Committee on Finance. - Vote 74—Office of the Minister for Health. – Dáil Éireann (12th Dáil) – Tuesday, 11 Feb 1947

Committee on Finance. - Vote 74—Office of the Minister for Health.

Minister for Health (Dr. Ryan)

I move:—

That a sum not exceeding £3,340 be granted to defray the Charge which will come in course of payment during the year ending the 31st March, 1947, for the salaries and expenses of the Office of the Minister for Health.

This Estimate represents the cost of the Office of the Minister for Health for the remainder of the present financial year. Until the Estimate is passed the salaries of the Minister and the officers concerned will be borne on the Vote for the Department to which they have previously been attached, the amounts so borne being repayable to the Departments concerned out of this Vote.

The expenditure for which the authority of the Dáil is now being sought relates only to the salary of the Minister and the Secretary and Assistant Secretary of the Department of Health, together with the usual secretarial staff attached to the Minister's office, and a round sum of £1,000 in respect of such additional staff as it may be found necessary to transfer to the service of the Minister for Health before the close of the present financial year. The provisions in the existing Estimate for all other staff and for the services for which the Minister for Health will be responsible, in pursuance of the provisions of Government Orders transferring functions, will be borne on and accounted for under Vote 41 (former Department of Local Government and Public Health). I want to stress that point because there is a difference in the next Estimate—that the expenditure will be accounted for by the present Department of Local Government.

General Mulcahy

The Minister has made a very remarkable statement in the light of what we expected to hear from him. I take it that he is moving the Estimate for the Ministry of Health. Considering all that was said here on the Bill for the new Ministeries and all that was said and promised before, it is a rather remarkable omission that the Minister has not made a statement which might be some substitute for the White Paper on the new Ministry of Health which the Taoiseach promised us specifically when dealing with this matter on a previous occasion in the Dáil and which has been referred to so often here. It would have helped us a lot if the Minister had made some kind of statement on the way in which he is approaching the work of putting together the machinery that is now being put into his hands and the broader aspect of the work which we understand he is facing. I hope that the Minister will do something to supply that omission before he asks the House to pass this Estimate.

There are some things I should like to say on the Estimate, but there is one thing I should like to deal with first. It may be a simple and individual thing, but it is urgent and I think it is no harm to throw it into the forefront of our remarks on this Estimate. On several occasions during the last year I have drawn attention to the condition of the people in the Blasket Islands. In dealing with the matter I was dealing with the possibility of their carrying on the work from which they get an existence and pointed out that, in order to help them to do their work systematically and properly and to live in their modest kind of way, it was necessary to provide them with suitable facilities for landing on the mainland. On two occasions I pressed very hard to have the condition of the pier at the Dunquin side looked after. Within the last three weeks a young man, one of the remaining population of about 30 on the islands, got ill. He was ill for a week. During that week he was not able to get the attention of a doctor because the boat could not set out from Dunquin. He was not even able to get medical advice by telephone, because the telephone arrangement was not working. There you have, in one of the sections of our people we are particularly anxious about because they form that part of our people who hold in its richness and in its continuity our national language, people left in circumstances in which they can die of illness within a week because they have no means of communicating with a doctor even by telephone. The Minister, according to what was set out when the new Ministries and Secretaries Bill was before us, is responsible for these things and I do not apologise in any way for asking him to see, with regard to this one remnant at any rate of our people there, that something will be done so that the small population there shall not be allowed to die in the way in which this young man was allowed to die within the last three weeks because contact could not be got in any way with a doctor.

The attitude seems to be that the population should be taken off the Blaskets. The school has been shut down there and there is very little likelihood of getting the Government to face up to doing anything that would improve the economic condition of these people. But, small as the population there is, within the last year two young married couples have started life on that island and, with any kind of realisation on their part that the Government was interested in them in any way, that island could arise again. At any rate, until such time as something is done for them, it ought not to be possible for us to have it said that the inhabitants of that island can die without the attention of a doctor or a priest. I speak of the doctor side of it because the Minister is responsible for it.

In the absence of any statement from the Minister, I should like to review the general spirit in which we have been asked to deal with public health matters in this House, say, during the last 12 months, since the Public Health Bill was introduced, in November, 1945. That Public Health Bill, although it is on the Order Paper, has been dropped, and I wonder would the Minister see that the Government ask for an order discharging the entry on the Order Paper. It need not stay any longer there to remind us of some of the objectionable provisions of it. I want to speak of the general atmosphere in which public health has been approached, as a result of the discussions that took place around that Bill and on another occasion since.

In the first place, it was indicated in connection with that Bill, that something like £500,000 requires to be spent in increasing medical services throughout the country, that half that amount will be raised from local authorities and half will be borne by the State; and that, in connection with nursing services, an amount, that the Parliamentary Secretary at that time was not prepared to specify, would be required. Very elaborate figures were quoted as to the cost of erecting new public health institutions or public assistance institutions of one kind or another and a very large bill of expenditure was foreshadowed. I think this would be an occasion for the Minister to review, in however broad details, the line of policy that the Ministry of Health has in mind and in respect of which this expenditure is contemplated, if it is contemplated now.

In the second place, I should like to ask the Minister whether the approach of the Ministry of Health to the organised medical profession in the country is going to be the approach of the Department of Local Government and Public Health in relation to the medical profession in dealing with the preparation and previous discussion of the Public Health Bill. The Minister will remember that the attitude was that the Minister for Local Government or his Department declined in any way to discuss with the organised medical profession any aspect of the policy that was enshrined in the Public Health Bill. Perhaps that is the matter that we would most like to have information about to-day and it is the matter in respect of which it is most important that we should be assured.

I do not think, therefore, that I need apologise for asking the Dáil to listen to a statement published by the County Limerick doctors on that aspect of public health policy. The statement was published in the Cork Examiner of the 28th January, 1947. A meeting had been held of the County Limerick Division of the Medical Association of Ireland. I read an extract from it:—

"Attention was drawn to the fact that, however great its importance public health legislation lay in a domain which had been found to be fraught with danger to the autonomy of the family. It is necessary, for instance, to guard the family's right and duty to control the physical welfare and physical education of its members, and it is necessary to respect the authority of the family in all its rights and duties, including privacy, in relation to medical records.

The demands of the natural and supernatural law may not with impunity be set aside for the purpose of achieving any fancied gain in efficiency or scientific knowledge. However spectacular the results, the ensuing loss of family morale would be disastrous even from the public health point of view. The conclusions of medical science are of inferior rank to those of moral science, and hence the practice of medicine is governed by the conclusions of moral science in a higher way than by the conclusions of its own science. The effective solution of public health problems requires not only the application of the rules of hygiene, but also the employment of all measures within the competence of the State which may be expected to enhance the sense of `family' in the community and, in particular, a spirit of family independence. This spirit will not flourish in the absence of good moral, social, economic and other environmental circumstances and especially of good food and good housing conditions. The State's problem is to secure these things for the community while at the same time upholding family morale.

If the doctor is to take his proper share in this work of promoting health and coping with disease, he must be allowed to retain that degree of professional freedom which is indispensable to him.

It should be remembered that, as the doctor is a servant of the patient or of the family—because this is the source of his authority for all he does to the sick person—it follows that any limitation of the doctor's clinical freedom is really a limitation of the rights of the family.

For these reasons, the profession is opposed to any suggestion that its members should become, primarily, State-directed officials. A case can be made for the right of the State to direct doctors `to' the work for which they are qualified, but no foundations exist for a claim to direct them `in' their clinical work.

It should be remembered that `it is no part of the normal function of the State to teach'. This dictum is most strongly applicable to the teaching of medicine. Health education can only be successfully carried out by individual personal teaching, for it requires that pupil and teacher be in intimate personal relationship."

The statement goes on to give certain points that I am sure will be brought to the Minister's notice or that we may refer to at a later date but there is a very considered and thoughtful statement by a section of the medical fraternity, speaking on behalf of part of their organised body, and it deals with matters that are troubling, not only Irish minds at the moment, but the minds of people wherever the State is asserting itself in any strong way with regard to public health.

The matter has been referred to within the past 12 months on very many occasions in Great Britain where, in connection with some of the changes they are bringing about in their machinery for dealing with public health, there has been a considerable amount of discussion—much more discussion and much more comment than there has been in Ireland. The same principles are involved, but, so far as we are concerned here, the same principles have been attacked.

Lord Woolton is reported in the London Times of 8th October last as giving an inaugural address to the students at the Westminister Hospital Medical School. He said there was no doubt that immense advantages had arisen out of the scientific and mechanical apparatus that had been brought to the aid of diagnosis, but he warns that medicine could not be mechanised, because the body was not the whole of man.

"The achievements of the men with specialised knowledge who used these modern wonders were truly great, but in the end the general practitioner's intimate knowledge of the patient was the greatest force in both curative and preventive medicine. It was founded on detailed observation of many facts and was built with the material of confidence."

He went on to add that there were doctors for patients even more certainly than there were horses for courses, and the patient must be free to change his doctor for no other reason than that he did not like him; and the doctor should be free to tell the patient to seek advice elsewhere because he knew that, for one reason or another, he would never do that patient any good.

Again, some time in October of last year, as reported also in the London Times, Sir A. Webb-Johnson, President of the Royal College of Surgeons, discussed the national health service in an address which he gave in Liverpool Cathedral.

"He said that the doctor's work was primarily a personal service and his calling exacted the utmost that man could give—full knowledge, exquisite judgment and skill in the highest, to be put forward not at any self-chosen moment, but daily at the need of others. The doctor had often to be his patient's confidant and friend. The well-equipped clinician must possess the qualities of the artist, the man of science and the humanist, but he must exercise them only in so far as they subserved the recovery of the individual patient. He must feel directly responsible to his patient— not for him to someone else. It was a hard doctrine but none the less true, that this essential function of the doctor—the care of the given patient—might involve the foregoing of exactly scientific diagnosis, of the artistic perfecting of an operation, or even of the interests of society at large."

Lord Woolton warns that the actual machinery that has been brought to the aid of diagnosis is a thing that you have to take care against; that man is both a body and soul and that to some extent the relationship of the doctor to the patient has some element of the relationship of the priest to the penitent. If that is so, that we have to be careful of machinery in the hands of the practitioner who realises his personal responsibility to the patient, the fear that we may have of the machinery of State working on the individual patient and interfering between the patient and the doctor is even greater still. In the Catholic Herald of the 29th March last year——

An Leas-Cheann Comhairle

Is the Deputy relating all this to the Estimate? Is it proper to discuss policy on a small ad hoc Estimate?

General Mulcahy

We are considering an Estimate giving the Minister power to administer a particular Department. I am not so much discussing policy; I am discussing the atmosphere in which administration will be carried out. We have had experience during the past year of a Department of State introducing proposals for public health and dealing with patients and doctors while claiming that they were not going to discuss the proposals enshrined in that legislation with the medical fraternity.

An Leas-Cheann Comhairle

That Bill is not before the House.

General Mulcahy

I know, but our experience of having had to discuss these matters with the Government is very strongly present in our minds. I think that it will probably save parliamentary time ultimately and help towards a little understanding if I am allowed to finish my point. I suggest that I am entirely in order in discussing the administrative approach. It is the administrative approach we are concerned with here. The Minister is embarking on a new Ministry and the principal machine he has is the medical fraternity in this country. I am speaking of the administrative approach of the Minister to the medical fraternity and in relation to that I am picturing to some extent the positions and the functions that are peculiar to the medical fraternity. The Catholic Herald, dealing with the national health scheme, gives the opinions of a practitioner and a priest. The priest is Father Bonnar and he says:

"The principles which must chiefly be invoked to throw light on the present matter are those concerning social justice, individual rights and duties, individual freedom, and full respect for the rights of conscience in doctor and patient."

Later on he says:

"Professional secrecy between doctor and patient is one of the most valuable and scared elements in the medical tradition. This is not a specifically Christian matter but it accords well with the Catholic view of the doctor's vocation, which is second only to that of the priest. There may be a definite danger that, in a State medical service of an all-embracing character, our health will be card-indexed and the information handled by a number of civil servants, and that this information will be used for other purposes than that of promoting our personal health. Another danger to the Catholic conscience is the possibility that treatment may be so standardised that the liberty of Catholic doctors and Catholic patients in respect of medical and surgical procedures repugnant to Catholic morality, may be crushed out. The more immediate danger is that Catholic doctors may be excluded from many positions...."

I think it well to bring these matters before the Dáil and particularly before the Minister because of our experience in dealing with the Public Health Bill and because of the way in which certain provisions of that Bill overrode the rights and invaded the privacy of individuals and seemed to hold out a strong State hand to grip and direct the medical fraternity in a way which I do not think that profession should be gripped or directed. I refer to this matter all the more because of the attitude the Taoiseach took up in the Seanad. He did not agree with the co-ordination of certain services under the Ministry of Social Welfare; he held that no good would arise from the coordination of these services, but that he was proposing to have them coordinated, so that they could be better managed and better supervised.

The Minister will not object to my recalling that he particularly, as a Minister, has declared that the day for the State managerial idea has now come and that, before the State manager, vocationalism will become less and less of importance. These are all matters that I think make it advisable that we should get some idea from the Minister, in asking the Dáil to pass this Estimate, as to what his relations are going to be with the medical fraternity. It might perhaps enter on the domain of legislation or policy if I went further, but I do think it would be advisable for the Minister to give the House at this stage some idea of the extent he contemplates private medical practice is going to be allowed to remain in the country. That may be asking him to comment on some of the provisions of the Public Health Bill which is being withdrawn, but if he were in a position to make a pronouncement now and give us some idea as to the extent to which he was modifying the Ministerial approach to the setting up of the new public health machinery, it would be helpful. It would help him, if he is going to enter into discussion with the various professional bodies connected with public health in the country, in his relations with these bodies.

The reason I ask for a statement of that kind is that the Public Health Bill as it stood aimed at making over to the local dispensary doctor the whole of the medical services for all children and all mothers in each area. I feel that it would be well if we could know definitely now whether the Minister was approaching the work of his new Department with the idea in his mind that he was going to place the whole of that work under the local dispensary doctor—that is, that the care of children from the time they are infants up to the time they are 16 years of age or until they leave school, would be the responsibility entirely of the local dispensary doctor and that the care of mothers would also be his responsibility. If that is going to be the position, then I think he should let us know to what extent any kind of private medical practice is going to be left in the country and in what way there is any likelihood of there being left in the country that relationship between patients and doctors of their own selection which the medical fraternity here and elsewhere feel is one of the most important aspects that can be considered in connection with public health.

Mr. M. O'Sullivan

I should like to ascertain from the Minister if he has now arrived at the stage at which he can say whether all the various items which are finally to come under the purview of his Department have been segregated absolutely from those dealt with under the Department of Local Government. If so, has he so advised the public bodies concerned and can he say if the arrangements arising out of these notifications are in actual operation? Further, would he say finally where it is intended to have the headquarters of his Ministry? I do not want to impinge too much on questions of policy. I recognise that there are limitations to the discussion on this Estimate but since the Minister is inaugurating a new régime, might I point out that one of the most important matters connected with the subject of public health is the question of the treatment of tuberculosis? In that respect I should like to have some information also. There are two phases of the treatment of tuberculosis which the Minister can approach quickly and deal with effectively—the question of accommodation and the question that has often been discussed in this House, namely, allowances for the dependents of those who are undergoing treatment in sanatoria. I mention tuberculosis particularly, because of the activities that were pursued in the late Ministry some months ago in connection with the setting up of regional sanatoria. One of these sanatoria was to be established at Santry where it was intended to have bed accommodation for up to 1,000 patients. There is a good deal of doubt existing at the present time as to whether in fact the project of the sanatorium at Santry is to be proceeded with. I think the Minister would be performing quite a good service if he would indicate whether there is a definite and positive decision to proceed with the establishment of the regional sanatorium in Santry.

There is the other question of allow- ances for the dependents of those who are undergoing treatment. There has been a disposition for quite a considerable time to deal with that question by the old worn-out method of public assistance. I would ask the Minister, now that he has the opportunity, to take into consideration the unanimous viewpoint of this House that we should have a fixed scale of allowances for the dependents of patients in sanatoria on the same basis as exists in the North of Ireland and in England. Members of the medical profession in this House and outside it will bear testimony to the fact that it is absolutely impossible to proceed successfully with the treatment of tuberculosis while individual patients are subject to the worry that their families and dependents outside are perhaps in want. I suggest to the Minister that he should give some indication so far as may be practicable as to how he proposes to deal with waiting lists, and also that he might make some pronouncement as to whether the sanatorium in Santry still remains a public project.

Dr. O'Higgins

I do not intend to delay the House very long on this Estimate. It is obvious that once the House has sanctioned the establishment of the new Department the salaries and wages required between now and the end of the financial year for that Department must be provided by Parliament. On that aspect of the matter I have nothing to say. Deputy Mulcahy referred to some evidence we had of lack of co-operation between the Minister's predecessor and the medical profession as exhibited very clearly and acutely in connection with the Public Health Bill. The Minister's appointment to the Ministry of Health has been welcomed by the medical profession as a whole—by individuals, and by the organised profession. I do not pretend to join in those notes of welcome, not for any particular objection that I have for the individual or to the Minister.

I stated very clearly in the House, at the time the proposal was made, that I thought it was a mistake to have a medical man in charge of the Ministry of Health. It is bound to lead to confusion between the medical minds of the paid medical experts and advisers and the medical mind of the Minister, and when there is a division between those two minds the medical Minister is in the position, in fact, of being a kind of superior doctor. A soldier in charge of the Ministry of Defence would be just as big a mistake. If we look to any of the older countries that have worked for centuries through the parliamentary system and the parliamentary machine we will not find a doctor in charge of the Ministry of Health, a legal man in charge of the Ministry of Justice, a soldier in charge of the Ministry of Defence or a naval man in charge of the Admiralty. Those technical expert matters are to be dealt with by the staff, by the experts, by the specially selected men, and the Minister is supposed to represent the mind of the layman only to see how the recommendations of those professional experts affect the lives of the ordinary people. If you have professional experts, with their minds duplicated higher up, the whole system and the whole idea of Ministerial control breaks down. For that reason and that reason only, I objected and still object to a medical man, a member of my own profession, being in charge of the Ministry of Health. It would be better to have a cobbler, a lawyer or a farmer there and have the present Minister, with his Ministerial experience and capabilities, in charge of some other Department.

Be that as it may, I make those observations in order to make it clear that, although the appointment has been generally welcomed by the profession, I think the profession generally is making a mistake. I do certainly congratulate the Minister on the fact that his early steps, as an infant toddling, as the new Minister for Health have been very wise steps. He has certainly completely departed from the policy of his medical predecessor. The previous medical mind in that Department seemed to consider that health—national health—was the affair of the individuals who frequent the Custom House, and was not the affair of the men and women down the country or of the members of the medical profession throughout the country. I think it was the height of presumption for any Minister to bring in a far-reaching, comprehensive Public Health Bill dealing with the health of all people from infancy to old age and death, and to state, in introducing it, that he had not gone into conference with, and had not consultation with, the members of the medical profession. His statement that his reason for that was that it was because they were addled politicians was ignorant and offensive. That Bill was doomed the day it was introduced, and even if it had been passed through this House it was stricken and doomed. Any Bill that deals closely with the health of the people, that depends for its implementation not only on the work but on the enthusiastic work of the professional men throughout the country, can only be formulated after full, adequate and ample consultation between the Department and the individuals who are expected to implement it. The present Minister's early steps were in the direction of inviting conferences and consultations. Those were wise steps, and will have very beneficial results for everybody.

It is nothing short of a scandal that a Public Health Bill should have been a matter of controversy, but that Public Health Bill, as introduced, could never be anything but a matter of controversy, because in its very introduction the gauntlet was thrown down to the medical profession. The members of that profession were treated with complete contempt and disrespect. The Minister has undone a considerable amount of the harm done previously. At the moment the relations between the Ministry and the medical operatives throughout the country are, if not harmonious, certainly very much improved. Relations can never be harmonious between the Ministry and the profession generally throughout the country so long as members of the profession are treated as if they were beggars at the back-door of the Custom House, as if they were lower in the social scale financially than people without profession, trade, or even any kind of common skill.

I should like, seeing that we now have a medical Minister for Health, if he would occasionally scrutinise some of the documents that go out in his name to various officers, boards and councils throughout the country. If he does he will realise that if his Ministry is to be respected by the profession generally it must show some respect for the profession. Doctors, take pride in their work. Their profession is an old, long-established one. It is a profession that is respected by the ordinary people, and nothing should be done by a Ministry of Health to bring it into complete and total disrespect. Since the Ministry was established, and since the Minister took up duty, I happen to have seen circulars that went out from that Department asking that cases of certain types of infectious diseases over the last 15 years should be visited by the district medical officer, that certain discussions were to take place and that certain specimens or samples were to be collected from those people's bodies— from people living five and seven miles away.

The doctor was to go out, he was to sit down and patiently argue, cajole and discuss the advisability of getting a particular specimen. He was to get the specimens, cork them, label them, parcel them up and send them away to a laboratory, get a report back from it, and send that report on to a county centre. When all that work had been done, the Minister would be prepared to sanction a fee of 2/6. Could anybody have any respect for a member of a profession or trade or for a worker or unemployed man who would be sent seven miles away to do a job of work and then be told that the value that would be placed on his services— having travelled seven miles there and seven miles back to do the work— would be this, that he would receive 2/6? That in the year 1947! That was broadcast throughout the country. I should respect the Ministry of Health and the Minister if they had asked to have that work done in the public interest without any fee. If the members of the medical profession, irrespective of poverty or anything else, saw that the thing was important to the health of the people, they would not haggle about a fee. They would rather by far be asked to do the work for nothing than that that circular should have been printed and circulated throughout the Twenty-Six Countries. Would the Minister, as a householder, send for a tradesman, living three or four or seven miles off, ask him to come to his house and look at a door or a window and produce 2/6 for his time and labour? He would be a very courageous man if he did that. Would he go to a taxi-man, ask him to drive him four miles out to his house and back and produce two shillings and six pennies as payment? That is a very unhealthy start and I advise the Minister, if he wants to have proper relations between the medical men who have to do the job of work throughout the Twenty-Six Counties and himself and his Department, to peruse for some time to come everything that goes out from his Department affecting the profession. If irritating things and worrying instructions have to go out, at least ensure that nothing offensive or insulting with regard to the profession generally will emanate from the Department. Let that be done, at least, until the Minister gets properly established and consolidated there and the avenues of approach between himself and his Department and the profession generally are reopened—reopened, I hope, with satisfactory results to the centre, the periphery and the public generally.

Deputy O'Sullivan referred, in passing, to a certain matter in connection with tuberculosis. I shall not explore that to any extent on this occasion but it is regrettable that, in spite of the best efforts and the best intentions of all concerned, tuberculosis should be getting farther and farther ahead. On the first occasion on which I address myself to a new Minister for Health, I am entitled to say that, when we are dealing with health matters, the people whose advice should be of the greatest importance are those who are responsible for health away down throughout the counties. Their advice should be as important, with regard to health measures and health matters, as that of those who do their work in the Custom House, Dublin. Although it gives me no pleasure to say "I told you so", six years ago from this bench I implored the Minister for Local Government and the Minister for Supplies to take some interest in the health of the people. At that time, motor-cars were taken from under the nurses of Ireland. It was illegal for any district nurse to use a motor-car. Health visiting completely broke down. The county tuberculosis officer was given for a month as much petrol as he had previously used in two days. That meant that contacts which should be seen from day to day were not seen even from month to month. The tubercular case had infected 15 or a dozen others before either the nurse or tuberculosis officer could reach on it. The same applied to every other infectious disease. Six years ago I said that, with the petrol allowance given to doctors and nurses, infectious disease was going to get completely out of hand. A nurse or a doctor was pushing a pedal-bike or walking many miles while motor lorries tore by— turf lorries, timber lorries and empty Army lorries—and there was ample evidence that, provided the case was put up sufficiently strongly, petrol could have been got from the Department of Supplies. The voice of the organised nursing profession and the organised medical profession throughout the country was either not heard or not listened to in the Custom House. I am mentioning that regrettable and tragic state of affairs—a state of affairs the results of which we shall be paying for for the next two or three generations—so that that policy of excluding the people who are primarily and most closely concerned with matters of health will not be pursued by the present Minister.

With regard to the late and, possibly, not lamented Public Health Bill, there is this to be said: it was a Bill that contained many good and beneficial sections, parts and portions. It was also a Bill that contained some matters which would make it absolutely unacceptable to the people and, I think, to the professional workers. It is a pity, because of the good portions that were in it, that it should be suspended for so long. The Bill could be very speedily amended. The views of those concerned could be readily heard. Deputy O'Sullivan referred to one portion of the Bill. That portion of the Bill made provision for tubercular patients when undergoing treatment. It made financial provision for finding a substitute for the mother or custodian of children while she was undergoing treatment for tuberculosis. With important sections like that in the Bill and with the state of that disease throughout the country, it is unfortunate that the measure should be unduly delayed because merely of administrative changes. The Bill in itself was an important one and the sections that were objectionable stood out very clearly. The Minister is in a position to get the views of those concerned, but with the objectionable sections removed I would certainly deplore any undue delay in introducing a Bill to take the place of the late Public Health Bill.

Mr. Cogan

On this Vote it is not possible or desirable to have a long debate on the administration of this new Department. We will have to wait and see how it will develop, as it is only in the course of formation; but we would like to have from the new Minister some indication of the general lines of policy he intends to pursue. I would like to know his views on two main questions. Firstly, is it his policy gradually to organise and streamline the medical profession until they become part and parcel of the Civil Service? If it is, it will be a step definitely in the wrong direction, a step towards complete disaster not only as far as public health is concerned but as far as the general welfare of our people is concerned. The Minister would be well advised to consider the views expressed recently at a meeting of the Limerick branch of the Medical Association, as reported in the Standard last week. They stated in a resolution:—

"It must be remembered that the essential means of securing good health is a good moral life in a good social order. If the doctor is to take his proper share in the work of promoting public health and coping with disease, he must be allowed to retain that degree of professional freedom which is indispensable to him. For these reasons, the profession is opposed to any suggestion that its members should become primarily State-directed officials. It is felt that such a condition of things would destroy the normal doctor-patient relationship which implies a mutual confidence and friendship."

The views expressed there are of such importance that the Minister should consider them very carefully, and I think he would be well advised to follow the advice given. There is a danger that, in the attempts that will be made in the future to promote a higher standard of efficiency in grappling with disease, and particularly with infectious diseases, the medical profession may be regimented to a much greater extent than in the past —and not only that, but ordinary people over whom the medical profession may exercise their duty may be regimented and controlled. That must be avoided and it would be well if the Minister could assure the House that it is his intention to preserve and protect the freedom of the medical profession and the freedom of the individual citizen to choose whatever doctor he wishes when he requires treatment.

Another matter of equally grave importance is the financing of the expansion of public health services which is envisaged. Will it be the Minister's policy to continue the practice which has been long in operation, of compelling local authorities to bear 50 per cent. of all costs incurred? There are so many grave and urgent needs in regard to institutional treatment and in regard to assistance for those who are obtaining that treatment and such a wide expansion of the service is so urgently necessary that it would be wrong and unwise not to face these problems on a national rather than on a local basis. Tuberculosis is a problem which must be tackled nationally and I do not think it would be desirable to impose even 50 per cent. of the cost on the local authorities. It would be a mistake to have this great work held up by reason of the natural reluctance of local authorities to incur additional expenditure and impose additional burdens on the local people. The national approach is necessary as well as a national system of financing it.

Deputy O'Higgins had rather interesting views to express on the subject of a doctor in charge of a Department of Health. He thought it should be controlled by somebody other than a doctor. I am sure that view will be refreshing to the present Minister, as one of the most frequent criticisms I heard of him—in addition to all his sins of commission and ommission—was that he was a doctor when in control of the Department of Agriculture. Frequently I have heard the view expressed, not only by the Minister's opponents but even by members of his own Party, that it was ridiculous to have a doctor in charge of the Department of Agriculture.

Dr. O'Higgins

Did he not cure all your ills?

Mr. Cogan

There is a good deal to be said for the view which Deputy O'Higgins has expressed, as far as public health is concerned, although I do not think any farmer would welcome another doctor to the Department of Agriculture.

I would like to bring to the Minister's notice a section of our people whose claim is seldom mentioned in this House and to whom attention is seldom directed. I speak of infirm people living alone, particularly in rural areas. Very frequently we read of old people being found dead in their homes, sometimes dead for two or three days and sometimes even eaten by rats. It is deplorable that that should happen in a Christian country and I have always felt that something serious and drastic should be done to bring the benefits of health administration to such people. I am not going to suggest that people who prefer to live alone in their little homes in rural areas or in isolated places should be hustled away to some institution, but a service should at least be provided by which these people would be visited in their homes and by which grave neglect could be avoided.

It might be said that neighbours and friends should look after them. That is perfectly true. It is the duty of relatives and even of neighbours, even though not relatives, to look after people living alone who may be old and infirm, but very frequently what is everybody's business is nobody's business, and often such people are neglected and come to sad and lonely ends. There is an urgent need for a special investigation into the needs of these people. Many of them may be proud and may not wish to seek assistance, while others may be mentally weak or defective and may be opposed to anybody interfering in their business, but it is a matter, I think, in regard to which all will agree that something should be done.

Mr. Blowick

With regard to tuberculosis, and what we are doing to check it, a Bill was before the House some time ago providing for three new regional sanatoria. I do not know what steps have been taken to complete these sanatoria and I should like the Minister to give us an outline of what exactly is happening with regard to them. From my experience in my own county, and I am sure the same applies to other counties, tuberculosis seems to be claiming more victims than ever, although we were told during the passage of that Bill that that was not the case, that tuberculosis was more or less on the decrease. Returns from many county medical officers, however, show that the disease is not by any means checked or decreasing. Some time ago in Mayo, we had to take steps to increase the accommodation for tubercular patients pending the erection of a sanatorium in Galway, and I think that the application for sanction for the new temporary erections will come before the Minister in a short time. If that be the case, I ask the Minister to expedite the matter—at least to have it dealt with with more expedition than we have been accustomed to get from the Custom House in the past.

We have beds in the county sanatorium at Creagh for 40 patients and 12 additional beds in the county home, a total of 52, but the county medical officer and county tuberculosis officer report that there are more than 52 patients on the waiting list. Some have died in their homes and possibly the disease has been spread amongst their families. There have been one or two painful cases of fine young men who have died while awaiting beds in the county home. If suitable accommodation had been available, some at least of these lives would have been saved, and I urge the Minister to help the Mayo County Council in the matter. The same applies, I am sure, to other counties, and it seems that it will be a pretty long time before the regional sanatoria are built and equipped, and many victims of tuberculosis who could be saved will have died by the time they are available, apart altogether from the infection they will have spread by then.

I think it was Deputy O'Sullivan who referred to a scheme of remuneration for the dependents of tubercular patients. Such a scheme will become an absolute necessity, and I ask the Minister to take all requisite steps to devise such a scheme, because what happens is that a tubercular sufferer—a father of a family—hangs on simply because he knows that if he goes to a sanatorium, he will have to spend six months, a year and possibly two years there and his family will be in destitute circumstances, and all the more so if the valuation of his holding is a bit high. There is nobody left at home in some cases but his wife and a few young children who are going to school or who have not yet reached school-going age. Something should be done in these cases because much harm is caused by the lack of a scheme of remuneration for the dependents of a bread-winner.

We have to a great extent got over the difficulty of the stigma associated with this disease because of which people cloaked and hid it and would not admit that they had it, because of which they would rather die at home than admit they suffered from it, and the next step is a scheme of the type I mention to enable them to go to the sanatorium without having to worry about leaving poverty or destitution behind them and so avoid the possibility of their hanging on in the vain hope that the disease may lift and they may improve, and thus cause harm to people in their households.

Mr. Everett

With regard to the salaries of dispensary doctors, I observe from some of the returns of county managers that, while provision is being made for increasing the salaries of all officials, including nursing staffs, they have omitted making any provision for increased remuneration for dispensary doctors, on whom the poorer section of the community are solely dependent in connection with health matters. The excuse which one county manager has given me is that he was awaiting some instructions from the Minister for Health, as he understood that dispensary doctors would be taken over by that Department. That might take a long time and, as public bodies are preparing their estimates at present, I suggest that he should communicate to the county managers his view that dispensary doctors should receive no less generous treatment than is being given to other officials. Even a third-class clerk under a public body has a higher salary than the dispensary doctor.

With regard to the attendants in mental hospitals outside Dublin, the position is that many county councils, in cases where applications have been made for increased salaries and improved conditions, are recommending different increases and different conditions. The union has made representations to the Minister with a view to having the county managers called together for the purpose of bringing about co-operation and deciding on one policy, and I suggest that the Minister might even go so far as to agree to a conciliation board to help and advise him in connection with disputes relating to mental hospital attendants. I am aware that a large number of institutions outside Dublin have had the matter under consideration for some time, and, in the interest of the health of the mentallyafflicted persons in their charge, I suggest that, as an urgent matter, he should forthwith take the matter up with the respective unions, with a view to bringing about a satisfactory solution of the problem with which he will be faced in relation to various attendants outside the Dublin area.

As to the question of tuberculosis, the public body of which I am a member did everything possible to give publicity to the fact that in tuberculosis cases a generous grant was given to provide accommodation by way of an additional room to houses on the recommendation of the county medical officer of health. We also give an allowance to any person discharged from a sanatorium or, if the bread-winner is in a sanatorium, to maintain his family while he is in the institution. During the last week we had no difficulty in having the national insurance benefit supplemented in some cases by a sum from the public body concerned to enable the patients to get extra nourishment while recovering their health after being in a sanatorium. I ask the Minister to give special attention to the two matters to which I have referred. I know the problem that has to be faced in connection with the attendants in mental institutions, and I ask the Minister to give the matter his immediate attention by having either a meeting of the unions held or a conciliation board set up to settle the matter.

Mr. D. Morrissey

I was rather disappointed that the Minister seemed to treat this Estimate as if it was an ordinary Supplementary Estimate for an established Department, and did not feel that he was called upon to say anything in connection with it, beyond explaining briefly the sums required and the purpose for which they were required. I should like to get from the head of the new Ministry of Health some indication that there will be a radical change in the approach to this matter of the health of the community from the way in which it has been dealt with, in so far as it has been dealt with at all, in the past. I think it is true to say that the health of the community has deteriorated and is deteriorating. I think it is true to say that there is an increase in disease in this country. I think it is true to say that we are not making any real effort to grapple with that or with the causes of it. I should like to get from the Minister an assurance that the matter will be tackled in a different and more comprehensive way and, certainly, in a more effective way.

We talk about tuberculosis and sanatoria. These sanatoria are very necessary because a certain condition has been allowed to arise and it must be dealt with by way of sanatoria and other curative measures. But, side by side with building sanatoria, are we still to have conditions that are undermining the national health, that are reducing the powers of resistance of the people to disease? I do not believe that the provision of more hospitals and sanatoria will improve the health of the community so long as certain conditions with regard to the health of the community are allowed to remain. The Minister recently—I think it was somewhere in the West—certainly gave more information than he gave us here as to what he proposed to do. Amongst other matters he dealt with national health insurance. I do not want to go into that now beyond saying—and it can be related to what has been said about tuberculosis—that there is a fear on the part of tubercular patients to go into a sanatorium for treatment because they have people depending on them.

Is there any man in his sane senses, unless he is so stricken that he is unable to work, going to lie up and send for the doctor when he knows that instead of getting £2, £3, or £4 a week for himself and his family he will get 15/- national health insurance benefit? That in itself is something that is crying out for a remedy. I hope that the Minister will indicate either on this Estimate or on the next Estimate his attitude on this matter. I would suggest, Sir, that we might have the whole discussion covering the two Estimates on this one. That is a matter, of course, for the House, but what I have to say I should like to say here and now.

An Ceann Comhairle

Yes, the Minister's salary is on the first Vote.

Mr. D. Morrissey

That gives us a little more liberty. I do not think there is very much liberty on the other Estimate.

An Ceann Comhairle

Not on the other Estimate.

Mr. D. Morrissey

I should like to hear from the Minister whether anybody can make a case for and talk about national health insurance benefits at a rate which was set up 30 years ago when one considers the purchasing power of 15/- then and the purchasing power to-day. If the thing were not so serious it would be laughable to call that national health insurance. I should like to hear from the Minister that some of the time of his Department and himself will be spent in dealing with that and I hope the Minister will be able to bring before the House in the near future something that will give us a real national health insurance service instead of the make-believe that we have at the moment.

Let us take another matter. I venture to suggest that a very big proportion or percentage of our community at the present moment, having regard to existing prices and conditions, are living in conditions bordering upon the existence level. These people cannot obtain sufficient nourishment to maintain good health or any powers of resistance to attacks upon their health. Do we not know that that is so? Do we not know that there has been a bigger strain put on the health of the people during the last four or five years than perhaps at any time in our generation? Do we not know that there is less protective clothing and that the quality of such clothing as is to be had is far inferior to what it was in pre-war days? Do we not know, notwithstanding all that has been attempted, that there is less heating available? So far as the ordinary poor family is concerned, one hesitates to speak about them, having regard to present-day prices and the difficulty of obtaining ordinary bed-clothing. Do we not know that, because first-class materials cannot be obtained, the footwear for men, women and children in this country to-day is absolutely inferior? Indeed one might say that the best of the footwear is not able to keep a dry foot on either child or adult. Do we not know all these things are affecting the health of the people?

I heard it stated here by the Minister's predecessor that poverty had nothing to do with tuberculosis. I know nothing about medicine, but it would take the whole Medical Association to convince me that a family reared in unhygienic surroundings, in crowded and ill-nourished conditions, are not much more likely to contract and perhaps die from tuberculosis than a family brought up in more up-todate and hygienic conditions and with plenty of nourishing food available for them. We have got to get back to that. We have to ask ourselves whether people in this country, from the old age pensioner up, can keep their bodies in a condition to resist disease on the amount of food their incomes will enable them to buy under present conditions.

These are the aspects of the matter that I should like to see the new Public Health Department turning their attention to. May I, as one who had a few words to say on the recent Public Health Bill, say that any efforts that will be made by the Minister or by the new Department towards improving conditions and improving public health in this country will have the wholehearted support of all sides of this House? There is no doubt about that. As Deputy Dr. O'Higgins said, there were certain features of that Bill that were good; there were certain features of it which were highly objectionable, and perhaps not the least objectionable feature of it was the manner in which it was introduced and in which it was sought to pilot it through the House.

Mr. McCarthy

When Deputy Mulcahy was speaking of the maintenance of the slip-way at Dunquin I found it rather difficult to visualise to where he was leading, but, when he explained that he was speaking about the atmosphere, then I had a better idea of his approach to this subject. We all regret very much the incident that, he recalled, took place on the Blasket Islands but the Minister could hardly have controlled either the atmosphere or the elements. At the time to which the Deputy referred vessels far more seaworthy than the boat in question were unable to reach their destinations or provide maintenance for those on the headlands, outposts and islands around our coast. Deputy Mulcahy then quoted from the Cork Examiner some comments from the medical profession in Limerick. I shall be very pleased to give the Deputy the report of a very eminent practitioner in Cork city, one of the most eminent men in the country, with full permission to pass it on to Deputy Cogan when he is finished with it, in which he praises the Government for the proposals in the Public Health Bill. That Bill has not yet come into effect but certain things were set out in it as being beneficial to the community and they have been carried out by that medical officer and in this report he praises the people for their co-operation.

Deputy Morrissey has stated that families reared in unhygienic conditions have not much chance but, at the same time, objection is taken to remedying that state of affairs in the houses where the people must remain pending the provision of adequate housing. Experience has shown, in the City of Cork at any rate, that with a proper approach to this matter, people will co-operate to the fullest extent. Certainly, nobody wants to interfere, least of all the Minister for Health, with the intimate confidences between doctors and their patients but, as the general health of the community is the concern of all, surely the authorities should be entitled to take such steps, within reason, as will bring about a better state of affairs in that regard. Deputy Morrissey has also stated that in his opinion there is an increase in disease in the country and that there is little being done to grapple with it. As one who has studied the statistics for a considerable number of years, I think the Deputy is mistaken, both in regard to the incidence of disease and the steps taken to grapple with it. However, this is not an occasion for going deeply into these particular matters. The matter under discussion is the Vote for the Minister's new Department. I, and many like me, are very glad that a professional man is in charge of the Ministry of Health. The only reason that I can see for the plea for a non-professional man is that such a man would know less about it and consequently would be able to do less to remedy the state of affairs. Surely a doctor who knows the problem intimately is the most desirable man to have in office.

Mr. Morrissey

You should have said that when he was Minister for Agriculture.

Mr. McCarthy

Yes. There were certain things in that Department that a doctor could handle and he proved that he could handle them and the country knows that he did handle them.

Mr. O'Leary

Why shift him then?

Mr. McCarthy

That is not my responsibility. I am sure he will acquit himself well wherever he is shifted to. I do not wish to enter into personal matters of that kind. I take a more broad and general view of the situation. It is deplorable on occasions like this that every kind of side issue is drawn in in order to criticise, before the Department is really started.

Mr. O'Leary

We have been waiting for a Public Health Bill for two years. The great man, who was to steer that Bill through, was steering other things, and had to be cast. As an ordinary worker, living with the poor, I would suggest to the Minister that the first thing he must do is to come to the aid of the sick poor. In reply to a Parliamentary Question 12 months ago I was informed that in the National Health Insurance Fund there is a sum of £4,700,000. Yet, every day in the week, honest men who fall sick and who have stamps to their credit have to wait sometimes three weeks before they get their first 15/- out of that fund. When they get a second 15/- the lady inspector is sent down to visit these people's homes and, if they happen to be outside the door, that is reported and benefit is cut off. I hope the Minister will not allow that to take place. No working man or woman would go sick for the sake of getting 15/- after three weeks, and sometimes it is six weeks. Referee courts are held and persons who have stamps to their credit may be disqualified. Then they have to go to the home assistance officer.

One of the first duties of the new Minister should be to increase old age pensions, widows' and orphans' pensions and the benefits to those entitled to them under our system of national health insurance. There are many deserving people who are on the verge of starvation; they are as badly off as many of the people who, we are told, are starving in Europe. We have people who are in receipt of 7/6 a week; widows for the most part get only 5/-, and the highest old age pension is 10/-. I hope the Government will not leave this issue dangling until the next election. Usually at election times we have platform statements and posters telling us that national health insurance benefits and pensions will be increased.

Even at the height of the emergency the condition of the poor people was never at such a bad level. Men receiving a trade union rate of wages of £4 or £5 a week were granted, on the Minister's figures, 15/- of a bonus. At the same time we have many old people who, only for their friends and relations, would now be dead of hunger. I entered the county home in my own town two Sundays ago to visit some old age pensioners there. There were 70 or 80 of them in the home, honest old men who had no one to help them outside and whose only refuge was the county home, where they had to hand over more than half of their pensions. They get a few shillings every fortnight in order to buy tobacco. That is the treatment given to men, some of whom helped to found this State and some of whom are the fathers of 1916 men.

I speak from practical experience when I refer to the conditions of the poor. I have signed in the labour exchange and I have been on a sick bed, and no one here can tell me that I am not stating the facts. The Minister, who comes from my own constituency, will, I hope, give some attention to these matters. When there is agitation throughout the country over old age and other pensions, I hope they will hold their meetings in public and not in rooms. Let the public know the truth; bring the scandal of the national health insurance before the public. In the North of Ireland and in Great Britain pensions for old people and for widows and orphans have been increased, but here the poor and the sick are left to die.

There is a great responsibility on the Minister for Social Welfare. Every year when the Estimates come up for consideration Deputies advocate better treatment for the sick and the aged, but the Government do not exert themselves. When the Taoiseach introduced the new Ministers we were all filled with hope that our social services would be improved without delay. No Party will oppose any amount of money that may be voted to help people in need. There is over £8,000,000 in the Hospitals Trust. I tabled a Parliamentary Question some time ago and I was told there was £2,000,000 for sanatoria but it would not be in the public interest to say where the other £6,000,000 was invested.

An Ceann Comhairle

The Minister has no control over that.

Mr. O'Leary

The former Parliamentary Secretary, Dr. Ward, answered the question, which appeared in the Official Report. In many parts of the country there are no fires to-night. In many homes there is very little bread or sugar and there is no bacon. There is nothing for the poor, but the people with the money are all right. They will not be short because they can get goods through the black market. In one provincial town an old age pensioner could not get a proper supply of milk and unemployed men with families could not get the milk they are entitled to. There was a letter sent to the Department and the milk supplier stated that he could not give the milk as he was not getting his usual supplies. The vouchers given to the people are no use in many cases; they are merely bits of paper.

We all hope that the new Minister, our own man from County Wexford, will tackle this matter in earnest. Delays are dangerous. If there is not something done soon many people now expecting benefit will have gone to their graves. The Minister spoke recently at a Fianna Fáil meeting in Borris. He was not very hopeful when he said that the only way we could increase unemployment, assistance was by increasing the stamps. Nobody would object to paying one penny extra if he thought he would help his neighbour, but though we are stamping cards there are many workers who are not getting sufficient benefit. We have lots of officials who are paid £5 or £6 a week going through the country doing little or nothing. On the other hand, there are many instances where married men are given only 15/- a week on which to support themselves and their families. Of course, members of the Government Party may say: "That man is all right because he is getting a family allowance and free boots." Supporters of the Government will tell you: "No one is hungry; is not the Fianna Fáil Government helping them in every way?" They are doing it in a half-hearted way.

Not half enough is done for the poor; there is too much attention given to the other classes. Stamps are paid for in order to give proper benefits to the sick and aged but they do not get them. Everyone is paying for the social services, but the Government is not giving sufficient assistance. The £4,700,000 laying to the credit of the national health insurance should be devoted towards increasing benefits for deserving people. They are looking hopefully to the new Minister for Social Welfare. If he does not help them they will give him their answer at the next general election.

Only that you are a decent kind of man I would say more.

Mr. Byrne

The Minister, a fortnight ago, in reply to a question put by me stated that:—

"State pensions are not my responsibility except to the extent that the expression refers to old age pensions. I have already arranged for the examination of the whole position in my Department."

I am not without hope that we will get an encouraging statement from the Minister to-night following the result of his consideration of this matter.

Mr. Cosgrave

While I realise that this is a small Estimate and that the Minister is really beginning at the end of the year in a new Department, I think the House is entitled to a survey of the work which the Minister had already carried out, as well as an outline of the policy which he expects to put into operation in the new Department of Health. It has been said that the change which has been made was necessary because the Department of Local Government and Public Health became overloaded, and because of the fact that many of the new services administered under both sections of it had increased. I think that the first thing the Minister should do in establishing this new Ministry is not to overload it with unnecessary officials. Rather he should start at the other end and ascertain first of all what are the minimum standards of health and of wages which are essential in order that the average family may have proper and nutritious food. I understand that, as far back as 1922, a survey was made here. I suggest to the Minister that the first essential, from his point of view in dealing with public health, is to set up minimum standards, and afterwards endeavour to see how they may be improved upon: how the services relating to them may be expanded as the necessity for such expansion arises.

I should also like to direct the Minister's attention to this, that nowadays, in dealing with public health, it is fashionable occasionally to say that efficiency may be got by direct bureaucratic action, by directing the public through official channels to do certain things. I think it is now universally recognised, even by those who have had no experience of national or State medical services, that ultimately the best type of service is that in which the relationship between the patient and the doctor is allowed to remain on a personal basis. So far as one can gather from the observations which are available from the members of the medical profession, the Minister is starting in this new Ministry with their goodwill. In view of that, I suggest to him that before bringing in any measure which may affect the members of the medical association he should have consultations with them. That does not mean that their views must prevail, but it would give the public confidence that the Minister had consulted those who were in a position to assess the merits or otherwise of any proposals that he might make.

It has been said here that, because the Minister is a professional man, he should know more about the work of this Department than, say, a layman. That very often is the popular view. It is true to say that, in many other countries, professional men are not in charge of departments for which their particular training would qualify them. Experience has shown that persons without detailed or professional knowledge of a particular type of work are afforded a degree of liberty and freedom which enables them to take a detached view of the opinions and directions put up to them by experts. It is quite common that when a professional person, or a person with experience in any particular line, is faced with conflicting views, possibly views by experts, his professional knowledge tends in some way to distort his judgment, whereas a person with no professional knowledge may rely on his own judgement and not follow the advice and information supplied by his experts. I imagine that the Minister, with his long dissociation from actual medical practice, will not fall into that error, and I suggest that he should primarily rely on the expert opinion and views put forward by the Medical Association: that he should consult with those people who have direct experience in public health matters, such as county medical officers of health or dispensary doctors. That is the course that, I think, he should follow in the case of Bills, such as the Public Health Bill.

Finally, I would suggest to him that at the start of his work in this new Department he should endeavour to wipe out as far as possible, and as quickly as possible, all traces of the poor law system which has been handed down to us. In many ways, of course, that system has been modified and altered considerably, but, nevertheless, some remnants of it still degrade our social and national fabric. I suggest to the Minister that the sooner the remnants of the poor law system are eradicated from the national health service, the more satisfactory, from the point of view of public acceptance, that service will be and the greater the effect on our public health. Finally, I suggest to the Minister that, in order to get in the future the most highly qualified members of the profession to take positions under the Department of Public Health, a radical reorganisation of the salary basis of these positions will have to be undertaken. Unless the salaries are considerably increased and the terms greatly improved, the Minister will not get into the public health service the best men from the profession. If the Minister is not in a position to give an outline of the policy of his Department to the House now, I ask that, either by means of a White Paper or other means, he give an indication of that policy before the Estimate for his Department for the year 1947-8 comes before us.

Dr. Ryan

I was placed rather in a dilemma owing to the pressure from certain Deputies that I give detailed information regarding the policy of my Department. At the same time, I was advised to consult all around me before I would make such an announcement. I have been only three weeks in the Department and I have not had time to consult the people whom I have been asked to consult. I think that it will be admitted that I could not be expected to give details of the policy of the Department of Health at present. Opportunities will be given to the Dáil in the future to discuss such questions of policy. The White Paper was referred to. That will be in the hands of Deputies in the near future. I cannot say exactly how long its preparation will take but I hope that Deputies will have it soon. The Public Health Bill had to be divided into two parts. Although the greater part of that measure would come under the control of the Health Department, some of it would be the concern of the Local Government Department, so that the draftsman has to give us two Bills. The Public Health Bill will come before the Dáil and there will be an opportunity of discussing many matters which arise upon it. The Book of Estimates for the coming year will be published in the course of a few weeks and, in the discussion of the Departmental Estimate for 1947-48, Deputies will have a full opportunity of dealing with the policy to be pursued. I hope to be able then to say more about policy than I can say to-night.

I have taken a note of Deputy Mulcahy's point about the Blasket Islands. In that matter, my Department would require the co-operation of other Departments. I am very sympathetic to the people of the Blasket Islands because, at one time, I spent my holidays in the vicinity. I shall see what can be done to prevent anything occurring such as occurred there in the recent past. Many speakers mentioned my relationship with, or approach to, the medical profession. I am only too anxious to discuss with the medical profession any matter that may crop up and to get their advice. As Deputy Cosgrave says, I need not take their advice if I do not think that it is right. I should be only too happy to have their advice on matters as they arise. I do intend to have a consultative council of medical men appointed with whom I can discuss matters of importance from time to time.

Some Deputies quoted a statement from the County Limerick Medical Association. I saw that statement before it was referred to here. It was a very flamboyant statement. I had not thought that the literary material amongst the medical profession in the County Limerick was so good. Their fears are absolutely groundless. Nobody has proposed that any limitation should be put on the clinical freedom of the medical man. Nobody has proposed— in fact, I think I could say it has been forbidden—that medical men should disclose any information about their patients. The Department of Local Government and Public Health were careful never to mention the name of a patient in any communication which might take place with regard, say, to infectious disease. An initial or a number was used instead of the name. I mention that to show that the Department of Local Government and Public Health were very particular that nothing like that should occur. I do not know how the members of the Medical Association of County Limerick could have got it into their heads that there was a danger of anything like that taking place. I was also asked what my idea was with regard to the future of medical treatment—whether it would be State controlled to a great extent. I do not agree with that. I do not think that such a medical service would be at all the best. I think that the medical practitioner will have to have his own practice and his own individual freedom, much the same as he has now, though there will be more State work put on to him as time passes. That is the only way a great deal of this public health work can be done—by putting it on to some medical practitioner or other.

Deputy Cosgrave referred to nutrition. At present a sample nutritional survey is proceeding and we expect to get some valuable information from it. I was asked as to the size of the Department and so forth. I cannot give Deputies very good information on that matter at the moment. When the Book of Estimates comes along, Deputies will see what the cost of the Department will be for a full year. Unfortunately, we have no building into which to go. Practically all the staff of the Public Health Department are in the Custom House. They have been there up to now and I am afraid they will have to remain there.

On the other hand, many of the staff of the Social Welfare Department are centred around Dublin Castle. My own office will be in the Castle, as well as that of the heads of the two Departments. We cannot have the whole Department in any one building, but that applies also to other Departments and it cannot be helped.

The staff working on the functions that are transferred will come over with those functions. In the Social Welfare Department it is a very simple matter, as there were distinct sections, such as the old age pension section and the national health insurance section. They come over with the staff, just as they are. In the Health Department, many of the staff were on health matters, but there were certain cases, as mentioned by Deputy Dockrell, where men worked part of the time on health work and another part on local government work. We have to divide as well as we can, giving some to me and some to Local Government. They all remain civil servants and there is no such thing as pensioning a man off because the work is gone. There will not be any additional staff, except at the head. There is, of course, a Secretary of each Department, over and above what was there before, as well as a Minister. These are the only additions I can foresee at the moment.

Tuberculosis has entered into this discussion. As everyone knows, it is one of the biggest health problems we have. A Bill came before the Dáil almost two years ago with regard to the building of regional sanatoria. It has been very slow, first of all, in getting the sites, as a fairly big amount of land was necessary, to spread the various buildings over, but now the sites have been got in Dublin, Cork and Galway. The Cork site is being taken over within the next two or three days; the Galway one is on hands and the Dublin one, as Deputies know, is at Santry Court. I cannot say at the moment whether we will proceed with Santry Court or not, as there is a certain doubt whether it is advisable to erect a sanatorium there.

The architects and the engineers have been working all the time and have done a great deal of the planning for the building of these sanatoria and I think that we should be in a position, in Galway at any rate, to get on with the contracts well before the end of this year. I am very sorry to have to be so guarded as to when we can get on with the building of these three places, but it is a very slow matter getting the plans ready and getting out the contracts and it will take some years—two, three, four or five years— before these sanatoria are ready for occupation. In the meantime, we are making every endeavour to add to existing institutions and as a result there will be before the end of this year a good addition in the number of beds available around the City of Dublin. Deputy Blowick mentioned that they were doing the same thing in County Mayo. I can assure him that, as far as possible in the Department, we will help any county that is making an endeavour to increase the number of beds for tubercular patients.

With regard to the maintaining of the dependents of a tubercular patient, that was in the Public Health Bill and when it comes back again before the Dáil that provision will be included. I can assure Deputies who asked some questions on that point that it will not be on the public assistance basis, but will be a right to the person and will, I hope, be on a liberal scale.

Many Deputies were rather troubled about the fact that I at one time got a diploma in medicine and on that account they think I am not the best person to be in charge of health. Well, I take a rather modest view of my medical knowledge at the moment. It is 23 years since I was in practice and in the meantime I was a farmer. I do not know what objection there is to a doctor becoming a farmer, any more than a school teacher or Civic Guard or shopkeeper, but there appears to be an objection. We will just have to get over it. Deputy O'Higgins is here and I can understand his fears.

Perhaps there is a good lot in the point that if a medical man were Minister of Health and depended too much on his own knowledge there would be a certain danger; but I think if you are not too confident of your own knowledge and can, as it were, get a quicker understanding of the technical advice tendered from the technical staff in the Department, it may be no harm to have studied medicine many years ago.

Two or three Deputies mentioned something—I did not exactly understand what they had in mind—about the patient being permitted to choose his own doctor. No one ever contemplated doing away with that option that the patient has at present, if he can pay. Any person who can pay a doctor can go to any doctor he likes and get advice. Of course, we all know that the person who cannot pay can go only to the dispensary doctor. That arrangement will continue; but doctors who are now in charge of dispensaries will get more duties and in that way there will be more people in each district entitled to free treatment. But they are not bound to take it: they can pay another doctor for his advice if they like and need not go to the dispensary.

Mr. O'Leary

There is very little at the dispensaries—only bottles of water.

Dr. Ryan

No, that is not right. The dispensaries do quite good work. As far as stocking the dispensaries with medicine is concerned, that matter will have to be examined, too. Anyway, the patient can choose any doctor he likes in the future, as he did in the past. The only difference will be that more people will be entitled to get free treatment than were entitled in the past.

A question was raised about dispensary doctors' salaries. All I can say at this stage is that dispensary doctors are as deserving of an increase as many others who have got it, but it is a matter for the county manager. One Deputy said that a county manager had told him that he was doing nothing about it as he was waiting for advice from the Minister for Health. I do not know why he should say that or why he should wait for advice. It is a matter for the county manager, in the first instance, to suggest what he thinks would be a fair increase, if he wants to give any increase.

Mr. Corish

They have not much initiative in that respect.

Dr. Ryan

That is their job. I do not think Deputies are consistent when they advise me to say to county managers: "You should give the doctors soand-so", because the Government has often been criticised recently and in the past for interfering too much with local authorities and we ought to leave them whatever little freedom they have and not interfere with them any more. I personally would like to see a fairly uniform scheme for doctors, mental hospital attendants and others, but it is very hard to see how that can be done so long as we have local authorities and so long as these local authorities have autonomy in matters of wages and so on. One of them may pay more than the other and it is not easy for anybody at the top to suggest that they should all pay the same.

The remainder of the debate centred around the Social Welfare Department. We should keep this in mind, that these social welfare schemes—old age pensions, widows' and orphans' pensions, national health insurance and so on— were never designed to put people in as good a state financially as they would be in if they were working. They were brought in, piecemeal, if you like, one by one, to help these people and at least we can say that the widow who now has a pension, be it ever so small, is better off than the widow who, some years ago, had no pension and that the person getting sickness benefit now, even though it is small, is better off than the person who is not entitled to that benefit because he is not insured under the scheme or for some other reason.

If we are to increase these amounts, the question is how are we to do it? Deputy O'Leary quoted me as saying in Borris that the only way was to raise contributions. I did not say that that was the only way; I said it was one way—in other words, that if the amount of 1/- a week which the farmer has to pay for stamping a card were raised to 1/6, no doubt higher benefits could be paid. Similarly with unemployment insurance. If the unemployment insurance stamp were increased by 50 per cent., the amount given to the unemployed person could be increased.

The other way is to take it from the Exchequer, and there is a limit to what the Exchequer can do. These are matters which we are examining and we must see what we can do. Deputy Byrne said that I stated a fortnight ago that I was having these matters examined, and he asked if I could say anything about them to-night. I am afraid not. They are being examined, but I have been only three weeks in the Department and three weeks is not a very long period in which to examine the entire social services of the country.

Mr. Corish

But the Minister did promise that they would be increased in the near future.

Dr. Ryan

Did he?

Mr. Corish

I think I read that.

Dr. Ryan

Vote put and agreed to.

Dáil Éireann debate - Tuesday, 11 Feb 1947