I thank the Ceann Comhairle's office for selecting this item out of a large range of issues which were raised for the Adjournment today. The issue is of importance. I am raising it on the Adjournment because of the unsatisfactory replies I received at Question Time on 15 March when I raised the matter with the Minister for Health. I want to make it clear what the issue is.
Psychiatric out-patients who previously received free of charge the drugs and medicines they required to live in their communities are now being charged for these medicines. The health board officials involved state categorically and repeatedly that this is a direct result of the cutbacks in the moneys provided by the Government for the service.
Treatment for psychiatric patients has always been free of charge, both for inpatients and out-patients. Indeed, it could be said that the charges to which I am now referring are a first for the present Minister amongst all previous Ministers. The basis for providing such service for psychiatric patients is contained in the General Health Acts, in the 1945 and subsequent Mental Health Acts and specifically for out-patients in section 56 (1) (a) of the Health Act, 1970, which states:
For the purposes of this section "outpatient services" means institutional services other than in-patient services provided at, or by persons attached to, a hospital or home and institutional services provided at a laboratory, clinic, health centre or similar premises, but does not include—
(a) the giving of any drug, medicine or other preparation, except where it is administered to the patient direct by a person providing the service or is for psychiatric treatment,....
Thereby, it is established that psychiatric patients are recognised as the weakest in our community and are, therefore, afforded special legal protection and free medical care. Despite this recognition psychiatry has always been the Cinderella of the medical specialities. The vast majority of people suffering from psychiatric illnesses are from poor backgrounds.To establish this point the Psychiatric Services, Planning for the Future Report 1984, demonstrates that out of the three higher grades of income groups per 100,000 persons there are 1,717 psychiatric patients and in the three lower groups there are 8,491 psychiatric patients per 100,000; that demonstrates one of the major problems attached to psychiatry and the way it has been treated. The vast majority of people suffering from such maladies are from poor backgrounds. As a result there is no money in psychiatry. It is not fashionable or profitable.
I want especially to congratulate tonight the medical staff, the nursing staff, the administrative staff and the health boards who carry out the services for psychiatric patients without it being fashionable or profitable. I am very mindful of the fact that their conditions of work are equally as bad as the living conditions for the patients. Traditionally we have dealt with psychiatric out-patients by simply locking them away behind high walls where they were forgotten, unseen and unloved by their own, and were not even visited.
My experience as a health board member demonstrated very clearly the Dickensian type conditions in which we keep our psychiatric patients. These institutions were neglected, under-funded, under-staffed and over-crowded. Buildings were literally falling asunder and there was the occasional outcry, for example, when the ceiling fell down on patients in St. Brendan's Hospital. The worst example I have seen in my time was in St. Ita's, Portrane. I remember there was a large barn which served as a kitchen and lorries could drive in as there was no door. As a result birds flew into that kitchen and as there was no ceiling they perched on the rafters and their droppings fell on the plates of food being prepared for patients. The conditions in the wards of that hospital could be described as barbaric.
After one visiting committee meeting which I attended as a member of the health board I remember writing to the Minister's predecessor, the Taoiseach — because I would not be back there again for 12 months and would have no real opportunity of raising the matter — notifying him of the conditions I found there. I must give him credit because I understand he arrived at that hospital and examined the matter for himself and there has been a vast improvement since. I will give him credit for initiating that procedure. About the same time it was regarded — and I would put a question mark after it — as great progress that the high walls were knocked down, padded cells were by and large dispensed with and straitjackets were no longer used. Because of the understaffing and the overcrowding this led to a régime, which I witnessed, of high doses of behaviour controlling and shaping drugs.
I do not believe these drugs had any medicinal purpose but they did have the effect of transforming the patients into literally walking zombies. They did not know whether it was day or night, whether they were coming or going, where they were, who they were or in whose company they were. They became institutionalised arising from that and from previous treatments to such a degree that they had no knowledge of ordinary things. The knew nothing about money, shops, purchases or the preparation of food.
At that time I also witnessed an experiment in St. Brendan's, Grangegorman. This was an EC funded pilot scheme where selected patients had their intake of drugs reduced on a progressive basis in a different type of environment in the grounds of St. Brendan's. The results of that experiment were near miraculous. People were transformed — and we should never forget that they are human beings — from a drug-induced constant stupor to knowing human beings who simply needed care. There is a very large question mark over the use of such behaviour-shaping drugs. There is a question as to whether they are simply therapeutic or whether they are used for managerial or custodial purposes. In the present circumstances of under staffing and over crowding such drugs are being used for managerial purposes rather than for the treatment of patients.
However, an extension of that experiment led to a new enlightened era in the treatment of psychiatric patients, which came to be known as the community based service. Highlighted in the Planning for the Future Psychiatric Services Report, 1984 to which I referred earlier was the proposition that patients were to be treated in their own homes and in sheltered housing outside of the institutions and that half-way houses between the institutions and the community were to be provided, with house fathers.
In my constituency I have seen the success of that programme but an essential part of it was that drugs were to be provided as required to enable the patients to live in the communities. They were to be provided without charge. That programme has led to quite a large increase in the number of outpatients. Section 56 (1) (a) of the 1970 Health Act gives legal protection and a right to such drugs to patients, but now we discover that there is a discrimination between one area and another in the treatment of patients. South Kildare is covered by another health board, despite the fact that we are in the Eastern Health Board and our patients are attended to by St. Dympna's in Carlow. Outpatients there have to pay for their drugs. Those in north Kildare are dealt with in the Eastern Health Board area and outpatients do not have to pay for their drugs. Why do one set of patients, because of geographical location not have to pay for their drugs and others because of the whim of the health board's CEO or because he has not sufficient money to provide the service, have to pay? That is not a fair distinction.
On 15 March 1989 in reply to my question the Minister said in the House that the question as to whether drugs are provided free of charge was a matter of clinical judgment. I do not understand what the Minister, who is a doctor, meant by that. Surely it is not good therapy, or any therapy, to insist that a patient pays for treatment. The treatment, whether with drugs, medicines or other therapy is a matter of clinical judgment but whether a patient pays for the drugs is a budgetary matter, a matter of administration. It now seems to be an entirely arbitrary budgetary matter in local areas. The Minister is disregarding the rights of patients under legislation. By what legal authority has the right of the patient under the legislation been withdrawn in certain areas? I submit that there is no legal authority for withdrawing those rights. This has occurred, although there is not a very large number of patients involved. This was a heartless and needless action which will undermine the whole basis of the community care services for psychiatric patients. A highly desirable development in psychiatric care is being undermined. Patients will be forced back into the institutions. The costs for the State in financial terms will be high but the cost for the patient will be very high indeed in terms of his quality of life. This decision will create real dangers for the health of patients who drop out from treatment and that is a likely consequence of putting a charge on the treatment. It will certainly reduce the acceptability of the programme of rehabilitation to the general community.
The Minister told us on 15 March 1989 that he is having talks with the chief executive officers of the health boards to try to get equalisation of treatment throughout the country. Have the talks concluded? If they have not the Minister should bring them to a speedy conclusion and should start giving directions to the CEOs. If the Minister provides the resources the service will be resumed. Having listened to the Minister for the Environment saying how well the economy is doing, surely the weakest sections who are unorganised and who have no voice in the community, can be cared for at least at the previous level that was available.
The health boards are acting illegally and without authority in withdrawing the service from the community. Outpatients who previously received free of charge drugs and medicines they required, in order to live in their communities, are now being charged. I would ask the Minister to take whatever action is required to ensure that that practice is ended.
