Dáil Éireann - Volume 343 - 02 June, 1983
Estimates, 1983. - Vote 48: Health (Resumed).
Debate resumed on the following motion:
That a sum not exceeding £978,602,000 be granted to defray the  charge which will come in course of payment during the year ending on the 31st day of December, 1983, 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 Health Boards, miscellaneous grants and a grant-in-aid.
—(Minister for Health.)
Mr. Faulkner Mr. Faulkner
Mr. Faulkner: Before the adjournment I had referred to the rights of each individual citizen and that we should remember that that includes those who are mentally handicapped. I mentioned the great tradition which had grown up in our institutions which deal with the mentally handicapped of regarding each individual person in the fullness of his being and not just as a number or a case within an institution. It is only by cherishing and developing this attitude that each of our mentally handicapped children and young adults can be assured of their personal rights.
As a nation we must ensure that our mentally handicapped children and their families receive the specific services and support guaranteed to them under the Constitution, services which will contribute to the growth and development of both the child and of the family unit.
While the general trend must be towards a more comprehensive community care service based on the community, it is only realistic to recognise that there will always be need for residential care. This could, of course, be more selective. Indeed, the proper support services in the community could assist in reducing a number of obstacles to which I have already referred in the area of adult care. However, whether in the area of community service, in the provision of hostels, half-way houses, shelter workshops, group homes or in the provision of full-time care in residential centres, more money is needed. I ask the Minister to provide extra money for these services.
There has been considerable development in community-based services for the mentally handicapped. These include services for pre-school children and their  families, for children of school-going age, for adolescents and adults and general community services. These also include assessment services to measure the extent of the mental and other handicaps. Much more might be done regarding assessment of children attending primary schools who are suspected of being mentally handicapped. It often takes quite a considerable time before such children are assessed. It is difficult at times for the layman — in this instance the teacher — to recognise the difference between a mildly mentally handicapped child and a slow learner. As the approach to educating the child is different in each case, the importance of the difference should be recognised early. I urge that more consideration be given to this matter.
In the larger primary schools special classes for mildly handicapped children are a possibility. While I recognise that it is not in the Minister's responsibility, he might speak to his colleague in Education in relation to what facilities could be or are being made available to facilitate the mildly mentally handicapped children in post primary schools so that they might pursue their education in ordinary second level schools. If such facilities were available this would make a major contribution towards the integration of the mentally handicapped with the rest of the community.
While entry into open employment and integration into the working community is the main objective of the additional teaching centres for the mentally handicapped, it must be accepted that the majority of those who complete the course will not be successful in securing and retaining employment in local settings. The courses at the vocational centre do, however, equip the handicapped person to participate either in a community workshop or in a sheltered workshop for the mentally handicapped.
Facilities are available to mentally handicapped people which go quite a considerable distance towards meeting their daytime needs when they are being maintained in the community. However — and this is a very important aspect of the matter — not sufficient concern is being shown to fill their social and recreational  needs in the evenings and the week-ends. There are many ways to education, formal and informal, in which the mentally handicapped person could be encouraged to integrate into the community and to assist them to use normal facilities. Unless sufficient attention is paid to this aspect of the matter there is a danger that a mentally handicapped person's only social outlet will be exclusively with other mentally handicapped people. This will reduce their prospects of being fully integrated into the community.
As regards the parents of mentally handicapped children, these at present receive some assistance but much more could be done for them. It is of the utmost importance that such parents who care for a mentally handicapped child at home should themselves lead a normal life. This involves being able to use leisure time away from the handicapped child or adult. In some cases parents have been able, because of their own particular circumstances, to do this. In other cases they have not been able and special assistance is needed in regard to the latter. All the services and facilities are necessary if mentally handicapped people are to live a satisfactory life in the community.
More important still than all the specialists services is the acceptance by the community of the mentally handicapped living among them. This does not mean a mere acknowledgement of their existence. It requires a positive effort to encourage and assist handicapped people to use the amenities and facilities which are part of every day living for most people.
To reach this objective, which will enhance the quality of life of the mentally handicapped living in our community, a conscious effort is necessary. That such a conscious effort is being made by some voluntary bodies should be an encouragement to others to do likewise. I strongly urge the Minister and the Department of Education to develop further the many schemes which are available for the mentally handicapped and to introduce any new measures necessary to give them the opportunity to become, where it is possible, fully integrated members  of the community in which they live.
I have concentrated my speech on this Estimate on the area of the mentally handicapped because it is vitally important that we continue to concentrate our endeavours in helping them. It is possible in a considerable number of cases for them to become members of the community in which they live. I appreciate that a lot has been done for them over the years, but much more is necessary. I request the Minister to do all in his power to integrate as many as possible of the mentally handicapped into the ordinary life of the community.
Mr. De Rossa Mr. De Rossa
Mr. De Rossa: In discussing the health services the fact that they were started on an ad hoc basis, developed on an ad hoc basis and have now been put on an ad hoc basis must be taken into account. There has been no clear policy in relation to the development of the health services and this has resulted in various vested interests pressing their demands and getting their particular section of the health services implemented.
The need for the introduction of a clear comprehensive health service goes beyond doubt or question. Such a service could be provided without the expenditure of additional money. What is required is a re-allocation of existing expenditure and a restructuring of the service. The vested interests, such as the pharmaceutical and medical profession, have up to now served their own and not the public interest. We spend an unusually high percentage of GNP on the health service. It can be compared with the percentage spent in Britain, which provides a comprehensive health service.
We have a service which could be classed as an illness rather than a health service. Over 50 per cent of our health expenditure goes on general hospitals and about half of this goes on voluntary hospitals which are controlled by a variety of private interests. Within the community health service over 60 per cent of expenditure goes on drugs. It is very clear from the representations made and the reaction to the recent report by Dale Tussing that the medical profession want health care sold as a product. Up to now  they have managed to ensure that was so. The recent report by Dale Tussing has indicated that it is not possible to provide a comprehensive health service free when we continue with the fee per item system, where the doctor is paid for every visit and the chemist is paid for every prescription. We cannot provide an adequate health service in this way.
There are many things that need to be done: the re-allocation of resources from hospitals and drugs to preventive medicine, including community care, and the complete separation of public and private systems. In other words, there would be no private practice in public hospitals and no public subsidy for private hospitals. Voluntary hospitals which get 90 per cent of their funds from the State would be brought under public control. There should be full eligibility for health services for everyone. There should be proper dental service. This is particularly so for pregnant women and nursing mothers.
Under the present Act dealing with family planning health boards have the power to provide family planning services. The Minister indicated that he intends to make amendments to this Act. One health board has blankly refused to exercise its power under this Act. In the past year to 18 months a campaign in the Finglas area has indicated that there is widespread demand for a family planning service to be provided through the Eastern Health Board clinics in the area. Despite the fact that this has been notified to the board they have responded by circulating a copy of a decision made by them three years ago. This is not an adequate response to a demand that has been shown to exist. About 2,000 people in Finglas have signed the petition to the effect that they want this service to be provided through the Eastern Health Board. The Minister should exercise his power over health boards which fail to carry out their responsibility.
A matter which was brought to my notice recently concerned sufferers from muscular dystrophy. No research has been carried out here into this disease. The sufferers from this disease are mostly  young boys. Many of the families concerned find it difficult to get the services which other sufferers from diseases which are incurable or long term are able to avail of.
I had a letter this morning from a person in Cork. He is living alone and some distance from neighbours. He has no outside toilet and is getting no assistance whatever in terms of home help or anything of that nature. While muscular dystrophy is listed as a long term illness it may be that the Department are not aware of the seriousness of the disease in its most severe form. I urge the Minister to look anew at this problem with particular reference to the need for medical cards for these young boys. I understand the disease takes effect when they are about three years old and is terminal in middle to late teens. While they have the books in respect of long-term illness, they do not have the facility of going free of charge to a doctor. This is an area that the Minister should consider seriously with a view to ascertaining what can be done by way of giving assistance to sufferers of this disease.
I should like to refer also to the question of reducing the amount of money returnable in respect of the purchase of drugs. The figure in this regard was increased recently from £16 to £23. This is a facility which is available to non-medical card holders. While the system may work well in some cases there are cases known to me in which families cannot afford to pay out the £23 and then wait for perhaps three months for it to be repaid to them. While it may be possible in some areas for arrangements to be made with certain chemists to simply accept the amount of money due on the prescription, less the £23, not all chemists are prepared to do this.
A further anomaly in this scheme since the increase in the figure is that it may be more costly for the Government to operate the scheme as presently constituted than would be the case if they were to provide medical cards for the people concerned. The present position is that drugs supplied free of charge to medical card holders are charged to the State by the pharmacist at the wholesale price plus a  dispensing fee per item. However, drugs supplied to non-medical card holders are charged for by the pharmacist at the wholesale price plus a mark-up which can be up to 100 per cent plus a prescription charge. A non-medical card holder suffering from a serious illness could have a drugs bill in certain circumstances of up to £180 per month. That could be made up of the wholesale price of the drugs, the pharmacist's profit and the prescription fee. A patient can now claim back from the State through his health board £157 of that; but if that patient were the holder of a medical card the State would be responsible for the full cost of the drugs. However, this would consist only of the wholesale price plus a dispensing fee per item, which in the example I am giving would be likely to be in the region of between £85 and £100. This anomaly results in a situation in which the State can find itself paying between £60 and £70 more than if the person had a medical card. Obviously, then, there is a need for a rethink in this whole area as it applies to non-medical card holders.
In conclusion I urge the Minister to consider the restructuring of the health services and to make a clear and distinct decision whereby those who wish to treat medicine and the health services merely in the sense of a product to be bought or sold on the market will no longer be tolerated. The Minister should treat medicine as a public health issue and develop policies whereby all those who require treatment can avail of it.
Mr. Tunney Mr. Tunney
Mr. Tunney: I appreciate that there is pressure in terms of the time avilable. Guided by the Irish proverb, tíus beagán a chaitheamh in éineacht, I propose in the five to ten minutes available to me to concentrate on one point in the hope that what I have to say will make an impression on the Minister of State and that he will convey to his Minister that, in the words of the proverbial man in the street, it is time something was done about the matter.
I refer to an appalling situation that exists and which has existed under previous Governments in respect of dental treatment. As the House will be aware,  we have a system whereby students are educated at primary and secondary level and then proceed to third level education at which stage they can opt for certain disciplines, dentistry included. In respect of third level education it is no longer a case of art for art's sake or of students pursuing education for the sake of their neighbour. Rather, education is pursued in the interest of requiring a skill for which those qualified can make certain charges to the beneficiary. That would seem to make very little of what is known as third level education, but unfortunately that is the depth to which it has fallen. We know that in the matter of preparing a dental student so that he can emerge qualified after five years, apart from the investment in his education at primary and secondary level, the subsidy at third level is in excess of £2,000 per annum for the five-year period. This means that a sum in excess of £10,000 of taxpayers' money is paid so that a student can emerge with a qualification which entitles him, in the case of dentistry, to look after the teeth of those people who have paid for his education.
Let us consider what happens. The moment they are qualified they export themselves to Britain, America, Australia, or elsewhere, so that we have the extraordinary situation whereby those who have made sacrifices to prepare people to care for the dental needs of the community are left without that attention. As other Deputies have mentioned, we have a situation of housewives who are faced with the choice of looking after either their own teeth or the teeth of their children. If she opts, as most good mothers will, to have her children's teeth cared for, this means that she has not sufficient money to have her own teeth attended to. We talk a lot as a nation about the importance of the family unit. We are forever paying homage to mothers, but if in the process of producing a family a mother's teeth suffer, that is her misfortune so far as the State is concerned, despite the fact that her husband will have been contributing by way of social welfare payments to ensure that there would be available a fund from which dentists would be paid to provide  a service. That is a situation that can be tolerated no longer. It is appalling that the people, who by way of taxation, are paying for a vital service, cannot avail of that service, while the people who should be providing the service have hiked it off to another country.
I said initially that I did not propose dealing in great detail with the points I wished to make. I am hoping that my contribution might be in the nature of shock tactics. I have referred to the housewife and I now want to refer to her offspring. In my constituency and in the constituency of the Minister of State there are countless young boys and girls in need of special orthodontic treatment. The practice has been to segregate the orthodontists from the dentists. I am familiar enough with the situation to know that a dentist can perform very useful and helpful orthodontic work. Apparently, this is not being done. I do not know if this concerns the profession in relation to a demarcation line. Those young boys and girls in need of orthodontic treatment could have prominent teeth set right if the people who are leaving the country remained at home and provided a service. I know they will not remain at home unless they are paid. While I would not allow any profession to hold the country up to ransom, on the economics alone, if we are prepared to pay £10,000 in subsidy so that a person can be qualified, surely we should be prepared to pay a worthwhile sum so that that person makes that service available to the people.
I will, with the Chair's indulgence, again refer to the case of a young girl in the Ceann Comhairle's constituency or my constituency who is now approaching 12, 13 or 14 years of age. When that girl was young she sucked her thumb or did something else to cause her teeth to be imperfectly shaped although they are good otherwise. This young girl becomes very conscious of this. She has been attending the local health centre with her mother for four or five years. I am saying this to set the Minister of State's mind at ease that I am not blaming his Government  for this. I am blaming all Governments. This girl's mother is told that orthodontic service cannot be provided until her daughter is 12, 13 or 14 years old. When she reaches that age she is told that there are no orthodontists available. The present Minister for Health has told the House what the previous Minister for Health and every Minister for Health since I came here has said. It is time they said they are not prepared to provide the service and to tell the people they have let them down and they are not doing this or else tell the people they must charge more for it. It is time we started looking for a dividend on the investment we have made in producing people whose qualification is to look after those orthodontic needs. If we have not got the money to pay them we should give them a subsidy and make it encumbent on them, as part of their training, that after they have qualified they will give one or two years' service to the people who made the qualification possible for them.
I hope the Minister will be able to tell me that it is the Government's intention to appoint those people. I have received the same reply in answer to Parliamentary Questions about this matter for the last three or four years. Will it be the same reply for the next three years? I am glad the Minister of State is nodding his head. If, during his term of office, he does no more than see to it that the housewife, her sons and daughters will be able to receive the service they are entitled to and which they have paid for dearly, I will be the first to say: “Well done, Minister for Health, and well done, Minister of State.”
Mrs. Geoghegan-Quinn Mrs. Geoghegan-Quinn
Mrs. Geoghegan-Quinn: I am glad of the opportunity to speak on what I consider to be one of the most important Estimates to come before the House during the course of any year in any Government's lifetime. Before I confine my remarks to four particular areas I am concerned with I would like to correct something Deputy Gay Mitchell said this morning — I am sure it was inadvertently — when he made a comparison regarding medical cards between Donegal and Dublin on the basis that the percentage  of people who held medical cards in Dublin was around 20 to 23 per cent and the percentage of those who hold medical cards in County Donegal would be far greater than that. He seemed to feel that people in Dublin were being treated more unfairly than people outside Dublin. It is important for the record to show that the guidlines which operate for medical cards are common to every health board area. If Deputy Gay Mitchell was referring to any unfair treatment it must be an indictment of the community welfare officers in his constituency. I presume it was his constituency he was speaking about this morning.
I am very concerned, particularly in the Western Health Board area, which deals with three very large rural counties, Mayo, Roscommon and Galway, with the whole orthopaedic situation as it has operated for quite a number of years. The average time spent by a patient in that health board area waiting for a hip replacement operation is 1.9 years. I have asked numerous Parliamentary Questions about this particular area. Tenders were received in the Department of Health for the provision of a new orthopaedic suite at Merlin Park Hospital some considerable time ago. I keep getting the same reply, as Deputy Tunney stated he got in relation to orthodontic treatment, over a period of years that the Minister is not in a position to say at the moment when the project can go ahead.
The Minister for Health recently informed me that he was reviewing the capital allocation of his Department with a view to looking at the contractual commitments which had been entered into, the level of resources available to him and the priorities of the various health agencies. There is only one main orthopaedic theatre available for the whole of the Western Health Board area in Merlin Park Hospital in Galway at the moment as well as the use of a converted classroom used as a temporary theatre. The Department of Health officials have agreed that at least three theatres are necessary to meet the workload of the orthopaedic surgeons in that area. The tenders from a recommended contractor were submitted to the Department of  Health in August 1981. The updated cost, according to the figures in the Department of Health and the health board on 1 January last, was £1,250,000.
There is a three-year waiting list for hip replacement operations. I am sure everybody in the House, as well as outside, would agree that for very many people this operation is a lifeline. We have seen those people all around the country coming into a hospital to have a hip replacement operation barely able to walk, maybe in a wheelchair or walking with the aid of crutches or walking sticks, and they leave after this operation has been performed on one or both hips like new people. In the Western Health Board area there are 2,900 people on the orthopaedic out-patients waiting list. The long waiting list is basically caused by the inadequate theatre facilities and because of this, great hardship, which I consider is totally unnecessary, is caused to all the people who are waiting for this operation.
There is another problem in the orthopaedic situation in the Western Health Board area. The facilities in one of the theatres cannot be used safely during the summer months. The Department is aware of the reason for that. It is because it is very difficult to maintain a proper degree of sterility. The result is that acute patients are being referred to Dublin hospitals where there are already long waiting lists. This situation has continued for quite a number of years. The solution to the problem lies in providing the orthopaedic surgeons in the area with proper facilities so that they can get on with the workload.
Like Deputy Tunney I, too, am concerned about dental services and in particular the orthodontic service. I was somewhat consoled to hear the Minister say this morning that arrangements are being made to appoint a number of orthodontists to the health boards. However, the statement rings a little hollow in the light of my own experience. I have been told on a number of occasions that it is expected the post of orthodontist will be advertised shortly and then one discovers that the period of waiting for treatment is no less than three-and-a-half years. In  complicated cases requiring fixed appliances the waiting period can be as long as five-and-a-half years. There is no use in telling parents of children who need treatment that applications will be invited soon because “soon” can mean three years' time or even ten years' time. The post of orthodontist was approved by the Western Health Board on 3 July 1981. Since then successive Ministers have stated the post is about to be filled or will be filled soon. In my opinion, as Deputy Tunney said, “soon” should be next week.
The Department have been pressurised by members of the board acting collectively to clear the vacancy. In the meantime the board have tried to provide a limited service with the help of a private orthodontist in the area. It is of the utmost importance — I cannot emphasise this enough — that this post should be advertised immediately. Here I am talking about next week, not next month, or in three years' time, so that we can clear the existing huge waiting list.
I have had personal experience of the maternity unit of the Regional Hospital in Galway. An extension of that unit is vitally necessary. As a result of my experience I am aware of the serious overcrowding that exists there. It should not be tolerated. Progress has been made, and I am delighted to say it was under a Fianna Fáil Government, in that we got the go-ahead for the extension. The bed occupancy is over 120 per cent and the average stay for the year ending 31 December last was 4.6 days. Most women who have occasion to use this unit can feel very low emotionally. Doctors and nursing personnel are under tremendous pressures. Patients quite rightly object to the lack of proper accommodation. There is no privacy. It is very difficult for the patients and it must be even more difficult for the nursing personnel and medical staff to operate under such circumstances.
In July 1982 application was made to the Department for extra funding to provide staff and equipment. That application has not yet been approved. Unless the staff and equipment are provided it  will not be possible to open the new extension and the serious overcrowding will continue. I asked a Parliamentary Question recently about this and the reply I got was that the new extension will not be ready for use until early November 1983. The question of funds therefore will not arise until that stage. Will it arise on the day the contractor hands over the new facilities and does that mean the matter will be put on the long finger once again and we shall have to await a further deterioration in the services? Is it not in the best interests of everybody that a commitment to funding should be given now so that the hospital authorities and the health board will know when the facilities will be available to come on stream immediately?
I was interested in what the Minister had to say about the drug problem. We hear a great deal about the problem in Dublin but we should not lose sight of the fact that there are other urban areas which have a drug problem, not as great perhaps as the problem in Dublin but certainly a growing problem. I would hope the special committee would not just review the problem in Dublin. I would hope they would look at the whole country. As public representatives we should encourage a much greater degree of co-operation between the medical services and the Garda authorities in relation to the problem. Glue sniffing seems to be a problem of the teenage group. Sadly it is now becoming a major problem. Very young children are falling into the trap. They think they will not be one of the gang if they do not sniff glue. We probably could do a great deal through health education in the schools, and that health education programme should start in the primary schools.
As I said, the problem is not confined to Dublin and so we should have regional centres to deal with the rehabilitation of drug addicts. I am glad the Minister recognises alcohol as a major problem. It is one that causes great distress and not just to the individual involved but also to the individual's family. It is one of the causes of marital breakdown. I am glad the Minister intends to give support to the specialised treatment programmes in  operation. Huge costs are involved in some of these. It sometimes calls for a major effort and involves a great deal of sacrifice on the part of a family to bring an alcoholic to a treatment centre.
One area about which we have heard a lot of talk, which has been given a lot of lip service over the years, and which needs to be tackled urgently is that of alcohol advertising. It is something that must be looked at very seriously by all of us and I would encourage the Minister and his Minister of State to do so as quickly as possible. All of us would agree that the advertisements we see, in particular on television — because what we see tends to have a greater influence on us than what we read — put drink across as glamorous, it is always associated with glamorous people, places and so on. This tends to encourage young people to take to alcohol earlier. There must be some curbing or control of this kind of advertising.
On the nursing situation there is just one comment I should like to make, that is, I should like to know if the Department could ensure that a certain percentage of the student nursing intake in each of the health board areas could be allocated to Irish-speaking students. It is very necessary in health board areas with large Gaeltacht areas within their jurisdiction.
I am somewhat confused about this £5 casualty fee we have heard so much about, both during Fianna Fáil's term in Government and indeed since the present Government came to power. I understand that it is operational in three health board areas only, the Western, the North Western and the Midland Health Board areas. That creates a sort of ill-feeling amongst people that, once again, people in different health board areas are being treated differently, or that they are different in some way from other areas. Either we should have it in every health board area or we should not have it at all. I know the Minister of State probably will say that in each of these cases it was a decision of the health board themselves. I am aware of that but the Department, as the overall controlling body, must decide once and for all that either we are  going to have a £5 casualty fee in every health board area or else we are not going to have it at all. For instance, excluded in my health board area are cases of persons referred to the casualty department by a registered medical practitioner and accident and emergency cases. Recently there was a case in which a little boy fell, a constituent of mine. His father was away; his mother rushed him to the casualty department of the local hospital where he had to get three or four stitches in his chin. His mother was presented with a bill a week later for £5. If we are talking about accidents I would have considered that to be an accident case and the quickest way of dealing with the situation was to take the child to the casualty department of the local hospital which was closer to the patient. The mother probably would have lost a lot of time trying to locate her general medical practitioner or, if he were not on duty, somebody else. Therefore, we need to clear up the question of whether we are going to charge the fee in every health board area or specifically in the three, as at present. We must also confine ourselves to what is meant by an accident case.
One area about which I am very concerned — and this will be my last point — is that of children in hospital. As a parent myself, and perhaps more so as a mother, I am very concerned about the whole attitude taken to children in hospital in this country today. It is perhaps one of the most traumatic experiences for any family to have a small child hospitalised, even overnight. In particular, it is a traumatic experience for the child itself, to be left alone in a large, impersonal building with so many strange people all around. Certain attitudes are adopted in hospitals — particularly after a child has an operation — that they cannot have visitors for perhaps 12 or 24 hours afterwards. We should have — and I think in my health board area we do — an open all-hours policy for parents of children in hospital. The quicker the Department of Health, as the controlling body, realise this has to be done in every health board area, in every hospital throughout the country, the better. Nobody can aid a  child sick in hospital and get them better quicker than one or other of the parents. It is very important that we provide facilities for parents to stay overnight even if, in certain cases, it means they have to sit beside the bed or perhaps sleep in another room. It may not always be possible — and I do not think anybody would expect that it would always be possible — to have 50 or 60 parents in the same ward as 50 or 60 sick children, but we can compromise; we can be helpful and the open, all-hours' policy is essential and something which the Department of Health should push with all hospitals.
Basically that is all I wanted to say. The Estimate on the Department of Health is one on which all of us could talk for a very long period of time but it is easier to pick out the areas of concern to ourselves immediately. I would ask the Minister, in particular, in relation to the orthopaedic services in the Western Health Board, the extension to the maternity department — and I would like to join with Deputy Tunney in his remarks on the whole situation regarding dental health and, in particular, the appointment of a consultant orthodontist — that he look at those as a matter of urgency. I think the Minister of State probably will have many cases in his constituency, in all of those areas, requiring immediate attention. I would ask him to have those points I have made taken into account.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: Before Deputy McCarthy commences, I would remind him that the debate must conclude at 5 o'clock and that the Minister has to conclude.
Dr. McCarthy Dr. McCarthy
Dr. McCarthy: I welcome this opportunity of making a few broad points in relation to the Health Estimate before us.
One of the most important aspects of our health services is the primary health care of our population. Very much to the forefront in this primary health care is preventive medicine and in this connection, there should be an expansion of the scope of the Health Education Bureau.  They have done quite a good job, I know they are continuing to do so, but I believe their scope should be broadened.
I was pleased to hear Deputy Geoghegan-Quinn mention the problem of alcoholism, that its dangers should be emphasised more to the population at large and particularly to young people. Just as there is now written on the labels of packets of cigarettes that cigarette-smoking may harm one's health, it might be no harm to have similar warnings on labels on bottles or cans of beer, Guinness, bottles of whiskey, spirits or whatever. At least that would be a warning to young people that they are consuming a substance which may be dangerous to their health, if abused. I believe also that the Health Education Bureau should continue to advertise the continuing dangers of tobacco smoking. The campaign they launched made a considerable impact on young people and many young people nowadays do not smoke. Indeed young people were fortunate to have been issued such warning because heretofore, certainly in my time, the only reason advanced for not smoking was that one was too young. At least young people nowadays have a very positive reason for not smoking, knowing that it may damage their health if they do. I believe that campaign should be continued and, if possible, intensified.
In the area of very serious of fatal accidents very often it is young people who are involved. There should be increased advertising of the dangers of fast driving. There should be the warning issued that, when one drives a motorcar, one is in charge of a lethal weapon, just as lethal as a gun or a bomb, that one is in charge of a vehicle which can kill others, just as oneself. There should be more advertising of the dangers of accidents, particularly through driving at night, especially when alcohol has been consumed by the driver.
I should like to see an expansion of services in the area of community care. If we could prevent people from getting certain illnesses we would not have the very high costs involved in our public expenditure. There should be more community care nurses and community care  teams should visit each central area on a more frequent basis. Mention has been made of vaccinations in general and specifically in relation to whooping cough vaccination. Unfortunately there was much adverse publicity about the possibility of brain damage as a result of that vaccination. This publicity was not confined only to this country. As a result there were considerable fears created in the minds of mothers. They considered it more dangerous for their children to get the vaccination. It also gave rise to considerable fears among many doctors. There was confusion about whether to give vaccination to children.
As a result of this scaremongering, whooping cough vaccination of children is as low as 30 per cent in many areas. When vaccination in one area is restricted it often extends to other areas. Parents get careless and do not bother having their children vaccinated. Polio vaccination has become less popular: in many areas only 50 per cent of the children are vaccinated against that disease, even though it does not involve the administration of an injection as it can be given orally. We must realise the dangers of whooping cough and poliomyelitis. There have been epidemics of whooping cough recently. It must be realised that it can and does cause fatalities. It is essential that the unnecessary fears that have arisen be allayed.
The Department of Health report that during the period 1975 to 1982 a total of 402 doses of whooping cough vaccine were administered with no reaction. Similar studies in other countries have produced similar results. In Czechoslovakia 11 million injections produced no reactions; in north London 80,000 injections produced no reaction and in Glasgow 180,000 injections produced no reaction. A recent national survey in the United Kingdom has shown there is no significant difference between the incidence of neurological symptoms in those who have been vaccinated against whooping cough and those who have not been vaccinated. I wish to emphasise to the Minister, as I did some weeks ago at Question Time, that his Department should continue to publicise that the whooping cough vaccination  is essential in most cases as a form of preventive medicine.
The GMS forms a vital and important part of the health services. The out-of-hospital care of patients is a vital service. Under our GMS we have developed a system of treating people by family doctors which is equal to any medical service elsewhere for out-of-hospital care of patients. It is an excellent service and is a far cry from the days of the old poor law dispensary type service which dealt with medical card holders. Less than 15 years ago holders of medical cards had to attend a dispensary doctor. People in an area were allocated to one doctor, who, more often that not, treated them in miserable hovels. Patients had to attend one doctor, whether he was any good at his job. In the GMS patients have a free choice of doctor and in most areas there are good doctors from whom they can make their choice. Medical card holders are very satisfied with the service they get.
A certain disease seems to have become quite prevalent recently. For a while we had a lot of politician-bashing and now the disease seems to have spread to doctor-bashing. There have been illinformed comments about doctors, that they are ripping off the health service, that they are over-visiting patients and that they are building large incomes for themselves. These comments are totally unfounded. Most doctors look after their patients in a very responsible way. They see them when it is necessary and no more than that.
Earlier today someone commented that the visiting rate of doctors under the GMS was higher than in the UK. That is so, but in the UK family doctors look after the entire population. Under our GMS family doctors look after approximately 40 per cent of the population. Among that group are the people most prone to illness: they are the old, those in the lower income group with very large families and people who live in poor housing conditions. These people are most susceptible to illness and naturally when they form almost the entire group of medical card holders the visiting rate  will be higher than if one compared it with looking after the entire population in the country. Some people have medical cards for the specific reason that they have severe chronic illnesses and need constant care and attention. To compare the visiting rate here with that of the UK is not comparing like with like and is distorting the facts.
I was appalled this morning to hear Deputy G. Mitchell mention a specific doctor in the medical services whom he said earned twice as much as the President of the country. I think we know the doctor concerned. Perhaps the Deputy has forgotten that he is working in a very difficult countryside, that he has to travel to islands and that he has to climb mountains which many of us would be afraid to climb. His gross income may be high but he has three assistants. When one considers what he gets out of the gross income one will realise that he is not ripping off the system and is not a millionaire.
These irresponsible statements are illinformed. They do not do the image of the doctor in the community any good. I am not setting myself up here as a protector of the rights of doctors. They have two organisations — the Medical Union and the Irish Medical Association — that exist specifically to deal with the protection of the rights of doctors. On the other hand, I should not like to see doctors vilified. Of course there is the occasional member of the medical profession, as one would have in any profession, who cheats the system. There are rogues in every profession. However, they are few and far between in the medical profession and those who have are dealt with and fined. They can be suspended if necessary from participation in the service.
Our doctors under the GMS provide a 24-hour seven-day-week service. If you were to pay them on a capitation rate how could you devise a system whereby people are paid for certain hours and what do you do for the overtime situation? You would find it impossible and you would end up paying much more than is paid at the moment. The average payments to GPs under the British  national health system were IR£42,000 as against the average gross payment of GPs under the Irish GMS of IR£15,000. If one were to extend this and Irish doctors were to look after 100 per cent of the population you would find that they would be earning IR£25,000 on average as against the IR£42,000 of their British colleagues. To suggest or imply that they are ripping off the system is unfair and should be refuted by anyone who is responsible, and I know that we have a responsible Minister here.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: Deputy, your colleague, Deputy O'Keeffe, wishes to come in for a couple of minutes.
Dr. McCarthy Dr. McCarthy
Dr. McCarthy: Again I ask the Minister in his process of hospital development to look at the real problems which we have in the orthopaedic services all over the country. I heard some of our other colleagues adverting to them. The Minister knows the terrible problem we have in south Tipperary where we have no orthopaedic surgeon. It is the only county in the South Eastern Health Board area which has no orthopaedic surgeon of its own and we have to share one with County Waterford. As a result of this it takes one-and-a-half years to see the orthopaedic surgeon in south Tipperary and after seeing him it takes another year-and-a-half before you have your hip joint or whatever else you want operated on. I ask the Minister to ensure that in the expansion of the health services he will provide an orthopaedic surgeon for the people in south Tipperary.
I would like to see our services and general hospitals more streamlined whereby we can ensure that people are not admitted to hospital unnecessarily and that conditions that can be treated as out-patient should be so treated; that people are not admitted to hospital before weekends and left lying around with no investigations done until after the weekend. I would like to see all the services more streamlined, and this would ensure a considerable saving in cost. We all think of £1,000 million spent per annum on the health services as an enormous sum, but the care of our community  surely demands that the services be properly supplied to the people. In fact, our cost per capita for health care is less than that in any other European country.
I will defer to my colleague, Deputy O'Keeffe.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: The Deputy has six minutes.
Mr. E. O'Keeffe Mr. E. O'Keeffe
Mr. E. O'Keeffe: I am grateful for the opportunity of making a short contribution. First, I would like to refer to the problem of the homeless and the failure of our system to care for them. The House is aware that a minority of our people who live rough are entitled to the same facilities as other citizens. I appeal to the Minister to do something about this. An investigation or survey should be carried out in order to identify who is responsible for the housing of the homeless, and funds should be made available to either the health boards or the local authorities to help to house those people. In my experience there is continuous buck-passing from the health boards to the local authorities and only after considerable time arguing with the various officials are those people housed or provided with facilities. I hope that the Minister will take some action here and that he will have some authority identified as the responsible organisation.
The health boards have failed as a body. We must move away from the bureaucracy of this type of system and put the responsibility once more into the hands of the county councils, who previously administered all health services through their various sub-committees. Authority must rest once more with local representatives who are fully aware of the problems. We must admit that the health board system as constituted has not worked for the betterment of the system. It is cumbersome, it is expensive and it breaks down through lack of cummunication.
I would like to refer to that in greater depth but I wish to cover some other points. The medical card system has come under severe pressure from the present administration. Many of our old  people were holders of medical cards for short periods due to a concession by Deputy Woods when he was Minister for Health. The medical card has now been taken from those people, many of whom are old age pensioners, after all their years of work in helping to develop our State. I hope that the Minister will have a look at this and waive the means test in the interest of our old age community.
The building of hospitals, particularly in the southern region, needs to be looked at. At this stage surely we have enough accommodation for our patients, because with modern medicine people have not been staying in hospitals for periods as long as heretofore. Equipment and the general technology of medicine have improved. We should examine the question of investment in buildings and modern sophisticated equipment which would be the way forward for many of our hospitals.
I would like to commend the voluntary groups who have been working in my area in the Southern Health Board region, particularly in the Mallow area, where they have collected considerable amounts of money for the assistance and further development of the hospital services in those areas. When we look at the spending of £500 million in the hospital service we may ask questions when that fund cannot provide the service and equipment that are so vital. An anomaly here is that after many of those voluntary groups had worked vigorously collecting this money and the equipment was purchased, very high rates of VAT had to be paid. This should be thoroughly examined. The Minister should use his influence with the Government in having this equipment excluded from a VAT charge, thereby making further moneys available to buy supporting equipment for some of the essential items purchased. I appeal to the Minister that this would be a very generous gesture on his part.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: Deputy, you have one minute.
Mr. E. O'Keeffe Mr. E. O'Keeffe
Mr. E. O'Keeffe: What can I do with it? I would have to elaborate for too long. I would not be able to make my point in  a minute. It would take about four minutes.
Minister for Health (Mr. B. Desmond) Barry Desmond
Minister for Health (Mr. B. Desmond): I thank my colleagues on the Opposition side and the Government side for their helpful and constructive contributions. Regarding the priority development areas, I am totally committed, as I indicated in my contribution, to changing the focus in relation to development of our health services. There must now be much greater emphasis on health education and prevention in developing community services. We will have to improve dramatically the quality of our psychiatric services. We will have to make them particularly community oriented, and in that regard I am very deeply impressed, as I am sure were other Members of the House, by the extremely thoughtful and sensitive contribution by Deputy Faulkner. This Deputy has obviously great experience in connection with the services for the mentally handicapped. I share with him the view that absolute priority rating should be given to these people. In particular, we must concentrate on services for the adult mentally handicapped, despite whatever shortage of funds there is. We must phase in new units of accommodation which must be given absolute priority from the scarce resources available. That is not going to be at all easy. Every Deputy and every Senator wants to have the best possible local hospital facilities available in his or her own area and the cost involved is enormous. I assure the Deputies, in relation to contentious matters such as casualty fees, that a number of health boards apply fees at present but I understand only in the case of persons without medical cards who should be going to a GP rather than an outpatients' department. I am subject to correction, but think that there are about three health boards which have at present the system of fee payment. It would be interesting to review exactly what is happening in those health board areas.
Deputy O'Hanlon raised the question of Tallaght hospital. I will be concentrating on giving that hospital priority and  also the other hospitals, the day hospital structures and outpatients' department — for example in the Dublin Children's hospital in Temple Street and in Crumlin. We are going ahead with setting up consultant outpatient facilities in Tallaght. I assure the Deputy that I will not be reluctant to deal with that matter.
Deputy O'Hanlon also raised the question of Cavan Hospital. The health board are in the process of inviting orders from selected firms, but again that involves the choice — for example, Monaghan or Clones — as to where they would operate. We are concerned with a choice on the closure of existing hospitals and the development of better hospitals in selected areas. These are difficult choices which we must face. The Deputy also mentioned the obstetric situation in Dundalk and Bantry. I assure him that both services are under review and I emphasise that our concern must be for the safety of the children and the mothers. We cannot put them at risk because of lack of comprehensive back-up of specialist facilities in all the hospitals. I appreciate that Dundalk and Bantry are somewhat unique at this stage and are currently under review. I am insistent, whether it be Carlow or elsewhere, that full consultant facilities be available because the mortality rate must be kept down. We cannot face accusations of not having total cover.
The Deputy also raised the matter of medicines on the general medical services list. The main point I would make is that a cough bottle is hardly a medicine as such, with great respect to all of us. Also, some of what one would call in laymen terms stomach powders are hardly medicines and do not require immediate and urgent supply as has been implied by some Deputies. For some of these the cost is not great. From October 1982 to March 1983, 854 items — an extraordinary amount — were removed from this list. The Minister then restored 12 items from 1 November. Again from 1 May 1983, 140 items were restored. These items included iron tablets, analgesics, eye applications, ointments for certain skin conditions. These were all put back on the list but again they were limited.  The cost is still very high. Just to put those items back cost £1,500,000 this year. A further 115 were excluded when we revised the list, mainly on the grounds that products similar to them had already been taken off the prescribable list and a number were removed because they were for hospital use only, and not under the general medical services.
Deputy Gay Mitchell made a number of points. I was astounded to hear him say that Crumlin Children's Hospital regarded themselves as not being treated fairly in terms of financing. That is not my impression. The hospital received £800,000 for equipment last year. On the revenue side, Crumlin got the same treatment as other children's hospitals. If they have a grievance I shall be glad to discuss it with them, but I understand that they have no grievance. This hospital is an outstanding one which is not short of funds generally or of equipment.
I fully support the statement by Deputy McCarthy in relation to the vaccine situation. I am surprised that Deputy Mitchell used the term “cover up” and said that we should come clean in the Department in relation to the vaccine damage. There is no cover up and there is nothing about which to come clean. The situation is absolutely above board and there is no way in which our Department can be held responsible in any respect arising out of that situation. I thoroughly share the views of Deputy McCarthy that mothers and fathers should ensure that their children are fully vaccinated by availing of the services. It would be regrettable if they were not to avail of these facilities and I hope that they will continue to avail of them.
These are my observations on this Estimate. I thank the Deputies and the Whips for arranging that we could complete this Estimate in one day and enable the Deputies concerned to contribute towards the work of the House and the adoption of the Estimate for 1983 much earlier than is usual. It gave the House an opportunity of dealing with it on a current basis.
Vote put and agreed to.
Dáil Éireann 343 Estimates, 1983. Vote 48: Health (Resumed).