Dáil Éireann - Volume 239 - 23 April, 1969
Health Bill, 1969: Second Stage (Resumed).
Debate resumed on the following amendment:
To delete all words after “That” and substitute “Dáil Éireann refuses to give a Second Reading to the Bill on the grounds that:
(a) it fails to provide a comprehensive health service available to everybody based upon insurance principles;
(b) it retains the injustice of financing half of the cost of health services out of local rates; and
(c) it gives, at the expense of local authorities and hospital administrators, excessive powers to central government.”
Mr. O'Hara Mr. O'Hara
Mr. O'Hara: Last night I was speaking briefly on the dental services, and I was making the point that we, in Mayo, had quite a good service, and a good county dental officer, but that there was a need for the appointment of two or three more dental surgeons. I was stressing the importance of trying to recruit dental surgeons who were trained and educated in this country and who have emigrated to England and America. Many from my own county have gone away. It is generally appreciated that in many counties there is a shortage of dental officers. I am aware that that is the position in Sligo.
This shortage of dental surgeons is a very serious matter. Dental health has much to do with general health. I know of many instances where people from Mayo have occupied beds in Dublin hospitals for long periods, due to the fact that they needed dental attention before they could receive surgical treatment. That applied particularly in relation to hospitals like the Meath Hospital, Jervis Street Hospital and others. If these people had received dental care at the proper time they would not have had to occupy these beds. The improvement of the dental service is of vital importance to the health of the community. I  am afraid it is a matter which has been overlooked by successive Ministers for Health. It is a pity that that should be so.
The school dental service in many counties is far from being of the standard we would all desire. The schools are the places where the problem should be tackled. The proper care of children's teeth is important from a health point of view. I appeal to the Minister to have serious regard to this matter and to endeavour to recruit dentists, and to get dentists who have emigrated to return to the country. The only way to induce them to come back is to offer attractive conditions and salary scales.
The ophthalmic service is not what is should be, either. The Minister must be aware that in County Mayo there is a shortage of qualified staff for this service. At least one man who was engaged in this work threw in the sponge, so to speak, because he got fed up with the accommodation and facilities available to him. Indeed, I admire the man for doing so. No doubt, the Minister knows the person I am speaking about, but I do not want to mention his name here. He was expected to carry out his work in conditions which were wholly unsuitable. One of the areas concerned is the Minister's home town of Ballyhaunis. The accommodation and facilities were not suitable. It is unreasonable to expect a qualified man who has a serious sense of responsibility to his patients, as this man has—he is a distinguished member of his profession—to carry out his work under the conditions obtaining. That is another matter I would ask the Minister to examine.
Last night I made a general reference to waste in the matter of requisitioning and distributing medicines and drugs. I want to add to what I said last night because, while I was very critical of the system that operates, perhaps I failed to make any suggestion to the Minister which he might consider and which might help to solve the problem. We all know that at present some official, having no medical or surgical qualifications—in other words, a layman; perhaps a welleducated man—is responsible for ordering drugs. His decisions as to the  types of drugs required, the quantity, and the specification of drugs and medicines are, in my opinion, based on guesswork. I have no doubt that high-powered salesmen representing pharmaceutical groups in this country, and perhaps outside it, come down the country and dispose of their wares. As I said last night, many of these drugs and medicines may be out of date or may not be in use at all now by the medical profession. The system needs radical alteration.
Our general practitioners, dispensary doctors and others who have the necessary experience and skill are the people best qualified to order medicines and drugs. It is not necessary to have a situation in which a van or a truck will unload at dispensaries tablets, bottles of medicines et cetera that may not be suitable at all. The proper approach would be to allow the doctors to requisition the drugs and medicines they require. If a doctor were in a position to order so many dozen of this and so many dozen of that, according to his requirements, there would be a substantial saving and the colossal waste that is involved in supplying medicines and drugs would be obviated.
As I said at the outset, this Bill was subject to strong criticism by Deputy Michael Pat Murphy of the Labour Party, and I join him in that criticism. My personal opinion is that this Bill was prepared not by the Minister himself but by certain elements in the Fianna Fáil Party. No doubt the draftsmen were given the bones of the thing, but it was prepared not by the Minister himself but by Ministers in the Fianna Fáil Party.
An Leas-Cheann Comhairle Denis Francis Jones
An Leas-Cheann Comhairle: The Deputy will appreciate the Minister only is responsible to the House for matters concerning health.
Mr. O'Hara Mr. O'Hara
Mr. O'Hara: With respect, Sir, I make the same point as Deputy Michael Pat Murphy made, that is, that there is collective responsibility in these matters. Knowing the Minister as I do, I think he is the type of man who would like to introduce a Bill here, listen to constructive criticism and be prepared to accept certain amendments to it if he thought it was in the best  interest of the country. There are many Members of this House who have experience of local authority administration in regard to hospitals. They have engaged in discussions with their county managers at county council meetings and have had discussions with the medical profession. I have had that experience, and when I see the Minister introducing a Bill like this it creates the strong impression in my mind that it is not his production at all, despite the fact that he is nominally responsible for piloting it through the House. The people who have been elected to county councils, who live among the people and who are members of different political Parties are the people best equipped to judge what is best for the health of our community. Great credit is due to members of councils who, without fee or reward, for many years have helped to build the present services which are available in district, voluntary and county hospitals. They have done this work in co-operation with nuns, clerical workers and other lay people.
The Minister's stamp is not on this Bill. He is not the type of man who would like to kick local public representatives around but he is definitely going to do that if this Bill goes through the Oireachtas. He is throwing out the people who have been elected as representatives in their respective areas by different classes of people, and he is appointing health boards composed of what I might call faceless men. I have no doubt that, with the pressure that will be brought to bear on the Minister, certain people will be appointed to these boards because of their political leanings and because of what they have done for the Fianna Fáil Party. The appointments will be given to them as a sign that they are respected by the Fianna Fáil organisation. They will be given to them as a sop, as a compensation for their services to the Party.
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: This is a parish pump speech.
Mr. O'Hara Mr. O'Hara
Mr. O'Hara: This is not the type of thing the Minister for Health, Deputy Flanagan, would like to be responsible for doing. I do not think this is his  Bill. I believe he is being pushed strongly from behind.
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: Nonsense.
Mr. O'Hara Mr. O'Hara
Mr. O'Hara: Knowing the Minister's form I cannot imagine him coming into this House of his own volition and recommending this as a suitable measure to our people. If the Minister says he is responsible for it himself, then let him take responsibility for it; but let him know this, that the people not alone in his own county of Mayo but throughout the length and breadth of Ireland will be sadly disappointed when they discover that the people they elected are no longer considered competent by the present Minister and by the Government to continue the work they have so nobly carried on for so many years without either fee or reward. Members of this House get their cheques, but the majority of the members of local councils have no income of any kind from any public sources. They leave their farms, their businesses, their professions and serve late and early in the interests of the people. If the Minister says he is prepared to take responsibility for bringing in this measure and recommending it to the people, then he is a different man from the man I thought he was and I am very disappointed in him.
Mr. J. O'Leary Mr. J. O'Leary
Mr. J. O'Leary: I should like to congratulate the Minister on introducing this Bill, on the draftsmanship of the Bill and on the flexibility shown in the Bill. I agree with the Government's proposition that the State has not the duty to provide unconditionally all medical, surgical, specialist, dental, ophthalmic and other services for everybody, irrespective of circumstances. The State has not the duty to provide medical services for the better-off sections of our community and the money saved by not providing services for these sections should be devoted to improving the services for the needier sections in our community. I agree that an insurance scheme would not work. In order to get sufficient revenue from such a scheme one would need to spread one's net very widely indeed. I am afraid that the bulk of the revenue would be collected from the workers  and the small farmers. I cannot see the sense in collecting insurance contributions from these in order to provide a health service for those better off. Already between 80 and 90 per cent of the community are eligible for hospital and specialist services; about 30 per cent are eligible for the general medical practitioner service. We know only too well what it costs to provide these services. The Minister has told us that in 1965-66 it cost about £33 million to run the health services. The cost today is in the region of £51 million. If we were to make all the services available to all, or if we were to extend the general medical practitioner service to the middle income group, an additional £20 million a year would be involved. That is a sizeable sum and we must ask ourselves can we — the ratepayer, on the one hand, and the taxpayer on the other — afford to pay the additional sum required to extend the existing services to the better-off sections of our community? I do not think we can.
One of the notable features of this Bill is the provision of a choice of doctor in the lower income group. Many people say that they will not have a choice of doctor because the areas in which they live are too remote from the larger centres of population. I see no reason why the powers given in section 56 could not be utilised for the purpose of amalgamating dispensary districts and providing group practices. This could be done. It would be a solution to the problem in the remoter areas. Provision could be made for group practices. I have no doubt but that with a bit of goodwill it should be possible to work out a solution with the medical profession.
Another notable feature is the change with regard to eligibility for the various services. Up to now we know that the means of an applicant for general medical services were calculated on the household income and family circumstances. The incomes of children who were earning were taken into account. This often deprived a person of a medical card. We all know that members of the family who work pay a weekly contribution towards the upkeep of the household. It is very hard to expect  these people, many of whom are saving to get married, to provide medical services for their parents. The Minister has gone the whole way in solving that particular type of problem. This change will mean a substantial increase in the number of medical card holders, but the money spent will be money well spent.
Again, for the first time, it is now proposed to give real power to the proposed health boards to provide drugs and medicines for those in the middle income group who cannot afford to pay for these over a lengthy period. Many health authorities have been very dubious about their powers in this regard. Some were very strict in the application of the authority given to them. I am glad the Minister mentioned the figure of £2 per month as an appropriate figure when deciding as to whether or not a contribution should be made towards the cost of providing expensive drugs and medicines for a person in the middle income group.
I must say I agree entirely with the proposal to set up regional boards for the administration of the health services. This is something I have been very much in favour of for a long time. When the regional boards are set up, we shall have uniformity in many fields. We shall have a degree of uniformity in the standards applied in the consideration of applications for the various services. We shall have, I would hope, a more efficient service, as well. Again, I feel that, with the setting up of the regional boards, we shall take politics out of the operation of the local health services, which is a very desirable development.
It will be very interesting to see how these regional boards develop as regards areas and boundaries. I feel it will be particularly interesting in Munster where we already have three health authorities — the Limerick, Cork and Waterford Health Authorities — and it will be very interesting to note what becomes of County Kerry. There have been suggestions within the county that it could well happen that North and West Kerry will be dovetailed with the Limerick Health Authority and that South and East Kerry will find themselves with the  Cork Health Authority. There is a great deal to be said against splitting a county. It would be very hard on the local representatives, particularly on those who would represent people in different regions. Again, it may be difficult for the Minister to decide as to how the county should contribute towards the cost of these regions when the county is split in two.
A very good case could be made for a region in Kerry even though every county, in its own way, can put up a case. Having regard to its population, to its remoteness from Limerick and Cork, having regard to the fact, in particular, that we shall have a new general hospital in Tralee, which is being recommended in the Fitzgerald Report, and having regard to the fact that probably in Cork there is already the ideal size of region as far as area and population is concerned and, again, probably, that the Limerick region may be overcrowded should other areas be added to it, I suggest that the Minister give very special attention to a region in County Kerry.
I like the idea of a chief executive officer working in co-operation with the members of the regional board. This will be a very interesting development. Some people seem to think that these executive officers will be doctors but I cannot see how that will happen. Surely the primary qualification for a chief executive officer is that he should have vast experience in the field of administration? Of course, on the other hand, if there is an able administrator who is a qualified medical practitioner, there is no reason why, on merit, he could not become a chief executive officer. I see no reason at all why that would not be so. I think the primary qualification however should be in the field of administration.
I should like to know the basis for contributions by local authorities to the regional boards — whether it will be based on valuation or whether it will be based on population. There is a great deal to be said for basing contributions on population. It would be something new in the field of local administration and I think the Minister should look into this matter. As far as the constitution of the regional  boards is concerned, I should like to know whether it is proposed to give representation to urban district councils on these boards. It can be argued of course that the urban districts have representation on the county councils and that county council members on the regional boards can see after the interests of the people in their own urban districts and that it would be their duty to do so.
The Fitzgerald Report, which, I understand, has been accepted by the Government, will, in years to come, form a very important part of the administration of the health services in this country. I am very much in favour of this report. We must remember that the costs of hospital services and specialist services are by far the largest element in the cost of the health service as a whole today and that, if we are to provide an efficient service, we must look first to the hospital service and the specialist service for efficiency. We should be guided very much by the Fitzgerald Report in the provision of an efficient service. The day has come when the needy man should be able to go to an eminent specialist, if necessary, just the same as a wealthy man. The only way this can be done is by more centralisation of our specialist services; and this in turn can be made possible by more centralisation of our hospital services. I do not agree with the principle of holding specialist services on a session basis, as has been the position up to now. It is time-consuming for a specialist to have to travel 70 miles to a clinic or, as some specialists are doing at the present time, to travel up to 200 miles to clinics and back again. If these specialists were living within the regions or were attached to the hospitals or clinics, this would go a long way towards providing the type of specialist service to which the lower income group is entitled.
The functions of the board, their executive functions and their reserved functions, versus the chief executive officer, are pretty well defined. The public are fairly well protected by the fact that at least half of the members of the board will be local councillors.  This is a very effective safeguard but I would appeal to the Minister to give these elected representatives a slight majority on the board. It is very important in any democratic society to make sure that the public interest is safeguarded. Before the regional boards are set up the Minister shall consult with the relevant local authorities. This will be a very interesting exercise and will probably be well worthwhile but my opinion is that the Minister will have a very difficult job because most counties will be making a case for a region of their own.
In section 6 it is proposed to bring within the ambit of the health services certain services the expenditure on which hitherto did not rank for recoupment under the Health Acts, such as the Births and Deaths Registration Acts, 1863 to 1952, the Sale of Food and Drugs Acts, 1875 to 1936 and the Blind Persons Act, 1920. It is also proposed that the local councils should operate the home assistance schemes. I welcome the provision that the Minister will appoint the chairman and vice-chairman of the regional boards. It is vital to have proper and suitable people for these positions, people who should work in close harmony with the chief executive officer. These men or women will have a vital role to play if these boards are to be a success. It is only right that the Minister should ensure that the proper people are appointed.
I want to congratulate the Minister for introducing something new in the field of local administration as far as the appointment of officers and servants of the health boards is concerned. I welcome the provision under section 13 whereby an officer may arrange for his duties to be performed for a specified period by a deputy, with the consent of the Minister or the chief executive officer. As far as I am aware, under existing local government law, only professional people, such as district medical officers, are entitled to nominate deputies to perform their duties.
Again, it is a very good idea to empower the chief executive officer to suspend an officer or servant of the board, under certain circumstances and for a period not longer than one  month. Up to now county managers, being human, were slow to suspend officers because it could take up to six months before the officer could be reinstated, or knew where he stood, because his suspension could be lifted only by the Minister. It gives the chief executive officer more control over officers and servants if the chief executive officer can take disciplinary action by suspending for one or two weeks without having to refer the matter to the Minister. There is a built-in safeguard for the officer too, because in certain circumstances the board may appoint a committee to hear his case and, if necessary, may recommend his reinstatement. I should like to congratulate the Minister for departing from normal procedure as far as the control of officers and servants is concerned. This flexibility will mean more harmonious relationships and, at the same time, obviously, more efficient service.
Under section 30 of the Bill expenditure by a health board is limited in that the board may not, without the Minister's consent, incur expenditure for any service over and above what is originally provided for in their estimates. Up to now local authorities, particularly county councils, operating the health services could, under section 11 of the City and County Management Act, 1955, by resolution, authorise additional expenditure in respect of any service. The pity of it is that the impact of such resolutions is not felt until the following estimates meeting when the authorities must make arrangements to pay bills which had accrued over the previous year but which had not been provided for in the previous estimates. Under section 30 there will be more control of expenditure and the health boards will probably be more realistic in estimating their expenditure.
I should like the Minister to give special consideration to health staffs who will be transferred from county councils to regional boards. I know he will do that. Many of these people will have personal problems in their own areas and any case made by them for the retention of their services in the local councils should get special consideration.
An Leas-Cheann Comhairle Denis Francis Jones
 An Leas-Cheann Comhairle: I do not want to interrupt the Deputy but an examination of the Bill, section by section, would be more appropriate to the Committee Stage than to the Second Reading. The Chair is anxious to ensure that there will not be repetition.
Mr. J. O'Leary Mr. J. O'Leary
Mr. J. O'Leary: Thank you. The Bill proposes that the Minister shall, by regulation, specify a class or classes of persons who shall be eligible for general medical practitioner services. This will be difficult for a number of reasons but mainly because of the varying economic conditions throughout the midlands. The Minister will find it difficult to make regulations which will suit the agricultural community in the west, and the east. He will find it difficult to make regulations suitable for urban areas which will also suit country towns and villages. But, at least, when these regulations are made there will be more uniformity in the application of services than there is at present where there are different standards not only in different counties but even within the same county and within the assistance districts of the same county.
The Minister should give special consideration to cases where medical card-holders are admitted in emergencies to private nursing homes. Kerry County Council have experienced great difficulty in many cases where medical card-holders came to them after a period in a nursing home, and produced bills and asked the local authority to make a substantial contribution, far in excess of that laid down by law and regulation. Some positive direction should be given to health authorities in this matter. Where a person is admitted in an emergency to a private nursing home and where this is certified by a doctor the health authority should be empowered to pay the full cost of treatment in the nursing home and to treat the case as if the patient had been sent by the doctor to a general hospital as happens under section 15 of the Health Act.
I wonder if it is wise to continue making a charge of 10/- per day in the case of the middle income group. Some health authorities have more bad debts  than money collected on the paying patients' register. It would be interesting to calculate the cost of collection in order to see whether there is a credit or a debit balance.
I welcome the provision for an appeal against a refusal by a health authority of a medical card. Up to now there was no appeal. Whether the appeal should be to the Minister or to an appeals officer is a matter of opinion. There will be so many appeals that it will be impossible for the Minister to determine all of them and for that reason I agree with the idea of an appeals officer. We would be only “codding” ourselves if we provided that the appeal should be to the Minister in each case: it should be to an appeals officer. Whether this officer should be appointed by the Minister or by the board is also a matter of opinion. I think it is more desirable that he should be appointed by the Minister as in that case he would probably have more independence than if he were appointed by the board.
As regards the provision of mother and child services I should like to know what can be done in cases where the medical profession in a town decide they will not operate the scheme, as has happened in one town in Kerry. Strangely enough, we have had no complaints from the public in that town. I am told that the doctors charge no more than they would have got from the health authority had they entered into an agreement with the health authority to provide a service. We should look into this matter The Minister will probably be able to sort it out with the medical associations.
I believe that home nursing and the home help service are the best means of keeping elderly persons out of hospitals and institutions. Therefore, I should like to see more public health nurses being appointed with responsibility for providing these services. Again, these services should get the backing of the local representatives and the local representatives should, in many cases, take the lead in the administration of home nursing and the home help service.
I should like to see a little more  attention being given to the rehabilitation service. I know that the Minister and his Department are doing their best, but perhaps more could be done at a lower level for this service. I know of a number of cases of slightly retarded persons in my own county who have difficulty in obtaining employment. The health boards should have placement officers whose sole function would be to arrange for rehabilitation and for the placement of the persons in employment afterwards.
It is also proposed under the Bill that, in cases of disabled persons who apply for disabled persons maintenance allowances, only the income of the applicant should be taken into account. That is a great step forward. I have come across numerous cases in my own county where persons were refused this allowance because they lived with a married brother who was in good circumstances or because some member of the family was in fair circumstances. We know, of course, that the provision of this service will mean a considerable increase in cost, but this will be money well spent.
In conclusion, I should like again to thank the Minister and his Department for the manner in which this Bill was prepared and brought into the House.
Mr. Dillon Mr. Dillon
Mr. Dillon: We missed a great opportunity in introducing this Health Bill. This Bill should have been a charter for the general practitioners of Ireland but, instead of that, we are about to make the catastrophic mistake of modelling our whole health system on the welfare state of Great Britain and on Medicare and the allied health services of the United States of America.
I recognise the Minister's difficulty. Owing to the familiarity of our people with the kind of medical services that obtain in Great Britain and the USA, there may have been a very high degree of expectation that our public health service should follow on the lines of those countries. That is where I think we have gone wrong. We could have shown the world and I say “the world” quite deliberately, an example of how to run a satisfactory and effective health service. I believe that, had  we had the courage to do so, countries like Great Britain and the USA — who, in my opinion, are getting themselves into an inestimable sea of sorrow on the road they are travelling — might well have drawn back and said “Let us do what Ireland is doing and see if perhaps they have not found the right answer to the problem which threatens to overwhelm us”.
The USA, which is one of the wealthiest countries in the world, have extended their Medicare service, as they call it, to include those whom they euphemistically describe as senior citizens — persons of 65 years and older. They are further burdening a Treasury which is already overburdened and practically crippled. Now they are talking of cutting down on their foreign commitments in order to meet the overwhelming burden of providing a comprehensive health service for that section of their community of 65 years and over before they make any effective impact on the health problem of the rest of the population.
The original estimate for the health service in Great Britain has already been exceeded by 300 per cent and is steadily rising to a point at which the British Exchequer itself is almost at the limit of its resources. We might not mind that if those who are familiar with the services provided had it to tell that everything ordinary people could reasonably seek has at last been made available, but the very reverse is true. The British health services are in a state of chaotic confusion. There is a pretence that the services are universally available. They are not universally available, and neither is it true that what is available is in any sense adequate or effective. There is a story non e vero ben trovata told of the British medical services which describes the case of a lady who applied for admission to a gynaecological hospital for an urgent gynaecological operation and being told that she must wait as the hospitals were overtaxed. Three years later she got a telegram to say that a bed was now available, by which time, in the ordinary course of nature, the lady had recovered and she thanked God that a bed had not been available when she applied because, if it had been, it  was likely that half of her inside would have been taken out. But then, of course, there are others, the others who were correctly diagnosed as needing hospital care in order to deliver them from chronic ill-health but who are not able to get it or who, when they did get it, found the hospital to which they were admitted grossly understaffed. It is common knowledge that, but for the fact they had a considerable immigrant medical population in Britain, a high percentage of the general hospitals in Britain would have to close down.
This all arises, in my suggestion, from the wholly illusory approach that the State should accept responsibility for everyone who is smitten with anything from a cold in his head to terminal cancer. There is a horrible by-product of that approach to the public health problem. It is that nobody now who does not describe himself as a specialist is regarded in the true sense as a doctor at all. I would have hoped that we in Ireland would have detected the profound error of that whole approach and that we would have said to our people: “Your doctor is the family doctor. Bring your troubles to him. We guarantee to you that, through the resources of the State, we will deploy behind the family doctor all the hospital requirements that he, in his experience, may consider it necessary to mobilise for the protection of your health.” I would have hoped that we would have said to the average member of the public: “Forget the hospital. Your man and the protector of your health is your family doctor. And when we say `your family doctor' we mean your family doctor, not the doctor we choose to impose upon you.”
I know it is part of the Minister's intention to provide, in so far as it is practicably possible, that there shall be a choice of doctor freely available under this Bill; but there is then going to be the endless struggle and battle between the Minister and the individual practitioners as to what the appropriate charges are to be. What I do not understand is why he could not have approached this problem on a wholly different basis, and, taking example from the eminently successful  principle of the Voluntary Health Insurance, why he should not have set up an insurance fund into which every individual citizen would pay an annual premium. Where an individual is not financially circumstanced to pay that premium, then let the State pay the premium for him. Then declare that any individual citizen consulting his own physician was insured against costs up to a certain limit as prescribed under the new Health Insurance system and that anything over and above that he choose to incur would be his own liability, leaving it to the general practitioner to deal directly with the patient. You might get general practitioners who wanted to charge a fancy fee. Very well then, let those who are prepared to pay a fancy fee go and consult them and pay out of their own pockets the difference between the fancy fee and the standard fee. If that is what they want to spend their money on, let them go and spend their money on it. That would limit the charge falling upon the Exchequer and avoid the detestable task which confronts the Minister of trying to cost every visit and cost every service the general practitioner provides for his patient. That would leave to the individual patient the widest possible discretion to incur whatever medical costs he or she chose to incur at the general practitioner level, and would put an end to the wholly obnoxious belief—I regret to see it growing not only here but in every other country in the world—that the general practitioner is a kind of inferior doctor.
I have been a long time in this world and I want to say with great deliberation that the general practitioner in a properly organised health service is the most important element in it. We are all familiar with the progress of science, which has been summarised as people knowing more and more about less and less. You can get a degree of specialisation building up in the science of medicine to the point at which if you go to one practitioner of high distinction in one particular branch of medicine, whether you have a pain in your toe or a lump on your head, he will determine that it is due to cardiac malfunction, if that is his  particular line of country. Then you can go around the corner to another specialist of the highest distinction who will tell you “Kidney malfunction is at the root of your trouble, my dear friend. Place yourself in my hands and the lump will disappear.” Both men speak in perfectly good faith. Both are men of the highest distinction in their own particular sphere. But both of them have become so immersed in one particular sphere of therapeutics that their whole instinct is to relate the syndrome presented to them to the speciality in which they are primarily involved. However, the patient presenting himself to a general practitioner presents himself to a man who, by his very training, is not only a doctor but a psychologist who if dealing with a sore foot first looks at the foot to see has the man got an ingrown toenail and then proceeds from that, step by step, through the various syndromes with which his training has made him familiar until he reaches the end of his capacity. At this stage he says, and has the courage to say: “I do not know what is wrong with you and because I do not know what is wrong with you I am referring you to so-and-so so that he may find out.” I remember once a distinguished specialist in this city saying to me about colleagues who did not belong to his hospital: “Ah, those fellows, if they were walking through Stephen's Green and heard sparrows singing in the bush, they would not admit they were sparrows until they had eliminated the possibility of their being canaries”.
What I think is so tragic is that we have not grasped this opportunity of restoring in Ireland a full realisation of the importance and of the significance of the general practitioner, a realisation of the standing he should have in the community he serves and of the reliance that ordinary people should put in him, and have not, given an assurance that the State would mobilise behind him and place constantly at his disposal in the fullest abundance the scientific equipment and laboratory facilities that the best hospitals can provide when his diagnostic capacity has been exhausted by the problem presented to him.
Had we done that, and had this Bill  been designed on the basis of insurance in so far as the charges between the family physician and the family were concerned, I would have said to the Minister: “You have got to face the facts in the modern world in which we live, and in the hospitals reorganisation programme on which you are embarking, and on which I think you are right, you have got to say to the Government that the only way to meet this is to make it a charge on the Exchequer.” The people have got to make up their minds, do they want first-class hospitals, economically administered, to support the general practitioner down the country, or do they not. If they want them, they have got to pay for them. If they are not prepared to pay for them, they have got to do without them.
I believe the people would have said: “We do want them. We are prepared to pay for them, and we recognise that this is a charge which ought to be carried on the Exchequer to be met by the taxpayer of the country as a whole,” because they are not for the service of the rich, and they are not for the service of the poor; they are for the service of everyone. It does not matter whether you pay your family physician a consultant's fee of three guineas, or a consultant's fee of 10s. Once he has reached the end of his diagnostic capacity, with the equipment available to him in his consulting rooms, the same hospital facilities are available to the 10s doctor as are available to the three guinea doctor, and it is for the head of each family to determine for himself then. Why have we not tried to do that?
I do not want to go into a detailed examination of this Bill on Second Stage. I do not profess to be a specialist in public health problems. I have not had the experience of Deputy Ryan and other Deputies who have served on public health authorities, although I was a member of the Roscommon County Board of Health 35 years ago, but the world has changed so much since then. We do not build hospitals any more in fields adjoining graveyards, because the man who owned the field beside the graveyard wanted to sell his field for twice the price he would get from anyone else.
 I have some experience of our local county hospital and the surgeon who operates it. I will not go into his political affiliations, although I have a pretty shrewd suspicion of what they are. Leaving that out of the question, he is a great and dedicated servant of the people. He is one of those doctors who would work 18 hours a day if he thought there were people who wanted his care. He is a great general surgeon. Of course he is something more. He is a great psychologist and he loves his patients.
I am prepared to concede, looking at the overall problem in the country, that the Minister is probably right in his desire to have general hospitals and regional hospitals. He is probably right in his belief that, with the progress of medical science, and laboratory techniques, and the requirements of modern equipment, it is no longer possible to maintain a multitude of small hospitals, but we should not forget in this House that 70 per cent — and I think that is a conservative figure — of all the cases going into a county hospital are eminently within the range of the competence of a general surgeon. I am sure 90 per cent of my neighbours would sooner be treated by the county surgeon near their homes and families, than by a high-powered panel of specialists in regional hospitals 60, 70 or 80 miles from home.
We have to recognise that, in effecting what we believe to be a desirable reform of regional and large general hospitals, we are taking from rural people an amenity which is very precious to them, and that is the ability to have their operation or their illness within reach of their neighbours and friends. We have to ask ourselves with great anxiety, are we completely sure about the price we are going to pay for withdrawing the hospital facilities, inadequate as they may be in some cases, from the immediate locality and will we get an adequate return in a superior service in the regional and general hospitals which it is our pur pose to create in the years that lie ahead.
We have to ask ourselves — and this is something on which I have not heard the Minister give statistics to the House — what percentage of surgical problems  are presented to the county hospitals which are well within the competence of what we habitually regard as a county surgeon?
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: Eighty to 90.
Mr. Dillon Mr. Dillon
Mr. Dillon: Eighty to 90 per cent come within his range of competence. So, it is for 10 per cent only that reference has to be undertaken to a Dublin, Cork or Galway regional hospital. We have to remember that, in order to provide for the ten per cent who are at present being referred from the county hospital to the larger hospitals in large centres of population, we are embarking upon a programme which will deprive the 90 per cent of the inestimable benefit, from their point of view, of a hospital which is accessible to their families and friends.
I know the Minister answered me off the cuff when he said 90 per cent, and I am certain that no one will quote that figure against him as being a scientific statistical calculation. It is a rough estimate of what the general impression has been. Probably there has never been any precise statistical measurement made of so amorphous a concept as the kind of surgical problems that are within the competence of a general surgeon. Roughly speaking it is of that order, measured by our past experience in references from the surgical hospitals to the central hospitals. There may be those who would say that maybe if another five or ten per cent were referred they might have done better than in fact they did. I think the Minister will agree that the vast majority of cases requiring urgent surgical treatment are well within the competence of a competent general surgeon in a county hospital at present.
We are making a substantial change in the whole system. If we are, this is all the more reason why we should try to build up a closer relationship with the general practitioner, and it is all the more reason why we should try to present to the country, and to the world, our belief that the real keystone of a satisfactory health service is the family doctor. If we are to do that, it seems to me that our prime purpose  ought to be to put it within the reach of every family to go to the family doctor of their own choice. I see no way of doing that except on the insurance principle I have just outlined. If we do that rather than seek to build up the whole complex machine which is functioning in Great Britain and the United States of America, we will have set our eyes upon a target which we will be much more likely to achieve effectively, to the far greater advantage of those whom we seek to serve.
Surely it is madness to slither into a whole dialectic of chaos because nobody has the courage to say stop? Let us look at this whole problem again. I do not know what estimate the Minister has made or what the ultimate total cost of this Health Bill will be, but it will certainly be a burden three or four times the original estimate which is at present in the Minister's mind. I do not believe we shall be able to pay that and, if we cannot, the whole system will break down. I do not want to see the situation arising in this country in which there is simply no accommodation in the hospitals for the people who need hospital treatment, no staffs sufficient to staff the wards which we have created in the regional and general hospitals envisaged in this Bill, and I gravely apprehend that this is the inevitable sequel to pursuing the general scheme on which the Minister's plans are founded.
In the context of costs I want to draw the attention of the House to this aspect of the problem. Fifty per cent of the total cost of the health services —and there is some argument whether it is 50 or 55 per cent—are to be borne by the State, and 45 or 50 per cent by the local authority. I believe that is substantially the position but, whatever the proportions are, I think the present position in Cork city is typical, in which the rates are now levied at the rate of £5 in the £, of which approximately £2 is in respect of the health services. We are always talking about the depopulation of rural Ireland. Rural Ireland does not consist exclusively of small farmers living on small farms. A very large part of the population of rural Ireland  live in small towns and every house in those towns has a pretty substantial valuation. When one talks of rates of £4 in the £ in County Mayo one should not be thinking of land only to the extent to which land is relieved of local rates; one should be thinking of the small shopkeeper, of the retired person living in a small house, of all the people who live in and about the small towns. Their lives are being made impossible by the intolerable rise in the burden of rates. Am I correct in stating that it is proposed substantially that half the cost of all the health proposals are to be borne on the rates in future? Perhaps Deputy Ryan would say if that is the case?
Mr. Ryan Mr. Ryan
Mr. Ryan: Yes. That is so.
Mr. Dillon Mr. Dillon
Mr. Dillon: Whatever the cost is, I want to warn the House it will not be borne on the rates because the ratepayers will not be able to pay it. I always remember Harry Truman saying when he was President of the United States: “I remember 1929 and 1930 and 1931. That is when they put me through the wringer.” What he meant to imply by that was that that was the period when his haberdasher's shop was made uneconomic by the fact that the cost of operating it exceeded the profits. So he went through the wringer, as he said himself, and turned the key in the door and went down to Boss Prendergast to look for a job.
Is there a Deputy who is familiar with rural Ireland who does not recognise that there are hundreds and probably thousands of small businesses in rural Ireland, each one of which supports and educates a family, which are just hanging on by the eyebrow? Increase the rates by another £1 in the £, put another 10/- a week on them by way of rates and they will be in the same state as Harry Truman was in but they will have no Boss Prendergast to go to to get them a job.
I have said at the beginning that I recognise the difficulty of the Minister for Health, but there is only one escape from that dilemma and that is to recognise that the financing of the health services is not a suitable burden for the rates. It ought to be shared by two  sources: (1), an insurance fund to which those who can afford to pay should make their contribution and to which those who cannot shall have it made for them by the State. It will be then for the fund to provide beneficiaries with the benefits to which they are entitled for domestic medical care, each individual making his own choice as to whether he will limit the expenditure to that level or supplement it from his own resources; and (2), the Exchequer, in respect of hospital administration which must be organised on the basis which enables the Exchequer to deal with it as it would deal with any business enterprise, on a basis of strict costings, estimates and results.
I said in an earlier discussion on an Estimate relative to this Minister's Department, that I was happy to hear the Minister lay it down as a principle of his policy that hospitals owned by the religious would be owned, operated and controlled by them. Under the new dispensation we shall have three kinds of hospitals: we shall have the local authority hospital, the hospital operated by a lay committee, and the hospital operated and controlled by the religious who own them. But, whoever operates them, whether it be lay people or a health authority like the Dublin Health Authority, or a religious order, whatever the management authority may be, it will have to be sustained by competent management personnel with whom the Exchequer can deal on the basis of costs and revenue and it is only the Exchequer that can reasonably be expected to measure these costs and to report to this House as to what is required in the form of taxation; and it is only this House which can ultimately determine whether we are prepared, in the name of the people, to shoulder these costs or to inform the Minister that the people have elected to have less comprehensive hospital services than he proposes because the people simply cannot afford to pay for them.
I, therefore, ask the Minister to look at this whole scheme again and to recast it, bearing in mind the circumstances of the ratepayers, bearing in  mind the future costs of hospital administration and bearing in mind, above all, that we should give a lead to the world in producing a charter for the general practitioners of Ireland so that the world may come to recognise that the most important element in a successful health system is the relationship that exists between the family physician and his patient, plus the possible accession to an effective family physician of the opportunity of earning by his own exertions and superior skill an income appropriate to that skill which he is prepared to deploy in the service of those who trust him as their family physician. I believe that, if we do that, the world may well follow us instead of the reverse procedure of our accepting the view that what has so manifestly failed in Britain and in the United States of America should be adopted by us in the certain knowledge that, even on our miniscule scale here, it will fail as it has failed elsewhere.
I do not want to overpaint the picture. I have had considerable experience from the point of view of the patient of the functioning of Medicare in America and of the health services in Britain and I believe Deputies would be shocked if they knew the extent of their inadequacy. They would be shocked to hear the stories I have heard, not only from patients complaining — these we must discount because those in ill-health are inclined to exaggerate — but from young Irish doctors and Irish nurses who have participated in the public health service in Britain. They have told me themselves they would rather work for half what they get in Britain under humane conditions in Ireland than go on participating in the farce of the public health services as administered in Britain at the present time. Bearing these facts in mind, I would suggest to the Minister he ought to look at this whole scheme again to see if the insurance principle advocated in Deputy Ryan's amendment, remembering that it redounds to the relief of the ratepayers, should not receive more sympathetic consideration before the Minister irrevocably commits himself to the principles of the Bill.
Mr. T. O'Donnell Mr. T. O'Donnell
 Mr. T. O'Donnell: First of all, I should like to express my disappointment with this Bill. When one compares it with the White Paper produced by the Minister's predecessor in 1966 all one can say is that this Bill is but a miserable shadow of the health services envisaged by the Minister's predecessor. This Bill, indeed, bears little resemblance to the policy adumbrated in the White Paper. In my opinion, there are two fundamental flaws in the Bill. It has been introduced without the Minister having been able to obtain the agreement of the general medical practitioners in the country. It is ludicrous for the Minister to introduce a Bill changing the health services without having reached agreement with those who will operate the services. The Minister said he had had detailed discussions with the medical profession with regard to various aspects of remuneration. The discussions bogged down in particular in relation to the method of remuneration of the doctors.
Speaking here some weeks ago on the Estimate for the Department of Health, I said the system of remuneration proposed by the Minister was totally inadequate and wholly unacceptable to the medical profession. If we are to have a satisfactory health service it is vitally important that those who operate that service should do so under what Deputy Dr. O'Connell described as ideal conditions. The proposal to pay the doctors on a capitation basis is a bad one.
Deputy Dillon drew attention a moment ago to the fact that the health services in Britain, operated on a capitation basis, are not giving the service it was intended they should give. I have discussed this with the medical profession and I believe that the fairest and most equitable system of remuneration is a fee-per-service basis. The capitation system proposed by the Minister would turn doctors into virtual slaves. There is no proper provision under such a system for free time and no really adequate remuneration would be available to doctors called out in the small hours of the night and after normal working hours. The dental service in Britain  is operated on a fee-per-service basis and it is not without significance that the dental service there is operating so satisfactorily that there is a mass exodus of newly qualified dentists from this country to Britain.
I urge on the Minister the importance of arriving at an early and satisfactory arrangement with the medical profession. It is vitally important to the operation of any health service that our doctors be happy and contented with their remuneration. Deputy Ryan, speaking here last week, emphasised this very fact. While advocating a fair deal for our medical doctors, I am not to be taken as overlooking the fact that the patient is the most important person. I gather, however, there is now good hope of an early agreement between the Minister and the medical profession with regard to remuneration. The information available to me is that the problem of operating on a fee-per-service system is a problem of control. I understand a committee has been set up by the medical profession to examine ways and means whereby a proper system of control can be applied to the Operation of a fee-per-service system. The professional man should be remunerated in respect of the service he gives. I said already I feel it is a pity the Minister introduced this Bill without having been able to reach agreement with the medical profession.
Another aspect of this totally inadequate Bill is that it seems to have been rushed — perhaps on grounds of political expediency and with a general election looming on the horizon. It is rather a surprising measure in the light of the comprehensive White Paper which was circulated in 1966. The reaction of everybody I have met since the Minister introduced this Bill has been: “Good heavens, despite what has happened in Dublin Corporation, despite the trouble in practically every local authority this year in striking the rates, the Minister has introduced a new Health Bill which makes no provision for a proper system of financing this health service.” It seems that the unfortunate ratepayers will be burdened still further, particularly the people to whom Deputy Dillon recently referred.
 I believe, myself, that eventually this country will have the comprehensive medical service we all desire to see it have but that it will be provided on the basis of insurance, as suggested and advocated for a long number of years now by Deputy Thomas F. O'Higgins. There is no reason why we in this country could not introduce a comprehensive health service based on insurance. It has been done in other countries. I believe it can be done here. In fact, I would go further and say that the only way a comprehensive health service can be provided in this country — taking into account our economic and social circumstances and the resources at our disposal — is through insurance as advocated by Deputy Thomas F. O'Higgins, and which represents Fine Gael policy on health services. Strangely enough, the Minister's late predecessor did, in fact, concede that this suggestion was worthy of examination. I regret very much that the Minister has been forced into the present situation whereby, as I have already said, with a general election on the horizon, he has had to introduce a Health Bill which contains merely certain modifications of the already antiquated and totally inadequate health service we have been operating in this country.
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: Which of the three insurance schemes that I have already heard from Fine Gael does Deputy O'Donnell favour?
Mr. T. O'Donnell Mr. T. O'Donnell
Mr. T. O'Donnell: We all agree on the one scheme. The position, as I see it, is that there are certain modifications in degree. Certain sections of the Bill are to be welcomed. I want to be fair about this. However, I have been looking at this in toto, so to speak, up to now. Certain sections introduce a number of much-needed improvements. Take, for example, the question of eligibility. It is now proposed, in assessing the eligibility of an applicant for benefit, that only the income of the husband and wife will be taken into account. Hitherto, the income of other members of the household was assessed as well. This is a welcome development. I am sure most Deputies have had experience of cases where applicants for medical cards and  applicants for benefit under the Disabled Persons Act have been turned down because, in addition to the father and mother, there might be one or two members in the household who were employed. Therefore, I certainly welcome this change under the heading of eligibility.
There is another rather surprising omission from this Bill. Certainly, the Minister made no reference to it. Maybe it was covered in a general way in the debate but it is a surprising omission. I refer to the fact that this Bill has made no provision for reorganising the dental services of this country. When I was speaking on the Estimate for the Department of Health a few weeks ago, I dealt in detail with the position of the dental services in Limerick. I said that I had come across people who had been waiting two or three years for dental treatment and were unable to get it. I referred to particular cases of people who needed treatment and who, because they were suffering from cardiac or other ailments, could only receive dental treatment in a hospital or would need to be hospitalised. There are no facilities available for this type of treatment. I understand that there is a shortage of dentists in the public service.
We all know what has happened in recent years — and I referred to this in a different context — and that newly-qualified dentists are crossing to Britain to take up employment there. I understand that in certain counties there is a serious shortage of dentists. This presents the Minister with a serious problem which is difficult to solve. I have a close relative in the dental service in Britain and I know that the remuneration there for newly-qualified dentists, compared with what they get here, runs not into hundreds of pounds but thousands of pounds. How our problem can be overcome is difficult to see.
I realise that in recent times there have been improvements in the salaries paid to public dental officers but the public dental services are not satisfactory. I am surprised that the Minister  has not specifically detailed any new provisions in respect of the public dental services, the school dental services and so forth. I have already stated that it is vitally important to the operation of the public health service that the people who operate it should be remunerated equitably and adequately. I have referred to the doctors and another section of the medical profession to which I should like to refer is the nursing profession, whose conditions of employment leave quite a lot to be desired. There have been improvements in their conditions and hours of work in recent years but there is still quite a lot of dissatisfaction amongst nurses in regard to remuneration, hours of service and conditions of employment. I know that the Minister, like myself, would be inclined to help this profession and I would urge him to examine the legitimate grievances of the profession with a view to giving them the fair deal they deserve. Rarely a week passes that we do not read in the newspapers statements, letters or complaints about the conditions under which our nurses have to work. The nursing profession is a very noble profession and one which in recent years has been attracting more and more attention. There are still minor grievances, minor problems and minor difficulties which could be easily removed and the Minister is the person to do this. I hope he will examine the whole set up in regard to the training of nurses, their conditions of service and so forth, and I have no doubt that by indicating his interest and by using his influence he will be able to right these grievances.
In the concluding part of his introductory speech the Minister referred to an aspect of the health services in which I am very interested, the question of rehabilitation. I understand that it is now proposed to enable the new health boards to provide workshops and so on, to aid the rehabilitation of incapacitated people. Heretofore this was done by voluntary effort. A large and very successful experiment is in operation in the Shannon Industrial Estate where we have a factory building being operated by an organisation called Retos Ltd. The Minister is probably aware of this, and indeed,  if my memory serves me correctly, I think he officially opened this centre. This is an outstanding example of the way in which voluntary effort can be organised and assisted by the State towards rehabilitating certain types of incapacitated people. I should like to see an extension of this type of experiment throughout the country. There are numerous types of incapacity which require rehabilitation. Rehabilitation is a wide and complex problem due to the fact that there is this variety of ailments, ailments which differ in regard to type and degree of incapacitation. The point I am making is that I am doubtful if it is a good thing to give these local boards full responsibility for organising this service.
The basic principle which applies to all types of control, particularly in relation to State participation and encouragement, should apply here and these local groups and voluntary organisations who are doing excellent work — we are very fortunate in this respect here — should be encouraged in this work and assisted in a big way by the State. Only as a last resort should the State take over this work. Perhaps the Minister would elaborate further on his plans in relation to this very important problem of rehabilitation.
I do not want to repeat points made by other speakers. I am very disappointed with the Bill but I am not without hope that before long there will be introduced comprehensive medical services financed by the system advocated by Deputy T.F. O'Higgins, a health service based on insurance.
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: It is hardly necessary for one Deputy after another to repeat the same old story in regard to health services year after year. The Minister must realise that as Minister for Health he occupies a most vital and important position in the Government. He is charged with the responsibility of providing out of the Vote passed by this House the moneys necessary for the administration of the health services and for introducing what in the considered opinion of his Government is the best possible health legislation and also with ensuring cooperation  between his Department and the medical profession, the nurses' organisation and the local authorities.
I have never heard the Minister or any of his predecessors advising people as to what they should do so as to live better and healthier lives. Year after year we seem to be commenting on increased medical services—undoubtedly very necessary — and on increasing the number of hospital beds—again very necessary, apparently. But may I inquire what practical steps the Department are taking to keep people who are healthy out of hospital?
The Department should have a special section whereby practical steps will be taken to teach people the importance of maintaining a high standard of health. That has not been done. Is it not true that a large number of hospital beds are occupied today because people eat too much fried food, too much white bread, too much white sugar, too little fruit and do not drink enough water. I have yet to see any advertisement sponsored by either a health authority or the Department to inform the public that white sugar is next to rank poison; that a certain bleach is used in white sugar and that analysis has shown that from a health point of view the proper sugar to use is brown sugar and, if possible, brown cane sugar. In order that people may live better and healthier lives they should be taught the importance of balanced diet. It has been shown beyond doubt by the medical profession that lung cancer is associated with excessive smoking and that deaths from lung cancer have increased. The Department are failing in their responsibility to warn the people of this danger. An occasional observation by the Minister for Health on television or radio is of little use. Local authorities under the guidance of the Department of Health should be able to alert the public to the danger. There are no people more careless about their health than the Irish people. Why, I do not know. We have an appalling deathrate from cancer and our hospitals are taxed to capacity. The Minister may not agree when I say that we have what can, perhaps, be described as one of the worst health services in the world, which does not provide the services the  people require, which is financed mainly from the rates. As Deputy Dillon correctly pointed out, the stage has been reached when the ratepayers cannot continue to pay for this inadequate health service.
I wish to join with Deputies Ryan and Dillon and other Deputies in welcoming any move by the Minister to improve our health services. An outstanding opportunity was presented to the Government of introducing a health service that would meet all the demands of our people. It is generally recognised that the cost of medicines, and particularly of modern drugs, is very great. Because of these everrising costs there has been a very great increase not alone in the contributions paid by the Department to health authorities but in the equivalent sum that must be raised by the health authorities themselves.
I had expected, as I am sure the vast majority of the people expected, a completely new approach to health. I wish to express the greatest disappointment with this Bill. I cannot see any relief in it for the local ratepayers who have objected in an angry manner to the severe imposition on rates in respect of health services.
The present medical card system is not a good or proper system. I subscribe to Deputy Ryan's view that we should have a health service in this country which would be an example to all democratic countries in the world. I say this because our excellent doctors, specialists, surgeons, nursing staff and nursing sisters make that possible.
We should have a health service based on insurance. Everyone has admired the success of the Voluntary Health Insurance scheme. I know of many people who would be out of house and home today, who could never have hoped to meet doctors' and specialists' fees, had they not been members of the Voluntary Health Insurance scheme. I had always hoped that the State would take the smooth working of this Board as an example for the provision of a proper and efficient health service, a health service based on a contribution paid by  the citizen when he is well against the time he may become ill.
There was an estimate sometime ago of what a normal contribution for a good efficient health service might be. I think it amounted to something like the price of a packet of ten cigarettes per week for every head of the population. The burden on the health authorities has now become so excessive that it cannot continue.
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: I should be very interested if the Deputy would spell that out. What does the Deputy mean when he refers to the price of a packet of ten cigarettes which, I think, would be about 2/4d?
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: I do not wish to embarrass the Minister but I am long enough in this House to remember Senator Dr. Ryan when he was Minister for Health telling us, when introducing the present Health Act, that about 2/- in the £ would be the rate required for the proper running of what he then described as a most efficient health service that would cater for all our people.
Mr. S. Flanagan Mr. S. Flanagan
Mr. S. Flanagan: Is the Deputy talking now about a similar figure? Does the Deputy know how much that would yield? Let us get some reality into this.
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: A proper health service should be provided on the basis of insurance. It should be so designed that the State would pay the contributions for old age pensioners, for widows, orphans, disabled and unemployed persons and those who are now covered by what the Minister describes as the “blue card” or the medical card, so that the service would be completely free for such poor sections of the community.
I cannot understand what the position in relation to health charges is likely to be in this country in ten years from now, but I say that the health of our people is of the greatest possible importance. Our people are entitled to a proper health service which will provide them with a choice of doctor or specialist treatment and which will provide them with hospital accommodation.  Every Deputy from rural Ireland, and perhaps from the cities, knows that one of the most urgent problems of our people is in relation to the health services.
The measure of relief given in respect of health services under this legislation is so small as to be completely insignificant in comparison with what the people expected and in comparison with the health service that has been promised by the Government down the years.
I want to make a brief reference to county homes. There are many county homes in the country in which our old people are ending their days and some of which are far from what we would desire in Ireland in 1969. I have been in some of them and I have noticed that while every effort is made to have them kept spotlessly clean their lay-out does not make them attractive accommodation. I am glad that Deputy McLaughlin is present. I have never been in the county home in Sligo but I propose to go there for the purpose of enlightenment on the first occasion on which I am in Sligo. I was told in the past week that a constituent of mine visited an aged relative in the county home in Sligo and was appalled and astonished. He never thought old people would have to end their days in such surroundings.
In Laois we have a county home on which £1/4 million was spent. It was one of the present Minister's first duties to officially open this reconstructed county home. I want to invite any Deputies who have been critical of county homes to visit the Laois one at Mountmellick. Not alone is it one of the most outstanding county institutions in this country but I venture to say there is not anything like it, as a hospital for the aged, in any part of Europe. It is an institution of which we are very proud. We do not describe it as the county home because it is no longer the county home. The sooner we get rid of the titles county home, union and workhouse, the better. Fifty years ago everybody wanted to avoid the workhouse as it was then known but we are now living in an age when people expect high and modern standards if they are to end their days in an institution. The sooner we get rid  of those buildings that were erected in the period 1839 to 1843, the better. They are a reminder of bad times and of hardship. There is a great deal of pride still left in our people and it is well that that pride should exist. Aged people who are friendless will go into an institution more readily if it has not got the title of county home.
While our young people are busy with all the attractions of modern life there is a great tendency to push old people out of their own homes. Greater provision should be made for the maintenance and care of old people in their own homes rather than in institutions. In every area there should be available a home nursing service whereby it should be possible for a nurse to call once or twice daily to render necessary services to old people in their own homes. In many parts of the country no such service is available. There is nothing so sad as to see an old person having to leave the home he loved and go into an institution. I am sorry to say that it is noticeable that, instead of keeping old people at home, members of their families are encouraging them to go into institutions and endeavouring to push them into them. There was a time when people cherished the idea of looking after their aged parents or relatives. The sooner we revive that spirit, the better. It should be possible to provide an up-to-date home nursing service for aged persons.
The county hospitals, in general, provide an excellent service. I have noted from a reading of the Fitzgerald Report that it is the intention of the Government to consider the establishment of hospitals on a regional basis. The existing county hospitals cater for the people of the county. Everyone knows everyone else. Everyone knows the staff, and there is an atmosphere of friendliness and confidence in such institutions.
I do not know if the Minister has ever been in any of the hospitals in the United States of America. Perhaps he has. One of the saddest experiences I ever had was when I visited a constituent of mine in the Bellevue Hospital in New York. It is one of the biggest hospitals I ever saw. It embraces  a few blocks of the city. We hear talk about the conditions in our old county homes, but there was one ward in that hospital with at least 80 to 120 beds and one could barely walk between the beds. Naturally in New York one would expect the hospital to be thronged and it was.
I remember the patient saying that it was bad enough to be ill in Ireland but it was a pleasure to be ill in Ireland compared with being ill in the United States. He said that when one is ill in Ireland one has many friends to visit one, but when one is ill in the United States one is out of circulation and is wanted no longer. They have not got time to call to the hospital. Everyone is too busy. I remember him saying that New York with all its millions can be a very lonely place in hospitals and visitors seldom turn up.
One thing that can certainly be said about the Irish here — it is probably because we are a small country — is that we are a most charitable people and a most sympathetic people, particularly when people are ill. It is looked upon as a work of charity and of mercy to visit a sick person in hospital. I hope that will long continue. Our system of county hospitals has been a success in this regard. In rural Ireland particularly, when you are ill, at the first available opportunity all your friends and neighbours come to the county hospital to extend greetings and good wishes for a speedy recovery. I wonder will we lose that atmosphere in the regional hospitals. Perhaps not. It would be sad if we were to lose the close contact which has already been established as a result of our county hospitals system. I am sure it is the intention of the Minister to have available in the regional hospitals every possible branch of the medical services.
In the report which is being considered by the Government it has been suggested that Tullamore should be the site for the Midlands regional hospital. I hope the Minister will not be browbeaten by any other local authority into altering that recommendation. I believe that report is an excellent document. Whether it is workable or  feasible is another day's work. I know that efforts have been made, because of the extensive stretch of territory in the Midlands, to have the recommendation in relation to the regional hospital for the Midlands altered. I beg the Minister to resist in the strongest possible manner any effort that may be made either by the Westmeath County Council or by any other county council to alter that recommendation. I read over the week-end that Westmeath County Council were about to ask the Minister to attend a meeting of the county council. If he goes to a meeting of the Westmeath County Council I am sure I am not foolish in presuming that he will receive an invitation to attend a meeting of the Offaly County Council.
Dr. Gibbons Dr. Gibbons
Dr. Gibbons: What about Deputy L'Estrange?
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: Deputy L'Estrange is an excellent Deputy and he is quite capable of looking after his own constituency. I have no doubt whatever that he will do that. Tullamore has been recommended. The Government have accepted the recommendations in principle. I see no reason why they should be altered. I want to give the Minister a reason why it should not be altered. What was the purpose of submitting this report to the Minister and the Government if it is to be disregarded? I am quite satisfied that a full and impartial investigation was made into the location of this regional hospital.
Offaly is blessed by having in Tullamore what can be and was described as the best county hospital in this State. I am not a member of Offaly County Council. I live in Laois. All over the Midlands there has been built up, not this year or last year or the year before but over many years, an outstanding confidence in the Tullamore hospital. It was built up by a man who is now in retirement, a man called Surgeon O'Reilly. Men of his type are few and far between. He is a man who devoted about 20 hours per day to this hospital. He had no hobbies. He seldom left the hospital and he was always to be found at the bedside of his patients. Because of his great skill as a surgeon, practically all  his cases in the theatre were successful. Because of his devotion to duty over a long number of years a bond of confidence was created in the Midlands in the Tullamore hospital which had not prevailed in other parts of the Midlands.
Mr. Carter Mr. Carter
Mr. Carter: That is a very wide statement.
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: It is a very wide statement and it is true.
Mr. Carter Mr. Carter
Mr. Carter: Strictly it is not accurate.
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: Because of the special devotion of this gentleman who is now in retirement, and of his staff and because of the extra care and devotion to duty of the Sisters of Mercy who are running that hospital, this great bond of confidence was created. I am sure Deputy Carter will agree.
Mr. Carter Mr. Carter
Mr. Carter: I am not disagreeing about Tullamore, but the Deputy referred to other parts of the Midlands. It is on that I am disagreeing.
Mr. O.J. Flanagan Mr. O.J. Flanagan
Mr. O.J. Flanagan: I appreciate the outstanding service rendered by the Sisters of Mercy in Mullingar County Hospital. I look upon that hospital as one of the most highly efficient in this country. Since it is run by the same nursing order as runs the county hospital in Tullamore it could not possibly be otherwise. I do not know any of the patients in Westmeath, but I seldom pass through Mullingar without dropping in to the county hospital and enjoying the hospitality of the Sisters of Mercy there. I am very much alive to the fact that the special care and attention of the Sisters of Mercy in the Midlands is something which has built up a terrific volume of confidence among the public.
If a hospital is to be a success it must have the confidence of the public. In Tullamore the confidence is already there. I make a genuine appeal to the Minister to have the terms of the report implemented so far as the location of the regional hospital is concerned. The Mullingar people may claim that they want this regional hospital in Mullingar and that they want  another regional hospital down in Portlaoise. If this was feasible I am sure those responsible for compiling the report would have recommended it. I strongly impress upon the Minister the necessity for adhering fully to the terms of the report. If there are to be regional hospitals provided in the Midlands, a more suitable location cannot be found than the County Offaly which would cater for Westmeath, Meath and indeed the greater portion of the Midlands.
There seems to be a growing practice that when a patient with a complaint, be it real or imaginary, approaches a doctor, after a short consultation the doctor will tell the patient he should see a specialist. He will write out a little note for him and make a suitable appointment. When he goes to the specialist the specialist will say: “I think we should have a second opinion”. I have a feeling that there is a ring somewhere. I am not at all happy about the passing of a patient from doctor to doctor, more especially when I have to see the bills involved. There are people who have no medical cards, who according to the present regulations would not be entitled to a medical card but who would be prepared to pay a reasonable fee to a doctor. I have seen some astonishing and frightening specialists' bills. There is a great hubbub about the £2,500 that a Member of the Dáil receives for his services here but, looking at some of the bills sent out by some of these highly qualified specialists and surgeons, one realises they would not have to consult very many patients before they could rake in £2,500. I suppose it is not for us to question the qualifications of these gentlemen. They are probably among the most highly qualified people in Europe and may be entitled to every penny they are receiving from a patient. I have no doubt they have very clear consciences when they are writing out their bills, but, as I said, some of the bills I have seen furnished have certainly caused me astonishment.
There are many people who are not in the Voluntary Health Insurance scheme and who do not qualify for inclusion in the general medical services  register. All I can hope is that they will be preserved from any dealings with these gentlemen to whom I have referred. The Department of Health should give every encouragement to people to join the Voluntary Health Insurance Scheme as a safeguard for themselves.
The financing of the health services should be based on insurance. I am not satisfied with the present rates of benefit available for the sick. I am not satisfied with the system whereby medical cards are made available. It would, I suppose, be unreasonable to expect any improvement because it is the system which is at fault. If we had health services based on insurance there would be none of the humiliation caused to some by the embarrassing investigation into means to find out whether or not people are entitled to medical cards and the time has come when these people must be provided with a better and more up-to-date health service.
I want now to deal with mentally handicapped children. A great deal has been said already about this very serious problem. We are short of trained personnel. We are short of accommodation. There are not enough suitable institutions available. I appeal to the Minister to give urgent attention to the provision of accommodation and properly trained personnel. The shortage of trained personnel is one of the most serious disadvantages from which we suffer. I hope a really serious effort will be made to provide both staff and accommodation for the care and training of the mentally handicapped.
All mentally handicapped children should be removed from mental hospitals. It must be heartbreaking for parents to have to put a mentally handicapped child into a mental hospital because of lack of proper accommodation for these unfortunate children. I know from personal experience that the resident medical superintendents in mental hospitals cater for these children to the very best of their ability. But mental hospitals are not suitable. These children should be cared for with other children. The environment of a mental hospital is not a proper environment.  I believe that the House will gladly vote any moneys the Minister may require. We have had this problem with us for too long. I trust the Minister will bring it to a satisfactory conclusion.
There are, too, mentally defective children for whom no additional allowances are provided to cover the extra care and attention these children require. There should be special monetary provision for these children. All of us appreciate the enormous burden resting on the parents of mentally defective children. I have known parents who literally became demented with the worry and torment of caring for these children. I know, too, the financial burden such children may cause in a working class family. I urge on the Minister the early formulation of a new scheme making generous financial provision available for the parents of such children.
The Minister has a very difficult task. It grows daily more difficult because of increased costs. That is why I urge on the Minister his acceptance of Deputy Ryan's insurance scheme for the purpose of financing the health services. Such a scheme will relieve the rates and ease the burden on the ratepayers. Indeed, the burden is one which the ratepayers can no longer carry. If the present trend continues we shall find ourselves ultimately going from bad to worse with every year that passes. The time to make a change is now. That is why I join with others in asking the Minister to reconsider his whole approach to health services because of the major part health plays in the community.
Mr. Andrews Mr. Andrews
Mr. Andrews: Sir, the first five chapters of this Bill deal with matters of administration, the setting up and rationalisation of hospital boards and the constitution of these boards. These chapters have been pretty fully dealt with already in the course of the debate, but I should like to make one comment in relation to health boards. Subsection (2) (a) of section 4 provides:
Membership of a health board shall consist of —
(i) persons appointed by the relevant local authorities,
 (ii) persons appointed by election by registered medical practitioners and by election by members of such ancillary professions as are specified in the appropriate regulations under subsection (1).
and, of course, three members appointed by the Minister. There have been complaints that there has been, as it were, a gap in communication between ordinary laymen and the medical profession itself. This section, however— really, it is a tremendous section— brings together three groups—the doctors, the laymen and the councillors. This is a most welcome development. This is the sort of thing we want. We want involvement by all sections of the community on matters of health. I imagine that the doctors would agree on this. Their main concern is the health of the ordinary people and, to ensure that they will continue to be in touch with the ordinary people as they are, this development of bringing together politicians, laymen and doctors will result in different ideas emerging from each of these three groups from which will emerge good decisions in regard to programmes, and so forth.
As I said at the outset, my contribution will deal mainly with Chapter IV of the Bill—Health Services—and onwards. Section 60 deals with medical and midwifery care for mothers. The section reads as follows:
(1) A health board shall make available without charge medical, surgical and midwifery services for attendance to the health, in respect of motherhood, of women who are persons with full eligibility or persons with limited eligibility.
(2) A woman entitled to receive medical services under this section may choose to receive them from any registered medical practitioner who has entered into an agreement with the health board for the provision of those services and who is willing to accept her as a patient.
(3) When a woman avails herself of services under this section for a confinement taking place otherwise than in a hospital or maternity home, the health board shall provide without charge obstetrical requisites to  such extent as may be specified by regulations made by the Minister.
If I may give an example of the type of matters that this section relates to, let me take the example of a condition known as spina bifida which, as we know, is a condition in children born with split spines. It is very important that this condition be treated within 12 hours of birth; it is as serious as that. An association has been formed in recent times of parents of children with spina bifida. The association was brought into being to co-ordinate work and to encourage further work in this line of medical practice. I should like to take this opportunity of congratulating that association on its establishment in the interests of the children concerned.
Spina bifida children are paralysed from the waist down. Up to 1956, approximately 94 per cent of these children died. Operative procedures for this condition were developed in Britain which we were able to follow very quickly in this country. Let us be fair to this country in terms of medicine and medical services. We are not averse to taking a lead and a line from other countries where good and effective practices have been developed. I congratulate the people here who were responsible for implementing so quickly procedures found to work so well in Britain.
Medicine is a universal matter. It is non-national; it is international—as it should be. However, as I say, these operative procedures were followed here very quickly and are now the practice in Crumlin Hospital and in the Richmond Hospital. As a result of following the British operative procedure it is now found that 70 per cent of these children survive. The fact that, before 1956, 94 per cent of children born with spina bifida died whereas now 70 per cent of such children survive, represents a tremendous advance and is a marvellous tribute to medical practitioners.
In order that maximum benefit may be received, the operation must take place within 12 hours of birth. If that is done, then only ten per cent of the 70 per cent will need wheel chairs. Consequently, early operation is essential. That is one of the reasons why  I welcome and, indeed, why the parents of spina bifida children will welcome the type of thinking behind section 60 and onwards of this Bill. In this country there are 62,000 births per annum and three per 1,000 births —roughly 180 births—per annum are spina bifida children. Out of these 180 children, 150 survive. That will give the House an idea of the cost involved. I take this specific ailment because it illustrates what I mean and it illustrates the importance of this particular section. The cost involved is absolutely prohibitive. Each spina bifida child needs five operations necessitating long periods in hospital. The mind boggles at the thought of the amount of money involved. Indeed, it would represent a charge on the health services for children of parents who could not afford to pay for this type of treatment. The Dublin Health Authority have been most co-operative in cases of this kind. The Voluntary Health Insurance Scheme covers cases where the parents are members of the scheme at the time of the birth of the spina bifida child. This is very good. It relieves the parents of some, if not all, of the expense involved.
I would suggest to the Minister to make this Bill even more effective by providing that, regardless of the income of the parents of a spina bifida child, the child—not the family—will be given a medical card, where the case is not otherwise covered, in order to ensure that the parents of that child will not be involved in any expense. It is recommended that spina bifida children be sent to ordinary schools. This is a good thing. It is self-definitive and does not require further explanation by me.
This operative service for spina bifida children is available at two hospitals— Crumlin Hospital and the Richmond Hospital—but quick diagnosis is necessary. A diagnosis within, at the maximum, 12 hours of birth is necessary. If the child is born in some remote part of the country this necessitates the fast transfer of the child to either of the two hospitals I have mentioned. A commission has been set up to examine the ambulance services. One wonders whether we have  ambulances which will take spina bifida children fast enough to either of these hospitals so as to ensure that the child will be cured, to some degree.
I use that particular ailment as an example of the sort of problem we are meeting and facing. I believe we are beginning to discharge our obligations to the parents of these spina bifida children given the type of thing that goes into Chapter IV of the Bill. In relation to the question of charges for the mentally-handicapped I notice that a figure of £3½ million out of a total of £40 million of the health charges was paid towards the mentally-handicapped last year. The Department pays towards the upkeep of the mentally-handicapped children in residential care and also contributes towards the diagnostic services and the disabled person's allowance that is given to about 3,500 adults. This is very welcome.
There is another matter which is dear to my heart in the context of the mentally-handicapped and the handicapped generally. If we encourage parents to keep children who are mentally ill and disabled at home, then we have a function to discharge to those parents who accept our advice. Regardless of income, these parents should be given a £500 tax-free allowance in respect of any such child they care for at home. I feel very strongly about this. At this point of time we do not give enough recognition to parents in respect of those children whom they keep at home. I would ask the Minister to meet his colleague, the Minister for Finance, with the forthcoming Budget in view, and to make this suggestion to him. A disability allowance of £3 a week is fiddle-faddle and does not help these people to any great degree. It is only touching the tip of the iceberg. We have a duty to discharge to the parents of these children. That is one way of discharging that duty.
The National Association for Mentally Handicapped Children is pressing for the right of every mentally-handicapped person to a disablement allowance payable to parents of children who are being maintained at home. There is an obvious reason why they  should be kept at home. Despite the fashionable misconception, mentallyill children do have emotions. Whatever improvement they can make, it will be greater at home under the care of their parents than if they were in some institution. This is not in any way to suggest that residential centres do not do a good job; they do a good job, but within the resources available to them. It goes without saying that dedicated parents of disabled children would be able to give more care to the child in its natural environment. One can appreciate the emotions, difficult though they may be, of the mentally-ill or disabled child and it is important that whatever encouragement is possible should be given in the child's natural environment.
On the question of the diagnostic services dealt with in this Bill, the Minister in the debate on his Estimate outlined the position of and the precautions taken in regard to PKU children. He stated that 80 per cent of these babies are now being tested but I believe we can reach the stage and at the speed at which the Minister is going we must reach the stage where 100 per cent of these babies will be tested. Let us refer to Dublin and Cork —I am not familiar with other areas— for their diagnostic services are first class and they do a very good job. The question of diagnosis is dealt with at some length and the question of the smear test for women which reveals cancer or cancerous tendencies is dealt with. This is the sort of service that money cannot buy and the Department, the hospitals and the medical people generally are to be complimented on their awareness of the need for this type of service particularly in relation to PKU and so on. It has been only in recent times that we have become aware of PKU but when we did become aware of it we did something about it. Given encouragement, even more will be done and more needs to be done.
Coming back to the question of the mentally-ill, the Hospitaller Order of St. John of God have introduced a very important diagnostic and assessment service in Dublin and throughout the country. They have a travelling diagnostic  assessment service based in Dublin which caters for the city and the country. The Order are to be congratulated on providing this service. I am sure the Minister is aware that there is a long waiting list for assessment. Anything we can do to deal with the waiting list, the better it will be from the point of view of the children concerned and of the staffs in the medical centres.
I should like to pay tribute for some of the information I have imparted to the House to the writer of a series of articles in the Irish Independent. I am not sure whether the writer is “Mrs.” or “Miss” Mary McCutchan. This series of articles was most informative and most helpful and I could be accused of plagiarism if I did not pay the writer this tribute because some of the information I have given the House I gleaned from these articles. On the question of the rationalisation of hospitals in Dublin city and county I would ask the Minister to seek the views of all those involved in the running of these hospitals.
Dáil Éireann 239 Health Bill, 1969: Second Stage (Resumed).