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Dáil Éireann debate -
Thursday, 11 Apr 1946

Vol. 100 No. 14

Public Health Bill, 1945—Committee Stage (Resumed).

Debate resumed on the following amendment:—
78. To delete sub-section (2).— (General Mulcahy).

When the debate was adjourned last night, I was expressing regret that, in sub-section (2) of this section, the Parliamentary Secretary was continuing his policy of directing rather than requesting or advising local authorities. I regret it particularly in relation to this section because it is the section which appeals most to me. I think we are likely to get far better results from a well-directed, intelligent educational campaign than we are from any of the drastic sections contained in the Bill, and it appeals to me particularly because it is more directed to the prevention of disease than many of the other sections we have discussed.

I was saying last night that I should like to see a very intensive educational campaign initiated in the schools, and particularly in the girls' schools. I believe that if short lectures were given in the schools and if we had a well-directed newspaper campaign, prepared under the guidance of experts in advertising and publicity, not merely for a week or two or for a month or two but continuously, if we had, as we might have, short films demonstrating the necessity of taking ordinary precautions and if children and adults were urged to call in the doctor earlier than is usually the case, we would be going much further to meet this problem than we are by most of the steps we are taking already.

The school medical inspection scheme, so far as it goes and so far as I know, is an excellent scheme and has certainly good results. My only objection to it is that it does not meet the situation. The scheme deals merely with physical defects which are found already existing, and, so far as I know, it is no part of the scheme and no part of the duty of any of the officials operating it to give instruction or lectures to the children on how best to safeguard and preserve their health. It is in the schools that this public health campaign should start, and, unless it starts in the schools and unless the children are taught at an early age how essential it is to take precautions regarding their health from every point of view, and particularly from the point of view of personal cleanliness, hygiene, sanitation and so on, I do not think that any number of Bills of the type of that now before us will solve the problem. Further, working along these lines, we are likely, and, I think, almost certain, to get more full and more close co-operation from all the people than we are likely to get by dragooning them.

I urge the Minister to consider favourably acceptance of this amendment. As I said last night, from my knowledge and personal experience as a member of the local authority, any such campaign as I suggest, and as apparently the Parliamentary Secretary has in mind under sub-section (1), would get the fullest and closest co-operation from every local authority. No local authority would jib at any expenditure considered necessary for a well-directed publicity campaign. I know that one of the difficulties in connection with the schools is that there is already what has been described as an over-loaded programme, but may I suggest that there are very few, if any, items in the school programme at the moment which are as important as the health of the children and of the nation, and I suggest it ought to be made part of the school programme that a teacher or somebody else would give lessons or lectures to the children on matters of public health and so on. So far as I know—I speak subject to correction in this matter—nothing of that sort is now being done, or has been done up to this. Again, I want to make myself perfectly clear.

So far as I know its operations, I have nothing but praise for the present school medical inspection scheme. I know that many children have had physical defects attended to and dealt with as a result of that scheme, which otherwise would perhaps never have come under a doctor's care and which might have been allowed to develop to such a point that it might not have been so easy, if it would not have been impossible, to cure them. What the Parliamentary Secretary wants to make this scheme of his fully effective is the fullest and freest co-operation of the local authorities, and he is more likely to get that if they are allowed to give it voluntarily rather than by direction. I suggest the Parliamentary Secretary will not only get the same results but better results if that co-operation is given by the local authorities at the request or on the advice of the Parliamentary Secretary.

We appear to be in general agreement that it is desirable to provide for an educational campaign in relation to matters of health and to incorporate in our legislation the necessary statutory powers. The only difference of opinion between us in the matter is as to how these powers ought to be operated. Deputy Mulcahy complains that the local authority is not allowed to carry out its functions under the section. I do not think that is an altogether accurate interpretation of the section. Under sub-section (1), a health authority may disseminate information and advice on matters relating to health by advertisements, notices, pamphlets, lectures, radio, cinema exhibitions or any other means. Now, that is pretty wide. Sub-section (2) empowers the Minister to direct the health authority as to the manner and extent to which these powers should be exercised. I submit to the House that, in this matter, direction and guidance is not only useful but is very often necessary. Deputy Morrissey suggests that we should confine it to advising and, presumably, if our advice is not acted upon, we are to let the matter rest at that. In general, that may work out all right; the vast majority of our local authorities will act on advice, but there are some who will not and who require a little bit of pressure in the form of direction behind the advice, if the advice is to be made effective. It is desirable that we should have some uniformity in the educational campaigns we try to inaugurate. If any substantial number of local authorities declines to carry out these educational campaigns, it makes it ever so much more difficult and it operates to lessen the effectiveness of the campaign of local authorities who do try to act in a spirit of co-operation and good citizenship. In fact, direction will arise only where advice has not been carried out. If we can secure the desired results by advisory methods alone, there will be no need and no disposition to embark on the process of direction. I fully agree with Deputy Morrissey as to the desirability of having health education—at any rate elementary hygiene and many minor matters relating to health—carried out in the schools. We are looking into that matter to see what can be done about it, but it is undoubtedly a very important matter and one which has not got much attention in the past.

The only powers that local authorities have at the moment in relation to health education are under the Tuberculosis Prevention (Ireland) Act, 1908, Section 14. We are repealing that Act, of course, as we are repealing all the tuberculosis legislation and bringing tuberculosis, as I have said on a number of occasions, into the category of an infectious disease. Consequently, it has been necessary to replace the power we had in relation to education so far as tuberculosis is concerned. Section 14 of the 1908 Act, sets out:—

"A sanitary authority may, with the approval of and subject to such conditions as may be prescribed by the Local Government Board, provide and pay for the delivery of public lectures within their district and for the distribution of pamphlets, notices, and leaflets on subjects relating to tuberculosis, and may, with the like approval and subject to the like conditions, provide any drugs or appliances which would tend to prevent or check the spread of the disease."

All we are doing is expanding that to cover all other infectious diseases as well as tuberculosis.

Under the 1908 Act, on whom did the cost fall?

I cannot say for certain, but I think it would fall for recoupment on a fifty-fifty basis.

In relation to the cost of Section 83, on whom will that fall?

This Bill does not determine that. The items that rank for recoupment have to be approved from time to time by the Minister for Finance. Any item in relation to the tuberculosis services and the mother and child services that the Minister for Finance agrees to include for recoupment purposes will naturally be included. All I can say on that matter is that it would be our recommendation to the Minister for Finance to include those on a recoupment basis.

It is not fair to the House, in a Bill which places such burdens on local authorities as this, to throw a power here and a power there for the Minister to order a local authority to provide and carry on a particular service and leave us in the position that we do not know whether the cost is to be borne by the local authority or by the State here.

In so far as it relates to tuberculosis, it will be 50-50.

So we are saying that the State will pay 50 per cent, if it is tuberculosis, one-third if it is whooping-cough and nothing at all if it is measles.

The Deputy might safely assume that, in so far as the application of this Bill is concerned, it will apply to any approved propaganda where education is carried on.

Is the Parliamentary Secretary telling the House now that the State will bear 50 per cent. of the expense under Section 83?

I am telling the Deputy that I believe the State will bear 50 per cent. of the expense under this section and that it will be the recommendation of the Minister to the Minister for Finance that this type of expenditure should be included for recoupment purposes. No firmer decision can be given than that, as at any time the Minister for Finance can object to the inclusion of any particular item for recoupment purposes.

The Parliamentary Secretary puts us into great difficulty. I object here to the Minister being able to order a local authority to go in for a particular service and a particular type of expenditure. I object to it on a number of grounds. One is that it spoils the sense of responsibility and initiative, that it spoils the particular type of approach by a local authority to a problem that is different in different areas. The incidence of tuberculosis varies in different areas and, consequently, the approach of mind will be different. The same applies to some other diseases. I object generally to Ministerial dictation to public representatives in important matters. Then, when it is dictation that may be without any financial burden on the State, but the whole of it falling on local authorities, it makes it extremely difficult. In view of the Parliamentary Secretary's statement on that matter and as a kind of encouragement to us to hope that the incidence of the cost will fall in that way, I withdraw the amendment.

Amendment, by leave, withdrawn.
Amendments Nos. 79 to 82, inclusive, not moved.
Question proposed: "That Section 83 stand part of the Bill."

I wish to suggest a couple of ways in which the information and advice on health matters might be disseminated. The Parliamentary Secretary might take up with the Minister for Education the possibility of having classes on hygiene for the dissemination of this information through the vocational schools. You have senior boys and girls there of a certain age and it is quite possible that they would be in a better position to learn than smaller children attending secondary or other schools. In addition to that, will you not make provision there so that the health authority, whoever they might be, could disseminate this information through some voluntary organisation such as the Red Cross? They are doing a lot of that at the moment and they might possibly be the best medium for carrying on that propaganda on behalf of the local authority.

Like Deputy Morrissey, I recommend the Minister to take out the words in Section 2 "by Order direct". You would possibly get from local authorities more co-operation by carrying them with you than by directing them at every step. This Bill is putting grave financial burdens on them and, if the Minister would direct them in every step they take, you would probably get their backs up. It will be admitted that over the past ten or 20 years local authorities were often more keen, and often led the Department in many directions, in the matter of public health. They were more keen and advanced in their views than the Department were on many matters. I think the Parliamentary Secretary will admit that. For that reason, nothing should be done to kill initiative. The successful working of this Bill will depend on the goodwill of the local authorities and the energy that they throw into the administration of it. No matter what the Department may do, if you have not the goodwill and co-operation and drive of the local authorities behind this measure, it will fall very flat. You can have county medical officers, dispensary doctors and nurses, but they are part of the machine, and if you do not get the drive and initiative behind the machine, and what members of local authorities and nobody else can provide, you will not succeed. Any Orders that are not necessary should not be made portion of the Bill.

As this section deals with the dissemination of information and advice on health matters, there seems to be one peculiar omission. There is no provision for the Department of Health directly disseminating information and advice. There would seem to be a good deal of propaganda and advertisement in work of that kind which could be done directly by the Department. In connection with the dissemination of education on this question through the schools, it would seem to me that the Department should take the lead and, by selecting and approving of textbooks on the subject of health and hygiene, they could direct the schools as to the information which should be given to children. As this is a purely propaganda and information section, it should be not only on a local but also on a national basis. I am quite in agreement with the Parliamentary Secretary when he says there should be uniformity. A lack of uniformity in regard to advice and instruction would be fatal. I cannot see why there is an omission here on the part of the Department to take direct action, where that is appropriate.

There is a good deal in the last point, particularly in relation to the dissemination of information by means of the radio. It would seem anomalous, to my mind, that a local authority should be asked to avail of the radio for the dissemination of advice on health matters that would more properly be within the province of the Department of Local Government and Public Health. I also suggest that, in the matter of advertisements, the Department might avail of the advertising space allowed to cinemas under the Cinematograph Act. There is a certain percentage of each programme allotted to advertising and I think the Department would be the appropriate authority to avail of such a facility. It would have the best results.

I am glad to see that there is machinery for the dissemination of information and advice on matters of public health. I agree with previous speakers who have said that it seems to be a matter for the Department of Public Health. I think the diffusion of information through the schools is the surest method in the long run, although perhaps it is the slowest method. I suggest there should be some machinery in this section, or perhaps in another section, for consultation with the Minister for Education concerning lectures for schools. I think that is the surest method of ensuring what we all would like to see.

Since this Bill came into the House, and since certain statements have been made to the Press, I have met people throughout the country who are not in very good health and who are greatly annoyed. They have asked me: "Are we going to be put into a concentration camp and gassed?"

That is a different matter.

It does not arise here.

They are also talking about schools. I cannot see that there will be any improvement, no matter what Bill you bring in, so long as you have schools without sanitary arrangements. The same applies to housing.

This is not the moment for reference to those matters.

Question agreed to.

Section 84 agreed to.
SECTION 85.

I move amendment No. 83:—

Before Section 85 to insert the following section:—

(1) A county authority may, with the consent of the Minister, make arrangements for attendance to the health of expectant mothers and nursing mothers and for the education of such mothers in matters relating to health.

(2) The Minister may by Order direct every county authority, every county authority of a particular class or a particular county authority as to the manner in which and the extent to which they are to exercise their powers under this section and a county authority to whom any such direction relates shall comply therewith.

I assume that the House will expect a fairly detailed review of the purpose of the new section which it is proposed to insert. If this new section is adopted, it is proposed to establish a service for expectant and nursing mothers and for children up to 16 years of age. The existing statutory power in relation to mother and child service will be found in Section 3 (2), paragraph (b) of the Notification of Births (Extension) Act, 1915, and Section 4 of the Child Welfare Act, 1918. These powers are being repealed. Under the Act of 1915, which gave statutory authority for the provision of that particular service for mother and child, it was confined to children under five years of age. While it was open to local authorities throughout the State to adopt that service, both in urban and rural areas, in actual practice it was only operated in a very limited way, outside the county boroughs, in a few urban areas and in no rural areas. The proposal is that this service will operate throughout the entire State in county boroughs, urban districts and rural districts. While removing the age limit of five years, and substituting the upper age limit of 16 years, it is proposed that the doctor operating the service will maintain contact with the child, in fact, from the pre-natal period and through the school age period, until 16 years of age, and that he will look after the mother pre-natal, attend at child birth, and during the nursing period.

In connection with the maternity part of the scheme, it is proposed to engage a whole-time maternity nurse in each district. Under the scheme, if it comes to be adopted, the expectant mother will be entitled to the free services of a doctor and a nurse. We have the maternity nursing personnel already in a part-time capacity. The proposal is that these maternity nurses should become whole-time nurses. Under these proposals, as Deputies realise, the mother and child scheme will merge in the school medical service scheme. As I mentioned earlier, when this Bill was under discussion, there are some serious defects in the school medical service scheme. Deputies on the opposite benches have from time to time referred to these defects. We are all agreed that very good results have accrued from the operation of the school medical scheme, but I think we will also agree, because of the defects in it, that the best results cannot be secured. The question, therefore, arises and, in fact, arose before these proposals were submitted to the House, as to how best these defects could be remedied. Within the school medical scheme, as it operates, and as we understand it, it did not seem possible to make the necessary changes to bring about the organised uniform service we have in mind. Consequently, another method was decided on.

Under the school medical service scheme in operation, notwithstanding the fact that our officers have worked very hard, by reason of the numbers of children to be examined, and the fewness of the school medical officers of health employed, inspections have only been possible at intervals of up to three years. Clearly we could not have a satisfactory service under these circumstances. Within three years many changes can occur in the life of a child. Many children will have passed out of school altogether, and many will have been for some years at school before they come under the supervision of the school medical officer. In that way, while we have got good results, as I stated more than once already, the experience of our school medical officers is that the defects and the ailments that are discovered at school medical inspections are very often deep rooted and far advanced before they come under medical supervision at all. Another serious defect in our school medical service arises out of the fact that we have no organised follow-up service. The school medical inspector, at the long interval inspections of children, finds that of the children presenting themselves on that particular date, a very big number requires skilled attention of one kind or another, whether it be dental, family doctor, opthalmic or specialist. He communicates with the parents and draws their attention to the defects he has found, but again there is continuity in the scheme, and no follow-up to encourage parents to take the necessary steps that are available to them, to have defects that have been brought to light dealt with.

Apart from the more serious defects, there is another aspect of the school medical service that is unsatisfactory, that is, that quite a number of children suffer from minor defects, the doctor is not brought in at all, and the parents look upon these minor defects as being insignificant. Very often they are significant but the parents are not always aware of that. There is no machinery to deal with that under the existing scheme. Coming around and inspecting every two or three years does not solve it. Coming around even every six months does not solve it if there is no direct contact between the school medical inspector and the parents and if there is no service available for the domiciliary treatment of the minor ailments that can be successfully treated at home without having to send the child to hospital.

These are the main defects of the school medical service scheme. I have already referred to the defects that exist in the maternity and child welfare scheme or, at least, the statutory limitations on its operation. It is therefore proposed, as I have said, to merge these two services. It does not follow, and it is not intended, that the school medical service as such should disappear. The school medical service as we know it—school medical inspection —will continue but it will be of a more specialised kind. The district medical officer who is to be the dispensary doctor will follow up the children and carry out school medical inspections at regular and frequent intervals, if possible spaced about three months apart. He will have a whole-time trained general nurse at his disposal and the defects that can be treated domiciliarily will be treated by the local doctor with the assistance of the nurse who will be the immediate line of communication between the parent and the doctor. I need not give any lecture on the types of diseases but many of these minor things at any rate can be successfully treated at home under the supervision of the nurse and if the case is not clearing up satisfactorily or quickly the nurse will report to the doctor that he had better come and see the case again and, if more active treatment or more specialised treatment should become necessary, provision will be made to supply it. This scheme will cost money. Deputies are not surprised at that. It is estimated that this scheme will cost in the neighbourhood of £550,000 per year.

Does that include the maternity scheme, the nursing scheme and the additional doctors?

Yes. That is the additional cost.

Is that under this section?

Of course, this is the implementing section. This is the section that gives us the statutory power to operate the scheme that I am trying to explain to the House. The cost of the scheme will be borne as to 50 per cent. by the local authority and 50 per cent. by the State. The estimate that I have mentioned, in addition to the domiciliary service, includes the cost of dental treatment, ophthalmic treatment, hospital treatment and specialised services, in so far as it is possible to estimate these matters in advance.

When the Parliamentary Secretary mentions £550,000, does that mean an increase on the existing cost?

There is at present no complete mother and child service. For all practical purposes it means an increase in cost. This is an entirely new service, now partially operating in a few areas, notably Dublin City, Cork and a few other City districts, but even in Dublin City increased cost will be incurred.

Does it follow from that that the school medical service will now be merged in the cost of this, or will the two costs be added together?

They are both on a 50-50 basis, anyhow, but the school medical service will continue. The school medical service will be more of a specialised service, for this reason, that, having a regular inspection, and having the district medical officer in close touch with the children from birth up to the school-going age, it will not be necessary for the school medical officer to trouble so much about the minor ailments in the future. In fact, he ought to act, and it is hoped that he will act, more as a specialist to inspect and to advise on selected cases—throat, nose, eye and ear, and such matters— that are picked out by the district medical officer for special advice, or special investigation, or, perhaps, tentatively anyhow, for specialised treatment. In that way, having reduced the volume of his work very substantially, his inspections will be more frequent even without increase in staff, because he will not have to inspect, closely, at any rate, all the children in the school. He will be devoting his attention more to the specialised service, and we hope that for our school medical service in future the officers will have some special qualifications in the matter of nutrition, because we feel that nutrition is a very important matter in relation to the ailments of children. I want to keep out of technical or scientific discussions.

Does that mean you are relieving the county medical officer of the responsibility?

No. The county medical officer is in charge of the whole scheme in his county.

But he will not have to carry out inspection, personally?

He will have, but he will have specialised knowledge. Our county medical officers have specialised knowledge and the future trend will be to specialise more and more because the ordinary routine things can be dealt with in another way.

Will the Parliamentary Secretary say——

I wonder would I be permitted to make my statement?

I only wish to ask a small question.

Would I be permitted to make my statement?

May I not ask a question?

Go ahead.

I will wait, I may have to say a little more, whereas by a simple question I might have got an answer.

I am quite willing to answer it. Will the Deputy put his question?

No, go ahead.

I am anxious to make this scheme as clear as I can because I do not want any misunderstanding about it and questions may more or less put me off the track. Later on, I will answer any questions so far as I can, that may be put. It may be argued, with some little foundation, I suppose, that the Public Assistance Act in fact makes provision for the treatment of mothers and children who are in poor circumstances. There is no denying that statutory provision exists and it is not for me to suggest, and I do not want to suggest, nor do I think it would be right to suggest, that our dispensary service, taken as a whole, is a bad service. I think it is a good service, taking it all round.

Labouring under great difficulties.

Labouring under difficulties and with a heritage that is its greatest handicap and, if it were not for that heritage, I think we would get much better results from it. It certainly has improved out of recognition within the past 20 years. When I say that, I may also say that it has not improved in the City of Dublin at the same rate as it has improved in the provinces. There is a special problem in relation to that on which we probably will have to have some discussion.

Since I have had any responsibility in relation to these matters, and that is a considerable time, the greatest problem that I find in instituting a satisfactory service is not so much in providing for the very poor—and I am not concerned about the very rich— but for the general mass of the people; the man who is above the public assistance line and who feels that he would prefer not to accept treatment under that system. He may be a labouring man with a fairly decent wage. He may be a small farmer or a reasonably large farmer. But that middle class, economically speaking, that class between the very poor and the people concerning whom we need not have any anxiety, constitutes a very big element of the community in this country. As I see it, and I have had a good share of practical experience to guide me apart from administrative experience, the position has worsened if anything since I was in practice.

The position is that that large class of the community that desire not to avail of the public assistance code cannot, in fact, provide the full services out of their own resources. A child gets ill, the father and mother have a consultation about it and they say: "It is only a sore throat, it may be all right in a day or two; I think we will wait. If we bring out the doctor, it will run into a certain amount of money and it may not be necessary." It is not that they are careless about the child, but that they take a chance because the money is scarce. Deputies on all sides of the House know it is true that very often that delay has fatal consequences. On the other hand, they may not be in so much doubt about it and they say: "We had better bring the doctor out to see the child anyhow." They bring the doctor out. But, having brought him out and got his opinion, owing to the fact that they cannot foot a bill that to them might be a substantial bill, though to us it might not be so very big, they will say to the doctor: "We will let you know to-morrow or the next day." That case may require close observation for seven or eight days, but the doctor is actually in the position that he cannot bring the best that medical science could provide to bear upon that case because he knows that the people cannot afford to pay a very big bill. They have a degree of independence that we would all admire and they do not want to be indebted to him. Whatever the psychology is I could never discover, but the one man who will be paid, if there is any money in the house, is the doctor.

That constitutes a problem. I see no other solution for that problem except some such solution as is proposed within the machinery that will be provided here. It will cost money, but it is worth it. While the expenditure will be very substantial under this heading, I think it must inevitably bring about a lessening of expenditure under the Public Assistance Act, because the mothers and children who would be entitled to treatment under that Act and who would secure it will now come under the mother and child service and the State will pay 50 per cent. of the cost of the scheme, whereas, if they remained under the Public Assistance Act, the local authority would pay the whole of it.

There is just one other aspect of the financial side of it which I should like to mention and that is that the general community would benefit by such a scheme as well as the individuals immediately concerned. If, in fact, by the operation of a better health service, by detecting disease in the very early stages and by curing many people who would otherwise be invalided for life, we can achieve anything substantial along that line, at any rate we are lessening the burden that the community may have to bear in the future. That is one aspect of it. The other aspect of it is that the individual who is above the public assistance line now but who may be unfortunate enough to have sickness about his house will certainly gain under this scheme, because what he will have to pay by way of rates and taxes will be small compared with what it would cost him if he had to bear the full cost of making the necessary provision for his dependents out of his own resources. His neighbours, who are more fortunate, who have not had illness about their house, will have to contribute towards the general scheme. I do not see anything wrong in that.

We hear a lot about contributory schemes, insurance schemes and all that sort of thing. This is a contributory scheme. Every section of the community are to contribute to it. If they contribute sufficient, regardless of their economic circumstances, to finance the scheme, they are fully entitled to it whether they are above the poverty line or below it. I do not know whether I have covered all the points the Deputies would expect me to cover. I have kept the House a pretty long time but it is an important section.

Not for a moment too long.

But I should like to have the fullest understanding. If the scheme is faulty, I should like to be told wherein the fault lies. If anybody in this House can suggest to me a better scheme, I will be glad to hear about it. I may be told that this scheme only applies to a section of the people. No doubt, but it applies to a very important section. If the House thinks, or if the Government should decide that a further extension of our medical services is possible within our resources, the scheme before the House now would fit into any service, because it deals with a problem that can be treated as a unit. I think that any Deputy who feels free to discuss this matter entirely on its merits will agree that it is sound policy, at any rate, to begin to try to build up a healthy population for the future, whatever we may be able to do in relation to the population as we find it at the moment.

I think it a very great pity that, in presenting a scheme to deal with the health of the mother and child for the community as a whole, the scheme should be presented drafted, as it were, in the brass hat spirit, without any consultation with the organised medical fraternity on the dispensary medical officer's side, the county medical officer's side or the general medical profession side, and that the plan involved should be a plan to throw the whole mother and child service into the dispensary system, which the Bishop of Clonfert, with his experience of the chairmanship of the National Health Insurance Society for a considerable time, described, in his review of the general situation, as "the core and the hub and the heart of the degrading poor law system".

It is very unfortunate that a widespread scheme for dealing with the mother and child, which is an important section of the whole of our public medical service scheme, should be launched in this way without any general public discussion of the problem involved in the safeguarding of public health as a whole and security against ill-health as a whole. The Parliamentary Secretary himself admits the stigma which has to be wiped out in relation to the dispensary system. He admits that there will still remain as part of the scheme in the dispensary area the public assistance law and the problems which have to be dealt with by public assistance, but he takes the same machinery as deals with these matters and says that the community, as between rates and taxes, must provide through that machinery a service for the entire mother and child population in that area, including the treatment of the child in the school as well.

The Parliamentary Secretary must have known the psychological problem involved in getting wholeheartedly accepted throughout the country a scheme of that type by the population as a whole. He has made no attempt to face up to that, to get rid of it or to put the fabric of the health service which should be carried on by the dispensary doctors in a different light. On the other hand, he is introducing a scheme which will practically reduce various parts of the country to the position in which there is no alternative medical person to whom the population there can go for attendance, unless they go out of their district to the nearest town, or, at any rate, travel some distance. I think he will create medical difficulties for a considerable class of people.

There is outside the mother and child problem a very big health problem to be dealt with. The Parliamentary Secretary shows that he appreciates the position in respect of medical expenses of the greater number of our employed people—those who would be called the middle classes, although I do not know where we are to place, when scheming out a set of adjectives for the various classes in society, the road worker. The question that arises, to my mind, is whether the road worker is to be a person who is to depend upon the public assistance side of the dispensary system for himself or the grown-up members of his family? Are we to have the mother and child dealt with by the non-public assistance side of the dispensary doctor's work and the father of a family and the children over 16 years of age by the public assistance side?

There is a problem of the health of the people outside the mother and child over 16 years, and I suggest to the Parliamentary Secretary that this does not provide a foundation upon which a general health scheme can be based. If we are to have a general health scheme based for the rest of the community on this particular type of scheme, it will be nothing short of what I call a brass-hat scheme. It will simply be a dictated medical service with the dictation coming in accordance with the general spirit of the Bill, without any public inquiry, without any technical or professional discussion beforehand, the Bill just being rammed down the throats of the community with the cry: "Save the mother and child; save the people from tuberculosis; save the people from the dangers of infection."

That is not the way in which to review our problems, and no matter what the Parliamentary Secretary thinks, in sneering at contributory schemes or their proposals, we cannot have a satisfactory system of medical service, a system which will be satisfactory to everybody and full in every way, except upon a contributory basis. By his proposals here, he is throwing on the rates and on the taxes a very considerable part of the population, and it will make it very difficult to disentangle the finances of such a scheme and to bring about a scheme the cost of which will be satisfied to bear, on the basis of contributions of one kind or another.

I know that contributions to schemes of this kind are in fact taxation, but the very fact that contributions are paid develops a system over the organisation and administration of which the people themselves have control. The Parliamentary Secretary is forcing an important section of our public services into an absolutely State-controlled scheme of which, except through their public representative speaking here in Parliament and through such spirit of independence as may be left in public representative speaking in local bodies, there will be no direct control or no power of influence over the management. I think the Parliamentary Secretary is making a very great mistake, a very great blunder. It will be unsatisfactory, and I believe it will be costly, because while you will have under this scheme to maintain a service capable of dealing with the whole of the population, the whole of the population will not accept it.

Nobody can criticise the aims and objects of this scheme, and I must say that I was impressed by what the Parliamentary Secretary said with regard to the problems of bringing a service of this sort to the different sections of the community mentioned. I was very strongly in agreement with his observations as to the class of the community just above the line of those who are entitled to benefit under the Public Assistance Acts, but I am not quite satisfied that this is the best method of providing a medical service of the sort for the people whom he contemplates. I am in agreement with him regarding the necessity to provide such a service. The pride and the independence he has referred to has resulted sometimes in throwing back very serious burdens and responsibilities on families who could not afford it. Since they were not prepared to seek any benefit from the poor law service, they attempted to shoulder grave financial responsibilities or, as an alternative, they did not seek any medical service at all. If a service of that sort could be provided for the very substantial section of our people to whom he has referred, it would confer a tremendous benefit on them. The Parliamentary Secretary suggests that the cost, at over £500,000, would not be very great because, over and above the particular class that would seek service under this particular scheme, a contribution would be made by people who would experience no sickness in any particular year. They would be contributing through the rates to the people who might be unfortunate enough to have to seek medical service.

The difficulty I see is that the service is to be given by the dispensary doctor. No matter what may be said, a certain amount of stigma attaches to the poor law service in the minds of the people. Some of them who are still entitled to benefit by such a service are not prepared to look for it. I am afraid people will scarcely differentiate between the services of a medical man as a poor law officer and his services as an officer under the public health scheme. While we are still mixed up in that matter, it is very unsatisfactory. I am sure the House is anxious to depart altogether from that particular system and, if we are to ensure that those whom we wish to benefit will benefit and will willingly seek the service, the scheme as outlined could scarcely be looked upon as satisfactory.

As well as that, there is a lot to be said for a scheme on a contributory basis. The individual who makes a contribution definitely feels that there is no stigma whatever attaching to the scheme and that he is absolutely within his rights, that it is not based on charity, so that he can look forward to benefit from it when the occasion arises. So far as the administration of the scheme is concerned, I am in agreement with the Parliamentary Secretary. It is the financial side of it that I disagree with. Notwithstanding the mother and child scheme being in the Public Health Act, the people will mix it up in their minds with the poor law assistance, as the one officer will be working under both Acts.

The Parliamentary Secretary told us there were serious defects in the schools medical service scheme and I am in absolute agreement with him there. In some counties, the scheme conveys very little benefit, because the inspection is carried out too rarely. Three or four years and more elapse in some cases between inspections. A great change could occur in the health of a child in that period. I am glad that we are planning under this scheme to provide regular inspections at shorter periods. I understand too, from the Parliamentary Secretary, that that will be the responsibility of the local doctor. The local doctor knows the health history of the families in his dispensary district and will be at an advantage in his inspections. I understand, too, that the county medical officer will make periodic inspections for dealing with specialised work for which he is particularly qualified. In that respect, the scheme should be satisfactory.

However, the ordinary dispensary doctor is a very busy man and I am just wondering how he will find time to carry out all his work. He may be planning to devote a whole day or a big part of a day to the inspecting of a big school. How is his ordinary dispensary work to be carried out at the same time? Is it going to work out as well as the Parliamentary Secretary anticipates? It means putting on to a very busy man a substantial increase in his work and I wonder how he will find the time to carry out these duties efficiently and effectively, even if it is contemplated that we are going to increase his salary, which is inevitable, I suppose, if we are going to increase the amount of work he has to perform. I would like to hear the Parliamentary Secretary on that aspect of the problem. If we are going to have any benefit from the school medical inspections, they must be done often and regularly. As the Parliamentary Secretary said, in between the present inspections, diseases may have crept in and become deep-rooted, and at present there is no provision for a follow-up to watch the child in the later stages of development. This new provision will place the family doctor in a very advantageous position. I have no doubt at all about the advantages of that sort of scheme, but I question whether the dispensary doctors will be able to carry out the work efficiently and carry out the dispensary work at the same time. When we take into account the cost of this rather elaborate public health scheme, to throw back that burden on the local authority is a very serious matter and it does not seem to me that it is the best method of financing the scheme.

The Parliamentary Secretary said he hoped that certain of the doctors who will deal with this scheme will have special nutrition qualifications. That is very proper. I should like to know, where a doctor with these qualifications recommends certain nutrition for a child and the parent is not able to provide the nutrition necessary, what will happen?

It will be possible to provide food in such circumstances under the scheme.

That is a satisfactory answer. This clause dealing with mother and child is very welcome but its administration can make it a great success or failure. If it is to be administered through the poor law system, as we know it in Dublin, it will be a great failure. There is a certain class in Dublin who, because of their sad circumstances, are compelled to depend upon the poor law system. In cases of unemployment and illness, it does seem a good work, but there are certain aspects to be considered. The Parliamentary Secretary said that because of the heritage of that rotten poor law system, and whilst he was satisfied that conditions improved somewhat in the country within the past 20 years, Dublin did not seem to go with the times. That was an honest and frank statement. I agree with him. I have often had cause to find fault with the administration in Dublin, where poor people were thrown half-crowns, sops by way of relief, whereas if there were a scheme like this in operation a man with a family would get an allowance of £1 a week or something reasonable that would help him to save his children.

Now that the Parliamentary Secretary has admitted that the Dublin poor law system has not gone with the times, I hope he will take the earliest opportunity of improving conditions here. He should endeavour to take away the pauper taint. No matter who goes for poor law assistance, he or she comes away with the feeling that that kind of assistance or relief is not acceptable. People are not inclined to go into a hospital in these circumstances. It is one of the sad things we must accept. I do not blame the old Dublin citizen, who has a certain pride. If you tell those people they have to go to the poor law hospital, they tremble with fear. Of course, I know that in those hospitals they get the best medical and nursing attention, but the taint of the poor law system in Dublin is so rotten that the people the Parliamentary Secretary wants to protect will not go near the institutions.

I hope this scheme will not be worked in Dublin through the poor law system. We have societies composed of voluntary workers, such as the Infant Aid, Child Welfare, St. John Ambulance, the Red Cross and several Orders, especially in the city. These people do excellent work. With great kindness they enter the homes of the poor and give a personal touch. You know they are not relieving or medical officers coming to examine means and prepared to make the smallest recommendations they can. I suggest the administration of this scheme in Dublin might be tested for a year or so with voluntary workers. The Infant Aid Society distributes thousands of bottles of milk and they have 400 or 500 voluntary workers, young girls and others anxious to do all they can. I would rather see these girls going into the homes than the officials representing the poor law authorities who go there with the idea in their minds that they must cut to the barest minimum what will be given to enable a family to exist.

I heard the Parliamentary Secretary say that the cost of the scheme will be pretty heavy and he has decided that it will be borne equally by the ratepayers and national funds. Perhaps I have a bee in my bonnet, but I would like to know what about the Sweepstake millions? Surely some grant could be given towards this scheme out of the millions accumulated in the Sweepstakes? Then the poor people would have the feeling that they are not getting charity. The public have subscribed handsomely towards the Sweepstakes and I suggest a proportion of the money would save the national fund and the ratepayers, to some extent. I do not want any saving on this clause. I want the Minister to do the very best he can, but I still think the Sweepstakes millions should come to the rescue in this splendid cause.

The Parliamentary Secretary said there was no organised follow-up in the school medical services. I should like to see a follow-up service. You see girls leaving school without any warning of the dangers that might befall them outside. They have no education in matters which should have immediate attention in this country.

We are dealing with the mother and child clause, and I will now touch on a point which, for some time, I hesitated to mention. I thought I had better not mention it, but I have decided it is well to do so. I want to know will this clause apply, without any great punishment or any third-degree methods of examination, in the case of the unmarried mother and her child?

There is no exclusion; no mother or child will be excluded under the Bill.

Will the Parliamentary Secretary see that there will be no third-degree methods adopted when the unmarried mother seeks aid under this clause? We who are in public life occasionally hear of sad cases. A mother and her daughter might visit you, having a sad story to relate. You would like to know how you could protect that girl and her baby and you are anxious to know whether the baby will get a name, will it be adopted, and what will be the method of adoption of the child so as to give the mother another chance. All these things must be dealt with sooner or later in the Dáil. They are things which we are all avoiding. We are afraid to mention them. I was a little bit nervous about mentioning it myself. I heard within the last three or four months the sad story of a Dublin family. The father is highly respectable, a good-class workman, who nearly lost his mind when he learned his daughter was in trouble. What of the wife of that workman, with her daughter in that state? What is she to do in these circumstances? Surely she is not to be hounded down by officialdom. I ask the Minister to make provision for such cases so that they may get a chance under this Bill.

I agree as to the outstanding necessity of a measure of this kind being incorporated in the public health code. The Parliamentary Secretary outlined the scheme and told us what it proposes to do. I propose to deal with the cost of it. I gathered that the existing dispensary doctors will be the pivot of the whole scheme to deal with mother and child. The work of dispensary doctors in future will come under the Public Health Act and, in that respect, I want to call attention to the problem that is going to be created in dispensary districts. As far as I can estimate, there are between 9,000 and 17,000 inhabitants in dispensary districts in rural areas. If we take the average at 12,000 inhabitants, almost half of them would be mothers and children under 16 years of age. If there are some 6,000 persons to be attended to in the average dispensary area, that means that 50 per cent. of the local population are going to receive free medical attention for all ailments. The dispensary doctor will also be expected to attend at the schools about once a quarter to inspect the children and, if necessary, to recommend that they should receive treatment by a specialist. He may treat them himself and then get the public health nurse to give further treatment and visit them. With the best will in the world I am afraid that the scheme will not work with dispensary doctors. I do not know anybody who works as hard as dispensary doctors. They are part-time officials, but they are liable to be called out at any hour of the day or night. They have to attend all cases coming under public assistance. They have also to attend private patients, as otherwise they could not carry on. In my opinion the extra duties involved under this Bill means that their work will be doubled or trebled.

If we are to provide this service, it is certain that a full demand will be made on it by mothers and children. I cannot see how dispensary doctors could possibly do the work that the Parliamentary Secretary hopes they will do in future. Beyond doubt, dispensary doctors are the proper persons to operate the public health services in their districts, but I suggest to the Parliamentary Secretary that, in addition to bringing 50 per cent. of the community under these services he should bring the other 50 per cent. under the public assistance code. How could a dispensary doctor go into anybody's house to treat children under the Public Health Act and then have to treat other members of the family as private patients? That is the difficulty that I see. I cannot see how it could work. The doctors are to have at their disposal whole-time fully-trained nurses and, in addition, whole-time maternity nurses. In future there will be two whole-time nurses in each dispensary district. That will take some of the burden off the doctors, but I doubt if that will be sufficient to enable them to carry out what is expected under this section.

In addition, I cannot see how a dispensary doctor can do without a clerical assistant to make out reports after his examination of children and for the information of the county medical officer of health. A full-time clerical assistant would almost be needed in order to deal with reports on behalf of the doctor if the scheme is to be effective. I see a further snag in the proposal. If we are to take it that mothers will be encouraged to go to a doctor for pre-natal treatment, the existing poor law dispensary will have to be used. There is no other place available at which a doctor could meet patients. I am sorry to say that from my knowledge of a number of dispensaries they need renovation, and rebuilding. In some cases new dispensaries are required. I wonder has the Parliamentary Secretary taken into consideration the necessity of providing in rural areas new dispensaries or public health clinics.

The Parliamentary Secretary talked at length on that subject on various stages of the Bill.

He admits the necessity of dealing with them. Did he include the cost in the £500,000?

I thought not. They are to be provided by the public assistance boards.

The scheme is an admirable one, with which I am sure every section in the House agrees, but I do not know if it will be possible to operate it side by side with the public assistance code. I suggest to the Parliamentary Secretary that he should go further, and at this stage, seeing that 50 per cent of the community will be under the public health service, he should take his courage in his hands and do away with the public assistance code as it affects medical treatment. We can have public assistance in other directions, for home assistance, for example, but I think we should have reached the stage when public assistance in respect of medical treatment for all sections of the community should cease to exist and that in future, district doctors should be public health doctors only and that in respect of medical treatment public assistance should not be available or necessary for anyone. I do not see how a doctor could operate it, say, having one patient as a public health patient and, in the same house, a public assistance patient and, perhaps, a private patient. That would raise all kinds of difficulties. I wonder if the Parliamentary Secretary took into consideration the fact that it would be necessary to provide a fairly substantial increase in the staff of local health authorities. It would probably require from six to 12 additional officials in county council offices to operate this scheme. Did the Parliamentary Secretary take that into consideration in estimating the £550,000? I want further to suggest to the Parliamentary Secretary and, through him, to the Government, that the cost of this scheme will be very serious for the community. Section 34 of this Bill makes it mandatory on the local authority to provide the total cost of maintenance. Under that section there is a very serious impost on local authorities.

We are not on Section 34.

We are not, but I want to point out that Section 34 already imposes a direct burden on the local authorities which the Parliamentary Secretary says will not be recouped to them in any way. Fifty per cent. of the cost of this scheme, coming on top of that burden, will probably be more than local ratepayers can afford to pay. The local ratepayer, in the first instance, is going to be charged as a taxpayer 50 per cent. of the cost and, as a local ratepayer, he is going to be charged the remaining 50 per cent. Very many people will escape. It is curious to relate that very many people are neither taxpayers nor ratepayers.

Do they even smoke?

They may not smoke or drink.

It is only in Wexford you will find them.

It may seem an extraordinary thing to say, but there are many people in the community who pay no direct tax. Deputy McGilligan may say that because we have tariffs in operation they may pay indirect tax on the clothes or the boots they wear.

There is not much "may" about it.

But you may have individuals who pay no direct tax.

Do they go around in their bare feet?

There are substantially well off people who pay no tax. That is true.

Would the Deputy introduce that group to the Minister for Finance?

If the Revenue Commissioners hear of them they may go after them. That would be most interesting. Joking apart, I want to suggest to the Parliamentary Secretary that the ratepayers who are going to contribute 50 per cent. of the cost of this will have already contributed a considerable proportion of the 50 per cent. that is going to be raised in taxation.

Do the taxpayers pay any rates?

Yes, some of them do. We know that quite well, but the ratepayer is going to contribute very seriously. All taxpayers may not be ratepayers. Remember that. A very big proportion of them are not ratepayers. Particularly, they are not ratepayers who have to eke out an existence on the land. I want seriously to criticise the proposals in this, from the point of view of the local ratepayers, and I suggest to the House that the financing of this section is going to place a very serious burden on the backs of the local ratepayers. It is an admirable section. It will be welcomed by all sections of the community and it will be operated, I am sure, by all sections of the community, but I want to point out again that I do not believe that it is possible to operate it partly as a public health measure while having a public assistance code in operation side by side with it. If the Parliamentary Secretary, who has practical experience of these matters, visualises a dispensary doctor trying to operate it, while trying to do his ordinary work as a dispensary doctor under the public assistance code and operating child welfare, school medical inspection, maternity schemes, etc., at the same time, he will realise that it cannot be done. To operate this scheme you would require at least twice the number of dispensary doctors that you have and you would need to reduce the dispensary areas. Instead of costing what the Parliamentary Secretary estimates it to cost, £550,000, he will find before it has been very many years in operation that it will cost £1,000,000 or near it. At the same time, it is an admirable scheme and I am sure once it is started we will find we cannot do without it. I welcome the scheme. I criticise the financial proposals, and I draw the Parliamentary Secretary's attention to the fact that I do not believe it is feasible from the point of view of having the dispensary doctor operating it, and continuing his present work, while the public assistance code is in operation.

That is a grand welcome.

Open arms.

Open arms, but closed pockets.

It is a pity that a service which is desirable and which has been anticipated for a considerable time has been introduced in such a haphazard and, I think, ill-considered way, as has been clearly indicated by the views expressed by the last speaker. It is a pity that before this particular service was embodied in this Bill, the Parliamentary Secretary had not studied carefully Dr. Dignan's report. Dr. Dignan says in his report—and it is applicable to this particular service—

"I shall be told that poor law has disappeared——"

We heard that to-day already.

"——and public assistance has taken its place: I respectfully submit poor law legislation has been repealed only in part. The change of name shows the authorities realised a change was necessary, but a mere change of name does not change the nature and character of the services rendered. The whole poor law legislation, the Medical Charities Act and similar legislation, should be blotted out from the Statute Book and —from our memories. The system is tainted at its root and it reeks now, as it did when introduced, of destitution, pauperism and degradation."

The Parliamentary Secretary in this section is seeking to implant upon that rotten system which the Most Rev. Dr. Dignan condemned, a new service, a service which is of a very far reaching nature and the financial implications of which can only be vaguely guessed at. The Parliamentary Secretary in introducing this amendment to the House and appealing for our support drew attention to a very deserving section of the community, the people just above the line of poverty, who are not covered by the existing home assistance and medical charities laws, and he dwelt on the sufferings and the hardships of such people by reason of the fact that because of the limitation of their means they are unable to avail of medical aid in time. But the Parliamentary Secretary overlooked the fact that, notwithstanding that this service which he is proposing is comprehensive, it still leaves out quite a number of deserving people. Only a few weeks ago there was brought to my notice a case of a widow with a large family, some of whom are very young. She was the owner of a small farm. She could not avail of free medical attention. She was told by her doctor that she would have to have an operation. She put it off because of her means and, as a result, she died. A somewhat similar case only came to my notice last week of a small farmer, a hard working industrious man, who had reared his family well and had reached the age of 70 years. A couple of years ago he was told that he should have an operation, not a very serious one. He found that his limited means debarred him from obeying that medical instruction and, as a result, he has been very seriously ill. His life may be saved but, if it is, it will be only as a result of good medical attention and specialist treatment. Such cases are not covered by this service.

When we have gone so far, the question is naturally asked by Deputy Allen, why we should not have gone the whole way. I think it would be impossible, or undesirable, to go the whole way on the basis on which we have started out. We should have introduced something entirely new, something entirely separated and cutoff from the poor law system. We should have introduced something such as His Lordship the Bishop of Clonfert advocated, some system under which people would contribute and as a result of which they would receive free medical and institutional treatment without having to bear the stain or stigma of being a burden on the rates, which has always been looked upon, particularly by the independent, respectable farming community, as a deep slur.

Like Deputy Allen, I can see great dangers in this new system. It is a system which requires very careful attention. It is right, perhaps, that doctors and the public medical service should be made available to mothers and children. There is, however, a danger in this that we may be turning the doctor into a Government official. We may be taking him away to a great extent from the ordinary work of his profession and making him a clerk. He will have to keep a lot of records, fill a lot of forms, and comply with an enormous number of regulations, having upon his shoulders the responsibility for all the mothers and children in his area. I think it is implied in this new section that he will have to keep records of such people in his area, of their condition of health, their medical history, etc. There is a lot of involved clerical work attached to such a service.

There is also another feature that just strikes me, that the people who are to benefit by this new service will not have what they would have under private medical practice; they will not have a choice of doctors. Having gone as far as you have gone, there ought to be some system by which the person benefiting may be able to make a choice, to a limited extent at any rate, in regard to the medical officer who is to attend him. I think there is some such provision in the legislation proposed in Great Britain. I think it is foolish to rush into such a measure as this without considering it from every conceivable angle and realising the dangers and the difficulties associated with it.

The Parliamentary Secretary may tell us that there is no stain or stigma attached to obtaining medical attention at the expense of the rates. I do not think that that point of view will be accepted by the majority of the people. He may say, perhaps, that the same stigma or stain might be attached to obtaining medical attention under such a scheme as the Most Rev. Dr. Dignan advocated. But the two systems are altogether different. Under one you have a direct tax secured from all sections of the people for various purposes. As originally intended, it was mainly for the relief of the destitute. The feeling will be associated always with receiving money from such a source that it carries the stigma of destitution. On the other hand, if we had a contributory scheme, even if the State did contribute portion of the cost, the person benefiting could hold up his head and feel that he was simply obtaining a service for which he had paid, a service which he had insured himself to obtain. There is need also to dwell, as I think Deputy Allen sought to dwell to some extent, upon the inequality and iniquity of the present system of rating. If you are to have a service of this kind based on direct taxation, it should be based upon a system of direct taxation that is fair and equitable.

There is another point which arises also: what will be the position of those district nurses under the Lady Dudley nursing scheme who have rendered such a service in the past? Will they be superseded and thrust aside, or will the valuable experience which they have gained in administering a service somewhat similar to this in the past be availed of to the fullest extent? Voluntary co-operation and help, from whatever source it can be obtained, is absolutely essential to make a service of this kind a complete success. For that reason, I think it was foolish for the Parliamentary Secretary to discard, and I think in a rather insulting and offensive way, the advice and help that was offered by the Most Rev. Dr. Dignan and, instead, try to initiate something which is not as good by any means and which is open to very serious objections from many points of view.

It is quite clear, to my mind, that the duties to be imposed upon the dispensary medical officer under the Bill will be so onerous that he will find it impossible to carry out his public duties under the Public Assistance Acts and this public health measure when it becomes law; but what is to become of his private practice? If he happens to be a very busy medical officer, he may also happen to be a very busy private practitioner. To what extent is he to be compensated if he must neglect his private practice in order to devote virtually his whole time to the duties now imposed upon him?

So far as I can see, the entire position of the dispensary medical officer is now being altered fundamentally. Formerly, he was a part-time official and he was there for a life-time, being almost irremovable from office, except in case of grave neglect or misconduct. Now, by virute of this measure and the 1941 Act, he finds himself converted into a whole-time State servant, and not only a medical servant, but to a large extent a civil servant, because a large part of his duties under these measures will be the recording and indexing of all these cases and the furnishing of various statistics to the Custom House.

I can see a position in which this machinery will break down, unless he is adequately compensated for his extra duties, or the loss of private practice, or, unless, as Deputy Allen has suggested, additional dispensary medical officers are appointed. In fact, if the figures quoted by Deputy Allen are anywhere near the mark—I am not in a position to judge them—additional dispensary medical officers will be absolutely essential for the effective operation of the Act. That aspect of this Bill leaves us in considerable doubt as to the financial effect of this measure upon the State and upon the community, and it was quite refreshing to hear Deputy Allen completely converted to the viewpoint expressed from these benches during the past fortnight. If we achieved nothing else, we certainly achieved a very desirable result in converting one member of the Government Party to our viewpoint on the financial aspects of the measure.

I do not want to reiterate what has been said already on this matter, but the provision we are now making is really an extension of the old poor law provision relating to mothers and children up to five years of age, and there is a danger that the stigma——

It was not poor law.

It was regarded as poor law.

A rose by any other name.

The name has been changed.

The service was never a poor law service and it was not administered by the poor law authorities.

By whom was it administered?

By the health authority.

In the popular mind in the country, all these services are looked upon as organised charities, whether they are called public assistance or public health services. When the service is free, it is an organised State charity. I would prefer to see some system whereby this could be done on a voluntary basis. It probably would be a very difficult matter to work out on a voluntary basis, but there should be some voluntary link left. At least the expectant mother should have the right to choose her own medical adviser, if she has not got one, or to continue to have the assistance of her own private medical adviser rather than be compelled to bring in another doctor in whom she may have no confidence.

She is not compelled.

The dispensary medical officer is given the duties under this section.

It is open to her to bring in anybody else, if she wishes. She is not bound to take him.

The wording of the section is very vague. It says "may make arrangements". I understood that the scheme depended on the dispensary medical officer.

There is no obligation on anybody who does not want to avail of it.

Is any mother who does not want to avail of the services of the dispensary medical officer for private reasons entitled to bring in a private medical practitioner?

That is a different story.

I think it is fundamental to the whole problem of the treatment of patients. Surely the citizen has a right to his or her own medical opinion, advice and treatment?

Nobody is preventing her.

You are compelling the dispensary medical officer to go into her home to look after her children and she has no choice in the matter.

What happens if she is not able to pay?

What would the Deputy suggest in that difficulty? Should we supply a whole panel of doctors in every rural area?

There is in Britain at the moment a health measure which is a national health measure, and the private relationship between doctor and patient is not being interfered with.

It is not being interfered with here.

I think it is, very largely.

Not at all.

It all depends on the effect of this section and other sections of the Bill. I want to make the point that if the mother seeks to exercise a choice she should have the right to choose whatever medical officer she will bring in. If an outside medical adviser, an adviser other than the dispensary medical officer, is brought in, let him be paid his fee. Let a scale of fees be drawn up. The effect of all these measures at the moment is that the medical profession will be reduced to a State service, and so many people will be getting free treatment of one kind or another that private practice will cease to exist, so that future generations of medical men here will have nothing to look forward to but an appointment in the State medical service where they must always obey the behests of the Custom House, or find themselves removed from office.

And they will not have the benefits of a State medical service.

There should be an entirely different approach to this problem and medical practitioners, whether working under local authorities or in private practice, should have a right to be brought in on this service and paid on a fee per visit basis, or on some such basis, so that the private relationship between doctor and client could be preserved.

I find it extremely difficult to know what we are debating. The Parliamentary Secretary has put down two amendments, one dealing with expectant and nursing mothers and the other with children. He made a speech which was somewhat analogous to a Second Reading speech as if these two new sections were the principles embodied in the Bill, and he gave the House an outline of what was intended to be done under this scheme, the scheme which was welcomed by Deputy Allen of his own Party with open arms but with closed pockets. There is no use in a Deputy like Deputy Allen saying that all sections of the community will welcome this scheme, but will not pay for it. There is no use in paying lip service to the scheme unless the full effects and significance of what is being done are adverted to and the full cost which the scheme will involve appreciated.

It appears to me that, taking these two new sections which the Minister proposes to insert, they will give the Department a blank cheque to do anything it likes regarding their subject matter. He gave an outline of what was proposed and spoke of the scheme being carried out through the machinery of the dispensary medical officer. He spoke of the assistance which would be given by nurses and of the defects of the old system, which did not provide for what he called a follow-up after the medical officer had inspected the children in the schools. He spoke of the defects of the old system, which involved delay, in periodic inspections, perhaps every three years. I have searched through the two new sections to find where he got the machinery. I thought I had misread the section. All that is in it is empowering the local authority to arrange for attendance to the health of expectant mothers, nursing mothers and children and to arrange for the holding of medical inspections of children in schools.

The operative word is "arrangements" and, as far as I can gather, that appears to be interpreted as giving the local authority on paper—in fact, the Department—power to do anything. It really is enabling the Minister to direct the local authority what they are to do. The word "arrangements" appears to be the operative word. If there is to be a power granted, either to the local authority—or, in the guise of empowering a local authority, really to the Department—to formulate a scheme of this kind, that scheme ought to be set out in the Bill we are debating. The House should have some knowledge of how it is to be done and what the cost of it will be. As it stands at the moment, the Parliamentary Secretary has merely told the House what the intention is in reference to the powers contained here if they are granted; and all that is supposed to be comprehended in the word "arrange ments".

I was further struck when the Parliamentary Secretary in answer to Deputy Coogan, said that it was not compulsory for anybody to submit themselves to the powers which are to be exercised in accordance with the arrangements, if those schemes are to be carried into effect. Deputy Coogan asked if the expectant mother who was able to afford it was entitled to have her own medical attendant and the Parliamentary Secretary appeared emphatically to state she was. But I have an amendment down providing that nothing in this section—or the section which replaces this section— shall authorise the compulsory attendance of school children for medical inspection. I take it that that is unnecessary now, as if the Parliamentary Secretary is right in what he said to Deputy Coogan and mothers are not bound to attend under this scheme for attention, similarly children under a precisely similar provision in the next section for the carrying out of inspection in schools, need not attend if they do not wish to do so. I would like to know if I am correct in that.

I have not said so.

I thought I was not, as a subsequent section, Section 87, provides that it is essential for school children to attend. There is compulsion. How it can be, in two similarly drafted sections with the same language, that in one section it is not necessary for the mothers to attend and in the other it is necessary for the children to attend, passes my comprehension. Perhaps the Parliamentary Secretary misled himself into two facile a reply to Deputy Coogan. I do not understand why it should be necessary, under a loosely drafted section of this kind, to give the wide and extensive powers which, apparently, he claims he will have under these sections. They should be set out specifically, so that some scheme may be available for examination, and that it may not be of a character which may vary from day to day or from Minister to Minister. There should be some specific statement of the scheme with which these sections are supposed to deal. We are supposed to regard these sections as introducing some sort of greatly longed for social reform. Frankly, I do not know what scheme is embodied in this at all. Arrangements are to be made and the Minister is to say what the extent of them shall be and the manner in which they are to be carried out by the local authority. That is the sum and substance of the two sections. There is nothing to show what can or cannot be embodied in the word "arrangements". I think the sections are entirely misleading and should be more specifically drafted.

I have very little to say on this section. I have said nothing on the Bill up to this point, as I think it is lamentable that the measure should be held up to these multitudinous amendments, 85 per cent. of which are purely vexatious.

There are 150 Ministerial amendments.

I am talking about the amendments coming from the Opposition Benches.

Does the Deputy question the right of the Opposition to put down amendments?

No one welcomes this whole measure, and particularly the sections under discussion, so much as the teachers throughout the country. They have had experience of the beneficial effects and results of school inspections. I myself have seen visiting doctors spot weaknesses in children and diseases that were quite unexpected. Very often, when they came for the purpose of mere inoculation, they found other serious things and prevented many a tragedy, to my own knowledge. That gives us reason to believe that, under the full service designed by this Bill, the health of the people will be safeguarded to a wonderful degree and that the results will be altogether satisfactory.

Reference has been made to the costs entailed by the measure before us. Some of those references were made by people who were condemning the Government previously for not implementing the Beveridge plan and other plans. If we implemented the Beveridge plan here, the cost probably would be ten times the cost of this measure. This whole measure, and particularly these sections dealing with the care of the mother and child, is to my mind, a very big slice of the best part of the Beveridge plan.

About one-tenth of it, apparently.

The whole plan would not be applicable to this country and would be altogether against the spirit and temperament of the people. Opposition speakers here have warned us against the liberties that may be taken away under this Bill. When the Opposition were pressing the Beveridge Plan and other plans on us, they did not refer at all to the restrictions on the liberty of the people under such plans. Under the Beveridge Plan, not only are restrictions placed on sick people, carriers or potential carriers, but also on every healthy man in the country. There are restrictions on his movements, on his associations and even on the spending of his own earnings. Here there is no restriction, to my mind, except that which is vitally necessary in the interests of the health of the people.

Dr. Dignan, at a lecture on social services, given on 12th March, 1945, unfolded his plan and a resolution was passed at the conclusion of that lecture. The Government was challenged, or possibly requested would be a better word, to produce a complete scheme of public health service for the country. Dr. Dignan's plans were found to be impracticable. I think this Bill is very largely an answer to that challenge, or that request, and it is a matter of great satisfaction to me, anyhow, to find that the mother and child will be well looked after, the child actually before and after birth and right up until a firm foundation of health is established. I think this whole measure is the very foundation stone of that complete edifice of public service which we intend to build in this country. I think the Minister and the Parliamentary Secretary are to be very highly complimented on the production of this Bill. It is the foundation stone of everything in the nature of public service and the members of this House will, I am sure, see that that stone is well and truly laid.

This must be a very peculiar day for the Parliamentary Secretary after a fortnight or so having nothing but the pedestrian efforts of his Party to support him. He has now had two speeches made by his supporters. I wonder whether there has been any discipline, as it were, put on the Party to insist that they should show some more intelligent interest in this great measure of reform in matters relating to public health? These speeches must have produced somewhat mixed feelings in the Parliamentary Secretary. Deputy Allen welcomes the Bill, but says it will cost far too much and he thinks it will not work. The other gentleman seems to think that it is a foundation stone. Foundation stones are generally buried. I wonder would he be glad to see this one out of sight because of the amount of criticism that have been poured upon it?

The Deputy appears to be annoyed that there is opposition to this Bill. If there had not been as many amendments from this and other sections of the House, I wonder would the Parliamentary Secretary be moved to produce 150 of his own? The measure would apparently deserve the epithet one of his colleagues put on the document of a certain public man who gave distinguished service in the drawing up of a report—it apparently would have been a somewhat slovenly measure if it were accepted as it was when it first made its appearance. This measure has been improved because of the fact that certain objections were made to it on an earlier stage. These got wide publicity and the Department decided that it was necessary to improve the measure in the way in which it has been improved by some of the amendments submitted.

Deputy Allen makes the point that this measure will not work, that there will be a break-down as far as certain services are concerned. He complains that whether it is good or bad, he, as representing the ratepayers, ought not to be asked to put his hand, or the ratepayers' hands, into various pockets in order to provide sufficient for this scheme. There is a more radical objection still, and that is the one voiced by Deputy Cogan of the Farmers' Party. That is, that when this scheme works, and even if it is not as expensive as it would seem, and if people will put up the money, it definitely does not go on the basis of the Dignan proposals.

Long ago it was said by somebody that Christianity had been tried and found wanting, and the answer Chesterton made was:—

"No; Christianity has been found difficult, but it never has been tried."

That phrase can be applied to the Dignan proposals. They are Christian; they were found difficult and there was an evasion of them. Now you have this half-baked scheme of socialism. Deputy Coogan pointed out that there is no choice left to the individual. The person who can pay can have his choice of doctor—that is not going to be taken away from him. As regards a medical service giving the individual the right to choose the person from whom he will get the medical advice, that clearly is not in this measure.

This measure is another sample of the bureaucratic working of the Government. The local authority are to be allowed to make arrangements and, after that, there immediately follows the provision that the Minister is, by Order, to direct the extent to which they will use the powers that they may take under the first subsection of each of the two relevant sections. We know what that means. The Minister will order what these people will do and he will further order them to pay for it, and if they do not strike a sufficient rate, he will sack them and put in somebody who will. That is supposed to be either the Beveridge scheme or the scheme that his Lordship the Bishop of Clonfert put forward. Of course, it is neither.

I wish Deputy Butler would intervene in this House when we have schemes like the Beveridge scheme under discussion. I do not know whether he has read it, but the Beveridge scheme is difficult to understand, lengthy to read and it certainly has not been improved by the hands the English Government laid on it. If it could be said that this is a substitute for the Bishop of Clonfert's proposals, then the British Government did very much the same with the Beveridge proposals. The Beveridge scheme was not such an interference with liberty as the present British scheme. Once the bureaucrats got their hands on it they messed it up; they made it much less of a free scheme than when it came from the author.

We are being asked to accept as a measure of public service the things set out in amendments Nos. 83 and 84. The local authority are formally given permission to make arrangements. In the background the Minister says: "If you do not make the arrangements, I will tell you what to do. I will indicate to you the extent to which you are to go. I will see you work the scheme and further, I will see that the ratepayers pay".

Very properly so.

If the people put in to represent the ratepayers do not foot the bill, then the Minister will abolish them and send down some servant to see that the ratepayers will be mulcted. Deputy Allen thinks this scheme will not work. If it does and when it is all over, the situation will be that if a person is well enough off to pay he can go elsewhere rather than accommodate himself to this so-called arrangement, but if he is not, he will have to take whomsoever is available.

You are reading a lot into the Bill that is not there.

I am only reading this section, which says that the Minister may, by Order, direct every county authority as to the manner in which and the extent to which they are to exercise their powers. What does that mean? It means that the Minister has power to tell the local authorities what they are to do. Am I saying too much when I say that? I am afraid the Deputy, before he spoke, possibly did not see there were amendments down, and we are discussing those amendments.

That is where I think His Lordship of Clonfert parts company with anyone in this House who speaks in favour of the Bill. You do not change a thing by giving it a different name. We have had a good deal of that going on. We were told that this was not an additional relief service. Whether so called or not it is so thought, and that thought will continue to attach to the services to be rendered here. We used to have what was called outdoor relief. It is now called public assistance. There was a thing called emigration. It commenced in the famine years. That is all changed and we have now a passenger movement outwards, according to the statistics. When you get a passenger movement outwards, and a passenger movement inwards you lose the same number of people under a new name. It was similar with home assistance. That name was preferred to outdoor relief. Deputy Butler was afraid of that taint. The proposal here is fundamentally opposed to that in the scheme of His Lordship of Clonfert. In the early part of his pamphlet His Lordship recognised that the pivotal point of any community must be found in family life. He took as the background of the family, people who were wage earners. He worked out a scheme by which workers would be provided with a wage sufficient to provide for the home, including health, education and something over for the amenities of life, as well as something for what is now regarded as a necessity, a little bit of leisure. He suggested that health was a thing that the family wage should encompass.

One of the rights that people should claim is the right to choose and consult their own doctor, as well as the right to choose the services they got from people with whom they had professional relations. They ought to be enabled to get that. The first two pages of Dr. Dignan's pamphlets speak in these terms. What he wanted was a scheme whereby a family wage would be paid to wage earners. Of course we have done away with all that. This is to be a substitute for that, because of the position into which we have been got by the Government, when people are definitely put below the level of meeting ordinary expenses, and when they are below the level in which they could be expected to pay in connection with health or other services. Then they must be provided for and it is sought here to provide for them by cheap and nasty phraseology.

The one thing cut out is freedom as to the person to whom people can go for medical assistance, and the freedom of county authorities as to what institutions in their wisdom should be set up, as well as freedom to set up services for the community. Instead of that we have direction of services from headquarters and complementary directions as to taxation. It was not a bad thing to have this measure delayed for a fortnight. I think what has happened during the week-end to Deputy Allen is that numbers of people in his area have been asking him to realise what this was going to cost, and whether the ratepayers could bear the new cost.

Can you suggest a cheaper way?

Is that what we are aiming at? The Deputy stated that these proposals would cost one-tenth of what the Beveridge scheme would cost. The Beveridge scheme was not based on this sort of nonsense at all. It left all that behind. The fundamental object of that scheme was full employment, and when there was full employment for wage earners, you could get people to provide these sort of services. It went in for the coordination of this type of services.

I am aware of all that. I did not go into the details of the scheme.

I would not like to go into them in detail.

You might mention the restrictions.

I would like at some other time to argue what the restrictions are in relation to this measure. I suggest that the Beveridge scheme left people free. In so far as people got service they were to contribute. The fundamental point was that that scheme was based upon employment which would enable people to bear the cost. Once you get into the region, to which the Government has reduced this country, of having 300,000 people flying from it, a whole group brought into the Army, another group added to the Civil Service, 80,000 unemployed, very big numbers receiving what is called home assistance, and wages lowered so that you have to provide for them as cheaply as possibly, then you provide them with the taint of the poor law, and you are getting far away from the decent policy of His Lordship of Clonfert. Even at this late hour I wish they would withdraw it.

I want to direct the attention of the House to two matters. If these two amendments are passed we will be doing what was never done before, and that is giving the Minister power to draft a scheme, the dimensions of which we have no knowledge. It is a scheme for ante-natal attendance, attendance at childbirth and on children. It could be very small or it could be very large. We will be giving the same Minister power, having provided the scheme, to compel the local authority to put it into operation and to raise whatever rate may be necessary to defray the cost. If they do not do that, or if any members of the local authority vote against it, the Minister will have power to take proceedings in the High Court to compel them, and to levy the costs of the proceedings on such members of the local authority as deemed it to be their conscientious duty to resist the proposal that the Minister in this section attempts to impose upon them.

Surely Dáil Éireann is suffering itself to be reduced to a greater degree of degradation than it has ever submitted to before, if it enacts a section without any knowledge, good, bad or indifferent as to the cost of the services which the section is designed to set up, and furthermore, while giving these powers, divesting ourselves in this House of the responsibility of answering to the people for the cost of the scheme and passing that responsibility over to county councillors down the country who may have no voice, good, bad or indifferent, as to the nature of the service, its scope or cost. Surely, if we want to renege on our own functions of judging the merits of any scheme for which we legislate and delegate our whole power in that regard to the Minister, then we ought to face any odium that may be incurred by that scheme when it sees the light of day. But we are not doing that. In the words of Deputy Butler, we are laying the corner stone of a great social structure and then we are passing over to men who have no discretion in the matter, good, bad or indifferent, any possible odium that may accrue from any imprudence of which the Minister may be guilty under the comprehensive powers it is sought to confer upon him by subsection (2) of the new Section 85 which it is proposed to insert in the Bill. That is one point and I am amazed that the Minister for Local Government and Public Health should have asked Dáil Éireann so completely to abrogate its functions as to consent to such a proposal.

The second point is made by Deputy Eamonn Coogan and I wish to underline it. Deputy Coogan says that under the scheme, if a poor person wishes to avail of it, he or she must go to the dispensary doctor because the Parliamentary Secretary has indicated that in any scheme set up under this section which he will approve the dispensary doctor will be the medical man envisaged by the plan. If you want to provide ante-natal care, all this care and attendance at childbirth and on children thereafter, you must open your eyes to the fact that there is no branch of medicine in which the personal relationship between the doctor and the patient is more vital and a matter of greater delicacy. I do not think any person with property in the country would suggest that even a woman's husband should impose upon her a gynæcologist of his choosing. There is no matter in which a woman's own personal preference should be or would be more carefully consulted than in the choice of a doctor in circumstances of that kind. Is it reasonable to say to poor people: "Because you are poor, you will just take what you are given"? I can understand that men who spend all their lives in cities, where a very impersonal atmosphere may be expected to obtain, find it hard to think that an ordinary poor woman should have any very strong preference as between one competent medical practitioner and another. The Parliamentary Secretary has lived long enough in rural Ireland, however, to realise that that strictly impersonal atmosphere does not ordinarily obtain in a rural community. The local doctors are well known to the people. The people are in constant contact with them and there may be individuals amongst them who are agreeable and acceptable to certain people and who are anything but that to others. It may very well be that the dispensary doctor, for a variety of functions, would be acceptable enough but, for the delicate and intimate service that a gynæcologist is called upon to render to a woman in childbirth and the months that go before and the months subsequent to it, any given woman in a country community might have a deep and well-founded reluctance to place herself in the hands of a particular dispensary doctor. It might not be due to any mistrust of his professional skill but professional skill would not be the only matter which might properly be reckoned in circumstances of that character.

The Parliamentary Secretary appears to think that a scheme which would leave the choice of medical attendant to the patient in those circumstances is unthinkable. I cannot imagine why. Under the National Health Insurance Scheme there is a free dental benefit. The patient can go to any dentist of his choosing who has registered himself with the National Health Insurance Society as being willing to treat a person upon the terms vouchsafed by the National Health Insurance Society to its beneficiaries. Is there any reason why, in a scheme of this character, provision should not be made for medical practitioners in the area to register themselves as being willing to give advice and treatment under this plan on the terms vouchsafed by the local authority, whereupon a poor person would be able to go to the doctor of her choice and enjoy the same amenity as her better-off neighbours at present have?

Look at it from the point of view of the doctors. The dispensary doctor is usually an established man once he becomes the dispensary doctor but in almost every small town in Ireland one will find one or two independent practitioners. They are often men who are making their way. If this scheme were to operate it means that all the patients of modest means who might ordinarily be expected to be the patients of the younger doctor, who would normally charge a smaller fee than a man of standing and distinction in his community, will be constrained to boycott the younger doctor because, should they patronise him, they are debarred from any benefits under the scheme here envisaged. On those three grounds I urge the Parliamentary Secretary to reconsider this matter.

In regard to Deputy McGilligan's observations here to-day, I find myself in great sympathy with them, and I believe that at the back of Deputy Butler's mind he also finds himself in sympathy with them. I view with growing concern this eternal tendency on the part of us all to usurp from the heads of families all the functions that a father might ordinarily be expected to discharge to his own family and to discharge those functions through the medium of some public authority. It is a bad tendency. There is no question whatever that an infinitely better system would be to have a social system which would enable every individual in the community to earn a family wage and to buy all the goods and services that his growing children may require and that his wife may from time to time need from his own resources. But, while recognising that, I am not prepared to say that we should leave the people unprovided for until we have realised so admirable a social system as would permit every individual to secure these benefits for himself and, in the interregnum, I am prepared to accept schemes of social services of the kind clearly envisaged by the section proposed to be inserted. I think the scheme for ante-natal care, instruction and assistance in time of childbirth is a good thing and a very necessary thing, particularly in our cities. I am not so sure that it is urgently required in rural Ireland. I think it would be a great pity, however, if, when we were putting our hand to that task, it were done in a way which must give rise to bitter resentment and legitimate resentment. Surely the Parliamentary Secretary will reconsider these amendments and put that scheme, whatever it may be, in some form of annex to this Bill. Before the House is asked to impose a plan upon a local authority and to require a local authority to raise the finances for it, the House should at least be told what the plan is and what a reasonable man might expect it to cost.

Lastly, surely the Parliamentary Secretary, from his own experience, appreciates how cruelly unfair it is to say to poor women in rural Ireland that they must take the dispensary doctor at this time or do without. How minitely preferable it would be to say that, until such time as the social system is reformed to permit of every woman's husband providing these services for his wife, the community will finance their cost, but leave to each poor woman the prerogative which all women, rich and poor, should enjoy, that is, to have about them at this time not only those in whom they have confidence, but those whom they feel to be sympathetic as well.

On the general principle that there should be a scheme which would be capable of adequately dealing with the case of nursing and expectant mothers, I suggest that there will be no disagreement on any side of the House. But where there may be disagreement is on a question merely of details so as to ensure that that service shall be adequate and of such a character that it can be accepted without any question of stigma so far as the recipient is concerned. The ideal system would be the system which has been propounded by a number of people recently and which is now being incorporated in a measure on the other side. Apart from any other question, so long as the need is there for that service, I am not going to be influenced in the least by the question of costs, more particularly as in this particular section we are assured of accommodation that we have not got in other sections, notably in Section 34, so far as the question of the dependents of tuberculous patients is concerned, that we have the advantage of a 50 per cent. recoupment in regard to this particular service.

I did not hear the Parliamentary Secretary make the point, but I understand from listening to the discussion that he maintains that this service will be linked with the dispensary service, that it will be worked in connection with the dispensary doctor. I want to give my experience so far as the City of Dublin is concerned. The city dispensaries, as he is well aware, are under the control of the board of assistance and for the last four or five years have been completely outside the jurisdiction of the city council, because the board of assistance has been abolished and the administration is now in charge of commissioners. I would suggest to the Parliamentary Secretary that it is desirable that this scheme should be operated absolutely and completely free from any suggestion of the old poor law system; that, even under the present administration of the board of assistance, the local authority in the City of Dublin might be permitted to operate this scheme under its own centralised medical staff.

Reference has been made to the inadequacy of the dispensaries throughout the country. I can understand that, because I know some of them, and it is obvious that they are totally unsuited for the purpose envisaged under this section. The same thing would apply, perhaps to a greater extent because of the number of people to be served, to the type of building in use in the city at present. I anticipate as a result of this section the provision of other types of buildings which would afford adequate accommodation for the type of service which will be rendered. I see no reason why that service could not be operated in a practical form, distinct altogether from any association with the board of assistance, whether the administration is carried out by commissioners or under the old system, with representatives from the Dublin Corporation.

The present system in Dublin is that nursing and expectant mothers are catered for under the aegis of the corporation by means of two voluntary organisations; one, the Catholic Social Service Conference, and the other, the St. John Ambulance Brigade, both of which are doing excellent work and to whose funds the city council makes a very substantial contribution each year. It is evident, however, that what they are doing, excellent as it is in every respect, is totally inadequate to meet the pressing requirements of the City of Dublin at the present time. But these two organisations are in a position to operate that service away from the atmosphere of the board of assistance. My plea in reference to this section, so far as the City of Dublin is concerned, is that the local authority be allowed to implement that service in its own particular way. Otherwise, as several Deputies have mentioned, the people who will be benefiting under that system, if they have to avail of it under the dispensary system, will not too readily respond, because, whether we like it or not, there is neither respect nor affection for the poor law system or anything associated with it.

I take it that sub-section (2) of this amendment was prompted by the fact that the Parliamentary Secretary feels that, in certain circumstances, local authorities would not avail of the facillities provided in sub-section (1) and that in such circumstances he feels it right that there should be this authority. I confess that I see no objection whatever to a provision of that character if the local authority fails to do its duty. If for no other reason, I certainly feel that the section should be supported.

I was very much struck by what the Parliamentary Secretary said. I agree with a certain amount of what he said, but I am afraid that in other respects I did not follow him. He seemed to suggest with regard to the present system of school inspection that an inspection which takes place on an average every three years was quite a farce. He did not use the word, but I suppose it is a farce and a ghastly farce. What the Parliamentary Secretary said about it might be summed up in the phrase, "too little and too late". I think the House is all in favour of increased medical benefits for the community, and what we are debating here to-day with the Parliamentary Secretary is the matter of the methods and the degree to which they are to go.

The Parliamentary Secretary said that the scheme as envisaged would run from the very poor right up to the very rich, whom he dismissed by saying that they would be able to make their own arrangements, or some such phrase. He then gave us a description of the class which lies between the very poor and the very rich. I describe them, for want of a better term, as the black-coated workers. I could entirely agree with what he said about that section. Without wishing to run down any other section, they certainly contain representatives of the very best of our race. Listening to the Parliamentary Secretary, it struck me that the question to be answered is: where is the line to be drawn? We have the poor who, I take it, are compelled to avail of these services and the people at the other end of the scale so well off that they need not think of availing of them. I should like the Parliamentary Secretary to be very precise as to where the dividing line is.

There is really none; there is none in the Bill.

In other words, the richest person in the land can call in the dispensary doctor without any stigma?

If he wants to.

I should be very glad if he did want to, because it would show that the richest in the land were prepared to avail of the service. Does the Parliamentary Secretary realise that? Does he realise that it would place a hallmark on him if people with free choice and with money in their pockets who could employ whom they liked called in the dispensary doctor? When that situation arises, we will have the very best medical service at the service of the community. We have heard about the Beveridge scheme on the other side of the water, or rather the revised Beveridge scheme, and it almost looks as if we are going to establish a State medical service here. I do not know what the Parliamentary Secretary's idea is, but I think he mentioned that, under this care of the mother and child system and the inspection afterwards in the school, there would be the services of the dentist and the eye surgeon, and no doubt of nose and throat specialist. Is that all to be linked up with this scheme?

The Parliamentary Secretary did not enlarge on that, but medicine, like everything else, has changed in this present generation. We are passing out of the period of the family doctor who looked after the family from the cradle to the grave, who attended every ailment and who was both doctor and surgeon. We have gone into an age, as I am sure the Parliamentary Secretary would be the first to admit, of specialists. He has mentioned the dentist and the eye surgeon, but I take it that if the doctor suspected a case of diphtheria, he would have to take a swab of the child's throat and have a culture made of it, and that would necessitate a very intimate association with an organisation in his own house where the swabs he had taken would be registered and docketed, and then sent forward to some central place for the next stage of the examination. Are all these specialist services envisaged under this Bill?

I am very glad to hear that, because it would be absurd to have it otherwise. I come now to another very important point in respect of which it is absolutely necessary that we should understand where we are. Is any alternative allowed to the mother or the family to the dispensary doctor? Most of us know some dispensary doctors. They are very hardworking, skilful men, but the most skilful man must occasionally make a mistake and I suppose there are dispensary doctors who have made mistakes. I have come across quite poor people who would not go to a particular dispensary doctor. Possibly, they might have a prejudice, which was very ill-founded, but rightly or wrongly those people should have some choice.

Another matter that calls for attention is the case of a dispensary doctor who may be really hard run to attend to a case that an anxious mother thinks should receive attention. It may very well happen that he could not come for a couple of days and might be run off his feet. Is the person to be left in the meantime without being able to obtain any medical care?

Another point which was made by Deputy Allen and which is a very good point was that of a dispensary doctor who was looking after a child in a house, when someone else was ill in the same house. In my young days, I belonged to a fairly large family and when one of the children would become ill a doctor would be called in. It is an extraordinary thing that, when you have illness in the house, it seems to spread, and very often it was a case of the child looking as if it was sickening for some illness and some other member of the family also was laid up. Supposing that was the father or the mother. Is the doctor to say: "I am treating the child, but I cannot look at the adult"? If that is the position, I think it is absurd and I hope the Parliamentary Secretary will be able to contradict me and say that a doctor who goes into the house is to look after anybody who is ill there.

The Parliamentary Secretary seemed to envisage a certain number of nurses in every district. I can well imagine that, if there are 9,000 people in a district, a nurse could usefully be employed—in fact, several nurses. He did not mention the position of the district nurses who are at present used in certain country districts. I think they get some sort of help from the rates in the shape of grants. Is it proposed to avail of their services and to continue that service as an alternative which might be availed of as well as the State service? I would like the Parliamentary Secretary, when he is replying, to answer that point, as it seems absurd that a voluntary organisation which has lasted for a great number of years and done good work and established goodwill in every district, should be done away with. I am sure he will realise also the effect on a voluntary organisation which has started up, does good work and then is squelched by a Government measure. I hope he will cover those points when he is replying.

So far as the Parliamentary Secretary's opening statement went, I welcomed it in the sense that he certainly gave us a considerable amount of information. So far as his intentions are concerned, I think we are all agreed, but I would say, with Deputy Allen, that it will be utterly impossible to carry out even the very restricted scheme embraced in this section—in so far as it is a scheme at all—through the machinery that he proposes to use. I think Deputy Allen's speech was useful to this extent that he certainly pointed out the more obvious snags and difficulties which we are going to come up against right away. I am sorry I cannot say the same of his colleague, Deputy Butler. I do not know whether it was the speeches from this side or Deputy Allen's speech that brought Deputy Butler to his feet, as he said himself, for the first time since this Bill was introduced. Having listened to Deputy Butler, one wondered why he decided to break his vow of silence.

The Parliamentary Secretary in the course of his speech referred to the dispensary system and said that the objection to it in the old days as the poor law system had been almost completely eradicated. I am sorry to say I cannot find myself in agreement with him there. I go this distance with him, that there is a more enlightened approach to the present-day services. I do not want to go into the whole question of the poor law system; but would like to confine myself to the dispensary system and the use of it for carrying out this scheme. Frankly, in my opinion, it cannot be done. No matter what we may say, the dispensary system and the premises in which the dispensary doctors have to operate are a disgrace to this country. The present buildings in many of the dispensary areas are not of a type that will enable the doctor to carry out efficiently the duties already placed on his shoulders, without putting further duties on him at all. We know the type of house in use not only in the rural areas but in some of our fairly large towns. It is quite a common thing to see on a dispensary day, in inclement weather, people having to line up outside the door because there is not sufficient accommodation inside. In so far as there is accommodation inside, it is quite a common thing to see people sitting in a cold, cheerless room without a fire on a winter's day. The fact of the matter is that, notwithstanding what Deputy Butler has said, this is an attempt to give us something in place of a contributory social service or health scheme—and it is a very poor attempt.

It is costly.

I agree. May I remind Deputy Allen of this? I do not know whether we may claim the credit of having converted him or whether he was converted in his constituency over the week-end.

It had no influence at all on me.

Deputy Allen made a speech to-day. It was the same type of speech which he has been chiding us for making for the last 14 days.

I never did.

From the Money Resolution onwards, we have been warning the House that this measure will place an immense burden on the shoulders of the ratepayers. We tried to get from the Parliamentary Secretary some indication of the limit and we could not get it. That has been mentioned, not only by speakers on our benches, but by the members of the Clann na Talmhan Party and the Independent Party here. We have been trying to convert Deputies on the opposite side of the House for the last 14 days. Deputy Allen's speech is the most effective answer I could give to Deputy Butler, who says that this is pure obstruction on our part. Deputy Butler said that 85 per cent. of the amendments put down to the Bill were vexatious. It is easily known that he has not taken much interest in the Bill. I do not think anybody should say that 85 per cent. or 25 per cent. or even 5 per cent. of the amendments are vexatious. I think many Deputies have observed that there was something in the amendments. It may be some consolation to Deputy Butler to know that, as a result of one of the vexatious amendments moved on this side of the House, he need not fear that he will be carted off and placed in some institution and there have some part of his anatomy removed against his will. He is free from that danger.

There was never any fear of that.

In the sense that the Deputy's organs are so healthy, I hope there will not be any reason to remove them.

At any rate, he will be able to find it out for himself; it will not have to be found out for him by a policeman.

I understand that the Parliamentary Secretary proposes to do something on Report about this Part of the Bill?

There is nothing to be done on this Part.

I take it the proposed two new sub-sections, which are to take the place of Section 85, will set out the full scheme?

That is right.

In that case, like many other Deputies, I want to know what is the scheme. There is no scheme before us. Since the initiation of the measure, the Parliamentary Secretary has been referring to the mother and child scheme. There is no scheme here. He has been talking about the machinery through which the scheme is to be operated. There is no machinery provided in this Bill. He has been talking about the dispensary doctor as the pivot of the mother and child scheme. The dispensary doctor does not appear in this part of the Bill. There is nothing beyond the bald statement that arrangements may be made. In view of the fact that the cost of this, in the main if not altogether, will fall directly on the ratepayers, we ought to get some more information. The trouble about this section is the same as the trouble about Sections 29 and 34. We are not given any idea of what the Minister may demand or direct the local authority to provide. We have no idea of the cost.

Was the Deputy here when I was speaking?

Did I not mention a figure?

Nobody believed it.

There you are.

The Parliamentary Secretary did say, after some pressure——

No pressure at all—that is not true.

If the Parliamentary Secretary objects to that, I will withdraw it. We were pressing to get an estimate of the cost of all parts of the Bill and the Parliamentary Secretary, without pressure, if he likes, said that a rough estimate of the cost of the mother and child scheme was between £500,000 and £600,000, half of which would be borne by the local rates.

I said it a week ago and I confirmed it to-day in a detailed statement to the House.

My recollection is that the Parliamentary Secretary said that that would be the recommendation of his Department to the Minister for Finance.

The cost will be borne as to 50 per cent. by the local authority and 50 per cent. by the State, definitely.

I take that as a definite, unqualified statement. The Parliamentary Secretary has given a rough estimate that it will cost between £500,000 and £600,000. Deputy Allen, going into the thing and analysing it fairly closely, out of his years of experience as a member of a local authority, and having regard to how he sees the present public health services operating, is inclined to believe it will cost double that figure. He points out that it is not merely a question of putting additional work on the local dispensary doctor. It means the provision of extra nurses and of quite a number of additional clerical assistants. In that respect, I agree with him entirely that if the doctors and the nurses are to perform efficiently the duties which this imposes on them, it will be essential for the doctor to have clerical assistance, unless the greater part of his time is to be taken up, not in medical work, but in clerical work, filling in reports for the Department. I think it would not be an exaggeration to say that, even under the present system, probably 50 per cent. of the time of the county medical officer goes in compiling returns. However, it is very hard to criticise a scheme that is not before us. All that is mentioned in the proposed new section is that the arrangements— what they are to be we do not know— will cost £500,000 or £600,000.

There are a few points I would like to deal with and I shall do so as briefly as I can. I need not delay the House by referring to the fact that already we have maternity and child welfare schemes operating in this country. They are operating under Section 3 (2) (b) of the Notification of Births (Extension) Act, 1915. That section provides that any sanitary authority—

"may make such arrangements as they think fit and as may be sanctioned by the Local Government Board for Ireland, for attending to the health of expectant mothers and nursing mothers and of children under five years of age."

Section 4 of the Maternity and Child Welfare Act, 1918, provides in addition to that clause of the 1915 Act the following:—

"and for the purpose of any such arrangements may, subject to the sanction aforesaid, exercise the like powers as they are entitled to exercise for the purpose of the provision of hospitals."

That is the statutory power under which our maternity and child welfare schemes have been operated up to the present. We are repealing the power to

"... make such arrangements as they think fit and as may be sanctioned."

Any arrangements that might be made have to be sanctioned by the Minister or they could not become operative. I made the case fully when I was speaking earlier to-day as to why it was necessary to take compulsory powers in order that we might be able to secure uniformity in the matter of providing services and so that the few local authorities that might be recalcitrant or reluctant to provide services should be forced to provide them. Bearing in mind that the State is bearing fifty per cent. of the cost it is reasonable that it should have a determining say in the matter. We do not want to run into a position in which in 75 per cent. of the geographical area of the State it would operate, and in the other portion it would not operate, because the local authorities might not agree.

Deputy Mulcahy says we are going to throw many people back into the dispensary system. This scheme will be operated by the health authorities, and not by the public assistance authorities. We can have a debate on that point. The purpose and the policy is not to throw anything on to the dispensary system, but to lift the dispensary into the health system. This is a considerable step in that direction. Deputy Morrissey and Deputy Dockrell and other Deputies talked about the buildings as well as the accommodation in our dispensaries. I think I spoke pretty forcibly on that issue during the last fortnight. Nobody in the House feels more strongly on that matter than I do. I understand the position and I have personal knowledge of it. It is not any credit to us and is one of the things that we must remedy, no matter what the cost. When speaking of the provision of institutions and compulsory powers in relation to them I had in mind, particularly, the provision of clinics throughout the country, in substitution for the type of accommodation we have at present. Until we provide such alternative accommodation we cannot hope to lift our health services out of the atmosphere in which they have grown up, as far as the poorer sections are concerned. That is the task before us. It will have to be tackled energetically.

When Deputy Byrne talks about millions being in the hands of the Hospitals Trust, I should say that I repeatedly pointed out that the millions in hands, or any further millions they may accumulate will be necessary for capital expenditure. The capital envisaged will include a substantial proportion, from two-thirds to 75 per cent. of the cost of clinics that will have to be provided if we are to operate services in keeping with the dignity of our people. Complaints have been made by various speakers that we are not giving a choice of doctors. In rural Ireland it does not seem to be possible to provide a choice of doctors for this service. The most ambitious development I can hope for in rural Ireland is to provide an up to date standard of service. If that does not satisfy the people, and if they want a team of doctors from which to select, I am afraid it is an ideal that cannot be reached. If anybody can show me how it can be reached in rural Ireland I will be glad. I do not think it is possible. I should say in that connection that when a patient goes into a hospital nowadays, even in Dublin, there is very little choice of doctors. There is no choice in the county hospitals. Our county hospitals are looked upon as providing a very satisfactory service— and no discredit to us—yet, there is one surgeon, and whether you are fully satisfied with him or not there is no team from which to select. The same applies to fever hospitals.

Deputy Byrne and Deputy M. O'Sullivan mentioned the position in Dublin City. The position in Dublin is exceptional. This scheme cannot apply to Dublin City without modification. Dublin Deputies know that. The Dublin Corporation has under consideration, and is in negotiation with three maternity hospitals in Dublin, with a view to evolving a scheme for mothers and infants. That problem arose out of the shocking death rate amongst infants under two years of age in Dublin. The maternity and child welfare scheme evolved in Dublin City extends far beyond that developed in any other part of the State. There is no intention of scrapping the good work that has been done. We will have to examine the position in Dublin City very carefully and, probably, the best policy there will be to build up the mother and child services and expand them. The scheme we have here is not applicable to Dublin City. I concede at once, that if we tried to operate that scheme in the dispensaries in Dublin it could not succeed in such surroundings and in such circumstances. If I might speak particularly to the Dublin representatives what we envisage is to provide clinics, build up the health services, and lift up our public assistance people from the type of institution that they are at present being treated in, and to give them a setting and a surrounding to which they are entitled.

Deputy Allen and other Deputies talked about the difficulty of securing full services in the rural areas, because of the amount of work dispensary doctors have to do. We will find that some of our districts are too big. I think it would be a sounder scheme to have more districts, rather than to put a couple of men into a rural district in which there was not, perhaps, a good living for one man. If we put too many doctors into an area where the scope is limited we are not providing the very best services. These are details we will have to work out in good time. The question that Deputy Dockrell raised about district nurses can be dealt with on Section 96. Meantime, I refer the Deputy to the statement I made on March 20th. It arose on the Money Resolution and will be found in the Official Debates. That was a general indication of our policy in relation to the nurses, and it gives a line of thought with which we can deal in greater detail when we come to it.

Is the amendment agreed to?

I think it might be better not to put it through until to-morrow. There are points that I want to raise but that I have not ready at present.

Amendment No. 83 agreed to.

I move amendment No. 84:—

Before Section 85 to insert the following section:—

(1) A county authority may, with the consent of the Minister, make arrangements for attendance to the health of children and for the education of children in matters relating to health.

(2) Arrangements under sub-section (1) of this section may include arrangements for the holding of medical inspections of children at schools or other places.

(3) The Minister may by Order direct every county authority, every county authority of a particular class or a particular county authority as to the manner in which and the extent to which they are to exercise their powers under this section and a county authority to whom any such direction relates shall comply therewith.

Progress reported; Committee to sit again to-morrow.
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