footling things because this is the privilege and right of the Deputy. However where a service is, in the main, good and where there may be a slight breakdown, due to personal inefficiency or neglect, absence or some such factor which is not repeated, I think that is a more suitable vehicle for correspondence than a Parliamentary Question. In regard to the supply of surgical appliances, I am satisfied that, in the main, the procedures adopted in Dublin involve little or no delay and that in the normal course the applicant is supplied in a matter of days.

Mr. Ryan: Information on Richie Ryan  Zoom on Richie Ryan  I have never known it to happen.

[565]Mr. S. Flanagan: Information on Seán Flanagan  Zoom on Seán Flanagan  I do not accept the Deputy's contention that the standard of eligibility for medical cards in Dublin either is deliberately kept low to reduce pressure on the dispensaries. Surely the fact that there are considerably increased opportunities for employment in Dublin must be taken to be a factor? There is also the fact that a number of firms provide general medical services for their employees through doctors they employ for their own firms. I am glad to note in recent times that some of these firms are also providing a dental service as well as a medical service for their employees.

I accept that the work load on dispensary doctors in Dublin is very heavy. I therefore accept that there can be frustration from the patient's point of view. If a doctor has to examine a large number of patients within a given time, he obviously cannot give the same minute examination as he would like to give. This is a situation which, of course, develops where you have a rapidly increasing population in developing suburban areas. I think it inevitable that there will be some backlog of delay in catching up on this on the part of the health authority. I think the Deputy, and I would imagine all Deputies who are associated with Dublin Health Authority are, is aware that the Authority are conscious of the need to keep abreast of the requirements of the people by way of doctors. Dublin Health Authority has, in the main, been assiduous in reviewing the situation from time to time and in trying to correct defects which come to their notice.

Mention has also been made of delay in toning down selections. I share the Deputy's concern here. I think in a situation where acute cases are concerned, these are given priority and there are no grounds for complaints so far as these acute cases are concerned. There has been over-long delay in regard to chronic old cases which are a cause for concern. I have asked the Hospitals Commission to recommend to me what measures can be taken with a view to solving this problem.

[566] Deputy Kyne also mentioned anomalies which arise from the school health examination scheme. These again are under examination at the present time and I am expecting a report shortly. I have also been concerned by the fact that by law a child examined in the course of a school health medical examination is allowed certain free treatment, whereas a child who is not fortunate enough to have attended the official examination in school and who has defects discovered privately by the doctor, is not so entitled. I would be inclined, without promising to do so, to abolish that statutory provision so as to make all children equal. However, I will not commit myself in this regard until I receive the report I have mentioned, and I will then make an announcement about my general intention. It is obviously desirable that all children should be treated equally on the basis that prevention is better than cure in so far as disease afterwards can be prevented if proper dental, medical and other services are available to children at the earliest possible stage.

I now come to Deputy Ryan's remarks in regard to the hearing aid service. He stated that there is only one type of hearing aid supplied and that people who get hearing aids discard them because they are useless. Not merely are these statements inaccurate but they are quite unfair. The hearing aid service is operated by NOR, National Organisation for Rehabilitation, and I do not have to tell Deputy Ryan anything about this organisation or the people who run it. I should like to tell him that there are four types of hearing aid being provided. There is a standard model which suits the majority of patients, a more powerful model which suits severely deaf patients, a wide band model, and a powerful one with a wide band range. The vast majority of people supplied with these are fully satisfied with them. Quite recently, the organisation called back 40 adult patients selected at random in the Dublin area. Of these, four had discontinued using the aids. One of these four had purchased an ear-aid privately; the other three, who were [567] quite old, had discontinued using them because they found them too noisy. The aids were adjusted to cut down the background noise and the three patients in question are now trying to use them again.

It is, I think, quite understandable that old people will find difficulty in accustoming themselves to the use of hearing aids, but this applies just as much to hearing aids privately purchased as it does to those provided under the national service. I should add also that the organisation provides aids to the Council of Education Advisory Service for Deaf Children, and all children supplied with hearing aids are regularly visited and their progress marked.

I now come to the remarks made by several Deputies in regard to the ambulance services. I think it is now appreciated that it is the constant concern of my Department to improve the ambulance services and to continue to improve them to their highest possible level of efficiency. Might I here thank Deputy Clinton for the remarks he made this afternoon when he so rightly said that it was about time people stopped criticising the ambulance services as being inadequate? Indeed, I would commend his remarks, not merely to those Deputies who seem to be able to find some inferences of neglect whenever it suits them, but to other people outside the House as well.

As Deputy Clinton said, you cannot provide an ambulance at every corner. You cannot anticipate where the drunk will hit the telegraph pole; you cannot even be sure that it is a telegraph pole he will hit and, therefore, all you can do is provide a service and a means of communicating with that service, ensuring (a) that the service is of high efficiency, and (b) that as far as possible the communications will be as fast as possible. In this country and, indeed, in any other country where accidents take place in remote areas, there is sometimes an unfortunate time-lag between the happening of the accident and the ambulance service being notified. Sometimes this delay has very unfortunate results for the injured person. But, to be realistic about it, [568] this is a situation which I think must remain indefinitely. All we can do is provide an adequate ambulance service with good ambulances properly equipped, expert personnel and the necessary backing of hospital services with it. I agree with Deputy Clinton that at this stage the ambulance service of this country is good.

I now turn to the question of the ambulance drivers mentioned by Deputy James Tully. There is a claim for increased pay and better conditions of service which has been on hands now for some considerable time. I have been most anxious to help the ambulance drivers in their claim which I regard as well-founded. To that end, I met the representatives of the unions concerned and subsequently saw the County and City Managers Association. Last month, the managers sent a letter to the liaison officer for the unions asking him to nominate representatives to meet the managers for a discussion. I shall be only too glad to use my good offices again, if necessary, to bring these parties together. The situation, so far as I am concerned, is simply that, subject to the ambulance drivers doing and passing the driving course, about which the House knows, the ambulance drivers will be entitled to a fair increase in their remuneration and this will be on a national basis. If there is any further help I can give to assist the processing of this matter, I shall be glad to give it.

A slightly different situation arises in regard to the remuneration of local authority staffs over the operative date for the tenth round increase. I think it was in regard to this particular matter that a member of the Labour Party, a Mr. Ó Murchadha, saw fit at Roscommon a couple of months ago to launch a vicious attack upon my predecessor, who is the present Minister for Education, and myself. This worthy gentleman was perfectly well aware—and, if not, he ought to have been well aware—that the decision in regard to this matter was a Government decision and that both my predecessor and myself were merely carrying out the instructions of the Government and were therefore not [569] in a position to vary the terms of the decision.

A number of Deputies referred to the inadequacies of our public dental services. This was merely repeating what I had said myself in my opening statement because I am gravely concerned about the fact that our dental service in many areas is indeed unsatisfactory and requires considerable improvement. The fact that agreement has recently been reached on a new scale of salary for public dental officers will, I hope, be a help. There are 25 vacant dental posts at the present time. If we fill these vacancies, we could immediately effect a considerable improvement in the understaffed areas, one of which, indeed, is my own county of Mayo, another being Donegal. We are most anxious to provide a fully satisfactory dental service.

I have been turning over in my mind the suggestion that dentists should be asked, or perhaps obliged, to give the public health service a year of their time after they qualify. At this stage, I am not prepared to say any more than that I am giving this consideration. The House will be aware that, in recent times, there has been a very considerable brain-drain from the western European countries to the other side of the Atlantic and that, at the present time, this is being operated deliberately on a selective basis in the United States.

We all know, and are acutely conscious, that it costs us a great deal of money to produce a doctor, a dentist, an engineer or an architect. We are naturally aggrieved if, as a matter of policy, any big nation should use its vast resources to select our brains, if we have paid to train them, and do so without return or offer of return to us. Furthermore, we have a serious manpower shortage, especially in the dental field. I should be slow to take steps on this side, but, as I say, I am attracted, to some extent anyway, by the idea of making it a condition of qualification that the dentist should give the first year of his service to his own country but, of course, on the basis that he will at least adequately be paid. I would [570] have, I hope, further ideas to offer on this problem at a later time.

In regard to the suggestion by Deputies James Tully and Healy that more use should be made of private dentists, I should certainly listen very carefully to anything Deputy Healy might mention in regard to a matter on which he is an expert. Some 16 authorities have already made arrangements with about 16 private dentists to hold treatment sessions either in health authority clinics or in their own surgeries, but other health authorities have no such arrangements, sometimes because the private dentists are not particularly interested in sessional work and sometimes perhaps because the matter of remuneration could not amicably be agreed upon between the parties concerned. I do not think it would be wise of me to say anything more about this matter at this time.

Deputy Mullen stated that children in Cabra and Finglas have to travel to Cornmarket when they need dental attention. I may have been mistaken but I thought at the time that Deputy Mullen said “Common Market” and I was relieved to know that at least they do not have to go to France. However, as I pointed out in reply to a Parliamentary Question on 1st December last, there is, in fact, a clinic at Ballygall Road, Finglas, where a dentist attends regularly, and the question of providing an additional clinic or clinics in the Dublin area is under review by the health authority, who, of course, are the people having primary responsibility. I understand that they intend to put up another clinic in Cabra as soon as they can get suitable premises. They already have a total of 25 equipped surgeries in 18 different clinics and also recently purchased a mobile dental trailer unit. They also have an arrangement with the Dublin Dental Hospital for treating patients who are eligible.

Deputy Healy also mentioned, towards the end of his speech, his concern about the oldest known building in Cork, namely Skiddy's, the old almshouse, and he came up with a suggestion, which I hope will be implemented that is, that that part of this building which could be preserved will be preserved. [571] According to my information, the building itself is incapable of restoration and, of course, it is very badly needed by the health authority for a nurses' home. I do not like to have old buildings destroyed, if there is anything preservable in them and if the needs of our times as well as the aesthetics can be met together. It seems that there is an arcade which is now invisible to the people of Cork, never mind tourists, which could be put up elsewhere, perhaps in Fitzgerald's Park or some such place, and I hope Deputy Healy and those interested with him in Cork will pursue this so that if Skiddy's should go, at least some part of it will be preserved and be visible for and in Cork in the future.

Reference was made also to St. Clare's Convent in Stamullen, set up some 15 years ago by the Poor Clare Order in Newry to look after abandoned babies. Most of the babies in this home are maintained at the expense of the local authorities and, to assist the nuns with the running costs, several increases in the maintenance rate were approved and the present rate, which was fixed on 17th July, 1965, is £5 a week. I understand that on 7th March there were 71 babies in the home. Eighteen of these were privately placed and the relatives contribute for some of them. The other 53 are paid for by health authorities at the rate I have mentioned. The order, therefore, is receiving about £14,000 a year. I should like it to be more because these wonderful ladies are doing a great service to these unfortunate abandoned babies. If and when a case can be made for increasing the maintenance rate, the House can be assured that I will consider it sympathetically.

Deputy Clinton today, following up the remarks made by others earlier on, mentioned what he described as the hard core of tuberculosis patients which still remains and asked that I should take whatever steps are necessary to attract public attention, especially the attention of parents, to the need for immunisation and X-ray. I would be glad to send a circular to the health authorities as suggested by Deputy Clinton [572] but I am glad to say that there are at least some hopeful signs. I have just learned from the Mass Radiography Board the figures of those who came forward for X-ray last month. It is the record figure of 38,611 and is the highest in any one month since the establishment of this service in 1951. Nevertheless, I agree that public attention should continue to be focused on this problem until such time as the disease is wiped out completely.

I now come to deal briefly with the references made to the efforts, some say “if any”, of my Department in regard to smoking. I agree that I am not much of an advertisement but at least I am honest about it. When I was opening the “Home Truths” series on Telefís Éireann, I admitted that I smoked cigarettes and regarded myself as being virtually incurable from that point of view at this late stage of my life. There are people who, apparently, have more determination than I have who do manage to give up smoking when they are over 40. I am convinced that the most hopeful way to tackle this problem is by concentrating on the youth. I do not propose to delay the House with details of what my Department are doing in the way of issuing leaflets and so on and so forth. Most Deputies are probably aware that there were three of the “Home Truths” programmes which were devoted in one way or another to this problem of smoking. May I say that in all the countries that have tried to mount a serious campaign against smoking the success achieved to date has been disappointingly small? In America now there is a notice on every packet of cigarettes sold warning the public that the consumption of cigarettes may be hazardous to health.

I accept that smoking is hazardous to health and, indeed, I accept the compelling evidence of the connection between smoking and lung cancer, between smoking and heart disease, between smoking and bronchitis, but there are very strong forces operating, these being manufacturers of cigarettes who have an enormous vested interest in ensuring that their product will continue to be sold. Every time [573] a concerted effort is made in any country to warn the public about the dangers of smoking, the cigarette manufacturers forthwith double, redouble and quadruple the money they spend on advertising their product in an effort to counteract the influence of the doctor or the politician.

If one accepts also that smoking is an addition to a drug, then it is not practicable to try to stop people who are confirmed smokers other than the occasional person who is frightened by his doctor into stopping smoking or who decides to stop smoking and has the moral courage to carry his decision into effect. I think the right way to approach this problem is to get at the youth and I think the right people to do that are teachers rather than parents—teachers in the school who are interested, because the children might think the parents were merely trying to stop them being manly when they grow up or some nonsense like that. In that connection, I believe children do now realise that smoking is injurious to their health. They realise their parents are not trying to make sissies of them by advising them or warning them against smoking. The only way we will ever make practical progress in this important matter is by concentrating our efforts on the youth, particularly through the teachers, as well as the parents, so that we will have more and more people who never have acquired the smoking habit.

I might add that, when I did mention smoking in my own few words in the introduction to the Home Truths programme, there was quite a flap because the amount of revenue involved for a certain organisation I am now going to praise is quite substantial. Incidentally, when I mentioned RTE in my introductory speech, it drew from a distinguished member of the Press Gallery an article suggesting all sorts of devious implications in my remarks. I do not know why my esteemed friend, that particular correspondent, decided to take so many meanings out of my simple remark, unless perhaps he was bored with writing about the farmers' dispute and [574] thought he would inject a little bit of excitement——

Mr. Lindsay: Information on Patrick James Lindsay  Zoom on Patrick James Lindsay  Perhaps it was the Minister's turn for publicity?

Mr. S. Flanagan: Information on Seán Flanagan  Zoom on Seán Flanagan  It might have been.

Mr. Coogan: Information on Fintan Coogan  Zoom on Fintan Coogan  It all ended up in smoke, anyway.

Mr. S. Flanagan: Information on Seán Flanagan  Zoom on Seán Flanagan  All I want to say, both to him and to the House, is that I was making a very simple statement of fact, that is, that my Department and I have had nothing but co-operation and help from RTE, especially in connection with “Home Truths” programme which, as far as I know, is the first programme in which a Department officially participated each week. This represented to me a considerable advance in the co-operation between Government Departments and RTE. I was glad to have the opportunity then. I was not acting as a decoy for anybody else or making anything other than a statement of simple fact which I felt was due to those who put so much work into the programme.

Deputy Clinton also mentioned an agreed policy on antibiotics in veterinary and medical matters. This is a very difficult problem. Fortunately or otherwise, one runs up against the fact that the prescriber is supposed to be the final and ultimately the only responsible arbiter as to the particular drug to be used by the patient. In an age when an enormous amount of money is being spent on the development of new drugs, with the resulting products very heavily advertised, this is a problem which has caused concern in every country in the world, because in the past few years, the cost of supplying drugs has increased out of all proportion in every country in the world. I had figures somewhere of the increase in costs in Britain since 1960, which was, I think, something like 25 per cent to 30 per cent. This has also been the trend in New Zealand, America and Ireland. It is one which is a source of concern and which, at the same time, raises very thorny and difficult problems in regard to its control. The ultimate [575] question is whether there are any circumstances in which you would deny the patient a very expensive drug, if it were recommended as being the only suitable one for him. I suppose there are not any circumstances, if a community can afford it. What is of concern is that expensive drugs are unnecessarily prescribed and the fact that, as I mentioned, there is very little an authority can do to control that situation.

May I now come to the question of the contribution by the Exchequer to the local authorities in respect of the 1967-68 Health Bill? I have been under very heavy attack by Members of the House because the Exchequer did not this year operate the freeze on the rates as it operated in 1966-67. Indeed, I have been accused of bad faith in this regard and of having gone back on the promises of my predecessor and the promises in the White Paper. I want to make it clear that there is a distinction between what is said in the White Paper and by my predecessor and the general impression the public got as to our intentions in regard to the freeze. I may have contributed to giving this impression. It is not easy for a member of the general public to look into the exact and precise meaning of, say, a paragraph in a White Paper, which, to the member of the public, is important only as to what generally it is going to give him.

As a fact, the Government promised a freeze on the rates for 1966-67 and redeemed that promise by putting the freeze into operation. As a fact, the Government did not promise that that freeze would continue indefinitely, but did say that the cost of new and extended services for future years would be met by the Exchequer and not as to any proportion by the rates. I would not expect a member of the general public to see the distinction and although the fact is that this distinction is there, the Government have not failed to honour the promise to pay for the new and extended services provided in respect of the year 1967-68, and if, to any extent, I may have given a wrong impression to anybody [576] in this connection, I certainly did not do so in bad faith, and it was because I did not sufficiently spell out the nuances of the differences between the Exchequer paying for everything extra and the Exchequer paying only for the extra cost of new and extended services.

I am very concerned about this whole matter. This country is not alone in being concerned about providing for the payment of the cost of health services. Any of you who have had an opportunity of reading an excellent article in the current issue of Look about British and American health services—one which I would recommend every Member to read— will appreciate that there are very grave fundamental problems in regard to financing health services which exist throughout the world, and if problems like this are a grave concern to the greatest and richest nation the world has ever seen, and if these problems are of grave concern to Britain, a highly industrialised and rich nation, how much more so to us? The cost of health services in America has increased by 24 per cent in the past two years and, as the article pointed out, the British system of socialised medicine now in operation for 20 years, is in danger of collapse. The Americans are equally worried about the capital cost of hospitalisation. The cost per bed now in America is something so fantastic as to be almost unbelievable. Each of us with any interest in health knows the amount by which the cost of hospitalisation has increased in this country over the past three years. We also know that the capital cost of our hospital programme has escalated enormously and is continuing to do so.

I only wish things were as simple as Deputy O'Higgins said they were tonight. Let me say to Deputy O'Higgins, as I said before to Deputy Ryan, although apparently Deputy O'Higgins was not listening because he said our thinking had stopped in 1953 and become fossilised, that one would imagine from what Deputy O'Higgins was saying that it was somebody else, the Labour Party or some bishop, who had produced the White Paper in [577] January 1966 that was produced by my predecessor Deputy O'Malley. This certainly did contain new thinking in regard to the development of our health services. I only wish Deputy O'Higgins could produce an insurance system which would be the answer to the financing of our current health services. If he can, I will take it from him, put it into operation and give him, or Deputy Ryan, and the Fine Gael Party the credit for it, if they want it, because I am not interested in who gets the credit, but I am gravely concerned about the escalating cost of our services, and I believe we must have a combination of ordinary financing and special financing, if this cost is not to become an intolerable burden on the people.

I also believe that, under the existing arrangement whereby the Hospitals Trust Fund has to make up the deficits of the voluntary hospitals, we shall have to think seriously about our capital programme also. So far as insurance is concerned, I do not know whether the Fine Gael proposal is or is not workable but, as I understand it, it was the Fine Gael aim that the entire cost of the health services would be met by the tripartite contribution by employers, the State and the community. I have serious doubts as to whether a practicable insurance system for our general medical service can be put into operation but I am very much attracted by the idea of some form of insurance in relief of the tax and ratepayers, and I am quite willing to put that into operation because I believe that something will have to be done, not merely to relieve the ratepayers as was done last year and as is being done on an increased basis this year, but to relieve the taxpayers of a burden which it is obvious will grow at too great a speed for their resources.

Some form of contributory insurance appears to me to be desirable and I am at present having an examination carried out as to the feasibility of putting it into operation and, as I said, I do not care who gets the credit for it; I do not want it because I am merely interested in providing better service for the people. Indeed, it seems to me that Fine Gael subsist [578] on the notion that if you play politics cleverly enough and long enough, you must eventually win, whereas Fianna Fáil hold on to this silly, precious and unchangeable notion and belief that it is the people and their service that matters. I could not help laughing when Deputy O'Higgins said this evening that the House was aware that no member of his Party ever talked from the teeth out. It is the first time I heard that Fine Gael had a political philosophy. I remember from the first time I encountered the organised phalanx of Fine Gael 25 years ago, it was the last thing they could be described as having, although they certainly had expertise in practical politics. Their idea seemed to be that the cliffs of life can all be climbed by flashing the trident, whereas I believe they can only be scaled by the slow and often mistaken effort of honest endeavour.

There are some other matters to which I should like to refer in a general way and in particular, to the allegation that nothing has been happening in respect of the White Paper and that no consultations have been taking place with the IMA and the Medical Union. This is not so. There have been more consultations in the past 12 months with representatives of the Irish Medical Association and the profession generally than at any time in the history of the Department of Health. It is important that this should be so because there are so many problems that arise as a result of the proposal to change from the dispensary system to the choice of doctor system, because of the necessity to discuss the form of payment for doctors who will participate in the new system, because of the need to set up a choice of chemist as well as a choice of doctor. In all this, there is not, and never has been, any suggestion that either the Medical Association or the Medical Union would be asked, in Deputy Ryan's phrase, to like it or lump it. There is no suggestion that we are not open to discussion about every single aspect of the proposals contained in the White Paper.

I admit personal responsibility for [579] the fact that any promise or undertaking that may have been given by my predecessor in regard to the introduction of legislation in November, 1966, was not redeemed. It is a fact that a Bill could have been introduced in November, 1966, though it would have been a scramble to do it. I took the view that it is better that consultations should be held early rather than late, that as far as possible these consultations should be amicably included before the Bill was put into form, so that when the House came to discuss these proposals, the widest measure of approval would already have been reached, and so that we would escape having an unconscionable number of amendments to debate and counterdebate and have referred back for further consideration.

This legislation is very important, not merely to Deputies, to the doctors and others who will operate it, but to our people. Therefore, it is especially important, to me anyway, that it should be well considered before being introduced here. Deputy O'Higgins says that he does not believe it will be introduced this year. Maybe it will not, but it will not be for want of trying on my part, or on the part of my officials, if it is not. Our aim is that it should be, at least, introduced later on this year and, if possible, made law. This will not mean that we will then, forthwith, be able to implement all the proposals contained in the White Paper and subsequently to be enshrined in the Bill. Even when it is enacted the broad statement set out in the preamble to the White Paper will still be valid and, indeed, having regard to the facts I have mentioned about increased costs, that situation will obtain for a considerable time, namely, that the proposals will be brought into operation as the resources available to the country improve.

I should like to mention the matter of the cost of hospitals, on which I touched briefly earlier on. It was because of my concern with the enormous increase in the cost of hospital construction that I undertook a tour of three or four countries and visited 13 [580] or 14 hospitals roughly a month ago and also, in the process, had long and detailed discussions with Dr. Sahl of the Kranken Institute in Germany, who has done an enormous amount of research in this field. It does seem clear to me now, having regard to the rapid changes in medicine that are taking place almost daily, that the ideal to be aimed at is a flexible construction designed to last 15 years at the maximum, a construction that can be expanded or abbreviated, depending on the changes that take place in the medical field as the years go by. In view of our very limited resources, it does seem a pity that we should put up solid cut-stone buildings which are obsolete by the time the official opening ceremony takes place and which during their lifetime are so inflexible as to be incapable of adaptation, except at enormous cost.

Only a few days ago, I visited quite a new hospital in Stanford University in California and was surprised, though perhaps a little consoled, to see that from a functional point of view, it had an unbelievable number of drawbacks. I visited the new and not yet fully operational hospital in Slough in Wrexham Park outside London very recently, and the laboratory there was the subject of a large number of complaints from the doctor who was on duty there at the time.

This is just to show that these problems exist in other countries, but they exist against a background of considerably more wealth than we have. It is very important that, if we are to give a service to our people, we should make the best possible use of our capital resources for hospital building. I would hope that as a result of the crystallisation of our ideas following these examinations, more standardisation can be introduced into this temporary type of hospital structure I have mentioned, so that, without great expense, we can rapidly provide a new or extended service, if required, or close down one that has become obsolete.

I have kept the House considerably longer than I had intended, but I shall conclude by again thanking all the Members of the House who took part [581] in the debate, and particularly those who wished me well in my post as Minister for Health. I say this especially to Deputy T.F. O'Higgins, who was one of my predecessors in that office, and I appreciate his good wishes the more for that reason. We have very great problems still to solve in the health field, and I hope that we shall tackle them in the right spirit, in the right priority, and that we shall during my time, however long or short it may be, achieve at least some satisfactory measure of success.

Motion: “That the Vote be referred back for reconsideration,” by leave, withdrawn.

Vote put and agreed to.


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