Dáil Éireann - Volume 210 - 04 June, 1964
Committee on Finance. - Vote 49—Health.
Minister for Health (Mr. MacEntee) Seán MacEntee
Minister for Health (Mr. MacEntee): I move:
That a sum not exceeding £10,387,100 be granted to complete  the sum necessary to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1965, 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, miscellaneous Grants and a Grant-in-Aid.
The Estimate for Health for 1963-64 was debated in this House as recently as late February last. On this occasion, therefore, I intend to be brief. I have, however, circulated to Deputies the statistical information which I should have given to the House orally.
The figures for births, marriages and deaths for the last five years indicate that, in comparison with 1962, deaths in 1963 were fewer by 0.8 per cent, marriages were fewer by 2.1 per cent but births were greater by 1.9 per cent.
While the number of deaths from all forms of cancer was up slightly in 1963, the number of deaths from lung cancer was slightly lower than in 1962. The number of Cobalt Units available for treatment of the disease is to be increased to three; a second unit being installed at St. Luke's Hospital, Dublin, and a separate unit at the special Cancer Clinic, Cork. All these units will be available to referred patients from all over the country. In this regard special arrangements exist between St. Luke's Hospital and the two other Dublin hospitals which specialise in the treatment of cancer.
As an element in our cancer diagnostic service, provision is being made for the early diagnosis of pre-cancer conditions of the cervix. For reasons of economy and convenience the facilities will be concentrated initially in a single laboratory at St. Kevin's Hospital, Dublin. The service will become available when the Dublin Health Authority have recruited a cytologist.
To publicise the association between cigarette smoking and lung cancer the following steps have been taken: the summarised findings of the United States Advisory Committee and other authoritative investigations are being  distributed to teachers, clergymen and others; posters are being prepared for display in public places; and the appropriate franking of letters is being arranged. The reverend editor of Our Boys and An Gael Óg has very kindly offered free advertising space to persuade the wide readership of these magazines never to smoke. Finally, the tobacco companies and advertising interests, including Radio Éireann, have been asked to meet my Department to discuss the formulation of a general code to regulate the advertising of tobacco.
Though there has been a considerable decline in it, and in infant mortality, the maternal mortality rate here continues to be higher than in the neighbouring island. It is recognised that there are special reasons for this, most noteworthy the later age of marriage among us, our larger families and the rarity of therapeutic abortion.
The death of a mother in childbirth has such tragic consequences for the family that, wherever possible, its cause should be ascertained and studied. With this end in view the Irish Medical Association have agreed to set up a special Committee to consider, as far as possible, the circumstances of every maternal death; but not, I would emphasise, with any other objective than to discover the cause and to search for a remedy. I would like publicly to thank the Irish Medical Association for their co-operation in this important and difficult matter.
It is relevant that I should mention that a revised form of the contract to be entered into between health authorities and doctors participating in the maternity and infant scheme, has been negotiated recently with the Irish Medical Association.
The decline in the need for beds for the treatment of tuberculosis, and in the number of new cases emerging, gives some cause for gratification, but none for complacency. It can be said with truth that the disease is under control. Yet elimination, and not just control, must continue to be our aim. We still have throughout the country, I am sorry to say, an undiscovered pool of infectors, estimated by  some authorities at as many as 7,000, a very large part of them males of middle-age. Men in the upper age groups have a particular responsibility to the community and to themselves in this matter; for it has been established that, of the new cases of TB currently being discovered in males, no less than 45 per cent are 45 years or older. The community has provided an excellent mass-radiography service for the detection of tuberculosis. Recourse to it has already saved very many lives. In their own interest all persons over the age of 12 years should avail themselves of the facility, should, indeed, come forward for X-ray every time one of the mobile units is in their district. If we were given this modest degree of co-operation by the public, I have no doubt that in a relatively few years the disease would have virtually disappeared from our midst.
The Commission on Mental Illness which I set up in July 1961, continues to apply itself diligently to its comprehensive and difficult task. It has made considerable progress and may be in a position to report towards the close of 1965.
The Commission has been anxious to ascertain whether in our circumstances psychiatric units, attached to general hospitals, would yield the good results which have been obtained elsewhere. I put the suggestion to the Waterford Health Authority and it has agreed to establish such a unit at Ardkeen Hospital. Currently the Galway County Council has under consideration the provision of another such unit in the Galway Regional Hospital. I hope that by the end of the year these units will be in operation.
A new mental hospital is being established at Newcastle in County Wicklow. It should be ready to receive patients within a few months; and, while reducing overcrowding in the Dublin mental hospitals, will provide a much improved psychiatric service for the people of County Wicklow. This new development has been made possible by the co-operation which was extended to me by the former Board  of Governors of Newcastle Hospital, the Wicklow County Council and the Dublin Health Authority, and for it I thank them most warmly.
I have made certain suggestions to the respective health authorities for Cork and Kerry for the improvement of their psychiatric services. The services currently provided by them are, I regret to say, among the poorest in the country. It must be said, however, that for this, no blame attaches to the present psychiatric staffs.
Time does not permit me to analyse the reasons why the patient population in our mental hospitals is so very much higher than elsewhere; but I must suggest the main reason for its decline in recent years. In my opinion, it will be apparent from the table, which relates this downward trend in hospital population to the upward trend of attendances at out-patient clinics. The figures demonstrate how effectively good out-patient services obviate the need for in-patient treatment, to the great advantage of the patient, his relatives, his employer and the community generally.
Residential accommodation for the mentally-handicapped increased by 156 places to 2,897 in the period April to December, 1963, and there have been further developments since then.
The Galway County Council is considering a request by me to transfer the former orthopaedic hospital at Woodlands to the Brothers of Charity. If this is acceded to, I shall make a grant from the Hospitals Trust Fund to enable the premises to be adapted for some 110 mentally-handicapped patients, later it may be possible to raise this to 150. The Order have also agreed to provide 60 places in one of their institutions at Waterford.
The Home run by the Sisters of Charity of St. Vincent de Paul at Lisnagry, near Limerick, is being enlarged to take 60 more children. Works in progress or about to commence at Stewart's Hospital will increase the number of places there by 50. By autumn an additional 60 places will be available at Delvin, County Westmeath; and I understand that in the next few months the Cork  Polio Association will be in a position to receive a further 50 children. Places for 30 more trained mentally handicapped persons from existing institutions, who cannot yet return to their homes, have been made available in Peamount Hospital since December. Excluding the possible further addition at Woodlands, this additional accommodation will represent 420 new places, an increase of almost 14½ per cent on accommodation available in December last. It is hoped that all of it will become available within the next 12 months. The Commission of Inquiry on Mental Handicap is still meeting regularly and will, I hope, be in a position to report by April of next year.
In 1957 the deficits of voluntary hospitals amounted to about £960,000. By 1960 they had risen to £1,440,000 and in 1962 were £2,160,000. That is to say they had more than doubled in five years, to the point, indeed, where almost three-quarters of the annual revenue of the Hospitals Trust Fund was being swallowed up in the payment of deficits. Such a situation, the House will agree, could not be allowed to continue, for the primary function of the Hospitals Trust Fund is to finance the building, improvement and equipment of hospitals, and it has developed because of the failure of the capitation rates payable by health authorities for their patients in the voluntary hospitals to keep pace with the rising costs of their maintenance and treatment in such institutions.
As a first step towards redressing this situation, the capitation rates were increased with effect from 1st October, 1963, and this secured a net reduction of approximately £140,000 in the estimated deficits for the year ended 31st December, 1963. When, however, the preliminary estimates, supplied by the voluntary hospitals for the year 1964, were studied it was found that the deficit would be £2.1 millions, and that a more drastic approach was essential. On the other hand, if the balance were to be redressed solely by increases in capitation rates, the burden on local authorities would be extremely heavy. To relieve the situation, the Minister for  Finance agreed to make a grant-in-aid of £1 million to the Fund for hospital building, so that it became possible to limit to £350,000 the additional net contribution required from health authorities. This sum of £350,000 is, of course, supplemented by a similar sum, payable by way of health grant, provided for in Subhead G.
After the new capitation rates had been settled, the ninth round of salary and wage increases was agreed upon, and it is estimated that this will cost the voluntary hospitals £350,000 for a full year. Thus one half of the yield from the latest increase in the capitation rates will be absorbed under the single heading of increase in the remuneration of staffs.
The daily rate at which health authorities are now paying for services provided in general teaching hospitals is £2 3s. 6d. This sum covers all services, including those of the visiting specialists, the only additional or special charges being in respect of a limited range of items such as exceptionally costly drugs, and radiation treatment in cancer hospitals. The average cost of treating and maintaining a patient varies from hospital to hospital, but in the case of the ten Dublin general teaching hospitals it is estimated now to lie between £2 16s. and £4 16s. a day. As with the teaching hospitals, so also with the nonteaching hospitals. In their case, the present daily rate of payment per health authority patient is £1 12s. but the estimated average cost of maintaining and treating each such patient ranges from £1 16s. to £2 17s. 6d., with the majority above £2 8s.
With the grant-in-aid from the Minister for Finance of £1 million, I have been able to continue with the hospital building programme; so that the value of building work in progress on the voluntary hospitals or to be in progress by the end of the year will be about £5 million. On the local authority side, the value of work in progress on 31st March last was £1.1 million and the value of the additional work which will be in progress by the end of the year is £1.55 million. The totals of these items for works in progress on 31st March last is £5.3 million and for  additional works which will be in progress by the end of the year is £2.35 million. Some major works in progress and which will have gone to tender before the end of the current financial year are listed in the statement circulated.
The works now in course on county homes and others for which tenders are expected during this year are set out in the statement circulated. Their total value is estimated at £2.8 million. These works are not financed from the Hospitals Trust Fund but from loans granted from the Local Loans Fund, the State subvention being paid by way of 50 per cent subsidy to loan charges.
The cost of drugs and medicines in the health services continues to increase and gives rise to anxiety. Where, however, the use of an expensive drug results in the speedier recovery of the patient, the immediate additional cost involved may be justified not only on compassionate grounds but on financial grounds also. Not only may the patient be spared a spell in hospital, or may have to spend less time there, thus reducing maintenance costs, but he may be able to resume work earlier, with benefit to the economy as a whole.
The existing system of purchase by local authorities ensures that what is bought is bought economically. It is to the system of user, therefore, that we must look for any possible economy. Accordingly, following preliminary informal discussions between officers of my Department and representatives of the Irish Medical Association, a small working party, consisting of representatives of the central and local health authorities and the Association, was set up to examine the situation and to make recommendations. I am again indebted to the Irish Medical Association for their willing co-operation in this matter.
I am glad to be able to inform the House that, coincident with the increases in Social Welfare non-contributory allowances announced by the Minister for Finance in introducing his Budget of this year, the rates of  Infectious Diseases (Maintenance) Allowances will be correspondingly increased. When I spoke in the House on 5th February last in regard to the rates of Disabled Persons Allowances, I expressed the intention to bring them into closer relationship with the rates of non-contributory old age pensions when circumstances permitted. As a step in that direction, the maximum rate will be increased by 5/- a week with effect from 1st August next. The new rate will be 32/6d. weekly.
Thalidomide was first introduced here in May, 1959, and was withdrawn from sale in January, 1962. The effects of consumption of the drug would, therefore, be reflected in births occuring from late autumn of 1959 to the late summer of 1962. I shall refer to this as the thalidomide period.
In 1962 the Medical Research Council, at my request, undertook a survey to ascertain, so far as was practicable, the number of babies born with deformities which might be ascribed to the use of thalidomide by expectant mothers. I should stress here that deformities resulting from thalidomide are of a particular pattern; but not all deformities of this pattern can be ascribed to the use of thalidomide. Thus in the course of the survey an investigation of the records of over 37,000 births which took place in 1953-54, long before thalidomide came into use, revealed 12 cases of defects of the thalidomide type, giving an incidence of 0.32 per thousand births. In the year 1961-62, which was the year of maximum thalidomide effect, the survey disclosed that the incidence was 1.20.
It also revealed that a total of 67 surviving babies were born with these defects in the entire thalidomide period, and of these, applying the incidence factor I have mentioned, about 53 might have been affected by thalidomide. The current survey being conducted by the Medical Research Council, covering births in the postthalidomide period, will show us whether the current incident figure of thalidomide type defects is greater or less than the 1953/54 figure to which I have referred and will enable us to say with greater accuracy the extent  to which thalidomide was responsible for these defects in children born in the thalidomide period. The results of the new survey should be available later this year.
While it is important that we should have this data, what is of far greater importance is what we can do for all these children born with limb defects, whether or not the defects are due to thalidomide. This is a task which I have assigned to the National Organisation for Rehabilitation. They have investigated very thoroughly the facilities which have been developed abroad and, as a result, are in a position to offer a highly specialised service, including artificial limbs of a special type and other devices, which will go a considerable distance towards minimising the disabilities of these children and will enable them to develop and lead reasonable lives.
Surveys have indicated that we have suffered no perceptible harm from nuclear weapon testing and, in the absence of renewed large-scale tests, are not likely to suffer any.
Much concern has been expressed at the possibility that the district services associated with the Queen's Institute may be discontinued, and in that connection I would repeat that I should be extremely sorry to see these services suspended or curtailed. I have always dealt sympathetically, as my predecessors have, with such representations as were made to me by the Institute and have undertaken to meet their representatives. It has been due solely to the fact that the Council of the Institute have been awaiting the views of the branches before they came to see me, that such a meeting has not yet taken place.
Before I conclude, I should like to mention a matter which may be of particular importance in relation to the state of our children's teeth. In April, 1962, I requested a number of persons to become members of a Committee to recommend to me the best procedure to be adopted to measure the effectiveness of (a) fluoridated water and (b) the topical application of fluoride in conjunction with fluoridated water, to plan and direct  the required survey work for these purposes and to precisely evaluate what will be the results in due course.
This Committee has seven members, four of whom are University or Dental Hospital personnel, the remaining three being from the Department of Health and the Central Statistics Office. A number of meetings have been held by that Committee and they have obtained expert advice from Dr. Baeker Dirks of the University of Utrecht. In February, 1963, they recommended the type of survey which should be carried out to measure the effectiveness of fluoridated water and the topical application of fluoride and also the staff that would be required for this purpose. It is envisaged that the director of the survey should be selected by the authorities of University College, Cork, who have agreed to co-operate in the survey work in consultation with the expert committee. I have approved the programme and finance sanction has been obtained for it. The item of £6,000 which appears under subhead G is for the purpose of carrying out the survey.
This short review has been necessarily sketchy. If time permits, I may be able to elaborate in my reply to the debate on particular points which are of special interest to Deputies. I feel, however, that we can justifiably claim that the quality of the health services available for our people is, on the whole, excellent and keeps pace with modern developments. Where we are behind as, for instance, in our psychiatric services in certain areas, we are rapidly catching up. I recommend the Resolution to the House.
Mr. T. F. O'Higgins Mr. T. F. O'Higgins
Mr. T. F. O'Higgins: On many occasions since 1958, I have had occasion on the annual Estimate for the Department of Health to draw the attention of the House to, and to remind the Minister of, the frustrating situation which existed between his Department and the Irish Medical Association. For the past six or seven years, a senseless barren feud has been going on between the Minister and the representatives of the medical profession. The same situation existed from  1951 to 1954, but, fortunately, it ceased to exist from 1954 to 1957. It reappeared in the period between 1957 and last year.
Therefore, it is worth noting, and I hope Deputies will be pleased to hear, that at least twice in his speech today the Minister had occasion to say he wished to express his thanks and his appreciation to the Irish Medical Association. The reason for that is that at last in the past six months or so—I do not know whether it was associated with the Whit holiday or Trinity Sunday; perhaps the Holy Ghost descended upon someone—reason has prevailed. It is gratifying, after so many barren years, to see the Irish Medical Association, the Department of Health and the Minister for Health working in co-operation and harmony. Long may that continue. Long may it be the pleasure of Deputies to hear the Minister, introducing his annual Estimate, drawing the attention of the House to some service, big or small, which is being rendered to his Department and to the Irish people by the Irish Medical Association, working in harmony with the Department.
I say that because I am genuinely glad that that situation has now been rectified. Time and again in recent years I felt that much good work was not being done because many people were taking up positions which appeared to be important to them but were not, in fact, in terms of the welfare of the people, of any significance whatsoever. I am glad that is over. May I say that whatever the future may hold with regard to the relationship between the Minister, or future Ministers for Health, and the members of the Irish Medical Association, I am certain the medical profession now appreciate the deep and vital interest the State must have in the manner in which medicine is practised and in the organisation of the health services. In my view, that deep public interest, which is, perhaps, a symptom of our times, will not wane and may, in fact, increase.
I hope that in the future, whatever form our health services may take— and in my view there will be radical  changes—any changes that occur will have the full understanding of the Medical Association, or whoever may represent the practising doctors, and that they will appreciate that in modern circumsances there must be greater assistance from the State in the organisation of the health services for those who cannot afford to fend for themselves. The situation which has been brought about in recent times— and by recent times I mean the past few decades—is due to the vast increase in the cost of drugs and medicines, and in the expenses attendant upon the different medical and scientific techniques. In many cases the cost to an individual of providing services for himself exceeds his capacity to pay.
Therefore, there is an increasing need for some community effort organised by the State to assist people who are unable to fend for themselves. I am certain that the doctors who are working out in the field, and who are in close contact with sick people and anxious relatives, will be the first to recognise that need. I would hope that when the changes come—and changes will certainly take place in the future—they will take place in a spirit of understanding and co-operation between the doctors and whoever is responsible for initiating those changes. I hope that what happened in the past will not be repeated, and that progress will be made in the interests of sick and needy people, in a spirit of harmony and full understanding.
I should like now to refer to some of the matters dealt with by the Minister in his statement today. I should like to express my appreciation of the way in which the necessary figures in relation to vital statistics were circulated to Deputies. That is a considerable convenience and help in appreciating the progress made in the past 12 months.
In the course of his statement, the Minister referred to steps which are contemplated in relation to the cancer problem. I entirely agree with the Minister that it should be the main concern of the health authorities, and public bodies generally, to try to discourage  smoking before it becomes a habit. I have no doubt that is the correct and sound approach. Indeed, I am frequently surprised and astonished to see so many teenage boys—I am not sure about teenage girls—smoking. If ever there was a generation that had the benefit of accumulated knowledge in that regard, it is certainly the rising teenage generation today. If they wish to smoke — I suppose it would be unparliamentary to say they are damn fools—that is that. It is a pity to see so many of them beginning to acquire the habit of smoking and going the same way as generations before them. For that reason I feel that pretty positive steps are required in the schools at the moment.
The Minister mentioned, and, indeed, it is pleasing to note it, the offer of assistance which has come from the Reverend Editor of Our Boys and so on. That is a very helpful gesture but I wonder is it enough. I should like to see school authorities co-operating with the Minister for Health in relation to this important problem. At present young boys and girls get lectures from time to time from Garda officers on how they are to conduct themselves crossing the streets and the rudiments of the Rules of the Road are frequently the subject of a lecture particularly in some of the Dublin schools. I do not suggest that there should be an undue concentration on the danger of smoking but I feel a little bit more may be required. I should like to see some arrangement being worked out with school managers which would permit, once or twice a year, a lecture or talk being given to young school boys and girls so that in their formative years they will begin to grow up realising the danger of smoking. If that is not done the habit will continue despite the best efforts of the Minister, because there is always the example of the older generation before the children and frequently it is an example in the home itself. Human nature being what it is that is bound to have its effects. The young boy grows up only waiting for the day when he can do as his father does. If nothing can be done for the father then something more positive  has got to be done for the young boy. I make this suggestion and I hope something more can be done in relation to the matter.
I am glad to learn from the Minister's statement that Newcastle is going to continue to play an important role in the health services. Newcastle Sanatorium through the years contributed in a very wonderful way towards the reduction and containing of the problem of tuberculosis. In the last few years the need for the services of that hospital in relation to tuberculosis came to an end and it would have been a sad thing if Newcastle, having made its contribution in relation to one particular disease, had no other function to fulfil. I am glad it will now be used for the really chronic problem of mental illness and I wish the venture well. The Minister has also told us of the plans in the coming year in relation to mentally handicapped children. That problem exists and has existed for a great number of years. It is one that continues to be a matter of concern to parents, health authorities and to everyone who has any interest in the health services.
For that reason one could not help feeling a sense of disappointment that the residential accommodation in the period April to December, 1963, had merely increased by 156 places making a total of 2,897. Then, on reflection, one is bound to say that to provide 156 new places in that period is a considerable advance, indeed, but it shows how very far we are still from the provision of satisfactory accommodation for these unfortunate children. I am very pleased to note that in the coming year the Minister hopes, with the assistance of the Brothers of Charity and the Sisters of Charity and the authorities in the Stewart's Hospital, and so on, to be able to announce a further addition of 420 new places. Once that is done we will be well on the road towards providing a satisfactory number of places for these children in our community.
I note also what the Minister says about the Commission of Enquiry into the Mentally Handicapped and that he hopes to have their report next  year. I can assure him that there is a very great and deep public interest in this report and in whatever new thinking may appear in relation to the problem. The mentally handicapped child has long been a problem to parents, friends, relatives and to the public and there is very genuine public concern that there should be new thinking and a new approach in regard to this serious problem. Therefore, I hope the Minister's expectations that the report will be published next April will be fulfilled.
The Minister also told us about the position in regard to the Hospitals Trust Fund. May I say that I observe with dismay that the Minister this year has been compelled to accept a grant-in-aid from the Minister for Finance? That is a bad day's work. While the situation in 1955 and 1956, from the capital point of view, was not of the best, one good thing as a result of that situation was that the hands of the Minister for Finance were removed from the Hospitals Trust Fund and, indeed, whatever plans were projected and had to be made were made in the knowledge that the Minister for Health had to rely on his own resources, that he would have to project and carry out any building programme without any assistance by way of grant-in-aid. I thought that was one silver lining in the black clouds of that period from a capital point of view. I am dismayed that now we are getting back to what I regard as the bad situation prior to 1954 when there is a doling of money by way of grant-in-aid into the trust fund. It should not be there, and if it continues, there will be the frustrating experience that existed prior to 1954 when Finance sanction was required for a great number of projects and where a stultifying effect was at times brought about. If there is a grant-in-aid this year, I hope it is the only one. I hope it is merely a temporary measure to get over the hump caused by the coincidence of rising costs and the effect subsequently of the ninth round of wage increases.
The Minister, in the figures he has circulated with his statement on page 8, refers to the major works in progress  at 31st March, 1964. These, in reference to voluntary hospitals, include the new St. Vincent's Hospital, the new Coombe Hospital, the extension to Erinville Maternity Hospital in Cork, major additions to the Delvin Home and work in relation to the Medical Rehabilitation Centre in Dún Laoghaire.
I should like to place on record—I have done it before and I shall do so again—that in relation to these projects, this is now 1964 and there is no reason why the new St. Vincent's Hospital should not have been functioning as a hospital for the past four years. The construction work on that hospital should have commenced in February, 1957, and would have commenced if there had not been a change of Government in that year. The same applies to the Coombe Hospital. The Coombe Hospital project was approved by me when I was Minister for Health and it was one of the projects that I decided must proceed. Despite the capital shortage and financial difficulties I had to face in 1956-57, the go-ahead was given in relation to the building and construction of the new St. Vincent's Hospital and the new Coombe Hospital.
There were other projects which I need not mention now but, in particular, the Erinville Hospital in Cork was a project which I considered carefully and fully. I am glad to see in the House the Lord Mayor of Cork because he will recall the many discussions we had in relation to that problem in 1955 and 1956. Again the go-ahead was given in relation to Erinville and it should have been completed many years ago. The Minister, after some seven years, now reports here that at last St. Vincent's Hospital has started, that at last the new Coombe Hospital has started—the Minister laid the foundation stone recently—and that Erinville has started. At the same time, he has to look for a grant-in-aid now in relation to the Trust Fund.
I wonder what has been happening. Having removed Finance from the Trust Fund in 1956, in the belief and the confidence that the Hospitals Trust sweeps would not fold up, I was able,  with the assistance of the officers of my Department, to pick out a limited building programme which would have enabled these and other carefully scheduled projects to proceed. They would all have been built now, adding to the health resources of the country, if the Government had not changed.
The present Minister came in in March, 1957, and took a different view. He felt you should not build until you had a bag of gold to sit upon and that you had to put the money piling up there somewhere. Meanwhile, the foundation work that had been laid for St. Vincent's Hospital could rot and wither away, and the people interested in the new Coombe Hospital would just have to wait. That was the Minister's approach. In fact, I was astonished to find that, while the receipts went into the Trust Fund, the Minister was investing the money. It went to different purposes. It was being used in the past few years in relation to other requirements of the State and eventually, 18 months or two years ago, the Minister decided the time had come to press ahead with some of these building projects.
Now, after another period of waiting, he is able to report that work has started. At the same time, he has had to say: “But the Minister for Finance had to come to my assistance”. I wonder what all this means. I do not believe it is progress. It is just going around in a circle. However, what should have started in 1957 is at least on its way and that is a good thing.
The Minister's statement also refers to the problem raised in relation to thalidomide. He has told us of the results of research carried out through the Medical Research Council and that in relation to the thalidomide period, it would appear, prima facie at least, that the incidence of malformed and deformed infants rose from .32 per 1,000 to 1.2 and that of a total of 67 surviving babies, some 53 might have been affected by thalidomide.
In relation to this problem of thalidomide, the very word itself is almost an emotional word now and people can get into a state of considerable concern and anxiety because of what happened, and we should not forget—  I am sure the Minister appreciates this —that what happened in relation to thalidomide caused a burning fright in the minds and hearts of most decent people. It is an appalling thing to think that a well-intentioned doctor treating a thankful mother should in fact have been bringing about the result of the birth of a malformed, unfortunate, poor morsel of humanity. It was an appalling thing to have happened, a most tragic and terrible result.
For that reason, I wish to say this to the Minister. He has told us that of the thalidomide births there may now only have survived 53 poor thalidomide infants. The Minister goes on to say that research is going on and that new figures may be available next year. I am sorry there was then a full stop in his statement. I should like to have heard him say and I would have been proud to have heard him say that as a result of a study in his Department, steps have been taken to ensure there will never again be a thalidomide fear in this country.
Those are the words I was waiting to hear him say; those are the words I believe most people throughout the country would have liked to have heard him say. I should like to recall to the Minister, and I do so without in any way endeavouring to score points, that I as a Deputy, and indeed others, raised this matter of thalidomide some three or four years ago. At that time I stressed my view—it may have been ill-informed but it was my view—that we required in this country some bureau of standards, some guide, something that would enable doctors and practitioners to know where they were going.
After all, from the point of view of drugs and medicines, largely speaking, we are a consuming country; we have to take and use pretty well whatever is produced on commercial lines by the big drug concerns of the world. These come into the country. There is no way here in which they can be tested, no way in which they can be compared, no yardstick or standard, and thalidomide happened here. Fortunately, it was on a very small scale indeed but it is worth recalling that thalidomide was  not allowed to be prescribed or used in America.
It was not permitted there because in the US, though it is the home of many of the great commercial empires built out of the sale of drugs and proprietary medicines, nothing can be put on the market until it is passed and approved. In relation to thalidomide, the appropriate officer in the Federal State services just would not allow thalidomide to be sold and it never went on the market. The result was that thousands upon thousands of personal tragedies were averted in that great country.
It went on the market on the continent and here, and that is why, years after, there are some 53 unfortunate children who will become figures in the vital statistics of this country. It is for that reason I would have thought, I would have hoped—I know the problem is difficult—that the Minister, his officials and advisers should have been concerned to prepare some plan which would at least ensure there would be some kind of a sieve which would prevent the untrammelled importation into this country and dissemination of drugs, the particular value of which is not clearly known. I hope the Minister will be in a position to give me and others some reassurance in relation to that matter.
I wish to pass for a moment from what is in the Minister's statement to say a word about something which is not dealt with in the statement. I have expressed pleasure that the Minister was able, inferentially, to report a state of harmony between himself and the Irish Medical Association. I wonder can he say the same with regard to the Irish Nurses' Organisation? As far as I am aware, there has not been, as there should be, the kind of harmony and good feeling between the Minister and the nurses. In particular, I am concerned with one branch of nursing and I understand difficulties in that respect have reached the stage at which strike action is threatened.
I express the hope most sincerely that that situation will not come about. I know it perhaps would not be helpful to discuss the merits or demerits of  any dispute existing and for that reason I do not propose to do so. However, I do express the hope that in relation to nursing and to work in hospitals, everyone will realise that if there were the carrying of a dispute to extremes the people who would suffer would be the sick in need of nursing and medical attention.
I am pleased with the progress the Minister has been able to report in relation to the general health of the people. I hope the omissions which I stressed and the contrary views I expressed will be understood by the Minister and the House as an expression of anxiety on my part and on the part of the people on this side of the House in relation to what appears to be tardy progress in some directions. Generally speaking, I feel the Minister for Health and his Department deserve congratulation from the House and from the country on the work they are endeavouring to do. I hope that in whatever changes in policy may come about in the future in the new organisation of the health services, there will be required what the Minister now has, dedicated officers of the Department.
Mr. Carroll Mr. Carroll
Mr. Carroll: I rise to repeat an expression of view I gave on this Estimate one or two years ago, that is, that if it were only because of the improvements the Minister has brought about in our mental health services, I would agree with his Estimate. I am pleased to see that in Dublin increased services in St. Brendan's are proposed but I deplore the lack of publicity for the services at present available in St. Brendan's for extern patients. While the service is wonderful, I think it needs further improvement. People in the initial stages of mental disease can avail of this extern service but it does not get sufficient publicity, nor is there sufficient availability of the service. Generally, our mental services some years ago were deplorable and it is gratifying that so much attention is now being given to them.
There is another service to which I wish to direct the Minister's attention, even though I regard it really as a municipal or local authoity function, that is, the provision of a doctor to  accompany every ambulance going out on an accident call. I raised this in the Dublin Health Authority even as recently as a year ago but I did not succeed in my object. Now, in view of the terrible toll of fatalities on the road, even in recent days, it is surely time to have ambulances going out on accident cases equipped with every possible means of saving life. Now that relations between the Irish Medical Association and the Minister's Department are normal, I do not think there would be any difficulty in that regard. A doctor is essential in an ambulance answering an accident call. We know that in recent weeks it would have been a most important factor if a doctor had been in the ambulance to relieve pain and possibly save life.
Our ambulance services are at present certainly below standard. I say that without fear of contradiction, having had the unfortunate experience of having had to ride in one of the ambulances. I do not believe the Minister will experience any difficulty in this matter, nor do I think it will involve great expense on anybody. Even if it did, it would be much more justified than some other expenses. Even in Dublin, what extra expense would it mean? We have the house surgeons and the ambulances and while, possibly, you cannot arrange to have a doctor waiting in the fire station, I do not suppose that would be necessary. This is a service I have been endeavouring to secure for the past three years and I trust it will soon be provided. There is a crying need for it with the increasing toll of the road and I again ask the Minister to give his attention to the matter.
We are making progress and I am very glad to see it. I do see it because of my business in the various hospitals that I visit, apart from being a member of a visiting committee. In regard to those with mental trouble, we should endeavour to make the best possible provision for them. Great strides have been made in this respect but the Minister will certainly have my support in anything he does to provide further improvements in our mental services.
Dr. Browne Dr. Browne
 Dr. Browne: I should like to join with Deputy O'Higgins in congratulating the Department and the Minister in presenting the case for this Estimate so clearly. It is a great asset to have the statistics laid out in this way. In regard to the contents of the Minister's introductory statement, it was a great satisfaction to everybody to see that, taken by and large, there has been a general improvement in the significance of the vital statistics.
Regarding the figures given for births, marriages and deaths, I want to draw attention to the fallacy which might be present in giving such bulk figures for a community which has tended to have a falling population. Figures such as the infant mortality rate per 1,000 live births are, of course, more valuable to us and of greater significance. It is very satisfactory to find that the figure has come down from the very high level of 45.7 in 1951 to the 27 that we have currently per 1,000 live births.
The Minister says there has been a considerable decline in the infant mortality rate. I suggest the decline is not as rapid as it should be. We have a long way to go yet to ensure that youngsters coming into the world get a real chance of surviving. Obviously, there is an irreducible minimum in this type of situation but I do not think—and I am sure the Minister will agree with me—that we have reached anything like that irreducible minimum here.
In relation to maternal deaths, I think the figure is still very high, undesirably high and, I suggest, unnecessarily high. With the great advances that have been made in medical, midwifery and gynaecological sciences and, of course, the availability of wonderful antibiotics, it should be very exceptional that a mother should die in childbirth and this is a figure which the Minister should have examined very much more carefully.
I wonder would he ever consider commencing an investigation such as was carried out a very long time ago? I think he carried it out himself. Certainly it was in his time in the Department—in the early 40's, I think.
 It was in relation to the income levels and occupations related to infant mortality and maternal mortality rates. He probably recalls the figures. They may have had something to do with his introduction of the magnificent 1947 Act, his own 1947 Health Act. They may have had something to do with it, particularly the mother and child provisions in it.
These figures showed an appalling discrepancy between both maternal and infant mortality rates closely related to the occupation and financial status of the mother. As far as I recollect, the infant mortality rate went from something like 30 per thousand in one particular group, the wealthier type of group, the professional group, and so on, to about 130 in the manual worker, labourer and so on, group. There was a very significant discrepancy and it was quite clear that the home background and the financial status of the parents were very important factors in the vital question to the child as to whether he should live or die.
I do not know—probably I am attributing to the Minister something that he had no intention of doing— but I would have said, anyway, that those figures, although they related only to Dublin, had their own relevant significance. To me at any rate, they would have justified the most radical changes in our health services. Of course, these radical changes were proposed in the 1947 Health Act, certain aspects of which, in relation to this part, the mother and child part, never came to fruition, regrettably.
I know circumstances have changed in post-war Dublin generally; living conditions have certainly changed and improved. I wonder would it be a help to go into that matter again in much the same way. It was relatively crude but at the same time it did give a significant indication that if you were a poor person your chance of losing your child or, if you were a mother, your life, was very much higher than if you were a wealthier person with money. Certainly, if I had a chance again, I would certainly like to carry out such investigation once again to  see to what extent there might be any validity in that point of view even yet.
An Leas-Cheann Comhairle Cormac Breslin
An Leas-Cheann Comhairle: Would the Deputy please remove the papers from the microphone? It is very difficult to hear him.
Dr. Browne Dr. Browne
Dr. Browne: Certainly. Everybody knows that the Minister has worked very hard on the question of mental illness and, as I said earlier this year, introduced as good legislation and progressive legislation in regard to it as it is possible to have. That is bound to have its own effects in time. It is a monumental problem. Anybody who looks at these staggering figures here of the bed occupancy of mental hospitals—something like 20,000, I think —can see that there is something terribly seriously wrong in the country from that point of view, that there should be so many people who are sick in that particular way. One recalls Swift's comment when he started Saint Patrick's Hospital, that he was starting it for the citizens of Dublin and nobody needed more this mental hospital. I am not making that comment. That was Swift's.
It is sad to think that there are so many people affected, that there is this necessity. I, personally, would not presume to try to say why it is so. I sincerely hope that the Commission which the Minister established will report as soon as possible in order that we can take the next positive steps towards reducing the number of people who find themselves in this distressing state of mental ill-health.
In passing, in relation to that, there is one factor which I think must have occurred to a lot of people. It has occurred to me recently because of my own personal experience from a medical point of view and I suppose it must have been brought to the public notice to a considerable extent by recent articles in the Irish Times concerning alcoholism, that a very high percentage of the inmates of mental hospitals are alcoholics. The origins of that, the medical reasons for it, nobody seems to know. I wonder does it ever occur to the Minister or to the Government that it  is a very costly thing that there should be such a high percentage of persons requiring care in mental hospitals for this disease? I am not blaming the incidence on the Government but is it not a fact that we do tolerate remarkably lax standards in relation to the promotion of drink sales in our society? I am not a prohibitionist because I do not think it is feasible. I do not see any objection to anybody having a glass of beer or whatever it might be occasionally but where drink brings persons to the state of incapacitating them, making them a burden on society, denying their family access to whatever abilities they may have, to professional qualifications or technical qualifications, it seems to me a very serious state of affairs. I wonder, as in the other matter in which I personally am interested, that is, cigarette smoking, to what extent the Government would be justified in taking another look at this whole question of the promotion of alcohol sales in society.
The most irritating thing to me of commercial television here and the other one that we get is this dreadful compulsive reiteration of this business of smoke and drink. It would seem that the only two pastimes accepted as being common in our society are drinking and smoking. One after the other the inane jingles chant stupid slogans advising people to do something which in a very high percentage of cases ends up in very serious physical and mental consequences and personal conflicts for the people who indulge in it.
Surely there should be some limitation on the advertisements in the very intensive promotional campaigns by the alcohol and the cigarette people, when the end results are known to be so serious from the community point of view. I know that the whole matter is tied up with revenue but what the Minister gains on the swings he loses on the roundabouts of hospital charges. He has a lot of people charged on his funds, some of whom may not be there, were it not for the fact that the State radio and television services are urging them to pursue practices  which may well end up by sending them to our hospitals, and in many cases to our cemeteries. I do not know if the Minister is as irritated as I am——
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: I hope I am not more so.
Dr. Browne Dr. Browne
Dr. Browne: ——by the idiocy, waste of talent and inanity of the advertisements in this regard.
For the mentally handicapped child, everybody has the deepest sympathy. I do not know whether the sympathy is greatest for the child or for the parent. There is always the dreadful knowledge for the parent that the child must be left eventually to somebody else to look after it with the uncertainty of what the after life will be. The most impressive thing I saw in my experience in the Department was the devotion of the Brothers who look after some of these children. I do not know how they can bring themselves to deal with some of these cases.
Some of the children are perfectly amenable but in some cases the attention required is more than money could buy. You could not pay for the work these Brothers and the members of the religious orders do for these young people. I understand there is some slight doubt in the minds of the people concerned as to what extent we should extend the hospital side of the treatment as against the dispensary side. I understand the general feeling is a slight tendency to believe that the child would become more integrated the longer it remains at home but under supervision at some sort of dispensary. I suppose the Minister must wait for the report of the Commission on the Mentally Handicapped to come to his final conclusion.
I know that in other countries the difficulty has been to find people to undertake the work of looking after these young people. In certain circumstances, some children are grotesque and difficult to handle. I should like the Minister to state to what extent we are getting the nursing staffs and the religious orders necessary to carry out this work.
 On the question of the deficits of the voluntary hospitals, I do not want to misrepresent Deputy O'Higgins, but I do not know why he is upset about the subvention from the Minister for Finance. If his case is that he fears that the money from the Hospitals Trust Fund has been misspent, he may have a case but I want to make the point that we must be one of the few countries in the world which has not had to build all our hospitals from the Central Fund. We have had the advantage of the Hospitals Sweeps providing the funds to build our hospitals and we have as good hospitals as any country in the world. They are better equipped than most. I do not see anything wrong in the Minister for Finance helping in this case. If we take the 40 year period since the foundation of the State, we must realise that we have saved a tremendous amount of money in this regard. The total outlay from the Hospitals Trust Fund has been tremendous and my attitude would be to ask the Minister for Finance for more and to tell him that he is lucky to get away so lightly.
Most countries do find themselves facing this problem of building hospitals. In regard to that question, there has been a very rapid rise in costs. I do not know what the cost per bed is now but it was £2,000 per bed when I was in the Department.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: It is £6,000 now.
Dr. Browne Dr. Browne
Dr. Browne: That gives us some idea of the need to take decisions to use the money while it is there. Of course there may be the other side, that while the value of money is falling, the receipts from the sweep funds are increasing.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: They are not.
Dr. Browne Dr. Browne
Dr. Browne: There may be a balance but it is a frightening thought that in a relatively short time the cost of hospital building has increased nearly three times.
I am sorry the Minister did not deal with our general medical services. About £1½ million of his Vote is to be spent on these services. I think the  public should get some indication from the Department as to what is to happen in regard to the general medical services. The position in regard to these services is that we have about as magnificent a substructure for the creation of a first-class medical service as any country could have. We have first-class nurses and the medical profession is pretty well informed. We have magnificent hospitals for all branches of medical services. To some extent, we have, for a certain section of our community, a service that is inadequate but it is a service, that is, the dispensary service.
I believe that in that service there is a great need for the provision of a free choice of doctors. That is becoming a more urgent need. As people begin to see the schemes available in other countries, as they watch television, as they travel and as their knowledge expands, they begin to notice even more acutely the defects in our social system. While the picture in regard to dispensary services is not wholly bad—at least it is some kind of free medical service—it could be greatly improved by relatively minor adjustments. The most important is this question of trying to give a free choice of doctor to the patient. The Minister should expedite his decision in that regard. I know a Parliamentary Committee are sitting on this, but they have been too long on the job. We must tell the people what is happening. The Minister should take this opportunity of telling them, even in the broadest way, what intention he has in this regard.
The fact is that three-quarters of a million people are treated in this type of service and the rest in a kind of pitiless free-for-all where they have to fend for themselves. It is probably true to say at this stage in our history that the white collar worker has a more frightening time than the dispensary patient when he and his family suffer ill-health. This has many serious repercussions. The most obvious is that they are frightened to go to the doctor—frightened by ill-health, by incapacity, by loss of earnings and loss of job. Then there are the consequences for the family. It is a harsh society  when the breadwinner loses his job. Normally, the white collar worker would expect to try to get his children through technical or secondary school, and possibly to the university. Unless he can do it himself, he is virtually denied what most other countries give people of that kind and give the dispensary patients as well.
It is a frightening prospect for the white collar worker. On top of his incapacity there is the doctor's bill. While that used to be the important aspect, it is the least important aspect now. The doctor's bill, at least on the general practitioner side, is not the really frightening prospect. The really frightening prospect now is the chemist's bill. I know of conscientious doctors faced with the dilemma of ordering an effectively out-of-date but cheap drug rather than ordering high cost drugs. The Minister will say that these people can, if they wish, get free service under the existing Acts. In practice this is very rarely claimed. As far as I can see, very few know about it. By the time a person gets around to getting the facilities, he may be dead. There is this very considerable defect in our health services which has not been mentioned by the Minister. The result on the family is that the individual goes to the doctor very much later than he should and what was an early trouble becomes advanced and may cost him his life. That is not an overstatement of the position for a considerable number of people in our society. They are conscious of the fact that this is there, but they are also conscious of the fact that it need not be there. They know quite well that most other societies have met this difficulty and have taken steps to deal with it.
In this country we have the dispensary service and the Voluntary Health Insurance service. The latter has all the inadequacies I mentioned before—lack of a general practitioner service, lack of a domiciliary service, the fact that the sick person simply does not qualify. There is nothing to protect the white collar worker at present. This issue has been discussed on a number of occasions. The political debate has gone on as long  as I have been in politics, nearly 15 years. The debate should be brought to an end, and we should come to some decision. We should, all of us, put our cards on the table, say what we believe and give the House and the country a chance of saying what they want.
I must confess I did not think the setting up of the Committee was necessary, although I took part in it. I felt we had already perfectly adequate experience of every kind of service here. There were pilot schemes to be examined and considered, where we could apply the good aspects and get rid of the defects. I should like to see an extension of the Infectious Diseases Scheme, which is free with no means test. There are other variations of that type of approach. As far as I can see, the Minister is content to carry on with his present type of free for all in the group outside the 700,000 covered by the dispensary service. He certainly has shown no sense of urgency over the years we have been on this Committee. He suddenly seems to have developed an extraordinary consciousness of the necessity to consult all and every possible group of individuals who might have the remotest connection with medical services and ill-health.
The Minister may reply that he is a true-blue democrat, a man who likes to defer to the general view, who goes into these things with an open mind, and who would not like to impose anything which had not been agreed upon. If it were virtually any other Minister in the Cabinet, or any Deputy on the Opposition side, we might accept that case if it were made, but the Minister's record is against him. He is a very strong-minded, strong-willed, opinionated, egotistical individual. Frankly, he is as little likely to be altered in his views by what he has heard in the past few years, as I am myself. I have made no secret of the fact that I knew what I wanted, and know what I still want.
I believe that while we may go on with this Parliamentary game, and carry out this intricate exercise of political in-fighting, people are getting hurt, and people are suffering. The dreadful fear and worry of ill-health  is over-shadowing the lives of a very considerable section of our population. I believe it is time for consideration and consultation to stop. I believe it is time we made it clear where we stand on the future organisation of our health services. The Fine Gael Party have come forward with their scheme. Deputy O'Higgins has made it public. Obviously their minds are clear on what they want, and they do not want to hear any further evidence, or have any further consultations. That has been true for a long time so far as we can gather. The scheme and its merits are of no importance to us at the moment, but the fact that they have made a decision is important.
We also are quite clear on what we want. Our proposals are that the health services shall be based on a flat-rate insurance-type scheme, with the usual social welfare variations and variations for agricultural workers and domestic workers. The scheme should cover those who are outside the existing service, who should continue to get the free service. Medical prescriptions should be free of all direct charge, and there should be a free general practitioner service, with a free choice of doctor so far as that is possible. We believe in that type of scheme at this stage. We believe it is realistic and practical.
We believe that, because of certain defects in our economy, due to the failure of Governments over the years to establish an economy which would permit the Minister for Finance to say: “We will have a medical scheme based on a scheme like the infectious diseases scheme, the British scheme or some other type of scheme”, there should be a flat-rate contribution to an insurance scheme so that we could give some assistance to the very large section of our society which is in very serious need at present. We believe that scheme should cover the whole population, and that 85 per cent, or 95 per cent, or any group, should not be excluded. We believe that insurance scheme should include the whole population, outside the social welfare groups I have mentioned. It should  include the self-employed person and the small farmer, and if people want to use another scheme, such as the Voluntary Health Insurance Scheme, or any private scheme, they should be able to do so. So far as the general public are concerned, we would like to see the elimination of the two-tiered type of medicine which is inseparable from the scheme we have in operation in the country at present.
The Minister may have better proposals than those. He may indeed, give us back the 1947 Health Act. If he does, and particularly if he gives us the mother and child proposals, he will be welcomed with open arms as far as we are concerned, and he will get full support. One of the great enigmas of politics — perhaps historians may resolve it—is the extraordinary political schizoid record of the Minister. I say that without meaning any disrespect. The Minister has been remarkably progressive in health legislation on one side, and extraordinarily conservative on the other side, in his political career. As I say, I do not want to make any disrespectful implications, but that is one of the things that has always fascinated me.
If the Minister has a better scheme, it is long overdue, and it should be made public. He owes it to the public to make that scheme available. Let him decide between the lot of us, and let us go ahead. The Fine Gael Party have nailed their colours to the mast, and said: “This is what we believe in.” We have said: “This is what we believe in.” The Minister owes it to everyone to say that, having reconsidered the position, Fianna Fáil have decided that the present scheme is all right with minor adjustments, or that a clean sweep and the establishment of a new scheme is the only approach to a resolution of our difficulties.
Speaking for myself — this is not Labour Party policy and I hope the Labour Party will not be attacked for it—in regard to the reference made by the Minister to cigarettes, and without meaning any disrespect to the Reverend Editor of Our Boys or An Gael Og, the Minister cannot be serious in thinking this is a significant contribution——
Mr. MacEntee Mr. MacEntee
 Mr. MacEntee: The circulation of those magazines is very great, and I would assume that the lesson which the advertisements try to inculcate would also be delivered orally to the boys.
Dr. Browne Dr. Browne
Dr. Browne: However, that is merely in passing. I always appear to be on the side of the advocacy of a sort of carthusian monk-like existence for society. I am not like that at all, and I do not wish to be portrayed as being like that, but I do happen to know people who contracted cancer of the lung and know what it is like, particularly the operation and particularly death from it. It is a dreadful thing and I feel one has a responsibility as a medical person to help in drawing to the attention of the person who might not know it, the fact that it is a dreadful prospect and that it appears to be avoidable, especially where cigarette smoking is concerned.
Again, there is no question of prohibiting the smoking of cigarettes because it could not be done. One of the most disturbing things to me is that when the American report was published, many of my friends stubbed out their cigarettes and that was the last cigarette they smoked for a week, or perhaps in some cases for a month, and for some a little longer. I was interested to find going back amongst them that they were all puffing away again just as they were before the report was published.
Mr. A. Barry Mr. A. Barry
Mr. A. Barry: It is very difficult to defeat human nature.
Dr. Browne Dr. Browne
Dr. Browne: Whatever it is due to, they are at it. It is significant because it shows how terribly difficult it is to give up the habit. As Mark Twain said: “It is easy to give it up; I have given it up hundreds of times”. My main complaint is that they get virtually no help from the Minister. The Minister has tremendous powers at his disposal, certainly in collaboration with his colleagues in the Government. Deputy O'Higgins abused the poor teenagers. I think the teenager who does not smoke must be a sort of crank because of the barrage of propaganda which is directed against him,  pressing him to smoke. A cigarette in your mouth is really a maturity symbol now, a sign that you have grown up, that you are emancipated and that you are like your father. I would not agree with Deputy O'Higgins that we should give up hope of helping the father, even if it is only for the reason that if the father does not stop smoking the child will certainly smoke. The best way to start a campaign would be to help the adult, to the best of our ability, to stop smoking. The best way is to tell the adult of the consequences and in accordance with the methods used by our opponents in this, the tobacco companies. One of the arguments frequently used by the Minister is in regard to the danger of creating panic amongst the people. Where people are mature and adult, and most of our people are, there is no serious danger of panic by telling them of the effects, by telling them the truth.
We adopt a very strong line in regard to opium, morphine and cocaine. Even though people might like to indulge in these drugs, we do not permit them to do so. There are very stringent laws for people who might be addicts or might become addicts. We do not suggest that we should insert an advertisement in Our Boys, for instance, saying: “Keep away from cocaine or from the opium pipe when you grow up because it is dangerous. If your daddy is at it, take no notice because he cannot help it”. It is an absurd argument and could not have any impact on young people. As I say, we take a very strong line in relation to those things and I am beginning to see cigarette smoking as a form of drug addiction, and as a cause of cancer of the lung, it is something that simply cannot be ignored.
It is suggested by the Minister that if one keeps plugging this idea, people will take no notice eventually. If he could persuade the tobacco companies of the validity of his point of view and get them to make a statement just once every six months or preferably every five years that cigarettes are good for you and that they have all the properties they claim for them, say, in the annual general report, and  then in the interval, let there be absolute silence about the merits of cigarettes, then I would be prepared to accept that there is some case on the Minister's side. However, the people who look after television and newspaper advertising are experts.
I understand that something like £4½ million is spent on advertising. It is a tremendous sum of money in a small country. Practically every day there are half-page or quarter-page advertisements and practically every time one looks at television, one sees people puffing cigarettes and smiling and grimacing, and there are all sorts of terribly dishonest suggestions that this is a healthy pastime, a great outdoors thing, that really tough men do it and all that sort of thing. It is all extremely clever and the waste of talent that goes into advertisements could provide material for an entire debate. The waste of high artistic talent of one kind or another which goes into the promotion of these things is simply immeasurable. This goes on all the time, virtually all day, on this terribly powerful medium, and there is simply no counter to it. People on television take out cigarettes and smoke them and then you have the programmes promoting them.
The Minister says he is going to see these people so there is no sense in prejudging him. Unless he takes very serious steps to stop this advertising on television altogether and to stop newspaper advertising altogether and insists that the tobacco companies print on their cartons “Smoking these cigarettes is likely to give you cancer of the lung”, I think he will leave himself open to the charge that he is more concerned for the revenue tobacco brings in than with his responsibilities to the public to tell them this is a very dangerous habit and one which can lead to cancer of the lung for which there is virtually no cure and for which the only hope is to remove the lung and then have the prospect of waiting for the secondaries to appear. I do not see why, when this fact has been fairly completely and authoritatively established, the Minister could not, would not, or will not  take very drastic action of this kind. I hope he will.
He suggested to me on another occasion that I should introduce a Bill here in order to have the matter at least discussed and, no doubt, voted on. I intend to do that and I hope when I do he will give us an opportunity of getting the point of view of the various people in the House on the question. I do not for a moment believe I would get substantial support for the Bill. My reason for saying that is that I have made a very strong case here for establishing the ingenuity and skill used by the tobacco companies in their salespushing campaigns. If my claims are valid and fair claims, then clearly the effects will be seen here. The strength of the vote against my point of view will reflect the efficiency of the campaign for the promotion of cigarettes. An overwhelming defeat for my Bill is likely and it will merely show how efficient has been the advertising campaign of the tobacco companies in persuading people to carry out this lethal practice on themselves. Advertisers tell you they can sell anything. One of their greatest triumphs must be the fact that they can sell something to someone which will eventually kill him. That will emerge from the debate, and if I am wrong, I shall be very glad to be wrong.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: The Minister in introducing his Estimate did not cover as wide a field as he usually covers. We can appreciate that, as we have recently had a Supplementary Estimate and a great many matters were debated at that time and replied to by the Minister; but there are one or two points I should like to raise in connection with our health services as a whole.
I am glad to note the Minister's references to retarded children and that further accommodation is gradually being provided in different parts of the country in relation to this problem. There is still one matter that requires adjustment in this regard. It is in regard to the cases that come to the Minister for Health. These are the extreme cases that have no educational  potential whatsoever; in at least 98 per cent of the cases dealt with by the Department, such as the vocation case. The line of demarcation between the two cases is difficult and the problem is accentuated and made more difficult by the fact that two Departments are concerned with it. The Minister mentioned that a commission is sitting and that the commission will issue its findings in April of next year. I have suggested before to the Minister, as he is the senior Minister, that he should take the initiative with his colleague and that there should be the closest co-operation and discussions between the Department of Education and the Department of Health. That co-operation may already exist. I do not know.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: It does.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: In regard to the cases as a whole, it is necessary to ascertain the number of retarded children in the country. I have been to the Minister's Department and they have indicated to me that they have the greatest difficulty in finding out where the retarded children are and their number. I do not think there should be that great problem. They have told me that in other countries exactly the same state of affairs exists, that it is impossible to get a hard and fast list.
All the cases of retarded children in this country go through the local authorities. I take it all these cases are passed through the responsible medical officer of health when the application is made for institutional treatment. Therefore, it should be possible for the Department of Health to secure from the medical authorities or from the local authority, the county manager possibly, who is the executive officer responsible for it a list of these cases and where they are. That being done, I would respectfully suggest to the Minister and to his officials that they then draft a plan of campaign in the siting of these new institutions that are being opened for retarded children so that as far as possible when children are admitted to these institutions, they will be within a reasonable distance of their parents,  so that they can be visited without great difficulty by interested relations.
My experience as a doctor has shown me that there is perhaps more devotional attachment to a retarded child in a home than to any other child, and it is right it should be so, but it is very hard to get parents, therefore to agree to have children sent to institutions if they are sent a considerable distance away. If the Minister could get this list and have an over all plan of campaign whereby these institutions would be sited across the country so that this problem would be dealt with at local or semi-local level, great advances would be made. It may well be the Minister will reply that the Commission is sitting and that the Commission will issue its findings. This is an urgent problem, one of the most urgent medical problems we have and I would suggest the Minister should consider it on those lines.
The Minister, speaking of cancer of the lung, gave statistics which indicate there is a slight decrease in the number of deaths.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: Only as between one year and another.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: There is a slight decrease in the number of deaths. In his reference to it, the Minister seemed to associate it entirely with smoking with which, no doubt, Deputy Dr. Browne would fully agree. Smoking is not, of course the only cause of cancer of the lung but it is a contributory cause. It would be helpful if there were a regional breakdown of these statistics, if we could be told that these deaths took place mainly in the urban areas, or that they took place in rural areas as well or if they were almost equally divided in relation to the population. If the Minister breaks down these statistics, he will find the majority of cases of cancer of the lung arise in built-up areas.
I have long had a theory which is supported by statistics and facts — scientists and others interested have gone into it—that one of the contributory causes of cancer of the lung is oil pollution. From certain types of heavy vehicles, particularly dieseldriven machines or engines and some  types of big lorries, there is a discharge of noxious gases or fluids. I think it is mandatory on these vehicles to have the exhaust so placed that these gases go out at the top and are disseminated more freely in the air. From buses in the city, and a great many heavy lorries, this discharge is occurring continuously at very low level. Noxious air tends to rise when discharged into a built-up area and there follows a considerable accumulation of noxious gases.
I invite the Minister to collaborate with his colleague, the Minister for Local Government, to see if this offensive irritant discharge cannot be forced upwards by placing the exhaust equipment on such vehicles higher up. I suggest it might eliminate many of the noxious gases we are now breathing. The Minister does not seem to agree. Of course he has banked all on smoking, but on what facts does he base that argument?
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: I am wondering only about the technical problem involved in carrying the exhaust equipment high up in the air and the assumption that if that is done, the irritant gases will not affect the pedestrian. I am questioning the validity of that assumption.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: I qualify that by saying that at the moment the gasses are discharged at very low level. The Minister must admit that. If he does not, I invite him to walk behind a slow moving bus and he will get enough gaseous vapours to last him for the rest of his life.
Mr. Kyne Mr. Kyne
Mr. Kyne: He does not need them.
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: That is a safety factor—that the gases are being discharged at a low level.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: Does the Minister suggest these gases go into the ground and disappear?
Mr. MacEntee Mr. MacEntee
Mr. MacEntee: I suggest they do not rise to breathable level.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: I suggest to him for his consideration that the  gases should be discharged from the top of the vehicle and eliminated or diluted in the air by the wind. They will become dissipated in the air. Does the Minister think it is a joke, not worth considering, or is the Minister interrupting me to try to lead me in various gaseous directions?
I wish now to say something about nursing and hospital staffing generally. It is becoming increasingly evident that practically all countries are facing difficulties in securing adequate nursing and general hospital staffs. In the United Kingdom, I recently had a discussion on the matter with British parliamentarians and they told me they have a tremendous problem to get nurses. Many of their nurses are being syphoned off to the US where the salaries are much higher. We come at the end of the scale in that respect. We are a poorer country, unable to pay the same level of salaries to our nurses and doctors as other countries pay. For that reason, we face an even greater problem with regard to emigration of our nurses. Perhaps the Minister would indicate how many nonnationals there are in local authority hospitals. I understand the number is growing all the time.
On top of that, I was informed quite recently that a dispensary vacant in my constituency, which the Appointments Commission have been endeavouring to fill for some time, will be filled by a non-national, if that is possible, due to the fact that the Commission are unable to get an Irish applicant. If we look at this from a reasonable point of view, it is only natural that is happening. Take two employees of one family. One goes into business and becomes a high executive at the age of 29 or 30, capable of earning £3,000 a year. His brother becomes a student of medicine and after considerable expense in the university, must do post-graduate courses at a low salary. He is lucky if he can command £1,200 a year.
We will have the problem here that already exists in wealthier countries. We have been told economic prosperity here is round the corner. The Taoiseach said this will be a very wealthy country in a short time and I feel sure the Tánaiste accepts that.  It may not have become very evident yet, but I submit it will, that there will be great difficulty in the future in getting graduates in as large numbers as in the past. It is only reasonable then to suggest they should be put on a par with other professions, and the position of business executive is a new type of profession.
I know there is difficulty in getting nursing staffs for hospitals. The salaries paid to our nurses are, in my opinion, inadequate. The Minister may say it is all the money we have at our disposal. In reply, I would refer him again to the economic prosperity round the corner. Across the water, because of the great difficulty they have in getting nursing staffs a scheme has been developed whereby married women are brought in to do temporary duty in hospitals.
I admit it is not very good for hospitals to be changing nursing staffs, but it is better to have some kind of nurses than none. As I said, I do not know whether the problem is quite so acute here yet but I assure the Minister it will be. I suggest that the Minister should get a register of nurses in an effort to locate all the married nurses so that they will be readily accessible, when and if the need arises. I have been advised by the British parliamentarians that the married nurses they employ in Britain are well past the childbearing age. The Minister may reply that there is no shortage of nurses here. I do not agree. I say that if there is not, there will be in the near future. While on the subject, I exhort the Minister to give every consideration to any application for salary increases by nurses. After all, they are justly entitled to the standard of living everybody else is enjoying and which they are not getting.
I should like to deal with the problem of heart disease. From the Minister's statistics, it is evident there has been a slight reduction in the number of fatalities. I suggest it would be advantageous to the House to have a breakdown of that figure. Could we get from the Minister some indication of the age groups of heart suffers? I have a feeling that quite a number  of young people, people at the age of 40, 45 or 50, are suffering and dying from heart disease nowadays. It is always important from the national health point of view that some consideration should be given to the matter and some educational instruction provided.
It seems to me much of the heart disease is due to the fact that people have given up taking exercise. In the past, people walked quite a lot, moved about generally. Young people nowadays take practically no exercise. They get into a car, drive to their business, finish work, go home, switch on Telefís Éireann and sit watching it. They are putting on weight gradually and find themselves suffering more and more from lassitude as a result.
Young people have given up even the Sunday walk with the dog. Instead they sit and read a newspaper. I suggest that is one of the reasons for the high incidence of heart mortality. I may be wrong, and I am therefore asking for a breakdown of the figures so that we can find out how many of the 10,000 who died of heart disease are below 50, below 45, and how many are above those ages.
I make another suggestion to the Minister. There has always been difficulty about who is entitled to medical cards and who is not. Each local authority under the Health Act must decide who is eligible. It has come to my notice that quite a number of people who have not got a medical card are under the impression that if they have to undergo specialist treatment or go to a hospital, they will have to meet the full expense. That is not really the case. Very often cases are dealt with on their merits, but I know that people do not go to hospital, and refrain from going even when advised to do so, because of their fear that they will not be able to afford to pay for treatment. I have actually had letters to that effect.
I should like to suggest a double medical card. I am not sure, but I think the medical card is a blue card, and I suggest there could also be a red card, and that, if a person has not a blue card, he should be given a red card which would indicate that  although he is not entitled to full benefits, he is entitled to some benefits. I think that would, to a considerable extent reduce mortality, especially in heart disease cases. It would also reduce the period people spend in hospital and would minimise the great anxiety fathers of families suffer in respect of members of their families whom they are unable to send to hospital for treatment.
Finally, I want to refer to the disabled persons allowances. I think that allowance is paid by the Department on the advice of the local authority. The Minister mentioned the cost of hospitalisation. Apparently, it costs something over £2 per day. There are many cases where the means test is strictly imposed. In many cases people are living at home; they cannot do any work and are totally disabled. They feel they are a burden on the home and they would welcome some allowance. Ultimately, the father dies or the brother marries and the disabled person must go to hospital. It seems shortsighted on the part of the Government or the health authority to be so strict in respect of this matter. Surely, if a person is totally disabled, unless he has a five figure income or is very well-off, he is entitled to this allowance. It would be to the advantage of the State to grant it and it would be to the advantage of the recipient. The Minister has no direct say in the matter except to advise county managers and those concerned to be more liberal in their approach. If they were, it would be to the advantage of the disabled persons and the State as a whole.
Mr. Kyne Mr. Kyne
Mr. Kyne: The fact that a Committee on which all Parties have representation is sitting at present to consider the health services prohibits those who are members of the Committee from dealing very extensively with health problems because actually the work of the Committee is to advise ways and means of providing better health services.
I do not condemn in any way our health services. Particularly in regard to my own constituency and that part of the county left to me, I feel the  health services are first class. Nobody who needs medical aid is deprived of it through want of money. In our health authority for as long as I have been associated with it, money is not the problem but there are certain restrictions, certain bars set up by the legislation of this House prohibiting the granting of benefits that in my opinion could and should be given. Because of legislation it is outside the means of the health authority to provide these benefits.
The Minister has repeatedly said in public that the health services come down to a question of what we can afford. The Labour Party attitude is the reverse. We say: “Can we afford not to be able to put up the money for health services?” When you think of all the questions of increased production, the targets for efficiency and productivity in industry and agriculture you must think also of the human factor. All this is not done by machinery. You can have as much machinery as you wish but you must always have a human brain behind the machine to control and direct it and make it work effectively. The important thing is to have productive workers able to do their work on each day of each year.
I have always felt that the divorcement of social welfare from health was a mistake because the ordinary worker when he feels ill and needs to stop work and, perhaps, go to hospital has to examine the question of what will happen if he does so. In Ireland his wages immediately—taking a normal worker earning £7 or £8 a week—fall by 50 per cent. Naturally, he is inclined to prolong the period before he stops work until he is driven by his illness to give up his employment. The delay he imposes on himself because of economic circumstances can often so aggravate his illness that his period in hospital will be much longer and involve much greater cost to the country both in loss of production and in maintaining him in hospital with nursing attention and medical aid, than it would cost to have what I feel should exist—an additional social welfare benefit which would mean one could say to a worker: “If you go to hospital and if you are genuinely ill, your wages and the care of your  family will be undertaken by the State.”
Too often workers postpone seeking medical aid and, on the other hand, too often they are too anxious to return to work even against their doctor's advice, because of economic circumstances. They cannot continue to exist on the benefits they derive from their social welfare contributions. A man cannot drop from £10 a week or, taking the minimum, £7 a week, to half that weekly allowance and recover as a sick man, when he knows that every day he stays out from work his wife and children are losing money. Very often a man returns to work against his doctor's advise. The doctor may say to him that if he feels well enough to go back he may go back but the important consideration in the mind of that man is that if he goes back he will earn money for his family and he will go back no matter how he feels, hoping that he will recover while he is at work.
The question of the separation of social services and health is a primary matter for examination. These two things are regarded separately at the moment. We have to accept the law as it is. I know that it is not permissible on an Estimate to advocate legislation. I am merely expressing the thought that some day, please God under a Labour Government, whenever that will come, we will have regard to the financial implications of illness as being one of the most important matters if not the most important matter in connection with health.
As a Labour representative, I want to state in a few short words our view as to what a health policy should be. I have said already that cost is a factor entering into the matter. The policy should be there and the cost should be found. I have also said that we have no grievance in respect of the existing Health Act. I want to repeat that. We want, however, to extend the Health Act. The Labour Party will suggest and have suggested in the past a health policy. Other Parties are now beginning to follow our lead. We produced a health programme in 1958. A health programme was produced by  another Party in 1964. I would have to look at the programme produced in 1958 and that produced in 1964 very closely indeed to distinguish between them. Undoubtedly, costs have been revised, owing to the change in conditions. I should like to congratulate the Party that has produced that programme. If Fianna Fáil are prepared to produce another programme, a better one, I maintain that the Labour Party have carried out an important function, the only function they can perform in opposition, in leading the way.
It has always been the fate of pioneers not to achieve much but by their failure to secure for those who follow them the means of achieving the aims the pioneers set out to achieve. For instance, there was the east-west flight by Nungesser and Coli in the “White Bird”. I remember, as a child, seeing them passing overhead on their way to America. They never returned and have never been heard of since. The Atlantic flight is now an everyday occurrence. The pioneer attempt by these men achieved something. Others learned from their failure and it means that they achieved what they set out to do. If the Labour movement is a voice crying in the wilderness at the moment, it is in a good cause. Because of the honesty and sincerity of our policy, we believe it will be adopted by some Government, whether in the immediate or the distant future. Certainly it will be adopted if a Labour group have the controlling power.
In our view, it is essential that social welfare and health should be correlated. The personal financial implications of illness must be considered in relation to a health service.
The general health scheme is excellent in its way. It needs, as my colleague Deputy Dr. Browne has said, one very important provision, that is, free choice of doctor. I do not have to tell the Minister of the importance of doctor-patient relationship. A patient must have confidence in his doctor. If the patient is limited to one doctor, no matter how excellent that doctor may be, even though he may be much more competent than the  doctor the patient would personally choose, he will not be satisfied. Christian scientists believe in mind over matter and do not believe in doctors. I do not subscribe to that view. I believe it is of the utmost importance for a patient to have complete confidence in his medical adviser. It is not satisfactory to have only one doctor to whom he must go. Free choice of doctor is of the utmost importance.
In Great Britain, there is a panel system and a choice of doctor, who is limited in the number of his patients. The number of patients is a matter of agreement between the British Medical Association and the British Minister. The Labour Party favour that. We are in favour of a system of appointing a panel doctor in an area, giving a choice of whatever doctors are willing to work the system.
I do not think there is a great deal wrong with our health services apart from the fact that the main worry of the ordinary working people is the cost of being out of work through illness. I can go further and say that in the higher income group, in the category above the limit of the middle income group but below the wealthy class, illness is a serious matter if it means hospitalisation for an extended period. There is also the consideration that these people contribute towards the health services in the rates, and rightly so. Cover should be given in regard to illness, not only to the 30 per cent who qualify for medical cards, in respect of hospitalisation expenses.
I and the Labour Party suggest that there should be an extension of the medical services to cover the entire population for all the medical services they need and the cost thereof, and that the cost in excess of the £22 million cost at present should be met by contributions from the workers, contributions from the employers who gain by the good health of the workers, and contributions by the State.
I am not suggesting a new health scheme but an extension of our present scheme which, as far as it goes for the 30 per cent, is excellent. I have never  met a case where anyone with a medical card had cause to say that he was neglected in any way. What I want is an extension of the scheme to cover all insured workers and I would say, as the Labour Party will say, that it should be compulsory. Certain arrangements will have to be made to cover people engaged in agriculture, to cover self-employed people, and the amount of the contribution may possibly have to be adjusted to meet the needs of the people. When the Labour Party submit their recommendations to the Select Committee, these details will be dealt with.
That does not mean taking from the ratepayers any of the money they have to spend on the health services now. It is not practicable to start fiddling about with that. Of the £22 million at present spent on health, the State pays half and the local authorities the other half. I do not think the State is able to carry the complete cost. Local rates form the best system of taxation because by that means you tax a person according to his ability to pay. Indirect taxation is a burden on the ordinary person without consideration of his ability to pay. The health charges which are so much decried by many members of local authorities are not something that we would decry. It is important that those who have much should contribute to the people who have the means of paying.
I want to pay a compliment to the Minister, to the Secretary of his Department and to all the officials of the Department. At no time during my 16 years in Parliament have I ever got into communication with the Department of Health that I did not meet courtesy and efficiency in dealing with any complaint I had to make. I have spoken with my colleagues on this matter and they are in complete agreement with me. Whatever delays there may be are occasioned by the fact that careful investigation has to be made into the different problems. Notwithstanding all that some matters which come under the jurisdiction of the Department need criticism and comments.
I find that the nurses are the Cinderellas of the medical profession. In  my county, the attendants in the county homes and the district hospitals, because of the fact that they have the support of their trade union, are now seeking a wage comparable with that of the nursing staffs. I do not say that should not be so, but I do know that nurses, although they belong to organisations and although many of them believe that nursing is a vocation rather than a job, and for that reason are loath to threaten to leave the services of the local authorities, have been relegated to the lowest step of the medical profession. That is completely wrong.
Our doctors play an important part in our health services, but without the assistance of our dedicated nurses, all their medical skill would be wasted. The Minister should encourage a much higher wage scale and much better conditions than operate at present in either the local authority hospitals, which are the best, and in the voluntary hospitals which, because of lack of finance, are the worst. The nursing profession here has been reduced to such a stage that our girls are leaving the country and going to America, Britain and elsewhere. I do not have to tell the House of the attractions that are being offered all over the world. If somebody could compile a register of the nationality of the nursing staffs in Britain, we would find that the Irish predominate there. If they have to leave the country, it means that the best of them are going, and if the Minister can increase their salaries, by automatic sanction of increases to the staffs of local authority hospitals or by making a subvention to the voluntary hospitals for this purpose, he should do so. These people are entitled to a much better reward than they are getting at the moment.
I realise that a commission on mental illness is sitting at the moment but I would say that in my own area and in any other area of which I have knowledge the main problem is overcrowding. The crowding of beds into wards so that there is scarcely room to move between must, of itself, be a detriment to recovery. I know it is a  big problem that will cost a lot of money to solve. Whether or not the new suggestion of out-patients' departments will sufficiently relieve the congestion in our mental hospitals, I do not know.
A number of years ago there was a directive from the Department as a result of which a number of feebleminded people in country homes were transferred to mental hospitals. I do not think that is a good policy. We should keep in our county homes everyone other than those certified for mental treatment. I realise, even though I say that, that you must always be certified to be sent to a mental hospital but it is done in a very loose way. I am aware of 30 or 40 people in my own area who are now certified lunatics and who take up space in the mental hospital although they could quite well have been accommodated in either of the two homes in my constituency and get the same treatment as they are getting in the mental hospital. If they were removed, that would leave greater accommodation for those who need more urgent attention for that disease.
I wish to refer to the supply of dentures under the health scheme operated through the local authorities. It is quite common to find people, particularly women, who had their teeth removed two or three years ago and are still waiting with empty gums for dentures. I am informed—and I have experience of it myself because I wear false teeth—that without dentures you cannot properly masticate your food and the absence of them for this purpose leads to ill-health. It is common throughout Ireland that there is a delay of two or three years in the supply of dentures. It is true that, if you get a medical certificate saying you are a special case, you will get priority. But the person who has not got that certificate is delayed that much more.
We are told that the delay is caused because dentists are in short supply. Maybe it is difficult to pay the staff you want, but in many other countries dentists are engaged in extracting teeth and doing necessary surgical work, while the making and supplying of the  teeth is done by persons skilled at that job who are not dentists at all. In Ireland, too, the dentist extracts teeth, takes the impression and sends it to skilled people, either employed by himself or employed elsewhere and it is they who make the teeth. The extraction of teeth is done without delay. The delay occurs in the supply of the dentures because, apparently—to use a trade union term — there is a closed shop in regard to the provision of teeth. I would suggest to the Minister that he should examine this question to see if this closed shop could be opened so that people will not have to wait. It is deplorable that people should have to wait two or three years from the date they get their teeth extracted until they get back the means to masticate and digest their food.
On the question of mentally handicapped children, some time ago I think the Minister paid tribute to a voluntary organisation established in Waterford which set up a clinic to help mentally retarded children or relieve their mother from the strain of continually supervising and helping them. I want to be clear that I am making no accusation, because I have no knowledge of this except what I read in the local newspapers. However, I understand there is some question between that association in Waterford and the Minister in connection with a grant for something the Waterford people feel they need for the progress of their association. I would ask the Minister to treat this as sympathetically as possible. You have this very devoted group in Waterford, mainly composed of women, who have interested themselves in this work voluntarily. Their only aim is to be able to help children less fortunate than their own. If the Minister or his officials could see their way to meet the needs of this association, even if there are difficulties in the way, whatever could be given would be for the benefit of the mentally handicapped children and their parents.
While our health services are excellent, I always feel there are certain irritations in them. I had one case in Waterford country recently. A scheme  was devised by the Safety First Association to encourage the drivers of motor vehicles in the employment of the local authority to exercise care. That was done through a reverend father, well known to us all, who came down each year to present certificates to accidentfree drivers. In addition to the certificate, the country council agreed to give a bonus of £2 for the first year and for various other years up to a certain amount. I found to my amazement that the health authority, although willing to give this bonus, are forbidden to do so by the Minister for Health, on the ground that in any event an ambulance driver should be very careful because he is driving sick people. Every driver should be very careful. He is driving himself and he should be careful for his own sake. If an element of competition is introduced, it makes drivers more careful. I feel the Minister's view on this is wrong, and that he should have another look at it.
I have pressed through private channels to the Minister and direct representation to him on behalf of my trade union, and I understand it is not a question of monetary reward but the fact that if you are in the employment of a health authority you do not get this, and if you are in the employment of a county council, you do; in other words, if you are bringing a load of stones and do not have an accident you get a reward, but if you are bringing human beings, you do not. That policy is wrong; that decision is wrong; and I suggest to the Minister that he should look at it again.
I have been asked by people engaged in this work in County Waterford— I do not do it myself—to appeal to the Minister for more co-operation with the voluntary body called, I understand, the Friends of St. Martin, who take care of old people who are not ill and not invalids, but just lonely and uncared for. In Dungarvan, there is a branch of the organisation of the Friends of St. Martin, which includes nurses, doctors and lay people. They are endeavouring to establish a community there—I expect that is the right word—with the help of the urban council, where old people of both sexes  could meet, and be introduced to pastimes and handicrafts to fill the void which exists if a person has no family.
As I understand it, encouragement from the Department is not very noticeable. I appeal to the Minister to endeavour to tell all the local authorities that, where possible, an organisation of this sort, which is purely voluntary and devoted to doing a job that seems to be just outside the Health Act, should be encouraged in every way and to contribute to their means and help them in every way. I am talking about the acquisition of sites and matters of that nature. Whether that is within the powers of the county councils, I do not know, but that question should be examined. I appeal to the Minister to give that co-operation.
As a member of the Select Committee on the Health Services, in honour bound not to discuss what is happening at that Committee until such time as it reports to the Dáil, I agree with my colleague Deputy Dr. Browne that a report is long overdue. The country is awaiting a report from that Select Committee, and if we adjourn in July without reporting, the full effectiveness of the work that has been done by that Committee will be lost. Certainly as a Labour member of the Committee—and I feel quite sure I can speak for my other two colleagues —I will feel that we have lost confidence in the sincerity and honesty of the Committee in their efforts to improve the health services.
Mr. Leneghan Mr. Leneghan
Mr. Leneghan: I am sorry the Minister is not present. I must say, in all fairness to him, that any health services we have in this country are of his giving. They may not be by any means the best health services in the world, but neither are they the worst. They are reasonably good health services, but they could do with a few improvements here and there, and a few very important improvements at that.
It is rather peculiar that in a Catholic and Christian country like this, a man has the right to obtain free veterinary services for his cattle, and has not the right to obtain free  medical services for himself, his wife and family. That is an extraordinary situation. I freely admit that the health services, in many ways, are being seriously abused. I do not believe that more than half the people in our hospitals and county homes should be there at all. Many people are pursuing a policy of ducking, dodging, and pretending they are ill, because today there is a premium on illness and people can get State aid as a result of having themselves certified.
In my county when the county hospital was opened back in the Thirties, when the population was greater by thousands than it is now, the hospital was not half filled. Today, with a much reduced population, and with all the medical checks and services, the hospital is not half big enough to hold them. There is something peculiar about that. If the Minister did nothing else except inquire into that side of the matter, he would be doing a very good day's work.
I may be right and I may be wrong, but I think the Department of Health and the Department of Social Welfare should be operated by the same Minister. If the same Minister operated the two Departments, there probably would be a change, and a very badly needed change. There must be hundreds and thousands of people pretending to be ill, who are not ill at all. If one Minister dealt with the two Departments, and if there were proper co-ordination of the services, many of the tricksters would be caught, and a lot of money would be saved—and would be available for expenditure on the health services— which is now obviously being paid out to people who are not entitled to it. I do not see why one Minister could not operate the two Departments. There is no reason in the world why they should not be amalgamated.
I hold the opinion that we should have much more comprehensive health services than we have. It should not be a question of giving someone a green card or a yellow card, as if it were for a cow, before the health services are obtained. That is wrong, and I do not see any reason for it. I know it will cost money but money  appears to be readily available for everything else and why should it not be available for health services? I admit that many people who can afford to pay do not pay but that is no reason for not giving a really comprehensive health service. There would of course have to be some type of check because people will take advantage of any scheme to get all they can for nothing. The money required to give a proper service will be money well spent.
I find it a rather remarkable thing— I do not know if many Deputies will agree with me or not—that the biggest advertisements in every paper are for either cigarettes or intoxicating liquor. When my generation were growing up, there were none of these advertisements. We still learned to drink and smoke, and unfortunately we learned these arts only too well. It is a public scandal that these advertisements are tolerated today. I do not know whether the Minister for Health or the Minister for Justice should deal with it but some Minister should deal with it. It is a disgrace in a Catholic and Christian country that whole pages of newspapers should be devoted to advertisements for intoxicating liquor or cigarettes. It is worse to find Telefís Éireann and Radio Éireann, semi-State concerns, at the same game.
If some Minister does not deal with this matter soon, the time will come when public opinion will be so well organised that it will have to be dealt with. It is unfair. Today the advertisement is for one type of beer and tomorrow for another, or for so-and-so's whiskey, or if you drink a particular lager, you give a penny to something or other. The thing is positively scandalous. Our young people read these advertisements which are hurled at them from every side—drink this, smoke that. It is long past the time when something should be done about this and I am asking the Minister to do something now. We have these advertisements flagrantly displayed for everybody to see, urging them to drink or smoke all they can and they will be happy ever afterwards. There must be something seriously wrong. This must  be one of the greatest reasons for filling our mental hospitals and certainly our county homes.
Today our hospitals are not able to cope with the numbers going into them. The population has not increased but the number of patients has gone up by thousands. There must be something wrong in an age when we are told we have drugs, tablets, pills and injections to cure everything, and yet we have this long queue for every hospital. I hope that this Committee which is sitting to deal with this matter of the health services will stand up fairly fast—they have been sitting down for too long—and make a recommendation which will alter the situation rapidly.
We have in our mental hospitals thousands of people who are no more mental than I am, probably a lot less, and who have been put in there for various reasons. They just cannot get out and nothing is being done to get them out. We have become very worldly-minded and there must always be some financial carrot held out before a person does anything, but surely there must be some way of getting these people out of the mental hospitals? In my county we have some 1,300 people in the mental hospital and I do not believe that half of them should be there.
The same position is to be found in the county homes. In Mayo, we are going to erect a county home which will be something like the Intercontinental Hotel. Needless to say, that will bring in more people as fast as they can come. I disagree completely with the idea of a central county home. You can call it whatever you like, but if it is centrally situated, people will be sent into it. If there were local homes in five or six different areas in the county, we would not have half as many people going into them because people would be ashamed to let their relatives in. When you can send them 50 or 60 miles away, it does not matter and people are delighted to get rid of them.
The position in Mayo is we cannot put anyone in because the crowd inside are trying to get out. They are overcrowded. If the Mayo County Home  could take 5,000 people, we would probably have that number of applications, but if there were local homes as I suggested, we would not have the same number of applications. As long as we pursue the present policy, we will have more applications daily. They are coming in so fast in Mayo that we cannot keep up with them and the position in other counties is even worse. As a matter of fact, the people in Mayo are about the last who would want to send their people into a country home. Unfortunately, you have people who will do that and it is a sad reflection on our times, especially when we are much more affluent than we were. It is remarkable that when people were poor, the last thing they would do was to allow their relatives into the county home.
Our nursing system of course has been ludicrous. Deputy Kyne described it as the Cinderella of the medical profession, and he was not far out. We are reaching the stage when we will not get nurses. They are not treated as professional people at all. In our hospitals they are grossly overworked and underpaid and no effort is being made in a serious fashion to remedy their situation. If we could get away from the idea of having nurses only in a hospital, we would be doing a good day's work. If we go back 40 or 50 years, we find we had what were known as midwives and they did good work not only delivering babies but caring for people in their own homes. As a result people did not go into hospitals.
Today we have no outside nursing system except a kind of inspection service but they do not go around doing anything to improve the position of patients in a house. If nurses were available to go around to people's homes and give domiciliary treatment, it would make a tremendous difference and keep hundreds of people out of hospital. Daft as we are, the last thing we want to do is to go into a hospital, county home or any other institution. We are not institutionally-minded.
The main reason our people are so anxious to get into these places is that there is no service to deal with them  outside. The nurses are not there; the doctors are not there. The youngsters who stayed in the country in days gone by are not there. They go to earn a livelihood elsewhere as they must do in the competitive world of today. If we had a better domiciliary nursing service, we would be doing a good day's work in keeping thousands of people out of hospital.
Old people have to be sent into country homes because there is nobody to give them the treatment they require. However, the clinics which have been set up are a great boon. This can be readily seen in my constituency. The western medical superintendents of the mental hospital have come out to the local hospitals to give treatment. This has kept hundreds of people out of our mental hospitals. There has been a big increase in the number of attendances at these clinics. If a similar service were operated by nurses, a great many people could be kept out of hospital and certainly out of the county home.
In regard to many people who are in these institutions today, we would have to use some very powerful incentive to get them out. People in mental hospitals and county homes are of no value to the nation and every effort should be made to get them out. I do not mind what money or what inducement is offered to get them out but it is past the time when this should be done. In my county alone, there are hundreds there who should not be there. I submit there are also people in county hospitals who should not be there either but the doctors are there to deal with them.
One of the most serious problems to be dealt with in relation to our health services is that of the sub-normal or mentally handicapped child. We do not seem to have the necessary services to treat such children. It is a very difficult problem and one which probably has confronted Governments in every country. However, it is wrong that we have not made some greater effort to make available the necessary accommodation and training for these sub-normal children. If this is allowed to go on, it could become an even greater problem than it is.
 At the moment it is mainly left to religious orders to care for these children. I have no objection at all to that. They are about the only people who can effectively care for them but they are not given the necessary financial support. If the money were made available, these people would go a great deal more towards relieving this serious problem. I know scores of children who should be in some kind of home or institution for treatment and education but unfortunately there is no place to send them. We are particularly unfortunate in Connacht. For some reason or other, we have practically no place to send our children and in a province where emigration is so rife, the effects of this can readily be seen. We have no millionaires or people with money who can go out of their way to provide these facilities and it is a problem which must be tackled by the local authorities, with the help of the Government.
I am not particularly blaming the Government in this respect. I was at a meeting about a year ago of the General Council of County Councils and everybody who spoke on this problem threw all the blame on the Government. As I said on that occasion, it was all right blaming the Government but the very people who were blaming the Government had failed to do anything at local level about it. Each local authority should have a place for these children. Surely if they have a place for people who become insane, they should have a place for sub-normal or disabled children who, when kept at home, are a very bad example to other members of the family. If they are allowed to remain at home, they may reach a point where they are beyond the possibility of being educated or trained. No matter where the Minister gets the money or what steps he has to take, I would appeal to him to do something about this problem.
The Minister said here some time ago that he could see no reason for bringing in legislation to deal with nursing homes. I cannot see eye to  eye with him on this. It is wrong that it should be possible for nursing homes to operate for financial reward without being subject to any type of inspection. It is a shocking position that there are thousands of nursing homes functioning about which we know nothing at all and which may be doing anything. I suggest to the Minister that if he honestly believes that there is no reason for introducing legislation to make these nursing homes register and have them subject to inspection, he should have second thoughts about it. He would not have to go outside the two streets in which his Party and the Fine Gael Party have their headquarters in this city to see how right I am.
Deputy Kyne raised a point here which I regard as important, that is, the question of dentures. It appears nobody will be allowed to go blind but the question of being able to eat and drink does not arise. Of course, one can drink without teeth but to try to eat without them is a tough job.
People who have teeth taken out under the health services at the moment cannot afford to have teeth put in. I understand dentures are expensive. I cannot say what the cost is but I believe it is considerable. I suggest to the Minister that, seeing he has thought it right to provide spectacles free, or almost free, he should regard it as much more important that people who get their teeth out under the health services should not be going around with open mouths and nothing stuck in them. In a big family it could easily happen that within a year, or even a week, four or five people would get their teeth out. They then have to go around with their mouths open until they can get to England where they can have the teeth replaced free.
I am not criticising the Minister. Any improvement we have had in the health services has come from him. I would, however, ask him to go the other bit of the road and improve the health services in this respect. It is tough to see a young girl going around without a tooth in her head. If nothing else it would leave her without a man  and that would leave the country with-a few extra people to buy the beer and the cigarettes and the other things that provide the country's revenue. It is past time that the Minister took steps to remedy this matter. No Deputy would oppose a proposal of that kind. I ask the Minister if necessary to compel the local authorities to provide dentures free for people who cannot afford them.
Mr. Byrne Mr. Byrne
Mr. Byrne: I wish to make only a brief intervention in the debate, primarily for the purpose of urging the Minister to do all he can to solve the problems confronting the Jubilee nurses is regard to their operations in the city of Dublin. I am happy to learn from the Minister's opening statement that he has this matter under review and I can assure him that all Parties in the House and outside it are most anxious to have these problems resolved.
The Jubilee nurses have, quietly and unobtrusively, for many years provided a wonderful service for all sections of the community. The striking feature of their activities is that there has been no question of a means test, no stigma of pauperism attached to their services, which have been operated by dedicated persons most deserving of every possible consideration the State and the local authorities can give them.
We are very fortunate that we have in this country bodies such as the Queen's Institute providing these services which in other countries are provided by the State. It is a fact that the domiciliary nursing services, operated in a very small way in Dublin by the health authority, are very restricted in scope, and if the Jubilee nurses are further to restrict their activities or suspend altogether their operations, the plight of many sick people in this city will be extremely grave.
There are two or three other points which appear to be worth mentioning very briefly. The cost of medicine is becoming prohibitive and that is a matter the Minister must consider very seriously. I do not know whether he has at present got the necessary powers to bring this under his control. If he  has not, he should acquire them. It is a fact that nowadays most drugs and medicines are produced and made available in patent form, even highly expensive drugs. I understand that dispensing chemists handling a doctor's prescription have been known to remove the label from patent medicine, put on their own label and charge a fancy dispensing fee. If that is so, it is a dreadful state of affairs which the Minister should quickly rectify.
In recent years, great pressure has been put on local authorities to have accident ambulance services provided. In the past few months the Commercial Travellers Association have seen fit to make a public protest about the lack or the inadequacy of accident ambulance services in many parts of the country. The rapidly growing road accident rate is causing tremendous concern and it has a bearing on this matter. The number of cars on our roads is rapidly increasing. Every other day we read in the newspapers of fatal road accidents.
If in that state of affairs we are to be saddled with an indifferent ambulance service, particularly in rural areas, we should hang our heads in shame. If there are local authorities dragging their feet in this matter, the Minister must call them to task. It is very desirable that State grants should be made available to local authorities for the modernisation of their accident ambulance services. Even where a service is operated, there are cases of inadequate and inferior equipment. I have heard of the minuteman oxygen apparatus with which modern ambulances should be equipped. I understand that in certain countries, perhaps in many counties, they are not so equipped, with resultant loss of life.
The Road Fund is in a sufficiently healthy state to warrant an assurance to motorists who are paying high motor taxation that if ill should befall them on the road, at least they will have as good an ambulance service as is provided in other advanced countries. It is a crying shame that it should be necessary to complain here about this matter and that the Commercial Travellers Association whose members travel thousands of miles should find  it necessary to take the strong stand they have had to take in recent months.
In the past few days, many people have been gravely concerned about Press reports of the very serious typhoid epidemic in Scotland. This epidemic had its origin apparently in lack of hygiene. It gives us cause to ask ourselves and the Minister if he is satisfied that the local authorities are enforcing existing public health laws in regard to sanitation and hygiene in the handling of food and drink. I do not suppose the Minister ever visits a Dublin pub; some of us do, and all too frequently we see obvious evidence of the unhygienic handling of food and drink and the lack of basic amenities. Sometimes the sanitary facilities are deep down in the dungeons in the bowels of the earth. People in the food and drink business are making sufficiently high profits to entitle local authorities to insist on their observance of high standards in these matters and I ask the Minister if he is personally satisfied that all that should be done is being done in Dublin because many people are not so satisfied.
When the Health Act came into force some years ago, one would see the bread roundsman with a basket full of loaves and a plastic cover over it. That lasted only a few months. I feel we may have got off to a good start in enforcing the most up-to-date standards of hygiene in other respects, but through lethargy or indifference, we have fallen somewhat behind. Because of the appalling epidemic in Aberdeen, it is timely to ask the Minister to take account of the great public concern in this matter.
I should like to urge the Minister to improve the status, conditions of employment and pay of the nursing profession. It seems that our nurses have much in common with the secondary teachers in that their dedication to their work and their vocation is grossly exploited by the State and by local authorities at large. Their professional status is not what it should be. Highly-trained nurses of many years' experience are paid less than a junior female clerk or unskilled  worker, a state of affairs we must no longer condone.
I was not present for the Minister's opening statement but I have skimmed through his speech and I was forcibly struck by his concluding paragraph. How smug can we become? The Minister says he feels we can justifiably claim that the quality of the health services available for our people is on the whole excellent. God between us and all harm! One rarely hears such a nonsensical statement uttered in this House. Our health services fall below the standard of advanced countries; our health services are inadequate and unreasonable. Health services and the provision of allowances are, like the provision of educational services, a form of social investment which does not yield a short term cash profit and on that ground do not appeal to those who control the economic policy of the Government. It is appalling to think a responsible Minister can utter such a smug statement as that with which he concluded his speech this morning.
Mr. Tully Mr. Tully
Mr. Tully: Whether we like it or not, this Estimate is one of the most important to come before us each year. I believe the solution to many of our troubles would be easily found if the health services were up to the standard which many of us think they should reach. In saying that, I am not criticising the Minister for what he has done or what he has not done, but I feel that after a number of years' operation, it has been fairly conclusively proven that either the Health Act is not sufficient to meet our needs or the interpretation of the Act by the local authority officials who administer it, is not what was intended. Therefore, an extra effort should be made at this stage to remedy the situation because there is no use in having certain headings there which seem to the Government and the House sufficient, if the actual administration of the Act shows that the interpretation of the headings given by the Minister and the Department officials does not coincide with that given at local authority levels. The biggest single point of irritation is, I think, the system by which the home treatment of patients is covered. I feel  that the domiciliary treatment laid down in the Health Act does not meet the requirements of this country.
Progress reported; Committee to sit again.
Dáil Éireann 210 Committee on Finance. Vote 49—Health.