Dáil Éireann - Volume 245 - 09 April, 1970
Committee on Finance. - Vote 48: Health (Resumed).
Debate resumed on the following Motion:
That a sum not exceeding £37,921,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1971, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Local  Authorities, miscellaneous grants and certain grants-in-aid.
—(Minister for Health).
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: When I reported progress I was talking about the overall amount of money and the fact that there will only be £5 million left to deal with some very tough problems arising out of the administration of the health services. The Minister made a very extensive statement. Reading his speech, however, it seems to me he does not fully understand the position because the idea appears to be to do away altogether with dispensaries.
The foundation of all medical practice is the general practitioner. The general practitioner service over the last century has been maintained by the dispensary doctors. Someone has now conceived the idea that dispensary doctors should be abolished and there should be a free choice of doctor for all. This is a most desirable object but we must be very practical in our approach and analyse whether or not such a situation is possible of attainment. The filling of vacancies has been most unsatisfactory over the last five or six years. When a dispensary becomes vacant it is said that it will be filled in a temporary capacity. What exactly that means I do not know; in practice it very often means that the vacancy is not filled at all and people in rural areas are subjected to considerable disadvantages as a result of that nebulous approach.
To my knowledge there are a great number of vacant dispensaries at the moment. Nobody knows whether or not these posts will be filled. Some have gone to the appointments commission. Whether or not appointments have been made no one knows. I am not conversant with what is happening in other parts of the country but I know that there are at the moment three vacant dispensaries in Wicklow. In the case of two of them there has been an agitation for some answer from the appointments commission as to whether or not appointments will be made. In the case of Annamoe, which has been vacant for four or five months, I do not think any decision has yet been taken. The position there is that the indigent classes, those who  have to avail of medical cards, have to go 12 miles for a doctor. With the extraordinarily unsatisfactory telephone service in the country one can imagine the hardship caused should any sort of medical emergency arise. There is a dispensary at Camolin in my own county which has been vacant on and off for the last 20 years. Several doctors were persuaded to take up appointment there. None has remained more than a few months because the post was not sufficiently lucrative. The employment of the dispensary doctor is part-time and none of them could make a living in Camolin and the moment another more suitable situation became available they cleared out straight away. At the moment there is no doctor in Camolin and there is no likelihood of there being a doctor there because no one will take the job unless the salary is increased.
The Minister gave us to understand that the dispensary system will be abolished at one fell swoop. The idea is to get away from the poor law administration of the last century; instead of dispensaries we will have clinics and a free choice of doctor. A free choice of doctor is possible and desirable in those areas in which there are doctors among whom to exercise a choice. The difficulty with all legislation is that most of the administration is thought out in the confined circles of Dublin. The situation is entirely different in rural Ireland.
Suppose, for the sake of argument, the Minister abolishes dispensaries altogether and gives a free choice of doctor, that will be feasible and possible in the city of Dublin, Cork, Limerick and, to a lesser extent, Waterford. Take the small provincial town with a population of 3,000 to 4,000 people in which there are three or four doctors. There is the dispensary doctor who enjoys a basic salary. Two may be connected with the local hospital and the other may be a private practitioner, setting up in the hope of building up a practice and ultimately getting a dispensary somewhere in the area which will enable him to live in the town while working as a dispensary doctor outside it.
The Minister proposes to abolish all  dispensaries with the idea of inducing as many doctors as possible to come into the area under the scheme. Knowing something about rural Ireland and medical practice, though I have never been a dispensary doctor myself, it seems to me that the likelihood is that you will have three or four doctors serving the same pool, and the end result will be that there will not be a sufficient living for any one of them. The whole lot will leave the area and there will be no replacements. If there are three or four people trying to draw a living out of a pool in which there is not a living for one, it is commonsense that they will all leave. How will the Minister deal with such a situation? He is abolishing the dispensaries, I suppose on the advice of those who know best, possibly those who advised him in regard to the FitzGerald Report, with which I propose to deal.
I would point out that at the moment the situation is bad enough, that there are isolated areas for which doctors cannot be obtained. If the system proposed here now—which is glorious on paper—is put into effect, as likely as not rural Ireland will be denuded of medical advice. The situation requires a serious review. There must be totally different legislation for rural Ireland. I am taking rural Ireland as divided into sections: places that are entirely rural, where there is no town or centre of population; places that have small centres of population; bigger centres of population.
Let me return to the question of the appointment of dispensary doctors. It is not good enough for successive Ministers for Health to come into the Dáil and to say that no appointment will be made in a particular area because the whole system is being reviewed. To a certain extent the Minister let the cat out of the bag yesterday when he said he was going to abolish dispensaries. The simple question I ask the Minister is: what will replace the dispensaries? What is the plan? That is the great unyielded secret of this century—what is the plan for the supply of medical services in rural Ireland? The people of rural Ireland are certainly entitled to as much consideration as those in bigger centres of population.
 I cannot see any replacement for the dispensary. I have always been in favour of the capitation fee. Even if you have a fee for service, there is not sufficient medical practice in a great many areas to qualify for it. If you do away with the dispensary service and offer a fee for service, doctors will not live in an area unless there is a reasonable living to be obtained there. All doctors are not philanthropists. There seems to be an idea among the public that doctors exist for the benefit of the general public. Certainly doctors do benefit the public. Doctors take an oath to do the best they can to prolong life and to alleviate human suffering. Doctors have to live, the same as anybody else. I suggest that that is the way in which the matter should be approached if the Minister wants to give the public the best possible service.
People may think that I am arguing solely on behalf of doctors. I am not. Having practised as a doctor, although that is a great many years ago, I know the best way to provide a service. I am satisfied from my experience that the existing dispensary system is the best for certain parts of Ireland and should be maintained. As against that, there is the other argument quoted by the Minister's predecessor, the late Donogh O'Malley. An attempt to abolish dispensary doctors is a breach of contract. Dispensary doctors have contracted to serve for a certain salary and to give a certain amount of their time. They have full pensionable rights, and so forth. Abolition of dispensaries —which is what the Minister's speech implies—will lead to a serious situation. The Minister will probably find himself having to face a great number of High Court actions which will increase still further the greatly inflated health costs which in my view are much too high for the services provided.
I should like to say a few words with regard to nurses. There seems to be an idea among the general public that nurses' conditions should be the same as those of other employees. I do not think the average person realises that nurses give a tremendous  service to the public. In the past they have given a service completely out of proportion to that given by the rest of the public. Nurses have worked long hours and have remained on duty beyond normal hours. In the case of workers in factories and other institutions, everybody troops out at a certain time. Nurses are not in a position to do that. Whether in a hospital or private institution, a nurse may be attending a patient who is in extremis or who is very ill and it would be quite impossible for that nurse to go off duty at a specified time. It is entirely wrong to imagine that you can fix a low scale of wages and still obtain the devoted service that male and female nurses gave in the past.
The whole question of nurses' salaries must be reviewed. I and colleagues of mine have asked the Minister for Health certain questions in regard to nurses. The answer invariably is that everything in the garden is lovely, that the conditions here are better than or as good as those obtaining anywhere else. Conditions here are not as good. When a conservative body of people such as the Irish Nurses' Organisation marched on the streets of Dublin recently to assert their rights, the Minister must be convinced that everything in the garden is not lovely in regard to nurses' conditions of work.
In some cases wardsmaids receive as much pay as nurses who have a highly skilled profession, whose training extends over several years and who require a high standard of general education for entry to the profession.
I do not intend to elaborate this evening on the question of nurses' grievances. I do not want to prolong the debate unduly. There are multiple grievances. I understand that the Minister is prepared to meet the nurses and to discuss their problems. However, from the answers I have received to Parliamentary questions I am not very sanguine that anything will take place other than a continuation of the lip service that has been applied to the problems of nurses over the years.
The same remarks apply in the case of doctors. If doctors are to remain in this country, they must be encouraged to do so. The emigration of any  university graduate represents a national loss. If doctors are to be encouraged to remain here there must be a review of doctors' salaries. I am stressing these points because I think these are the things which really matter in the administration of the health service. Unless we have contented personnel we are never going to have a good health service. Far too much money is being spent on administration instead of being used to deal with health problems.
We lag behind in a great many fields. Only recently two important factors have come before the public and have aroused the national conscience: they are, firstly, mentally handicapped children and, secondly, geriatrics. I am taking an active part in the care of mentally handicapped children in my own constituency but, before I deal with that in full, I want to say a word or two about geriatrics, which has become a very serious problem not only in this country but all over the world, the only difference being that other countries recognised it before we did.
There are two reasons why geriatrics has become more important: the first is that nearly everybody works today whereas 20 to 30 years ago there was usually some female relative available to stay at home and look after the aged people. Nowadays however there is no one at home to look after them and old people have therefore become a national problem. The second reason is that the life expectancy is considerably above what it was some ten or 15 years ago. Antibiotics have played an extensive part here but, despite their use, there has been an increase in certain killer diseases. In general these diseases kill people in middle age rather than later on.
Much has still to be done about geriatrics. The nursing problem has not been properly dealt with. It is gradually dawning on those who administer the health services that geriatrics is a specialist field. It is a form of domiciliary nursing, and it is very difficult to get personnel to deal with it. The Department are not going the right way about it because they do not recognise geriatris as a specialisation; neither do they recognise the right of  the nurses to promotion within that particular sphere.
It has been put to me by the Irish Nurses' Organisation that there have been quite a lot of instances where promotion to sister-in-charge of a geriatric unit has been given to someone with an overall training. This is a short-sighted policy because you may get a nurse who has many years experience in the theatre, many years experience of dealing with acute conditions and many years experience of acute mental nursing but who may not have the particular knowledge necessary to deal with geriatric problems.
I ask the Minister to recognise geriatrics as a growing speciality and to recognise that those who qualify or specialise in geriatrics should be promoted within their own ranks and should be allowed to run their own nursing section. I would ask the Minister also to ensure that the State gives full support to any private organisation dealing with geriatrics. It is essential to direct available funds in that way rather than spending them on administration costs. No doubt the Minister will ask how you can administer the health services if you give the money away to someone else and before I sit down I propose to tell him how that can be done.
Institutional treatment for mentally handicapped children is the responsibility of the Department of Health. We have only started to look into this problem in the last few years. There are 350 severely handicapped children waiting for admission to institutions. The Minister and his Department are trying to make arrangements to take in as many of those as possible. There is one thing I want to stress. Institutions for the severely handicapped only have an inflow: there is no outflow except in a coffin. In other words, all children put into these institutions will stay there for life, whether it is a long or a short life. With a waiting list of 350 and the strides being made today they are only just keeping in balance. The number of these children coming up is increasing all the time. The law of averages is the same in most countries throughout the world. In fact, the position will be the same in 20 years  as it is now unless a more radical approach is taken by the Minister and his Department.
From discussions I had with the Department of Health about this problem I have found that they have great sympathy and are trying to help in every way but are extremely cautious and are not prepared to take any risks. An institution for mentally handicapped children must be a one-storey building: it must also have every fire escape facility available; and then four trained personnel are required to look after every mentally handicapped child. I should like to say to the Minister and those who advise him that that is absolute unadulterated rubbish. I have visited Cregg House in Sligo, which is one of the most up-to-date institutions for handicapped children in this country. I do not know if the Minister has visited it.
Mr. Childers Mr. Childers
Mr. Childers: I have seen a number of them.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: I hope the Minister will listen with interest to the good advice I am giving him. I was told by the Department of Health that there was no point in even considering opening an institution for the mentally handicapped unless I had four trained personnel to mind each patient —that would mean 40 trained personnel for every ten patients. I am glad to know that the Minister for Health has been to Cregg House and seen it.
Mr. Childers Mr. Childers
Mr. Childers: I have been to others.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: The Minister has not been to Cregg House?
Mr. Childers Mr. Childers
Mr. Childers: No, not yet.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: I shall tell the Minister what I found in Cregg House. The number of patients escapes me now—it is some time since I was there—but it is considerable. I found that they had 12 trained personnel. Of course they were members of a religious order and they do not work by trade union hours. Even so, there were only 12 of them and somewhere in the neighbourhood of 100 children, if not more. They managed to look after them and they were recognised  as a probationer training centre. They take in girls from all over the west and train them to be specialist nurses of mentally handicapped children. It works well and makes rubbish of the suggestion that it takes four trained personnel to deal with each individual case of a severely handicapped child.
I want to stress that to build up personnel to deal with severely mentally handicapped children, one must bring an organisation or institution into existence. If we are to wait until these institutions are built according to the regulations prescribed by the Department we will not have a waiting list of 350 in 20 years time but a waiting list of about 1,000 severely mentally handicapped children. I would suggest to the Minister and his Department that they should take every opportunity presented to them of opening such an institution. Even if it is a two-storey institution, provided it is not openly dangerous, it will at least create the organisation. It will also create a nucleus of the personnel. Then, when they are satisfied that such exists, let them, within the confines of the building, build a modern up-to-date institution if they want to.
I visited Moore Abbey in County Kildare quite recently. I would not like to tell the Minister why I was in Kildare. I visited this institution which belonged originally to the Earls of Drogheda but several people have lived there since then. It is an old country residence with plenty of oak panelling. They have handicapped children there and they have epileptics as well who are even worse. They have built up an organisation there and I think they are allowed to train probationers too. They started a considerable number of years ago to build a centre for this work.
It is glorious on paper to wait until everything is perfect, until all the plans have been drawn up, but to deal with this problem we must move and move fast. The Minister should take the initiative now. His advisers will say: “What will you do when the whole place is burned to the ground?” The answer I would make if I were in the Minister's position would be: “That is my responsibility. I would prefer to risk that now, and it is a very small risk, than to see 350 children waiting for  admission and who may not get in for years and years.” In regard to being burned to the ground I would draw the Minister's attention to the fact that there was an up-to-date institution in this country which complied in every way with the wishes of those who advise him. I understood that it was to be an indestructible building—but unfortunately it was burned to the ground. It can happen. Of course everybody was all right then. This institution had been passed, but that did not stop it from being burned to the ground. I would ask the Minister to step in here. It is only the Minister who can do this.
The Minister has the authority and the sovereign right to do anything he likes within the confines of his own Department. If he is warned that he will be blamed if anything goes wrong the simple answer is: “I want to try to house the children and the only way is to get moving.” To start from the ground and build an institution I have been told costs £50,000 or £60,000 and then the personnel must be found. What I want to make clear is that it is important to have some sort of institution, no matter how small it is, already established with the personnel and then build around that. Let the Minister approach it from that angle and he will find that he will solve the problem. It is the only chance of solving it. As it is now, it is an insoluble problem. I suppose there is no need to tell the Minister that it is a very great tragedy. He is a Deputy, the same as I am, and I am sure he is approached by people who are absolutely worn out by this type of patient; the mother is tied hand and foot and it is bad for the other children in the home. I write, as probably the Minister and other Deputies write, to these institutions and I get the reply, with great sympathy, that they have a waiting list half-a-mile long and that there is no hope for a long time to come.
I asked the Minister a question yesterday about married women doctors and he told me that it would take a major change in policy to re-establish married women doctors. There will be a shortage of doctors and quite likely the first real shortage of doctors will be in the public health section. There is not a very high concentration of  specialisation in that section. It is the type of section that women often go in for. I know quite a few people who have specialised in that, have all the qualifications—diploma in public health, child welfare degree and so on —and they are ready and willing to do this work and some married women whose families have grown up or who have no families are prepared to come back to work again but they are non-pensionable and non-permanent. In other words they come back on a day-to-day or year-to-year basis. If they are fit to do the work surely they are fit to be made pensionable? It took many years to get the Department of Education, when they had no teachers in this country, to recognise married women teachers. One had to absolutely brow-beat the Minister of the day across the House. I am sure it is simple for this Minister to do the same thing. If he does not do it now, he will find himself doing it in a couple of years time. He should look into this and find out the number of married people who are back in institutional work. After all it is not a revolutionary change. The FitzGerald Report was compiled by a group of Dublin specialists mainly.
Mr. Childers Mr. Childers
Mr. Childers: That is not true.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: Will the Minister tell me of any practitioner? There are a few surgeons from parts of rural Ireland who in most cases have actually got a hospital for their areas. However, if he can tell me of anybody, outside the particular surgical advisers or specialists, I will be glad to hear who they are. I looked through the FitzGerald Report. I know most of these people and their qualifications. The Minister was largely advised by specialists. I am waiting to hear of those who are not specialists.
Mr. Childers Mr. Childers
Mr. Childers: There were people from Galway, Cork, Sligo, Castlebar, Tralee.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: They are all surgeons or consultant physicians. There is not a general practitioner in the bunch. That is the tragedy of it. There might be one. Can the Minister find one, I wonder? I am listening with all ears.
Mr. Childers Mr. Childers
 Mr. Childers: They are fully representative of the medical profession as a whole.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: Fully representative of consultative medicine. The administration of a hospital does not begin and end with those who carry out appendix or brain tumour operations or whatever the case may be, or give blood transfusions. The administration of a hospital is dependent on the supply of patients. Again I come back to the rural setting of this country. It is different from practically every country in Europe. The only approximation to it is Finland which is something like this country. Therefore the introduction of a report by people who operate in hospitals has nothing to do with the transmission of patients to hospitals and is therefore insufficient. The advice the Minister got from the FitzGerald Report is inadequate. That is my submission to him. That is why there has been such a wholesale rejection in most parts of Ireland of the suggested spacing of these different grades of hospitals.
I would go all the way with the Minister and his advisers in agreeing that in the modern world with so many advances in surgery a high degree of specialisation is desirable. I would go all the way in agreeing that you have to have certain centres with highly qualified people. Apart from having some one of the standard of a consultant physician you would also need a consultant heart specialist and a consultant brain surgeon and so on. You must also have the most up to date laboratory techniques and all the latest methods of treatment. That does not mean that you can abolish practically all the hospitals in Ireland which, in effect, is suggested. In effect this is the thin end of the wedge. It is another administrative gimmick. Somebody conceived the idea that if six hospitals cost so much you should abolish five of them. The difficulty is that the advice the Minister got was inadequate.
I know more about my own part of the world perhaps than I know about other parts of it. Although our problem may be acute if we lose our hospital in Wexford—and I venture to suggest it will not be done while I am  in public life; it will be done over my dead body; I will fight it to the last because I think it is unreasonable and does not make sense—it is in the half-penny place compared with the West of Ireland. A Deputy told me quite recently that the abolition of the Roscommon Hospital, a fine hospital in which excellent work has been done over the years, would mean that patients would have to go 50 miles to Galway.
These are things that consulting surgeons and consulting physicians do not think about. They sit in their happy surroundings and a few yards from the hospital they get out of their cars and go into the hospital and the patient is put on the table for them. They take out their knife and they have every facility around them for the operation. They never stop to consider how the patient has come there. The Minister ought to take another look at the FitzGerald Report. If necessary he should appoint a body of people representative of all shades of the medical profession and also the county managers to advise him.
We have the National Health Council of which I was once a member. I am not a member now so I do not know what is going on there. It is certainly a problem we would have dealt with when I was there. We would have offered advice to the Minister on the subject. I do not know if they have advised him. They seem to me to have all the qualifications to advise the Minister. There are representatives of practitioners, surgeons, consultants and county managers and people from every walk of life. I can claim some credit for the setting up of the National Health Council because, when the disastrous 1953 Act was going through this House, I insisted that a national health council of some sort should be included in it so that the Minister could get advice from all sections of opinion. If the Minister has not done so already I would ask him to put the case of the FitzGerald Report to the National Health Council.
Mr. Childers Mr. Childers
Mr. Childers: The National Health Council approved in principle.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: In principle.
Mr. Childers Mr. Childers
 Mr. Childers: So did the Irish Medical Association and the Irish Medical Union.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: For the Minister's information the Irish Medical Association met in Wexford.
Mr. Childers Mr. Childers
Mr. Childers: I know all about that. They approved a special resolution about Wexford. I met the Wexford County Council. I heard the case very ably put and I will consider it.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: Wexford is no different from anywhere else.
Mr. Childers Mr. Childers
Mr. Childers: I am just mentioning that——
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: Because we were able to fight in Wexford.
Mr. Childers Mr. Childers
Mr. Childers: The Medical Association did not reject their previous resolution. They merely referred to Wexford.
Sir Anthony Esmonde Sir Anthony Esmonde
Sir Anthony Esmonde: While we are on that meeting, I might add that a resolution with regard to married women doctors was received with acclamation and enthusiasm. I did not even know they were passing it. The association met a conglomeration of all members of the profession. I attended only one function myself. As far as I could see most of the doctors were practising in rural Ireland and they would be conversant with all the facts I have been trying to put before the Minister.
I have spoken at some length and I am sure the Minister does not agree with much of what I have said, but I cannot help that. I conceive it my duty to try and put the case across with whatever knowledge I have. At the beginning of my speech I mentioned the amount of money being spent on the health services. The Minister is giving £2½ million to try to keep down the overhead costs on the rates but that is only a palliative. These costs are increasing all the time and they will increase again. The Minister will probably be back with a Supplementary Estimate. It would not be fair of me to say all these things without giving some indication as to what I propose should be done I am not suggesting  that there is any great variation in the services available under the existing Acts. Ultimately some Minister for Health will be forced to introduce a different system with different financing. In relation to the health services we have always divided the people into three sections: the lower income group, the middle income group and the higher income group. I can see it is only right that those who can afford to do so should pay their way medically, just the same as I can see that people who cannot afford to do so should be subsidised in full by the State.
For that purpose the closest parallel I can give is the voluntary health insurance system, though that in itself is not perfect. I suggest to the Minister that a tremendous drop in administrative costs would be effected if a board were constituted to run the administration of the health services and if, at the same time, he were to introduce a compulsory contribution from all sectors of the community. Before I fully clarify what I mean, I should like to point out that under the existing health administration system a man may be earning £20 a week and he may have a family but he is regarded as being within the middle income group—I think the figure would be £900 per year. It so happens that he would be a wage earner. Suppose he becomes ill. His income then is nil. He drops into the lower income group and he has to be fully subsidised by the State.
That does not make sense to me. It is not any fault of the individual concerned. It is one of he reasons why health charges are so high. There is no provision whatsoever under the existing system for that man to have any standby to meet a problem like that. My suggestion is that the full contribution should be made by higher income people, that in the case of the man I have instanced he should make a voluntary contribution and along with it the State should make a similar contribution to bring the amount up to the level of the contributions of the higher income group. The lower income group, old age pensioners and other social welfare classes, should have the contribution paid by the State.
If such a system were introduced it  would reduce the administration costs by approximately a half or a third as they arise under the new Health Act of which I personally do not approve— I think it should be scrapped. It would mean that next year the Minister, though he would be looking for £40 million, would have a considerable balance with which to deal with other urgent matters such as geriatrics, mentally handicapped people, the aged and the infirm. I commend that to the Minister but there is no use in my talking about excessive charges unless I can show the way to reduce them. I have suggested a way. Unless the advice is taken, the Minister next year will be back looking not for £40 million but £50 million. Everybody will be grousing and complaining still at the inadequate health services. I hope the Minister will consider the few points I have made.
Minister for Health (Mr. Childers) Erskine Hamilton Childers
Minister for Health (Mr. Childers): First of all, I wish to thank Deputies for the very constructive way they dealt with the Estimate and for the very pleasant things they said about me, to some extent, and about the officers of my Department. I should like to take this opportunity of saying to Deputies who referred to the officers of my Department how splendid I think they are. They deal with innumerable deputations, some 30 separate boards, committees, commissions and other bodies of various descriptions and it has been a delight to me to move through functions of various kinds and to hear consultants, doctors, GPs tell me how lucky I am with the officials of the Department I have to work in. I wish to pay them that tribute.
They are far from being the traditional type of civil servant so well described by people as being the conservative kind, incapable of looking forward to future developments. I have had the most happy experience of civil servants in all Departments but in a Department with the complexity, the tremendous volume of work, of the Department of Health, a public tribute is due to those who conduct the service.
Deputy O. J. Flanagan spoke about  my meetings with the county councils on the question of the establishment of the regional health boards and he said I had done so in a courteous manner. I thank Deputy Flanagan for his remarks, but obviously when one wants to make revolutionary changes in the health services one must do the best one can to satisfy those who have given loyal service to the health system with very much smaller units operating. It is essential, therefore, to meet them to get their understanding and sympathy. For that, one had to listen to discussion, prolonged in some cases. They met me on the whole in a very sympathetic way. They understood the problem and the necessity to provide better health services, more streamlined services.
I am dealing with some of the miscellaneous matters which have arisen first of all. There were some references to medical education. All I can say is that I consult with the Minister for Education who is mainly responsible for this matter through the support given to the universities. As well, officers of the two Departments consult to see what can be done to facilitate discussions of suggestions that have been made for changes in medical teaching and having an examination made on a purely voluntary basis. There is a committee set up in the Royal College of Physicians and the Royal College of Surgeons dealing with the implications of the growth of specialised teaching within the terms of the Todd Report.
I do not wish to comment now on the suggestion that medical courses are too long. We graduate 250 to 270 medical students in this country biannually of whom we need 100. It is a great vocation and it is true to say that in Great Britain and in other regions the medical services would collapse were it not for Irish doctors and nurses. It is a natural vocation for Irish people.
The courses are examined within the universities from time to time and I heard the other day that the course in relation to anatomy, where an awful lot of natural absorption is required, is being examined. That is all I can say about medical training. What we try to  do is to get people to discuss it. We are in no way responsible for the rationalisation of the two universities: the Minister for Education is responsible and he consults us from time to time if any proposals come in which require to be fitted in with the hospital system.
Deputy Dr. Gibbons as well as some other Deputies made one or two remarks about district medical officers. We propose to apply the principle of arranging for doctors to take part in the choice of doctor scheme whereby they will spend periods in the more remote rural areas on the condition that they will have a post in an urban area which may be more suitable to their personal circumstances or to the education of their families.
The trend in regard to living in rural areas may change within the course of ten years. I notice that quite a number of people who come back to this country do so with the deliberate objective of living in a rural area rather than in a town. Rural life has its social advantages and disadvantages and, in the case of doctors, relates to the education of their families and to their particular enjoyment of the country. I agree with Deputy Dr. Gibbons that, perhaps, the arrangements we are making for district medical officers may help us to overcome the difficulties. There are places where it is very difficult to provide the kind of medical service that is based on people being permanently placed in a particular area.
Deputy Dr. Gibbons also referred to district medical officers who may wish to opt out of the choice of doctor scheme. The position is that permanent district medical officers will be assured at least of their present salary and will retain their pension rights. There will be special superannuation terms for any of these doctors who wish to opt out. Temporary district medical officers of two years standing have been assured of admission to the new scheme but, as the House knows very well, we are now negotiating with the Medical Association and the Medical Union on the question of the choice of doctor and on how the service will be remunerated and administered.
I shall deal next with questions which  seem to have more relation to financing the various aspects of the health services than to the services themselves. Some Deputies suggested that we were not spending enough money on health services. International comparisons are difficult to make because health services are compounded of taxation, rates and insurance contributions in different proportions in different counties. However, if we take the first 18 countries in order of gross national product we find that the precentage we are spending is a respectable one. Some people may say we should be spending more but at least we are in the respectable arena as it were and from comparative studies that have been undertaken there is nothing to suggest that there is gross under-spending on our health services.
A Deputy suggested that because we do not have more satisfactory arrangements for subsidising the health services a number of people who should go to hospital are not doing so. I can hardly believe that is true. The number of persons entering hospital is increasing by three or four per cent per annum and in the current year the number of people who entered hospital was about 300,000. As a proportion of the population that is also a comparable figure with the well to do countries and I might add that the earnings of the people have more than doubled within the past ten years in real terms while the standard of living has gone up by about 40 per cent in that period. No doubt these factors are an encouragement to people to seek hospital services. Having regard to the numbers entering hospital each year, exclusive of certain classifications of people who must have immediate treatment, there is no evidence to indicate that large numbers of people are failing to go to hospital because of fear of the cost or because of the cost of drugs.
Deputy Ryan referred to the choice of doctor scheme negotiations. He is completely out of date with regard to negotiations for general practitioners under this scheme. A meeting with the medical associations is taking place today in the Custom House. We have put a particular scheme to the associations  and this will be considered at today's meeting and subsequent meetings.
Deputy Ryan said that hospital doctors should be paid while they are sick. Any doctor who is prepared to join the local authority service and who can get into that service is paid during sick leave. There is no provision for payment to voluntary hospital doctors while they are ill. We have not yet been asked to take part in negotiations for such doctors but if and when a new method of payment is negotiated sick pay will undoubtedly fall to be considered.
Various Deputies referred to the cost of drugs for the middle income group and they mentioned that there is a scheme in existence under which, when the cost of drugs constitutes a hardship, the health authority can provide a contribution towards the cost of such drugs. I do not think we need say any more except to point out that during the course of the debate on the Health Act of 1970 I said that with the consent of the Minister for Finance we would be making arrangements whereby people in the middle income group would receive a subsidy towards drugs which cost more than a certain amount per month. A figure in excess of £2 per month was suggested but this suggestion is not necessarily the final one. As the House is aware, the subvention for drugs for long-term disabilities is also provided for under the Health Act.
I do not propose to debate the question of insurance for the middle income group because the matter has already been discussed but I should like to say that the Government have examined the possibility of introducing insurance contributions to offset the cost on rates for the health services. The possibility is being examined at considerable length but there are great difficulties involved. For example, the contributions in the case of self-employed persons would be very costly to administer. The whole question must be examined in relation to the general claim that agricultural incomes are lower than other incomes and there is the question of whether farmers should  be asked to contribute to the health service in addition to the taxes that they already pay in various ways.
The question of where to draw the line is also a point of interest and I very much doubt whether people in the middle income group would consider that they were doing anything but paying taxes in a different form. I do not know what their reaction would be to the idea of having insurance introduced into the health service with the voluntary insurance scheme operating at one end and the medical card scheme at the other end. I do not know what the reaction would be of those people who would be asked to pay what would only be a partial contribution towards the cost of their health services. There is always what I might describe as the psychological receptivity to taxation about which all those who have served for many years in this House will know a great deal. It is possible to charge a person so much for a packet of cigarettes and he will pay the amount of the tax on the cigarettes.
If you suddenly, for example, put another 10s on his insurance stamp or made him pay 10s a week towards a middle-income group service, and if he knew that that, in itself, would not pay for the whole of the middle-income group service, his receptivity to such a proposition might not be, in effect: “Here is a wonderful contribution scheme. I am paying the contribution and I am getting the service.” It is an extremely complex matter. We shall have to examine it again. At the moment, I have suspended action on it —at least until the Health Act, 1970, is implemented. But, having said that, regulations will be coming before the House for the medical card group standards and the middle-income group standards. This question can be debated there again. There can be an opportunity for an examination of the standards for the middle-income group which perhaps, without any great extra cost to the State, could be made more flexible and could be an answer to some of the objections by Deputies in regard to the manner in which the middle-income group decisions are now made. I am not making a false promise. I do not guarantee that there  will be any marked level of change in relation to the middle-income group standards but there might be, within the framework of what we do, perhaps an examination of certain kinds of disabilities which might be looked at—such as people with large families on the fringe of the middle-income group at the lowest end of it.
I think the nursing profession is very wonderful. I shall always take a sympathetic attitude towards suggestions made, and proved, that the nursing profession is inadequately paid. I have paid public tribute to the nursing profession. I realise that, compared with the rest of the community, up to some years ago they were very badly remunerated. The situation has improved in the past five years. Within quite a short period of years, the situation of the general and psychiatric nurses has improved with increases of the order of from 47 per cent to 67 per cent. Their hours have been reduced to an 85-hour fortnight. Increments have been granted in various circumstances. We have at last arranged for married nurses who come back to the service to have an allowance of five increments for their previous service as nurses. The rest lies in the hands of the health authorities and the Irish Nurses' Organisation in regard to any demands that are made. Demands are, of course, constantly being made in all branches of the health service for increased remuneration. I just wanted to mention that there has been a considerable improvement.
Deputy Ryan referred to a recent march to Leinster House by a number of hospital nurses employed by the local health service. He alleged it was provoked by a long period of ministerial delay and inaction in regard to negotiation on nurses' claims. There is absolutely no basis for this allegation. Officers of my Department met a representative group of these nurses. The official cause of their protest march was dissatisfaction on the part of the nursing staff of the James Connolly Memorial Hospital with the existing system of appointment to ward sister posts in that hospital. They claimed that the nursing staff within the hospital had been deprived of sufficient opportunities  for promotion. The inquiries by the Department into the complaints are nearly completed. We hope to convey the results to their organisation shortly.
The selection of nurses for promotion to ward sister posts is decided by the employing health authority and not by me. There is a very great demand for promotion to vacancies involving promotion to posts of ward sister and other grades to be thrown open to enable nurses who want to move from one place to another to have an opportunity of securing these appointments. Within a great many hospitals, there is equally a pressure for existing staff to have an opportunity for promotion. This is a matter for tactical understanding and for an overall point of view to be secured by the health authority in conjunction with negotiations with the appropriate organisation. I should not like to interfere with it in the ordinary way at all.
Deputy Ryan said that drug prices here are very much higher than in Britain. I do not think we have any great evidence of that. They may, in certain cases, be higher. I would not say it constitutes anything in the nature of a scandal or something that needs to be investigated.
Deputy Tully criticised me mildly for not bringing forward the new regulations for a standard system of means test for the medical card group at an earlier date. I simply had not the time. I am moving towards the implementation of the Health Bill in a practical sense by 1st April, 1971. The officers of my Department are stretched to the limit in regard to this whole change of administration. The regulations will come before the Dáil. I hope there will be the same constructive attitude in the debate on the standards devised for the medical card group and the middle income group. I do not believe that what I propose will please anyone. Naturally, if I were an ordinary Deputy, I never would be satisfied with what a Minister proposes for the first time, as distinct from a health authority. But, as Minister, I know that we have not an infinite amount of money and that it would not be possible to increase very greatly the total percentage of people receiving medical  cards. I think the proposals will in the end be acceptable although perhaps everybody would like to see them more liberal.
Deputy Tully asked what would happen in connection with the health rate struck if there is an increase in salaries and wages this year. This will create a debit balance on the health account of the health authorities. I shall have to move a supplementary estimate for my contribution towards health expenditure. I cannot give any guarantee next year what I shall do about the health rate structure to the extent that it will have been increased by the cost of salaries, wages and materials arising from the 12th round of wage increases. It would be impossible for me to commit myself.
Deputy Tully also referred to the conditions under which student nurses operate. I hope that if there are nurses in a certain hospital which he mentioned who are not receiving the right kind of treatment they will take up their case with the Irish Nursing Organisation, which is fully competent to deal with it. Deputy Tully also complained in regard to a number of different matters relating to conditions of service and wages. I think he should know that there is proper conciliation and arbitration machinery devised for that purpose. I think he should know also that the Minister for Local Government is preparing a new and extended form of arbitration and conciliation machinery in the form of a board. He also knows what the attitude of my Department is. This is in the first instance the responsibility of the health authority but, on occasions we regard as suitable, we inform a health authority that we will facilitate them if they will consider certain matters in relation to pay and conditions which we regard as important to the health service. If we think there is an urgent need for some particular improvement, we let the health authorities know that we will gladly sanction certain changes that may be agreed to by them. On the other hand, we like the health authorities to take the first and major responsibility for changes in remuneration.
 I come next to questions relating to the FitzGerald Report. Quite a number of Deputies spoke about closing hospitals. There is no proposal in the FitzGerald Report to close local hospitals, certainly not on any large scale. If surgery is not carried out in a county hospital the surgeons' wards will not be closed down but will be used for other purposes and will continue to be staffed. District hospitals will be retained as homes for old people. It is a question of the user of the particular hospital that is involved and, with the increased number of people who have survived to the ages of 70 and 80 years, we will need all the beds in reasonably well-built district and county hospitals for geriatric purposes. If the population in the rural areas increases we will also need more maternity beds.
I have already told Deputy Sir Anthony Esmonde that the Irish Medical Association, the Medical Union and the National Health Council have approved in principle the implications of the FitzGerald Report. That does not commit them to approving the detailed recommendations but they have approved the general principles involved in implementing the report.
I do not know whether I need argue again the case of the FitzGerald Report in detail. Deputy Hugh Gibbons was trying to distinguish between various kinds of surgery. I suppose it is true that there is what could be described as “cold” surgery—the simplest type of surgery, involving hernia, appendicitis and so forth—but I cannot find any well-versed consultant who could tell me other than that the chances of being restored to full health are better in a hospital with a number of consultants and more elaborate paramedical equipment. I cannot find any consultant to deny that statement and that is what is involved in the FitzGerald Report.
Deputy Hugh Gibbons referred to the necessity for examining this problem and this I shall do. There is no need for any county council or urban district council to start passing resolutions immediately, or to continue to pass resolutions, on this matter because I have promised to consult the local committees established under the  Health Act, 1970, before there will be a change in the functioning of a hospital and local inquiry will also be necessary. One-sixth of the surgical cases in this country involve going outside the health authority area already and it rises to 25 per cent in the case of some counties. There is already a movement outside an immediate health authority area for people who require many kinds of treatment.
Observations were made on the time taken in relation to the surgery performed on a patient. We must compare the time taken to treat a patient in a regional hospital on a 24-hour basis with the time taken in the case of a patient who goes to a smaller hospital, has to wait for diagnosis and, if it is not urgent, has to wait for the surgeon. We must also consider the duration of convalescence. All these matters are the subject of examination by the experts when they make recommendations for larger hospitals.
Deputy Hugh Gibbons spoke about a rather controversial matter and I was interested to hear what he said. He spoke about the distance of a hospital in the instance of a patient suffering from an acute perforation of the appendix. There will be some doctors who will take the point of view that it is better for the patient to go to a hospital very quickly. There will be others who will say that the patient who is properly prepared for an emergency operation—whose appendix may have been perforated—who is conveyed by a good ambulance service to a large general hospital with all modern facilities will have a greater chance of survival than he would in a small hospital ten miles away. Some expert consultants would disagree with Deputy Hugh Gibbons on this matter. They would say that if a doctor puts a patient, properly prepared, into the ambulance it is probably better to send him in a grave condition to a hospital further away which has better facilities.
Deputy Gibbons made reference to the cost of patients in various hospitals and I think the best answer is this: I agree there is a certain amount of difficulty in analysing the comparative cost of patients in one kind of  hospital and another. There is a variation in the age levels of patients in different hospitals and a variation in the extent to which elderly patients are taking treatment and will spend longer in a hospital than young and vigorous patients. The Medico-Social Research Board research into bed occupancy may yield interesting information on all matters about which Deputy Gibbons spoke so sympathetically, namely, that if we are looking into the implications of the FitzGerald Report we must examine the comparative costings apart from the main point which is to ensure a better service for the public and reduce mortality.
Any proposals made to have a second surgeon in a hospital or to have a visiting surgeon come to a hospital must be examined not only in relation to what the people would like to have. There must be a sufficient work-load to enable the surgeon to consider that the job is worth doing. You could construct an ideal system for consultants and surgeons all over the country designed to give the best treatment, and you would not get people to apply for the positions because if they were not spaced according to requirement there would not be a sufficient work-load. The work would not be interesting and would not result in their being able to get promotion because they would not get the experience necessary.
One Deputy suggested that a surgeon should be available on the premises of maternity hospitals. There is an enormous number of normal maternity cases examined in hospitals where there is not a surgeon, but the real answer is that we ought to have the maximum consultation for maternity cases by an expert consultant obstetrician who will decide whether it is safe for the mother to have her child in a hospital with no special facilities for emergency treatment, or whether the mother should go to a hospital having full gynaecological services. That is the test that should be applied.
Deputy Gibbons spoke most constructively on this matter. He recognised my difficulties but at the same time he spoke out, as did other Deputies, for the perpetuation of single-surgeon hospitals if at all possible. I  was glad he recognised the difficulties involved in the Todd Report. The implications of that report will not have very great effects for three or four years.
I should say, in passing, that I do not want to give any indication that what I am saying refers to any particular individual but, in regard to certain appointments made in the last five years—I say five years so that no one will gather what the particular place is—one can see the beginning of the difficulty of finding at a particular time, when one is looking for a particular person, a really competent surgeon where there would be competition by others for a single surgeon hospital. We are beginning to see that process taking place and I am being sufficiently vague about it because I do not want to suggest any particular individual is involved. I make the statement advisedly that the signs are already there.
I now come to the question of psychiatric illness. Deputy Dr. Browne made many constructive observations in regard to psychiatric medicine. An appointment to the post of clinical director for forensic psychiatry under the Dublin Health Authority is now in train following a recent competition. I am sure the Deputy will be glad to hear that.
The Deputy also referred to bed occupancy reduction in relation to attendances at psychiatric clinics. I would remind the Deputy that the cases treated in these clinics are not necessarily cases which would have occupied beds if they were not attending clinics—those suffering from neuroses, inadequate personalities, behavioural problems, etc. For others attendance at clinics may postpone hospital admission. The Deputy will agree with me, I think, that more can be done to keep people in the community than is being done at present and I am having a meeting with county managers and resident medical superintendents within the next few months to discuss the implications of the report of the Commission on Mental Illness. We are making advances but the resident medical superintendents and their assistants will have to move together in step with us  if we are to make the progress we want along lines upon which I might say I see very little disagreement between Deputy Dr. Browne, who is an expert in this field, and myself and the officials of my Department. We are all agreed on keeping people out of mental hospitals, on having more domiciliary attention, more short-stay accommodation and more outpatient clinics, with nurses visiting the patients in their homes. We are pressing forward to that end as rapidly as we can.
Deputy Dr. Browne asked about the reduction in the number of patients in St. Brendan's. The reductions represent a real reduction in the numbers resident. They are not due to reclassification in any part of the hospital itself.
There have been comments on overcrowding in Portrane. We do not want to increase the size of mental hospitals and the Dublin Health Authority is being asked to consider the provision of accommodation elsewhere for some of the geriatric patients in Portrane. We are awaiting a reply from the health authority.
Deputy Dr. Gibbons referred to the fact that it was no use sending people home from a mental hospital unless there are follow-up visits. This is the basis of the policy. The policy is to have some of the psychiatric workers in the mental hospitals visit patients in their own homes to make sure they are taking any drugs prescribed, to discuss their condition with their relatives and to find out if their condition is deteriorating or improving. If it is deteriorating they will be referred back to the psychiatric specialist. We shall have to make very considerable progress before we perfect the system. It is as yet only in the initial stages.
Deputy Ryan asked about autistic units. The unit in Cork is not yet available but the unit at Beaumont is operating and is taking patients from all over the country.
I think it was Deputy Ryan who referred to the undesirability of having drug addicts and alcoholics in the same unit. The Dublin Health Authority have now decided to find other premises for drug addicts. Drug addicts  and alcoholics will no longer be housed in the same unit.
Deputy Dr. Browne referred to the thousand bed differential in regard to the salaries of medical superintendents of mental hospitals. We are satisfied this type of differential is undesirable and we are looking into the matter. The Deputy knows we have been examining the grading of the staff structure of mental hospitals. I answered a question tabled by him on this subject recently.
There is an exclusion of psychiatric nurses from the grant of increments to married nurses because we have not had any demand for this concession and no difficulties are experienced in regard to the number of psychiatric nurses available.
With regard to child health services, there seems to be some misunderstanding about the operation of the service. The children are examined by the county medical officers or the assistant county medical officers They are referred by these to the general practitioner in charge of the child or associated with the family. The ACMO may tell the practitioner that the child needs to be hospitalised and ask if the practitioner would object if he sends the child or would the practitioner prefer to make arrangements himself. It is a matter for the general practitioner then to say which course he prefers. There is no question of by-passing the general practitioner.
I do not accept Deputy Ryan's contention that gastro-enteritis is due solely to bad housing. It arises from various causes. It is not a precisely defined disease and a great many people who are said to be suffering from gastro-enteritis are really suffering from a virus infection. There are recognised preventive measures, but the disease is still too extensive in this country. There is need for the education of mothers or mothers-to-be in infant feeding, in the value of breast feeding, in the need for hygienic methods of preparation of feeds. I shall soon get a report prepared by a committee of the Medical Research Council on gastro-enteritis in Dublin. I have seen the results of some research done in  Cork and it is quite clear from that research that some mothers were not sterilising the bottles properly. The public nurses will encourage mothers to sterilise bottles and that will be very valuable, particularly where housing conditions are poor. I recognise that better housing conditions are essential if morbidity is to be reduced but the incidence of the disease is not due solely to bad housing.
There seems also to be some implication that I have expressed myself as being entirely satisfied with the present school health service. On the contrary, I have decided to implement a four-year programme for its improvement by reducing the excessive number of routine medical examinations, by bringing the parents in greater numbers to the smaller number of examinations, by arranging to have teachers note certain very obvious defects to be examined in children and by having a truly selective examination when the child first goes to school. I am not prepared to say that the present child health service is anything but extremely effective even although it can be improved. The child health report that was furnished to me showed that the school health service found 223 health defects requiring specialist attention for each 1,000 children examined. By contrast, only 27 defects per 1,000 children were being treated outside the school health service and the proportion of children examined, while not perhaps as much as one could wish under the prevailing system when there were a great number of examinations, nevertheless, I think, was splendid. There were 135,000 children examined in one year. I do not think we need be ashamed of that but as I have said the system will change. It will take four years to make this change.
Deputy Oliver Flanagan referred to health education. It would take me too long to speak about that in detail. We are extending education this year both on radio and television and through leaflets. A great deal is being done in relation to smoking, to dental care and so forth. We do issue leaflets for mothers-to-be on preparing for their baby and on the diet they should have, and so forth. There is a series of leaflets produced and Deputy Flanagan need  have no doubt that mothers are given the chance to find out what kind of diet they should have when they are expecting a baby.
There were a number of matters relating to hospitals in general. Deputy Dr. Browne queried the need for a new 300-bed hospital in Tralee and suggested that the area could be catered for by Limerick regional hospital. The proposed hospital in Tralee will replace the existing county hospital which is not up to standard and the medical, surgical and maternity services required for County Kerry, which has a scattered population of about 113,000, involve the construction of this hospital and it is not outside the ambit of the kind of considerations that were mentioned in the FitzGerald Report and which long before that were taken into account in deciding where a new hospital should be.
Some Deputies referred to the whole position of voluntary hospitals. I hope to secure the co-operation of voluntary hospitals to engage in further integration with local authority hospitals, to engage in management and work study and I hope that they will also consider any request made of them, if it was felt by a regional health board or by a regional hospital board that a particular voluntary hospital might participate in looking after geriatric cases. All that will be part of the work of the new regional health boards and new regional hospital boards.
There is a greater proportion of people staying in St. Kevin's Hospital for a longer period because on the whole the ages of patients in St. Kevin's tend to be older and the younger and stronger patients in Dublin are treated in the acute voluntary hospitals. That is the answer to that query.
A number of Deputies referred to out-patient facilities and to the long delays experienced by patients waiting to be examined. We are going into this. I quite agree with everything the Deputies said. There will have to be an examination of this matter.
The annual output of radiographers is 12. I am not aware of any serious scarcity of such staff at present. The  existing training school will increase its annual output by 50 per cent, from 12 to 18, when its activities are transferred from St. Vincent's Hospital, St. Stephen's Green, to the new St. Vincent's Hospital at Elm Park. That is the answer to the Deputy who suggested that there was a great scarcity of radiographers.
Some Deputies referred to a shortage of nurses. An Bord Altranais are going to conduct a survey, which should highlight the reasons for shortages, in the form of a questionnaire addressed to nurses which should give us some useful information about the whole nursing position.
Deputy Tully referred to meals in hospitals. I would encourage hospitals to give a cup of tea and some biscuits to patients who have to be kept waiting a long time and who have come from long distances. I understand it is quite possible for them to do this under the existing Health Acts.
I understand in regard to Deputy Dr. Browne's question about the financial advantages for voluntary hospitals participating in the combined purchasing scheme with the Department of Local Government for their materials that voluntary hospitals have been encouraged to make use of the facilities offered under combined purchasing arrangements and they use the combined purchasing scheme, particularly in relation to furniture, equipment and medical supplies. Perhaps they should use it more. Nevertheless, I do understand that they are making use of this very excellent system.
Deputy Dr. Browne asked a question about the daily occupancy figures for non-surgical, cardiological, non-TB patients in Merlyn Hospital, St. Stephen's Hospital, Sarsfield Court and James Connolly Memorial Hospital. These figures were included in the statistical data circulated to all Deputies, except in the case of the James Connolly Memorial Hospital where all non-TB acute patients are admitted with a view to surgery.
The Deputy asked what was the future use of the three sanatoria. In the case of the James Connolly Memorial Hospital it is proposed in the immediate future to use part of the hospital as a general hospital which  will initially have 120 beds and to use the balance of the accommodation for tuberculosis and geriatric patients. It is intended at a later stage that a general hospital will be built on this site. The services provided at Merlyn Park Hospital will be integrated with those of the regional general hospital in Galway to form a major hospital complex providing specialist services for the western region and general medical and surgical services for the appropriate catchment area. St. Stephen's Hospital, Sarsfield Court, will be used mainly for the treatment of psychiatric patients.
I should have said in reply to Deputy Ryan and others with regard to the out-patient difficulty that a study has been carried out in association with the Irish Medical Association of the out-patient problem and the results are being processed. I hope it will be possible to effect improvements but this is going to be a very difficult matter. There is, first of all, the punctuality of the patients themselves and there is the difficulty of predicting how long it will take to treat a patient having a particular condition, by a particular doctor. It is not an easy form of work study, as one might describe it, or time and movement study, to process effectively but I hope we will be able to make progress because, there is no question, there are appalling delays.
Deputy Ryan and others asked a number of questions about additives in food. The Minister for Health has power to control additives in food through the operation of Part V of the Health Act, 1947. Additives are controlled under section 56 of that Act which relates to the fixing of standards for the composition of food. Following the advice of the food advisory committee comprehensive regulations dealing with the control of additives such as lead, anti-oxidants etc. will shortly be made by me. They have already been approved by me in principle and will come into force with provision for a transition period. I think this will bring us up to date in regard to the whole question of additives.
I hope Deputy Tully will give me  some more information about the syringes left on a beach in Meath by a group of people who came there and made trouble. That kind of information should always be made immediately available to the Garda Síochána.
I do not think there is any need for me to deal again with the question of drug abuse, I have already given the House a full account of it. However, regulations will be put into operation within the next two or three weeks arising out of the section in the Health Act which will enable the Minister for Health to control the use of another group of drugs other than those already controlled under existing legislation. The Garda Síochána drug squad is either increased or is going to be increased. We have the Jervis Street and St. Dymphna's unit for both day and residential treatment of patients. I hope the operation of the Health Act dealing with drug abuse will be effective. There are very few countries which have prohibited the sale of amphetamines and we are still in the company of the very few countries who have done this. The whole problem will continue to have our attention. I want to make it clear that no Minister for Health anywhere in the world has prevented addiction to dangerous drugs. All Ministers for Health can do is to make it as difficult as possible for people to get hold of these drugs. I am no different from any other Minister in regard to this fearful problem.
Deputy Ryan was wrong in saying that the misuse of electricity was a major cause of death in connection with home accidents. There have been 13 deaths from misuse of electricity and defective electrical connections in the period from 1958 to 1968. The major causes of death are open fires, scalds, burns, falling asleep while smoking a cigarette, the physical conditions of floors and so forth. All these matters are dealt with in the report on the care of the aged.
Deputy Ryan said that the State should help to subsidise the payment of home assistance. I have made it quite clear in connection with the Health Act that I hope home assistance officers will be employed by health boards so that they can co-ordinate  with all the other staffs in relation to domiciliary care and domiciliary examination of people, but I cannot arrange for any subsidy to be given in respect of the cost of home assistance by itself and this will continue to be levied from the rates.
Deputy Flanagan made a mistake when reading the Estimate. He thought that in relation to homes for the aged £190,000 was the total provision but the subhead which he referred to, namely subhead I, merely provides for the Exchequer contribution of 50 per cent towards the loan charges on borrowings by local authorities for this purpose. The statistics we circulated showed the extent of the work completed last year, or in progress or at an advanced stage of planning. Deputies can read these reports in the memoranda which I circulated before the debate began. Works completed last year will accommodate 1,200 old people and works in progress will accommodate nearly 600 old people, so we are making progress here. We are going to go ahead with our programme for the care of the aged and this involves participation by community associations in all these arrangements. I should like to commend all the community associations now operating and it is through community associations that we want health authorities to give assistance such as is provided for in the present system and which will become more available when the Health Act is fully implemented.
Deputy Ryan suggested that my Department prevented the Mass Radiography Board from screening the population for diseases other than tuberculosis. This, in fact, is not so. It is the board's practice that when X-rays uncover a non-tuberculosis chest condition of significance they do bring the matter to the patient's attention so that the patient may have the condition investigated fully.
Deputy Dr. Browne spoke at length about lung cancer and its connection with cigarette smoking. It is now generally accepted that cigarette smoking makes a contribution towards coronary heart disease. I am going  to consider what more can be done to educate young people about the dangers of smoking but I will not forbid smoking in this community. Constant increases in the price of cigarettes have not stopped people from smoking. People are still smoking who have read all the publicity about it, who know all about it and who either believe or do not believe what they have read about it. If I were to forbid cigarette smoking many people would turn to some other form of addiction. They would go in for placebos or some other drug to relieve their anxiety and to make them feel more cheerful. I disagree that death by lung cancer is nearly as serious as the ultimate effects on a family of addiction to dangerous drugs. Neither do I think the effects are so serious as those of alcoholism which, as I indicated in my opening speech, result not only in the alcoholic going into a home but also result in members of the family going into a hospital or home as a result of that alcoholism. What I intend to do is to see what more can be done in relation to health education in this matter. As I have already indicated, cigarette advertising on Telefís Éireann will cease at the end of this year.
I do not think I need give the House any great details about what we are doing in relation to propaganda against cigarette smoking but the House might like to know that the National Film Institute includes in every school health film show of which there are 1,000 a year, on our behalf, the film Smoking and You which graphically illustrates the dangers of cigarette smoking. We also participate in a mid-morning programme on radio called the “Liam Nolan” hour in which the danger of smoking has been dealt with. We are trying to see what we can do to extend this form of propaganda and to have lectures in the schools.
I am not going to start the argument again with Deputy Ryan on fluoridation. I disagree with everything he has said about it. The overwhelming majority of opinion is that fluoridation is effective and non-harmful.
Deputy Dr. Browne referred to the question of whether or not there is enough appreciation of the need to  treat mental illness just as a form of ill health and to eliminate the element of shame in regard to it. Other Deputies have made it quite clear that the whole atmosphere is changing. I shall be meeting the Mental Health Association shortly and I shall be discussing their programme with them. A good number of mental health associations have been established locally in different areas in order to give assistance to those who have mentally ill patients to create the right kind of atmosphere for the patients, to create the best possible conditions when they come back home, to get the community to accept the fact that mental illness is inevitable having regard to the enormous complexity of the human brain which consists of several billion cells. It must inevitably be defective on occasions. I think the miracle is that there are so many people who are mentally normal in view of the complexity of the brain.
I think I have dealt with virtually every important question that was asked but I shall have the debate looked through and if I find that Deputies asked some very definite and particular question with which I have not dealt I shall communicate with them. I should like to conclude by thanking the House for the way they have accepted the Estimate and for the constructive manner in which they discussed it.
Vote put and agreed to.
Dáil Éireann 245 Committee on Finance. Vote 48: Health (Resumed).