Dáil Éireann - Volume 290 - 29 April, 1976
Vote 50: Health (Resumed).
Debate resumed on the following motion:
That a sum not exceeding £249,983,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1976, for the salaries and expenses of the Office of the Minister for Health (including Oifig na Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.
—(Minister for Health.)
Mr. S. Flanagan Mr. S. Flanagan
 Mr. S. Flanagan: I was talking about the expressed desire to reexamine the structure of the health services in general. Implicit in what Deputy Haughey was saying was the suggestion that we ask ourselves now where we are going. Perhaps a more relevant question is to ask: where are we? By comparison with what the health services cost even a few years ago the present level of expenditure is astronomical. Yet Deputy Haughey complained that services are declining and Deputy Dr. O'Connell complained that hospitals will not be able to keep going beyond December next. I agree with the basic proposition that something has gone wrong and that we are not getting value in terms of services commensurate with the increase in the cost of their provision. As I wrote in the Irish Medical Times, I fear that the health boards are a failure. Indeed, listening to the experiences of individuals dealing with health boards, reminds one of a Health Robinson contraption and in particular that vastly amusing one about the Christmas dinner. Heath Robinson apparatus depicted on a wall is very amusing, but a health board structure which at this stage, on admission of the Minister, requires re-examination is anything but amusing. But when it is accepted that there is duplication, waste, too much paper work, that too many people are involved in doing the same job, or a job that could be done by one person, then these are things, at the present cost of administration and of the administrator, which seriously require examination. I welcome the fact that the Minister recognises that this is so.
The proper jumping off point for any examination of what is happening today has to be the publication of the white paper in the mid-1960s. As I said elsewhere, I have now the gravest misgivings about the wisdom of the then Government's decision to implement the recommendations of the white paper in full. I do not doubt the sincerity of the Government; I do not doubt the sincerity of the people who carried out the massive re-examination process at the time and emerged with the recommendations which subsequently formed the basis of our present legislation. I do not doubt my own  sincerity, for instance, in going about trying to persuade local authorities that the new health board structure would be more efficient and would result in the provision of a better service for the patient, the sufferer. Nor do I doubt the motives of any of the people involved.
However, the fact is that, in practice, these boards have not emerged in the way that had been envisaged at that time. They do not appear to have achieved the fundamental objective envisaged for them in the white paper proposals. It is a very difficult thing to dismantle any such structure once created. The creation of positions is one thing; their amendment or abolition is another. If restructuring of these boards is required in the future I warn the Minister, this House and the public that it will require strong-minded and determined effort by all concerned inside and outside the Department, inside and outside the medical profession, inside and outside the subsidiary boards, committees and so on.
That is why it seems to me to be very welcome that the general feeling is that these are issues which transcend party politics and should be dealt with, and seen to be dealt with, without party political bias. Indeed, I believe that, all down those years from the time that the idea of examining the existing services was thought up 12 to 13 years ago, all of the people involved have been motivated in the best possible way and have not been interested in self-aggrandisement or basically in party gain. They have been motivated by a genuine, sincere desire that people who suffer and need help, either in a curative way or through preventive medicine, will not suffer in the future. I am convinced that all of the people concerned were motivated by the highest of ideals and the fact that re-examination is necessary now does not reflect on anybody concerned. It is a good thing that the Minister recognises that even now, a bare couple of years after the creation of these health boards, the time has arrived for some sort of committee to examine their operation.
 The question arises also of the overall level of expenditure in this field. The Minister comes in here, not just as Minister for Health but as Minister for Social Welfare also. One must judge overall expenditure in this field of social protection, if one may call it that, by adding up the total of what social welfare and health attract out of the national revenue. Taking the overall figure it does seem that the portion now being given to health and social welfare combined is quite generous and yet the Minister complains about allocations where health is concerned and has become involved in cutting back expenditure which may lead to the kind of situation Deputy O'Connell mentioned in which wards will be closed down later this year.
Has sufficient study, I wonder, been given to the question of the application of the aggregate amount of money being spent between social welfare and health? Is too much being given go social welfare and too little to health? Which is the better way socially to go about things, to give more for certain aspects of health or more to social welfare? That is the question I pose. Quite honestly, I do not attempt to give an answer. I have my own views about certain aspects of the social welfare system. I have my own views about the ultimate effect of paying money to people who are in good health and do not need help from any health services. There are instances when people must be aided by the State. Nobody fought harder than I did in the late fifties to see to it that the small farmers in the west, for instance, would be given a naked and unshamed subsidy to enable them to keep on living there. But times change and the question must arise now, and must continue to arise, as to when it becomes improper to give money to people who are otherwise in good health when that money should be diverted directly to the health services, particularly to those people instanced here so often who have to wait a very, very long time for remedial treatment for non-acute conditions.
These are questions which involve  deep political considerations and they are questions which have to be answered politically. I was talking earlier about what the new president of the association, Dr. O'Donnell, said in Kilkenny. He referred to the development of St. James's Hospital in Dublin. This brings me now to the question of hospital reorganisation and rationalisation about which so much discussion has gone on over the years. In fact this has been very difficult to achieve. Dr. O'Donnell said that one of the tests of the sincerity of the Minister—to him anyway and, I take it, to his association—is the completion of St. James's and of the facilities to be provided there. He would regard that as a touchstone. I think he could be right because I believe that, as in previous years, money is still being dissipated in providing help for equipment here, buildings there and staff somewhere else in institutions which should no longer exist. This applies especially in Dublin. St. James's should be a first priority. There you have a hospital complex where some of the buildings are so old and decrepit as to be a fit object of scrutiny by the dangerous buildings section of Dublin Corporation. Within the same complex you have a new building without any equipment. That raises the question as to whether even now a proper system of priorities has been established.
I appreciate the difficulties. There are political difficulties. There are personal difficulties and the personal difficulties are often political. They are not party political; they are medical political. They are no less complex and difficult for being medical politics rather than party politics. At the rate hospital charges are rising throughout the world we just have to come to grips with the problem. Deputy Haughey referred to experiments in other countries designed to reduce hospital charges and so on. There is an article in the current issue of Time Magazine about experiments being carried out in America where people, who are able to look after themselves, after careful screening are given certain minimal facilities in an institution and, after that, they are made to look after  themselves. These would be certain types of cancer patient, people recovering from strokes, paraplegics and so on. The cost of a hospital bed per day is in the region of $113 which is a rather frightening figure when translated into sterling at its present value. In New York, Washington and other big centres the cost is $200 per day or even more. Experience in recent years has shown that slowly but surely every country is beginning to approach the cost level in the United States and we have only to look at the situation in western European countries over the past five to ten years to realise that this is so.
I remember on one occasion meeting Mr. Walter McInerney, the head of the Blue Cross in America. He was going to Washington to try to pilot his budget through whatever federal agency was involved. He said: “You know, what I am beginning to worry about now is not the cost of medicine but whether we can afford the premium”. The Blue Cross system is roughly an insurance system and he was worried as to whether or not people would be able to afford the premium. When we talk here about a compulsory insurance system, an extension of the VHI, or any other system, we must do so against the background of rising hospital costs, with no evidence to show they can be controlled, certainly not for specialist acute treatment. Looking after people on the lines suggested in Time Magazine would be very helpful because it would mean that people who are capable of looking after themselves could do so during the periods in which they require certain minimal treatment, but would not have servants, nurses and nurses aids surrounding them to make their beds, bring them their breakfast in the morning and bring them their drugs, medicine and so forth. It shows what the savage increases in the cost of hospitalisation generally has resulted in in other countries. Anything which is done elsewhere is worth looking at by us.
Some people are bound to get hurt in the rationalisation of the structure of hospitals. From that point of view I regret the implications of the Minister's  announcement that Mallow Hospital will be retained as an acute hospital. I have nothing against Mallow or against the idea of retaining a hospital there. My misgiving arises from the fact that a great deal of political pressure was exercised by and on behalf of the people concerned in Mallow. This criticism is not aimed at the Parliamentary Secretary who comes from Mallow and who would have been involved in the representations. Mallow is now to be retained as an acute hospital after being told it was to be a community care centre. It is not relevant to me whether the original decision or the present decision is right. This decision will be interpreted as being the result, although this may not be the case, of sustained political pressure at every possible level. This hospital will now be equal with a hospital in Cork city with which it will work as a component part.
I have always felt that too many public representatives are too sensitive about decisions in matters like this and I speak in the presence of Deputy Enright who will probably be talking about Tullamore hospital very shortly. I accept his reasons but I do not accept, in regard to many other parts of the country, that the cases put forward by politicians of various views were basically valid. I regard their behaviour in general with something not too far removed from contempt.
I will give an example from the other side of the matter. The recommendation some years ago that certain facilities should be withdrawn from Wexford was not appropriate. It was admitted afterwards that it was not appropriate at the time. It opposed the establishment of a structure which did not exist. The withdrawal of the services from Wexford was not envisaged until the infrastructure was available. I can understand the attitude of public representatives saying: “For God's sake, how could you do that?” I agree that they had a good point but there are other parts of the country where I do not agree that if the public representatives were looking at things from a national point of view as distinct from a parish pump point of view there was any validity at all in the  cases they were making to whoever was Minister for Health at the time.
Reorganisation of the hospital services in Dublin and throughout the country is a key to the improvement of the health services and must be done as a national imperative even though certain individuals on the medical side will get hurt in the process, even though the part that will be played by particular institutions in the health services will be changed and even though what appears to be downgrading of certain areas becomes necessary.
If one of the by-products of an all-party committee on financing and restructuring the hospital services and if necessary the realignment of expenditure between health and social welfare was to be that we as public people could finally adopt a hospital rationalisation programme broadly acceptable to all we would have done a marvellous century's work for this country. It must be accepted by the representatives of the medical profession and other organisations concerned that people will be hurt in the process. It is because I believe an all-party approach is possible and that it is also possible to get broad agreement in principle from the associations for such a programme that I am optimistic enough to believe that li = "2" fli = "-1"what everybody agrees to be necessary can be achieved.
Another matter which concerns both health and social welfare and also involves the question of payment is whether or not any function basically in regard to health should remain in social welfare. There is a health element in the insurance stamp. Would that be better abstracted from social welfare and the stamp devoted purely to employment and so forth? Is this not an area which should be reexamined? Would it not be better to have those things controlled by one agency and not divided up among two or three where collections are made under one heading by one Department and under another heading by another Department and there is an independent collecting agency in the middle? This could be regarded as part of the brief of the new Department of the Public Service where this duplication  of effort within Departments, with regard to collecting money and in regard to responsibility, should be straightened out. Anybody who has any knowledge at all of the working of Government Departments will realise each likes to hold on to every area of responsibility it enjoys, to expand it as far as possible and hates to be told that it is to lose responsibility even though the circumstances of its having that responsibility may be entirely incongruous. Again, there are human factors involved and if the Department of the Public Service are not prepared to study and make recommendations on matters of this kind they will have to be studied, adjudged and implemented at political level.
The examples given by Deputy Doctor O'Connell of people with, for instance, osteoarthritis and such diseases having to wait upwards of two years for operative treatment raise a question as to what the Department could do to improve that situation. There are other examples in the non-acute field of very long waiting periods in the case of patients. While this is partially a problem of personnel it goes back ultimately to the question of hospital reorganisation because if we knew what facilities would be available we could arrange, at least in the long term, to train the appropriate personnel and if we could not train them, to acquire them.
I should like to praise all those involved in the various aspects of the health services which have definitely shown great advances over the years since they were first envisaged. Community care in general is much better now than it was in the past. The great improvement in the number of nurses in the field is very welcome. The continual addition to the number of institutions catering for elderly people near their own homes is also very welcome. The overall functioning of the general medical service is praiseworthy. There are certain abuses within that service and I hope they will be eradicated although, human nature being what it is, there will always be a small percentage of people who will abuse a system such as that which operates to-day.
 I was astonished by the figures given by Deputy Haughey showing that 65 per cent of the cost of the general medical service arose other than by payments to doctors but I am sure the doctors cannot complain about their conditions now or about what they are being paid. As I have said elsewhere they would not have done as well had I been Minister instead of my successor. But they have given good service in return and too much emphasis should not be placed on the occasional breakdown. While every effort should be made to ensure that the sort of incidents mentioned here and rightly publicised in the newspapers—who are still our friends despite what we may have said about them—should not develop. Doctors should be capable of, and are sufficiently well paid to be capable of organising a service which will, on the existing structure, operate on a 24 hour basis. That should be accepted by them and they should be able to organise it with or without group practice so that nobody in a given area at any time is left without a doctor when a doctor is urgently needed.
Many people have worked very hard and, in general, the service has at certain levels improved enormously but the cost has got out of hand and re-examination is definitely necessary, preferably without party political overtones. I think this reflects every-body's view. Nobody—at least I have not—has any doctrinaire conviction as to how financing should operate or what categories of people should be envisaged. I dislike categorising people because sometimes in doing so we put the emphasis on the wrong end of the scale. We should be thinking of providing a first class service within a first class structure and not trying to amend a third class service to cater for people's needs and this appears to be what is being done consciously or unconsciously for some time past. Reappraisal is certainly needed and we, on this side of the House, will certainly be glad to give our support to practical measures to bring the system nearer the desire of the hearts of all who were involved ten or 12 years ago in the decision  to uproot the old and establish the new system. All concerned were motivated by the highest principles. The fact that we are disappointed and in some ways disillusioned now should not take away from that fact but should spur us now to the same idealistic approach and the same unselfish attitude so that whatever is necessary on re-examination we will get down and do it. Even if difficult political decisions must be made, these should be faced.
We must avoid a situation where we lose control over what is happening in regard to our services and we must not be afraid to look at the question every day and decide what service is genuinely needed by the community, because service per se is merely a word and the idea that people are entitled to service by definition applies only to a very small section of the community. We should re-examine our whole approach to the matter, because words are only words and we should not allow ourselves to be cribbed, cabined and confined by doctrinaire ideas of any description or any background, historical or otherwise. We should look at our own unique country and see what we can do with its resources. We should employ those resources to the best possible advantage of those who need service. We should not be afraid to amend, withdraw, or otherwise change, if we keep the ultimate objective firmly in our mind.
Mr. Enright Mr. Enright
Mr. Enright: I should like to congratulate the Minister on presenting a most comprehensive document and speech. I should also like to thank him for furnishing us with the details in connection with the speech and his Estimate a number of days prior to his coming into the House to read his Estimate speech. On too many occasions we find Ministers coming into the House and giving us statistical information on their Estimates at the same time, which does not give Deputies an opportunity to analyse a speech.
This afternoon I intend to praise the Minister's speech where praise is  due to him, and I intend to criticise his speech, his Estimate and his Department where that is necessary. There are a number of omissions in his speech which are all too glaring. One is in regard to our dental service. The word “dental” is only mentioned once. The second one is in regard to orthopaedic surgery, and the third one is in regard to ophthalmic services. I intend to elaborate on these as I proceed.
In approaching the Minister's speech one has to look at the situation and ask oneself, first of all, has the general service to the patient improved? The answer to this question is that in the vast majority of instances the general service to the patient has improved. A further question we must ask ourselves is: has the Minister made progress in the vast majority of spheres within his Department? Again, the answer to this question is “yes”.
Irrespective of what people say— and the Minister has had criticism in regard to the financial aspects of his case—I believe we should congratulate the Minister. He has come into the House and looked for a sum of £249,983,000 for the running of his Department up to 31st December this year. It is a very large amount of money to be spending on the running of the Department of Health. It is a very necessary and most sizeable contribution towards the running of the health services. The non-capital Exchequer allocation for the Department of Health each year is of the order of £242 million.
Some things are necessary in regard to the Department of Health. This applies not alone to the Department of Health but to every other Government Department. It is absolutely necessary to ensure that the money being spent by the Department of Health and by the health boards is spent in the most efficient manner possible. It is essential to ensure that the benefit of the bulk of this money is filtering through to the patient. It is essential to ensure that the bulk of this vast sum of money goes directly towards the services of doctors and nurses, the provision of hospitals and  services and for the benefit of the patient. It is essential to ensure that unnecessary waste and expenditure is curtailed wherever possible.
The Minister has had great difficulties in regard to eligibility for health services. He has come in for considerable criticism in regard to this matter and many doctors have been very critical of the Minister for increasing the eligibility for the health service, which deals with in-patients and out-patients in our hospitals. Deputies are aware that insured workers and their dependants are eligible under the health services for in-hospital treatment, as are farmers with a valuation of £60 or less. Up to now, non-manual workers with an income of £2,250 or over were not eligible for in-patient hospital services without payment. In bringing this figure up to £3,000, the Minister has done something essential. I congratulate the Minister and his Department for making an effort to ensure that a greater number of people are brought within the scope of in-hospital treatment at this time. This means an increase of £750, which is a considerable amount, but it is absolutely essential that this increase be made. Whatever difficulties the Minister finds in introducing this scheme I wish him every success in seeing its fulfilment.
In regard to uninsured people, the limit was brought in in 1971. At that time it was £1,600. The Minister is raising this figure to £3,000. As a practising politician I have come across a large number of people who found that they were not insured but that their income was in excess of £1,600. In all honesty they stated in their application forms that their income might be £2,000 or £2,300. It was then up to the health board to decide whether a person was a hardship case. The health boards have their own criteria for deciding who is a hardship case. If the health boards refused an application a person had no redress and had to pay up. I have come across many people who have received demands for payment from health boards and solicitors and quite a few of them have received civil processes from District Courts. This is a great source of worry to people at a time when they are least  able to face a situation of this nature. In raising the eligibility level to £3,000, the Minister will take the burden from a large number of shoulders. Many people are affected by this and I meet such cases daily. I know of one person who had a large number of bills. After persistent representations by me this person was eventually considered a hardship case. This man should not have had to come to me. He should have had this as a right.
The Minister mentioned medical cards. I recommend that health boards use a generous and flexible approach with regard to medical cards. A lot of people who apply for medical cards are not in bad health at the time of making application. They rarely have to go to a doctor. It is like an insurance policy. It is a matter of mental satisfaction for them to know they have a card and that is why they apply for and are anxious to get them. There has been an increase in the number of medical cards issued. At present there are 1,162,382 medical card holders, or, 37.2 per cent of the population have medical cards. I hope this figure is increased.
Deputy O'Connell, the Minister and his advisers appear to be satisfied with the hospital patients' statistics. The Minister said that in 1960 there were 16,204 hospital beds. In 1974 the number of beds had increased by only 274. Over a period of 14 years, that was a very small increase. The number of patients treated in hospital beds at that time was 254,000. In 1974 that number had risen to 435,000. The Minister said there had been a decline in the average duration of stay in hospitals from 18.7 days in 1960 to 11.6 days in 1974 and because people were leaving hospital sooner, there was no necessity to increase the number of hospital beds. He said:
This indicates more efficient use of our hospital facilities and we would continue in the future to study measures to improve this still further.
I am in constant communication with hospitals at both local and national levels. I honestly believe that to try to shorten people's stay in hospital is not the correct procedure. I know a person who had a very serious operation.  His kidneys and bowels did not work. He was in a very critical condition. He was told he was being discharged the following morning. When his relatives visited him that evening they were alarmed to hear he was being sent home. They contacted me and I got in touch with the hospital. I was told that he was being sent home the following morning. I said if this happened I would have to make the strongest possible representations to the Department of Health and would require a certificate from the matron taking responsibility for his discharge. After a great deal of representations he was kept in hospital.
My point is that this person should never have been considered for discharge at that stage. In too many instances people have been discharged before they were ready. The only way to remedy the situation is to increase the number of hospital beds in our county hospitals. This is essential because I honestly believe there are not enough hospital beds available. Since I have been involved in politics since 1967, this has been a continuing factor. I hope the Minister in his wisdom, will have it remedied as soon as possible.
I will now deal with the Minister's general hospital development plan. This was touched on briefly by Deputy Flanagan. He dealt with Mallow rather than the other hospitals. I am sorry he is not present to discuss it further. The general hospital development plan was announced by the Minister on 20th October, 1975. He recommended that there be 23 general hospitals. Only five provincial hospitals did not retain their status under this plan—Tulla-more, Longford, Monaghan, Manorhamilton and Navan. Two of the hospitals affected are in my area. The largest hospital affected is Tullamore.
There are 227 beds in the Tullamore hospital at present. There is a full range of services—surgical, medical, maternity, geriatric and paediatric— available there. Outside the three cities, Dublin, Cork and Limerick, Tullamore is the largest hospital. There is an excellent range of staff in the Tullamore hospital. There are two surgeons,  one full time and one on a relief basis; two physicians, one full time and one on a relief basis; a geriatrician, two gynaecologists, two radiologists, a surgical registrar, three house doctors, one paediatrician, one anaesthetist, and over 100 nurses. There are also other specialist treatments provided on a regular basis, such as orthopaedic surgery and ear, nose and throat services, by specialists visiting the hospital. I think it is true to say that Tullamore is one of the finest hospitals in the country. Very briefly, I would like to refer to the Minister's guidelines for the general hospital service as he laid them down in September, 1973. They indicated reasons for the allocation of a general hospital to a particular area or county. The first one is:
The general aim should be to organise acute hospital services——
An Leas-Cheann Comhairle Denis Francis Jones
An Leas-Cheann Comhairle: Would the Deputy give a source for his quotation?
Mr. Enright Mr. Enright
Mr. Enright: The Minister's guidelines as laid down in 1973.
An Leas-Cheann Comhairle Denis Francis Jones
An Leas-Cheann Comhairle: Has the Deputy got the Volume and column numbers?
Mr. Enright Mr. Enright
Mr. Enright: I am quoting from column 746, Volume 286, of the Official Report of 3rd December, 1975.
Mr. Haughey Mr. Haughey
Mr. Haughey: The Deputy is quoting himself then?
Mr. Enright Mr. Enright
Mr. Enright: I am, but I quoted the actual extract on that occasion.
Mr. Haughey Mr. Haughey
Mr. Haughey: That is fair enough.
Mr. Enright Mr. Enright
Mr. Enright: The recommendation was:
The general aim should be to organise acute hospital services so that the population served would be within a radius of 30 miles of the hospital centre.
On that occasion I pointed out that there are a large number of areas that are over 30 miles from the hospitals recommended by the Midland Health  Board and accepted by the Minister for the Midland Health Board area, which are Portlaoise and Mullingar. A number of these towns are outside the 30 mile radius. One of them would be Birr; villages would be Crinkle and Shinrone. All of these are well over 30 miles from Portlaoise and Mullingar. Birr would be 45 miles from Mullingar and 40 miles from Portlaoise, and the other areas would be approximately the same distance from either Portlaoise or Mullingar, Shinrone being further from Mullingar. In fact there are a number of areas outside the 30-mile limit which will be affected by not having the general hospital retained in Tullamore. I quote another guideline from column 746:
The minimum staff of such an acute hospital should consist of two consultant surgeons and two consultant physicians with other consultant medical personnel and other staff as required by the case load.
The numbers of staff I have given for Tullamore hospital prove that there are sufficient trained personnel there to provide a first-class service for all the people availing of these services in the health board area. It would require very little extra to ensure that the services provided here would be the equivalent of those provided in any other hospital in the country. I quote the third guideline from column 747 of the same volume:
Where there were special considerations such as low density, a lower figure would be appropriate ranging down to 75,000 in exceptional circumstances.
The projected population for the Midland Health Board area by 1986 is between 215,000 to 220,000 people. Again this will bring the hospital in Tullamore within the appropriate population figure required by the Minister's guideline.
There are also a number of exceptional circumstances in this area. I pointed out—and I repeat it because it is important that the Minister and his staff should be aware of the situation—that one of the special circumstances is that the Slieve Bloom mountain range runs between Laois  and Offaly. There is a low density population here. There are exceptionally bad roads, and the people on the Kinnitty-Birr side running along towards Mountbolus are closer to Portlaoise and are on the other side of the Slieve Bloom range. It is important that these people will have a hospital service available to them, and the appropriate hospital is Tullamore.
Let us also take the people in the west Offaly area, such as Ferbane, Banagher, and up towards areas like Doon. These are areas where there is a wide expanse of bog roads. For the last 20 years we have been making representations to different Government Departments, particularly the Department of Local Government, for contributions to improve these roads. The necessary finance for such improvements has not been forthcoming. It is important therefore that the Minister for Health should recognise that this is a special circumstance which should be taken into account.
The statistics I have given in regard to the hospital personnel and the other information should prove to the Minister and to his Department that the services of the three hospitals in the Midland Health Board area are absolutely essential. The Minister should ensure that Tullamore, Portlaoise and Mullingar hospitals are retained, and that not alone should these hospitals be retained but they should be upgraded to general hospital standard.
As far back as 1928 a Government commission investigated the position in regard to general hospitals throughout this country. At that time this group recommended that hospital services should not be dependent on one surgeon. They mentioned that groupings of three or four countries together for hospital services would be a better approach. I am quoting from the Fitzgerald Report, 1968, which referred to this matter. This was something that was considered in 1928 and this commission reported in 1936. At that time no action was taken on this report or recommendation until the consultative council was set up to investigate the services in  1967. When the Fitzgerald Report was issued in 1968 it dealt with reducing the number of hospitals.
Because of the large number of people who are attending hospitals at present—as I quoted earlier, 435,000 people were admitted to hospitals in 1974—the Minister has recommended that 23 hospitals of general hospital status be provided. I believe the 23 general hospitals as provided, together with the hospital that I have recommended, should be retained. This would help to encompass and cater for a wider section of the people. To do otherwise would not be wise at present because, with the hospital built up to this size, it would be incorrect to change it.
In regard to Tullamore it is important to realise that there is land available at the hospital to extend the hospital if extension is necessary, and I believe it is. The expansion and extension of this hospital could be done at very little extra cost to the taxpayer and would help to improve the general services in the county. The goodwill of the staff and of every person in the county would be received with the retention and extension of this hospital.
The Minister accepted the recommendations of the health board for hospitals in Portlaoise and Mullingar which arose out of the resolution passed at the Midland Health Board meeting by 19 votes to no vote in opposition. I would ask the Minister if his Department have received a further recommendation and a further motion from the Midland Health Board in Tullamore which was passed unanimously at the February meeting. It is an important recommendation in that every member of the four counties comprising the Midland Health Board area—Offaly, Laois, Longford and Westmeath— passed unanimously the motion which was to ask the Minister to consider the special position of Tullamore hospital. When the Minister made his decision in regard to general hospitals this resolution had not been passed. I would ask him to consider it from the facts and figures I have already  furnished to him. His decision would have the goodwill of every person throughout the Midland Health Board area. That is all I wish to say on this topic now. I will be returning to it on any occasion that arises because I feel very strongly about it. It is causing me a lot of concern.
The Minister dealt at considerable length with mental illness. With the stresses and strains of modern society there has been an increase in the number of people suffering from mental illness. The cost of our mental illness, according to the Minister in his statement, is £36 million per year. The only comment I have to make on that is that I believe that there is not at present a sufficient effort being made to rehabilitate people suffering from mental illness. If one of a family spends some time in a mental hospital sufficient effort is not made by his people to help him, to bring him home and rehabilitate him among his friends and neighbours and to try and provide him with a job. This, irrespective of the efforts of the Department of Health and of the mental hospitals, requires the goodwill and effort of the people in their own home environment to rehabilitate such people and get them back to work within their own sphere. We should all try to ensure that this comes about, because this is essential.
The Minister stated in his speech that over 50 per cent of the beds in our hospitals are occupied by adolescents and adults. This is the biggest problem facing those concerned in the provision of residential services. It is important that as great an effort as possible is made so that when people are ready and anxious to go home they should be brought back to their environment.
The Minister should be congratulated on the work he has done in regard to mentally-handicapped children. Good progress has been made in regard to hospital care for these children. I wish to congratulate also the mentally-handicapped associations throughout the country who have done outstanding work for mentally-handicapped children. This is essential work. Those associations have carried  on, in conjunction with the Department of Health, great work over the years. The National Rehabilitation Board are also carrying on excellent work in training handicapped people in voluntary and health board workshops. Handicapped boys and girls undergo excellent courses at these workshops. It is essential that every effort should be made to train these young people so that they can lead active lives. However, a little more effort could be put into this work. In 1972 I asked, in the course of a question in the House, how many handicapped and blind people were employed in Government Departments and my recollection is that only the Department of Posts and Telegraphs employed a number of blind people. No effort was made by the other Departments, or semi-State bodies, to employ physically handicapped or blind people. That is wrong and the position should be changed.
In this regard Government Departments and semi-State bodies could give a lead to industry in the employing of handicapped people. It is all too easy to shove off the responsibility on somebody else but unless a lead comes from Government Departments private enterprise will not employ such people. It is disappointing to see that so few handicapped people are employed in Government Departments, but I believe the Minister will ensure that this trend is changed without delay.
Major-improvements are necessary in the dental service. The dental service was not mentioned in the course of the comprehensive speech of the Minister, with the exception of a reference to a dental board. There is a serious shortage of dentists in all health board regions. I should like to make an appeal to the Minister to ensure that a great effort is made to encourage more dentists to participate in the health board system. When the question of the shortage of dentists was raised at a meeting of the Offaly Advisory Committee to the Midland Health Board in January I was informed that there are three vacancies for dentists in County Offaly—there are four such vacancies in the entire region. I was also informed that in spite of repeated  advertisements the board was unsuccessful in encouraging anybody to take up these posts. I seconded a proposal at that meeting that the board should train a person as a dentist on that person giving an assurance that he or she would come back and practice as a dentist in Offaly when qualified.
The only service being provided by health boards in regard to dental treatment is extractions and the provision of dentures. There is such a delay with regard to extractions that many people are concerned. By the time they are called for the extractions people discover that they need to have other teeth extracted. This will have to be looked at. Health boards should also provide a service for school children needing fillings.
There is a great need to improve the orthopaedic surgery service. Many people approached me anxious to gain admission for orthopaedic surgery at Kilcreen Hospital, County Kilkenny. The waiting list at that hospital for orthopaedic surgery is more than two years. In many cases by the time a patient is called for that surgery he cannot benefit from it. This is something the Minister inherited but I hope he will be in a position to do something to relieve the problem.
Another matter I would like to refer to is in connection with Birr District Hospital. There was a bomb scare at that hospital recently and the fire officers involved had to carry the patients out. There is no lift in that hospital and those officers told me of the necessity of installing one. It was fortunate that there was no bomb there on that occasion because it took quite an amount of time to evacuate all the patients. I have raised this matter with the Minister on many occasions but nothing has been done. Local people feel so concerned about the matter that they are considering making a collection throughout the area to provide a lift. The bomb scare proved the necessity for a lift.
If this lift were provided there would be an extra floor available in this hospital. There would be increased accommodation for patients. I would specially appeal to the Minister to immediately look into the possibility  of providing this lift to Birr hospital. This is a local matter but unless it is aired in this House it may not get the attention from the Department of Health that it deserves. I have written to the Minister and his Parliamentary Secretary and to officials, but the lift has not been provided. To provide it would cost in the region of £10,000 but it should be installed as soon as possible. It would be of great benefit to the people who are attached to this hospital.
I wish the Minister every success and I ask him to bear in mind the points I have made.
Mr. Toal Mr. Toal
Mr. Toal: I commend the Minister on a very comprehensive statement which he gave to the House on the activities of his Department. There are many points which deserve the highest praise. As a Deputy for Monaghan, I must honestly say that a dark cloud hangs over all of this. I am referring to the Minister's very brief comment on the general hospital development plan. I will not reiterate here the many arguments which I put to the Minister in private but I can tell the Minister that the message coming from the people of Monaghan is that there is great anxiety among the entire populace about the future development of the hospital services in the county. Nothing short of a full accident service being provided will suffice.
The Minister and everybody knows that the situation in Monaghan has changed dramatically in recent years. Monaghan is only a stone's throw away from the North of Ireland which has erupted into violence, and people fear that that situation might occur throughout the country. That fear may not arise in Cork or Kerry but the people of Monaghan are not so fortunate. Bombs have been exploded in various towns throughout the county. No matter what town you go through in County Monaghan it is only a hen's race into Northern Ireland. I put it to the Minister that the situation in the North of Ireland is a very material consideration when it comes to making plans for the future of the hospital service in the county.
 The people want a full accident and emergency service provided in the county, and nothing short of this will suffice. There have been changes in Government policy on many things— equal pay, the request for a national pay pause, and so on. Plans and Government policy must change to meet new needs and I put it to the Minister that there is nothing more vital than the necessity to preserve human life. All the arguments in the world about transporting patients to the nearest general hospital, which could be 40 or 50 miles away, will not satisfy the people of Monaghan. The only answer which they will be satisfied with is the provision of acute medical and surgical facilities in our county hospital.
In the recent past I have noticed a kind of tension growing up between the Department of Health and the general practitioners throughout the country. There has been talk about the escalating cost of drugs and about general practitioners over-prescribing. I would ask the Minister to strive to maintain the confidence of the general practitioners. They are the corner-stone of the health services. In most urban or rural areas the presence of the family doctor is greatly needed. It may be great to co-ordinate the various social services. The stage could be reached where young social workers will be running around the country telling old people what to do, but I believe the best service which the Minister could provide for the people is a good family doctor service. If that were guaranteed many of the related problems would look after themselves.
Deputy John O'Connell mentioned the question of nurse training, which is of growing importance. Deputies are bombarded with requests almost every weekend from students who are sitting for examinations at school asking them to try and assist them to gain admission to a training centre. Deputy O'Connell made a very good suggestion when he recommended to the Minister that An Bord Altranais should take over the question of admission to nurse training. This whole question should be reviewed as a matter of urgency because there is  great disillusionment among the student population, particularly among those who wish to go on for nursing.
Many things were said during the course of the debate about the structure of health boards. I was glad to hear that the Minister will set up an all-party committee with representation from various other interests to review the activity of health boards. Health board operations at times are carried out in a very haphazard fashion. The members of the board are engaged in other occupations, and they have very little time to go into deliberations. As a result important decisions are taken in a very speedy manner, and this is definitely not conducive to the better running of the health services. I am glad to learn that this review is about to take place and I look forward to any recommendations the Committee may make.
There are many aspects of the Minister's speech which are deserving of the greatest praise. For example, we must laud the extension of the limited eligibility health services to include persons whose incomes are as much as £3,000 per year. This is a very good step. We must welcome, too, the increases in the various allowances. The health services are costing the country more than anybody could ever have dreamed of, but in these times of economic difficulty I trust that the Minister will be able to continue the good work and I wish him well in the years ahead.
Mr. Moore Mr. Moore
Mr. Moore: At the outset I express my appreciation to the Minister for having circulated to us some days ago a document detailing health costs. This is very helpful in speaking on the Estimate. When we note that the amount being spent on health this year is almost £250 million we get some picture of what the services are costing and also of the rate of inflation, because not so many years ago the same amount would have constituted a national budget.
I serve on the board of a voluntary hospital in this city and I am aware of the concern of the governors in relation to increasing costs. I am not making  a carping criticism of the Department but am merely indicating the position. We may have to cut back on services in that hospital because of inadequate finances. The Minister may point to what is being given; but although we are spending this huge sum of money on health this year it is inadequate. Therefore we must endeavour to ascertain what can be done in order to reduce the cost of hospitalisation and to ensure that we get full value for the money we spend. At the same time we must ensure that patients in the hospital receive the best treatment possible. We must cut administration costs to the minimum without inflicting injustices on any hospital staffs.
The hospital with which I am associated has a board of voluntary governors. In order to provide any special facilities, such as the fitting of a children's ward, the board raise money by various means, since grants would not be given for such work. Recently they bought a block of flats close to the hospital which they intend using as a residence for nurses because nurses today are not keen on living within the precincts of hospitals. The Department helped us to buy the flats but as soon as property in town belonging to the hospital is sold we shall pay this money back to the Department.
There is much goodwill between the Department and this voluntary hospital but despite this we continue to experience an uphill fight in ensuring sufficient resources to enable the hospital to operate efficiently and to give to its patients the best treatment possible. In these circumstances there is an onus on the Department to study the cost factor in hospitalisation. A patient's recovery may be impeded if, by reason of his not being covered by the Health Acts or by VHI, he realises he must face a big bill on leaving hospital.
I am not native enough to think in terms of an Utopia in which we could provide free hospital services for all. Therefore we must examine the Minister's figures and each of us should endeavour to suggest ways and means of improving the health  services while realising that there is a limit to the amount of money the State can provide in this field. The Minister's figures indicate that, of the entire population, 8 per cent or 9 per cent are hospitalised once a year. That is an over-simplification because while some people suffer ill-health which necessitates them spending several terms in hospital each year, there are many others who are fortunate enough not to be hospitalised at all.
The cost of the health services must cause the Minister much anxiety. Since the foundation of the State there has been progressive improvement towards better hospitals, but we must realise that there is a long way to go yet before we can claim to have the best hospital services that we can afford or that we can achieve. There are many aspects in relation to the entire hospital services which give rise to concern. I call to mind in particular optical services. At the hospital in Dublin which specialises in this field much excellent work is done, but despite the help they receive from the Department they find it necessary to keep patients waiting for many months for beds.
One elderly man I know must wait many months before being admitted for the removal of cataracts from his eyes. I suppose one of our most important faculties is our sight. Picture what a person goes through if he knows his sight is deteriorating, and not very far from where he lives there is an excellent hospital with some of the best eye surgeons in Europe ready to treat him, but they cannot do so because the hospital is overcrowded. Be it said to the credit of the Department, in recent years improvements have been made. We cannot rest until such time as, when a person is ordered eye surgery by his doctor, he will not have to wait more than a week or so, or at the very longest a month, before being admitted to hospital.
The hospital staffs are only too willing to do anything they can, and they are doing it, to reduce the time  lag for admissions to hospital. Perhaps there are other less serious ailments which are being treated in our hospitals because they are traditional ailments. I would ask the Minister in the coming year to give top priority to reducing the waiting period for admission to hospital when a patient has been ordered eye treatment and especially eye surgery. That is the most important thing I can think of. Other people who are suffering from other diseases or ailments might not agree with me. There may not be a definite cure for some ailments, but eye surgery has been perfected to such an extent that the staffs in these hospitals could effect a permanent cure of an eye ailment if they got the patient in time.
I do not envy them their job in trying to select patients for immediate attention or other patients who are told they have to wait for some months. I am not suggesting this is a new development. For so long as I can remember, this has been a fact of the hospital services. There are cures for eye ailments. There are other ailments also but I do not think the delay is as long as it is for eye surgery.
Mr. Corish Mr. Corish
Mr. Corish: In the case of cataracts there is a delay until the cataract matures.
Mr. Moore Mr. Moore
Mr. Moore: I appreciate that but, even if it matures today. I do not think the patient will be taken in for quite a while. It could be some other disease besides a cataract. There is need for further thought on this aspect.
Mr. Corish Mr. Corish
Mr. Corish: With the advances of medical science in some cases people are now going in for operations which some years ago they would not go in for. That is one of our difficulties.
Mr. Moore Mr. Moore
Mr. Moore: We still have the problem of people who need eye surgery.
Mr. Corish Mr. Corish
Mr. Corish: Some people did not bother about hip replacement until medical science designed a method to deal with it satisfactorily.
Mr. Moore Mr. Moore
Mr. Moore: With a growing population we will have more people who will need eye surgery and hip surgery.
Mr. Corish Mr. Corish
 Mr. Corish: There is a cure for that too.
Mr. Moore Mr. Moore
Mr. Moore: After that speech last night I had better not comment on that. I am sure the Minister appreciates the seriousness of the situation.
Mr. Corish Mr. Corish
Mr. Corish: I do.
Mr. Moore Mr. Moore
Mr. Moore: I have a note about hip operations also. Last week I met a well-known soccer player who played great soccer in this city. He is a comparatively young man, much younger than I am. He has been waiting for months for a hip operation. I remember him playing first-class football That is another aspect of the queues at the hospitals.
Mr. Corish Mr. Corish
Mr. Corish: I am sorry I interrupted the Deputy.
Mr. Moore Mr. Moore
Mr. Moore: The acid test of our whole health service is: “Are we helping our people?” I believe we are. In my young days I saw children with rickets and twisted limbs. Thank God we very seldom see that any more. We are making progress, but are we making it at the quickest possible rate? I do not think we are. We could be going faster in certain aspects. I realise that the faster we go the more money it costs. People do not begrudge money for the health services.
This brings me to the vexed question of the medical cards. I am told— I do not know whether it is true; I suspect there is something in it—that it is much harder to get a medical card in Dublin than in the provinces. I do not know whether the city section of the Eastern Health Board or the Southern Health Board in the urban areas are tougher with applicants than they are in the rural areas. Some years ago I had figures which showed the percentage of medical cards in Dublin was lower than it was in other parts of the country. There may be some sociological factor involved but, when Deputies sit in what  they call their clinics and people come in to inquire about medical cards, there is not much use in saying: “Because of some sociological factor you are being denied a medical card. If you lived in another part of the country possibly you would have one.”
It is very difficult to have to decide that if a man earns more than £X a week he does not get a medical card. I believe when people get a medical card their health improves. They feel they have a safeguard against want. They may not use it to any great extent because they have a sense of security. A person's next door neighbour may not have a medical card and may have to pay £1 a week for drugs. To some people even £1 a week is a lot of money. The Minister might have a look at the situation in regard to medical cards. I do not say this is the ideal way of looking after our people. It would be great if we had a scheme under which a man's word would be taken if he said he could not afford to pay. I suppose this would be Utopia if we were all so honest that we would declare our means and whether we could afford drugs.
With regard to illness in general, one of the contributory factors is lack of money to meet bills. A person may want to see a well-known specialist in Dublin or elsewhere. If he cannot afford it he may feel he is being cheated. He may have great faith in this well-known surgeon or medical practitioner. We can point with pride to our local authority hospitals where we have some tremendous medical figures. People are admitted to hospital and given the best treatment. St. James' Hospital is being improved all the time and it has some of the best doctors and medical staff in the whole country.
The Dáil adjourned at 5 p.m. until 2.30 p.m. on Tuesday, 4th May, 1976.
Dáil Éireann 290 Vote 50: Health (Resumed).