Dáil Éireann - Volume 167 - 22 April, 1958
Committee on Finance. - Vote 64—Health.
Minister for Health (Mr. MacEntee) Seán MacEntee
Minister for Health (Mr. MacEntee): Before moving this Estimate, the Dáil may find it convenient to take Votes 64 and 65 together. Perhaps we could have agreement on that course. As well as that, there is also on the Order Paper a motion expressing, among other things, dissatisfaction with the administration of the Health Acts and it seems to me that that would probably arise for discussion on the Estimate.
Mr. Kyne Mr. Kyne
Mr. Kyne: I agree.
An Ceann Comhairle Patrick (Clare) Hogan
An Ceann Comhairle: That means then that we shall take the subject matter of Health, Dundrum Asylum and Motion No. 6, all to be discussed together.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: I move:—
That a sum not exceeding £6,092,900 be granted to complete the sum necessary to defray the Charge which  will come in course of payment during the year ending 31st March, 1959, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora) and certain services administered by that Office, including grants to local authorities and miscellaneous grants.
The sum now being moved, in addition to the figure of £2,060,000 already granted in the Vote on Account, makes a total of £8,152,900. This is the net total of the Vote for my Department. The gross total, before deduction of various Appropriations-in-Aid, is actually £8,486,120, to which might be added the sum of £40,343, which is the estimated cost to other Government Departments of services rendered on behalf of the Department of Health. The total estimated cost to the Exchequer next year will, therefore, be £8,526,463. The Appropriations-in-Aid, totalling £333,220, which are deductible from this figure are mainly made up of receipts from the local taxation account in respect of licence duties grant (£262,200) and estate duty grant (£52,700), which are really charges on the Exchequer. In addition to the Exchequer provision, local authorities will have to find about £8,210,000 from local rates, to meet their share of the total cost of our health services. This means that during the coming year the services administered by my Department and provided by local health authorities, will make demands on taxpayers and ratepayers to the extent of nearly £16,750,000.
To get a complete picture of the annual cost of health services, however, we would also have to include another rather large item, that is, the grants made from the Hospitals Trust Fund towards the deficits incurred in running voluntary hospitals. In the year which ended last month, these grants totalled roughly £1,250,000. In our budget for expenditure from that fund for the present year, I have included a sum of £900,000 for this service. Admittedly, these deficit grants are not a charge on ratepayers or taxpayers as they are paid from the Hospitals Trust Fund, which, of course, derives its income from sweepstakes.  Nevertheless, I suggest they should be included in the gross total expenditure if we wish to obtain a complete picture of the cost of our health services. If the deficits of the voluntary hospitals were not met from the Hospitals Trust Fund, it would be necessary for those hospitals to increase their income from other sources. The only sources available would be the pockets of the patients or the funds of those bodies who pay for patients. A rough assessment of the effect which a transfer of this burden would have indicates that local authorities and the Exchequer would have to find about £360,000 each, and hospital patients themselves about £180,000 if the voluntary hospital deficits ceased to be met from the Hospitals Trust Fund. Adding a sum of, say, £900,000 for deficit grants to the £16,750,000 already mentioned, we find that in 1958-59 it will cost well over £17,500,000 to provide the health services. This is a very considerable sum and I feel sure that the House as a whole will agree that we have now reached a stage when any developments which would increase the costs of our health services would have to be most carefully examined before they could be agreed to.
The main sub-head of this Estimate is sub-head H, under which provision is made for grants to health authorities. In the coming year, these are expected to total £8,200,000, which is £50,000 more than the sum provided in last year's Estimate. Generally speaking, that figure represents half the cost to local health authorities of providing services under the Health and Mental Treatment Acts. The total net cost of these services in 1958-59 is expected to be £16,420,000 spread over various sectors. The increase would have been much greater but for the fact that the cost of providing hospital treatment for tuberculosis patients is expected to show a decrease of about £290,000 on last year's Estimate. If realised—and there is no reason to anticipate that it may not be—this will be a significant saving, not only in terms of money, but also in terms of curative and preventive achievement. Due to the diminishing prevalence of the disease and of  the increasing efficacy of modern methods for its prevention and cure, we may look forward over the years to a downward trend in expenditure on the tuberculosis service.
Before proceeding to deal with other aspects of the Estimate more particularly related to the health services, I should like to refer to one other sub-head besides the main sub-head in the Vote—namely, sub-head L (5)—which provides a sum of £1,760 for compensation to two superintendent registrars of births, deaths and marriages whose offices were abolished without statutory authority.
Section 10 of the Vital Statistics and Births, Deaths and Marriages Act, 1952, provided that the public assistance authority became the superintendent registrar of births, deaths and marriages in any county where a vacancy in that office existed at the date of coming into operation of the Act, 1st April, 1953, or where one occurred subsequently.
Two superintendent registrars had retired from the local service before the operative date, but had continued in office subsequently on what was regarded by my Department as a temporary basis. In the belief at the time that their permanent tenure of office had, in fact, ceased before the 1952 Act brought about the change in the performance of the duties of superintendent registrar, the provisions of the Act were utilised to make the appropriate public assistance authority the superintendent registrar in the areas in question. This view as to the cessation of these officers' tenure of office was based on the belief that their tenure was governed by the terms of Adaptation Orders made in 1923 and 1925 under an Act of 1923 which was repealed by the Local Government Act, 1941. The two officers concerned challenged this view and claimed that they were still the permanent holders of the office. They surrendered office in March, 1953, but later submitted claims for reinstatement and for compensation for loss of office and for loss of certain fees.
In the course of examination of these claims, which raised some very complicated  legal questions of interpretation, an opinion was obtained from the Attorney-General to the effect that the Adaptation Orders to which I have referred did not, in fact, go as far as had always been assumed and could not be regarded as having the force which was imputed to them. It was considered, accordingly, that the two superintendent registrars could not be held to have ceased to hold permanent office, and it was decided to negotiate a settlement of their claims in preference to defending any proceedings which might be brought in the matter.
Both officers having resumed their posts as superintendent registrar, negotiations have taken place between their legal representatives and the legal representatives of the local authorities and the Department. As a result, a settlement has been arranged on the basis of the local authorities paying agreed compensation to the two officers and the Department recouping to the local authorities their expenditure on this compensation, their legal expenses and the net cost to them, after allowing for fees received from the public, of keeping the registers and issuing certificates as superintendent registrar. Provision is accordingly being made for a sum of £1,760 to cover compensation and legal costs, in sub-head L (5) of the Vote which is now before the House.
The fact that local health authorities are now spending nearly £16,500,000 a year on health services—that is about £5 10s. per head of population—has occasioned comment. Some of this comment is ill-informed, in so far as those responsible for it seem to think that medical services on a generous scale can be provided by public authorities without considerable demands on the resources of the community. In the same breath as they assure us that they agree that health services should be provided, either free or at reduced charges, for those who need them, they express resentment at the cost and at the fact that it must be met out of rates and taxes.
This is a completely unrealistic and unhelpful approach to the problem. No one is likely to question that, consistent  with the provision of an adequate and efficient service, the cost to public funds of the health services must be kept to a minimum. Our difficulty in effecting this, however, is not lessened by those who demand expanding facilities, coupled with more generous subventions to individuals, but refuse to consider how these are to be paid for. The hard fact is, of course, that the health services organised by the State have to be paid for, either directly by the persons obtaining benefit, or indirectly by ratepayers and taxpayers. There is no other way of financing them.
The total cost of these services is now very formidable. As against this, an extensive range of medical attention for all citizens is provided on a scale that 15 or 20 years ago would not have been accepted by public opinion as justifiable. For instance, 28 per cent. of the population—that is, those in the lower income group—are entitled to free attendance by the local dispensary doctor, free medicines from the dispensary, and free hospital, specialist, maternity and infant services. Women in this group are also entitled to a cash grant of £4 in respect of each confinement. In the year ended 31st March, 1957, the total cost of these grants was £114,488, and they were made in respect of 28,622 births. As the total number of births in that year was 61,455, it may be said that almost one-half the total number of women who had babies within the period received a maternity cash grant.
Again, full treatment for most infectious diseases, including tuberculosis, is available free of charge to all persons in the community. Under this heading is included, not only diagnostic, hospital and surgical treatment for these diseases, but also maintenance allowances payable to needy patients while under treatment. The cost of these allowances in the year 1958-59 is expected to total over £500,000.
The mental hospital service, which in the coming year will cost nearly £3,500,000, covers more than 20,000 mental hospital patients. We have also to provide for the maintenance and care of the chronic sick and of mental  defectives. Then we have the provision of allowances for disabled persons. These allowances are payable in the first instance by local health authorities to chronically disabled persons in poor circumstances. They now amount to about £700,000 a year, a much greater sum than was originally anticipated, and of this the State pays half. To all these there is to be added the expenditure on the maternity services and general hospital and specialist services which, either free of cost or at reduced charges, are available now to the middle income group.
Naturally, the question must arise as to whether citizens are getting value from the expenditure of so much money on health services. In a general way, it can be argued that the health services are a form of insurance which the community provides for the individual against contingency of ill-health and the cost of treating it. And it can also be argued that in general the vast body of ratepayers and taxpayers only pay for the services against the time when, as individual sufferers, they may need to call on them. Like all insurances, however, the health service has its disadvantage from the viewpoint of the exceptional individual, in so far as he may rarely or never need to avail of the facilities which it offers. On the other hand, these are there, should he require them—and which of us can say that he will never need them? It might be said, too, of certain of these facilities that, if they are not provided for the mass of the people, they will not be available for anybody. Moreover, there is the all-important fact that in the case of each one of us the success of the public health campaigns against tuberculosis, poliomyelitis, diphtheria and other infectious diseases, enormously reduces the risk of our contracting them.
Nevertheless it is difficult to give a completely satisfactory answer to the question as to whether value is being received for the money spent. It is difficult because, in the nature of things, it is impossible to measure the amelioration of sickness and ill-health, the value of human lives prolonged, and the consequent relief and happiness experienced by individuals and their families in terms of pounds,  shillings and pence. One measure of the progress which is being made is the vital statistics which are published each year. If we compare those for 1957 with those for a decade ago—say, for the year 1947, the year in which the first great Health Act was enacted and in which the reorganisation and expansion of our health services began —we can form for ourselves some idea of the return which has been given for the money spent.
First, the total number of deaths in 1957 was 34,308, compared with 44,061 in 1947. The death rate varies somewhat, of course, from year to year but, generally speaking, there has been a noticeable improvement in recent years. Indeed, it is beyond doubt that the average expectation of life has considerably increased. In 1947, there were 4,687 deaths among infants under one year old; last year the figure was a little over 2,000—in other words, infant deaths have been more than halved within ten years. Correspondingly, maternal mortality has fallen appreciably. Moreover, the principal diseases of childhood are now being effectively combated. In 1947 the total number of deaths due to diarrhoea and enteritis (in children under 2 years old), to whooping cough, measles, diphtheria and scarlet fever, came to 1,212. Last year the figure was only 150—a saving, compared with 1947, of over 1,000 young lives.
Ten years ago tuberculosis killed 3,700 people, most of them young. Last year the number of deaths caused by this disease was recorded as 697, or less than one-fifth of the figure for the earlier year.
Again, take the group of respiratory diseases, including influenza, pneumonia and bronchitis, but excluding tuberculosis. Despite the fact that the number of influenza deaths last year at 687 was the highest since the 1951 epidemic, deaths occasioned by these numbered 3,034 in 1957, as against 4,252 in 1947.
I should mention that all the figures I have quoted for 1957 are provisional and subject to minor adjustment. I have also to point out that in two of  the examples cited—maternal mortality and tuberculosis—the death rates in 1957 show a disimprovement when compared with the previous year's figures. Last year there were 80 maternal deaths compared with 52 in 1956, and deaths from tuberculosis increased from 689 in 1956 to 697 in 1957. I feel confident, however, that these are only temporary fluctuations. Despite them, the general picture continues to be one of steady progress, reducing the occurrence of killing diseases and preventing mortality from them. Improved sanitation, better housing and a higher standard of living must be given much of the credit for this. Nevertheless, the improved medical treatment which is now more readily and less expensively available to a greatly increased proportion of our people has played an essential part in bringing about these improvements.
There are, however, some headings under which, unfortunately, we cannot show any improvement as yet—for example, the continuing increase in the number of deaths due to cancer. As a preface to what I am about to say in this connection I must stress that although the total cancer death rate continues to increase slowly, many major forms of cancer, such as the gastro-intestinal groups, have not increased. In 1947, 4,045 persons died from cancer in its various forms. In 1957 the number had risen to 4,817. Thus in the last decade, the death rate from this disease has increased by 23 per cent. and in 1957 it accounted for 14 per cent. of all deaths, compared with 9 per cent. in 1947. In assessing the significance of these figures certain qualifications must be borne in mind. First of all, facilities for diagnosis of diseases have improved, so that the certification of fatal diseases is now more accurate than was possible in earlier years. Secondly, the percentage of deaths registered which have not been certified by medical practitioners is now much less than in former years. In 1947, 12.5 per cent. of all deaths were uncertified; whereas in 1956 this applied to only 7.7 per cent. Thus the increase in the proportion of deaths medically certified nowadays is probably uncovering a number of deaths  from cancer which would not have been so designated in earlier years. Finally, with the marked mitigation of mortality resulting from other causes of death, more people are now living to the ages at which cancer is most prevalent.
While I am on this subject I would like to refer to the remarkable increase apparent in deaths from lung cancer within the past few decades. Much publicity has been given to this topic in recent years and to the relationship which seems to have been established statistically between this form of cancer and tobacco smoking. Arising out of this, my Department has issued a statement informing the public of the risks involved in smoking, particularly heavy cigarette smoking. The statistics for 1957 strengthen the assumptions on which that warning was based.
Last year, 465 men and 157 women died from cancer of the respiratory system, mainly lung cancer—a total of 622, which was nearly two-thirds the total deaths from either pneumonia or bronchitis, and a figure which, for the first time, exceeded that for deaths from respiratory tuberculosis, which was 584. The number of deaths from lung cancer among men is particularly significant and is twice the total deaths due to this form of cancer in as recent a year as 1950. These figures are high enough in all conscience but the really significant factor is that deaths from lung cancer, especially among men, are increasing at a remarkable rate. These figures point a moral which requires no further exposition from me. They speak very eloquently to those who are prepared to hear.
Before I leave this distressing topic, perhaps I may mention that in 1957 the general death rate was 11.9 per 1,000 population, compared with 11.7 in the previous year. These rates are much the same as those in England, Wales and Scotland. The slight increase in the general death rate last year compared with 1956 may be attributed largely to an increased number of deaths from influenza, bronchitis and pneumonia last year over 1956. It should be remembered, however, that the 1956 death rate was the lowest on  record for this country. There is some further comfort in the fact that the 1957 rate, though slightly above that for the previous year, is the third lowest on record.
The number of marriages last year (14,423) showed a decrease on previous years and the marriage rate, I regret to say—5 per 1,000 population—was the lowest in any single year for some time past. The number of births, however, on the other hand, remained fairly high, giving a rate much higher than those in England, Wales and Scotland.
I have already mentioned that 2,026 infants under one year old died last year. This works out at 33 per 1,000 live births, which, while it is the lowest on record for this country, is higher than the rates in England, Wales and Scotland. It is nevertheless lower than the infant mortality rate in West Germany, Austria, Belgium, Spain and Italy.
Whatever the cause, deaths from influenza totalled 687, as compared with 401 in 1956. Deaths from this disease, which is an epidemic one, vary from year to year. Their number last year may have been affected by the Asian 'flu, which though, at the same time, disturbing and costly to the community, was of a comparatively mild nature and had not, we think, a very serious impact on the total national death rate.
There were six deaths from diphtheria last year, compared with 15 in 1956. All six were in Dublin City, where the disease is, regrettably, still fairly common. Regrettable also is the fact that some of the deaths might not have happened, if only parents and guardians had availed of the existing free service and had had their children immunised against this dangerous and highly infectious disease.
Another infection which is causing grave concern is poliomyelitis, which appears to follow no set pattern as to incidence or mortality. Last year there were 147 cases, with 13 deaths. In the year before, there were 499 cases—the highest on record—and 20 deaths. Last year, we had available for the first time, but on a limited scale, a vaccine which provides a measure of protection against the  disease. Vaccination with it was offered by local health authorities, free of charge, for children over one and under five years of age, and nearly 38,000 such children were vaccinated. This year, as has already been announced, health authorities have been authorised to provide free anti-polio vaccination for children over six months and under ten years of age in the lower income group. Expectant mothers in that income group will also be given the necessary injections free of charge. As the vaccine has now become more freely available in this country, other persons will be in a position to make their own arrangements with private medical practitioners for vaccination, if they so wish.
Last year, on the Estimate, I drew attention to the difficult position which had developed in relation to the hospital building programme. Due to the difficulty of meeting commitments in respect of current contracts, aggravated by the fact that the resources of the fund had already been exhausted by 31st March, 1957, I had no choice but to defer, as a temporary measure, the undertaking of new building works unless (i) they were absolutely essential to maintain existing services, and (ii) the cost of them was comparatively small. Indeed it was only by this drastic curtailment of new building activity that we were, in fact, able to meet our liabilities during 1957-58.
Sweepstake income, I am glad to say, has continued at a satisfactory level; but I must emphasise that about half this income is devoted nowadays to meeting priority charges. By far the greatest is in respect of the deficits of voluntary hospitals, but priority provision has also to be made for grants to the Medical Research Council, the Hospitals Commission and certain other bodies, and for grants for minor, but essential, works of repair and replacement in the voluntary hospitals.
A large part of the remaining sweepstake income is naturally required to meet commitments in respect of works already in progress and on completed works for which the final accounts have not yet been cleared. This position  will last for at least another year. Notwithstanding this—hope springs eternal—many new building projects continue to be proposed. In regard to them, I must stress that their cost would far exceed the resources which are likely to accrue to us during the next few years. It is inevitable, therefore, that most of them will have to be deferred. The resources of the Hospitals Trust Fund were exhausted by the beginning of the last financial year. Not only must those resources be replenished as soon as possible, but an adequate reserve must be built up to give a reasonable measure of assurance that commitments imposed upon the fund can be met. Therefore, in framing future building programmes, prudence demands that for some years to come a margin between expected income and expenditure should be maintained as an insurance against the possibility of adverse developments. Otherwise projects may be begun, which for lack of funds may never be completed.
The present picture regarding the need for tuberculosis accommodation is encouraging. At its peak as recently as 1953, the demand for respiratory tuberculosis cases stood at almost 6,000 beds. At the end of February this year the number of beds needed was 3,850, representing a decrease of over one-third in four years. The reason for this is that the number of new cases of the disease has fallen and that the average length of stay for sanatorium patients has shortened. Arising out of this favourable and gratifying development it became possible during the past year to divert an additional number of tuberculosis hospitals to other purposes. The largest of these were Crooksling and Ballyowen Sanatoria, County Dublin, from which patients have been moved to the new Regional Sanatorium at Blanchardstown, County Dublin. In future these premises will be used for the reception of suitable types of patients now accommodated in overcrowded conditions in Grangegorman and Portrance Mental Hospitals. Smaller tuberculosis hospitals at Rathdrum, County Wicklow, at Lota Park and Skibbereen in County Cork, and at Tullamore, were also diverted from the tuberculosis service. In addition it is  now possible to release from the service some further buildings, including Ardkeen Chest Hospital, Waterford, the Tuberculosis Institution, Lisdarn, County Cavan, and the Tuberculosis Hospital at Monaghan. Agreement has been reached with the Cavan County Council for the conversion of the Lisdarn Institution into a general medical and maternity county hospital; and with the Monaghan County Council for the transfer of the Monaghan hospital to the local mental hospital authority, so that it may be adapted to serve as an admission unit and infirmary for the Monaghan Mental Hospital, which serves the counties of Monaghan and Cavan. Negotiations are proceeding with the local authority concerned to utilise Ardkeen to provide a badly needed county hospital for Waterford City and County.
There are some 20,000 patients in mental hospitals here. They constitute by far the largest individual group of hospital patients, and unfortunately many of the hospitals of which they are inmates are sadly overcrowded. Overcrowding is not conducive to the attainment of the high standard of treatment which our mental hospital staffs can render to those in their charge; nor in such conditions is it possible to secure the degree of reasonable spaciousness and recreation facilities which are especially necessary in institutions inhabited by longstay patients. Apart from these considerations an inflated mental hospital population throws an unnecessarily heavy financial burden on the community. It is essential, therefore, to use every effort to make certain that those now in mental hospitals whose needs could adequately be met otherwise are not retained as patients, perhaps to the detriment of others who stand in greater need of skilled mental treatment. As regards overcrowding, I have already mentioned the relief which will be given in the Dublin area by the diversion of over 500 beds from the tuberculosis service, consequent on the closing of Crooksling and Ballyowen sanatoria, as such, and in the Monaghan area by the return of the present tuberculosis hospital to the Monaghan mental hospital authority. In Cork, about 180 elderly patients  have been discharged from Cork district mental hospital and are now accommodated at the former sanatorium at Heatherside.
In other directions, it has been found possible to secure improvements in dietaries; in the serving of meals; in the lay-out of dining halls and the decentralising of dining arrangements; in the decoration of wards; in lighting arrangements; and in the gradual replacement of out-moded and broken furniture and table-ware. Provision has also been made to relax as far as possible restrictions on patients' movements both inside and outside the hospital, and to encourage the preservation of individuality among them in their dress and occupation.
About 2,300 beds are now available in mental defective institutions but this still falls short of the total demand for such beds. Within the narrow limits of our resources, I am considering what further relief can be afforded in regard to this problem.
I do not propose to discuss in any detail the other services provided by local health authorities. No doubt some of them will be touched upon during the debate, but it may help if I clarify a few points in relation to them.
Firstly, in regard to the dispensary service, which is available free of charge to persons in the lower income group—that is, to persons who are accepted by the local health authority as being unable by their own industry or other lawful means to provide medical services for themselves or their dependents.
The total number of such persons, including dependents, who are now entitled to free medical services is roughly 830,000, which is about 28 per cent. of the population. In deciding on applications for medical cards, local health authorities must exercise their judgment and discretion on each individual case, with due regard to the financial circumstances of the applicants. No hard and fast rule has been laid down to determine eligibility, but I should like to make clear, once again, that the Minister for Health has no function in individual cases. He must  rely on the good sense of each local authority to act in accordance with the law and to act justly, charitably and responsibly as between the applicant and the community. It is understandable that complaints should be made about some people being granted medical cards while others are rejected but, in the nature of the dispensary service, this type of complaint is bound to arise. Each case has to be investigated separately. Despite a similarity of appearance the actual circumstances of any two applicants are seldom the same, and it is hard to satisfy everybody.
In addition to the medical service provided by maternity hospitals in certain cities and large towns, there are now about 1,000 medical practitioners providing maternity service throughout the country, under agreements entered into by them with health authorities. It is of great importance, if the maternity service is to be of maximum value to mothers and infants, that expectant mothers should avail themselves of it intelligently which, in fact, means in time. Those who can influence them should urge them to visit their doctor early in the pregnancy and have the benefit of his advice and supervision throughout the whole of the period. Much of the anxiety, difficulty and subsequent ill-health associated with child-birth would be avoided if expectant mothers would do this and, of course, act on the advice which will be given to them.
The hospital and specialist services in general seem to be giving reasonable satisfaction, though there are complaints here and there. As there is at present on the Order Paper a motion which alleges grave dissatisfaction with the provisions of the Health Act, I assume that those responsible for it will let me know what failures in administration they wish to criticise and blame me for.
Mr. Kyne Mr. Kyne
Mr. Kyne: Not the Minister but the services.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: One other branch of the local services should be referred to. Within the past ten years or so there has been an increasing demand  for improved and extended dental services. Unfortunately, the demand has coincided with an increasing need for economy in State and local authority expenditure. In these circumstances, it has been necessary to urge health authorities to concentrate on the children, because it is they who will benefit most from dental care. As matters stand now, free dental services for other age groups cannot be developed as satisfactorily as I would wish; for the cost of a really comprehensive dental service would be very high indeed. It must be deferred, therefore, until better times.
The terms offered by the Voluntary Health Insurance Board which recently offered its first schemes to the public have proved to be attractive upon which my predecessor in office may congratulate himself. Indeed, in the short time which has elapsed since they were launched, applications on behalf of about 45,000 persons to become members have been received. The bulk of these have been accepted already. This response has shown how great is the room for such an insurance scheme in this country, particularly among those who are not eligible for hospital services under the Health Acts. The State has provided a loan to help the Voluntary Health Insurance Board to launch and establish itself in business and supports it further by allowing persons who join its scheme to deduct from assessable income, should they be subject to income-tax, the premiums paid to the board. Accordingly, in the case of persons liable to the full rate of tax, there is a resultant reduction of about one-third in the net cost of premiums.
Looking at the picture as a whole, I think that most people will concede that, having regard to our national income and resources, we have reached the point where for the time being the scope of the health services must be accepted as stabilised. Thanks to the health legislation enacted between 1945 and 1953, those in straitened circumstances are as fully covered as the means of the community permit; and while those who can make some contribution towards medical costs are expected to do so, they also are assisted  substantially in meeting those heavy medical expenses which would be beyond their means. As for the remainder of our population, the scheme of voluntary health insurance is attracting, as I have said, a gratifyingly large number of participants. Thus, between the subsidised health services and the voluntary health insurance scheme, we have made reasonably full provision to help the various sections of our people to withstand and overcome the disabilities and discomforts arising from grave illness or long-continued ill-health.
My view is that our major task now is to see that the services now existing are efficient, equitable, and economical. There can be no question—at least, not in the near future—of further large-scale developments in them. We have not got the money for such developments, and until such time as the productive labour of our people provides additional funds on a substantial scale, we must be content to use our limited resources as judiciously and as effectively as possible. Accordingly, one of the prime responsibilities henceforward of the officers of the Department of Health will be to scrutinise very closely the actual workings of the health services, and by positive action to weed out inefficiency, slackness or neglect where these exist, whether in procedures or personnel, and by so doing to bring the services in general to the highest possible pitch of efficiency.
Mr. T.F. O'Higgins Mr. T.F. O'Higgins
Mr. T.F. O'Higgins: Would it be convenient if the motion on the Order Paper were debated now?
Mr. Kyne Mr. Kyne
Mr. Kyne: On account of Deputy O'Higgins' position as ex-Minister for Health, I did not wish to take precedence over him.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: Deputy Kyne might like to speak now, and then Deputy O'Higgins might be in a position either to substantiate what he says or give him some assistance.
An Ceann Comhairle Patrick (Clare) Hogan
An Ceann Comhairle: If Deputy Kyne wishes to speak to his motion now, I shall call on Deputy O'Higgins afterwards.
Mr. Kyne Mr. Kyne
 Mr. Kyne: All of us will agree that the health of the community is the grave concern of the people of any country. We all know the cliché, “Health is better than riches.” It is of the utmost importance that the health of the people should be safeguarded. I should like to strike a note somewhat different from that introduced by the Minister. He claimed that the cost of health services has reached its maximum and said that he and his Department would see to it that no further unnecessary expense would be permitted. We all agree that unnecessary expense in anything should not be incurred, but I regret the emphasis being put on the amount of money spent. He should take pride in the work carried out by the Department under various Ministers during the past decade; he should take pride in the convincing figures which he has produced. He should have said: “Well, what about the cost, the fact is that the work has been done.” If he had taken that line, I would have agreed with him. The Labour Party as a whole are prepared to take that line in the motion we have put down.
Our motion says:—
That, in view of the grave dissatisfaction which exists in respect of the provisions and administration of the Health Act and the serious hardships which are being inflicted upon many needy persons, the Dáil is of opinion that the Government should introduce proposals for the immediate amendment of the Health Act to remedy the widespread and justifiable complaints.
That is different from the question as to whether the Department has carried out its work: it is a question as to whether the health scheme as such has been administered properly or whether hardships have been caused under it.
I submit there are grave hardships under the health scheme and that it was wrong for the Minister to say that a person speaking to that motion was finding fault with him. I understand the “him” in this case to refer to whoever is acting in the capacity of Minister for Health. Nevertheless, it  is not the Minister with whom we are in disagreement; it is with the fact that a certain Act was brought in as an experiment and that since then it has not been amended at all. There is very little law in this country which has been found foolproof or flawproof from the first time it was brought into operation and there are very few Acts of Parliament which have not had to be amended.
The Labour Party suggest that it is time now, having examined the working of this scheme, to bring in an amendment of the Health Act. Here are some of the grievances. We all know that the lower income group comprises the people entitled to medical cards. Irrespective of what the Minister says or what the former Minister said, that there was no means test, that the local authority had a right to decide as to whether a person was entitled to a medical card, based mainly on the question of whether he could by his own lawful earnings provide medical services for himself or not, the local authority so wonderfully described in this Health Act and so stressed by the Minister, boils down not to be the public representatives of the people, not to be any group of individuals at all but to be one, and one only, the county manager.
If that county manager, acting on whatever advice he has got from his officials, or whether or not he acts on their advice, decides that a man and his family are not entitled to a medical card, there is no right of appeal either to a court or a Minister. I suggest that there are serious cases where wrong decisions have been made and where there is no redress. I appeal to the Minister seriously to consider the right of appeal to him or his Department, or to permit an appeal to some body set up by him. Nobody suggests that county managers desire to deprive the people of health cards but all of us must realise that county managers are hard working officials who have not the time, not possibly the qualifications, to examine individual cases and in many instances they have to depend on the views of minor officials.
 I suggest that most of the qualifications for a medical card are based on the reports of relieving officers throughout the counties. These relieving officers are, in my opinion, minor officials. I am quite satisfied that, in many cases, these officials have given wrong decisions. I am satisfied that if appeals against these wrong decisions could be made and if there was some place where actual facts and figures could be produced, the decisions would be reversed. Unfortunately, there are no such facilities. Those of us who are interested enough to examine the position know that there is a salary basis fixed by regulation made either by Deputy O'Higgins, when he was Minister for Health, or by Deputy Dr. Ryan, when he was Minister for Health. I want to tell this House, and the public through this House, what the basis of this means test is. In my constituency, it is that you are entitled to a medical card if you are a single man, if you live in a rural area and if your income is £4 10s. or less. If you have a wife you are entitled to add 10/-, and for each child under a certain age, 7/6. In an urban area you are entitled to a further 10/-, and in a city area a further 10/- I challenge anyone from the Department of Health to say that such a circular was not issued to all county managers.
Mr. T.F. O'Higgins Mr. T.F. O'Higgins
Mr. T.F. O'Higgins: It was subsequently withdrawn.
Mr. Kyne Mr. Kyne
Mr. Kyne: Nevertheless it is still being acted on by the County Managers' Association. Let us be very clear and very fair. In my opinion, the regulation was quite a good one at that time. Perhaps somebody better qualified than I can assess what means a person should have to render him liable to pay for a general medical practitioner's service. Perhaps the person who worked that out worked it out in greater detail than I did. The national wage agreement which provides for 10/- a week increase, which is now implemented throughout practically the whole country and which was compensation for the increased cost of living, will, in the coming year, deprive  thousands of people from getting the medical cards which, prior to this year, they were entitled to get. That fact alone is ample reason for the Labour Party's belief that an amendment is required to the Health Act and certainly that an amendment is required to that regulation.
The Minister gives us a figure of 28 per cent.—I had worked out a figure of 25 per cent.—for the percentage of people receiving medical cards. A little over 800,000 people received medical cards. With that I would have imagined went all health services. It is quite true that the dental service is included in the service given under medical cards. I heard Deputy O'Higgins, when Minister, admit two years ago that dental services, as from that date for the lower income adult group, would be of a minus quantity, and that the emphasis would be on children and young people. The implication was that if you had reached the age of 60, 65 or 70 and if they pulled out your bad teeth, there was no point in providing more for you because the country could not afford it, in other words that you could wait for relief until you died off. That is a shocking attitude of mind. I think the poorer groups are as much entitled to have their teeth extracted and to be supplied with dentures as people who have the good fortune to be born in better circumstances and who are able to pay for their dentures. I think it a deplorable attitude that because you belong to the lower income group, and cannot afford to buy teeth, you are to be deprived of them.
Another fact of which some of the public do not seem to be aware is that very often the lower income group are charged not alone with the cost of providing the dentures but that sometimes 50 per cent. is added. I am aware of the contract price for dentures in a certain area and also well aware that the poorest person in that area has often been charged more than the contract price. It seems to me that there is something seriously wrong with people who take the attitude that the Health Act is showering blessings on the lower and middle income groups. I am not decrying the Health Act. I  voted for it at its inception and I still stand unconvinced that it is a bad Act but I am also convinced that it does need amending. I suggest to the Minister, who was a keen exponent of the Act, that after the years of trial, we can learn something from the working of the Act and that it would be worth his while to examine and amend it.
While some 800,000 people are covered by medical cards the total population in 1956 was 2.8 million people. I would suggest that the higher income group number between 100,000 and 150,000 and that the middle income group comprises 60 per cent. of the total population. What does the Health Act offer them? They pay for all their general practitioner services. If they go into a hospital they can be charged up to 10/- per day or £3 10s. per week. That is supposed to be the maximum charge, but as in many other cases the maximum becomes a minimum. I know very few cases in which the charge is less than 10/- per day. If there is an excellent county manager and if there is an excellent representative, sometimes he may be able to make a case that appeals to the authorities; or perhaps the circumstances are so deplorable that the person concerned should not be in the middle income group but should have a medical card and then the county manager may accept a lesser rate. The fact is, however, that grave dissatisfaction exists among 60 per cent. of the people in regard to the 10/- per day maximum charge for that group.
In reply to a parliamentary question some months ago the Minister gave me the approximate cost of abolishing the 10/- per day charge. This he put at £200,000 stressing that it was an approximation. I accept that; I understand the Minister's difficulty and the difficulty of his officials in trying to give even an approximation because of the various categories involved and because of such cases as that of a farmer who would have a valuation qualification and also an employment qualification, through working part of the year. Accepting the Minister's figure, or even making it £250,000, I would suggest it would be well worth while for the Minister to consider  whether that charge should be borne by the individual at all or whether it should properly be chargeable to the health services and paid by all the people in the form of taxation. There is grave dissatisfaction and extreme hardship in many cases where people have had prolonged illness, particularly where it results in the death of the bread-winner when people attempt to pay the charges forced on them by many public health authorities and boards of public assistance such as operate in the constituency in which I live.
In that middle income group dental services have not yet been introduced. The Minister has put it just like that and I am quite sure he is aware of the fact that at present in most small towns the cost of extractions varies from 7/6 to 10/- per tooth and the cost of a set of dentures varies between £20 and £40. I suggest that a man in the middle income group, such as a man earning up to £600, with a wife and family of three or four children, is not in a position to provide either himself or his wife or members of his family with dentures or even pay for extractions even though he frequently has to do so.
The Minister might note the fact that children very often need extractions and of course are entitled to free extractions under the Schools Act as they are entitled to free hospital attention, provided some doctor certifies it. In many cases the school doctor attends them only once a year or even less than once a year, but toothache cannot wait until the school doctor comes on his annual visit like Santa Claus. Children may also suffer from appendicitis or tonsillitis or other complaints of that kind. The middle income man has not only responsibility for dental care and extractions but also, in most cases, he has to bear the cost of maintaining a child in hospital during operations because the Schools Act is not properly administered, even though the child is normally qualified under that Act.
In one area under the Waterford Board of Public Assistance the cost of maintaining a child in hospital is  equally as great as the cost of maintaining an adult. I think that is unusual. Under the old scheme the cost for the child was usually half that for the adult. I have queried the county manager and the local officials in the case of the Waterford Board of Public Assistance of which I am a member and they tell me they are investigating the case. This arises years after the coming into operation of the Health Act; a child of five or ten years is charged at the adult rate. I do not know if that is general. Deputy Corish says it is, apparently, general in Wexford and I must assume that each county manager, or perhaps the County Managers' Association, has decreed that the loss on adults shall be made up on juveniles. If that is so, it is wrong and the Minister should make regulations to deal with the matter.
I now want to make a suggestion which is not my own to the Minister. I am a member of the health consultative group in the Waterford area. It met last Monday week and was attended by a number of prominent and excellent doctors in that area, some in public service, some in private practice. Their unanimous suggestion was that the attention of the Minister should be drawn to the advisability of issuing a special card to the middle income group to distinguish them from the upper ceiling group which is not entitled to benefits of any sort. I am simply stating this because I promised to do so.
Their main point was that when a patient came in, not holding a medical card, he was accepted as being in the middle income group but there were many emergency cases of people who had not bothered to apply for medical cards although entitled to them. They had to be treated immediately, whether middle or lower income group, and it often took longer than the period of treatment to decide in what group they were. The result was that the patient would have left the hospital by the time a decision was reached and, if the decision was that the patient was in the middle group, the responsibility for collecting the debt was left on the doctor. The doctor had no  means, beyond the courts, of doing this and very often doctors were not inclined to take that course. In the normal practice if that patient came in with a card indicating which group he was in the appropriate fees could be collected through the local authority.
I do not know whether or not that is worth the Minister's consideration. I think there is something to it. I am not particularly briefed to speak for the doctors in this case. I am sure they have much more able people and better sources of contact with the Department than an individual Labour Party Deputy speaking in the Dáil but because I undertook to do it I am carrying out that obligation. I would ask the Minister to consider it on the merits.
I should like to congratulate the Minister in regard to many of the things upon which he spoke but I am afraid that I shall have to disagree with him on other things. He spoke about mental hospital patients and there are just a few things I should like to say in that connection. My impression was that the Minister stressed that accommodation was overtaxed to some extent because of the fact that some of the patients in the mental hospitals were chronic cases of feeblemindedness or were patients who were just too old and were not, properly speaking, mental hospital cases at all and could be taken care of by some other means.
I think I agree completely with the Minister on that. I know that in our mental hospital in Waterford, where we have some 640 patients, some 100 would be mentally defective because of old age. They are holding up beds which are urgently needed for other cases. I would suggest a reversal of the policy which the Department for Health started about ten years ago by insisting that old people in county homes who showed signs of mental derangement should be transferred to mental hospitals. I would suggest that with the new grants for our county homes—many of our county homes have become modernised and are excellent places—a reversal of the policy should take place and that these people should be drafted back to the county  homes. That is in the interest of these people, too. They could then be visited by their relatives and given added comforts by way of luxury foods, say. In the county homes of which I speak, excellent food is given to all people.
I would suggest that there is a grave need for a place for mentally defective children of a certain age. We all know that matter is engaging the attention of the Department. We all know that, with the tuberculosis drive and other factors, it was not possible to do everything at once. There is a grave urgency and need for even temporary accommodation for mentally defective children. I am not speaking of backward children. I am speaking of children who are practically imbeciles but of tender age.
I know from my own personal experience that there is the greatest difficulty in finding a place to cater for these children in Ireland. That is not due to the default of anyone. It is due to the fact that we had not time to build up our institutions as the money is not there. These services are afforded by charitable Sisters and Brothers who devote their lives to that work. They are limited in their accommodation. If any vacancies or sections of beds could be allocated temporarily to these types of children in a section of our mental hospitals, it would be a stop-gap until such time as the building programme catches up with the need for hospitalisation for the type of children I mention. The Minister should seriously consider that.
I should like to say just one or two words on this Estimate in appreciation of the terrific work carried out by voluntary polio committees in connection with the rehabilitation of polio cases. I should like also to pay a personal tribute to the Minister for the great assistance he has given me within recent weeks in dealing with a particular polio case. His attitude to the case which I drew to his attention and his decision on it have given me a very high opinion of the interest he has in that type of suffering child who needs the assistance of the State to rehabilitate him. I compliment the Minister on the attitude he adopted in  this case and I hope that his general attitude will be the same in respect of the many other cases which will come to his attention.
I should like also to pay a tribute to the great value of the work carried out by voluntary committees in connection with polio rehabilitation centres in this country. I would make an appeal to Deputies on all sides of the House to co-operate to the utmost in helping to establish centres in the various areas to carry out the very laudable work of helping the most helpless type of people in this country.
There are a few personal matters— personal in the sense that they deal with my own constituency—upon which I should like to ask the Minister's views. I noticed that at the close of his speech he mentioned Ardkeen Sanatorium in County Waterford as being now available for general hospitalisation. I take it that the Minister's statement was that it would be available in the very near future and that he had hopes his Department would be able to make it available. The fact is that at the moment Ardkeen is practically full. I understand that there are plans to divert from it some of the people from outside counties to their own centres and that we shall have that much accommodation available for hospitalisation. I treat that as a practical solution to our difficulties there. I would suggest that as well as that it would be desirable, in connection with County Waterford in general, that the Minister and his Department should try and agree with the county manager, the board of assistance and the medical people in Waterford and have a joint conference to plan for, say, a 20-year programme.
What is going to be the future of hospitalisation in Waterford? Is St. Patrick's Hospital—the county hospital in the city—going to continue or will it close down? Is the orthopædic unit in St. Patrick's Hospital to continue or close down? If it is to continue is it desirable that the orthopædic unit should remain in St. Patrick's or that the general surgical unit under Surgeon O'Reilly should be stationed perhaps two miles away? I am told  that very often it is absolutely necessary to have both Dr. O'Driscoll and Surgeon O'Reilly—the two leading men —operate jointly. The fact that they do so will save hundreds of pounds in regard to subsequent possible specialist expenses due to doctors with no particular orthopædic qualifications carrying out operations.
Is the tuberculosis hospital which was in Lismore to remain closed indefinitely or is it to be opened as a district hospital? I would suggest that there are 101 different problems arising in Waterford that should be decided upon one way or the other so that the local authorities would be able to say they are implementing part of the programme per year but that they are sure that each part of the programme will be part of a decided whole which will be in operation 30 years hence when many of us will not be here at all. At least we will know that the money we are spending is being directed into the right channel. I suggest to the Minister that it might be well worth his while to send an official of his Department to meet the county manager, the board of assistance and the various officials to discuss that. I have already asked the county manager to hold such a meeting and I suggest to the Minister that it might be desirable to have one of his officials in attendance.
There is just one other county problem on which I should like to take advantage of this Estimate to speak, that is, the question of a third dispensary in Waterford. That problem has been there for quite a long time. I think Deputies Kenneally, the Minister for Posts and Telegraphs, Deputy Ormonde, if he was available, and Deputy Lynch, would agree with me when I say that there is urgent need for this appointment. As far as we—I mean the lay people—who are connected with health matters there are concerned, all that is necessary from our side has been done. We are awaiting permission to have a dispensary built and to have the doctor appointed. I think the question of medical cards has been settled and the boundaries fixed. I would appeal to the Minister to ask for a decision within the  foreseeable future, because the health of the people of Waterford, I am informed by those who live in the city, is being affected by the fact that a third dispensary doctor is not available there at the moment.
There is just one other matter to which I wish to make reference. It is not as parochial as the last two, although it did arise from a decision of the Waterford Board of Assistance, that is in relation to the contribution of £25 per year which the Waterford Board of Public Assistance made available to the Society for the Prevention of Cruelty to Children for a number of years. We received a letter which drew our attention to the fact that that society had now ceased its connection with the British counterpart and were more dependent than ever, in fact, totally dependent, on Irish subscriptions, and they asked for an increased amount.
In view of the work which this society do, that is, in restoring where-ever they can, husbands to wives they have abandoned, and in seeing that fathers provide for their children, the Waterford Board of Assistance, rightly, in my opinion, took the attitude that an increased contribution should be given. We felt, first of all, that it was right that we should have an Irish society doing this work and, secondly, because they were deprived of contributions from Britain, those of us who were patriotic enough or nationally-minded enough felt that we ought to meet the situation. We proposed that we would increase our £25 subscription to £80, but we regret that the Minister has decided that that is not permissible and that we will have to confine ourselves to the £25 we had always given. I understand the Minister's Department would have to pay half that sum and I expect that is the reason for the decision.
I appreciate the need for economy, but I would ask the Minister to co-operate with the board of assistance. If the activities of that society's inspectors are curtailed, the loss sustained to Waterford by way of payment of additional money for children not maintained by mothers or fathers  would be greater than the loss sustained by the combined contribution of the Central Fund and the local authority.
I would agree with the Minister that it is a very happy situation that our death-rate from tuberculosis has declined so considerably. That is a great tribute to Deputy Dr. Browne, who initiated the campaign for tuberculosis hospitalisation and who, in fact, it can be claimed, made us tuberculosis-conscious in this country. I remember, about six or eight months prior to 1948, when I was an ordinary county councillor and a member of the board of assistance, I endeavoured in my small way to make people tuberculosis-conscious and I was rebuffed by the people who were then dealing with tuberculosis and who told me in that year, 1947, that the total number of deaths in County Waterford from tuberculosis was something like 20. Of course, that is all that were registered. I knew, from being an insurance agent, that it was a very undesirable thing to register if you wanted to claim benefit. Most of the dispensary doctors were human beings and they were quite agreeable to put down some other cause of death, so that the private insurance company would not raise a quibble and deprive the people of benefit. However, I pay all tribute to Deputy Dr. Browne for the wonderful work he did in initiating the campaign and I think the decline in the deathrate is the greatest tribute that could be paid to him.
It is wonderful that the Minister is able to tell us of a reduction in the infant mortality rate. In Waterford, we are very proud of the fact that we have a most excellent hospital for maternity alone. The Medical Missionaries of Mary took over, at the request of our bishop, the hospital in Airmount. We have an excellent gynæcologist and our results in Waterford agree with what the Minister has said, that infant mortality in any year is coming to a very low figure. We are very grateful for that. As I have said, the slight increase which the Health Estimate shows this year, something about £38,000 to £40,000, is well worth while because of the very valuable  work that has been carried out by the Minister and his Department and by the various doctors and voluntary associations connected with him during the past 12 months.
Mr. T.F. O'Higgins Mr. T.F. O'Higgins
Mr. T.F. O'Higgins: I should like, first of all, to make a few remarks about the subject matter of the motion on the Order Paper, in the name of Deputy Kyne and other Deputies, and to which Deputy Kyne has made reference. The motion relates to the existence of widespread dissatisfaction with the administration of the Health Act. I must say that ever since the Health Act went into operation, in part, in August, 1954, and practically in entirely in April, 1956, I have always found a general body of criticism with regard to its administration. A great deal of the criticism has not been well-founded, but the fact is that the Health Act has got, if I may use the phrase, a bad Press.
A great number of critics blame the Act itself for deficiencies in services and indeed for not achieving what the Act was never intended to achieve, but I do agree with Deputy Kyne that the most prolific source of criticism is the administration of Section 14 of the Act which has reference to the general medical services. I might remind Deputies who were here at the time, that when the Health Act was a Bill being discussed and debated in the House, it was pointed out by my late father in relation to Section 14 that the effect of endeavouring to put on the register dispensary patients throughout the country would result in nothing but confusion from one end of the country to the other. It involved, as it must involve, an up-to-date examination as to means, a reassessment of the family's position, and, of course, inevitably a number of people who were traditionally regarded as dispensary patients by the dispensary doctor suddenly found their rights to general medical services at an end. That is largely what has happened.
There has been necessarily under the Act and under the regulations consideration of each individual family's  right to be regarded as a family unable—and this is what the Act says —by their own industry or other lawful means to provide these essential services for themselves. That section in the Act is not new. It is a re-enactment of what was there before, but the trouble is that, if officials are to interpret these words literally, only the destitute are entitled to free medical services. I know from my experience in office and my experience in my constituency that officials do their best, within the wording of the section, to try to give a right to free medical services to persons who, perhaps, are not definitely entitled under a strict interpretation of the Act to such services. That is by the way.
The fact is that, no matter how often one discusses here or elsewhere the administration of Section 14, it will still be criticised. Indeed, if 50 per cent. of the entire population were entitled to free medical services under Section 14, there would still be criticism. Possibly that suggests that there are still many people who feel that all services should be free. That is a view to which I do not subscribe, but undoubtedly criticism will continue.
I might say to Deputy Kyne that, when I was Minister, I had determined to provide a right of appeal in relation to decisions with regard to medical cards. I came to that decision against the concentrated advice of the officers of my Department. I did not see any other way in which the growing body of criticism could be dealt with. It is now a matter for the Minister to consider whether at this stage a right of appeal to himself or some official of his Department would be the appropriate means of dealing with the criticism Deputy Kyne has expressed.
Deputy Kyne mentioned, too, that local authorities and health authorities operate a means test in determining eligibility. I do not know whether or not they do, but, in my opinion, they should not. It is true that a circular containing a suggested scale was issued by my predecessor, the present Minister for Finance, at an early stage. I found, on examining that circular, that, in fact, it could not be observed  and might cause hardship. I accordingly directed its withdrawal and another circular was issued to each health authority, informing them that they should not operate any particular scale of means but should decide each case on its merits. I am quite certain that represents the present position.
Mr. Corish Mr. Corish
Mr. Corish: They do examine each case on means.
Mr. T.F. O'Higgins Mr. T.F. O'Higgins
Mr. T.F. O'Higgins: They decide eligibility on means, but they should not decide that a person is not entitled to a medical card because his means are not within a particular range. They can decide that everybody below £5 per week is entitled, but they are not entitled to say, by operating a scale, that merely because a person is over a particular figure, he is not entitled to a medical card.
Deputy Kyne also referred to dental services. It is quite true that, when I was Minister, I found the position impossible in relation to the provision of dental services. We had not the resources in either money or personnel; we had not the equipment; we had not the means to provide the services envisaged in the Act. At that time, the dental service for the adult poor was extremely bad. In addition, the dental service for children was extremely ineffective. A choice had to be made as between adults and children. We could continue to provide both services and provide them badly, or we could provide one service and provide it well.
I decided the proper thing to do was to concentrate on building up school dental services. I explained my reasons for doing so at the time to the various health authorities. I visited them and explained the position on the spot. Talking now of perhaps two years ago, I was going to inquire from the Minister whether, in the period that has elapsed, it has been found possible to decide or plan for any improvement in relation to the service for the adult poor. Perhaps the Minister might deal with that when he is closing the debate.
With regard to the other dental services envisaged in the Health Act itself. I do not know whether they will ever be provided or whether it will  ever be found possible to find the money to provide them. Certainly, if my memory does not ill-serve me, I think I saw an estimate of what their cost might be and it ran into something approaching £2,000,000, on one possible reckoning. This would be more costly than the present cost of all the other individual health services. I do not know whether an expenditure of that kind could be envisaged; indeed, I do not know whether an expenditure of that kind could be justified. In my opinion, it certainly could not.
May I say a few words in relation to Deputy Kyne's speech? I agree with him there is dissatisfaction. I do not say it is completely well-founded, but there is dissatisfaction with reference to the administration of the Health Act. I am quite satisfied that it is not possible for the Minister, the Department of Health or individual health authorities to do anything about it under the present Act. With slight amendment of the Health Act, it may be possible, dealing specifically with the question of determination of eligibility for general medical services, that some redress might be given under that heading. Further than that I cannot see that very much can be done.
May I now turn to the Estimate? I do not propose to keep the House very long, but there are some matters I should like to raise. First of all, I should like to know from the Minister what progress has been made in relation to the provision of a rehabilitation service. I am aware, from an answer to a parliamentary question, that the Minister has before him at the moment the report of the National Rehabilitation Organisation which was considering in what manner such a service could be provided. I would hope that the Minister might be able to give the House some information on this matter in closing the debate.
May I just say that rehabilitation— the equipping of an injured or maimed person for some effective work—may not be strictly a health service, but it is undoubtedly a very important matter to be considered from a national point of view? If we could turn into some form of productive work the many thousands of crippled and maimed  persons who have to eke out an existence, depending on either public or private charity, we would be doing excellent work for them and for the country. Therefore, I would say to the Minister that the provision of a rehabilitation service of an effective kind throughout the country, even if it imposes expenditure, is likely to yield quite a definite return. In so far as it comes within the Health Act, it is the kind of productive expenditure that should engage his attention.
It has come to my notice in my profession—and, indeed, I surmise from some questions asked recently that it is the experience of other Deputies— that in some cases medical men on the staffs of voluntary hospitals are seeking to charge fees in respect of treatment of patients in the public wards of their hospitals. These instances arise particularly in subsequent court proceedings arising out of an accident which is the occasion for the patient's visit to hospital. I should like to express my complete condemnation of any person who seeks to impose any such charge.
In the discussions which I had some two and a half years ago with the Irish Medical Association in relation to the implementation of the specialist services under the Health Act, it was agreed that no member of the staff of the participating hospitals would charge a fee in respect of the treatment in the public wards of any patient, whether the patient was sent there directly by a health authority or was exercising a choice of hospital under Section 25 of the Act. I know the Minister's functions in this regard are nil. Possibly the only way an abuse of that kind—and I would regard it as an abuse—could be terminated is by public expression of disapproval, in the hope that any person who does seek to charge fees in cases of that kind will discontinue the practice.
I was glad to note from the Minister's statement that planning for the alternative use of sanatoria is proceeding satisfactorily. I am glad in particular to note that local difficulties in some cases appear to have disappeared.  I am certain that is as a result of the diplomacy which, I am sure, the Minister was able to exercise. May I join with Deputy Kyne in that regard in expressing the hope that some of these institutions which were used for the tuberculosis service may now be used to deal with or to house mental defectives? I know that as many of them as possible will be used by the Minister to deal with his mental hospital overcrowding problem, but to the extent that there are still only about one-third of the beds required for mental defectives, I hope the urgency of that matter will engage the Minister's attention.
The Minister referred to the position of the hospital building programme. As I understand what he said, it means, in effect, that, apart from projects or building under construction, apart from urgent repair works of one kind or another, there will be no hospital building for some time to come. The Minister advances as the reason for that the heavy call on the Trust Fund for the payment of the deficits of the hospitals, and so on. I can understand the Minister's point of view in this regard, but I would urge that there can be undue caution in this respect.
There is a very pressing case to be made for the provision of a new maternity hospital in the city. It would be a tragedy if the provision of such a hospital were to be postponed indefinitely, and I hope that the Minister does not mean by what he said that he would not encourage embarkation on a project of that kind, until there was a sufficient fund there to pay for it in full. If the Hospitals Sweepstakes come to an end, we will have completely to review everything in relation to hospital services, because the maintenance of hospitals and all the planning is now intimately associated with the continued success of the Sweeps.
I think the Minister is entitled to plan his hospital building programme on the basis that the Sweeps will continue to be a success and that, for years to come, he can continue to rely on an income into the Trust Fund of something over £2,000,000 a year. To  wait and to allow urgent projects— and there are two or three of them— to be postponed, in my opinion, would be a mistake,
I appreciate in that regard that the Minister faces considerable difficulties and that, in relation to the four major projects, no matter how well he might plan and no matter what chance he might take, he could not possibly contemplate embarking on more than two of them, certainly within the next two or three years, but I would hope that, if that is his decision, the new maternity hospital for the city, the new Coombe hospital, would be one of the two.
May I also refer to something I mentioned last year which is in some way relevant to the matters dealt with by Deputy Kyne in relation to general medical services? I had hoped that the Minister might have been able to tell the House that he had considered the suggestion to abolish the present dispensary system, certainly in relation to urban areas. I felt, as Minister, that a free choice of doctor for those entitled to the services under Section 14 should and could be provided, certainly in the large centres of population, in the Cities of Dublin, Cork, Limerick and, possibly, many of the larger towns.
It always seemed to me slightly anomalous that an expectant mother under the mother and child service was entitled to go to any participating doctor of her choice in relation to her pregnancy, but, on the other hand, if she were a person entitled to free medical services and injured her foot or had some medical condition not associated with pregnancy, she had to leave the doctor who was attending her, if he were not a dispensary doctor, and go to the dispensary doctor. In my view, once a choice of doctor has become an accepted fact in relation to the mother and child service, it becomes urgent that a choice of doctor should also be considered in relation to the general medical services for the poor.
Again, money is involved, but it is my view that it is not such a considerable sum. The Minister will be able to  correct me on this, but I think it is many years since there was a permanent dispensary appointment in Dublin City. Possibly, the same is true of Cork. I do not know. Certainly, in Dublin City, most of the dispensary doctors, particularly in the newly built-up areas, hold their posts temporarily. It would not be a great administrative change to try out in this city the experiment of enabling every person who has a medical card to go to any doctor he or she selects, provided, of course, the doctors agree. The service, undoubtedly, would cost more, but I do not think the additional cost would be outrageous. The service would probably be a more effective service.
I should like to say, in conclusion, that I am very glad to hear from the Minister that the work of the Voluntary Health Insurance Board has, so far, been attended with success. It is gratifying to know that there are over 40,000 persons already covered by health insurance, and I am particularly conscious of the assistance and help which the Minister has given in the launching of the scheme of health insurance. I express the hope that more of the general public will realise the duty they have to themselves, when they can afford it, to make due provision in relation to ill-health by taking out this form of health insurance. If they do so, they not only provide for their dependents and themselves, but, also, they ease the burden, which is a very heavy burden, on the general public in relation to the provision of health services.
Mr. J. Brennan Mr. J. Brennan
Mr. J. Brennan: It seems to be agreed by all Parties that this is the most important Estimate that comes for discussion in the House. The Minister's statement, in the main, revealed a very happy situation indeed, in so far as he was able to point to a reduced rate of mortality, particularly noticeable during the last number of years, and to the improved expectation of life. These are things which cannot be measured in actual £.s.d. The saving of one life would justify any expenditure one might imagine, however critical it might be at the time.
There was a good deal of criticism of the Health Act when the Bill was  introduced and debated in this House, and that criticism to some extent continues. So far as I remember, the main criticism at that time lay in the repeated allegations that we had not sufficient hospital accommodation for the services sought by those who would partake of the improved benefits under the Act. I think that criticism was not very well justified. We have ample hospital accommodation at the present time, so far as most hospitalisation services are concerned. We have reached a stage now where we have surplus beds in respect of a particular type of service.
I endorse what the other speakers have said, and join with them in appealing to the Minister to see that the redundancy of beds in certain directions is used for the purposes of those services for which we have not yet enough beds, mainly for the treatment of mental diseases and backward and mentally deficient children. Those two services still present a particular problem which I would say should be the main concern of the Minister for the future.
Since the new Mental Treatment Act was passed a great many voluntary patients have come forward for treatment. A mental hospital is no longer considered a place of detention. It is a place to which people go for curative treatment and, in that respect, we find in a great many counties that a great number of voluntary patients have to mingle and live with chronic cases. There is certainly nothing conducive in that to the cure that the voluntary patient expects when he goes in for treatment of what may be only a mild nervous attack. There should be facilities for segregation in the mental hospitals.
One thing which every member of the House, particularly those who are members of local authorities, will endorse is that local authorities are faced with rising costs which at the moment do not enable most of them to grapple with the situation, however apparent and urgent it may be. The main criticism of our health services at the moment lies in the impact in cost which they have had on local authority  budgets, and therein lies the most difficult anomalies with which local authority members have to deal. Those members of the House who are also members of local authorities will readily understand what I mean when I refer to the anomalies with regard to the rising cost of health services and their impact upon local authorities' budgets.
During the year we have people coming to us appealing to us to make representations on their behalf that their hospital bills be reduced; making complaints that they were overcharged for hospitalisation out of accord with their means. We are sometimes able to present to the county manager facts and details which may not earlier have been known to him, and consequently we succeed in cases of great hardship in having the accounts reduced. Then, however, when the annual estimate meeting comes along and the rate is to be struck for the coming year, everybody is crying about the increase in the rate and about the cost of the health services, particularly those who are lucky to be in good health and who have been fortunate enough not to call on the health services of the local authority during the year.
A farmer may have to face an increase of 3d. in the £ on his rates as a result of improved health services in his county and, when I say improved health facilities, one could include housing and sanitation as well as such things as actual health services. He has to face those few pence in the £ on his valuation but he more than obtains the benefit tenfold if he has to spend one week in hospital. He cannot be charged more than 10/- a day if he is one of the middle income group as most of our people are. I do not think in the main there is any great reason for grievance there at all. For that reason I think the Labour Party motion seeking an amendment is premature.
The services under the Health Act are only yet in their infancy and it is to be expected there would be a great deal of criticism and a great many anomalies arising as a result of its administration. This motion which  says: “That, in view of the grave dissatisfaction which exists in respect of the provisions and administration of the Health Act and the serious hardships which are being inflicted upon many needy persons, the Dáil is of opinion that the Government should introduce proposals for the immediate amendment of the Health Act....” is premature. There is one thing which should not be levelled at the present health services and that is that serious hardship is being inflicted on needy persons. I do not think that is a criticism which can justifiably be levelled at the health services in any county, as far as I am aware.
Wherever a proper case can be made that a person is not in a financial position to meet his hospital account I have not yet known a county manager who has not been ready to ensure that the best possible service is provided at the lowest possible cost and, in many cases, entirely free of charge altogether. I do not think anybody is being neglected, particularly needy persons, in providing the best possible services irrespective of the cost if they are not able to pay for them. If that position obtains I would regard it as falling far short of what was hoped for when the Bill was first brought into the House. I say that while amendment of the Act must inevitably come at some stage it is premature now because we are still at the teeth-cutting stage so far as the health services are concerned.
There are a number of things which will possibly level themselves out later on. There is the lack of uniformity in the administration of Section 14. Each county manager obviously makes his own interpretation of the section. The Minister told us to-day that there were some 830,000 persons in receipt of free medical cards. If you examine the position county by county, you will find that the manager in each county must have used a different yardstick in ascertaining the means of those whom he considered entitled to free medical cards. In some counties, the percentage is twice as high as in others. In County Donegal, where we have a good many people with small means, our percentage is not nearly as high as in some of what we would  consider the more wealthy midland counties. For that reason, there may perhaps be justifiable criticism, but these are things which will ultimately level themselves out and uniformity may take the place of what at the present time is a rather haphazard interpretation of Section 14.
Most of the criticism in relation to the health services comes from the middle income group, from people who believe they should not be charged the maximum rate in hospital. One person learns that somebody else whom, perhaps, he considers better off than himself has got off more lightly than he, and in that way a good deal of criticism is aroused. Public representatives are frequently asked to make representations to the Minister when the people concerned find they have no redress from the local authority or the county manager. I have refrained from making representations to the Minister except in a very few cases, and only when I thought an appeal would reverse the decision which the county manager was obliged to take.
By and large, I find that the Health Act is being fairly and squarely administered for the benefit of all, ensuring, in particular, that no needy person is left without the medical services he requires, even though he has no means whatever to pay for them. Sickness of any kind is an affliction and a great hardship. To charge people according to their means for the treatment they require and receive is merely to minimise the hardship which must necessarily and unfortunately fall on those who are afflicted with illness at one time or another during the year. There are very few families which at one time or another do not suffer from that unfortunate affliction and who do not thereby benefit under the services to which they subscribe by way of the general rate struck for health services in their county.
I would ask the Minister to consider the point I made with regard to mental hospitals. I would ask him to consider if it would be possible to find some means whereby the present system of treatment in mental hospitals could be arranged so as to provide the necessary segregation for voluntary  patients who are admitted and have to be treated and who must live with the chronics which is certainly not a desirable thing. Some counties may already have that accommodation. Some of the buildings already used as mental hospitals should be capable of adaptation so that separate apartments could be set aside for the voluntary patients. I feel that many more people would seek voluntary treatment for early mental or nervous diseases, if they had not to mix with the chronics in the mental hospitals, and, in saying so, I am not making any disparaging remarks about the unfortunate patients who have to be treated in mental hospitals.
Out of that, another problem arises. Many people from the rural areas come to some of what they consider the better mental nursing homes in Dublin. They come here quietly. They then find that the local authority will not accept any responsibility for them, as they were not first examined by the R.M.S. in their own mental institution to ascertain whether or not he considered they should be treated in an outside hospital. They try to have that amount of privacy, namely, admission to a Dublin mental home or institution. In doing so, they find they have infringed the regulations with regard to admissions and are therefore deprived, in most cases, of the contribution towards their maintenance which they would have got had they gone to the home institution. Most county managers, or many of them, try to meet the case as well as they can. Sometimes they are prepared to pay the difference in the cost of the homes here and that which is applicable to the institution in the county. However, it is a very particular type of disease which requires careful and sympathetic handling. I earnestly appeal to the Minister to initiate as far as possible, with the resources at his disposal, a scheme whereby the burden will not fall too heavily on local authorities, if they are to make the change-over which is 100 per cent. more necessary as the years go on.
The other type of problem to which I have already referred is that in regard  to mentally defective or backward children. I am sure there is no Deputy who has not at some time or another been asked to expedite the admission to a home of a mentally deficient child. I have found myself completely helpless in trying to make any progress in such cases, due to the fact that when one approaches the doctors in charge of these homes in, say, Dublin, one is informed that there is a long waiting list which will not be exhausted for years. Naturally, they are reluctant, and rightly so, to take somebody from the bottom of the list and admit that patient before others who may have been waiting for years, and in some cases even longer.
The shortage of beds for that type of patient is understandable, because when a backward child is admitted to a home or institution of this kind, the bed is occupied for many years—in some cases ten, 15 or maybe 20 years, unless the child dies or is discharged in an approved state of health. For that reason, the number of vacancies is few. The result is that the list piles up in all these institutions. From every area, we find a number of persons continually asking why their child cannot be admitted to, for instance, the St. Vincent Home, Cabra, or other such institution. If a redundancy in hospital beds has arisen and if the position can be adapted for that sort of institution it will be another progressive step towards improved health services in this country.
There is another type of hospitalisation also which is much in demand and for which there are few beds or very little accommodation. I refer to a suitable type of home for old folk. There is the Darby and Joan type, where persons would be prepared to contribute a portion, if not all, of the maintenance charges. If any enterprising group of doctors or nurses were to set up a private home for that purpose, they would do good business.
I have known cases of people who were destitute, as far as means were concerned, but who had endowments and where the solicitors in charge of the estates had been endeavouring for years to find a suitable home for them and eventually had to send them to the  Six Counties for suitable accommodation. Those people do not like to go into the county home; they are prepared to contribute towards their maintenance, some of them being prepared to pay the entire cost. Without much extra charge, without further increasing the burden on the State, we could and should make extra provision for that type of patient. They are not wanted in our hospitals. In most cases, the time allowed in a medical hospital is limited to a month, in order that there may be a proper rotation of beds for the waiting lists those hospitals may have.
I should like to refer to another section of our medical services which has suffered as a result of the Health Act. I refer to the maternity services given by midwives throughout the country. The present tendency is for expectant mothers to seek accommodation in the maternity hospital, thus reducing the number of cases to be met by the midwives. Many of them have not in the past year reached the necessary 25 cases and will soon find themselves redundant, with nothing to do. Perhaps the Minister would examine the feasibility of having this service amalgamated with the local nursing service, where the district nurse—Jubilee or Lady Dudley nurse—practises in a district. I hope the Minister in his reply will make some reference to what he thinks he may be able to do in the future for those midwives who may not have the requisite number of cases to quality for continuation in their respective districts.
Some of those who have already spoken have referred to the rehabilitation of tuberculosis patients. There was a good deal of talk about that in previous years on this Estimate, but I wonder if anything really practical has been done to help those people. Very often the patient has been discharged with a clear bill of health but finds it difficult to obtain suitable employment. As a result, he is often compelled to take up unsuitable employment, entailing heavy work and drudgery, which will finally put him back in hospital again. It is surprising to find that the State is the greatest offender in this respect.
 If any candidate for a post in the Civil Service or the Garda Síochána puts on his form that he is a discharged tuberculosis patient, he will find himself debarred from admission to that post, even though he can present a clear bill of health. If we are to tackle the rehabilitation of tuberculosis patients seriously, the State must be the first to take notice of the importance of rehabilitiating these people, instead of depriving them of a chance equal to that of those who have been fortunate enough not to have become infected.
There was a time, unfortunately, when people did not like to work with ex-tuberculosis patients, but that dislike has disappeared and now I do not think anyone takes any notice. That was certainly one good thing which the improvement of health services has brought us, as the entire sting has been taken out of this disease. With that improvement in attitude, an equal chance should be given to those people to compete for any post in the public service. How can we expect people to take such ex-patients into their employment in shops or offices if the State refuses to accept them as suitable candidates for the public service? I also support the view that they should be the holder of free medical cards. There are many little things for which they may require attention. Perhaps at a later stage there could be an amendment of the statutory regulations under the Health Act.
I also advocate the choice of doctor for the holder of a free medical card. Very often people may not be on good terms with their local doctor and may be reluctant to use a medical card which compels them to attend the local dispensary to get the treatment to which a card entitles them. The number of people of that kind may not be large, but even if there are only a few in each area, that would justify the freedom of choice.
Our hospitalisation programme in the past is to be commended; but even if we have caught up with the shortage of beds, some unsuitable buildings remain. Our future building programme, however quickly or slowly it may move, should learn from the  mistakes of the past and should ensure that the hospitals are built only in suitable areas, where they will give the minimum discomfort to patients who have to travel from the surrounding district.
We in Donegal have an example of a hospital built in the wrong place. It is too late when the hospital is built to find that it should be elsewhere. A splendid hospital is to be opened shortly and a great number of patients who will attend that hospital will have to travel much further than heretofore. Consequently those who are visiting the patients—and that is an important point in the service of any hospital, the visitors who attend the patients on visiting day to console them, to talk to their immediate relatives and to bring them the little things which are so much appreciated when one is in hospital—will not be as numerous as would be the case if the hospital had been placed in a more central and more suitable position. If we made mistakes in the past, due perhaps to impetuosity in our building programme, or through lack of foresight in planning, we should learn from those mistakes in future.
Many of our hospitals have been converted from workhouses. An excellent job has been done with some of them and credit is due to the staffs, to the nuns and doctors who have made them suitable institutions where great work is being done under the health services. Many of them have outlived their usefulness as suitable buildings. It is only at extra cost to the local authorities that they are maintained in suitable condition and at the high standard of cleanliness and repair demanded for a hospital. The experience of years has shown us that many of them should not have been built where they are. When we come to replace them, we should ensure that they are located in an area that will make for the greatest facility and the minimum discomfort of the patients who have to travel from backward areas, the rural and mountainous districts.
I do not think there is anything else one can say without indulging in  repetition but I certainly do not agree with the Labour Party's motion when it says that serious hardships are being inflicted on many needy persons. I do not dispute that there are many anomalies so far as the administration of the health services is concerned. That is to be expected. The services are yet in their infancy and it would be too soon to say we have yet learned all the pitfalls that might guide us to a suitable amendment of the Act. I do not agree that serious hardship is inflicted on needy persons because I believe the manager in every local authority does everything possible to ensure that even those who have no means are not precluded from obtaining the best possible medical services applicable to the particular case of illness.
I think that while health services may be costly—in many cases more than the local authorities feel they are capable of bearing—we must take the view that the picture which the Minister presented to-day was, in the main, a very happy one. As I said at the outset, the saving of lives, the reduced rate of mortality, is something which cannot be estimated in terms of pounds, shillings and pence. Unfortunately, the same happy picture cannot be painted in regard to some diseases which show a high rate of mortality, such as cancer.
Some day we hope the medical profession will be unanimous in telling us whether we are to smoke or not to smoke. Perhaps the Minister for Finance may have something to say in that regard to-morrow but I do not think that anything that might be done in regard to the quality or price of tobacco, in its different forms, will reduce its consumption as would a definite and unanimous statement from the medical profession that they can link this growing mortality from cancer with the smoking of cigarettes. The younger generation which has not yet become addicted to the habit could easily avoid taking the risk and while there is doubt, and while the medical profession are not agreed on it definitely, I think those of us who feel like it, must continue to have a cigarette now and again.
Dr. Esmonde Dr. Esmonde
 Dr. Esmonde: Before I go on to discuss the general administration of health, there are one or two matters in my own constituency which I should like to mention. They are to a large extent associated with the rather complicated position that exists with regard to the appointment of nurses. The Gorey Nursing Association which some months ago had provided a district nurse for the area found it necessary, by force of circumstances, to go into liquidation. They notified the local authority whom, henceforth in this debate, I shall call the county manager, that such was the case and suggested to the local authority that he should, by the power conferred on him, appoint a nurse in the district. They did not even get an answer to their letter.
They held another meeting subsequently and decided to refer the matter to me. I wrote to the county manager and I received the usual involved reply that one gets nowadays from any local authority on any matter appertaining to health—that the matter was under consideration as the whole nursing question was somewhat involved. The outcome of it is that six months have passed, and, although a nurse was provided before by voluntary contribution in the district, there is now no nurse in the Gorey area and no sign of a nurse being appointed there.
The other matter to which I want to refer is also concerned with nursing. The New Ross district midwife reached the retirement age some four or five years ago. No successor was appointed to her and she was continued in office for a couple of years beyond the specified period. There was a nurse living in the district who was a qualified general nurse and who held as well the C.M.B. degree. After considerable correspondence and considerable help from the Department of Health, it was decided she should be appointed temporarily, from six months to six months. I was recently informed that her reappointment would not be sanctioned now and I am told she is to be sanctioned from month to month.
I should like to give the House the nursing position in the town of New Ross, which has a population of 5,000.  I was told there were three midwives and a district nurse in that area already. Therefore it was inconceivable, under intended economies, that this nurse whose case I was interested in and who was fully qualified for her job and doing good work very satisfactorily, could be continued longer than a possible three months. The overall position at the moment is that she is appointed from month to month, and, in three months' time, I understand, she is to be discharged.
In New Ross, there are also two other midwives who are called “New Ross midwives”, although in one case the nurse's district is ten miles away, in Old Ross, and the other nurse is six miles away and she functions in an area a good deal further out. There is also the district nurse who is active in that capacity. She is qualified as a midwife, but has not practised as a midwife for 25 years. If the temporary midwife is discharged, I take it New Ross is to be left with a district nurse who has not practised as a midwife for 25 years and with two other midwives, one living ten miles away and the other six miles away. If that is not muddled thinking, what is?
I know the whole nursing situation is under review and I know the object of the Department and the Minister is to appoint nurses who have dual qualifications. There may be several opinions on that point; it is not unreasonable, but surely if this nurse is not reappointed for a reasonable period, such as six months, does it not create a ridiculous situation? People in offices administering health do not see that. If we consider a person who wishes to engage a midwife, I presume they will not wait until a month beforehand, but that they will go along four or five months in advance and say to her: “Will you attend me?”, and she has to say: “I may not be there. I am here only from month to month.” She may have to emigrate like many others.
I want to stress the point that there is too much administrative interference in medical matters and people sitting in offices, whether in the Department of Health or in the local authority, have no particular knowledge of these  facts. They have no inside knowledge except what comes to them from administration. That is the whole setup of health administration now.
In regard to the Labour Party motion that the Health Act should be amended, I should be the last to disagree with that. The administration of this Act is just impossible at present. The Minister's statement to-day was a full statement covering all points. I was particularly interested in the phrase he used: “Whether this Health Act has justified itself or not....” Quite frankly, I do not think it has, and I propose to give the House some of my experiences relevant to the matter.
The day before yesterday, a man came to me in my own constituency and told me he could not get a medical card. I asked him what his circumstances were. He was a working man earning between £5 and £6 a week. He had a wife and seven children and he had been refused a medical card. If the Minister or any of his officials could tell the House who is entitled to a medical card he would be a very clever person——
Mr. Corish Mr. Corish
Mr. Corish: That is a top secret.
Dr. Esmonde Dr. Esmonde
Dr. Esmonde: Yes, nobody knows that, but I am speaking from experience——
Mr. S. Browne Mr. S. Browne
Mr. S. Browne: That is nonsense. Hundreds have got them.
Mr. Corish Mr. Corish
Mr. Corish: And hundreds have not got them in the same circumstances.
Dr. Esmonde Dr. Esmonde
Dr. Esmonde: No doubt, Deputy Browne will give us a very learned discourse on this later. I practised for years and I know people who had been getting free medical benefits but who are not entitled to them now. I know an unemployed worker who is asked to pay £4 a week in hospital. That is what this Health Act, under its present administration, has given the country. I see no harm in the Labour Party's motion. They approached the matter from a different angle. I feel there is nothing but  State interference in medical matters, and, when that is happening, there must be an official approach which is not compatible with circumstances that change from day to day.
I think it was Deputy Kyne who said that the authority is the county manager in regard to the issuing of medical cards. He has the final say in that, as he has in the administration of practically all health matters, but it is delegated in most instances to the relieving officer whose job is, or appears to be, in most areas, to keep expenses down as much as possible. A relieving officer goes purely on the amount a man is earning. A man may be earning £7 or £8 a week and may be in good and regular employment, but he may have six or seven children whom he has to feed and clothe. That is no small matter nowadays, with the cost of living rising, not only here but all over the world. The human element comes into it. Is he able to pay for medical treatment? But the relieving officer's job is to see the man, find out his earnings and send in a return, and if the man is receiving a certain amount, he is not entitled to a medical card. That is the position and that proves what an absolute farce is the administration of the health services in Ireland.
Added to that, we have the position in which the county manager is put to the pin of his collar to keep down expenses, even though health services have gone up considerably, as the cost of everything else has gone up. Some years ago, health services were administered for approximately half of what it costs at the moment. Nobody would vote against increased health charges, if the charges would benefit the people as a whole, but they do not, and every Deputy knows it, whether he is a member of a county council or not. He knows there are people who are not getting the services that primarily and originally they were intended to get, when this Act went through this House. I disapproved of it at the outset, because I can truthfully say I saw all these difficulties arising, and I knew that there would be interference by the State in the administration of these matters. I knew that those entitled to get the services would be  the weakest section and would find themselves at the end of the queue.
Another thing which strikes me as being entirely wrong is that somebody seeking a medical card has to go to the local authority, or to a member of this House. We are approached on practically all these matters now because nobody can get anything from the health services, unless, in the first instance, they make public most of their private business. I think that is wrong. I would even go so far as to say that it is immoral. They must apply for this card. The matter then goes to the county manager. I have absolutely nothing against county managers as a body. I think they are an excellent body but they have an impossible job to do, since the Health Act came into operation. They are the final arbiters as to whether or not it is to be allowed. They collect their information from the relieving officers. The county manager has only to decide whether a person in indigent, unable to support himself by his own efforts, and he is then entitled to get a card. The county manager has to take the advice of people who are in no way conversant with the particular circumstances or indeed with the circumstances of home life in general. His decision is final and there is no appeal against it.
If a man looks for an old age pension or a social welfare benefit of any kind and is turned down, he can appeal, but, in medical matters, he cannot appeal. If a man with a farm of over £50 valuation is in debt and has a big family, and there are repeated illness in that family, such a person may get out under a section of the Act administratively. The county manager may exercise his discretion. In the case of people with an income of over £600 and people with farms of £50 valuation, I have never known the section to which I have referred to be used for the benefit of the patient, from the point of view of a special concession.
In a way, you cannot blame the county manager. His job is to keep down expenses. The pressure is continually on him for more and more  expenses and more and more costs of administration. No one would object to that, if any benefit accrued from it. I cannot see any. The last Deputy said that health services were in their early stages, but this Act has been functioning for years and there is nothing but dissatisfaction, especially in the lower income group. There is also a very great deal of dissatisfaction in the middle income group. It may be they were led to believe that the whole thing was free. People in the middle income group are asked to pay the full amount of £3 per week and they are unable to pay it. I have five or six cases of people who are just unable to pay the bills they get from hospital, and if Deputy Browne does not believe me I can give him the names.
It is a great pity that the voluntary health services were not introduced before the implementation of the Act which is being administered now. I feel that many more people would have joined the voluntary health services. There are quite a number of people who have not had occasion to go to their doctor and be referred to a specialist. So far, many people, particularly those in the middle income group, do not really know that the treatment which they believe to be free is not, in fact, free at all. They have to pay, and if they do not go to the particular local institution which has contracted with the local authority, they have to pay even more. If people knew the very limited benefits that accrue to them from this State Act many more would join the voluntary health insurance scheme. I believe that the voluntary health insurance scheme would become a snowball which would grow in size.
So far, it has a very good record. It has been a very short time in existence. I think the Minister said that already there were 45,000 members enrolled. My guess would be that many of those members would be from Dublin. I think there are many people in the country who, if they were to realise the limitations of this particular type of legislation, would join the voluntary health insurance scheme and it would grow to be a great source of relief and consolation to people and save them a lot of financial worry in the future. I  hope the Department of Health will make known in every possible way that this voluntary health insurance scheme exists. It is in their own interests to do so. I am sure that even they with their grandiose notions of the State being the paternal influence must realise that the bill is getting a little too costly and that the returns are not quite what they thought they would be.
The Minister referred to some statistics to-day. As I have spoken against the health services, I might say a word in their favour. The maternity service would seem to provide some opportunity. It paid tribute to what I hold to be sacred, private enterprise. It permitted people to go to the doctor of their choice. That meant that an expectant mother was more liable to go to a doctor much earlier than she would in the ordinary way.
It seems rather disappointing to find that the maternity death rate is up, since 1956, from 52 to 80. That may be due to a variety of circumstances, but it is a rather high increase, in my opinion. I do not know what exactly is the reason for it. Perhaps the Minister could break down the statistics in his reply and let us know the reason why he thinks that is taking place. It would be of interest and benefit to see what the reason is. One possible reason occurs to me, but I may be wrong. There has been a tendency for everyone to rush into hospital. It is not always easy to get the constant attendance of a midwife at home and people see they would be better off in hospital. Then again, it may be that doctors prefer to send a case to hospital. With so many people going to hospital and with such limited bed accommodation available, it may become necessary to send many of these cases out earlier than would otherwise be the case. That may be a reason for the increase in the maternity death rate. I take it that the statistics cover the whole period of convalescence and not only the actual birth itself.
Again, on the question of midwives, it was originally decided that if a midwife had fewer than 25 cases, she  should be made redundant. Of course, that, again, was an example of official thinking, without any knowledge of the facts. If you were to remove all the midwives in Ireland who have fewer than 25 cases a year and leave only the ones who have 25 cases, you would not have any midwives. I understand that the Department reconsidered the matter and were prepared to reduce the number to 20. I would still respectfully suggest to the Minister and his advisers that that figure is a little bit too high. The midwife is in the district for the purpose of being on call when she is required and if you retire all the midwives from the different areas you will have an outcry all over the country.
A great many of these people have been in employment for a good many years and have given very loyal and devoted service to the people there. If they are put out of employment they will not have much chance of starting out afresh. Many of these midwives are middle-aged women. They have been there all their lives, living in the locality, where they very often marry. If you put them out of practice by some statistical futility such as not having 20 cases in the year you will inflict hardship not only on the midwives but on the whole people of Ireland. The result will be that everyone will be going into hospitals and overcrowding them because they will have no alternative.
This is a matter which requires very serious consideration. I know from being a member of the National Health Council that the Minister has been considerate in this matter and that the question is being reviewed. I understand there is a possibility of fitting these midwives in by giving them pediatric courses so that they may divert their energies elsewhere for the benefit of the State.
Another matter I should like to mention is that of hospitalisation. I am not an ex-student of Jervis Street Hospital so I have no axe to grind, but Jervis Street Hospital is in the centre of Dublin and everyone who has ever gone through a medical course or has had anything to do with medicine knows that most accidents in the city, including very serious accidents, go  into Jervis Street. They are very badly in need of an up-to-date operating theatre. I know that allotments are made a long time in advance, but this is a case that ought to be given priority. It may seem strange for a rural Deputy to make an appeal on behalf of a Dublin hospital, but you must remember that anyone who is in Dublin and who meets with an accident in the centre of the city will invariably find his way into Jervis Street. With the record they have for taking accident cases, they ought to be given special consideration.
The last matter to which I should like to refer is the question of cancer. We all know that there has been a great deal of research done on cancer and that certain attempts have been made to eliminate that scourge. According to the Minister's speech there is a general tendency towards a decline in the rate of cancer. That is a welcome development because it is a fact that there is a much higher rate of diagnosis of cancer than heretofore. Previously cancer cases were not diagnosed as such; nowadays they are diagnosed.
One of the principal ways in which this scourge manifests itself is through a lung condition. There is a great deal of controversy as to whether smoking is responsible. It is very hard to dog-matise on a matter like that but one can safely say that cancer is a thing that comes of its own accord. It is an overgrowth and no one knows the real reason for it. If the medical profession could discover that they would have the cure for it. However, it is well known for a long time that an irritant predisposes to cancer. Statistics go to show that anyone who works with oil runs a big danger of contracting it. Statistics also go to show that very heavy smokers, particularly those who inhale, may also have a predisposition to it.
It would be hard to say that smoking in itself is the direct cause of cancer but one could safely say that very heavy smoking is a predisposing cause. In my opinion, however, the rise in lung cancer cases is probably due to the pollution of the atmosphere from oil. There is a much greater use  of oils than heretofore. It has been found that there is a very high mortality from cancer amongst those who work in oil-burning ships, amongst those members of the community constantly in an atmosphere of fumes, and it is well to bear in mind that those fumes are oil fumes. A good deal of research has been done in that line to obviate them as far as possible.
Mr. Faulkner Mr. Faulkner
Mr. Faulkner: Ba mhaith liom cúpla focail a rá ar an Meastacháin seo. I wish to make a few brief comments on this Estimate. I would appeal to the Minister to examine the whole question of accommodation for mentally retarded children. The wonderful work which is being done by the Brothers of St. John of God and by various communities of nuns for these children is being seriously handicapped by the fact that there is little or no accommodation for these children after they have been trained or when they have been trained to a point where nothing further can be done for them from the training point of view.
The position is that where one of the homes for the training of these children is full, there will rarely be a vacancy except on the death of one of those who are already in occupation. I have myself witnessed the very fine work which has been done for these children by the Brothers of St. John of God at St. Mary's Drumcar, in my constituency. To those who have not seen for themselves the work that is being done it would be hardly credible that these selfless teachers could do such really magnificent work, but, as I said at the beginning, the work is handicapped by a lack of accommodation, and there are hundreds on waiting lists to get into these homes. It is heartbreaking for parents who love these children more than any other child in the family to find that they cannot get the training for their child and cannot avail of the very definite advantages which accrue to the children from this instruction.
I might also say that it is distressing for a Deputy to find when he tries to get a child into one of these institutions that, through no fault of the religious in charge, the door is closed to children who could genuinely benefit  from instruction, especially when he realise that unless these children are taken in at an early age the benefit of the instruction will be very much lessened. Every month that passes, reduces the amount of benefit which these children derive from the instruction. I would, therefore, recommend to the Minister that this question should be very carefully examined.
With regard to the Health Act, there are, of course, anomalies. As another speaker has said, this is a young Act and we should be able to get around some of the anomalies, at any rate, without having recourse to amending legislation. In many cases the people themselves are not always aware of the benefits to which they are entitled. There is one particular type of case that I have come across where a patient is sent by a private doctor to hospital without going through the local authority institution. Even though the patient has a medical service card, that patient is regarded by the local authority as coming under Section 25 and is charged accordingly. I appreciate that the local authority which pays part of the cost, must have some control but, at the same time, cases like that I have cited are dealt with on a technical point. If people are entitled to certain benefits and if, because of some technical flaw they go outside the Act, the case should be re-examined and they should be entitled to acceptance as proper people under the relevant section.
There is also the anomaly where members of a family can obtain benefits under the Act because of increasing income. Where a man has six children and where, because of his income, he is not entitled to benefit, two of those children, on reaching 14 and going out to work to earn, could apply for and get medical service cards. If they do not go to work they are still regarded as a responsibility of the parent and do not benefit under the Act. The Act should apply to them irrespective of whether or not they are earning.
With regard to the Voluntary Health Insurance Act, the large number of people anxious to avail of that scheme is proof that its value is appreciated.  There is one point I should like mention in relation to the scheme. A illness from which a person suffered any time during his or her life exempt, if that illness is entered the application form. I can apprecial that in the first year of operation condition of this kind may be needed but I do not think it should be carried on down through the years. A particular illness from which a person suffered as a child should not be held against him in his adult life.
Mr. Desmond Mr. Desmond
Mr. Desmond: Like the last speaker I wish to draw attention to the position of mentally retarded children. I is only fair that we should equally draw attention in this connection to the wonderful work done by the religious communities who are endeavouring to cope with this problem. The Brothers of Charity in Cork are setting an excellent example. It is most important that something should be done to tackle the problem of these children in a constructive way.
I want to refer now to the problem with regard to dispensary buildings. A decision was reached last year which has had disastrous results in South Cork, and probably in other areas as well, in relation to the building of dispensaries. If we had properly equipped dispensaries, a certain number of people who are at present compelled to enter hospital for treatment could be treated at a much earlier stage in such dispensaries. That would relieve them of the necessity of subsequently entering hospital. As a result of a circular issued last year local authorities are denied any grant towards the erection of dispensaries. A prohibitive impost is placed upon local authorities in relation to the provision of dispensaries.
Coupled with that is the problem in relation to the dispensary districts themselves. It was not possible to embark upon a scheme of building. Last year the data had been prepared and arrangements made under the compulsory acquisition legislation to secure sites. The Department issued this circular—at the instigation of the Minister no doubt—making it clear to the local authority that no grant would be made available. That has brought  the building of dispensaries to a complete stop. I would appeal to the Minister to give special attention to the urgent necessity for erecting proper dispensary buildings and to make the necessary grants available for this important work.
Deputy Dr. Esmonde spoke at length on the question of midwives. Coupled with that is the necessity for having trained general nurses available. I do not suggest that a properly qualified midwife should be thrown out after years of service in an area, but it is vitally important that, wherever a vacancy occurs, that vacancy should be filled by a trained general nurse with, of course, midwifery qualifications also. From our limited experience in South Cork—I have no desire to be too parochial—people seem to have more confidence in going at an early stage to have their complaints remedied when they know that, as well as the dispensary doctor, there is also available to them a trained general nurse. From experience I must say that the nurses appointed to the various districts in that area within the last six or seven years have been a credit to themselves in their efforts to solve the problems of health in the locality.
Hospital conditions are a very big problem. It is not necessary to elaborate on the terrible conditions obtaining in Cork City in regard to patients from the city, the suburbs and the adjoining rural areas. The Minister was made aware of it in discussions at a recent conference. It is about time we knew where we stood in regard to these buildings. I appreciate the necessity of having a queue system, so to speak, for money for the improvement of these hospitals. But 12 months have now passed and the position should be clarified.
The problem of overcrowding is not only acute but, in some instances, desperate. Even with the utmost cooperation from staffs, the fact that beds are not available means that patients are dying outside hospital who might have had some chance of recovery if a bed had been available. This will continue in Cork until the necessary extra accommodation is made available. Whether the problem  is to be solved by erection of the regional hospital or by additions to the other hospitals, it is too serious a problem to continue arguing. The Minister may be faced with division within the ranks of the Cork representatives themselves irrespective of Party. Some believe it is urgently necessary to proceed with the erection of the regional hospital while others are of opinion that the problem may be solved by additions to the existing hospitals. We can differ on that, but it is time a decision was arrived at in respect of the overcrowding of hospitals.
Deputy Esmonde mentioned medical cards and Deputy Kyne spoke on the same subject earlier this evening. It is not necessary for me to dwell at any length on the matter. The position is most unsatisfactory and has been so for the last few years. The Labour Party supported the introduction of the Health Act and its members are anxious to see it improved so that existing anomalies can be removed. It would be a great pity if outside people could point the finger at us and say: “Your Health Act is not working satisfactorily.” We believe the members of the Government do not wish that. It is essential that the Act be examined so that we can have improvements where necessary. A remedy should be provided for the problem of the many people who are being denied the right of medical cards.
It is also essential to draw attention to the fact that we have a Minister for Health who refused to answer a question put to him on to-day's Order Paper. We have a Minister who, when he does answer, finds it suitable to answer in such a manner that, when the answer is published in the newspapers, it is nothing less than an unqualified attack on the parents of children, people who cannot answer for themselves to the Minister. It may be true that the Minister for Health is interested in individuals with national records. We differ there. We, the younger members of the House, are prepared to give full credit and honour to people with such records. But we can go no further. Having supported the introduction of the Health Act, we consider there is a duty on  officials to put it into operation in the manner in which it was meant, without distinction between persons who held national records or not.
I appreciate it is a serious matter for any Minister to come to a decision regarding the handling of staffs of local authorities. But it is difficult for members of local authorities to do what they consider best when they find officials are not prepared to do so. In the last report the Minister in charge of the particular Department is the judge. I can almost say what the Minister's reply will be, if he considers it worth while to reply. He will do now as he did two weeks ago—change completely everything put before him, change a statement submitted by the parent of a child, a copy of which I have got. He will say again, as he said two weeks ago, that the fact of a poor unfortunate child being left to suffer from the after-effects of polio from the month of February to October was solely the fault of the parent.
Is the Minister still adamant in taking that line or is he prepared to show that, as the responsible Minister, he is a fair-minded judge? Is he prepared to examine the case on its merits and not on the question of the mother of a child versus a national record? In the statement submitted by the parent of that child about a fortnight ago, which the Minister has in his possession, it is clearly pointed out that, when the dispute arose between an official and the parent, when that mother was warned off, as it were, on the next occassion, the mother of that unfortunate little boy did not go into the building but sent in the child by an ambulance driver. Is that correct? I cannot swear to it but neither can the Minister swear that it is not correct. Is it not the simple answer to have a proper investigation? Is it correct that the ambulance driver brought out that little child to the mother and said that the official refused, and would continue to refuse, treatment to the child, until the mother apologised? Is that what officials in local authorities are paid for? Thanks be to God, in my limited experience of officials of local authorities  and Departments of State, I have never found such a case.
The Minister must judge; he is asked to judge. What will his answer now be? Does he not now realise that, either in writing or verbally, a statement was made on 2nd January of this year, purporting to be a statement from an official of the Cork County Council, when, in fact, even according to the Minister's answer to the question to-day, that official had nothing whatsoever to do with the Cork County Council on 2nd January? Would the Minister not be fair and say that the fact that the official concerned made a clear statement at the local authority meetings that, while he was not satisfied with the official's attitude, there was nothing more he could do, was an admission to all members that the person who was then county M.O.H. could do nothing more, although he would wish to do so? Yet the statement made on 2nd January, condemning the mother of a child, fully supporting the attitude of the person concerned in the official service, was made by none other than that same official, a person who had not been county M.O.H. in Cork County since 1st November.
It is a serious case. Let the Minister twist it as he may in his reply, but let it be on his conscience, whatever way he may twist it. It will be a serious thing. It will be a serious headline for officials of any local authority in rural Ireland or in Cork or Dublin. Because of that case, where an official purported to act on behalf of Cork County Council when, in fact, he did not hold such a position at the time, officials in any Department can say that, if they are well in with the views of such a Minister, they can act in any manner they like towards these patients and be sheltered by a Minister of State for so doing.
I shall not delay the House on this issue, but I say as seriously as possible that this is a case for inquiry. All I asked for and all I ask for even at this late stage is a fair, honest investigation into it. Is it beyond the capabilities of the Minister to consider that aspect of the case? Let the Minister forget, as I have tried to do, what may  transpire in relation to abuses by officials and the mother of a child. They had a remedy. The official had not the authority, but is now being given it by a Minister for Health, to deny treatment from the month of February to the month of October.
We are entitled to ask one simple question. The child did get treatment in October. Why? Is it not right to say that it was because the matter had to be thrashed out in public at a health services meeting in Cork that the treatment was resumed? If the Minister is prepared to be sincere in his responsibility towards all concerned, he must ask himself one question, that is, why was it that, without any apology from the parent, the official found it necessary to resume the treatment in October, although that same official refused treatment in all the months up to October from the month of February? That was the question that I put to the Minister and the question that he could have answered a few weeks ago by being fair to all concerned.
I do not mind what his answer may be. I say honestly to him, as a member of the House, that whatever answer he gives, it will not and cannot be the end of it. It may be the end of it in public. Let the Minister answer for the inefficiency of a service which means that a little boy of tender years is condemned, perhaps for life, to wearing irons around his leg, is condemned to practical blindness for life, partly due to the fact that an official, without its being in the terms of her or his appointment, found it suitable, in a so-called Christian country, to let a child suffer. The official concerned was apparently suffering from the same malady from which the Minister for Health suffers, an overdose of vanity.
That is the decision for which the Minister will be responsible. He can now say what he likes. I know he is prepared to change it all to suit himself, prepared, perhaps, to change it to suit officials who, by their actions, have proved how unfair they were to a child. By supporting such actions, the Minister will be bringing upon himself the wrath, not of a mother or child, but  the wrath of people who want only fair and honest treatment under an Act— the Health Act—the introduction of which every member of Fianna Fáil proudly supported and every member of the Labour Party proudly supported. If we have a Health Act, surely it is for the benefit of a little cripple? Surely it was never intended that it should be transgressed in such a manner by such officials, and that such officials should have the support of a Minister of State in so doing. That is the issue. The Minister may defend his judgment in this case, and in all other cases like it, but it will be taken from his hands and my hands ultimately.
Mr. Sherwin Mr. Sherwin
Mr. Sherwin: I know nothing about medical or surgical services. We have doctors here who will enlighten us on that, but I have very strong opinions on matters affecting administration, and on some aspects of ill health, such as physical deformities. Though the public may not be very well informed, they still have a certain amount of sense and they often ask: “Where is all the money from the Sweeps going?” One would imagine that, with the amount of money subscribed by the Sweeps, there would now be very little ill health in the country, that most of the hospitals would be closed up and that most of the doctors would be emigrating. In spite of that expenditure on hospitals, there still seem to be as many people suffering from ill health as ever. We organise facilities for people suffering from ill health. We say to people: “When you suffer from ill health, come in and we will treat you”, but we should try to prevent ill health by advising people to kill it in its early stages. There should no need for hospitals at all and it should be enough for people to go into a clinic.
I have always felt that there should be compulsory medical X-rays and treatment every couple of years. We will have these facilities for cattle, but it seems that what is all right for cattle is not all right for human beings. A person goes to a doctor only when he feels bad. Even when some disease is latent in him, he gets some magnesia, or something like that, and seeks treatment only when it becomes serious.  That is my point—when will we try to diagnose cancer and various other forms of disease in their early stages?
What are we doing to treat physical deformities? One notices in the streets a good many people suffering from physical deformities of one kind or another, and that applies also to children. All children should be examined periodically. In the schools, there should be proper instructors, not just P.T. instructors, because if a child is suffering from a physical deformity, unless the physical instructor had a knowledge of chiropractics, he could not cure such a child. There should be some authority dealing with matters of a chiropractic nature. If a child suffers from a slight physical deformity, I do not know if there is any service for him. That deformity is allowed to develop and when it becomes serious, it is too late.
There should be people to attend the schools to build up children's strength, to watch over any case of deformity, and to try to prevent this state of affairs developing which has resulted in there being thousands of cripples throughout the country. I suffered from a serious physical deformity myself and, as a result, was obliged to attend various clinics of one sort or another, both here and in America. I know how helpless those people are. I know from the stories they told me that they suffered for a long time, and, when the disease got to a certain stage, nothing could be done for them. It was never a matter for the medical profession to straighten a man's spine and do anything of a chiropractic nature. If the thousands of people who are cripples had received proper attention in the early stages from people who knew their business they would not be crippled to-day.
As regards the Health Act, as a public representative and as a councillor living among poor people, I know this Act requires revision in many ways. People who are earning only £8 or £9 a week are told that the Health Act does not apply to them, and it would appear there is a means test. People are asked what they pay in rent and what other income comes into the home, and when these factors  are broken down, a man with £8 or £9 a week is not entitled to a blue card. The average worker with such an income is lucky to have the price of a cigarette on Thursday. How will such a man meet a hospital bill of £5, £10 or £15, if a child of his needs treatment? If he appeals and begs, he may have it reduced by half, but even then, how is he to meet a bill for £7 10s? It is still a problem for him.
I have known many people in danger of being evicted because they had not got their rents for the corporation. If there is rent owing before each gale day, they will find themselves in the hands of the sheriff, and many of them in that predicament have come to me and said: “Look, Frank, we had to meet a doctor's bill and the rent doubled up.” Children used to be treated in dispensaries and it only cost 1/- or 1/6, but now if a child is attended by a doctor for a cold, it costs 5/- each time, and then there is 5/- or 6/- for a prescription. It is a lot of money for a child's cold.
Then there are cases of influenza striking families. Johnny has it to-day; Mickey gets it to-morrow; and Mary has it the next day; and parents have to pay the doctor for each visit, as well as the chemist's bill. That is the factual position people are up against. In my opinion, everybody, irrespective of whether they have blue cards or not, ought to be able to get free treatment in the local dispensary. It is all right if they have to meet hospital charges, but, in cases of simple ailments like colds affecting children, treatment should be given in the local dispensary.
With regard to the dissemination of information and advice on health matters on the radio and through the Press, I should like to ask the Minister to consider the advisability of using a half-hour programme on the radio—it would be cheap at the price—to give such information on health matters, to advise the public in simple language — not in the medical vernacular but in language that ordinary people can understand—that, if they have certain symptoms, they should go to such and such a place. You would be amazed at the way people will take that kind of  advice. It may help a lot to get early diagnosis and early treatment.
I want to deal now with the question of cancer, in which I have some interest because a number of my friends died of it, people very near to me. One person had cancer for 20 years and did not know it. It was a stomach cancer. That is the worst form because if it is deep, it is hard to diagnose in the early stages. This person treated himself with such things as magnesia which gave him a certain amount of relief, but all the time he was suffering from cancer. Stomach cancer is serious and, unless there is early diagnosis, it is more than likely to prove fatal because by the time stomach cancer has such an effect that it requires medical attention, it has gone so far that little or nothing can be done. Actually, it means having to cut away a good deal of the person's inside. What I am saying may seem a joke, but I am suggesting a simple and practical way of combating the problem.
I want to deal now with the problem of old people. In my view, old people should receive certain massage treatment and light forms of exercise, because most of them suffer from muscular ailments which cripple them. Any little treatment of that sort would be a great relief. We know from our own experience, that, with a cramp in the leg one cannot walk. Old people suffer a great deal from that sort of thing and some form of treatment such as that which I have suggested, especially if it were available in clinics for old people, would be a great relief.
I want to make one further reference to mental homes. I do not know whether or not it happens here, but I know that in some countries it is the practice of people to get rid of those who are a little mental—to put them in homes and leave them in them, once they get them there. It seems to have been the practice that, unless the people who put them in were prepared to accept them, the unfortunate people were left in the homes. Quite a number of people in such homes cannot get out because there is no one to claim them. There have been cases of people who were certified and put into homes  who should never have been put there. Not so long ago, there was a case in England of the escape of a person from a criminal asylum. As it happened, he could not be recertified as mental. There is a case in point. The man was able to prove that he was no longer mental. Had that man remained in that mental institution, he would never have got out. Of their own accord, people should have the right to apply for discharge, irrespective of whether or not those who put them in are in agreement. No person should be certified except by at least two doctors and certainly never by one doctor only.
Mr. Carty Mr. Carty
Mr. Carty: The Minister's introductory statement and the statistics he gave us were very gratifying. They reveal an improvement in the mortality rate of our people, on the whole. That is a trend for which the Minister can pardonably take credit. However, I do not think all the credit for that is due to the Department of Health or to the health services. Over the past decade, there have been considerable improvements in other aspects of our living that affect health. There has been a great improvement in housing. There has been an extension of sanitary services and there has been a general improvement in our standard of living. All these factors must have affected the trend to which the Minister made reference in his opening remarks.
I think the Minister proved conclusively that the moneys spent on health services, and the legislation which has been enacted in this House over the past ten or 11 years, have shown very good results in the saving of human lives and in an increased expectation of life. Indeed, I think the Minister surprised many of us when he told us we are budgeting in the coming year for an expenditure of £16,500,000 on health services.
This time last year, I referred to the health services in the county with which I am familiar, County Galway. In particular, I referred to our regional hospital there. I deplored a trend which I noticed, namely, the trend to crowd our regional hospital with beds and increase the capacity of that hospital beyond what was originally  laid down when the hospital was first occupied. I regret to say there has been no improvement but rather a deterioration in that regard, since this time last year.
The Central Hospital, Galway, had been adversely criticised in respect of overcrowding. There was talk that patients had to lie on mattresses on the floor, and so on. For that reason, a regional hospital had to be provided. If the present trend continues, then, in some few years' time the regional hospital will be as badly overcrowded as was the Central Hospital in days gone by. Much of the blame for this state of affairs must be placed on the Department of Health. They have directed the medical staff to provide increased accommodation. Even rooms that had been set aside for nurses are sometimes taken over. The nurses are highly critical of this state of affairs and the medical staff of this hospital are perturbed.
Our hospital in Galway is different from many of the county hospitals. It is rather unique, I think, inasmuch as it is a teaching hospital associated with the university. In a teaching hospital, high standards have to be aimed at and maintained. We in Galway are apprehensive about the future of our hospital and the continuance of its status as a teaching hospital. We feel that if overcrowded conditions are allowed to continue and if the position worsens, then people who, in due course, will come to examine our hospital and certify it as a teaching hospital may have to take stock and refuse to continue to grant us the status which we now enjoy.
There should be no reason for overcrowding in our regional hospital. In Galway, we have what might be termed an auxiliary of the regional hospital, a modern hospital accommodating 150 patients. It has been standing idle and derelict for the past 12 months or more. I refer to Woodlands hospital or sanatorium. Many Deputies may have read in the Press that, just before the Department decided to close it down, they appointed a matron—a matron for a hospital that was not occupied. That lady has been living there for the past year and a half,  until quite recently—matron of a hospital with no patients or nurses. Only the Department of Health could do a thing like that.
I must congratulate the medical staff of the regional hospital in Galway on the facilities which are available. It is an excellent hospital, well maintained and adequately staffed by excellent surgeons and doctors.
If I have a criticism to make of our dispensary doctors and the doctors in private practice in my county, it is that they are inclined to send patients to institutions other than our regional hospital. We have a Health Act and I think it is the duty of doctors to make themselves familiar with the schemes and services available under it, and then to advise their patients accordingly.
I would refer, in particular, to the middle income group. I have known doctors to send patients in that group to private hospitals and to institutions, although those doctors knew that the patient's illness would be prolonged and that costly treatment would be involved. Nevertheless, they have seen fit to beggar their patients by sending them to places outside the regional hospitals, where no county subvention would be payable and where the doctors' bills had to be carried by the parents themselves. Those doctors should realise they have a duty to their patients in the middle income group, a duty to advise them as to their rights under the Health Act and of the services available in our county and regional hospitals.
Another trend that I notice in Galway, but not in the Regional Hospital, is a rather shady practice that obtains with patients of the middle income group who are sent in. I know cases which are sent in as public ward cases, and, when they reach the hospital, by some inducement or inference they are told that if they go to the public section of the hospital they will not get the same treatment or the services of a particular doctor, whether it be gynaecologist or surgeon, that the surgeon will not be available to that patient unless the patient opts for the private section of the hospital. Consequently, when the  patient leaves the hospital, he or she is presented with a bill—although that patient went in in the belief that the doctor would be free and that the patient would be liable only for the ordinary maintenance of ten shillings a week, because that hospital is one that has entered into an agreement with the local authority.
I am not talking “through my hat” —these things have been referred to at meetings of the county council, and of the Consultative Health Committee, mentioned not only by me but by many county councillors in County Galway. I ask the Minister to put a stop to this practice. It was not intended or designed that the public in the middle income group should be liable, in any institution which has entered into an agreement with the local authority, to pay for services by a doctor or pay for a private ward when the patient was sent in as a public patient.
I would like the Minister to clarify the position with regard to specialist services. What specialist services are available under the Health Act? Are ophthalmic services available for the lower income group? Can the possessor of a card, an M.S.R. card, have his eyes tested and glasses supplied, and supplied free, under the Health Act? It is the same with regard to E. and T. services and the provision of hearing aids. We in Galway want some information about that matter.
We also want some information about the question of dentures. In my county there are upwards of 600 people whose teeth were extracted in the Regional Hospital by the regional dentist, and those people believed they would be provided with dentures. Dentures are being provided, but only at the rate of about 30 or 40 in a year. I do not know when those 500 or 600 will get their dentures. The Minister said last year, and repeated this year, that the resources of the State and of local authorities are being concentrated on the school services. I have some knowledge of the school dental services, and I do not want to say much about them, because if I said anything about the dental services I could not speak of them in a complimentary manner. I am sure that the  same can be said by any teacher Deputy in this House.
In our county we have reason to be perturbed by statements which have been made by people associated with the Regional Hospitals, not by dispensary doctors, about the quality, nature and substance of drugs supplied to dispensary doctors and to our Regional Hospital. No later than last Friday, our Assistant County Manager took a note of complaint made to him by a member of the Consultative Health Committee, that a thyroid preparation supplied by an Irish firm under the Combined Purchasing Order, a drug, was not of B.P. standards. The doctor administered it to a child, a mentally deficient child, and after a week he was so upset at the condition of the child that he sent the child to the Regional Hospital, where it was discovered that the child had been poisoned by an overdosage of this drug. That is no isolated case.
We are also informed by people associated with the Regional Hospital that streptomycin and other drugs supplied by firms on the official list of contractors of the Department, were not up to the standard and had to be withdrawn. I do not know whether the Minister for Health is a picture-goer or not. I presume he is; he is interested in the arts and in literature, and I am sure he might go to the pictures occasionally. I wonder if he saw The Third Man? If he saw The Third Man, he knows the racket conducted in post-war Germany and in other countries, where inferior drugs were supplied.
Mr. Loughman Mr. Loughman
Mr. Loughman: The alleged racket.
Mr. Carty Mr. Carty
Mr. Carty: A doctor who attended our meeting and gave us this information told us that he had been in consultation with chemists in the locality, and they told him they would not stock the drugs that were supplied to the Regional Hospital in Galway and to the dispensaries of the county. I assume that is what Deputy Loughman is referring to.
Mr. Loughman Mr. Loughman
Mr. Loughman: I would say that the Deputy's statement is absolutely wrong.
Mr. Carty Mr. Carty
 Mr. Carty: The Minister for Health will get a copy of the minutes of the meeting in due course. The statements were made by reputable people.
Mr. Loughman Mr. Loughman
Mr. Loughman: They should not be repeated here until people are sure of them.
Mr. Carty Mr. Carty
Mr. Carty: The Deputy will get an opportunity, I am sure, of reading them. I shall get a copy of them for him.
Mr. Loughman Mr. Loughman
Mr. Loughman: The Deputy need not. I have plenty of experience.
Mr. Carty Mr. Carty
Mr. Carty: Reference was made here to preventive medicine. Deputy Sherwin referred to it. He said that health is something one cannot win in the “Sweep”. He also referred to keeping in good health, so as to avoid having to pay the expenses of doctors when one is ill. The Chinese had a system under which they paid the doctor while he kept them well but when they became ill, he got no pay. That is preventive medicine. I think sufficient publicity is not given by the Department and the health authorities to preventive medicine—B.C.G., mass radiography, the anti-poliomyelitis vaccine, and all the other excellent services that have been introduced over the years. They suffer from a lack of proper publicity, especially the anti-poliomyelitis vaccine. Some confusion exists regarding that and it might be in the interests of the Department to give it proper publicity.
Reference was also made to district nurses and to the danger of midwives becoming redundant and losing their positions. That has already happened in Galway. Some of them have not got the required number of cases—20 or 25—and accordingly have been declared redundant and district nurses have been appointed. The Minister should go slow in that direction. I join in the tributes paid to midwives by Deputy Dr. Esmonde and other speakers. Personally, I think we should not get rid of them so quickly. They have rendered very good service to the community in the past; they can do much good work all the time if they are retained and not declared redundant simply because the number of  cases attended is deemed not to justify their retention.
During the year I was shocked to read—I do not know whether the statement was true or not—of the salaries paid to probationer nurses in some of the voluntary Dublin hospitals. Local authority hospitals have a very good record with regard to the rates of pay applicable to probationer nurses but I think the same cannot be said of voluntary hospitals. I read particulars in one Sunday newspaper of the pittances paid to these nurses. The particulars were denied but I have reason to know that many of the statements made then were true. The Minister for Health should lay down a standard, such as they have in England, providing for a minimum salary for probationer nurses and not let these big Dublin hospitals get away with paying nurses a salary of £2 or £2 10s. a month. How do they expect nurses from the country to live in Dublin on such small salaries? I know that some of the allegations are true because I have been speaking to some nurses here in Dublin. In Galway, in hospitals regarded as training hospitals, the minimum salary is £9 a month. In Dublin these hospitals with high-sounding names are saving on the nurses and drawing from the Department of Health, which bolsters up their deficiences every year. I say to the Dublin hospitals: “Pay your nurses a decent salary and I am quite sure the Minister for Health will not grudge you the extra money necessary to make up probationer nurses' salaries.”
Mr. O'Sullivan Mr. O'Sullivan
Mr. O'Sullivan: The Minister, in introducing his Estimate, gave us a detailed review of the situation in his Department and the difficulties which have to be met at the moment. He also had a very pleasing report on the improvement of certain aspects of health. Over the past ten years remarkable progress has been made in the reduction of the incidence of tuberculosis. Ten years ago it was still a dreadful scourge affecting the country. Our people were prone to it for a variety of reasons. Until recent times our housing was not up to the standard that one would expect in a civilised country. Our sanatoria services  have gradually improved down through the last 30 years and, above all, we have succeeded, in the last decade, in eliminating the psychological attitude that prevailed in regard to tuberculosis.
I would ask the Minister to have a word with his colleague, the Minister for Lands, and ask him to desist from decrying the expenditure on hospitalisation over the last ten years. Week in, week out, he has been reported in the Press as drawing attention to this matter. Surely this is something on which there is no difference in policy among all Parties? What was spent was necessary for the elimination of tuberculosis. To-day, thank God, we have got a remarkable report of results flowing from that hospitalisation programme, flowing from the administration of the Department of Health in providing assistance of various kinds, early diagnosis as a result of the utilisation of mobile X-ray units, and the financial assistance given to dependents of affected persons consequently relieving them of the worry inimical to their chances of recovery. The Minister can point to a reduction in the mortality rate but it is hard to trace with any exactitude the many hundreds of wage earners that have returned to productive employment in a very much shorter  time in consequence of institutional treatment for tuberculosis.
Discussing economics, and State expenditure, “groaners” outside the political Parties, who seek to decry the administration since we achieved self-government, absolutely omit any reference to our successes. In this field, we have achieved a success of which any country could be proud. If to-day we have a plenitude of accommodation in hospitals, it is a good thing to have. There are people in other nations who spend much greater sums on armaments, on activities injurious to human life and to the possibility of obtaining just that standard of living expected in a civilised Christian country; but we here, with our climate, have met the challenge of tuberculosis very successfully and by the constant provision of mobile X-ray units, are ensuring a continuation of early diagnosis and constant treatment and attention. That is forthcoming from our excellent medical and nursing staffs.
Progress reported; Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, April 23rd, 1958.
Dáil Éireann 167 Committee on Finance. Vote 64—Health.