Thursday, 15 January 1970
Seanad Eireann Debate
Mr. W. O'Brien: I was referring to health benefits. Very often people have to wait for five or six weeks before they receive benefit and I hope something will be done about this in the near future. I should also like to refer to nursing staffs. I think we take too much for granted and vocation and dedication have their limitations also. We should be very sure that nursing staffs who work long hours and on night shifts are being looked after while we are resting at home. I wonder if we recognise fully the service they give to us.
Another point I would like to raise is in regard to the assessment for medical cards. We often come across cases where people have a basic rate which  would qualify them for general medical services but because they have worked overtime they have exceeded what the health authority have allowed. Overtime, particularly in isolated cases, should not be taken into consideration because some of the people to whom I am referring, who earn overtime work for very long hours, often have broken time or work at night-time and these hardships should be taken into consideration. Finally, I should like to congratulate the Minister for accepting some of the amendments in the other House. With that outlook and with our co-operation I hope the Bill when it is passed will be a success.
Mr. Walsh: As a member of the Dublin Health Authority I should like to welcome this Bill. It is only natural that members of a local authority should welcome any improvement in the health services. The opening words of the explanatory memorandum circulated with the Bill state that “the objects of the Health Bill, 1969, are to provide for a number of improvements and extensions in the health services.” I was somewhat concerned when I received a memorandum which set out the proposals regarding the setting-up of the health boards and when I read that the local authorities were not going to have a proper majority on them. As a member of the delegation of the eastern board which met the Minister some time ago I should like to compliment him on the manner in which he received us and listened to our views. I was very pleased when I heard him say that he was prepared to give local representatives a majority on the health boards.
Other speakers today have mentioned that up to now members of local authorities and of the Dáil and Seanad have played a very important role in the administration of the health services. Members of local authorities do play a very important role in this regard. Senator Boland mentioned that the responsibility for striking the rate falls on the shoulders of local representatives. It is the local representatives who will have to listen to people's complaints when they do strike a rate.
Mr. Walsh: That is a matter for themselves. I did not contribute to that. In regard to the proposed improvements and extensions one has to ask what improvements are there in the Bill, and the one that strikes me most is in regard to the choice of doctor. It is a wonderful thing for ordinary people to have a choice of doctor, that they can be treated in hospital by their own doctor. I listened with great interest to Senator McGlinchey. There is no doubt that in our present system there are a number of weaknesses and this applies very much to the matter of medical cards. I would welcome and support any improvement in this service at any time.
Yesterday Senator Belton asked the Minister if a body would be set up to ensure availability of doctors and the Minister said this would be done. Following that, a number of rural Senators expressed concern about the availability of doctors in rural areas. That may be a problem, but speaking as a representative in a built-up area, I am faced from time to time with a problem of a slightly different nature but still a difficult one—the availability of a doctor at night for people living in built-up areas. I am not criticising any particular member of the medical profession but I hope the Minister will have a look at this problem with a view to ensuring that the medical boards will be able to deal with it in some way.
In the industrial sector, various organisations arrange for such things as a night medical service. Today, when planning is playing such an important role in our everyday lives, I cannot see why some members of the medical profession should not be available at all times in these areas. What I am saying is that in a particular area one member of the medical profession should be available at all times. It could be so arranged and organised that a member of the profession would be available in a particular area on a particular night. I have been approached when going home late at night by members of families unfortunately unable to get a  doctor. They have asked me for help. This is something I am very concerned with and I ask the Minister to take a serious view of it. It merits serious consideration because of its importance in our lives.
Another point I should like to compliment the Minister on is the abolition of the means test—the fact that it will be only the earnings of the man and wife that will be taken into account. I have a number of cases in mind which will be affected. I am thinking particularly of people suffering from asthma, people who pay £4 or £5 a week for drugs which they must have to keep them alive. They are deprived of medical cards because two or three members of their families are earning. Some of these are looking ahead, some of them are about to get married, and in these circumstances the amount they have to hand over is very little. However, the fact that they are earning, perhaps, £17 or £18 a week is taken into account. Therefore, this revision of the means test is most welcome.
Now I wish to speak of hospitals. In Dublin, and I am sure the other members of Dublin County Council will agree, very often we are faced with the problem of getting a person admitted to hospital. I wonder to what extent there will be an improvement in this under the new health boards. There are people in the border areas between Louth and Dublin, people from Drogheda for instance, who would welcome any improvement. People have to wait too long for admission to hospitals.
When I first read the Bill I became worried about the chemists employed by health authorities and I was glad to hear the Minister say that none of them will become redundant because of the closing of dispensaries and the issuing of drugs through local chemists. These men have given a very fine service to the health authorities and to the people and I hope that when the Bill is implemented it will not be just a matter of giving something to them. Their positions should be considered seriously.
Like other Senators, I compliment the Minister on the manner in which he steered the Bill through the Dáil. Without  doubt, each section of the Bill received wide discussion and a number of amendments were accepted. I have no doubt that on Committee Stage here some amendments will be included. The best tribute to the Minister, I suppose, is the fact that Senators from all sides have complimented him. As I have said, I met him with other local authority delegates in the Custom House and I was impressed by the manner in which he received us and listened to us. When our views were made known, he said that from time to time amendments would be made to the Bill. Members of local authorities play a very important role in the administration of the health services, they are very much in touch with local problems and they are the problems which must be solved if the Bill is to be a success.
Dr. Sheehy Skeffington: This Bill, as most Senators have said, has a great deal of good in it and I think the Minister has piloted it in this House and previously in the Dáil with his usual patience and flexibility. He has three or four colleagues who tend to regard the text they submit to us as if it were Holy Writ, quite incapable of improvement or amendment in any way. The present Minister for Health is prepared to listen to argument, he is very well acquainted not only with the text he puts before us but also with its implications and the possible consequences of certain amendments, and he is always prepared to argue the point and to concede it if he thinks it merits further attention. Therefore, I associate myself with those who have thanked him for his long and patient listening to the debate and his attitude towards it, which is characteristic.
As I have said, there is good in the Bill. There are many points to which we did not advert enough because, as Senator Bourke said, on Second Stage we tend to talk critically on certain points. One should underline the fact that out-patient treatment is to be free. It has been mentioned that as far as possible people are to get choice of doctor. This is excellent also, and we await the implementation of it in order to see it in practice. However, I am  sure the Minister intends it to be as big a choice as is reasonable.
There has been reference also to mentally handicapped children, to the stricter control of access to drugs and to the examination and the treatment of children at school. There have been times in the past when defects in children were discovered but there was no treatment for them. In those times it was regarded as enough to examine the child, and that was that. Now, the question of active treatment is coming into being. Free access to optical and hearing aids is not yet readily available. It is something the Minister has in mind and we hope that in the future this may be given. He is very strongly to be congratulated also on the administrative implications of these regional health boards, the coalescing of several counties. All of this deserves the greatest praise and in practice will work out very well.
It has been mentioned—and I think the point is a good one—that it is important that the counties from which the various people come to a given hospital ought through their local representatives to have some say at least in the running of that hospital and this, one feels, will be done far better by these regional health boards than it can be done now by a county health authority.
I recall that when one of the Minister's predecessors, Deputy Tom O'Higgins, was Minister for Health, when he was introducing the Voluntary Health Insurance Bill he mentioned the fact that at that time—it must have been about 1956—all but one-sixth of the population of the Republic was covered by a State health scheme, covered at least to some extent; that only one-sixth of the population remained uncovered by the various Health Bills and authorities. I should like to ask the Minister now what is the present percentage or present fraction of the population which remains uncovered by our official health services. It is a point of interest. My guess is that it is now less than one-sixth. So that a great deal of our concern about means tests and the rather complicated and sometimes expensive apparatus that is brought  into play to discover how much money is available to various people, to know whether they come under a health scheme or not, is devoted to a tiny fraction of the population.
I listened with great interest to Senator McGlinchey and the various anecdotes he gave us from real life about private patients and the terrible things that happen in the case of, he made it quite clear, a small minority of doctors. I thought he was leading up to a speech condemning all means tests and asking to have the health services available to all, to let it become a State service in full, but he seemed to stop short of that. I was not quite sure what was the logic of his speech. He was very indignant at the different treatment apparently being meted out to people who can pay and to people who cannot pay but he stopped short of asking for the abolition of means tests which would seem to me to have been the logical outcome of his speech.
Fine Gael is asking for an insurance scheme to cover the health needs of the country. I find myself quite definitely and directly opposed to this and in this —I make it clear that I am referring to a specific instance—I think Fianna Fáil is right and Fine Gael is wrong. I do not think the answer lies in generalised insurance. I think the answer lies in a total extension of our present health schemes to cover the whole population. This is based, after all, upon income tax which is based on capacity to pay and this, in fact, is a principle which is not only invoked but applied in my experience—which is not small—by the vast majority of doctors in relation to their patients. Doctors do as a rule give treatment to the patients in accordance with their needs and take from the patients in accordance with their capacity to pay. This is very laudable, very just and an almost universally applied principle in medicine. Certainly, I can testify that in the case of many doctors this would appear to me to lead to a wider extension of the scheme and to the elimination of this means test which I think most of us find it embarrassing to defend.
This brings me to the question of eligibility and this new phrase “limited  eligibility”. I find, for instance, when I refer to the First Schedule of the present Bill, on page 35, the various enactments that are repealed. For instance, the whole of the Health and Mental Treatment (Amendment) Act, 1958, is repealed. That was the Act in which the point at which the means test started was carried from £600 a year to £800 a year. Another Act that is totally repealed is the Health and Mental Treatment (Amendment) Act, 1966. That was 18th January, 1966, just four years ago. That was the Act which brought the limit for the means test from £800 a year to £1,200 a year, the present figure, and brought the rateable valuation for farmers benefiting by the scheme from £50 to £60.
(c) adult persons whose yearly means are, in the opinion of the chief executive officer of the appropriate health board, derived wholly or mainly from farming, if the rateable valuation of the farm or farms concerned (including the buildings thereon) is not more than £60,
Yearly means for the purposes of this section shall be calculated in accordance with Rule 1 of the Rules contained in the Seventh Schedule to the Social Welfare Act, 1952, and shall include, in relation to any person, the yearly means of a spouse of that person where the spouse is resident with that person.
I would ask the Minister and the House to consider whether this is not a rather dangerous method of legislation. We read that and say: “Yes, yes, let us by all means apply a means test in  accordance with previously agreed rules” and very often we do not bother to look up what the rules are. We might pause and ask ourselves just what was this Seventh Schedule to the Social Welfare Act, 1952, and what was Rule 1. I have it here. It reads as follows: (1) In calculating the means of a person, account shall be taken of the following:—
(1) The yearly value of any property belonging to the person (not being property personally used or enjoyed by the person) which is invested or is otherwise put to profitable use by the person or which though capable of investment or profitable use is not so invested or put to profitable use by the person, the yearly value of the property being calculated as follows:
Now, what that means is that anybody who is applying to be counted as having limited eligibility will find that in his or her income is included not only capital sums which bring in interest but also capital sums which could bring in interest even if they do not bring in any. Not only that, but we note that the first £25 of the capital sum gets off scot free, the next £375 of the capital sum is included as being one-twentieth part of the capital sum or coming in as income at the rate of five per cent. All right, that is not unreasonable, even if it is not producing income, but the rest is treated as if it were bringing in income at the rate of ten per cent. Even with the change  in money values it is rather difficult for any of these applicants to make sure that their capital is bringing in a full clear ten per cent, and I suggest that the firm application of this particular rule is a dangerous thing.
I note with pleasure that in the present Bill the third subsection says that the Minister may, with the consent of the Minister for Finance, by regulation substitute for subsections (1) and (2) other provisions defining in such manner as he thinks fit the categories of persons eligible on a limited basis. I would urge on the Minister the necessity both for reconsidering the maximum figures of £1,200 a year and £60 valuation, and would also ask him to consider revising the principle underlying this Rule One of the Seventh Schedule of the 1952 Act which suggests that, if a man or woman has a capital sum of a certain amount after the first £400, it is treated as if the rest was bringing in 10 per cent. I also suggest that in legislating we must be very careful not to refer to previous legislation without having a full awareness in this House of what it is exactly that we are further approving.
In this connection I want to illustrate the point I am making by mentioning a case which drew my own attention to this fact. A man of 75 or 76 who was a retired civil servant had to be hospitalised. His wife had to be hospitalised first and then he had to be hospitalised, and because his pension was £650 a year it was assumed by the hospital that the Dublin Health Authority would be able to meet a pretty big proportion of the cost. Both those people were quite ill when brought in and they were put into semi-private wards on this assumption. The amount due by them when they left hospital exceeded £110. I think it was £120 for the two of them. Now the man's pension was £650 a year. Because they were elderly they had recently, within a few months, moved from a big house which they had sold into a small bungalow. There was a residue of £2,000, for furniture that they had sold and also for the house, standing in his name in his current account in the bank.
He was an honest man and, when  asked what money he had, he mentioned this £2,000. Under this rule I have read out the first £25 was excluded, after that the next £375 was charged against him as if he was getting 5 per cent on it, which he was not in fact. Nevertheless, that was not unreasonable. That would give him between £18 and £19 a year; but the remaining £1,600 which was lying temporarily in the bank before he could fully equip and decorate the new house, was charged at 10 per cent, amounting to £160, which meant that a total of £179 was added to his pension of £650, which brought it over the £800 level by less than £30, which rendered him liable for the total amount. This meant that it was assumed that he did not come within the means test. That was decided because there was this unwarranted assumption that anybody with £2,000 is getting at least 10 per cent on that. I think that this is unjust, and we may even be surprised that it was allowed to slip through in 1952. I would draw the Minister's attention to this in the hope that perhaps some amendment or change in this might be thought of before the Committee Stage.
There is another point that I want to make in connection with this £1,200 a year maximum. I have mentioned that this was introduced in 1966. The Act became law on the 18th January, 1966. We all know that in January, 1966, £1,200 a year was worth in real terms quite appreciably more than it is worth now. We have had in the interim a devaluation of the £ and I do not think that it would be an exaggeration to say that £1,200 in those days would now be about £1,360 or £1,370. It might in fact even be as much as £1,400. Therefore I feel that to continue in 1970 a means test based on £1,200 a year is to fail to allow for the fact that money values have appreciably changed since January, 1966, and I am hoping that the Minister will advert to that point also.
I recognise, of course, that in this Bill, as in previous Acts, certain discretionary powers are given to the executive officer of the health board or the health authority. In the case which I mentioned those discretionary powers were used to a certain extent but I  feel not to a sufficient extent, but they were brought into play, and if my memory serves me correctly the bill of £120 was reduced to about £70, which was a fairly high hospital bill to pay. The person in question is dead and gone now, leaving a widow of a Civil Service pensioner who was entitled at the time of death to no pension at all. I therefore feel that our law is too stringent and that the discretionary power, although we welcome it, is perhaps not always used with a sufficient sense of mercy.
In that connection I want to say that it was mentioned to me—and I am not speaking now about this particular case, because the reasons were given —that always when a discretionary power is refused it seems just that the reasons should be stated for the refusal. The executive officer or the official should be prepared to give reasons for excluding the person from the scheme and to state his reasons.
I do not want to take up the time of the House much longer, but there is one point that I want to make briefly, and it is a very important one which has been referred to by Senator William O'Brien, about the conditions and the pay of nurses. We all feel this and can speak easily about it, and of course great improvements have been made in the pay of nurses, but the fact is that they are one of the most grievously underpaid sections of our community at this date. Senator William O'Brien said that there is talk about vocation and dedication, but this can be abused and we can take advantage of it in that way. I am mentioning it here simply to draw the Minister's attention to it. It does not come strictly within the terms of this Bill but it is something that is a major priority— the improvement of the pay and conditions for nurses and sisters.
(1) A health board shall make available without charge medical, surgical and midwifery services for attendance to the health, in respect of motherhood, of women who are persons with full eligibility or persons with limited eligibility.
 (2) A woman entitled to receive medical services under this section may choose to receive them from any registered medical practitioner who has entered into an agreement with the health board for the provision of those services and who is willing to accept her as a patient.
(3) When a woman avails herself of services under this section for a confinement taking place otherwise than in a hospital or maternity home, the health board shall provide without charge obstetrical requisites to such extent as may be specified by regulations made by the Minister.
I shall not quote section 62 which refers to the medical care of infants. This is, of course, a mother-and-child scheme without charge. I want to welcome the fact that the present Government have at last, partly at any rate, caught up with Dr. Noel Browne. It has taken 20 golden years but it is very satisfactory that we can introduce a mother-and-child scheme under the present Bill totally free of charge. We can all remember the kind of opposition that idea met with 20 years ago and the way in which the Coalition Government cravenly dropped their Minister because they were, I think, afraid to back him on something that now may pass and nobody questions it. I want to salute the Fianna Fáil Government for at least, in this respect, catching up with Dr. Noel Browne's mother-and-child scheme which was killed or mutilated 20 years ago.
The Minister in his opening speech said that in the case of many draft regulations, according to the terms of the Bill, they will be placed before both Houses and will require to be approved and may be vetoed by either House. He legitimately drew the attention of the Seanad to the fact that if we reject one of these regulations we are, in fact, being given by him in the Bill more power than is normally ours because normally we have the right to delay but not to reject a piece of legislation. Here we can actually reject; we can veto it for good. Nevertheless, I am a little worried at so much being done under this Bill by means of regulations even if we have the right  to reject them because I think I am right in saying we have no right to amend them. If we reject a regulation, out it goes.
I speak subject to correction but I think I am right in saying that we shall not have the right to amend. I should feel happier even if our power was less if some at least of what will be covered by regulations was covered by the Bill itself so that we might amend it or propose amendments with, in the case of the present Minister, some chance of his seeing the particular amendments were reasonable and accepting them. We are being asked, in other words, to give the Minister very comprehensive power to make very comprehensive regulations in return for the right which he has conceded in the Bill in the final analysis to veto all these powers for which he is asking. I should prefer that much of what is being dealt with by regulation should be dealt with by ordinary legislation so that we could debate it and so that points for and against would be brought out and so that we would have at least the option of proposing amendments, so that the Minister could explain or defend and possibly accept amendments. That would be better in many of these cases than a regulation which has to be either vetoed or accepted.
Cáit Uí Eachthéirn: Tá cuid den chás i gcóir an Bhille seo curtha go maith ag na dochtúirí agus na daoine eile a labhair go dtí seo ach, mar sin féin, tá rudaí le rá againn go léir agus ní féidir deagh-rud a rá go ró-mhinic.
Ar an gcéad dul síos, ba mhaith liom fáilte a chur roimh an mBille. Mar adeireann an tAire níl ann ach creatlach ach is creatlach iontach é agus nuair a bheidh an fheoil air i bhfoirm rialacha agus ordaithe beidh an cóir sláinte is fearr sa domhan againn. Sin rud mór le rá. Sé an chéad rud a cuirim fáilte roimhe ná an rogha maidir le dochtúir a chuirfidh an ghnáth-dhuine ar aon leibhéal leis an othar príobháideach. Is rud é sin a bhfuilimid ag tnú leis le fada an lá.  Tá áthas orm, leis, gur féidir as so amach druganna agus cóir leighis a faidh sé seans do na poitigéirí sna sráidden ualach óna dochtúirí agus tabharfaidh sé seans do na poitigéirí sna sráidbhailte a sheas an fóid le fada an lá agus a thug druganna agus cóir leighis dona daoine.
Cuirim fáilte roimh an mBille seo freisin tríd na forálacha atá ann maidir leis na réigiúin sláinte. Cuirfear dá bhárr seirbhís níos fearr ar fáil don duine breoite. Roimhe seo bhí na saineolaithe go léir lonnaithe i mBaile Átha Cliath, i gCorcaigh, i Luimneach agus i nGaillimh ach le bunú na réigiúin raghaidh na saineolaithe go dtí na réigiúin so. Cé go bhfuil Ciarraí i réigiún Corcaigh anois, tá súil agam go n-athróidh an tAire a aigne agus go gcuirfear Ciarraí Thuaidh isteach le Luimneach. Tá an scéal seo mínithe ag na dochtúirí cheantair sin.
Cuirim fáilte roimh an seirbhís teallaigh. Is mór an cúnamh é sin dona banaltraí paróiste agus tabharfaidh sé seans do na sean daoine fanúint sa bhaile. Rud eile atá an-thábhachtach ar fad i gcás daoine a bhíonn ag iarraidh seirbhís shaor a fháil isea nach gcuirfear san áireamh ach teacht isteach fhear an tí agus a mhná amháin.
I want to compliment the Minister first on the manner in which the Bill is laid out because it is really the outline of our health services. As I said in Irish, it is the skeleton on to which much of the meat will be put in the form of regulations and orders. As many people have said, it is good to have this flexibility. As far as I can see, the measure is built around the patient, the doctor, the health board and the administrator and this is the order of priority in the Bill, which is as it should be. The central person in the whole health service should be the patient. Next comes the doctor and last, but by no means least, comes the administrator. Several times when a suggestion is made we are told it is very hard to administer. It is a very poor reflection on us if something  which is very good must go by the board because some way cannot be found to administer what is a good idea.
I think everybody in the House has admitted that this is a most progressive Bill. It should bring many of the advances of modern medicine within reach of the rural areas to a far greater extent than up to now. First, I wish to welcome regionalisation. As I said in Irish, up to this we have had all our specialists grouped in the bigger centres, Dublin, Cork, Limerick and Galway, In each of those regions we will have those people nearer to the sick.
I want to congratulate the Minister on the long and, I would say, tedious consultations he had with the Irish Medical Union and the Irish Medical Association, and with the local authorities. Those consulations were well worthwhile. Their fruits are evident in the Bill to anyone who views it with an unbiased mind.
In all professions and in all walks of life money is no longer the be-all and the end-all of a job. In today's paper Con Murphy outlined this very well. We should all read and re-read it. Conditions of service and job satisfaction are just as important today as money. This is more important in regard to medical services than any other service because a tired and overworked doctor cannot possibly do justice to the patient nor can he do justice to himself. I am very glad that some arrangement has been made to give time off to doctors and that the Minister is doing everything he possibly can to give them better terms of service.
I should like to add my voice to the voices of those who welcomed the eligibility provision. Only the income of the husband and wife will be taken into account in future. I also welcome the fact that a uniform standard will be laid down, declaring who is entitled to full service and who is entitled to partial service. Senator Sheehy Skeffington suggested that the ceiling should be raised. That is only fair. Not only would I ask to have the ceiling of £1,200 raised, but I would also suggest  that this should be reviewed at intervals, because of the change in the value of money.
Referring to eligibility I would ask that the application forms be made more simple. I would also suggest that the rights of people in the health services should be made known to the people in a very simple form. I know there is a booklet which sets out what people are entitled to in the health services, but I would like it to be even simpler for rural people.
The hardship clause is very welcome because many people have been worried about some people not being able to afford medical service. We have our county managers and people in politics of course and when we bring hardship cases to their notice they are only too willing to meet us half-way and all the way most of the time.
I also welcome the right of appeal because, no matter what laws we have in relation to social welfare or health or anything else, there are some people who will have a grievance. It may be a real and genuine grievance in some cases but, on other occasions, it may be an imaginary grievance so, from that point of view, I am glad that there is a right of appeal. I would appeal to the Minister to deal with those appeals faster than they are dealt with, with regard to social welfare, because I know people have to wait months and months before their appeals are decided.
All Senators welcomed choice of doctor and the people of the country will certainly welcome it also. This will give a proper doctor-patient relationship consistent with the dignity of both. Choice of doctor is also welcomed by the doctors themselves. This was not possible under the old dispensary system and, while the whole pattern of the health service is changing, at this changing of the guard we should pay tribute to the dispensary doctors who have served us so very well and given a wonderful service in their time.
Any doctors I have spoken to have said that the day of the one-man service is definitely gone and they are hoping that, under the new Bill, there will be group practice arrangements. This would give us a continuous service.  Some people were worried about a night service. If a group service is introduced—and the doctors are thinking along those lines—there is no reason to believe we will not have a night service.
Senators have welcomed the provision in regard to home help. I will not discuss “may” or “shall” to which some Senator referred. The country has been clamouring for home help. It will be of great benefit to our older people and to incapacitated young people. Perhaps before the Bill goes through this House the county councils could start making a survey of the number of those people in their areas and avoid a mad rush when the Bill becomes law.
Senator Sheehy Skeffington dealt with the maternity service. I should like to refer to the £8 grant. This is completely inadequate. I know cases where the husband had to stay at home while the wife was in hospital and I would ask the Minister to have another look at that grant even though he did increase it a hundredfold. I think the minimum should be £20.
I come now to drugs. Again, the whole country has welcomed the Minister's quick dealing with this drug question. I should like to mention another problem, that is, the harmful effects on men and the possibility of thalidomide-like deformities in the unborn that may result from food additives. I do not know whether this is the place to suggest legislation dealing with them, but I should like the Minister seriously to consider legislation in relation to food additives. I know he moved very quickly on the  cyclamates, but I understand this monosodiumglutamate is also a very serious additive. I do not know whether it is Agriculture or what Department should deal with it. There are also the problems of pesticides and insecticides and proper labelling of foods. I am sure that between whatever Departments are involved this will be looked into by the Minister, and that we can look forward to more legislation on health and on foods.
I should be glad if all bodies concerned would bring the benefits of the Voluntary Health Insurance Scheme more to the notice of the people. I also hope that in administering this service our doctors will not be tied down to the kind of paperwork to which doctors in England are tied down. Someone told me that in Britain more time is spent filling in forms than treating the patients.
Tribute was paid to our nurses and I should like to join my voice in that tribute. I would ask the Minister to look into existing training facilities because I understand there is some point about the number of beds available. Nurses being trained in hospitals have not a sufficient number of beds. I would ask the Minister to bring our training facilities into line with international standards. We know our Irish nurses are second to none and, knowing that, it is only right that their training should take place at international level and on international standards.
Many people have cried out for a free-for-all health service. Wealthy countries like the United States of America have not been able to afford this and surely a country of our size could not aspire to it. Even in England, where a free-for-all has been attempted, it has been far from ideal. Doctors in England have told me that in order to make a decent living they have to take on so many thousands of patients that they cannot possibly give the proper treatment to their patients.
Cáit Uí Eachthéirn: Before we adjourned for tea I stated that many people in this country were crying  out for a free-for-all health service although even wealthy countries such as America cannot afford this. Some countries have in fact tried, but they found it far from being an ideal way of dealing with health problems. Even if we could afford such a service I believe that people with good jobs should pay for their own health services. This can easily be done by joining the Voluntary Health Insurance Scheme for a fraction of what it costs these people to go on their annual holiday.
I appeal to the Minister to do everything possible to help the mentally retarded. I want to congratulate the religious orders who were the pioneers in this field when nobody else did anything to help these unfortunate people. I want to congratulate the Minister for putting forward a Bill with many excellent provisions. I am sure when he has drafted the regulations these will lay for us the foundation of an ideal health service in this country.
Mr. Alexis FitzGerald: I welcome this Bill as striking evidence of the ending of a conflict which has had too long a history and the beginning of an era of co-operation between the Department of Health and the medical profession. The distrust which existed was unnecessary, unhappy and bad in its consequences for the health services of this country. It is appropriate I say this in the presence of the present Minister for Health because he has shown by his attitude that he wishes to be seen as a sort of bridgebuilder between the different sections of the community. It would not be right if I did not point out that his predecessor introduced this measure and had a similarly happy relationship with the profession.
When opening this debate the Minister said—unfortunately I was not able to be present to hear him—that there was much more in this Bill than one would infer from its length. He described it as short, but I do not think it was short enough. He said there was much more in it than there appeared to be. I sense that we can happily look at the reports made to his predecessor and by the Department to see the background  to this and I also sense that there is behind this Bill a plan in the preparation of which the experts, on the professional level, have participated and have learned much from their association with those who have to advise the Minister in the public interest.
There is a degree of devolution of power which I welcome very much as being desirable in the interest of the country and its harmonious government. I would prefer to reserve myself on this matter of the degree of devolution and the nature of the organisation for Committee Stage and to direct myself now to the fundamental matter involved in this. A Health Bill, like any Bill, involves a choice by its promoters and by those whose duty it is to consider it and, if they deem fit, to pass it, a choice between what they are enacting and what they could be enacting. It seems to me that a correct decision has been made here. The welfare of the patient has been felt to be paramount. I understand what is intended here but the degree of running down of existing hospitals which is planned has been greatly exaggerated. Inevitably there must be some running down somewhere; rationalisation involves a curtailment but if we are talking about health we should think very carefully about the choice which is involved.
We have to believe in the existence of goodness. The only thing we know is the existence of evil and one of the greatest evils is human suffering. Any plan which is designed to relieve that suffering seems to me to force you to simplification which otherwise might be thought to be injurious to culture. A great Swiss historian, Burckhardt, referred to “these terrible simplifiers who have come along to destroy our old Europe.” I should like that to be put up as a text in Departments of State. The terrible simplifiers. Things should not be simplified unnecessarily. As far as I can understand the argument for the simplification and rationalisation planned here is justifiable. The situation is—it is something which should be repeated in this House and in the other House so that we should always be reminded of it—that we are dealing with the administering  of scarce resources. There is not anything unlimited available and therefore we must try to eliminate waste.
A suggestion came from the surprising person of Senator Bourke that the report, which I prefer to call “The Report of the Consultative Council on the Hospital Services,” is weighted in favour of specialists. I should like to say about that, that in the rationalisation which seems to me to be required in our health services, we have a right to get, must get, the benefits of specialisation.
The arguments for specialisation can be derived from economic history and from economic theory and I can supplement that argument by some references, which may be of interest, to the proposition contained in that report that the extent to which you can devise labour to increase productivity is determined by the market you can serve. In other words, you are limited in the degree of specialisation possible by the extent of the market. This proposition does not appear in the report but it is implied in the writings of a gentleman who has no economic training that I am aware of: “The bigger the population served, the more comprehensive the service, the better the people can be served, the more suffering can be relieved.”
It would be useful to anyone who wished to argue against that proposal if they had come here with evidence against it. It is claimed that the significant benefit of specialisation here is safety. We all know we would benefit from the experience of each other if we listened to each other. We can all benefit from discussion, if we listen to each other. If we share experiences, discussion is very helpful. Repetitive action, even on the highest level, means that one tends to do that action better, that one knows the new problem which is coming up and, as the example in the reports puts it, if you have three surgeons working together—they have got to be working together, they have got to be in agreement—they will do more work and do it better and serve their patients better than if each of them was working separately. We all know that.
One of the psychological factors in  this is that you waste time. This point is 200 years old—it was made 200 years ago. You lose time moving from one occupation to another. Senator Bourke lost time moving from the Law Library to this House and she will lose more time going to Galway where she has to be tonight.
One of the things involved in specialisation is that you do not have to do other things: you do the things you know how to do and you get to do them better, and one of the results of that may be that life is saved—we are not talking here about one of the borderline questions of whether life should be maintained: we are talking about the question of saving life. As I have said, the benefits of specialisation are spelled out in the report as being the safety of the patient.
I think, however, that there is another, perhaps even more important, benefit to be derived from specialisation, and I am thinking all the time of the potential rationalisation of the whole health system. It is the benefit to the general hospitals from the experience of the regional hospitals in conjunction with the universities—the extent to which the knowledge of the specialist hospitals can be shared by the general hospitals and ultimately by the people of Ireland. That must be our concern, and it obviously is.
We are living at a time when there is a scientific explosion taking place. Somebody has asked what would be the position if 80 per cent of all the scientists of all times were alive at the moment. The point is that it is not possible for us to stand still in this situation without Ireland going backwards. That is why the regional hospitals, in conjunction with the universities, are the foundation stone of our medical services, of the Minister's thinking and of the Department's activities. There is important international co-operation in medical research and we must be in on it.
Somebody initiated a biological study and he said that it would be completed 70 years after his death. That gives some idea of the approach being made in these matters. It gives some idea of how essential it is that we have the regional hospitals, and  quickly, in association with the universities, sharing benefits with the general hospitals, with the doctors and nurses and ultimately with the people.
There is a whole background to medicine which was not there half a century ago. We now have the benefits of automatic devices, the computers, the measurements in the social sciences, the measurement of things like cardiovasculars. It all means that lying behind the work of the hospitals is the experience that will benefit all the doctors in Ireland. The need is that the work in the regional hospitals reaches the doctors of Ireland. We have heard about pure science. The work of pure scientists is seen to have application to the practitioners in the field. Of course, one must be a specialist to see this.
It is argued for the proposed regional and associated hospitals that we will be avoiding waste—waste in using acute bed accommodation. It has been suggested that this provision would reduce the number of beds from about 14,000 to 12,000. The point about that is that an acute bed is a more expensive bed than another one. The benefit of this will be that we will be able to provide a 24-hour service which is obviously an enormous advantage. It will mean that out-patient work will be on a larger scale and will cover a greater distance. Many people think that to be free of this work is enormously important.
The equipment, of course, will be come more expensive as it becomes more complex. We all know this. We simply have got, therefore, to have regard to the fact that we are not a country with unlimited resources and we have got to see how we can keep getting the best equipment to save lives that would otherwise be lost. It seems to me that the general plan here is right for this purpose.
I understand that the approach made to determine what was the appropriate size of a hospital was, first, to determine what was the appropriate size of expert staff. I am talking now, of course, about the general and regional hospitals which will have many similarities except that the  regional hospitals will be bigger and, working in association with the universities, located in Dublin, Cork and Galway. They ended up with a figure which was the result of research done in Scotland but arrived at by a different route, if I am correct in understanding the procedures.
There is that degree of originality in the approach of this body that they came to the conclusion that they should look at the costs that experts of this kind must have and see how much work they would be likely to get through in a day if they were kept busy all the time. These were chaps who would turn over work rapidly and who would be pathologists and radiologists. They decided that there should be two pathologists and two radiologists and this would give rise to the need for eight physicians, obstetricians and gynaecologists who could manage approximately 45 beds per skull—if that is a Parliamentary expression—working out at approximately 300. This is the only part of this report in which there is a particular emphasis laid on the importance of the size of the general hospital not falling below 300.
To attack a report on the basis of who made it seems to me not a proceeding of as high a level as I would hope every Senator would adopt. According to my analysis, there would be a total of 18, seven of them surgeons, nine physicians, one obstetrician and one pathologist, ten for Dublin, four from the south of the country and four from the west, eight having to do with local authorities and ten with voluntary authorities. Politically, somebody made a mistake in not putting on a number of GPs and benefit would have been found in this report if someone had thought of doing that. It was overlooked, apparently. The distribution is given. The point I wish to make is that these people, coming with these different backgrounds and different disciplines, are unanimously of the view that the hospital must not be less than 300-bed in size and unanimously of the view that regional hospitals are an absolute priority for the beginning of the rationalisation scheme.
There has been an underrating of  the importance of education. The better the regional hospital will be, the better it will be able to aid in the training of doctors and nurses and, incidentally, on nurses, the report on England and Wales was that the number suitable for proper training of nurses was a number not less than 300 beds, which is the recommended size here for general hospitals.
If the regional hospital skills are developed, obviously, they will be training their doctors better and the general hospitals will be better. They will develop in a natural kind of way ancillary services. There should be agreed specialisation between these three surgeons and three physicians and, a very important point, a matter of local loyalty, fewer patients need be sent to the bigger centre. This will be one of the real communal benefits that, in fact, a patient will be much nearer his home, if he is an acute case unable to get back, as is intended by the plan, to the county home or the district home, reconstituted and renamed. He is more likely to be closer to his own people under this system than he is at the moment. He will not necessarily be in Dublin. He will be in one of these areas that are suggested, and suggested only. It is worth noting all that. This shows the political unwisdom of the authors of this document.
If one reads them closely one finds that the recommendations for the areas are quite diffident and they leave it open for examination by people better equipped. It might well be that there would emerge out of the experience of the Minister a proposition that a special body might consider whether in particular cases other areas might not be chosen for general hospitals than the ones recommended by these gentlemen who would not have any particular expertise in this matter, it seems to me.
This business about the county home and the district home has got to be emphasised. As I understand what is planned, they will continue, even at the stage when the specialised surgery is gone from one area to another because it is going to be better done in the other area and the lives of persons will be saved by going to that other  area; that there will remain normal obstetrics in that home. It will be a nursing home where a patient would convalesce very close to his own home. If he is an old man receiving geriatric treatment he will be in his own environment and if he is in a hospital, as so many unfortunate citizens are, when they need not be if their own homes were better—socially necessary medicine I believe it is called—needing attention there because he cannot get it because of the lack of facilities in his own home, he will be at least near his own home.
In addition, it is planned that these county homes should have increased diagnostic facilities. It is planned that they should have more comprehensive out-patient departments than they have and the out-patient department's work, being served by the general hospitals and the regional hospitals, will, as I understand it, be more extensive, will go further and be better and is intended to be. This is all to rationalise and to make the skills of doctors and nurses available to people in a rational way and to have beds at present occupied in the expensive way that they are in these other county and district homes occupied in a less expensive way.
It is also intended that the x-ray and laboratory facilities should continue and that there should be as part of this plan—and this is something I feel very strongly about—an integration of the general practitioner, the family doctor, into this system. He should be in association with these hospitals and get benefit from that and can go and enjoy the medical libraries and listen to the lectures and have discussions with the more specialised people who will be in the general hospitals.
One matter has been mentioned with regard to the ambulance service. Senator Mrs. Farrell said that there was no reference to an ambulance service, that the committee had not thought about it. I read this report with care, as even my markings may indicate. Section 3.59 gives a good deal of attention to it. Paragraphs 7.28 to 7.35 deal with it. There is also reference to a possible alternative use of hospitals for rehabilitation, a  reference to the necessity for resuscitation, talk about accidents. In fact, there is a recommendation that every district hospital should have a high standard of first aid ready and available.
I do not claim to know any more than I learn in listening about this but I do know that, in fact, though this is not something that one would wish to stress, there are many matters which are thought capable only of treatment if you get there in a few minutes. This is a matter of which there are a few illustrations given in the report, but, perhaps, it is better that I should not give them; but many acute cases anywhere in the country, including the city of Dublin, depend for the survival of the person concerned on the ready availability of the advice and good sense of the general practitioner, which looks to me as if he is dead within a few minutes if he is not available.
On the question of the ambulance service, I am given to understand that already the Department have undertaken and set in motion work of a valuable kind on this. I think that the Minister and the Department are to be congratulated on doing this. On this question of the ambulance services it does seem to be vital to the success of the whole scheme that there is a speedy and properly equipped ambulance available for the cases that have to be brought to these general hospitals. I do not know who makes our ambulances, but I am told that they are not adequate. I hope that no economic consideration, no question of protection or anything else, will affect the making available to the people of Ireland of the very best ambulances that can be got anywhere in the world. I do not know whether there are better ambulances than those that we have serving the Irish people at the moment but I believe there are.
It would not be right for me to sit down, having said nothing but nice things as I have tried to do and wanted to and believed to be true, without saying one thing that I think should be said. I do not know whether it is in the Minister's mind that he is so much opposed to the present extraordinarily inequitable system of valuations that  he has chosen to kill it in this fashion. It may be very subtle, and I would congratulate him if he succeeds, but it seems to me that the local financial system is like a man with a bad heart disease and a great big trunk is now being given to him to carry. Either one of two things will happen. Either he will drop dead or—which I would prefer to see—he will go quickly to his doctor and the valuation system will get revised as quickly as this health report was made and this Bill enacted in consequence of it.
Mr. Gallanagh: At the outset I should like in the absence of Senator Farrell to say that on the matter of ambulances what she said was that the report was almost silent. She maintained that eight paragraphs in a report like this is almost silence.
May I say that I agree entirely with the system of devoting a percentage of the local rates towards the health system. It is 44 per cent at present, but the percentage is more, I think, because I maintain, though people disagree with me, that there is a relief to the lower income groups in this. These people pay a big lot already in direct and indirect taxation, and there is a measure of relief to those people by the fact that 44 per cent of what is going towards health is paid out of the local rates. The second reason I say it is that it enables the Minister to exercise his preference in the appointment to the board of more than 50 per cent members from the local authorities. In this I disagree entirely with those on this side and the other side of the House who say that this board should be made up of all these pious people who believe in the social services at every level, because you would finish up with a mutual aid society spending ab lib and there would be much more in the latter end to pay. The local authority member knows that he must go back at the next election and meet the people and be responsible to them for any increase that may have come in the rates or his handling of their money.
There seems to be a big question here on this matter of rates today, and there must be many people who do not understand the rating system. To compare County Cavan with County Meath  in the matter of rates or what a penny in the £ means is completely misleading. Anyone who has ever travelled through County Cavan can see farm residences and farms there corresponding to those in Meath but you have to have regard to the comparative valuations. Without doing this there is no point in comparing one with another. If the rates are £5 in one county and £2 in another, a man paying £5 may be on a £7 valuation and so would be paying £35 while the other man could also be paying the same amount on a much higher valuation. You cannot, therefore, make any general comparison. Another point is that an increase in rates is still in direct proportion to the increase in the cost of living. Today people are paying about as much in proportion on rates in comparison with what they were years ago.
I should like to congratulate the Minister on his very fine Second Reading speech. But I should like to disagree with him on one point on page 6 when he says “In addition, for rural areas, the State, from the agricultural grant, makes a further substantial contribution to the cost of the health services through relieving farmers from paying rates.” I disagree with that. I think that it is a contribution to the farmers, not to the health authority.
I do not wish to delay the House very much longer, but I should like to make some points on section 40 and section 60. Section 40 provides for a body to regulate consultant appointments. I would welcome anything in legislation of any description that would bring these consultative services to the people. It is scandalous at present. People from the country are coming up here to Dublin, being sent by their local doctors to a name in Dublin. They go in there because they must. Many of these people do not have medical cards, and not all people can afford this great expense, because the £1,200 allowance is very small. They come to Dublin into the consulting rooms and see the doctor for five minutes at the most. Because he says that they have to go into hospital, for saying that there is a ten guinea demand and no receipt in most cases,  because it seems unprofessional to give a receipt—it is not done. Then this same man operates on those people and charges a fee for operation. I cannot see the justice of this. If I go to a shoemaker, although maybe I should not compare one with the other, he tells me that my shoes need soles but he is not going to charge me for that advice. He will look after the shoes and then charge me for his work.
This brings me to the matter of voluntary health, which somebody else has mentioned. I should like to mention it again because I think that there is not sufficient publicity in this matter. Not sufficient people realise until they are in trouble how important voluntary health is and how cheap it is and how necessary it is for people to have this voluntary health service. This should be brought home to them more forcibly, and in this respect I think that they should be warned not to disclose to the hospital that they are in the voluntary health when they go there as patients, because the voluntary health are going to be taken to town by the hospitals, and if the voluntary health are taken to town, then in return the following year the people will have to be paying increases, so people should not tell any hospital that they are paying voluntary health.
I should like to say something on section 60 with which I agree very much. This is the section which deals with home help. I knew a case recently, as late as December. There was a mother in a home at 60 years of age. She had creeping paralysis. There was a father with an old age pension. The daughter of 18 was looking after them but because she had not three years' stamps she could not get anything for looking after them. This is changed now under the social welfare code. The father gets an additional 55/-. With the provision made here I think they will be able to get something else. As the Minister said this is a very important section. Apart from humanitarian considerations, I think people should consider, if they feel they are not getting sufficient allowances, sending their invalids to the local authority hospital where they can say to the local authority: “It cost you so much to keep them in hospital. Give me so much and I will keep them at home.”
Possibly Senator Dr. Belton could tell me what it costs to keep a bed in hospital. At present it may be £20; I do not know. The people who are keeping invalids at home should get something reasonable. Otherwise, their task is impossible. What are the prospects for a young girl who is going to look after her parents for perhaps five or ten years and then finds herself at an awkward age and cannot get a job? It is bad enough to go on without training while looking after her parents but to go on doing so on an insufficient income is asking too much. I congratulate the Minister on the Bill. I am delighted that he has introduced this provision in particular and I shall not delay the House any longer.
Mr. J. Boland: This measure is a major one in the number of sections involved but to me in many respects it is like the curate's egg. Unfortunately, I fear that the bad spots are so bad that to a large extent they outweigh the merits of the good parts. But before I begin to speak about it I want to join with other speakers on all sides of the House in congratulating the Minister on the manner in which he handled the Committee Stage of the debate in the Dáil and on the minor surgery he carried out on the patient and which I hope he may again undertake on the Committee Stage here so that we may be able to send out some sort of patched-up measure that will be capable of being implemented by the local authorities and the new health boards.
In common with other speakers on this side of the House I want to say that to us at this stage to have a Bill introduced which purports to be a major measure in relation to health services and which in no way seeks to change the method of financing those services is totally unacceptable to us as members of the Fine Gael Party. Surely it is unacceptable to the people who drafted the Government's White Paper in 1966 which clearly said that in their opinion the rates were not a  suitable way of financing the health services. For that reason we should oppose vehemently the particular section which sets out the proposed method of financing these services.
The White Paper clearly said that they did not consider the rates a suitable way of financing health services. In the explanatory memorandum we are told that the Bill is primarily based on the proposals for changes in the health services and their administration contained in the White Paper. Yet, in this most important aspect of the service we find no change whatever. We find a rather interesting situation arising where, in the tentative details which were sent to members of local authorities, of this House and of the Dáil last September, we were told that in recent years the State's contribution to the health services as an average was 56 per cent. Yet, following that, the Minister, as in the other House and here again yesterday and today, asks us to accept a measure which provides that the State will make a contribution of one-half or 50 per cent. Bearing in mind the fact that the State is at present contributing on a national average—I emphasise that because there are parts of the country that insist they are not getting anything like that figure—56 per cent, even if the Government have decided not to deviate from the policy of financing a large part of the health services from the rates, one would imagine that they would have provided for at least a statutory 55 per cent contribution in accordance with the amount that has been contributed in recent years. We do not get that in section 31. We get instead a clear statement that the State's contribution will be half and this may or may not—and this is the important part of it; it is not obligatory—be supplemented by additional payments to a health board.
As Senator Belton pointed out yesterday, at the time of the estimates meeting last year we in the Dublin Health Authority received a circular from the Minister's Department which had the temerity to ask us to effect economies in our estimates for the year. Senator Belton dealt very efficiently with the way in which that  circular was received not alone in the Dublin Health Authority but also in other health authorities throughout the country. I want to refer to an interesting sideline. We in the health authority examined our estimates and we duly contacted the Department of Health and said: “Yes, we can immediately effect a saving of £60,000 if the Minister would sanction oil-fired boilers in our hospitals instead of turffired boilers which we have been requesting for the previous five years to no avail.” The answer from the Department was silence. So we have a situation where somebody in the Minister's Department would send a circular of this nature and when he receives an answer pointing out where £60,000 can be saved, because it does not suit either that Department or some other Department of State, the economy which was so urgent and pressing when the circular was issued is suddenly no longer necessary.
It seems to us that this Bill has set out deliberately and clearly in certain sections to straitjacket and confine further the power of local authorities to protest about the amount of the contribution they will have to make to the area health boards in any year. We have written into the Bill a specific provision that if any local authority hesitates about making its contribution in response to the statutory demand that will be made upon it by the area health board any Minister of any Department may withhold from that local authority funds to the amount which the local authority is hesitating about transferring to the health board.
Presumably this is a section which may have originated to some extent from the other Department which uses the Custom House rather than from the Minister's own Department and is intended, to some extent, to prevent the type of democratic protest which was engaged in last year by members of Dublin Corporation against the excessive increased demand being made upon them.
It would seem that never again in this democratic country can the majority of members of a local authority decide, as it their right, that they will refuse to meet a demand  because they feel it is excessive, unjust and unbearable from the point of view of the ratepayers in their community because, instead of registering their protest in this way, we will have the Minister for Education, perhaps, withholding the financing of the higher education grant money from that local authority area or, perhaps, the Minister for Local Government withholding the State grant for road works in that local authority area and transferring the money directly to whichever health board happens to be administering the health services in that area. This does not seem to me to be an extension of the democratic system which was referred to by some speakers over the past two days and of which this Bill is supposedly a part.
We also have the provision written into this Bill, again for the first time, that no health board may, save with the Minister's consent, engage in any excess expenditure over and above the estimate adopted. We, and by “we” I mean especially my colleagues, Senator Belton, and Senator Walsh from the Fianna Fáil side of the House, are members of the Dublin Health Authority which was, in effect, the one big regional health authority operating heretofore. We know, as I am sure the Minister and his officials know, that that authority handle a budget so vast, for a population so vast and constantly changing, the needs of which are always increasing and changing, that it is impossible in any year to arrive at a proper estimate.
In fact, the estimates presented to the members of the Dublin Health Authority in any year are little more than a calculated guess and, for the remaining 11 months of the year, excess expenditure authorised, I think, under section 11 of the 1955 City and County Management Act, has always been sanctioned by the members, and the moneys form part of the estimate at the following year's meeting.
Now we will be prevented from authorising that excess expenditure unless we have the specific permission of the Minister. This, I think, is in section 30 of the Bill. It seems to us that this section, taken in conjunction with the right of the Minister to  transfer funds from the local authority to the health board, means that the Government can, if they so desire, completely straitjacket the health board, decide how much money it will spend, how much money will be contributed to each of its component local authorities, and whether it will spend any additional money in a particular year.
A situation could very easily arise in which the Government of the day, in a particular year, for financial reasons might not want to see a great amount of extra money being spent, and a particular health board in a particular area, because of special circumstances, might need very badly to spend quite a sizeable sum over and above the estimate they had adopted. The Minister of the day of whatever Government we happened to have could, under the provisions of these two sections, refuse point blank to allow that expenditure to be made. To us this does not seem to be progressive or the sort of thing one would expect in a Health Bill which has been so long awaited and so much talked about as this Bill.
The Minister deserves our thanks and compliments for the great time and trouble he took in travelling around the country to meet representatives from each of the local authorities and hear their views at an early stage in the course of the debate on this Bill. I should like to think it was to a large extent because of the views he heard that he agreed that the local authority members should have a majority on each of the health boards.
However, I feel very strongly that we can still ask the Minister to go further in this regard. The Minister has provided that the local authority members will have a slight majority. The rest of the members will be nominated by the various professions of which they are members. These appointed men, faceless men I think they were referred to as either here or at some stage in the other House, have not got the responsibility at any stage of going before the people to explain their actions during the previous four or five years since the election took place in their own  county council area, or of explaining to the ratepayers why the rate demand has risen, or why it is that they have not got additional health services.
Yet, these people will constitute almost half of the health boards which will decide how much money is to be spent, and the sad slight majority will be sent back with their tails between their statutory legs with their statutory demands to their local authorities, and they will have to give an account of their services to those authorities. Whether or not their fellow-colleagues on the local authorities like the account they hear, they, too, will be obliged to adopt whatever levy is made upon them. When the next election comes around, the members who were representatives on the health boards and their colleagues on the local authorities will all have to go out and explain actions which were decided upon by almost 50 per cent of people who were not public representatives and who, despite any assertions to the contrary, will never be public representatives because they never had to and never will have to stand before the people and ask them for their votes and give an account of their stewardship.
By any standard this does not seem to me to be an extension of the democratic system. Once again an additional burden is being placed upon the very excellent members of local authorities. They are now being asked to explain the expenditure of money over which, to a large extent, they had no say. Remember, most of the members of any local authority will not be on the health board. There will be at most three or four from most local authorities out of a membership of 25 or 30. They have to accept the financial demand made upon them and explain it to their constituents.
As a member of the Dublin Health Authority, and fully aware of the type of administrative difficulties which that authority had to face over the years and, to my mind, the magnificent way in which the senior officials of the authority have worked to surmount these difficulties, it seems to me and to both the officials and members of the different parties that the powers of the new CEO under this Bill will  be far less than the powers the CEO with the Dublin Health Authority has at the moment or the powers county managers have in their local authorities. We do not believe that will be a good thing.
The administration of the proposed health service by the eastern health board, with a population of 1,000,000 people, may require the board to meet two days a week to examine accounts, to authorise various purchases of individual items and discuss small details of administration which, up to this, the senior officials, in whom we had every confidence, attended to on our behalf. The Minister gave an assurance in the other House that if we, in the eastern region, felt strongly enough about this he would be prepared to make concessions. My reason for referring to the matter at the moment is to forecast that the Minister may very well be receiving urgent representations within two years from the setting up of the eastern health board for permission to revert to the system which obtains at present.
I am disappointed that a braver step was not taken in this Bill to untie the strings running from the Custom House and tied tightly around the hands of senior officials of local authorities throughout the country. I do not think anyone will disagree with the suggestion that it is conceivably possible that there may be men in the local government service, working for county councils or health authorities, who are more efficient, more intelligent and who have a more enlightened attitude to the administration of the service than the officials in the Custom House who have the final say and sanction in regard to schemes put up by the men in the local area.
There is widespread agreement among public officials themselves that control over the local authorities is often far too detailed, a view echoed recently by the Secretary of the Department of Local Government himself.
When changes in the relationship between  the CEO and his board were being mooted, irrespective of whether or not we agree with them, there could have been and should have been a braver look taken at the relationship between the officials in the Custom House and the senior administrators in local authorities and health authorities throughout the country. This did not happen. It is another omission I regret.
There is, in my opinion, excessive representation in regard to the professions. The members of the local authority are the people responsible to the public. The medical profession and the nursing profession have a fair case for representation but having six or seven doctors serving on a health board will, I am sure, prove to be an unworkable proposition. I am a young man with a brief three years experience of health administration in this city and those of us who serve on the boards of hospitals, other than local authority hospitals, are not always enamoured of the administrative abilities of the medical people, however highly skilled or qualified they may be in their own professional field. There are, of course, notable exceptions and I would include Senator Belton in these exceptions. It may not be a very valid criticism, but I did hear someone remark rather ironically that we would end up with everybody represented on the health board except the patient. Public representatives, of course, represent the patient and that is one reason why I think public representatives should have a sizeable majority on these boards.
There would not be a health service of any kind were it not for the contribution made by public representatives over the years, public representatives who gave of their time and their energy, without payment, to assist in the evolution of our health services. To turn around at this stage and say to these public representatives that we are so unhappy with the present health services we have decided, having heard a great many complaints, to give these public representatives a bare majority over professional representatives does not seem to me to be a very graceful way of saying “Thank you” or of acknowledging the debt society owes  to these men for the contribution they have made. They are quite willing to go on contributing and I suggest there should be a re-examination of the proposed structure of the health boards to see whether or not public representatives should not have a sizeable and clearcut majority.
If the forecast of the administrators of the Dublin health authority is correct the amount of time members of health boards will be asked to give weekly will be so great that I fear the Minister will very soon have to consider making some sort of financial payment to the members—certainly, if not to the members, to the super-chairman, because super he will have to be. Attending those boards will involve members in a considerable loss of time, loss of revenue in their normal occupations and considerable expense.
This Bill will regionalise and rationalise our health services. It would be a useful exercise to examine the before and after situation. The before situation, which is the position as it exists today, is that there are 27 county councils in the country. In the case of four of these, namely, Dublin, Limerick, Waterford and Cork, the health authorities administer health services for both the city and the adjoining county and in the remaining 23 county councils the councils themselves are the health authorities. The 23 county councils plus the four health authorities and one hospital commission give a total of 28 bodies administering health services in the country at the present time.
The after situation will, I think, be something like this: each county council will have a local committee. They will total 27. Presumably, the corporations of Dublin, Limerick, Waterford and Cork will each be allowed to have a local committee and that will give us a further total of 31. The Borough of Dún Laoghaire is in some doubt, but I imagine in the normal democratic process they will be allowed to have a local committee and this will bring the total to 32. There will be eight health boards which will bring the total to 40, three regional hospital boards which will  make it 43 and Comhairle na nOspidéal will make it 44. After the policy of regionalisation and rationalisation has been carried out we find there will be 44 committees administering the health services at present being administered by 23 county councils and four health authorities. I feel sure the delegated committees, which the health boards will be allowed to appoint to investigate the suspension of officers and deal with local inquiries, whenever a hospital is about to be closed or extended, will mean that the bodies administering the health services will number more than 50 for the first few years at least. In an effort to rationalise our health services we are almost doubling the number of bodies administering those services. I feel sure the situation would be of considerable interest to Parkinson.
It seems to me rather strange, when embarking on a policy of regionalisation, that it should be decided in eight areas that local county boundaries are to be abolished. By that I mean within a particular area the county boundaries of counties forming part of that area will no longer exist as far as the health services are concerned and yet for the exterior of each health area we are maintaining the county boundaries. This is going to produce a rather ridiculous situation bearing in mind the policy of regionalisation. There is a rural area in North County Dublin which is only a few miles from the town of Drogheda. A very fine hospital exists there and it is much more convenient for the people in this area to go to Drogheda. The Dublin Health Authority has realised this and over the past years it has maintained an ambulance at the Lourdes Hospital in Drogheda to carry out work on its behalf in North County Dublin. When the new boards are operating I should like to know if an arrangement can be made to allow a patient living on the edge of a boundary where facilities are much nearer in the adjoining health board to cross the border and receive their treatment in that area?
Mr. J. Boland: I am glad to have the Minister's assurance on that. We all realised that, whatever areas had  been suggested for these health boards, there would have been criticism from various local members who felt their area was being downgraded. I think a long, hard look should have been taken at the county boundary system in an effort to produce eight, ten or any number of regions which it was felt to be administratively possible and which could work to the best advantage of the service without taking into account county boundaries. I think it would have been better to decide the areas on a geographical basis as well as on the basis of existing road networks and hospitals instead of simply containing ourselves within existing county boundaries. I imagine my suggestions are rather late at this stage.
Perhaps the Minister can tell us what is going to happen to the existing dispensaries and health centre buildings once the choice of doctor system comes into operation. The Minister is no doubt aware that Fine Gael have for some years been advocating major reforms in the health services. One of these reforms involves the choice of doctor system. The suggestion was then made that when the dispensaries were no longer necessary these buildings should be changed into community welfare centres which would contain the district nurse's office, the family social worker's office, the welfare clinic for mothers and babies, out-patient clinics and the home help centre. This seems to me to be a useful way of using existing buildings. I would be interested to hear if any thought has been given to what is going to happen to these buildings. I understand it has been suggested where a general hospital is to be closed down that the administrative centre for the health board should be sited in the county where the hospital is being closed.
Perhaps, the Minister would let us know whether it is the intention to have the administrative headquarters for each health board sited in the same town or city in which the main hospital for that board will be sited. It seems to be the obvious thing to do, both from an administrative and an economic point of view, but, perhaps, there are reasons for suggesting that it  should be placed in one of the other counties. I am inclined to think that the only reason at the moment is to have it act as a sop to disgruntled members of the county in which the hospital is not sited.
I hope I will not be considered parochial if I refer to the Dublin region and, indeed, it could not be termed parochial as we have in the region, certainly if we want to refer to the eastern health board, almost one-third of the population. Indeed, if present trends continue we shall have more than one-third within a short number of years. I want to suggest to the Minister, as I did when local authority members from the proposed eastern health board area met him, that the area at present administered by the Dublin Health Authority is as large, if it is not too large, as can be administered properly bearing in mind the vast population already in Dublin city and county and Dún Laoghaire borough.
It has been stated by officials of the Dublin city and county planning department that the rate of expansion taking place in County Dublin is one of the most rapid either here or in Britain. They forecast that within 15 or 20 years the population of Dublin city will remain static, in the region of 600,000, but that the population of Dublin county will rise to equal that figure. I am not quite sure what figure they give for Dún Laoghaire but it does not represent a sizeable increase because of the fact that the major part of the borough area has already been built upon. One can see that Dublin county is fast becoming a largely dormitory area in which new suburbs are being created and new towns being planned so that within a relatively short number of years—and I presume this Bill is intended to cover the functioning of health services for a considerable time to come—the Dublin county area will be an area of one rather large city surrounded by satellite towns between which there will be large suburban dormitories.
It does not seem to me in the long term to be a good thing, bearing in mind these forecasts, and, indeed, just taking the evidence of one's own eyes  as one sees these developments taking place, to join with this urban and surburban area, which is essentially becoming more urban, the essentially rural areas of Kildare and Wicklow. Whatever expansion may take place in Kildare, and to whatever extent the towns in Kildare will expand, as they obviously will, the terrain in County Wicklow—as the Fine Gael Leader in the House could so well explain—is so mountainous that it will largely remain a rural area for some time to come if not for ever. To join the mountains and hills of Wicklow to the urban complex of Dublin does not seem to be the best proposal administratively. Even at present in Dublin County Council we resent our link-up with Dublin Corporation because we feel that the larger body gets the better deal. We may or we may not be right but I am afraid that once Wicklow and Kildare become joined with the main area there will be serious complaints from those counties, especially Wicklow, that they are not getting a fair deal from the health board and that all the services are geared towards Dublin city and county at the expense of the ratepayers in the other counties.
I would urge the Minister to examine the situation which exists in Dublin in view of the population forecast and also the fact that Wicklow will remain an essentially rural area and to see whether or not Wicklow might not be served better, and, indeed, whether Dublin area might not be served better, by leaving the Dublin area much as it is at present and joining Wicklow with, perhaps, the south eastern region. The Minister stated that 56 per cent of the health costs had been met by the State in recent years. In the case of the Dublin Health Authority the official percentage in recent years has been 54.7 per cent but there is a feeling that the State contribution has not even been 54.7 per cent. The main reason for this is that many of the good provisions in later sections of the Bill were already being provided by the Dublin Health Authority because we —and as Deputy Ryan pointed out in the Dáil the Fine Gael Party are in  the majority in this authority—and our officials were conscious of the need for a home help service, meals-on-wheels and a domiciliary service and we were providing these services and providing them in a number of cases by financing them completely from the rates. Someone has done the mathematical calculation which I was always too frightened to embark on and has arrived at the conclusion that instead of 54.7 per cent —the figure thrown up by the Dublin Health Authority accountant—we were only getting 46 per cent of our health costs from the State because some of the services were services for which we could not seek a State contribution.
An interesting point about the Dublin region is that while there is a national average of 30 per cent of our people holding general medical cards— and in some counties the figure rises far beyond that—on the last occasion I inquired about the percentage of the total population covered in the area the figure was 14.5 per cent and that percentage, of course, was taking the actual number of card holders as a percentage of the whole country as shown by the 1966 census. It is obvious that the 1966 census is quite out of date: the population has increased substantially so that the percentage, if it were accurate, would be even less for that area.
Bearing all these things in mind, the Dublin area deserves closer attention. A special scrutiny and study should have been made of the present Dublin Health Authority. The eastern health board, as the provision stands, will administer for a population of one-third of the country, and of the figures given in the Minister's memorandum, therefore, 30.9 per cent of the total estimated budget, estimated presumably by the Minister's officials, for the entire country, will apply to this region. I am taking the figure given by the Minister's officials. I am not being in any way critical: I am merely pointing out how rapidly things change in regard to health services and how difficult it is accurately to estimate financial need to run a service.
The budget the Minister's officials gave was £15 million for the eastern region, comprising Dublin City, Dublin  County, Dún Laoghaire and Counties Kildare and Wicklow. Yet we, as members of the Dublin Health Authority, have in the past three weeks tentatively accepted a budget for the coming year of £16½ million, not taking into account the amount of money needed for the present health services in Kildare and Wicklow. If the estimate for Kildare and Wicklow could be added to the Dublin Health Authority estimate, and if the population of Dublin is to continue to increase, it must become obvious to the Minister that the eastern health board will be administering approximately 40 per cent of the total budget for health services throughout the country, due largely to the suburban area with the rural tag on it.
I should like to refer briefly to the representation of local authority members on health boards. County Dublin has a population of 174,000 and they have three representatives. The whole of the midland region has a population of 178,000—approximately 4,000 more—and they will have 12 local authority representatives. It seems to me that when considering local authority representation account should be taken of population increases and of immediate future increases and decreases.
I do not know whether it was through my inattentiveness or because of the dreadful acoustics in the House —something should be done about this —but I understood Senator Belton to speak about the transfer of the Dundrum Central Mental Hospital to the health board or to the Board of Works. The question the Senator was asking was whether the ratepayers of the eastern region would have to bear half of the cost of running that hospital. I was not able to hear the Minister's answer and, perhaps, he would be able to repeat it when he is replying.
It is a good thing that the administration of that hospital will be undertaken by a civic board, whether it be the eastern board or the board as suggested my myself and other Senators. It is long overdue that the administration of that hospital should be taken from the hands of the Department and  handed over to proper administrative people.
Following the debate in the other House, I noticed that the Minister— I can congratulate him—decided to allow the health boards to appoint chairmen and vice-chairmen. That decision interfered with one of the schedules. The Bill at that time used the schedule to explain the set-up in regard to the hospital boards and as a result of the Dáil discussion the Minister is allowing the boards to appoint their own chairmen and vice-chairmen, and consequently he abolished part of the schedule which allowed him the right to appoint the chairmen and vice-chairmen of the regional hospital boards. The suggestion was made to me—I felt, rather unkindly—that the Minister was retaining the right to make these appointments because the three regional hospital boards would be what I might call the crunch boards which would set up the procedure in relation to the closing down of any hospital or institution, a process which would be most unacceptable except from a political viewpoint.
The suggestion was that consequently the Minister was taking on himself the responsibility to make the appointments of strong personalities in order to ensure that this line would be carried through. I do not imagine that is what the Minister had in mind. It may be that he wished to retain these appointments to himself because these were the boards that would be engaged in the long-term planning of the hospital services of the country and that he felt there should be some close connection between these boards and the country. It would be useful if the Minister opened his mind to us in this respect when he is replying.
The suggestion has also been made —it is hard to decide whether there is validity in it because of the vagueness of the relevant section—that when the regional boards are set up there is a danger a clash may occur between these boards and the employees of the boards, between the CEOs and the senior officers of the health boards. It would appear from certain indications in the section allowing for the setting up of the regional hospital boards and  Comhairle na nOspidéal that a consultant employed by the boards to provide services in general hospitals might be in conflict with the CEO or the administrator of the local general hospital and that the consultant might adopt the attitude that he was not an employee of the board and that he would not accept the dictates of the administrator—that he owed his allegiance to Comhairle na nOspidéal. This might lead to discussion on lines of demarcation. It is something that should be clarified by the Minister so that there will be a clear-cut distinction between whom allegiance is owed to.
In relation to the three hospital regions as specified in the Bill as being based in Dublin, Cork and Galway, these boards will provide the new regional hospitals. It was suggested that the board based in Cork would administer the area of the south and mid-west, that the Galway board would administer the west and north-west and that the Dublin board would administer the eastern and midland regions.
The Minister's predecessor said in the course of the debate in the other House—Volume 239, column 2087 of the Official Report—that approximately 80 to 90 per cent of the surgical problems in any local authority area at present were within the competence of the county surgeon and that presumably it would be—I think Senator Ryan referred to this early today—only the remaining 10 to 15, perhaps as much as 20 per cent, who would have to go to the regional hospitals for surgical treatment. If this is the case, presumably contained within that percentage would be a fairly large number of persons who were urgently in need of an operation and whose condition was so acute or so dangerous or so rare that it could not be dealt with in the local general hospital. Why, then, are we to have a situation where the county of Waterford, in the south-eastern health board region, will have its regional hospital in Dublin and where a patient in west Waterford who would be approximately 40 miles from the regional hospital in Cork would have Dublin as  his regional hospital board area? A similar situation would obtain in parts of north Clare where the people would be very convenient to the regional hospital in Galway but presumably would be expected to attend the regional hospital in Cork because they were living in the mid-western health board area. Such anomalies will arise in any policy, programme or suggestion for rationalisation or regionalisation and we ought to get a clear-cut, categorical assurance from the Minister at this stage as to whether people will be allowed to cross regional hospital board boundaries if a regional hospital in another area is more convenient or adjacent to them.
It seems ridiculous to suggest to somebody who is in urgent need of surgical attention and who is living in west Waterford that he lives in the Dublin regional hospital board area where there are the finest hospitals, the finest medical and surgical staff, the finest equipment and the finest nursing-home waiting for him if only he can survive the rather dreadful 120 or 130 miles trip by road by ambulance. Unless this problem is tackled at this stage we will get a situation where the press of rural Ireland will be reporting that the verdict at various inquests was that the patient could have been saved had it been possible to get him to the regional hospital in time where the finest equipment awaited him and everybody will regret that fact.
Can the Minister give us some clarification on this point at this stage? Obviously the new regional hospitals will be ambitious. Presumably they will have the very best and most modern equipment available and will be staffed by the most competent persons. All of this will involve very high costings. I do not think we have got any indication from any source as to who, in fact, will be responsible for the financing of regional hospitals.
It is interesting to note the proposed constitution of the regional hospital boards. One-half of the membership of these boards will be ministerial appointees and one-half will come from the health boards. It is interesting to bear in mind that the health boards  are creatures which already have almost one-half of their members appointed so that by the time the regional board comes to be set up we will be lucky if even one-fourth of the members of the regional board are local authority members, public representatives, the people who are responsible to the general public. Indeed, as one goes through the proposals for administration one sees that the power, influence and scope of local authority members, public representatives, is diluted to such an extent that it is almost washed out.
I rather facetiously referred to the creation of all the additional committees which will be necessary to administer the policy of regionalisation and rationalisation. I can assure the Minister I realise that many of them are very necessary but I want to say something which perhaps will not be very acceptable politically either to members of my own party or to other parties. As far as I can see, the proposed local committees, who will have solely an advisory function, are being set up as no more than a sop to members of local authorities who realise only too well that their powers are being taken from them and that the health services will be controlled very definitely from the Custom House in future and the only reason for setting up these local advisory committees is to endeavour to convince county council members that they still have some power and some say in deciding on health policies. They have not and they know it and they resent it. If these local committees are still meeting six months after the initial meeting, that will be a matter for surprise. There was provision made in the 1960 Act for local committees to meet within the Dublin Health Authority. These local committees ceased to meet after a few months because the members realised only too clearly that there was no point in meeting to discuss something on which they could not take any decision.
No man becomes elected to a local authority unless he has some degree of commonsense and some intelligence. He will not be a member of any body for very long before he realises what  its power or usefulness is. Normally, he is a busy man and he will resent being expected to appear on committees like this where he cannot come to any decision or make any clearcut recommendation. It would have been better if the Minister had been more honest and had said: “We are taking the power away from local authority members. We are allowing some of the members of each county council collectively to form just over one-half of the membership of the health board. We are restricting the way in which the health boards can spend money. We are ensuring that no local authority can refuse to provide the money. We are doing all this because we do not like the way in which you have been administering the service, because we do not like the way in which Dublin Corporation protested, and in order to make sure that our system of financing almost one-half of the health services out of the rates will continue. We are going to make darn well sure that nobody is going to protest about it in the future. We are not going to have any local committee because it would serve no function. It would be a waste of time—of your time and our time—and incidentally it would waste a considerable amount of the ratepayers' time because of the necessary attendance of officials there and the rooms that must be available, and the expense of subsistence allowances and all that, which will be of no avail.”
Perhaps, it is not too late yet for the Minister to consider either doing away with those committees or deciding to give them some real power, recognising the contribution which the members of those committees have to make and deciding to give more teeth to those committees and allow them to do more work. I assure the Minister— and I am sure that from his visits around the country he knows it only too well—that these people are only too ready and anxious to help in furthering the administration of our health services.
There is an interesting departure in this setting up of those local committees in that for the first time ever as far as I can see or find out the  county manager, a man who derives his whole position from the Management Acts and who had a very definite position in relation to members of his local authority, has been taken out of that official position, which is clearly laid down by the Management Acts, and is being told “You serve on a committee with elected members and you serve as a member of that committee.” Now I am not the greatest advocate of the management system. I believe that there are many changes that could be made to the Management Acts, but to just decide to make one small change like this which changes the position of the county manager in relation to public representatives does not seem to me to be a very worthwhile thing to do, especially when it is in relation to a committee which will have no useful function anyway.
Many of us hoped that when a new Health Bill would be introduced the old Victorian poor law system, the concept of someone being eligible for services if they could not provide from their own income or other lawful means, would be recognised as what it was, and that a fresh approach and a new look would be taken at this whole business and that there would be a clear-cut definite line laid down. While the Bill does abolish this dreadful phrase of “lawfully from his own income or other lawful means” it gives us instead the equally trite and meaningless phrase “undue hardship”. My definition of undue hardship, the Minister's definition and the definition of any of the other 58 or 59 Senators in this Chamber could differ, and differ radically, from each other. What might be undue hardship to the Minister might not be undue hardship to one of the Members here, but it might very well be great and grave undue hardship to somebody sitting in the public gallery. We are asked to accept this as the modern 1969 replacement for this Victorian set of words. I think, again, that this is a section which should be examined to see whether there cannot be some definite and clear-cut things laid down here to give a fair indication to the general public as to what  undue hardship or whatever it is was in the mind of the Minister or of his officials or the draftsmen when they wrote that section.
I want to welcome with all my heart —and that is an awful lot to give—the provision that from now on only the husband and his wife will have their incomes taken into account in deciding upon eligibility. How often have so many seen the situation where a large family were refused a general medical services card because of the income of one of the eldest children where we as public representatives knew, and knew only too well, that that eldest child either through selfishness or for personal reasons was, in fact, making no financial contribution whatsoever towards the home? Yet the health authority were obliged to take a certain amount of the income of each child into account. They were not allowed to investigate whether or not that child was making a contribution to the home. I can assure the Minister that the numbers who will immediately become eligible for general medical service as a result of this move will be considerable and I hope that the increase in numbers has been budgeted for. I know that it will be welcomed in many parts of County Dublin. Indeed, if the Minister ever has to seek a new constituency he might well think of coming down there after this. However, what I do want to say is that it is rather a dreadful thing in this year of our Lord 1970 that we feel it necessary to consider continuing this blue card system, this general medical services card system with its means test to any extent. As far as I understand it virtually every country in Europe with the exception, I think, of one particular part of Finland has managed to provide some sort of medical service for all its people, and apart from Finland the Republic of Ireland is the only place where a general service for all the people is not provided and this continuing means test with all the annoyance and embarrassment which it invariably must cost is to be continued. I am sure that the Minister would like just as much as I that this should be abolished, and I recognise that presumably it is just not economically possible at this time, but I would  hope that it is the thinking of the Minister and his officials that as soon as ever we may we will get rid of this means test and of the questioning and probing which almost invariably fails to elicit the true picture, fails to bring out that, perhaps, the husband has gone on spending more money on drink than actually reaches his wife, which is a very small sum indeed. It often amazes me that with all the questions asked by these inquiry officers about the family's situation hardship of that degree is invariably overlooked, and they seem to be more concerned that the people may have cabbage planted in the back garden from which they might derive an income of 10s than to find whether, in fact, the husband brought his wage packet home at all last week or the week before.
I understand that in the future rather than each local health authority deciding on what should be acceptable standards for the issue of the general medical services card the Minister or his Department will issue clear-cut standards which cannot be deviated from by any health authority. This is a good thing which is to be welcomed, and I hope that it is something which will be brought into operation at the earliest possible date.
I want to refer to the provisions of section 45 whereby there is a ceiling of £1,200 for limited eligibility. This is a ceiling fixed late in 1965. If I may I would point out, as other speakers have done, that there has been a very definite and marked fall in the value of money since then, as Members know, and as Members of the other House know even better, because shortly before the Christmas Recess, in answer to a parliamentary question, the Minister for Finance explained that the 1969 pound was worth 16s 8d in 1966 or 16s 4d in 1965 terms. Taking it in terms of 1966 and working out what £1,200 is worth in terms of 1969 we arrive at a figure of £1,440. Yet, here in this Bill we have the same ceiling of £1,200 continued even though it must be quite obvious to the Minister's advisers and draftsmen and to himself that the people who were entitled to services with  £1,200 in 1966 would be no better off today if they were earning £1,440. There is a clear case for asking the Minister to amend this figure and at least bring it into line with the fall in the value of money, if not to increase it substantially.
In regard to section 52, I very much regret that the Minister has felt it necessary to continue the provision whereby charges may be made per day for hospital service. I think the Minister and his officials know that the amount of revenue derived from this charge in the past few years has been a very small fraction of the revenue required to meet costs, something like one-sixtieth, without taking account of the administrative costs of collecting that 10/- per day. A Bill that sets out to be a modern Bill dealing with health services should not continue this provision.
The Minister is to be congratulated in regard to his decision to allow free choice of doctor where possible. This is something for which the people have been agitating for a very long time, something which has formed one of the cornerstones of Fine Gael policy on health in the past few years. We have been agitating for it at every available opportunity. As a party we feel proud that this part at least of our suggestions is to be implemented in this Bill.
When we refer to free choice of doctor—this is a choice of general practitioner—it is only right to acknowledge the debt which Irish society owes to general practitioners down through the years. Very often, especially in remote rural areas, they have acted as friends and advisers as well as medical practitioners. They have given very considerable service and because of this I am specially concerned that, wherever it is not found possible to provide a choice of doctor, every effort should be made to ensure that some doctor is available. Obviously, in more remote areas doctors will be reluctant to stay and we should see to it that very definite incentives are made available so that they will consider it worthwhile to live in these remote areas.
Remote areas are not always, as  Senator Dr. Belton suggested, in places like the Aran Islands. In this respect I want to quote from the Irish Independent of 8th January of this year an article on the front page dealing at some length with the fact that the tiny village of Tinahely perched high in the County Wicklow mountains has been endeavouring to combat a raging flu epidemic without the aid of a resident doctor. “Already,” it says, “one villager has died from flu complications, according to a local resident. Almost every house in the village (population 417) has been struck by the virus and the only medical assistance available is from the doctor in the district dispensary who travels the six miles from Shillelagh twice a week.”
Interestingly enough, a member of the other House who is also a medical practitioner, Dr. Hugh Byrne, who travelled to the stricken village at the request of the Irish Independent said: “There is near-panic here at the moment. When there is a fantastic incidence of flu as at present, it is these isolated places which are worst hit.” Dr. Byrne blamed the new Health Act, to become law in April, 1971, for the difficulty in attracting resident dispensary doctors to places like Tinahely. “These temporary part-time non-pensionable positions are not attracting any applicants because they offer no security. The shortage of doctors in such areas should have been anticipated when the legislation was being introduced,” he said.
Mr. J. Boland: If that is so I am glad I have given the Minister the opportunity of making it clear now. Presumably, there is some difficulty in providing a doctor in Tinahely. If we take it as an example it is quite obvious that, when a choice of doctor is being made available to people who are  fortunate enough to live in populous areas where doctors are willing to live, the loss to people in remote areas is even more severe and rather than having a choice of doctor, they may not be able to get a doctor at all. That is why I again urge that every effort be made to see that doctors are available in all parts of the country. This must be done by making it advantageous to doctors to live in remote areas.
If I understood the Minister correctly when he intervened yesterday when Senator Dr. Belton asked about the method of payment of GPs I am glad to know that the Minister has now accepted in principle the fee for service system which operates so successfully in many other countries and which the Medical Union are so anxious to see introduced. This is in no way a criticism of the present Minister who has been only a few months in this office, but it is remarkable that a White Paper was published in 1966 which dealt with all these problems and which, as far as I know, almost immediately initiated a series of meetings between the Minister and his officials and the Medical Union and yet, when a Bill is introduced in Dáil Éireann in 1969 and in Seanad Éireann in 1970 by the Minister for Health, the Minister does not know if he has got a definite, agreed system of payment of GPs who will be carrying out the choice of doctor service. It is regrettable that in all this time negotiations could not have been satisfactorily concluded. The blame must be laid to a large extent at the door of the Department officials who, for some reason, seem to be opposed to the fee for service system. They have given in at last and presumably some form of working agreement will now be arrived at. I hope it will not in any way hold up the implementation of this.
Obviously when the dispensary, per se, no longer exists and a choice of doctor system operates, there must be some way in which the patient can get drugs which are prescribed for him. So far as I know, at present the local authorities buy the drugs at something like 46 per cent of the retail cost of drugs purchased over the counter in a  chemist's shop. Presumably, some register of chemists will be drawn up in the same way as the suggested register of doctors participating in this proposed new service will be drawn up.
I wonder whether an acceptable or accepted system of payment has been decided in relation to chemists because, obviously, if the chemists were to look for the full retail cost of drugs that would mean that the cost of drugs to the health service would immediately double. Perhaps, the Minister could enlighten us in this regard. Perhaps, he might also tell us how the chemists will be selected to enter this register and to participate in this service. Will all the chemists in a town be entitled to enter the service or will it be only one? If it is only one, how will he be selected? Will he be selected by tender or will he be selected because he is more competent than the others? If he is selected because of that who will decide whether he is the most competent in the town? These are the things we should have been told.
It seems to me that there is a need for a national formulary. Some time ago we in the health authority witnessed a fantastic increase in the cost of drugs despite the fact that we were not providing service to a greatly increased number of people. There had not been any tremendous or costly epidemic during the period in question. When we investigated it the report which came back to us from our chief pharmacist was that the dispensary doctors had been influenced by pressure exerted by salesmen on behalf of the pharmaceutical companies and that they were now, in the main, prescribing drugs that were far more costly and no more effective than the cheaper versions which had sufficed up to then.
It seems to me that if we had a national formulary it could lay down what was the minimum standard of drugs necessary to treat the various diseases or ailments and what might be the maximum which would serve as a guide and be a very effective guide for GPs. In this modern world with its increasing pressures they are having more and more difficulty in keeping up to date and they very often prescribe the most modern drug because it is the  one they heard of most recently from a visiting pharmaceutical representative. A national formulary could lay down clear guidelines for GPs participating in this scheme. Obviously, this would produce economies and it would assist chemists. They would not have to carry fantastic supplies of drugs in order to meet all possible types of prescriptions that might come to them from the various doctors who had different ideas or different friends in the pharmaceutical companies. Do I understand that there was an agreement that the Minister would get in at 9.15?
Mr. J. Boland: My understanding was that this was a tentative arrangement depending on whether there were any more speakers. I understand that there is another speaker. I do not want to deprive anyone else of the opportunity of speaking but there were some other points to which I wanted to refer
Mr. J. Boland: I will press on then. I welcome the section which provides for the setting up of the home help and home nursing service. This is something which the Dublin Health Authority have been doing for a number of years without official approval. It is something which we in Fine Gael have been pressing for and advocating. We welcome this very much. Obviously, when it becomes operative it will be of great help in dealing with the problems of the aged and in dealing with geriatrics.
For quite a long time there has been great pressure on our geriatric homes which arose because of the fact that many old people had to enter these homes, not because they were completely helpless or incompetent, but because there were certain small things they could not do for themselves. If someone was living with them and could give them a little help or even  cook one hot meal a day for them they could stay at home and be far happier and the pressure would be taken off our institutions. It is good to see that the Minister recognised this and introduced this provision into the Bill making it operative on a national basis. I am also glad to see that it covers section 61 in relation to pregnancies.
Provision must be made for the nursing of the aged. This is becoming an increasingly pressing problem and it is becoming increasingly obvious in the Dublin Health Authority area probably because it is a large urban area. It is regrettable that our young families are becoming more and more reluctant to have older members of the community living with them, perhaps, even their own elderly fathers and mothers. If these people have any disability they are inclined to insist that they should be taken into an institution rather than keeping them in the bosom of their families. If this continues the pressure on our homes for the aged and our geriatric homes will be very considerable.
Already there is a great amount of pressure on the nursing staffs in these hospitals and there is a marked reluctance on the part of nurses to serve in hospitals and homes catering for geriatric patients only. Obviously, there is a small extra financial inducement available for any nurse who chooses to serve in a geriatric home. I do not think that alone is sufficient. In this regard I regret to have to say that I do not believe that the Dublin voluntary hospitals generally have played their part in taking their share of the geriatric patients over the past few years and because of this an increasingly heavy burden is being placed on the health authorities and consequently on local authority institutions.
I made inquiries several times in the course of the past year or two about the general accident hospital, St. Columcille's Hospital in Loughlinstown, and I discovered that at all times in those two years one bed in every seven was occupied by long-stay patients, by old people. Those people had relatives and the matron asserted that they could be living at home if  their relatives were prepared to give them a little care.
I am sorry more coverage has not been given to mental handicap in the Bill. The Fine Gael attitude on this question is that one statutory authority should be set up to co-ordinate and expand the mental handicap service. More diagnostic services, five-day recreational centres and day centres and hospitals should be provided for the mentally handicapped. I should like to have gone into this in more detail but I appreciate that there is a time factor.
In relation to section 62 could I suggest to the Minister that the period of six weeks which is stipulated for free treatment of ailments in new born infants might be far too short? We should consider expanding it considerably. I believe, as do many other Senators on this side of the House, that the abolition of the unlimited eligibility for treatment of the ailments and defects discovered in school medical examinations is very regrettable.
Like the curate's egg, this Bill is good in parts. It is bad in regard to financing. That a Bill should, in the middle of the rather good sections, turn around and provide: “We will remove a service which already exists, the service by which every family with school-going children suffering from defects or ailments discovered in school medical examinations can avail of free treatment for those defects and ailments” is most regrettable. The system that obtains at the moment will no longer apply when this Bill becomes law. It is not a good thing to remove a facility already provided.
The Minister should look into the urgent need for a review of the Infectious Diseases Act. This is something about which members of local authorities and others concerned with health administration are somewhat exercised in their minds. It is a pity there is no provision in the Bill for large-scale grants for cancer research and for an enlightened approach to the considerable financial burden placed on any family unfortunate enough to have a member stricken with cancer, terminal or otherwise. I welcome the introduction of section 76  for the purpose of controlling drug abuse. This control is long overdue. I shall not go into this matter in detail now.
In conclusion, may I say that special emphasis should be placed on preventive medicine? Such medicine is safer and ultimately cheaper. The more we engage in this kind of activity the more economies we can effect in the long run. The point has been made to me that, when mass radiography is advertised, there should be special emphasis on the danger of lung cancer because that is something which frightens the general public to some extent and, if this aspect were concentrated upon, one would get many more people availing of this service and in the course of the examinations, we would discover heart ailments and chest ailments. Nobody pays much attention to posters calling attention to chronic bronchitis.
Mr. J. Boland: I have practically finished. The Bill must be welcomed because of the many useful provisions, but the fact that the method of financing the service will not be changed in any way and that local authority representation is unfair causes me to have grave reservations about the Bill as a whole. When we come to deal with these particular sections on Committee Stage I will again be talking to the Minister.
Minister for Health (Mr. Childers): First of all, I want to thank all the Senators for the very kind things they said about me. I do not think I merit them, but it was very nice to hear them. I should say that the Bill before the House is the work of many people, people who work silently and without advertising themselves. There were the people who prepared the FitzGerald Report, the people who prepared the three other reports, professional people and people interested in public health, the draftsman and the absolutely dedicated and splendid officers of my Department. The Bill was also the responsibility of two of my predecessors  so we had better get our sights in order in so far as I can be held to be responsible for the Bill itself. It was, of course, examined in great detail by the Government. Nevertheless, I thank the Seanad for the very kind reception they have given to the Bill. I think Senator Boland was the only Senator I heard speaking who sounded as if he would like, perhaps, to tear up the Bill and write another one. There was criticism of various clauses by some Senators, but Senator Boland seemed more hostile than all the other Senators together.
I shall deal as briefly as I can with the enormous number of points raised, many of which will be more relevant for consideration on Committee Stage. With regard to expanding populations and changes in population, quite obviously we may have to change the character of the boards in future years. I hope the Dublin conurbation will not increase excessively but, if it is necessary to change the character of the board, this will have to be done by amending legislation. I have not made any decision so far as to how to confer a majority upon the local authority representatives on the regional health boards, but I imagine that in most cases it will be through an increase in the number of representatives in relation to the total size of the board. I still do not believe that local authority representatives will vote en bloc against the professional representatives. It might happen in the case of some boards on occasion but I do not believe it would happen in the case of many boards. Nevertheless, I am yielding to the request made to me that local authority representatives should be in a majority. I trust the members of these regional boards will meet in their corporate capacity and that they will work together as a team, understanding each other's point of view and doing excellent executive work. From the point of view of numbers, if the boards are to work effectively I believe the number should be in or around 30. I could not possibly conceive designing a board which would satisfy all those wanting representation. I do not believe such a large board would be able to do really effective work.
With regard to the enormous turnover  of work in the Dublin Health Authority, I have already explained that there can be delegation of authority to the chief executive officer. I shall, however, have a management examination made throughout the country. We will ask the managers to give us the number of orders they had to make or the decisions they had to take, which did not relate to staff or remuneration, or the decisions about eligibility of service relating to day-to-day management of the whole of the health business. From that examination we will be able to estimate to what extent we can recommend some further delegation of authority to the CEOs other than that specified in the Bill at the moment. Delegation can be done under section 16 (4) (e) of the Bill.
I decided I would appoint the chairman and vice-chairman of the regional hospital boards because they will be doing not alone the work of the Hospitals Commission but also some of the work of my Department in the planning of hospital services in the future. In view of the huge capital commitments involved and the fact that the central Government provides, in one way or another, some 75 per cent of the cost of the health services, and a very considerable amount of that cost relates to hospitals, it is only right, I think, that I should have some clear-cut and definite relationship with the regional hospital boards.
In reply to the Senator who raised the point about crossing regional hospital board boundaries, people can cross such boundaries; in other words, patients can be sent from, say, Galway to Dublin for specialist treatment.
The suggestion has been made that we should abolish completely the present medical card, but even the Fine Gael Party, in their proposal for an insurance scheme, made it absolutely clear that people in the lower income group could not be included in an insurance scheme and, therefore, in one way or another, there would still have to be some kind of test even if an insurance scheme replaced the present rating system.
Mr. Childers: But you still have to have some way of distinguishing between them and the middle and upper income groups. Senator Boland objects to the Minister controlling the level of expenditure of the health boards and, at the same time, he holds that the local authority should have the right to refuse to raise its share of the cost. Now that is inconsistent. I think a local authority should not have power without also having financial responsibility for raising the money.
There have been complaints about the budgetary control which the Minister exercises in this Bill, but I do not believe it will prevent the development of an effective health service. It is a good thing to have proper budgetary control. Supplementary sums can be secured in an emergency of any kind with the Minister's permission. I assure the House if there should be a disaster, an outbreak of some fever or any difficulty of that kind, that emergency expenditure can be sanctioned by telephone if necessary.
The suggestion was made that as Minister for Health I should make quite sure that the Department has a complete and absolute stranglehold over all these new authorities. I do not think that is true. I think the formation of the new bodies is a step towards the devolution of authority in health administration. Of course, the Minister for Health must have ultimate responsibility; he has responsibility to the Government for the health services.
Senator Boland made what I think was rather a joke about the number of bodies involved in administering the health services. He included the local advisory committees, which are advisory bodies, and from the point of view of Parkinson's law they cannot be included in the number of bodies doing executive work. If he had made the comparison by including the present number of health authorities and the present number of consultative local committees that exist at the present time he would have found that the figure is 60 compared with his figure of 44. I do not think such calculations are genuine. It must be borne in mind  that we are having larger regional boards but I do not think there will be a Parkinsonian result.
Some Senators referred to the relationship of regional health boards to the local government regional areas. We have tried, as far as possible, to draw the regions to correspond with the regional areas for local government planning purposes and for tourist purposes. I need not go into detail about how far we departed from that.
Senator Quinlan spoke at length about the need for specialists in the health services. I agree with a lot of what he said. I hope the people who will join the regional health boards and the regional hospital boards will not only be specialists but people with a good general administrative sense. I think that is very important.
Senator Jessop, who made a very helpful and good contribution to the debate, asked why psychiatric nurses are to have a special representation on health boards while obstetric nurses are not to have such representation. I am afraid we could not divide the nursing community up into its various categories in such a way as to provide two places for nurses, other than psychiatric nurses. Psychiatric nurses have a separate register and different training and this was the only way we could make the division.
A number of Senators from the Dublin area asked what will happen when the regional health boards are formed if there are still no representatives on the Dublin Corporation. I understand that the powers that the Minister for Local Government has to fill vacancies in subordinate boards consequential on his dissolving Dublin Corporation are very wide. Either Mr. Garvin, the Commissioner, on his own or with a number of persons could be appointed. I cannot make a pronouncement on that at the present time.
Senator McDonald suggested that section 10 of the Bill could be used to establish three regional health authorities, presumably by making the proposed health boards into joint bodies, but it is not intended to use section 10 for that purpose. The general purpose of that section is to enable  health boards to undertake joint action in order to provide facilities where the economies of scale would make that worthwhile, such as, for example, the payment of chemists and doctors.
Senator Jessop referred to the necessity of bearing in mind the importance of the teaching hospitals when appointing members to regional hospital boards. That will certainly be done. Quite evidently, in the case of the three very large bodies we shall have to take into account the importance of teaching hospitals. Senator Jessop referred to the difficulties in connection with the method of appointing consultants under Comhairle na nOspidéal. We already have a precedent in that the Local Appointments Commission, when making certain types of appointments where teaching hospitals are involved, have departed from normal procedure, and has a committee of selection formed in a special way in which the teaching hospitals and universities are represented. This is a good precedent for our being able to work out, over a period, some new method of selection procedure which will satisfy the medical confraternities. Senator Jessop also raised some very important matters in relation to teaching appointments and the formation of Comhairle na nOspidéal. These points have been discussed with the President of University College and with Senator Professor Jessop, Trinity College. They are reasonable points and we shall consider, on Committee Stage, whether section 40 setting up Comhairle na nOspidéal requires further amendment.
In reply to Senator Keery, the chief executive officer's post will be open to people outside those engaged in local authority service. The terms of reference will be sufficiently wide to attract people with the required administrative experience. The selection of each administrative centre of each regional board is being left to the boards themselves. If they cannot decide I shall have the rather unpleasant duty of making the decisions and will, surely, make some enemies in borderline cases. Senator Keery asked, with regard to the removal of a chief executive officer, what the nature of the inquiry would be. The local inquiry into the proposed  removal of the chief executive officer will normally be held in private, whereas an inquiry into the proposed closure of a hospital will normally be held in public with the press in attendance.
Senator Bourke raised some matters in relation to the security of existing district medical officers now that the choice of doctor system is coming in. I have given an undertaking—and I do not think it is necessary to put this into the Bill—that no district medical officer need have any fear that he is going to be dismissed or that he will lose his position. All district medical officers will be retained until normal retiring age. Many of them will be required in the remoter areas. We already offer doctors, practising in remote areas, additional salaries, and in future we shall have to do all we can to attract doctors to practise in these areas. I can see the inevitable retention of the district medical officer as distinct from the doctor in private practice who engages in a fee per service operation. Unless there are some changes we shall need these people and we may even have to appoint new district medical officers in some remote areas in future.
Mr. Childers: If the Senator feels keenly about this and puts down a particular amendment I will be able to refer to it in greater detail and guarantee the position of district medical officers at least by what I say in the Seanad if it is not considered appropriate to put it into the Bill.
Mr. Childers: Senator Bourke also raised an interesting question, whether  consultants of health board hospitals and voluntary hospitals, to be employed by the regional hospital boards, would be subject to the routine regimen of the hospitals to which they were assigned. An arrangement has been made as a result of consultations with the consultants' organisations. I need not go into detail but the Senator need have no fears in regard to regional hospital boards being unable to appoint consultants who have functions both in voluntary and health board hospitals.
I have to some extent dealt with the organisation of these boards and other matters of organisation and now I had better say something in reply to the many observations made about the services. First of all, I should like to remind the House that the volume of health services expenditure, after eliminating inflationary cost increases, has doubled since 1958 and the volume of our gross national product has increased by about 50 per cent in the same period. We always have to be careful not to allow the cost of social services to increase beyond the growth of real production but certainly we have endeavoured to expand the health services enormously. When I mention the fact that the actual volume of expenditure has doubled in the last ten years I should like also to mention that by international comparisons we are in the top bracket countries in regard to effective health services. We still have very great improvements to make and many changes to make and I am not being complacent when I say that, judged by the well-known statistics available from the United Nations handbooks in relation to death rates, life expectancy and so on, we are making progress and we are among the leaders in that respect. Our job is to see that we make further progress.
I should like also to mention, by the way, that with the exception of remarks about mental handicap not many Senators, and indeed not many Deputies in the other House, spoke in detail about mental illness. This is perfectly natural and I find myself as Minister for Health having constantly to remind myself that in about ten years time mental illness is going to play an even more overwhelming part  in our lives than it does at present. We are paying attention to this and we are improving the mental illness services but we have got to go a great deal further. I will not go into the future but I feel the stress of modern existence and people's acceptance of that stress is going to present us with tremendous problems. In fact the effect of modern stress is already presenting not only psychiatric specialists but GPs and consultants with some pretty frightening problems. We have constantly to watch the emphasis we place on the various types of health services offered in relation to the growing importance of mental illness and health as it reveals itself not only in this country but in every other country.
Some Senators did suggest that we were not doing enough in relation to prophylactic and preventive services. I have not given in detail what I propose to do in the child health services but this will be announced next Monday when I will be opening a course for assistant county medical officers. I should like to say that my greatest enthusiasm is for the development of preventive services for young people and the development of child health services. We are going ahead with this and I hope that we will have a sufficient number of examinations between a child's birth and the child leaving primary school so as to give the child every opportunity to arrive at later life in a healthy condition. As I say, that is one of my greatest enthusiasms.
It is not true, therefore, to say that prophylactic or preventive services are being ignored. I might also say that we will be expanding our publicity services in the coming financial year and the number of films and leaflets and the amount of publicity in relation to all aspects of the health services will be steadily expanded because I believe they are of very great importance.
Senator J. Fitzgerald suggested that the Bill was only a watered down version of the White Paper proposals but all the changes proposed in the White Paper are provided for in the Bill, every single one of them. I wish to make that clear. I do not think I need go into detail about sections 55 and  58 which do in fact provide for free out-patient service and drugs, medicines and appliances for children suffering from prescribed long-term illnesses or disabilities. In section 51 the health boards will be empowered to provide in-patient service for children in all income groups suffering from certain long-term diseases and disabilities and I am certain that one of those which will be prescribed will be mental handicap.
Senator Jessop raised a number of matters in connection with the information services which he regards as being essential. He and some other Senators mentioned this and I will consider whether we can adjust the terms of the Bill in relation to the particular arrangements available to health authorities to provide information services in order to see whether they cannot be made a little bit more mandatory. It is remarkable that only one health authority up to now has provided a genuine information service. We will look into that matter on Committee Stage. I should like to see that kind of development continue much more rapidly. Senator Lyons and some other Senators raised the question of the public being educated on the danger of drugs. I am awaiting a report from the working party on dangerous drugs in regard to what they think should be done in the way of education.
A number of Senators referred to the necessity to give an opportunity to general practitioners to have more close connections with the general hospitals. There was general agreement on it, and I do not intend to go into it in detail now. Senators seemed to imply that we are behindhand in the provision of places for severely and moderately handicapped children. We have about 1,500 extra places being arranged and provided for. We are working as fast as we can. We depend on the wonderful religious orders who have helped us along throughout the years, with assistance from some splendid lay organisations.
I repeat that there will be 1,500 extra places available over the next year or two when we shall be able to provide places for all the severely  handicapped and moderately handicapped of whom we have knowledge. We have taken the views of those who have written the report in this respect. If I have one priority in so far as a particular field of activity is concerned, it is to provide that all those children can get properly looked after. I have been quite aware of all that Senators said in regard to the anguish of parents of such children and their despair because some of the children have to go to mental hospitals, although everything possible is being done for them there.
Senator Jessop made some very important comments on the matter of general practitioners in this country. I wish to say now that I believe group practice will develop. The Todd Report made some important statements in regard to the general practitioner world. It is quite evident that they will require some further training in the future, and it is possible that encouragement will be given to them to attain some specialist knowledge from the consultants in general and regional hospitals—some slight speciality in a particular discipline that will mean the growth of group practice, particularly in the more remote rural parts of the country.
I agree with those who said there should be some sort of apprenticeship in this field and I have examined the reports of the Royal College of Practitioners in regard to two English hospitals. There has been an arrangement with the board of one hospital that students should have an opportunity of moving around with a general practitioner when they have passed the medical degree examinations.
Senator Lyons suggested that we could be doing some research on rheumatology in Galway. That would be beyond our means at the moment, but the consultant most recently appointed in Galway has special knowledge of rheumatics and arthritis.
A number of Senators referred to the nursing profession, which I have not time to deal with in detail. This is a great Irish vocation, and people have said that we train more nurses than we need. Of course many of them go  abroad, some of them come back and some of them go permanently away. The whole hospital system in England would collapse were it not for Irish nurses. As I have said, nursing has been a very great vocation for Irish girls. Indeed the Minister for Industry and Commerce recently told me that he found ten Irish nurses in Kuwait, which shows how far-flung our nurses are throughout the world. We are keeping a careful eye to see there will not be any apparent scarcity in regard to the placement of nurses throughout the country. The situation may, of course, change from one year to another, but there are no real permanent shortages of nurses here except in very tiny areas. We have asked an Bord Altranais and the Matrons' Association to establish clearly the whole question of nursing shortages, to examine problems regarding nurse-patient ratio in hospitals and to do everything they can to advise us on these matters.
A number of Senators asked about home helps. I agree that home helps should be available to everybody who requires them but they will still be scarce even when the health boards are getting sufficient money. It will not be easy to get home helps to deal with everybody, but I hope I am wrong in this. There has been consideration of the entire principle of community associations, with the help of voluntary organisations, providing part-time home helps for this very valuable service. As has been said here, I am quite sure the people in the higher and middle income groups will be willing to make contributions towards home help for those in the lower income groups who will receive this service free of charge. First of all, we have to see how many people will be available.
I mentioned earlier the fee for service principle for doctors. We naturally are considering such matters as the remoteness of patients in relation to fees and also the provision of a guaranteed minimum income for doctors in regard to fee for service in remote areas. These matters are all included in negotiations taking place.
I agree with Senator Boland who suggested we should establish a formulary for drugs. He said there are  drugs with the same content which cost three times the price from one manufacturer as against another. However, with the aid of a computer we should be able to devise some kind of formulary so that we would be able to analyse the cost of drugs in an effort to try to keep down the cost to the people who so badly need them. I cannot go into detail on this matter now but Senators will appreciate that the control of the retail price of drugs is a matter for the Minister for Industry and Commerce. We have co-operated with that Department in cases where the prices of drugs seemed to be excessively high.
There is a course of training in radiology being conducted at the present time. There are about four or five doctors engaged in this training. St. Luke's and some other voluntary hospitals co-operate in running the training. It lasts for about four years. It will therefore be some time before the training of this group is completed. I may add, in reply to Senator Quinlan's question, that radiologists are scarce, not only here but over the whole of Europe.
A number of questions were asked about food additives and ingredients added to food, and so forth. It would take too long to explain to the House what we can do under existing legislation to prohibit the use of certain additives and what we will be able to do when the Poisons and Drug Bill is passed some time during this year. We intend to take every possible action to have sufficient control over a wide variety of products and substances for the sake of the health of the community. It would take far too long to give the details of it.
Senator Seán Walsh made a complaint about the medical night service in Dublin. I wish he would give me some examples because my Department have not received letters of complaint in this regard and people are not afraid to write to me or to the Department when they receive what they regard as very bad medical service. So, I should like to hear more about this because I have not had any complaints about failure to provide prompt medical assistance at night in the city of Dublin. As Senator Walsh  said, with the development of group practice there will be less cause for this than there is now but I would like to hear complaints about it if they exist.
Senator Jessop asked why we could not include a provision giving general practitioners the right of entry into hospitals. This is scarcely appropriate for direct legislative provision. By administrative action under section 25 of the Bill we can do this but to put it as a statement into the Bill might cause difficulties for us because we do have, naturally, to have the consent of the medical profession to this and it has to be done by way of negotiation in certain cases because of the particular rights of the doctors in various hospitals. I think it would be better if we do it by administrative action and through general discussion with everybody involved.
Senator Belton asked if there is any element of compulsion on school managers in section 65, subsection (4). There is a right under the subsection to require a manager to provide facilities, which is quite reasonable and, in fact, is a re-enactment of an existing provision in section 32 of the Health Act, 1953. In the year 1970 it is quite reasonable to suggest that school managers should be agreeable to health examinations in the primary schools over which they have authority.
Perhaps, it is rather late to talk in great detail about the whole of the controversy in relation to the concentration of hospital facilities. We have already had some excellent speeches about it from both sides of the House, including a recent speech by Senator Alexis FitzGerald. I have got to listen to experts on the subject. It is no good listening to the man-in-the-street. I have got to listen to people who I believe can tell me whether mortality can be reduced; whether people will remain a lesser time in hospital; if we can have more healthy people by the concentration of acute surgery and medical services in large hospitals. My decision will be based on that and no one is going to dissuade me from taking the right course if I believe we can have less mortality and a better health service thereby. But, I do want  to say that I cannot see why people think that a hospital becomes downgraded or inferior when, first of all, there is a far better out-patient service provided by visiting consultants, with all the laboratory equipment required in the hospital, when, secondly, general practitioners from the area can have a greater interest in the hospital, enter it and look up their patients there and, thirdly, when the obstetrical facilities in that hospital can be continued and even improved and when, fourthly, in the area there has been, not a concentration of services, but a decentralisation of services through development of the public nursing service, through the choice of doctor principle, through greater domiciliary care for old and sick people and through the provision of all the services that can be seen as possible under this Bill. I just do not believe that a county hospital is downgraded if all those things are happening at the same time. One has to think of the total services available to people in the area within ten, fifteen or twenty miles of such a hospital.
I should say, also, that while I cannot predict this absolutely, I do not believe that eight or ten years from now it will be possible to appoint a single surgeon to a hospital in this country, if the implications of the Todd Report are fully appreciated. If the Todd Report is implemented in Great Britain there will be such a development of speciality work by surgeons and by consultants of various kinds that I do not think it will be possible to have a single surgeon consultant unless he did simply the simplest dry surgery, the very simplest operations. The actual fact is that we have now a tremendous growth of specialisation, specialisation to the point that all the conditions which affect, for example, a child from birth to four years of age can now be dealt with by special paediatric surgeons of a great number of different types of disciplines. There are paediatric surgeons solely specialising in cardiac conditions of new born babies. This kind of specialisation is growing and growing and there is nothing we can do to stop it growing. It simply means that more  and more when a person becomes ill and has to be hospitalised the situation will be that there will be always more than one consultant to look at him at the time of the operation and a great deal more laboratory apparatus will be required and it will be impossible to get people who wish to have full time work and a great deal of experience in a particular speciality unless they are appointed to a sufficiently large hospital.
These are the facts and all I can say is that I will consult the local advisory committee of any county hospital where these changes may have to take place and will have regard to all the facts and all the circumstances involved but it is the kind of change that is taking place not only in relation to the medical world but in a great many other activities where science is involved.
A number of Senators asked about the regulations that are coming before the Dáil and the Seanad in relation to the standards to be adopted for the medical card group and the answer is that the House can either accept or reject the draft and if they reject it then I will have to bring another draft before the Dáil and the Seanad. The Seanad can imagine that if you had a long debate proposing endless amendments in regard to the standards of means tests of that kind, the debate might never end and the Minister might be in very great difficulty because there could be so many permutations and combinations in regard to various ways of calculating people's means.
Mr. Childers: When a regulation in draft comes before the Dáil and the Seanad and when it is passed by both Houses it becomes a regulation. As far as I know that is the position. I was asked a number of questions about means tests but, perhaps, we had better leave these until Committee Stage as some of them are rather complicated.
Senator Boland asked about the change in the value of money. He is  right in saying that if you take the date when the means test was last fixed in 1965-66 at £1,200 a year you would have to change the figure to £1,450. But in answer to the Senator the Minister for Social Welfare and I would have to agree about any changes that would be made so that they would be the same for the Department of Health and the Department of Social Welfare in connection with social welfare insurance. It is impossible for me to say what changes are likely to take place. If the Senators work out the changes in the cost of living they will find that if you go back to 1958, £1,200 is a reasonable figure. It depends on how far you go back as to whether you decide it is no longer reasonable. I do not think that is something we can debate tonight.
I must contradict a statement made by Senator Belton who said that in the White Paper we said that rates would be frozen permanently at the 1965-66 level. The White Paper at paragraph 116 quite clearly said that the Government had decided to make arrangements which would ensure that the total cost of the services falling on local rates in respect of the year 1966-67 would not exceed the cost in respect of the year 1965-66. It goes on to make certain statements about local rates not being entirely suitable as a form of taxation or that they were now representing a very heavy cost to the community. That was the only promise made and that promise was kept.
A number of people suggested that we should put the rate of the statutory grant at some specific figure above 50 per cent. I do not think that would be practicable. The amount varies from 54 per cent to, I think, 57.8 per cent  in various health authorities at present. Naturally, we shall always do the best we can to make contributions to supplement the rates in every area Senators might be interested to know that in relation to all health expenditure as expressed in the cost of living index analysis of the expenditure of households for what, generally speaking, is the middle income group, health expenditure is reckoned to be 7s 6d per week per household. That compares with 45/- per week expenditure on drink or tobacco. I shall not comment any further on that; I merely mention it in passing.
Many Senators spoke about the heavy incidence of health charges on the rates. The House is aware of what the Minister for Local Government has done in the way of legislation to enable the rates to be paid by instalments and to enable an extra rate to be levied to assist in the reduction of rates to necessitous persons. Although strictly it does not appertain to my Department, I should like to mention that I think rates by instalments should help because a person who smokes 20 ordinary cigarettes a day is paying about £65 a year in cigarette tax Naturally, the same person is appalled at the thought of paying £65 rates on his house in two instalments at £32 10s each.
Mr. Childers: That is true but they do not control the smoking. There are other comparisons which were made by the Minister for Local Government on this matter. I think the petrol tax expenditure on a car of medium size before the last increase in petrol tax if the car travelled 10,000 miles in a year, was, again, between £60 and £65 I do not say that the rating position is perfect. The Minister for Local Government has a committee that has been examining it but I should mention that rates, as a percentage of the total expenditure of the State in all forms, have been falling in recent years and rates as a percentage of gross national production have not risen. May I again mention that 75 per cent of all  health services expenditure is paid by central Government although, admittedly, that does not benefit some of the towns and urban and city areas where there is no agricultural grant and very inequitable.
Mr. Alexis FitzGerald: I do not want to interrupt the Minister but my particular criticism on this point was based on the valuation system to which the rates apply. This is antique and very inequitable.
Mr. Childers: I should not like at this hour of the night to be briefed by somebody to speak on the subject of valuation. Senator FitzGerald and other Senators would know far more about it than I do. The whole matter of the growth of valuation and the changes that have occurred are an utter mystery to me and I am sure we shall have to examine this matter further.
Senator Belton raised the question of loan charges. There are separate arrangements for the recoupment of authorised loan charges to health authorities. Overdraft interest is not recognised as recoupable health expenditure. I have had complaints about this and I have asked my Department, following the raising of the matter in the Dáil, to take up again with the Department of Finance the question of more frequent payment of health grant instalments. I think I have answered a great many questions and that the remainder  of them can be answered in the course of Committee Stage. Again, I should like to thank the Seanad for the very helpful and constructive debate which we have had and I look forward to Committee Stage.
I believe we can make progress there. I should like to give a very gentle warning that I believe that a great many amendments which I accepted were in the minds of the Senators and I do not know if I shall be able to accept as many amendments on Committee Stage here. Many of them would be very obvious to either House. I hope I shall not be asked to accept amendments that would better the Bill too much or make it difficult for me to maintain the principles of the Bill which I regard as very valuable.
Mr. O'Higgins: We will not ask the Minister to accept amendments that he has already accepted. Before the question is put may I, by way of explanation, say that there seems to be a misunderstanding in regard to the time schedule agreed on? I understand Senator Nash wished to speak and it is only fair to him to record that fact. Certainly, it was not intended to crush him out. I understand he wanted to speak and there was some misunderstanding and, as a result, he did not get his opportunity.
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