Dáil Éireann debate -
Wednesday, 11 Apr 1956

Vol. 156 No. 2

Committee on Finance. - Vote 63—Health (Resumed).

Mr. Bartley

Last night, I was referring to a service which came into operation under the Health Act and for which there was a long-experienced want. That was to help people who had been touched by the hand of God and for whom apparently, under our health services, there was not any relief forthcoming in the way of improved health. The community would have felt an obligation on them to do what they could to relieve the circumstances of people in such an unfortunate position. The burden of my complaint in the matter is that the intention of the Oireachtas and the spirit of the Act in respect of this provision have been outraged and I do not think that is too strong a word to describe the administration of this provision, as it has come to my notice.

I have before my mind a certain number of cases and I think I am entitled to express the opinion which I have formed on the administration of the scheme in so far as these cases showed it. It might have been a better arrangement to have taken this type of service from the Health Department entirely and to have put it under the Social Welfare Department which would seem to me to be more appropriate for the idea which animated most of us in relation to it, when it was being enacted. In cases of people who have been invalids for long periods —some of them all their lives—and who have been unable to do anything to contribute to their own incomes, and some of them have been so ill from birth as not to be able to receive education, one would have thought they would not be ruled out on some narrow technical medical decision. It seems to me, unless one of the official doctors in a county is prepared to say that an applicant is suffering from organic trouble which is likely to cause his death within a reasonably short time, he does not qualify for benefit under the disablement benefit regulations.

I have gone to the trouble to argue out the question with one of the official doctors. I stated more or less what I have stated now with regard to the intentions of the Oireachtas and the spirit of the legislation and he disagreed flatly and fundamentally with me in the matter of interpretation. People who, to all intents and purposes, were not disabled but who were found, as a result of his minute examination, to suffer from what he thought was a dangerous complaint have in fact qualified for these benefits; people who have never been able to earn a livelihood, or any part of it, and who are in the general opinion fully entitled to these benefits, people for whom the legislators intended these benefits, have been refused.

I think that situation is a mockery of Parliament and its intentions. If there is within the wording of the sections any justification for the operations of the official doctors in the various counties, then I think the Minister ought to take serious notice of that situation, and, if necessary, have a conference or any other consultation which may be within his power to have this position examined.

Another matter which has caused a good deal of misconception and disappointment is the question of entitlement to domiciliary attention. I admit it is not a matter easy of solution. Very often in the past, those least able to pay have been least able to get out of paying, while those who were most vociferous and possibly not quite so deserving got free treatment, in relation to which there might be a doubt as to their entitlement. What the solution of the problem is I cannot say; I cannot put my finger on any method by which it can be solved. It does seem to me, however, that the administration of old age pensions is a possible pointer to a solution. There is there a mixture of local representatives, plus an official, to deal with old age pension and blind pension applications. These two elements in local administration do not always see eye to eye and do not always agree. Usually, there is a conflict, but, if there is, there is also an official arbitrator. That particular type of administration has worked well and satisfactorily on the whole. The amount of injustice done under it has been very small. As a matter of fact. I think it is true to say that the balance would be in favour of the applicants.

Whether or not a somewhat similar scheme could be worked out in relation to free domiciliary treatment is a matter to which I should like the Minister to pay some attention. Domiciliary treatment is every bit as important as hospital and specialist treatment. We know a great many people do not require hospital treatment. We know that in many cases, if the people get treatment at the earliest possible moment at home, it is a reasonable assumption that fewer people will require to go into hospital than is now the case, because the possibility is that hitherto they have left treatment too late; and the reason they left it too late was that they did not wish to involve themselves and their families in the cost of treatment.

I have come across—not in recent years—some very extreme cases. They were maternity cases in which deaths resulted, because of the inability of the people to pay the recognised fee for the treatment required and because of their unwillingness, too, to accept the red ticket. Whether a red ticket would have been accepted by the doctor in that matter is something about which I am not quite sure. Those were extreme cases, but they demonstrate to me the importance of getting a satisfactory solution for the problem of domiciliary treatment.

I shall pass from that now. In my constituency, they are certainly important problems and I hope the Minister will give all the attention he can to solving them. There is just one other point. When we were amending the managerial legislation here, a good deal of credit was claimed for the fact that additional powers were being given under that amendment to local authorities. On a reading of the Bill, it was not very clear as to where these additional powers would lie and I myself tested the position out in an amendment in relation to certain appointments. I found that the Government and the Parties supporting it had their tongues in their cheeks as far as these extra powers were concerned, and they turned down my amendment which would have given a little bit of real power in the matter of temporary appointments. The note struck by Government speakers was that, now the powers of local authorities were being enlarged, there would be some real inducement to people of merit and capacity to offer themselves for representation on local bodies.

I should like at this point to draw the Minister's attention to a recent action of his. I have as yet no official confirmation of the information to which I am about to refer, but, if I am wrong, and the Minister says I am wrong, I will accept his correction and sit down. I understand that within the past week the Minister sent a sealed Order to Galway County Council in connection with the appointment of staff to the Central Hospital in Galway, which has now become the Galway Regional Hospital. There are two schools of thought as to the method of appointing the staff to that hospital. The respective appointments are: a wholetime surgeon, a wholetime obstetrician and gynaecologist, and a part-time ear, nose and throat specialist.

There was a conference on this matter, participated in by the Galway County Council as the principal party, representatives of the Department of Health, representatives of University College, Galway, and representatives of the Irish Medical Association. I understand there was a two days' sitting to consider the best basis of appointment of these persons. The issue was whether the appointments should be part-time, with the right to full private practice, or wholetime, with a very limited right to private practice. I understand, with regard to the surgeon, that he would have the right to be consulted, but that he might not operate. What exactly the purpose of tying a man like that was I could not see, because the man could very easily charge 100 guineas for a consultation and not give the patient the benefit of a manual operation. In any event, it did seem strange to those of us who had been listening to the principles enunciated—if principles they were—and the viewpoints expressed by the Minister and by Fine Gael spokesmen generally and by the Irish Medical Association on this question of the right of citizens to have what private consultation they were able to pay for to have these persons in an important place like Galway, a university town, cribbed and confined in the way proposed by those who have been backing wholetime appointments.

In my remarks on this Estimate, I am not so much concerned about the merits of these proposals as with criticising the Minister if he has taken this action—if he has not done so, I hope he will stop me in my tracks—and has sent down a sealed Order to Galway County Council compelling them to make wholetime appointments. The Galway County Council, as I said, participated in a two-day discussion with people of great importance, knowledge and experience in the matter, and, having heard all the viewpoints, decided by a two to one majority that these appointments should be on a part-time basis.

Heretofore, that was the basis on which these appointments were made, and in the view of Galway County Council, that had given general satisfaction, and, in fact, had given more satisfaction than their limited experience of full-time appointments led them to expect of such full-time appointments. If the local authorities—as has been claimed in the amendment of the Managerial Act—have been given these greater powers and fuller discretion than was formerly the case, it does seem a very striking and strange commentary on that amendment of the Managerial Act that the Minister should now send down a sealed Order directing the Galway County Council to adopt a course which they had very definitely turned down by a two to one majority.

I do think that the Minister would have contradicted me, if my information was incorrect and, therefore, I take it that the information which is the subject of current rumour in Galway—that is the only authority I have for referring to it here—is correct. If I were wrong and the Minister had not made this Order, I think he would have corrected me. I take it, therefore, that this Order has in fact gone out and that the people in close association with the service in Galway, who believe it has gone out and who informed me it was received, were speaking the truth.

I am not going to delay much longer on the point, but I do wish to castigate very definitely the high-handed and dictatorial attitude of the Minister for Health in dictating to the Galway County Council in a matter which had been fully examined by experts at a conference to which they as a council entirely, and not merely by way of delegation, were a party and were fully informed. After getting the fullest information on the matter, they take a decision by a two to one majority in favour of part-time appointments, with the full right of private practice, and the Minister, by his sealed Order, has upset that decision and directed them to make these appointments on a full-time basis. I would like to hear the Minister, when he is concluding, justifying his action in this respect, if, in fact, he has taken it.

Mr. Coogan

May I ask a question on this point? Is the Deputy aware that a certain thing happened in that hospital which is the subject of an inquiry and whereby, under the old system, a child was allowed to die; and is he aware that, at a second sitting of the county council, there was a different vote? That should clarify the position.

Mr. Gogan

In so far as the Minister is prepared to further implement the Health Act of 1953, we, on this side of the House, will be prepared to give him every support. We believe that a job well begun is half done. But I would like to remind the Minister, however, that half done is still only half done, and that he will have to go much further in his implementation of the Act before he satisfies members of all Parties of this House.

I congratulate the Minister on fulfilling the promise he made last year when he was introducing his Estimate, that he would extend the benefits of the Act to the middle income group. I would, however, like to protest against the unfairness of bulking the family earnings to constitute the limit of £600 under which individual members of such a family will benefit under the Act. I think a good deal of the criticism levelled against the increase in the rates would be dissipated if those paying rates participated in the benefit of the Act. I am aware that the scale of domiciliary allowances is primarily a matter for the local authority, but I would respectfully request the Minister to ask the local authorities to increase those scales or at least make a more generous interpretation of what constitutes the earnings of a family. At present, as the Minister is aware, the full family income is taken into consideration except where the wife is earning, when only 80 per cent. of those earnings are taken into consideration; otherwise the total family earnings are considered.

I understand that in the Dublin Corporation area there has been a number of cases where overpayments were made in the allowances due to the concealment of the family earnings or family means. I understand that in some cases this runs into hundreds of pounds. I attribute that to the manner in which the regulations are framed. The regulations are forcing people to become liars to enable their children to get food to eat.

In speaking on the Estimate last year I voiced a certain number of complaints regarding the administration of Section 50 of the Act dealing with disablement allowances. As far as Dublin is concerned, there has been a vast improvement in the administration of the Act and I thank both the Minister and the officials of the Dublin Corporation for bringing about that improvement but there are still many cases to be dealt with. I would ask the Minister to see that the 200 cases still awaiting a decision from the point of view of medical examination should be dealt with immediately. There are two assistant medical officers who should have those cases examined but they are engaged on maternity and child welfare work.

In addition—I am sure the Minister will follow me in this—quite a number of cases were refused during the initial stages of the Act on the grounds that the people concerned had means from other State funds—such as widows' pensions and national health insurance. I would ask the Minister if he could have those cases which were so refused reviewed without putting those people to the necessity of making an appeal because quite a number of those people are not aware that they have a right of appeal under the Act.

Further, I should like to ask the Minister what provision has been made for the re-examination by the medical officers of the existing cases. I do not know whether it is proposed to review them but I should imagine that it would be necessary to review those cases from year to year. I wish to refer to Section 14 of the Act under which applications for maternity cash grants and eligibility for inclusion in the medical register are decided.

From time to time the Minister has indicated his point of view and asked for a generous interpretation of the section. As far as I am aware, the same scale that was in operation in the initial stages of the Act is still observed although wages have increased very much during the year with the result that a greater number of people are being refused both the maternity cash benefits and inclusion on the medical register. I would suggest that the scale under which people qualify should be published. If that were done, people who were obviously disallowed would not make application.

I should like to refer to what I consider a blot on this capital of ours— the disgraceful condition of slum property in Dublin. During the war years there was a great deterioration in tenement property due to the lack of building materials. I think very little has been done since then. Whether that is due to the fact that the sanitary staff that was engaged on this work has been diverted to other purposes such as the inspection of shops, hotels or food, I do not know but from observation I would say that the position in this regard is really bad. I have come to the conclusion that slum owners are getting away with sheer murder.

An Ceann Comhairle

Has the Minister any jurisdiction in that regards

Mr. Gogan

As far as the sanitary inspection is concerned——

An Ceann Comhairle

That is a function of the Minister for Local Government.

Mr. Gogan

It is, I know, but I thought that the health inspection aspect would come under the Minister's Department. I would join with the other Deputies who made an appeal for better facilities for the old age pensioners. I do not favour very much the provision of homes for old age pensioners. I would much prefer to see those pensioners housed in homes of their own. I shall conclude by appealing to the Minister to give further support to the geriatrics section of the Irish Red Cross Society which is doing a good deal in the provision of entertainment for old age pensioners and old folk generally. I congratulate the Minister on his statement that he proposes to put a nurse into each dispensary area for the purpose of looking after old age pensioners. It is a most deserving object.

Mr. Desmond

So much has been said in relation to health services that I think that there is not much need for me to speak at length on them. At this stage, however, I should like to state that certain complications are bound to arise since, when any new legislation is put into operation, there are bound to be, in the interim period, some mistakes whether in the administration of the Department or that of the local authorities. Very often it will be found that sections which can be regarded as innovations in an Act are rendered rather complicated by reason of the methods employed by the local authorities to carry them out. I believe that it will take us at least three years before we are in a position really to praise or criticise the health services. Therefore, it might be wiser, if, at this stage, we did not spend too much time criticising the services.

I could not agree at all with the line of approach adopted yesterday by Deputy Briscoe. He drew attention to the danger, as he saw it, of the present method of allocating money for hospital buildings. During the emergency period money accumulated because no building was going on. When the emergency ended, the "kitty" was full. In my view, the wisest course was adopted when it was advocated that so much of this money should be earmarked for the building of hospitals. On various occasions when the inter-Party Government were in office and when Fianna Fáil were in office, I have, as a member of hospital boards, resented the policy of reserving all the hospital money instead of going on with building. Consider the position of voluntary hospitals which had money available to them at that time. If they had spent some of that money wisely before the war, on the improvement of the hospitals or on the erection of additional buildings, it would have been much more advantageous from a long term point of view instead of having to tackle that job now when building costs are so very much higher.

I am aware that some months ago, there was propaganda to the effect that plenty of hospital beds were available but that the Minister's Department was not utilising them. We here know that such was not the case. At the present time in Cork City the position is that it is not possible for everybody who wants to enter a hospital as a patient to do so. The problem is one not alone of free entry but of having a bed available for the patient.

It is vitally important, in relation to the overall picture of health services, to admit that we are still in a bad way so far as accommodation for patients in hospitals is concerned. It is essential that we should strive to provide that extra accommodation. I admit that every Minister for Health in this country has, in his time, done his best. It is tragic that so many years have elapsed from the time of the initial planning, the acquiring of a site, the preparation of plans, the alteration of plans, and so forth, so far as Cork Regional Hospital is concerned. It is possible that my attitude is different from that of other Deputies who have spoken in this debate on this matter but my view is that this hospital is urgently needed. I trust that, before this year is out, the work which has been delayed for so long—not by any particular Minister for Health but by everybody concerned—will begin. I hope the long delay will end and that, so far as the Regional Hospital for Cork is concerned, we shall be able to say we can provide the accommodation for the people in the area under the health services.

I do not desire to dwell too much on it but I think it is right for me to say I am disappointed, not with the Minister or his Department, but with the overall picture of our dental services. I realise that the Minister is aware of the problem. I hope the bottle-neck in that side of the health services will disappear. While it might be better for everyone concerned if we left it at that for the present, nevertheless we are entitled to expect from everybody in the service, professional and otherwise, full co-operation to ensure that the people of our country will have a proper dental service under the health services.

In his opening statement, the Minister mentioned the problem in relation to mental hospitals. First of all, I should like to congratulate him on his common sense approach to this subject. In addition, I congratulate the members of the Cork Sanatoria Committee on their wise choice, by a majority vote, to acquire Heatherside Sanatorium for the purpose of easing the problem of unfortunate mental patients in Cork. As the Minister is aware, the overcrowding there is tragic. I hope the problem of providing mental hospital treatment will be eased by the acquisition of Heatherside Sanatorium. It is a tragic burden and it has been very noticeable in Cork City and County for many years past.

With regard to this whole problem of mental hospital treatment, I feel attention should be given to the necessity for out-patient departments in these hospitals in view of the overcrowding. I do not see why it is not possible to have special departments in local authority hospitals throughout the country earmarked to deal with out-patients. There was a time when the relatives of a mental patient did everything in their power to ensure that nobody would know of the tragedy which had fallen on the family or that the person had—to use a phrase in current use at the time—"gone to the asylum." With the passage of time and with improvements in medical science and equipment, it is quite conceivable that many persons could attend an out-patients' department or a particular section of a local authority hospital without their neighbours knowing that they were suffering from mental illness. We have highly qualified doctors to deal with this matter and, if such an out-patients' department were set up in various local authority hospitals, it would case the present overcrowding in the mental hospitals and it would mean that every person who was a bit "touched" would not have to be put into a mental hospital.

It is easier to get into a mental hospital than to get out of it. Deputy James Tully laughs, but I know cases of patients who are certified to be sane now but who are still in the hospital because there is nobody to take them out. It is true that some of them are working there now and that may be an advantage, but I do not think it is fair to them. It is essential to case the overcrowding in the mental hospitals and patients who are suffering in a mild way can nowadays be treated in a speedier and perhaps more effective way at an out-patients' department, with better results to the patient himself.

I realise that the Minister is doing everything possible, but it is only right that it should be stated here that it is vitally urgent to continue to concentrate on the provision of sufficient homes for the treatment of mentally defective children. Wonderful work in that connection is being carried out by religious communities in Dublin and Cork, where the efforts of the Brothers of Charity at Glanmire are outstanding. The big problem is accommodation. This Government and every Government we have had in the past eight or ten years have concentrated on tackling the T.B. problem. It is well to know that the results have justified the battle fought by the responsible Minister in each Government. That problem is now easing and the death rate decline has been most satisfactory.

That being so, perhaps we could concentrate now on providing homes for mentally defective children. Any money spent on trying to alleviate the hardship on these unfortunate children and their parents would in my opinion be well spent. The parents of such children are ill-equipped to do anything in the way of treating these children or improving them either mentally or physically. It would be well, therefore, if as much concentration were placed on this problem in the years now before us as has been placed on the problem of T.B. in previous years.

Most of the points I would have concentrated on have been mentioned by many speakers and I do not see any reason for repetition, except to say that Deputy Finlay set the ball rolling in the discussion on cancer. We know that there is great credit due both to hospitals in Dublin and indeed to local authorities for trying to face this problem. In view of the enormous number of people who are suffering from this dread disease which is of such an appalling nature, it is essential that every co-operation possible be given in tackling it, in an effort to case the problem and reduce the number of cases or, as a last resort, to help people by reducing the terrible sufferings they must endure from it. It is as well to know that, for some time back, through the great co-operation of the Departments concerned, even in Cork City, such patients can now be treated by an eminent member of the profession going down to Cork, whereas in the past these unfortunate persons had to be transported to Dublin.

There is one other point which I should like to mention to the Minister and it is one of which I have had word only in the last day or two myself. It is in relation to the salaries of registrars in local authority hospitals. It seems strange that, while there is a fixed salary in a particular hospital, because it is classified as a teaching hospital, the same salary cannot be given. If that is correct, I certainly would like the Minister to examine it. I am aware of some medical registrars who hold the highest possible qualifications. There will be no hope of keeping these professional men in the positions they are in, if it is going to be a case of their not getting the same salary as a man in a smaller hospital with lesser degrees. Mention has been made here during the discussion of fees for medical men, and so on, but we must admit that we are fortunate enough to have men holding such high degrees proving their ability in the work they are doing for the community, so that there should be no differentiation by keeping their salaries at a lower scale than obtains in the other hospitals. I would ask the Minister to have that matter investigated.

The Minister made a statement which we have been struggling to bring to the forefront for many years back and at this stage it is only fair to give credit to Deputy Dr. Ryan who was Minister for Health at the time. It is true he was a bit slow in agreeing to our proposal, but I suppose the Cork accents penetrated so hard that he gave in eventually, that is, in regard to the desirability of having attached to every dispensary district a fully qualified trained nurse, with midwifery qualifications. We may speak of regional hospitals and do our utmost to see that they are built when they are so necessary, but I am convinced that if we tackle the problem in relation to the dispensaries and the service that may be given in the dispensary districts, it will help us to eliminate the terrible problems of overcrowding in the general hospitals and will also be of assistance to the patients.

Even at present, in many of the remote areas, dispensary buildings are so bad that most people have a horror of going there unless they are so unwell that, from one look at them, the doctor will send them into a hospital which is already overcrowded. In South Cork district, at any rate, we can say that from the experience of all those concerned and from the most satisfactory reports we get, the system in operation of having a general trained nurse attached to each dispensary district is undoubtedly of vital importance to the people concerned and is also giving excellent returns to the local authorities, who must employ these nurses, and to the State.

As I said, I had no intention of discussing in any detail the problem in relation to the operation, at this stage, of the health services, but this I will say, as many members have already said, that it is essential that we discuss health problems outside the realms of political controversy in this House. We know that it was made clear in this Chamber back in 1953, that 50 per cent. of the cost would have to be carried by the local authority. We know it now as we knew it then and as the Minister introducing the Bill at that time knew it. He may remember that in Cork City, at a conference for areas including Cork, Waterford and other counties, when he attended with some of us who were representing the various local bodies there, I myself asked him, as I considered it my duty to do, what would the cost be on the local authorities, and the answer Deputy Dr. Ryan, the then Minister for Health, gave was that he could not tell. It was a very fair answer, but he did make it clear that 50 per cent. would be paid by the State and 50 per cent. by the local authorities. We knew it then, and we know it now, and it is unfair that any members should state outside this Chamber that there are alterations as regards these figures when what I have stated is the fact.

May I suggest finally to the Minister that as so many various sections of the Act are now in operation, many people are still confused as to what benefits they may be entitled to, whether they are entitled to hospital treatment under the various provisions in the Act? If the Minister would encourage the local authorities to issue, through the local dispensary doctors or through the home assistance officers, a small booklet setting out as plainly and as briefly as possible the benefits to which these people are entitled, then we may have the health services giving us the return for which we are hoping. The people will then understand what they are entitled to, without coming to any of us politicians and getting expressions from us which may unfortunately at times be tainted with political outlooks. If the individual who has the right to services under the Health Act is informed in some brief manner through the local authorities what those rights are, then, please God, we will have what we are hoping for, the satisfactory operation of the health services in this country.

Dr. Ryan

First of all, I should like to say that we have had heartening news in the Estimate, as it has been for some years back, on the vital statistics. The improvement in the death rate in the case of infants and in the case of mothers in childbirth is very good news indeed. As the Minister pointed out, we should not be too complacent because we must go a bit further before we have as good a record as some of the neighbouring countries. However, we have made good progress and we are glad to know that.

I am very glad also to learn from the Minister under this heading that his departmental experts are keeping in touch with world development in the prevention of poliomyelitis. I do not think there is any more terrifying disease for parents than poliomyelitis because it strikes so suddenly and leaves such terrible consequences that people actually dread it. Anything that can be done to prevent it should be done. I am glad that the technical experts in the Department are keeping in touch with this very important question.

I should like to support the Minister in his appeal to parents to have their children immunised against diphtheria. The figures are conclusive in showing to any parent how the incidence of that disease has been cut down by immunisation. Also, there are figures to prove that, even when the immunised person gets diphtheria, it is a very slight attack and passes off with out any great consequence. Parents, of course, like everybody else in the community, are sometimes very careless and it has to be drummed into them, I am afraid, that it is important that they should look after their children in this way. I would advise the Minister to try by every means possible, advertisement or otherwise, to bring this very important question home to parents.

I am also, of course, very glad to see that the death rate from T.B. is still going down. Again, we have not the same good experience as some of our neighbouring countries have and we have a good way to go yet before we reach their very gratifying figures, but we have made remarkable progress, no doubt, over the past eight or ten years, and if we continue at the rate we are going, we should reach the very good position that other countries are in.

The question of maintenance allowances for chronically disabled persons has been raised by many Deputies. It is a new service and we cannot say very much about it at the moment. I notice that some Deputies criticised the severity of the conditions. When the Bill was being drawn up in 1953, it was one provision I was very keen on personally. We had dealt with many classes under our social welfare legislation, but we had left a certain number of people who were not insured, a certain number of people who had no means and who were chronically disabled. We introduced in the Health Act a clause enabling local authorities to give a maintenance allowance to these people and to rehabilitate as far as possible those who suffered from permanent injury, or who were born with a permanent deformity. The conditions laid down in the Act were severe, because no possible estimate could be made—it was useless to make an estimate because it might be 100 per cent out. The only way we could deal with the matter was by trial and error, if you like.

Deputies will realise that, under these conditions, a Minister for Finance would be very reluctant to allow any Minister for Health to go too far and it was therefore laid down in the Act that the person must be chronically disabled and permanently disabled, must have no means and, of course, "no means" would include the provision that he would not be drawing insurance.

Now we have gained a little experience. The Minister told us that, at the end of last September, there were about 13,000 people drawing this allowance and he told us that about 3,000 were under consideration. I do not know whether those figures exhaust the number of possible applicants or not, but it gives an idea of what the problem is. The number is somewhat higher than I had expected, but not very much higher. It may be a little longer before the experience will be sufficient to work upon and it may be possible, after some time, for the Minister to discuss with local authorities as to whether they think it would be possible for them to afford to treat these people a little better, either by making the conditions of qualification a little easier or by giving a little more and the Minister might consider paying his necessary portion of whatever that might cost. I am not by any means saying that this should be done, but it is a matter that might be reviewed as soon as firm figures are available.

Of course, it must be remembered that there is also the cost of rehabilitation. The cost of rehabilitation, we hope, will have some good effect, because, if a person is rehabilitated, at least he comes off the maintenance allowance group and there is a certain saving. The cost of rehabilitation may not altogether be met by the savings on the other side, but there is some saving where the rehabilitation is successful. I have no idea what the cost of rehabilitation may be.

The Minister, in speaking of the Health Act, which I may refer to again, said that it was by no means, in his opinion, the ultimate solution of all our health problems. I quite agree with that, of course. In particular, it would not be regarded as the ultimate solution for these chronically disabled people. In respect of them, it was a trial on a severe basis and, when that trial has produced the figures, their case possibly could be reconsidered.

On the question of hospital accommodation, I agree with one statement of the Minister at least, that is, that, when the present programme is completed or about to be completed, we should review the situation before new hospitals not already sanctioned are sanctioned. It is possible that, when the present programme goes through, we may have reached a fair measure of hospitalisation in the country, and, if we have, it would be very foolish to spend more money in building new hospitals. I had experience, when I was Minister, of people in various towns and villages complaining that they had hospital, but I am afraid we cannot afford to give a hospital to every town and village. Even though it may be difficult for a Minister or Deputies for the particular area to withstand that demand, in the interest of common sense and business, the demand must be turned down.

That would apply in particular, I should say, to general hospitals because as soon as the three hospitals mentioned by the Minister are completed, we would appear to be reaching the stage of having enough general hospital beds in the country, that is, when St. Vincent's, St. Laurence's and the Cork Regional Hospitals are completed.

As has been pointed out already, we have enough beds for T.B. and we have already long passed the stage where we had enough beds for fever. So, fever and T.B. can be crossed off the list and we only have remaining, then, mental hospitals. There is, I believe, a shortage of accommodation in mental hospitals generally. Some people think that that is because there is more lunacy in the country. I do not think that is the case. I do not think we have very much more than ever we had. I think people nowadays, for one reason or another, are inclined to send their relatives into institutions rather than keep them at home. We find now very few houses, in contrast to 40 or 50 years ago, when we found persons of unsound mind living at home with relatives. Any measures that may be taken therefore to increase the accommodation for mental patients are necessary and we should support them in every way possible.

There is a much greater need in my opinion for accommodation for mental defectives. This is a question that had not been dealt with to any great extent up to comparatively recent years anyway. When I was in the Department of Health, I remember a calculation being made that there would probably be about 6,000 beds required. I do not think we have, so far, reached more than 2,000—if we have reached that figure, in fact—so that we are a long way from having sufficient accommodation for our mental defectives. It is a very important consideration. Undoubtedly, mental defectives can, in nearly all cases, be improved by proper treatment, and it is not possible, I think, to treat mental defectives unless in institutions. They cannot be treated in clinics like mental patients and must be brought to institutions to be treated properly. There is, therefore, a great need for more beds for that purpose.

Our experience of these institutions is that a person, let us say, of the higher grade, a person who is least defective, can be trained in an institution to the point where that boy or girl will be able to earn a living. Then we have the medium case which can usually be trained to the point where he or she can at least look after himself or herself when at home and would not be any burden on relatives with regard to care. Then there are the bad cases which, unfortunately, must be kept in institutions for all time but would be better looked after there than if they were at home because they would have trained people to look after them.

From any point of view, we should support any proposal put before us for further accommodation for mental defectives. It is not altogether a question of money; I think it is—at least two years ago, it was—more a question of nursing personnel. Deputies are probably aware that looking after mental defectives is a specialist business. It is done in most cases by religious orders, and I think a person needs a very strong vocation to devote his or her life to that particular purpose. There was a difficulty some couple of years ago—I presume it is still there— in getting sufficient nurses trained in these religious institutions to take over more and more institutions for the training of the mentally defective. I have no doubt that has been attended to.

Another matter to which I would like to refer is the question of county homes. On one occasion at least—if not more—I had a meeting with the county managers and suggested to them that we should at least try some experiments in the segregation of people in the county homes. Over the years, the unmarried mothers, first of all, were taken away, and then imbecile children were taken away to a great extent. There may be some still there if no other places can be found for them. The old mental defectives were removed and we were, I think, getting down—perhaps we have got down now, for all I know—to the position where there would be nobody left in those county homes except those chronically ill, or old people with nobody to look after them. We have, of course, in those county homes some who are chronically ill and bed-ridden, inmates who require a certain amount of nursing—not very much, but a certain amount—and it would appear that we would require in each county, let us say, a hospital for chronic cases to which these very old people not able to look after themselves could come.

I had hoped we would get some of the old people out in colonies. I suggested some big house in the county might be taken over from the Land Commission or some body of that kind, and that 18 or 20 men or women might be moved into that house, a group able to look after themselves, more or less, and thus form a colony. I thought the cost would not be very much because I had in mind that a lady, a retired nurse or a person of that type might act as housekeeper, and allow them, or get them to do most of their own work. We might attempt, as they have done in other countries, to construct a very simple building composed, let us say, of three or four cottages, somewhat like labourers' cottages, where each old person would have a room and where there would be a common dining-room and reading room combined where they would all congregate for the principal meals. There are various things of that kind that could be suggested and some of the county managers, in their discussion with me on that matter, appeared to be very keen to do something of that kind. I would like the Minister to let us know if any progress has been made in any direction in that matter.

I am also glad to see that a certain amount of money is being used by counties to improve their county homes. Indeed, some of them required improvement and I am glad to say some of them have been improved and are very good on the whole.

I want to congratulate the Minister on implementing the Health Act. It was a long and tortuous procedure from the time the Act was passed—I suppose I should say through its passage—and up to the present we were never very sure whether it was going to be implemented or not. There were times when we were told it would be implemented; other times when we were told it would be postponed indefinitely. That may not have been anybody's fault in particular; it may have been due to the usual rumours that go around in these matters. Anyway, the Act is now implemented to a great extent. There are certain matters outstanding and it was foreseen that some of these matters would be the last to be dealt with, for instance, a full dental service. The Minister, in implementing the Act, has no doubt come to the conclusion that it is better that it should be operated.

He did make his position clear by saying that he did not think it was the best Act that could be brought in. We do not expect him or anybody else to think along those lines. I may have thought at the time that it was the best Act that could be introduced, but I might now see that there are certain useful amendments which could be made to it. He said also that he did not think it was the ultimate solution to all our health problems. There is no doubt about that. As the years go by, there will always be suggestions for improvements and amending Acts coming in one after another. We should be thankful, therefore, to have the Minister implement the Act even though he does not give it his full approval as being the best that could be done and as being the ultimate solution of all our problems.

There have been certain criticisms of the Act and some Deputies have gone so far as to say that they do not agree with it. That is a very difficult attitude to understand. I would have thought that when the Minister had implemented the Act, he would have the full approval of his colleagues in the Government and in the Party. I would have thought that, when dealing with a very important Act of this kind, if any Minister in the Party to which the Minister belongs or any Deputy strongly objected to the Act resignation by that particular individual would have followed. There was, in the past, and there have been in very recent weeks, further condemnations of the Act from some of the Minister's colleagues. At least one Minister and one Parliamentary Secretary, in the last few weeks, have condemned the Act very severely. It is rather a strange thing, in our conception of democracy here, to have that sort of cleavage where one Minister brings in an Act and another condemns it.

An Leas-Cheann Comhairle

A full debate on the Health Act is not in order on the Estimate. A debate on the administration of the Act is in order.

Dr. Ryan

If you will bear with me, Sir, the point I am making is that we can hardly expect to have good administration of the Act here and by the various local authorities unless we are quite clear as to how things stand. There were various suggestions made, one of them being that the Act should be scrapped entirely and replaced by a better Act, but we will let that pass for the moment and go on to the point that the Act is now being implemented and that we must do the best we can to make it a success.

We must assume, I suppose, that the great opposition there was to this Act in the past has now disappeared and that we have more or less reached unity on this particular point. Fianna Fáil brought in the Act without any great help from Fine Gael. Labour have taken credit for having it implemented and Fine Gael have implemented it. So we have reached unity in favour of the Health Act. Each Party should now take full responsibility for the successful working of this Act. We have experience of discussions at local authorities down the country with the usual criticism against the Act from some of the Parties and we have other Parties trying to defend it. Now that all Parties have agreed to the Act, we should have unity in its defence at the meetings of local authorities.

I take it that, as far as this House is concerned, there will be very little discussion on the merits or demerits of the Act from this on and that, as far as all Parties here are concerned, we will have no trouble in seeing that the Act is put to the best possible use. It is unfair that a Party like the Labour Party, at meetings of local authorities, should adopt the attitude of claiming that the Act would not be there but for them and then blaming the Fianna Fáil Party for the cost of it. That is very much in line with the Labour Party attitude on many important things. They claim the credit wherever credit is going and wherever there is blame they put the blame on somebody else. I think that both Fine Gael and Labour, now that the Act has been adopted, should try to do their best to make it a success.

There is also the question of the cost to be met. We all know that, when the Act was going through this House, there was a good deal of discussion on the cost of it and it was admitted that it would cost a fair amount of money. Deputy Desmond quoted me as saying in Cork that I did not know what the cost would be. I think that I often said that but I went further and said that the cost of the Act to the ratepayers would not be more than 1/6 in the £. I do not know whether I shall be proved right or wrong in that.

There have been very big increases in health services and when that matter is brought before the local authorities by the county managers, some of the members of the councils, particularly Fine Gael and Labour members, have been blaming the whole thing on the Health Act. The Minister made it very clear in his speech that that was not fair and that there would have been a very big increase in health services even if the Act had never been brought in in 1953. It must be obvious to everybody on a local authority that the cost of maintaining a person in an institution, whether a sanatorium, mental hospital or general hospital, has gone up. It must be apparent also, that apart from the maintenance charges, those who are employed by the local authorities to look after the institutions have also got increased remuneration. These costs would be there whether the Health Act was brought in or not.

The Minister analysed the figures and it would be well for every Deputy to read the Minister's speech generally and see how he arrived at his analysis of the figures. The Minister said, first of all, that, if the Health Act had never been passed, the local authorities would now be paying at least one-third more for their health services than they were paying previously. That would go a long way indeed to build up the increased charges on the local authorities for the health services. There would be a margin left out of the £1,600,000 so that the most any hostile critic of the Health Act could claim is that the T.B. legislation of 1947—that is the legislation which provided maintenance benefits in cases of infectious diseases—and the charges under the Health Act of 1953 put together have cost the local authorities about £1,600,000.

The Minister said that in this year's Estimate the increased cost for all health services, payable by both the local authorities and the Department of Health, has gone up by £2,000,000. One million pounds of that increase would be payable by the local authorities and the Minister said that would amount to 1/6 in the £ on rates. He also said that only about 7d. of that could be attributed to the provisions of the 1953 Health Act. These are figures which, as I said, Deputies should take home with them and should mention at meetings of their local authorities so that members of local authorities would not be deceived into believing that all these increased charges are due to the 1953 Health Act on which we have now agreed to unite and to defend.

That 7d., it must be remembered, will cover a very big portion of the expenditure under the Health Act of 1953. It will deal with the portion of the Act affecting middle income groups. Everybody in the middle income groups—about one-third of the population—will be entitled to free medical service, to specialist service and to hospital service. They will also be entitled to maintenance in hospitals at a maximum charge of 6/- per day. I think anybody reading the 1953 Act will agree that this was the big charge under the Act. We may find with more experience that the dental service will cost a lot of money, but at the moment, as far as we can judge, the big charge will be because of the middle income groups and if these are covered by the 7d. in the £ mentioned by the Minister, I do not think that the original estimate of the cost of the Health Act, allowing for increased cost of living and higher remuneration for doctors and nurses, was very far out.

The Minister, when speaking on this matter and when asked by Deputy Briscoe about this increase of 2/- per bed in hospitals, said that when I was Minister I had sanctioned that and that he was only putting my recommendations into effect. It is kind of the Minister to do that, but surely the Minister did not take my place to do everything I told him to do.

Mr. O'Higgins

I do not think I said that. What I said was that the capitation payments were intended to bring a reduction in deficits. So the increase that I permitted really was my own act.

Dr. Ryan

I am sorry if I misquoted the Minister. I do not in any way ask the Minister to do everything I recommended. What I meant to do was to ask the Minister to come to his own decisions and not to mind what I did.

Mr. Briscoe

The Minister laid the blame for this procedure on Deputy Dr. Ryan.

Mr. O'Higgins

Certainly.

Mr. Briscoe

But the Minister has not said that now.

Mr. O'Higgins

I do not believe there is any occasion for blame.

Mr. Briscoe

The Minister sought relief yesterday by saying it was not his doing but Deputy Dr. Ryan's.

Mr. Aiken

That is correct.

Dr. Ryan

The Minister in his statement did disclaim responsibility for the Health Act. He was entitled to do that. He said in his statement—I am not quoting him word for word but giving the sense of what he said—that these extra costs were not of his making. I think it is wrong of the Minister to take that attitude. I think the Minister should not have implemented the Act if he thought it was wrong in any way. He should have rejected it, if he thought it wrong and should have brought in a very much better Act. The present Taoiseach said at that time that he would have produced a better Act even if it cost £10,000,000. That was not done and, as the Act was accepted, my point is that now the Minister, the Government and the Parties behind them should accept the Health Act and work it to the very best advantage.

Mr. O'Leary

You said Fine Gael were sabotaging the Act.

Dr. Ryan

That is right. I said the Deputy did too. The Labour Party supported it with the exception of the Deputy. Now he is supporting it. I have further bouquets to throw at the Minister. I congratulate him on his success with the Irish Medical Association. I congratulate him on getting the executive of that association to agree to allow their members to work the Act. I think that was a very big achievement. Any remark I might make about the members of the Irish Medical Association I do not want to be taken as referring to the doctors generally in the country because they are just as good as any other section of the community. I want to say that the Minister was successful where I failed. The Irish Medical Association had very strong objections to the 1953 Act.

These objections were grouped under three headings. No. 1 was that it interfered with the doctor-patient relationship. The doctor-patient relationship is a very difficult matter to understand but I suppose a Deputy can make up his own mind what it does mean. The Medical Association said the relationship was one which should not be interfered with. Genuinely, I said I could not understand how that relationship would be interfered with by the Act and I was told the point was that the State would employ the doctor and, therefore, the doctor's contract was with the State and not with the patient. The patient's contract was with the State too and not with the doctor and there fore the doctor-patient relationship was being interfered with.

The second objection with which we had to deal was the keeping of records. Undoubtedly, if people are getting free treatment from the local authority, the local authority must keep some record. The Irish Medical Association were very much against the Act because they said local authority officials would have access to these records and would therefore know what the people concerned were suffering from. I pointed out as well as I could that this could be avoided by a loose-leaf book, the pages of which could be perforated and torn out half-way. A number only would be furnished to the local authority, the doctor keeping both name and number. That did not satisfy them. The association's third objection was to the State control of the profession. They said this Act was striking at the very foundation of medical ethics, that it was putting medical ethics in peril and that, therefore, it was morally wrong, as far as they were concerned.

I should like to say—and this is for the benefit of those Deputies who may not have been here and who now have to support the Act, if they have any qualms of conscience—that the Act was amended after consultation with the highest moral authority that can speak for the majority, and a copy of the Act and a copy of the amendments were circulated to the heads of the other churches. We found no objection from them and we can now claim, therefore, that the Act which we passed did not incur censure from any of the religious authorities here. Despite that, the Irish Medical Association, at its subsequent annual meeting, said that, as far as they were concerned, the Act was still repugnant.

Again, in July, 1954, long after the Act had been passed, the president of the Irish Medical Association in his address to the delegates, after election, said that the Act was just as repugnant as ever. It appeared to me as if every president of the association had to make that statement as a sort of testimony to ensure that the whole thing would be wiped out.

As I have said, I was wholly unsuccessful in getting the Irish Medical Association to agree to work the Act. I had tried to help them to get over their moral objections by getting the best authorities to give advice, which advice was followed in the amending of the Act; but that did not get them to change their objection to the Act. The present Minister has been successful. Perhaps he knows them better. Perhaps they like him better.

Mr. Briscoe

Perhaps he pays them better.

Dr. Ryan

I do not know which it is, but, at any rate, he has been successful. He did not try in any way, as I did, to soothe them in their moral objections. As Deputy Briscoe says, he is paying them better. They have agreed now, reluctantly, I admit, and they have got over all their objections. It is a very distressing thought that medical ethics can be bought. If the medical profession, as I pointed out to them at the time, objected to the Act and said like any other trade union that they could not agree to working the Act because they would lose money, then we could see their point. But, when a body comes along and raises objections, which are afterwards removed by the payment of a little more money, it is a dreadful thing indeed that we should have to suffer that.

On one occasion, they challenged me to produce any moral authority which would sanction the provisions of the Act. We have the moral authority now; we have the Irish Medical Association now with their moral advisers evidently regarding the Act as all right. Now we do not know as yet what is in the Minister's agreement with the Irish Medical Association. I do not say we should know, because, in all probability, the Minister has to see other people before he can make that known. I am not complaining about that, but I do complain about the method of fixing terms with the Irish Medical Association.

When I returned to the Department of Health on the second occasion, I came to realise after some time that it was wrong for the Minister to make agreements with any of these bodies, medical associations, nursing associations, mental hospital attendants or anyone else. I made a rule then that all applications for remuneration should go to the county managers. After all, the county managers were going to pay. It is true they would be recouped by the Department of Health and they had to satisfy the Minister they were not spending too much. But before I left office the practice had been established of getting the county managers to deal with all these applications for increases.

The county managers were naturally anxious to have uniformity. I think that was a sensible thing. We all know that if one county pays, let us say, its mental hospital attendants better than another county, there will be discontent and that discontent will remain until the lower county comes up to the level of the county which is paying better. For that reason, the county managers very sensibly negotiated as a body with these various organisations. They evidently came to the conclusion, too, that they could not all be present at such negotiations and they, therefore, appointed a committee. I presume they gave instructions to the committee as to how far they could go. That committee negotiated the new scales, whatever they were, with these various bodies. It had, of course, to get the sanction of the Minister before any final decision was made, because the Minister has to pay half the amount.

The position is different now. At that time, county managers were solely responsible in all questions of remuneration. Since the passage of the last County Management Act, the county councils have more control and therefore the county councils must come into the picture, too. I know it is a very difficult problem, but I think it can be got over. I think a committee from the county managers and from the General Council of County Councils to discuss things with the Minister would be the best way to do it. It is certainly not right that the Minister should make an agreement and leave the local authorities no option but to accept. The local authorities will be told what the scales or rates of remuneration will be, and, if they do not agree to pay, in all probability, they will not get the services. They will, therefore, either be left without the services or compelled to pay.

There is another matter which has given rise to a great deal of trouble and a great deal of misunderstanding. At the same time as the Health Act was passed and certain provisions in it came into operation, a white card was issued. The Act did not lay it down that there should be a white card. The white card was coincidental, if you like, but most people—one can hardly blame them—came to the conclusion that the white card was the result of the Health Act. Now, the white card was really the result of consideration over a long period. I had often heard here complaints about the red ticket, complaints that it bore the stigma of pauperism. Many Deputies, and also people outside, had appealed to us to get rid of the red ticket.

It was argued that it was most inconvenient; if there was sickness in a house and a crisis occurred suddenly at night, the responsible individual had to send for the doctor; but, first of all, he had to knock up the warden to get a red ticket and then go for the doctor. I admit that not all doctors would insist on that. In fact, only a minority would; but they had the right to insist on it, and some of them did, and the person was put to all that trouble. It was considered desirable to give some sort of authorisation—it took the form of a white card—to the head of the house entitling him to the services of the dispensary doctor for 12 months to come for himself or any member of his family.

That was done as a matter of convenience and also, to some extent maybe, to remove the taint of pauperism about which we had heard so much in relation to the red ticket. Now, that unfortunately came in at the same time as the Health Act and a great many people believed that that was as a result of the Health Act.

Unfortunately, in the issue of these white cards the local government authorities were stringent—more stringent than they should have been, in my opinion. It must be remembered that, in the 1953 Act, the words used are the very same as in the 1939 Act to define those who are entitled to free medical services. Therefore, there should have been no change as far as the Health Act of 1953 was concerned. The very same people should have got free services as got them before. On account of the issue of the white cards, there was a more strict examination of those who applied and people were turned down who, up to that time, had been accustomed to get free medical services. That was a great pity and I think that as far as possible it should have been avoided. I want to make it clear to the Minister that I am not blaming him for this—it started in my own time—but I think we should have the matter corrected.

If we go back for a minute, I think we will find that, before that white card came in, everybody who was drawing any sort of social benefit, old age pension, widow's pension, sickness benefit, unemployment benefit and unemployment assistance, all automatically got the red ticket, if it was needed to get the dispensary doctor in order to receive free treatment. In addition to that, many workers—I think it could be said nearly every labouring man— were entitled to free medical services. There may have been—I do not know— a distinction with regard to tradesmen. I think in fact a good many tradesmen did not ask for the red ticket at all. I do not know whether they would have got it or not. I think the same scheme should have been continued.

By the time the white card came along, wages were going up and a man may have £6 this year who only had £4 or £4 10s. last year. The reason for the £6 was that the cost of living was going up and he needed £6 where he needed £4 10s. before. Therefore, if he needed free medical service when he had £4 10s. last year, he would also need free medical service when he had £6 this year. I think that is how the local authorities should look on this matter and that the same people who got free medical services perviously should get them now, even though wages have gone up. I would ask the Minister to look into that matter. I know that the Minister, strictly speaking, has not the power to order that, but, if the Minister expresses that opinion to county managers generally, I think most county managers will at least pay him the courtesy of considering the matter and carrying out the scheme in that spirit, rather than in the very strict spirit in which they are carrying it out at the moment.

As I said already, and I say it very sincerely, we have now come to the stage in this House where all Parties agree that the 1953 Act should be implemented. It follows from that that all Parties agree that, in the implementation of the Act, the best possible use should be derived from that Act. That means that every Deputy should try to understand and acquaint himself with the figures quoted by the Minister. In that way every Deputy can remove the prejudices of certain people against the Act, if they point out, as the Minister pointed out here, that, as far as the 1953 Act is concerned, there was only an increase of 7d. in the £ on the rates for that purpose. The increased rate for health services was, in large part, not due to the Health Act at all. Deputies who have now agreed to make the best use of this Health Act should remove any misunderstanding of that kind there may be in the country. Deputies—in particular those who are members of local authorities —should try to see that the ignorance of certain people with regard to this Health Act is dispelled as soon as possible.

When bringing in the 1953 Act, I remember making the statement that it was designed to make available the best possible medical attention for everybody and to make sure that nobody was deprived of this attention, through lack of means. I am quite sure that there is not a Deputy who does not agree with that. We should aim at that ideal—to make the best possible medical treatment available to everybody. And, if we find that it is not available, through lack of means, then we should remove that barrier and see that the people who cannot afford to pay for it will get that treatment without paying for it. That is, as I said, what we were aiming at in the Act.

I know that some Deputies thought we had gone too far and were bringing in people who could well afford to pay; and some Deputies on the Labour Benches thought we were not going far enough and that we should bring in more than we had brought in. I think I can claim that every Deputy, whether he belongs to Fianna Fáil, Fine Gael, Labour—no matter where he belongs—will agree that the aim should be to put the best possible medical services at the disposal of everybody. I believe we can do that, if we all unite to make the Health Act a success in its implementation. If the instrument does not altogether satisfy that, and if we find, after experience, that there are certain classes we have not dealt with, and that we have not gone far enough in our Act, then it will be a matter for whatever Minister is in office to bring proposals before the Dáil to amend the Act and to see that everybody gets the best possible medical attention, irrespective of means.

Mr. O'Leary

Take away the means test.

Dr. Ryan

That would be one way of doing it, but Deputy O'Leary would probably tell Wexford County Council that the next shilling on the rates was due to Fianna Fáil.

Mr. O'Leary

Who put the means test there?

Dr. Ryan

I put several means tests in it.

Mr. O'Leary

Why did you do it?

Mr. Briscoe

To save the rates.

Dr. Ryan

To save the rates. I do not want to say any more. That should be our aim. I am quite sure we are all united in that aim to see that the best medical attention is given to everybody. If we all unite now to do our best to see that the Health Act is put to the best possible use, I believe we will achieve that end in the very near future.

Mr. O'Leary

Deputy Allen does not agree with that.

Mr. Allen

I certainly do. You are the only Labour man in the House who voted against the Health Act.

Dr. Esmonde

It is only natural that this debate should revolve largely around the recent implementation of the Health Act. There are just a few matters with which I would like to deal, and I propose then to come back to the discussion of the implementation of the Health Act.

Several Deputies have referred to the treatment of mental defectives and I was very interested both in what Deputy Desmond said and what Deputy Dr. Ryan said; and I find myself substantially in agreement with both of them. We have reached a stage in this country where we accept the fact that those who have the misfortune to be affected in any way by mental disability should be looked upon, not as they were in olden days, as incurable lunatics, but as people who are capable of receiving treatment, just as are those in any other condition. Our difficulty, the difficulty of local authorities, hospitals, medical practitioners and anyone concerned with this lies in the fact that so many of these cases did not get to the centre early enough to have treatment. In many cases, mental defectives who should have received treatment in the early stages and have become perfectly normal again have become chronic cases and it is necessary for them to spend years in an institution.

One of the main difficulties in getting people to go to institutions is the present system of certification of mental defectives, and, until a new Bill is introduced, the present state of affairs does not meet requirements. If a mental defective attends a private doctor, he cannot, under the existing circumstances, be sent by that private doctor into a mental institution, unless he is in a position to pay for his maintenance there. That, in itself, leads to interminable delay. In rural Ireland, where in some cases there is only one doctor, or maybe two or three, the people like to attend their own medical practitioner. This is a free country and they are entitled to go to whomever they wish.

If a person suffers from mental disability, he cannot be sent into a public institution by his own doctor. That means he will have to go to the existing dispensary doctor, who, perhaps, will be called something else in future under the new medical regulations. That leads to interminable delay. I should like to draw the Minister's attention to that. Much suffering would be saved not only to the people looking after the mental defectives, but to the mental defectives themselves if the difficulties were removed and it were possible for them to be sent sooner.

I wish to bring another matter to the notice of the Minister. As far as I know, the external patients' department dealing with mental defectives is confined entirely to where the mental institution is. I think it would be a very good thing if in all counties we had these doctors.

Mr. O'Higgins

I think that applies just to those of unsound mind and not to those mentally deficient.

Dr. Esmonde

It is very hard to draw a hard and fast line between a patient of unsound mind and a mentally defective patient. Let me put it this way. Anyone who has to go for institutional treatment which will entitle him to be certified within the meaning of the Act can only be certified by a dispensary doctor. My plea is that he should be free to go to any medical practitioner. Let me revert to what I was saying. So far as I know the facts, at present where we have in a county a mental institution and we have one or two doctors who are highly qualified to deal with the treatment of mental cases generally, it is possible for practising doctors to send patients to these institutions only for out-patient treatment and advice.

In my own constituency of Wexford, the institution is situated in Enniscorthy, right in the centre of the county. It often means that if one wants a second opinion from the medical officer of an institution and wishes to send a person to the institution merely as an out-patient, the person may have to travel, perhaps, 20 miles and, in some cases, if the person concerned lives in the south of the county, 30 miles, to have that consultation. I suggest that we set up the same system as obtains throughout the country as a whole in relation to T.B. and have consulting clinics with an out-patients' department to deal with mental cases throughout the different parts of each county, or constituency as the case may be.

I do not think it is generally recognised that consultations such as these are very necessary. It very often happens that a person suffering from a mental defect could if he gets electric shock therapy treatment, which is the most modern treatment, in the early stages, be cured entirely of his ailment in a very short space of time. I actually know a person who holds a very highly skilled and dangerous position in life and who suffers from mental disability. From time to time, he obtains this shock therapy treatment and is perfectly able to carry on his avocation in life, until such time as the symptoms return again.

We have a long way to travel in regard to mental treatment in this country. What we want is a better approach to the problem—a more rational approach. We ought to realise that anyone suffering in any way from a mental disease is in the same position as a person suffering from any other disease. It is curable, if taken in time. The Minister should make available all the facilities he can for that purpose.

I should like to say a word or two on midwives' salaries. I think it is only doctors who can appreciate the hard work and the hardship that midwives have to undergo. They work long hours for small salaries and they are an important unit of our national life. In many cases, they have to travel long distances. I can truthfully say that they are the worst paid section in the community and I ask the Minister to give them all the consideration he can. I asked the last Minister to do that and I now ask the present Minister.

I should like to say a word with regard to the maintenance allowance— the weekly disability allowance payable to people who are totally incapacitated. I think that is an excellent arrangement and I am very much in favour of it. I feel, however, that it is being worked too harshly. It is being subjected by local authorities, through the county manager, to a too rigid means test. If a person is totally disabled and even though he is living in a home where there may not be actual want or distress, there is a psychological effect on him. He has to depend entirely on relations to maintain him, give him every enjoyment and attend to his wants. That leaves him with a sort of inferiority complex—an understandable reaction. The Minister should impress upon our local authorities to be generous to anyone who is totally disabled even though the person's circumstances may be fairly good.

Take the case of a person totally paralysed. I know of cases where such people live in circumstances which are not too bad. They are not actually in want, but it would be a source of great happiness to them if they were enabled to get this allowance, because they would feel they were contributing something towards the home. I feel that Deputies on all sides of the House will support me in regard to this matter. I would go so far as to say that people who have been in that condition from birth and persons who reach 16 years of age and are able to show that they are totally disabled and are likely to be so for all time should get this allowance. After all, it would not cost the country very much.

I want to deal now with the implementation of the Health Bill. I listened very carefully to what Deputy Dr. Ryan had to say. He rather gave me the impression that he was rather surprised and disappointed that the Health Act is being implemented.

Mr. Briscoe

Surprised, yes, but not disappointed.

Dr. Esmonde

I do not know if the Fianna Fáil Deputies feel, deep down in their heart of hearts, that this Act will be a success. I concur 100 per cent. in Deputy Dr. Ryan's statement that every Deputy would like to see health services that will be of benefit to the people. In the previous Dáil, opposed this Act; I opposed it because I felt it would not give to the Irish people suitable and satisfactory services. We have to remember that we are a country with a small population. We are not a great industrial nation like America or Britain. It is our duty as legislators to try to give the people the best services we can. I have never been satisfied that the Health Act of 1953 will have that desired effect and I shall try to tell the House why. I have always said that, where you have a lot of people competing for something which is not able to satisfy everyone, the weakest will, in the end, have to go to the end of the queue. That is one of my reasons against this Act.

The position at the moment is that, with the implementation of the specialist services, anyone is entitled to a specialist service. Human nature being what it is, everyone who goes to be examined will want to go to a specialist. As a rule, everyone, in the first instance, goes to a general practitioner to be examined. General practitioners are the foundation of medical health in every country in the world and they always will be if we are to have a satisfactory service. They are dealing directly with the public and with families. No one has the intuition or insight into health matters that they have and no one else could be expected to have that knowledge, because they have not got the opportunity.

The implementation of this Act will, we are told, cost £2,000,000 this year. Take, for example, a patient who goes to a general practitioner for examination. I suppose there is nobody in this House who has not at some time or other thought there was something wrong with his heart. I have never yet met anybody who has not thought there is something wrong with his heart.

Mr. Briscoe

Sometimes they are right.

Dr. Esmonde

In 90 per cent. of the cases, they are wrong.

Mr. Coogan

They never know when the head is wrong.

Dr. Esmonde

The patient is examined by a general practitioner. He goes to exhaustive trouble to examine him as his predecessors did. For generations, people went to general practitioners and were satisfied. The patient goes away and meets somebody down the street who says: "There is a new Health Act. Why do you not go and get examined by a specialist?" The person is entitled under this legislation to go to a specialist and have the State pay for treatment by the specialist, whether it is necessary or not.

Mr. Briscoe

Did general practitioners in the past not send such cases to specialists?

Dr. Esmonde

When it was necessary.

Mr. Briscoe

When they were doubtful of their judgment.

Dr. Esmonde

They sent the patient to a specialist when they felt it was in the interest of the patient to do so. It was the duly qualified practitioner who decided whether or not it was necessary to send the case to the specialist. I am arguing that the patient will now decide that he wants to see a specialist and the doctor has no power to stop a patient from seeing a specialist. Is it not human nature that everybody who is being examined for a heart condition, or any condition you like, will demand specialist treatment, if they feel they can get it? That brings me back again to the argument that you will have a long queue waiting to get into the hospitals. As I said before, when there is a queue, it is the weakest who goes to the end of the queue. That is one of my main objections to the condition of affairs that will exist in this country. I may be wrong—I hope I am. I am only giving my opinion for what it is worth.

Deputy Dr. Ryan said this afternoon that one of the objections to the implementation of this Act was that it would remove the intimate association that exists between patient and doctor. He says he does not see that that can happen. Of course, it can happen. The very argument I have just made proves it can happen. If what I say is right, if the patient is going to decide whether he will go to hospital or not, and not the doctor, is it not a breach of the confidence that existed in the past? The country will pay for all that. I should be a poor sort of a doctor and a Deputy, for that matter, representing a constituency, if I stood here and grudged anybody in this country the right to the best medical services, but what I do not want to see is huge sums of money being expended and the taxpayer drained to the last drop to pay for services that will not be of benefit to the people. I may be wrong, as I say, and I hope I am wrong. I hope that these health services will be a success. I have always opposed them for the reasons which I have stated. I felt it only right that I should justify myself and say all this again this afternoon.

I believe the Minister is acting in good faith. I am speaking now as a lone voice. The Minister has probably done the right thing in implementing the Act. At any rate, he has achieved one thing: he has been able to get the doctors to work the Act. He has been able to get the service established here. Whether or not it will be a success is another matter. I hope it will be a success. We face an expenditure of £2,000,000 here. I believe that sum will grow from day to day and from year to year. I believe that more people will seek these services than really require them.

Mr. Briscoe

Surely healthy people will not look for medical treatment?

Dr. Esmonde

No.

Mr. Briscoe

That is what the Deputy is saying.

Dr. Esmonde

Perhaps Deputy Briscoe will allow me to speak. I have been in practice myself for years.

Mr. Briscoe

And I have been consulting doctors for years.

Dr. Esmonde

I am sure you have.

Mr. S. Collins

They must be very good doctors to have kept you so healthy.

Dr. Esmonde

Fortunately, many people who consult doctors have not got any serious organic disease. I think I would put the number as high as 70 or 80 per cent. The main point which I have been trying to make all along is that in the past people believed the doctor and left it to the doctor to decide whether or not they were to get treatment.

Mr. Briscoe

What about the hypochondriac?

An Leas-Cheann Comhairle

Deputy Briscoe must allow Deputy Dr. Esmonde to make his speech without interruption.

Dr. Esmonde

Under this Act, a new state of affairs will be created. As I have said, I may be wrong: I hope I am. We have got this Act and let us work it as best we can. It is the law of the land. Let us implement it. However, I feel that, alongside it, we should build up some sort of private enterprise or a private insurance, so that persons who would like to pay their way, and who feel that they would get better service by doing so, will have the opportunity to do so.

Mr. James Tully

For the past two days, we have heard various opinions on the health scheme—how it should be worked and how it will be worked. Let me say at the outset that, whether Deputy Dr. Esmonde is right or wrong, I should prefer to see 50 persons who did not need medical attention going and looking for it, and holding up doctors and everybody else, rather than see one person who needed it being refused it, because he could not afford to pay for it.

Mr. Briscoe

Hear, hear! That is the attitude.

Mr. James Tully

That is the main difference between the people who have supported the Health Bill and those who are or were opposed to it. I feel sure that time will prove that the health services being introduced will mean a very big difference to very many people—even up to the present time, there are far too many of them in the country—who have not received the proper medical treatment for one reason and one only, that they could not afford to pay for it.

I do not propose to go over the ground covered by the previous speakers, but I should like to draw the Minister's attention to one or two points. There are cases occurring where people, because they live beside certain hospitals, have been sent by the local dispensary doctors for treatment into those voluntary hospitals. The local authorities for the area where they have been taken have paid what is laid down as the regulation amount for those patients, and, shortly afterwards, a hefty bill is sent out by a surgeon from that hospital seeking payment of professional fees. We have that difficulty in my constituency, and I am sure it occurs in other places. When we approach the local authority officials, they say that the amount being paid to the hospitals is an all-in fee, but the surgeon apparently is not prepared to accept it. I urge the Minister to do his best to have something done to straighten out this matter.

Even as recently as last week, I saw a man who himself is ill and drawing disability benefit of 50/- a week for himself, his wife and his three children receive a solicitor's letter asking him to pay £6 13s. 9d. for treatment of his child in hospital, although the local authority had previously paid for the treatment, but had not, apparently, paid the surgeon's fees. It is a great hardship on those people that this should occur. I would ask the Minister to see if something could be done about it.

I was very interested to hear reference made to the salaries, if they could be called salaries, being paid to midwives, particularly in the country districts. There is some attempt being made to improve the position under the present Act, but I am afraid it will not compensate those people for what they are doing. In case everybody is not aware of what is happening, let me point out that very many of those midwives up to a few years ago had a fairly important private practice and were being paid for private patients, as well as what they were receiving from the local authorities. At present, almost 90 per cent. of the people who were formerly private patients at home are going to maternity hospitals, and the result is that the private practices have disappeared. Despite that, we find those midwives travelling sometimes as much as ten or 15 miles to attend patients six or seven times and receiving in return something slightly over £3 a week. It would not pay the car hire, if the people concerned had to hire a car for the journey. I am sure that something could be done to change the position.

The suggestion was made recently, I believe, that when the old midwives died out they would be replaced by general purposes nurses, with midwifery experience. I suggest to the Minister that he might be able to include very many of those midwives who have received general nursing experience in the present scheme and do something for them, because their position is very bad. It is no answer to say that they are only part-time employees. Actually, they must be on call for 24 hours, day or night, if required.

There is another point which I should like to raise with reference to the home assistance officers in the country districts. I know that very many of them are receiving their proper rate of pay, but there are many others who would, if they liked to apply for it, be almost entitled to home assistance themselves. You have only to see some of them travelling around the country for miles on bicycles, in bad weather over hilly districts, to realise what those people have to do.

Mr. O'Higgins

I think that is Social Welfare.

Mr. James Tully

Well, they should be entitled to something, anyway, but I will raise it again under the other head. Another type of employee I wish to bring to the notice of the Minister is the non-nursing staff of the public hospitals. They include ambulance drivers, porters, wardsmaids, wardsmen and all the rest. Some years ago, a regulation was made by which the nursing staff was put on what is known as the 96-hour fortnight. That was a very big step forward, and was welcomed by everyone concerned, but there was a grave mistake made when it was introduced, that the ordinary working people in the same hospitals were not also put on the 96-hour fortnight. Surely, it is a bit out of the way to find people going on duty in hospitals at 7 o'clock in the morning and the same people on duty at 7, 8 or 9 o'clock the same night. That applies to women as well as men.

I do not think it should be done for very good reasons, one of the main reasons being that it must affect their general health. Attending sick people for a long number of hours like that is surely something that must affect the general health of those people. The fact that they are receiving a very low rate of pay for that work makes the matter worse. I ask the Minister to have this investigated, and I appeal to him to introduce the 96-hour fortnight or 48-hour week, for all employees in county hospitals. That is something which should have been done many years ago. I did bring to his notice recently cases where people worked long hours in some hospitals. I do not know how it was allowed to continue so long. It did not happen in County Meath, but in other parts of the country. I must compliment the Minister on his very prompt action when it was brought to his notice. I regret that somebody did not take the trouble to find out about these matters over the years.

In conclusion, I should like to refer to the question of the general attendance being given to people by the dispensary doctors in some country districts. We all know the usual cases where the dispensary doctor will attend to patients whenever he is needed, and will attend very promptly. I regret to say, however, that there are still instances of doctors who will make darn sure that they are not available if a dispensary patient seeks them, particularly if it is late at night or in very bad weather. I have brought cases of this sort to the attention of the Minister before. I feel it is wrong that dispensary doctors should treat their patients, who are in every case poor people, in such a way.

In addition, I should like to point out that it has become a practice with some of those people, since the introduction of the Health Act, to claim that, for one reason or another, they are outside the scope of the Act, and patients must therefore pay for services for which previously they did not have to pay. It is all right to say that they should apply for a medical card and be issued with it but I had an instance, which I brought to the Minister's notice, of a doctor who asked an old age pensioner receiving 24/- a week to pay for attention when that old age pensioner called to the dispensary. These things should be stamped out immediately by the Department of Health, and other things of that kind which are brought to the notice of the Department should be dealt with; not alone that but disciplinary action should be taken against the people who are responsible.

Another point is the question of the issue of medicine. This is a matter on which we have various views in the different local authorities. You all know that when a dispensary doctor attends a patient he usually gives the patient the necessary medicine. Sometimes the doctor will say that he has not got it in the depot where he is attending the patient or at the house and will instead give a prescription. I have had instances brought to my notice of prescriptions for medicine costing as much as 17/- or 18/- being given to working class people by doctors who should have given them free medicine. I raised this point with my own local authority, and I maintained that if the doctor says, as he did in one instance, that he has not got the medicine available, somebody other than the patient should be responsible for paying for that medicine or paying that bill. I would be very grateful if the Minister would consider this when he is replying and state who should be responsible in these cases. If, as I think, the local authorities themselves are responsible for seeing that this medicine is issued without charge to the patient, I hope that this will be brought to the notice of the local authorities concerned.

Mr. Cunningham

One of the matters I want to raise is in connection with the Inishowen area of County Donegal. That area is isolated from the rest of the county and the nearest hospital service is in the City of Derry. It has been the practice for years for patients, especially emergency cases, to be sent from that area to the various hospitals in Derry City for the very good reason that it is more convenient to do so and, as I say, it has been the practice. I find recently that even in cases where these patients would have gone a longer and more round-about journey to get to Donegal hospitals or hospitals elsewhere in the State, they would be entitled to free hospital treatment and free medical services, whereas when they, due to force of circumstances, are sent to the nearest hospital even by their dispensary doctor, in most cases they are asked to pay for their maintenance in those hospitals. Even in cases where the local medical dispensary doctor recommends and makes arrangements for these patients to be received into a hospital there, we find that afterwards the local authority does not pay for the expense.

I have been dealing with this question for a couple of years past and there seems to be an impression that this is something that is outside our scope here. I would earnestly ask the Minister to make an arrangement in this connection. I know of a number of cases, especially accident cases, where very poor people, people who are eligible and should get free hospital treatment, have to pay £4, £5, £10 or higher sums for a short stay in one of those hospitals. I have made inquiries at the other end and the hospitals in the City of Derry are very willing indeed to cater for these patients. They give them very good attention and it is only right that we should make some effort to help these people and to see to it that they will not have to pay the expenses themselves or that the hospitals there do not have to go to all sorts of trouble to get the few pounds which is their due and which in some cases they do not get at all because there is no way of enforcing payment of such hospital debts outside Derry.

I hope the Minister will find a way of arranging with the local authority that these cases in that special area will be treated free. It will only be for a short time because a start has been made on the erection of a new hospital in Carndonagh which is in the centre of this Inishowen area. In a couple of years' time, when that hospital is completed, the local authority there will be able to deal with the types of cases that I have mentioned. All I am asking is that in the meantime an arrangement will be made to have payment made.

There is one other point which the Deputy who has just spoken mentioned, the medicines distributed at the dispensary to deserving cases, that is, to public assistance cases. It is only right that public assistance patients, who are entitled to all the other services free, should also be entitled to free medicines. The fact that those medicines are not available at the dispensary is no good reason why these people should have to pay for them.

Mr. O'Higgins

They should not have to pay.

Mr. Cunningham

The position is that they are paying for them and, as the Minister knows, the payment for modern medicines is no small sum. I have a note here of cases of diabetic patients who require regular supplies of insulin. I do know of the case of one patient, the head of a large family who is a diabetic and who is not able to work; he is getting whatever allowances are going and he told me that for, I think, a fortnight's supply of insulin he had to pay 14/- or 15/-.

Mr. O'Higgins

The position is that if that person is in the old public assistance class, in other words, on the medical register, he is entitled to get the medicine free from the dispensary. If the dispensary doctor has not got it, the local authority must provide it. If the Deputy would give me particulars later I will have the matter investigated.

Mr. Cunningham

I have in mind a small number of cases in respect of insulin, but a large number of cases where the other fairly expensive medicines are in question also. When a patient goes to the dispensary and the doctor tells him that he has not got the medicine, is the onus on the doctor to tell him where he can get it free? If the medicine is not available in the dispensary or at the doctor's house, as the case may be, all that the doctor does is to give a prescription to the patient which the patient understands must be taken to a chemist and the chemist, of course, will not give medicine without payment. How is a public assistance patient to know that these medicines are provided free of charge by the local authority, unless the doctor tells him? If the doctor does tell him that they are provided free of charge by the local authority, the patient should be told where they are to be found.

Personally, I should like to know where the patient can get the medicine free of charge, if it is not available in the dispensary. I do not know and I have been dealing with cases of this kind for some time. It is difficult for the patient to know where the medicine is available.

These are the only two points I wanted to mention. They are fairly important and I should like to have them investigated.

Mr. Corry

I should like to see a few of the boys over there. I want to convert them.

An Ceann Comhairle

Is the Deputy asking for a count?

Mr. Corry

I want a House.

Notice taken that 20 Deputies were not present; House counted, and 20 Deputies being present,

Mr. Corry

Some Deputies here were seriously troubled about maternity services. My personal viewpoint is that the midwifery service should be abolished. There should not be duplication of services. Where there are maternity hospitals and cottage hospitals catering for mothers, midwives should not be provided. It is a double expense on the ratepayer and the State. I studied this matter some time ago with reference to the South Cork area. In the Midleton area the average number of cases is six per annum; in Walshtownmore there are two cases a year; in Castlemartyr, three cases a year; in Killeagh, three cases a year; in Youghal, one case a year.

I suggest to the Minister that you could take that lady from Youghal to Dublin, provide for her in the Gresham and have four doctors to attend her for the £190——

An Ceann Comhairle

The Deputy should not make reference to public officials.

Mr. Corry

I am making no allusion whatever to public officials. I am alluding to the number of cases.

An Ceann Comhairle

The Deputy said that somebody should be taken from Youghal.

Mr. Corry

I am saying that there has been only one midwifery case in Youghal per annum for a number of years. Where there is a cottage hospital or a good maternity hospital in an area, people will go there. Deputy Tully was quite right when he said that private practice is gone. The majority of the people go to the maternity hospital or nursing home, which is the proper thing for them to do. I do not believe in the ratepayer providing a maternity hospital and a cottage hospital and, in addition to that, paying a midwife. Take the case I have mentioned in Youghal, which is costing £190 a year for one case a year.

These are the things to which I should like the Minister to give his attention. I understand that where midwives are dying out, they are being replaced by somebody called a general nurse. That is another waste of money. What is happening is that the dispensary doctor is now lying down at home and sending out the general nurse to do his work. It is another duplication of service. The time has arrived when the ratepayers must take due note of those things and deal with them or see that they are dealt with. I had not intended alluding to this matter until it was brought up by two Deputies. I have given the facts as I know them as chairman of the public assistance authority in South Cork.

I understand that some Deputies called attention to the position as regards the proposed regional hospital at Wilton. As far as that is concerned, it is a definite waste of public money and should be ended. We require two homes in the South Cork area. One would be a home, or an extension of a home, for mental defectives. That is certainly needed. What is needed even more is a home for the aged and infirm, something on the lines of the home in Mallow, which is a very good institution and which is now endeavouring to cater for the whole county.

From time to time I have endeavoured to ascertain what was the sense behind the ideas that have come down to us from Departments in connection with these things. For example, on one occasion, when we went up to see the previous Minister, he insisted on a maternity hospital being built at Wilton. Then he went and had a discussion with some team that he thought represented the bosses instead of ourselves and he was about to shift the maternity hospital somewhere else on their instigation. Due to the action of the former Minister, Deputy Dr. Ryan, who took a sensible view of the whole matter, we have now established at St. Finbarr's Hospital in Cork the best maternity unit in the State by converting some of the old blocks into a decent, modern hospital.

We endeavoured to do the same thing in regard to other needs that existed, but every step we endeavoured to take in that direction was blocked by the Department. I might say that we have a superintendent medical officer second to none in this country to-day in St. Finbarr's, and that is Dr. Goold. He has gone to work there and has given it his whole care and attention during the period he has been in the medical service. He knows what is needed and has endeavoured to provide it.

We wanted to clear out two blocks there which are at present occupied by the aged and infirm—I do not know what the expense would be—and we suggested the old Kinsale hospital, or the Youghal hospital could provide suitable accommodation for them. In both cases the experts from the Department came down and said that would not do at all, presumably, because an architect would not draw fees out of it. The Youghal hospital, with all due respect to everybody, could be converted into an ideal home for the aged and infirm with only one-tenth of the expense that would be needed to build a new home for the aged and infirm. I got the opinion of our own engineers there recently and they said it would cost about £75 a bed for that. That would leave two blocks clear for us in St. Finbarr's, into which we could put some 150 extra patients which I suggest would cater for the whole matter so far as hospital treatment is concerned.

Why must we spend £3,000,000 on another building, and who is going to look after its upkeep afterwards? The Minister very wisely alluded to that here last night. I wonder if he is aware that the upkeep of the orthopaedic hospital in Cork is costing over £35,000 a year and that the upkeep of the new St. Stephen's Hospital in Glanmire is costing over £150,000 a year? Who is going to pay it and where is the money going to come from? Those are the things I would like the Minister to consider seriously.

Every step taken by any hospital authority in Cork for the last 15 years has been blocked by officials of the Minister's Department on the plea that the need would be catered for in the new regional hospital. I remember when we were in the difficult position in Cork that all orthopaedic cases had to be sent up to Dublin for treatment and when we had little ones waiting for nine or ten years for a bed, it was with the utmost difficulty we succeeded in getting sanction from the Department to start the orthopaedic ward in St. Finbarr's. That was before the fever hospital was changed into an orthopaedic hospital. In spite of the fact that we had over 100 little ones being catered for in St. Finbarr's we also had over 100 more on a waiting list. That is one of the main difficulties we are up against.

I understand the North Cork people were up with the Minister last week and that they wanted a maternity hospital, or an extension in Mallow to enable them to have a maternity unit there and that the Minister again told them that a regional hospital would be built in Cork. It is not a maternity hospital that is to be built in Cork, so that that plea made by the Department officials in that particular case is wrong. Those are the things I would like to have straightened out if they can be straightened out without imposing a burden that the people will be unable to bear. I suggest that burden is being put on steadily. Every new hospital that goes up now costs more for its upkeep than three of the old hospitals. That is the difficulty. To my amazement, when I asked for figures last week in order to deal with another proposal of the Minister's and when I examined those figures in regard to the upkeep of patients in St. Stephen's T.B. Hospital in Glanmire as compared with the upkeep of patients in small hospitals in Macroom and Skibbereen and Millstreet, I found it was far cheaper to keep patients in those hospitals than to bring them to Glanmire and to keep them there.

Those are the things that, in my opinion, the Minister should get after. Surely if we have all this modern equipment and everything else in the new hospitals they ought to be cheaper to run than the old ones instead of being three times as expensive. That is what is happening.

In connection with St. Stephen's Hospital also, we had another problem regarding patients from other areas coming in there. We all know the difficulty in regard to that. I know that when ten patients out of some 21 that we had in St. Finbarr's were asked to go to the T.B. hospital in Glanmire, they absolutely refused to move. They said it was too far away. How can you expect patients from Counties Clare and Kerry to come up to Cork for treatment? That is what is wrong with the whole thing—we will not get the numbers that have been anticipated.

They have handed over Heatherside Sanatorium as a mental hospital and the peculiar thing is that, while Heatherside is being handed over, the sanatorium authority in Cork has three hospitals on loan, one each from the South Cork Board, the West Cork Board and the North Cork Board. Each of these hospitals that is on loan holds from 20 to 25 patients and they are handing over a building to the mental hospital authorities in which they could put the whole lot. Steps should have been taken long ago to compel the mental hospital authorities in Cork to build their hospital in Youghal. With the sanction of the Department, ground was purchased for that hospital and an architect was paid fees. The whole thing was abolished because a certain number of gentlemen on the committee in Cork want everything to be in Patrick Street, or as close to it as they can get.

Those are the difficulties we are up against. I do not know what to do with the Health Act. As far as I can make out from the officials who are working it in Cork, they do not know where they are from morning until night. I think the proper thing to do is to make it free for all and get done with it in that way. If there was no means test, you could wipe out a horde of officials who are now being paid for checking as to whether Mary has £9 or £9 2s. 6d. What you are paying these bunches of officials to carry out this check would go a long way towards paying the cost of the people who would take advantage of the Health Act if there were no means test.

I find that in Cork it is impossible, in regard to the health services, to get anywhere or to know what treatment people should get. In regard to T.B. patients, I know men who have got no financial assistance whatever, who have had to pay for every X-ray they had taken. I know one man who had a little shop in the city, and, when he went back to business, he found that all his business had gone. I always understood that any T.B. patient was entitled to free treatment and assistance where necessary, and I have sent particulars of this case to the Minister for Social Welfare.

What we would want from the Minister for Health and his Department would be a little thing called co-operation, if it could be got. If there is that co-operation, the money that is being squandered on a regional hospital for Cork could be very usefully used to provide a home for the aged and infirm and mentally defective. We would make the Minister a present of the other half of the money and he could do what he liked with it. Before the Minister goes any further with the regional hospital project in Cork, he should have a full investigation carried out and have the matter examined from every angle.

I believe the Minister is in earnest and is trying to do his best, but I do object to a burden being put on the people which, in my opinion, they will not be able to bear, particularly when there is no necessity for that burden. I say that there is no necessity at present, and no need that I can see in the future, for any regional hospital in Cork City. There is certainly an absolute necessity for taking the 300-odd aged and infirm people, at present living under terrible conditions in St. Finbarr's, which is overcrowded to the extent of 110, according to the latest figures, and providing a proper home for them. I say that if the Minister and the Minister's officials showed ordinary sense, and came down to investigate the Youghal hospital, they would find there a building that could very easily be converted into a home for those aged and infirm people at very small cost. I suggest that the Minister should use the money which will be squandered on the regional hospital in that way.

We are faced with very many difficulties. I do not know where the figures that were given here in connection with the operation of the Health Act came from, but I do know this much, that as far as the rates are concerned, they are up by 5/2 in South Cork and up by 8/3 in the city. Those are pretty hefty figures to get over. I know that when the Minister announced his intention of implementing the Health Act in full, the estimate we got for it from the county manager was £66,000. We found difficulty in cutting any little bit off that when we came to consider the estimates.

Those are the things I should like the Minister to consider. There is undoubtedly a great necessity to have a full investigation of the whole position of the midwifery services in Cork County and also the position as regards the regional hospital. There is necessity for some degree of co-operation between the Minister and the South Cork Board of Assistance towards providing in some way for the aged and infirm who are in that hospital, and who, in my opinion, are treated in a manner in which no one would like to see any old person treated. We cannot help in such cases because we have no room for them.

Mr. Allen

Build a regional hospital in Cork.

Mr. Corry

Will you come up and pay for it? As far as I can see, Cork County is over-hospitalised altogether. That is my opinion of it.

Seosamh Ó Cinnéide

Ba mhaith liom cupla focal a rá mar gheall ar an meastachán seo. I should like to deal with a few matters on this health Estimate. I think the Minister should expedite the readjustment of dispensary areas. Hand in hand with that would go the establishment of up-to-date dispensaries. In the Health Act, provision is included for a general nursing service. Midwifery has been referred to here. The sooner that is replaced by a general nursing service, together with good dispensaries in readjusted areas, the less hospitalisation we will have to deal with. Added to these improvements, we should have a good schools health service. The Health Act has had the effect of taking the health services out of the Cinderella position in which they were and has made them of some importance. I hope it eventually makes them of primary importance.

When he was dealing with the question of medical cards, the Minister said there should be no difficulty in certain categories of people in the lower income groups getting these cards. He referred to old age pensioners, to recipients of widows' and orphans' pensions, of unemployment assistance and of home help. In some of these categories, we found that medical officers claim fees. This has been referred to from the other side of the House. The fact is that, in exceptional cases, old age pensioners, when not in receipt of full pensions, are not given medical cards. The doctor disputes the right to give them medical cards. The Department of Social Welfare have investigated the circumstances of these people and given judgment in these cases. They find out that these persons have not sufficient incomes, that they have been deprived of their pensions and that on every ground they should get medical cards. The Minister should see that all the old age pensioners in this State are provided with medical cards, because unfortunately the tendency in this country is to consider such people as a burden on the family who should be put away into some institution. I think the Minister would be doing a good service if he insisted that these people would be provided with medical cards.

I should not like to see in existence the state of affairs advocated by Deputy McQuillan and supported by Deputy Corry, who sounded as if he were throwing up the sponge, in which there would be free service for all. That would be opening the door for the Socialist State here and it would be a poor day for our people were such conditions to obtain here. The resistance to all that kind of thing will become more intense as the years go on. But I am digressing. In our country, the majority live on small bits of land whose valuations are very small. That pattern of life has been preserved, but unfortunately it seems to be disappearing. In present circumstances, however, I think it would be wise to insist on a means test in social and health services and so forth.

I referred to the readjustment of dispensary areas. I am a member of a local body which has been dealing with this matter of readjustment for quite a considerable time. I think the Minister should put his foot down where there are two areas beside each other and where he thinks readjustment would be to the general advantage. The more speedily readjustment of dispensary areas occurs, the better for the country as a whole. That brings me to a particular district in my own constituency—the dispensary area of Clonmellon. The people there naturally do not want to lose the dispensary doctor who at the moment lives in their midst. I feel sure the Department are well aware of the circumstances obtaining in the area, which is on the borders of Meath. We suggested to the Meath people across the border that they should come in with us. You have only to go about 100 yards on the Kilskyre road and you are out of Westmeath and into the other dispensary area. People live in cottages within a stone's throw of the doctor in Clonmellon. The Meath people will not fall in with this suggestion.

I am subject to correction, but I think the Minister has power in that case to decide that there must be an adjustment of the area altogether. It would be wrong to leave a doctor in a purely rural part of Meath and take the doctor out of Clonmellon, but a lot of people have carried on a campaign there to try to have the doctor removed from Clonmellon which is a populated centre, having the phone and various other things. That disposes of the question of dispensary areas.

A lot of work has been done on the construction of new dispensaries in my county. I believe it should be done all over. I referred earlier to a general medical nursing service. At the moment, a lot of cases attended by a midwife are sent unnecessarily to the county hospitals. If you had a trained nurse on a fairly good salary in these areas, most of the cases could be dealt with locally. The sooner such a system comes about, the better.

Deputy Dr. Esmonde talked about the tendency for everyone to attend specialists. The way we can prevent that is to have adequate school medical services and a good dental service to deal with extractions more speedily than at the moment. These services are not adequate at the moment to deal with the number of children seeking treatment. Side by side with that must come assistance for medical officers to carry out periodic inspection of schools and proper treatment of children as contemplated in the Act. In that way we can cut down the number of people going into the hospitals.

I was not here when the Minister was introducing his Estimate and I can only go, therefore, on what I have read in the papers. Reference has been made to the malpractice of putting old people into mental hospitals. There is some stigma about the county home— the old stigma of the workhouse. It is felt that it would disgrace the family to have a relative in the county home and consequently many a good citizen, and many a good father, has been certified as insane, when he is really as sane as anybody else. He is put in with mental patients when he should really be in the county home.

In the Book of Estimates, there is provision for a contribution to local authorities for the improvement of county homes and for alternative accommodation for certain classes hitherto maintained therein. That provision amounts to only £5,000. Now, the sooner the Minister speeds up that kind of work, the better it will be. The Camillian Fathers in Killucan are providing some of our poor with institutional care. I think more of these institutions will have to go up in the future. It would be all to the good if we could get our people east and west of the Shannon to devote their energies to that kind of thing in order to relieve our hospitals. I am not saying a word against the work done by the Sisters of Mercy; I have praised it here. The fact is, however, that we are overcrowded in our county homes and the sooner that overcrowding is relieved the better.

There is very little else I have to say on this Estimate. The three points I wanted to make were, first, the readjustment of dispensary areas; I made a special plea in that regard in relation to Clonmellon. I hope the Minister will look into that. The people there are anxious to keep their doctor and they should be given every opportunity to do so. Nobody in Westmeath would deprive them of the services of their local doctor. Secondly, I referred to the speeding up of the school medical services and the building of dispensaries. Thirdly, I want to stress again the fact that I, for one, do not— and I do not think my Party as a Party—stand for the abolition of the means test, either in social or health services.

Mr. Allen

Deputy Corry has told the House and the Minister that they do not want a new regional hospital in Cork. They want the old building reconstructed. I have the opposite plea to make. In Wexford we want a new county hospital—and we want it very badly. I appeal to the Minister to do all in his power to make provision at the earliest possible date for the erection of that hospital. Recently he received a deputation from the county council and, though he did not make any promise, he did not flatly turn them down. He held out some hope for the future. If Cork does not require the hospital, I am sure that should bring the Wexford project forward a few years.

Quite a number of years ago the Wexford health authority spent a considerable sum in reconstructing the old workhouse and, while it served its purpose in the interim, its service is now nearly at an end. The council are faced with a very large capital expenditure on the maintenance of that building. We hope the Minister will at least give the green light to Wexford to prepare the plans. It is the experience that from the commencement of the preparation of plans to the time when building actually commences, a period of anything from five to ten years elapses. If there is any hope of money being made available inside that period, the Minister should now authorise the local authority to prepare plans. With the best goodwill in the world, none of that money will be spent for a considerable time; by the time the architects, the engineers, the Department of Health and all the other interested bodies have considered the problems arising out of this project, a long period will have elapsed.

The maternity accommodation at the moment is altogether inadequate. Indeed, the building needs capital reconstruction. The local authority will be very slow to spend that money, if they see any hope of a new hospital. There is a suitable site which was acquired about 15 years ago. I think the Minister should authorise the local authority to go ahead with the project. Remembering that Cork has now more than adequate hospital services, we would be delighted to take a much smaller building than the proposed Cork Regional Hospital. I am sure one-tenth of the proposed expenditure there would meet our needs.

The Health Act has now come into full operation as from 1st April. We all hope that henceforward that Act will have the goodwill of everyone, in its operation and implementation. It deserves the full support of every section of the community. A good deal of effort has been made in the last two or three months to misrepresent the Act, and to show that all increases in the cost of health services are due to the coming into operation of the extra sections. As the Minister rightly pointed out, that is not so. The major portion of the increase falling on local authorities and on the Exchequer this year would have been necessary, irrespective of the Act, in order to maintain the services already there. Services have been increasing in volume all the time. They have been costing more; they require more highly paid staffs; and so on.

I should like to point out that we are spending far less on health services than we are on the maintenance of our roads and I think the health of the community is at least as important, if not more important, as good highways. When I hear people complaining about the cost of health services, I always draw their attention to the cost of our highways. I think that is a fair comparison.

Possibly in the past we have not provided adequate health services for the community, and this new step is in keeping with what we have been doing in this country since the establishment of native Government to improve our health services, social services, etc. I can well remember that, when this State took over, there was no such thing as a county hospital in any county. All you had were the old county homes; and we know what they were at that time. There has been a revolutionary improvement in the health services over the last 30 years. I suppose not a quarter of the Deputies remember, because they were too young, the conditions of the health services that were there when this State took over from an alien Government. Step by step, down through the years, there has been a general improvement; and this step that has been taken this year is only in keeping with the policy of successive Governments in improving the lot of the people in regard to health and social welfare benefits.

I am glad the Minister has seen fit to implement those sections of the Act, and I have no doubt but that they will give to the community benefits and services in the matter of health and specialist treatment that they did require. My colleague, Deputy Dr. Esmonde, has only one objection to the implementation of the Act at the moment. He said that a lot of people would go to their ordinary medical practitioner in the first instance and, if they were dissatisfied with his diagnosis, would demand to see a specialist and that they would go to this specialist at the expense of the local authority and the State. As far as I know, they cannot get to the specialist except through their local medical practitioner. I think I am right in that, and that Deputy Dr. Esmonde's worry in that direction is absolutely unfounded. It is not going to cost a halfpenny to the ratepayers or to the taxpayers for that class of person. If they need a specialist, their practitioner, whoever he may be, whether he is a free-lance or a dispensary doctor, must recommend that they need a specialist and state that they come within the categories entitled to health services under the Act. If he does that, they will then get treatment. It is only if their own practitioner recommends them and in no other case. I hope the Minister when he is replying will ease Deputy Dr. Esmonde's mind on that point and that Deputy Dr. Esmonde will not be able to make false propaganda in that direction against the implementation of the Health Act.

Deputy Dr. Ryan dealt with the question of the white card. There has been difficulty about the white card, and members of local authorities have come across that. You will find, for instance, an area where certain medical gentlemen took it upon themselves to determine to whom they should give service and to whom they should not. That is what has created the difficulty and nothing else. In fairness and justice to the medical profession, so far as I know them operating in my constituency, 95 per cent. of them gave treatment where they should but just a few—I will call them inexperienced medical practitioners—came along and set out to determine what the law should be in respect of individuals in their dispensary areas.

However, the local authority took steps, through the county manager, to bring those gentlemen to a realisation of the fact that it was not they, but the county manager on behalf of the local authority, who should determine who would or would not receive medical treatment. There is some danger in that direction. From time to time I would suggest the Minister should make quite plain to local authorities the classes of people who are entitled to free medical services and that the medical profession have no right to determine that. They can, of course, bring to the attention of the manager cases where they think an individual should pay. They have a full right to do that and nobody is denying that to them. They had that right previously and the Health Act of 1953 did not change the services that were provided under the 1939 Act or the Acts previous to 1939. As far as I understand it, the law is the same now as it was for the last 50 years in respect of the people entitled to receive free medical treatment.

I am glad that the controversy on this has come to an end and that from now on we can all try to implement those services that are provided. I am sure that future Dála, if they see the necessity to improve those services in any way, will not hesitate to bring in legislation to again effect improvements. After the experience of working what is there at the moment, and with the goodwill of the members of local authorities, of the county managers and of the Department of Health, I have no doubt but that things will go smoothly henceforth.

Mr. MacCarthy

I should like to support Deputy Kennedy in the appeal he made for a redistribution of the dispensary areas. I think that matter has been considered for some years but not very much has been done about it. It has become an acute problem in the environs of Cork City where about 10,000 of the population, formerly within the borough boundary, are now housed in suburban areas which have been readjusted for inclusion in the city. These people have been moved into dispensary districts which are now very inconvenient, both for the doctors operating them and for the patients trying to attend. One case in point is that the medical officer of Blackrock dispensary district is supposed to attend the Ballyphehance area, which at one time had very few houses but was composed of green pasture land and market gardens. Now that position has very radically changed, and I am sure that attention will be given to it at the earliest possible moment because it is an urgent problem.

Another point with which I would like to deal is the utilisation to the best advantage of existing hospital buildings. I am talking now, not about reconditioning derelict county homes or workhouses or buildings of that kind, but about buildings that were retained as fever hospitals close by the cottage hospitals. These buildings were used during the high incidence of T.B. to treat patients. Now that that position has been altered, they will again revert to another purpose. They were idle for years and consequently deteriorated until they were reconditioned as fever hospital units to deal with emergency cases. We all know that, with the advance of medical science and all the rest, the danger of serious incidence of fevers has long since vanished, and these buildings should be examined and, when the T.B. patients are moved from them to the sanatoria, it should be decided what is the best use to which these buildings may be applied.

I was not in the House when my colleague Deputy Corry spoke, but he evidently made a case that at this stage the regional hospital at Cork should not be built. Deputy Corry was speaking for himself in that regard and for a very small minority. He put the matter to the test at a recent meeting of the South Cork Board. Of course, there can be no doubt but that the need is there for the hospital and that the project which has taken so many years to fructify will not, at this late stage, be knocked on the head.

It is most difficult to get bed accommodation in Cork for patients. That is the experience of every Deputy and of every public representative. The need is there, and I am sure the Minister and his advisers will not be thwarted at this stage from carrying out the programme envisaged in that regard. The public representatives are heartily behind that, with very few exceptions.

I would back Deputy Corry, however, in regard to the closing of the fever hospital, which was examined at one stage as to its suitability to treat T.B. patients, mental patients and others. The report was so bad that we really could not do anything whatever about it. It is now useless and wasteful to retain a fairly big staff there, with very few patients. The accommodation in the fever unit of St. Finbarr's hospital may be adjusted in such a way as to be able to give proper accommodation for the people who are now there. They are very few and only on very rare occasions are there any at all.

The accommodation for mental defectives is, as many members have said and as the Minister himself is aware, now one of our coming problems. No attempt whatever can be made to educate them or train them at home. It will take one member of the family all this time to give some attention to their ordinary domestic needs. An expansion of the accommodation where they can be properly treated is a great need and the extension being made in Lota will be very helpful. I understand that about 80 extra beds will be available there in the near future. The people who deal with these have a special vocation and must have a special vocation for that type of work. The Brothers who are doing such excellent work there will be able to accommodate more and the sooner we are able to deal with that problem adequately, the more pleased everybody will be.

There is also the question of homes for old people. That is not as urgent a problem as the other, but yet it is a problem that will have to be faced sooner or later. With regard to old people living alone, too often do we read of tragedies in the last days of their lives when, through helplessness, with nobody to care for them, these poor aged people fall into the fire or are the victims of some other distressing or fatal accident.

The question of the mental defective and the disability pensions are much on the same lines. Very many of these disabled people take up the full time of a member of the home to look after them. An appeal was made from all sides of the House to the Minister to be as generous as possible in giving that benefit, no matter what the circumstances of the home are. It would cost much more if these people were removed from the home to an institution. Home may be the best place for them, if they have some member of the family with a special vocation to look after them. I think the allowance of £1 would be well spent and that there should be no cheeseparing in regard to it at all.

I should much prefer to see utilisation of the present hospital buildings where the central unit is adequate to deal with cases. We should have no wasteful expansion of staffs where they are going to be subsequently a burden, not only on the ratepayer, but also on the State. When the operations of the Health Act are stabilised in a year or so, we will all know better where we stand in that regard. We are all unanimous as to working the Act to the best advantage and providing for the people the specialised services they cannot afford themselves. By improving the general health of the people, we will have a more vigorous race, and those who are afflicted by illness will know that they will receive the best attention in the country.

Dr. Hillery

I would not agree with Deputy MacCarthy that the need for provision against infectious diseases has long since passed.

Mr. MacCarthy

I referred to fevers.

Dr. Hillery

I believe we must be continually on the qui vive against the recurrence of epidemics. While a great deal of credit can be given to preventive medicine for the present low death rate from infectious diseases, I think most of the effect we see is a natural movement of the organisms concerned. It is quite possible that the organism which in scarlet fever or other diseases is now attenuated would become virulent again and that we would be visited by epidemics which would cause a considerable rise in the death rate.

For that reason, I think provision should be made for beds for any infectious fever which may arise, because I am sure it is the experience of the Minister that isolation is one of the greatest limitations to any infectious disease. Medical treatment and other measures taken after that have a very much smaller effect on the epidemiological outlook than the actual isolation of active infectious cases.

I should like to stress as often as I can the need for providing for isolation in the event of the recurrence of any infectious disease in a virulent form. It is very gratifying to see the death rate from T.B. so low and I presume we can expect to get it even lower. We will find we will have a small core with us always. The achievement in regard to T.B. is one of the great achievements of preventive medicine on a national scale. I wonder if the Minister can visualise a time when we may have some spare sanatoria, because I believe that the pavilion type of accommodation would be an excellent place for the rehabilitation of mental patients. Mental diseases in many countries are still treated with a certain amount of the snake-pit attitude and our treatment institutions still appear very much like prisons. While scientifically the treatment has improved, I think the general atmosphere in which a mentally ill patient finds himself is not good, even after a certain period of treatment.

I believe the Minister should, if he ever finds it in his power, make available one of the pavilion type of open free sanatoria for the accommodation and final treatment and rehabilitation of people who have suffered from mental illness. We have good treatment, but I think the final cure of these patients could very well be effected in such a congenial place as an open unwalled pavilion type of sanatorium. I suggest to the Minister that if ever we reach such a redundancy in beds in sanatoria we should experiment with that idea of mental treatment in a free atmosphere.

The death rate from accidents is very striking. In his opening address, the Minister asked the people to exercise more caution. That opening address will not be read by all the people and that single line will hardly have the good effect the Minister would wish for. There are places in the classification of accidents where the Minister could do a lot of good. First, there are burns and scalds of children. It is my experience that you meet most of those in the autumn and early winter when children are confined to the house again after the summer. It would be a very good time for a propaganda campaign on the part of the Minister's Department to bring to the notice of parents the dangers of pots of boiling water, pots of porridge, open fireplaces and the various other sources of burns and scalds to children. Nothing could be of more benefit than a proper education of the public.

Mr. O'Higgins

We have a propaganda film which I hope will be used by local authorities. It is called, "The Life of Reilly".

Dr. Hillery

That would be very good. I hope the film will have a good effect. I think the newspapers could do a lot also. I remember the Department's propaganda on T.B. It was very widespread and, I am sure, very expensive. I think the newspapers could play a very big part if the benefits that would be derived from a series of articles on accidents were pointed out to them. Recently, we have seen articles on road accidents in some of the newspapers. Such a series run by the papers, without having to be paid for by the rates, would be of great benefit to the people and I am sure that, finally, the people would be very grateful to the newspaper proprietors.

Another matter in regard to which the Minister could make some effort is road accidents. It seems ridiculous that one Minister comes to the Dáil in good faith bewailing road accidents, while another Minister refuses—I am not blaming the present Minister but all Governments—to bring in a driving test. It is like supplying monkeys with firearms. If you have a pound you can get a driving licence and drive at any speed you like anywhere you like. You could be a mental defective or anything else. On the road to-day a man was driving in front of me. He must have been 90. He was coasting along at 90 miles an hour. He put out his left hand indicator and then he turned to the right. He paid his pound and he can drive where he likes.

An Leas-Cheann Comhairle

That would be a matter for another Minister.

Dr. Hillery

I suggest it is a matter of vital statistics. The Minister for Health should bring this to the notice of the Minister for Local Government, who should bring in some driving test or even a test of courtesy or a mental test to see if they are fit to be out at all.

The rise in the cancer death rate is probably more apparent than real. I think the diagnosis of some forms of cancer is becoming more common because the doctors are more aware of the presence of these things. It is possible, too, that through the good work of the Minister's Department more people are living into the cancer age. Therefore, I doubt if any new factor is working in the country to cause an increase in the cancer death rate. It is just an apparent increase. I would not suggest that the Minister should spend any of our money on cancer research because much richer nations are spending from their resources and we shall always benefit by the international publications on medical research.

In my view, we could do something about cardio-vascular disease. I expect it is the highest cause of death in this country. Again, if we approach this whole matter from the point of view of the education of the people, a great deal of these conditions are preventable and many of them are reversible by treatment. I think the Minister could enlighten the people on the proper use of the medical services available to them.

The implementation of further sections of the Health Act with the agreement, albeit reluctant, of the Irish Medical Association is an achievement. It is creditable that the aggressive attitude on both sides, but particularly the aggressive attitude of politicians towards the doctor is dying out.

Mr. A. Barry

Did you identify him?

Dr. Hillery

I am fighting myself. It will be a pity if we cannot get the people and the doctors to work this scheme. The Dáil has done as much as it can do. We have quickly reached adequacy in our services. We are now at the stage where members of local authorities are feeling the financial side of the question and are looking for efficiency in a service where it is very hard to assess it, that is, the balance between costs and results. If, by efficiency, they mean the minimum of wastage, we shall need to have the co-operation of the public and the doctors. While the Minister's Department has inspectors, they cannot hope to have efficiency in their service if they have not the full co-operation of the medical profession. While I may compliment the Minister on having an adequate service or a service fast approaching adequacy, I think we need to get the doctors working to reach a common ethic with the people they are dealing with so that both will co-operate in getting the medical services at the minimum cost to the Exchequer.

It probably would be wise for the Minister to point out to the medical profession that the scheme, in its present or near future condition, is quite adequate and if they use it to the proper and full extent there will hardly be any need for any future health legislation. It is really up to the doctors to make the best use of the good services available now. This type of service brought in at Government level, with people reluctant to work it could lead to a certain amount of resentment on the part of doctors, and resentment, again, could lead to passive resistance. The only result of that type of attitude in the medical profession would be the need for further legislation, and I think that, now that the relations between the politicians and the medical profession are somewhat amiable, it might be a good time to get it across to them, that it is a good time also to prevent the need for further health legislation or further limitations on the freedom of the profession. I am sure the profession will appreciate that if they work those services well and properly the people will be satisfied and there will be no need for further legislation.

I think it was Deputy Allen who mentioned some doctors and what they did. You could have thousands of crooked businessmen or lawyers and you would hear little about it, but when one doctor does something wrong Dáil Éireann and every county council in the country is up in arms. It is easy to prevent doctors doing wrong by having the people properly enlightened on the services available to them and on what they are supposed to pay. My experience of people is that you cannot tell them a thing once and go away.

You have to let people know day after day and year after year where they stand. Again it would be a very expensive job for the Department, but I am sure the newspapers would help. They could help a lot by letting the people know exactly where they stand in all circumstances dealing with the medical profession. I would much prefer the movement to be from the Minister to the profession and from the profession to the people.

I think you could get a very fine service with near full adequacy and near efficiency, if the doctors set themselves out now to meet the public squarely, let them know their rights and the doctors' rights—because, in spite of what you hear in public places, doctors have rights the same as other citizens. The doctors could educate their patients, because they are more likely to know what the patients will not have available to them in the line of information as regards what services exactly they can have and when they can have a specialist and when they must pay. The Minister would be doing a very fine year's work, perhaps, if he gets the medical profession to cooperate with him on these lines.

I do not know if I should mention anything about the Act, but I will say that I do not think you can equate £600 a year against a £50 valuation. I do not believe a man with £600 a year is as well off as a farmer with £50 valuation. Indeed, the man with £600 a year at the present cost of living is not able to afford services any more than a man with, say, £20 valuation.

Mr. Allen

The man with £50 valuation will exchange with him any time.

Mr. O'Higgins

I wonder will he?

Mr. Allen

He will.

Dr. Hillery

I do not think it is a fair equation.

Mr. Allen

Try him out. I would like to challenge that.

Dr. Hillery

I have nothing more to say.

Mr. O'Higgins

The debate which has just concluded has ranged over a wide area, and many important matters have been referred to by Deputies. The fact that so much has been said with regard to so many different matters arising on this Vote indicates in some small way the very great increase in the work that the Department of Health is doing now and has been doing for some years back. The debate has, I suppose, divided itself into a helpful side and a very unhelpful side. Like the curate's egg, it has been good in spots, and as I am firmly convinced that this debate in these last few days should see the end of the political controversy on health, I propose to deal with both the good and the bad parts of this debate in the hope that that may be the end of dissension and discussion on these matters.

I think that the speech we heard to-day from Deputy Dr. Ryan was a very fine speech, a speech made by a man who has had years of experience in dealing with the subject of health and the provision of health services; and he joined with me in expressing the hope that we would see the end of dissension on these matters. I believe that, if Deputy Dr. Ryan had found it possible to be in the House yesterday afternoon and to have opened the discussion on this Estimate on behalf of the Opposition, the debate we have experienced would have been an entirely helpful debate. Unfortunately it was not possible for him to be present, and his place was taken by Deputy Briscoe. Deputy Briscoe, in what he had to say on this particular Estimate, and in some of the extremely mischievous statements he made, was, I hope, speaking only for himself. In so far as he did speak at some length, it is necessary for me to deal with what he said.

Deputy Briscoe yesterday, in effect, charged me as the present Minister for Health with doing something injurious in relation to the services that are now being provided under the Health Act. He made the usual charge that if I made an agreement it was a bad agreement and that somebody else could make a better agreement. I want to remind the House and the country of the situation which I have had to face in the last 18 months or so.

When I took office as Minister for Health I found that the Health Act, 1953, had been put into operation by my predecessor. That was the legal end of the Health Act. It was the administrative end of providing that the statute itself would have legal effect. But, of course, that in itself by no means indicated that the services contemplated or envisaged by the Act could be provided. I had to study the situation that confronted me, and I found, to put it mildly, that a state of warfare existed between my Department and the medical and allied professions. Those were not circumstances conducive to the operation of good health services in the country. I found, in addition, that certain necessary facilities for the operation of the services envisaged in the Act were in fact not available and, of course, in addition, that a great number of necessary preparatory arrangements had not in fact been made. I am only dealing with the facts that confronted me and with the situation which I had to tackle. It would have been an easy thing, perhaps a politically sound thing, for me to stand aside and to say that this situation was not of my making, to do nothing and allow chaos to develop in this country. I was not prepared to do that, nor were any of my colleagues in the Government prepared to do that. Accordingly, I was authorised by the Government to seek from this House powers which I believed would make it possible for me to implement this Act in due course and in order to make it workable and possible.

I want to remind the House of what I said in introducing the Health Bill, 1954, because Deputy Briscoe suggested yesterday that my decision to implement the Act and to bring in additional services on 31st of last March was some new decision brought about by political pressure from the Labour Party. That is not so. My view on this matter has always been consistent; it has always been clear. There has been nothing secret about it because there has been nothing to hide.

On 7th July, 1954, a few weeks after I became Minister for Health, in introducing the Health Bill of that year, I said with reference to the Health Act, as reported in column 1342, Volume 146, of the Official Debates:—

"I decided not in any way that could be avoided to interfere with the Health Act, 1953. I voted against that measure when it was before the Dáil. I do not think that it incorporates the best that could be obtained in this country. I was against it and spoke against it but I do feel that a contribution can be made in this whole turbulent controversial subject of health by accepting what has been done by those who went before me. I propose to accept the Health Act, 1953, in so far as the services are concerned in full. I do not intend to change them. I do not intend to alter them, to minimise them, to counteract them in the slightest. I do intend to see that they are made available. I do intend to see that the Health Act works and that is the purpose of this Bill."

I went on to say in column 1343:—

"May I say that, if the Bill proves acceptable to the House, I intend, with all sincerity, to provide these services to the other classes as quickly as possible, but I do not propose to do it until I am satisfied that it can be done, and I do not propose to allow any person in this country who is unable to fend for himself, or herself, to suffer?"

That was the view which represented the policy of this Government as expressed by me on 7th July, 1954. The Bill which I asked the House to pass was passed and I was given powers then under that Bill to deal with the situation which I have mentioned and which confronted me. I felt it necessary to make immediate regulations providing that the Health Act, 1953, would in fact operate by degrees, in accordance with all the arrangements I could make and in accordance with all the facilities that might become available. It became my concern and my duty since the passing of the Health Act, 1954, to try to make the parent measure a workable one, to try to see that it came into operation in a reasonable way and that it would be acceptable to those who had to work it. It was my concern to see that whatever legitimate objections different people might have would be considered in a reasonable frame of mind and that so far as was possible to me, the Act would be made to work.

In the task that faced me, I was not aided by the charges which were made by different Deputies of the Opposition. I was not, for instance, helped by Deputy Briscoe who, in the discussion on the Health Bill, 1954, in column 1389, Volume 146, of the Official Debates of 7th July, 1954, said:

"I protest on behalf of the citizens of Dublin, on behalf of all those people who are under the £600 a year income level and all those insured workers who are being cut out now that they are being denied the benefits of the provisions of the Act, particularly so far as it concerns the maternity side. I see no reason why one-sixth of the people of the country should be denied the benefits of this Act until such time, some years ahead, when every corner of the country will be able to say: ‘We are now able to implement it'."

In my efforts to make the Act workable, I was not aided by statements such as that which were intended to suggest that I was deliberately depriving the people of Dublin, or the people of the rest of the country, of some benefits, of something of inestimable value which was being offered to them by the Health Act, 1953. I was accused time and again of trying to sabotage that Act.

In different parts of the country, certain Deputies in this House made it their prime concern to suggest that I and this Government had prevented the people from getting something that they would have got automatically on 1st August, 1954. Despite the temptation, which was often strong, which I had to undergo in reading these speeches, and in hearing these expressions, I think that it has been better to let the people see by what, in fact, has been done that these speeches represent nothing more than the utterings of people who wanted to be mischievous.

Now that we have put all that behind us, now that these services will operate, not as a few words in a section of an Act of Parliament, but as something tangible, as something which can be seen and experienced by the people, I regret to say that we still find some Deputies anxious to cause mischief. Deputy Briscoe yesterday gave us an example of a very disappointed man. Judging from Deputy Briscoe's speech, he is extremely annoyed that it has been found possible to make the Health Act workable. He is extremely annoyed that agreement has been reached with the medical and other professions and, of course, he makes the charge that I made a bad bargain. Maybe I did. I do not know. At least, I made a bargain and, at least, agreement has now been reached, and I hope that harmony and co-operation will take the place of the state of warfare that confronted me when I became Minister for Health. There is very little sense in allowing a situation to exist in which there is strife—warfare—between the Minister for Health and the medical profession, with the sick and the needy given a ringside seat to watch the show. That is not helping the people who need health services. Even though the cost may be felt, I think it is much better to stop the row and to get on with the work. Deputy Briscoe said some other things and I fear that in most of his speech, he was more than anxious to be as harmful as he could be.

I said all I want to say about the Health Act and its implementation, but its effects are now clear to everyone. You cannot expect the services envisaged by that Act to operate, unless they are paid for. There is no more expensive service open to any State than its services for health. The provision of better health services will always cost more money and I have no doubt that, as we continue to expand our health services here, they will become more and more costly.

Deputy Briscoe protested yesterday against what he called my action in transferring to health authorities the cost of insured workers. The plain fact, of course, is that the cost of hospitalisation of insured workers is transferred to health authorities under Section 15 of the Health Act, 1953, and, if that is wrong, if it imposed an intolerable burden on the ratepayers of Dublin City or elsewhere, it was Deputy Briscoe's duty to make that criticism when the Health Act of 1953 was being passed through this House with his support.

Mr. Briscoe

I was not protesting against the transference. I was protesting against the Minister not taking account of the saving to the State.

Mr. O'Higgins

Deputy Briscoe went on to say, in his second point yesterday, that the increase in capitation payment for patients in hospitals which I recently sanctioned was intended to help out the deficits of voluntary hospitals. That, I think, was about the only accurate statement which Deputy Briscoe made.

Mr. Briscoe

Now, be careful.

Mr. O'Higgins

Deputy Briscoe seemed to think that that was wrong. In Dublin area, the hospitalisation available to the health authorities is largely non-local authority. There are up to ten large teaching hospitals which traditionally have provided the hospital services for the people of this city and county and, indeed, for other parts of the country also. These voluntary hospitals have for years found it impossible to make their revenue meet their expenditure and they have for many years been faced by rising deficits in their accounts. One object of the Health Act of 1953 was to remedy that problem by transferring to the ratepayers of Dublin City and County a share in the cost of reducing these deficits. That was part of the policy behind the Health Act. My predecessor felt that, under the Health Act, by making Dublin Corporation make a capitation payment, which was then 16/- per day, in respect of every single patient sent by it to Dublin voluntary hospitals, the deficits would be reduced, and, if the deficits were reduced, the call upon the Hospitals' Trust would be lower and, of course, the Exchequer would benefit by a smaller Grant-in-Aid.

Prior to the Health Act of 1953, the situation was quite different in this city. In fact, the Dublin ratepayers were getting away with murder, compared with their situation now.

Mr. Briscoe

"Murder"?

Mr. O'Higgins

The entire cost of the hospitalisation of corporation patients was met by a charge of one shilling in the rates.

Mr. Briscoe

Up to what date?

Mr. O'Higgins

Up to 1st August, 1954.

Mr. Briscoe

Oh, no.

Mr. O'Higgins

That is the day the Health Act came in.

Mr. Briscoe

On a point of correction, the Minister is wrong on that.

An Leas-Cheann Comhairle

The Minister is in possession.

Mr. O'Higgins

Up to the operation of the Health Act, one shilling in the rates in Dublin, which raised about £120,000, represented the full cost to Dublin ratepayers of providing hospital treatment for thousands of patients in respect of whom they had responsibility.

Mr. Briscoe

May I correct the Minister?

An Leas-Cheann Comhairle

If the Minister gives way.

Mr. Briscoe

The Minister cannot make a wrong statement and get away with it. The change from a shilling was made many years ago.

Mr. O'Higgins

That £120,000 was divided amongst the different hospitals and that represented the cost to the ratepayers of Dublin in respect of this important service.

Mr. Briscoe

That is not so.

Mr. O'Higgins

Under the Health Act, all that was changed. Under the Health Act, each patient in the lower income group, on 1st August, 1954, in respect of whom, under Section 14, the Dublin Corporation had a responsibility, became the subject of an arrangement under which a sum of £5 12s. per week—16/- per day—had to be paid by the corporation to the treating hospital.

Mr. Briscoe

That was raised from 8/- to 16/- in 1945.

An Leas-Cheann Comhairle

Order! Deputy Briscoe may not interrupt.

Mr. O'Higgins

This very extreme change of a weekly capitation payment in respect of each patient as against a global charge or contribution from the rates—that was part of the policy behind the Health Act, and I agree with it.

Mr. Briscoe

It was done much earlier.

Mr. O'Higgins

It was aimed at reducing the deficit of voluntary hospitals. It was hoped by my predecessor —I do not think, in fact, that this hope of his has been fulfilled—that, as a result of this payment, while the burden on ratepayers would increase, nevertheless a more real situation would operate in the Dublin area and the deficits of the hospitals would be reduced. I mention that because yesterday Deputy Briscoe had the audacity to suggest here that, because that capitation rate of 16/- per day was increased by me to 18/- per day, I had done something so unusual as to indicate a complete reversal of policy.

Mr. Briscoe

Plus 15 per cent.

Mr. O'Higgins

We will come to that. I mention these matters in regard to Deputy Briscoe's speech, in the hope that, as they will be on the records of this House, people interested in this matter may know what the truth is. Deputy Briscoe went on yesterday to make what I regarded as a rather mean charge. On this subject of the deficit of voluntary hospitals, he referred to what he called the dissipation by the first inter-Party Government of Hospitals' Trust Funds in 1948.

Mr. Briscoe

Amounting to nearly £10,000,000.

Mr. O'Higgins

I want to explain the position to the House before I deal with that charge. It was at one time contemplated by the Hospitals' Commission in the early '30's that Sweep funds could be put into a pool which, by means of its interest, could meet the deficits of the voluntary hospitals. A sum of £2,000,000 was taken as a capital fund some time prior to 1938. In 1938, this capitation fund had been increased by £600,000. It was later increased to £3,350,000. In 1941, the fund was £4,220,000 and further increases were necessary. But here is the interesting thing: in 1933, the deficit figure for the voluntary hospitals was just £64,000. It was easy then to contemplate interest from the capital fund which would meet a small debit of that kind, but in 1933, the deficit had risen to £115,000; in 1943, to £149,000; in 1948, to £398,000; in 1951, to £628,000, and in 1953, to £690,000.

Mr. Briscoe

Will the Minister say what the capital sum was in 1948?

Mr. O'Higgins

In 1948, with a deficit figure of close on £400,000, there was available in this fund a sum of between £5,000,000, and——

Mr. Briscoe

£7,000,000.

Mr. O'Higgins

I have not got the exact figure, but it was something more than £4,500,000. In any event, the sum in 1948 was a sum the interest from which could not meet the huge deficit payment of the Government. At the instance of the Minister for Health at that time, it had to consider whether it would continue on building up a capital fund in order to get an interest payment which would chase rising deficits. The Government decided it would be daft to do so. Supposing they had decided otherwise, as apparently Deputy Briscoe would have decided, if he had any voice in affairs —if they had decided otherwise, I would have tied up to-day a sum of £17,500,000 in order to meet the deficit payments of the voluntary hospitals.

Mr. Briscoe

Would that have been bad?

Mr. O'Higgins

I think that, in 1948, the then Government and the then Minister for Health came to a very wise decision when the Government and the Minister said that the money available there would serve a better purpose by building hospitals for those who were sick and in need of treatment. I think the Minister was wise and the Government was wise in that decision, and years later, when Deputy Briscoe comes along to attack him— and although that man is now a member of Deputy Briscoe's own Party— I think it is only right that the decision which was correct then should still be correct and that he should be vindicated some years later. If the decision was, as Deputy Briscoe would have liked it—and I hope Deputy Briscoe's constituents will realise this —there would now be no Ballyowen Hospital in Dublin; there would be no St. Mary's Chest Hospital, no James Connolly Sanatorium; no Cherry Orchard Chest Hospital, and St. Kevin's Hospital would be a disgrace to the Department of Health and to the corporation and public representatives.

Mr. Briscoe

And who changed it from being a disgrace?

Mr. O'Higgins

Instead of that, these sanatoria have been built by reason of a decision taken in 1948 by the first inter-Party Government and the first inter-Party Minister for Health. Money has been poured into St. Kevin's Hospital to change it from a workhouse into one of the finest clinical——

Mr. Briscoe

That was done before the advent of the 1948 Government. Such nonsense!

Mr. O'Higgins

But, of course, Deputy Briscoe being over-anxious to cause trouble, over-anxious to make political capital out of any difficulty, comes along and says: "You did wrong in 1948. Why did you not tie up all that money and get interest at 4 per cent. on it and everything would be grand?"

Mr. Briscoe

And save the ratepayers and the taxpayers these disgraceful charges to-day.

Mr. Casey

And do without the hospitals?

Mr. Briscoe

The hospitals were built. There were more hospitals built under the Fianna Fáil Government than by any other Government.

Mr. O'Higgins

I want to make it quite clear that if Deputy Briscoe's mentality had any effect in 1948 on the decision taken by the Government—it could not have because it was an inter-Party Government—there would now be none of these sanatoria available for the people.

Mr. Briscoe

That is not true.

Mr. Casey

Of course, it is true.

Mr. Briscoe

It is a deliberate untruth. What does the Deputy know about it anyhow? The Deputy knows nothing about Dublin. He is talking about Cork.

Mr. Casey

You are chancing your arm——

Mr. Briscoe

I am not.

An Leas-Cheann Comhairle

Deputy Briscoe has interrupted on several occasions since the Minister rose to conclude——

Mr. Briscoe

The Minister is provoking interruptions by stating deliberate untruths.

An Leas-Cheann Comhairle

The Deputy must withdraw the expression "deliberate untruths."

Mr. Briscoe

I withdraw that. Untruths, then.

General MacEoin

I respectfully submit that is not a withdrawal. He says he withdraws the word "deliberate."

An Leas-Cheann Comhairle

The Chair insisted on the withdrawal of the word "deliberate." The Deputy has withdrawn that word. The word "untruth" has been used in this House on many occasions.

Mr. O'Higgins

Deputy Briscoe ended up his speech yesterday by saying that, by reason of the new services under the Health Act, the ratepayers would be faced with a very large increase in rates in this city. I just want to give some figures with regard to that. I said that the cost of the new services which came into operation on Holy Saturday would be met by a rate of not more than 10d. in the £. I now repeat that. The new services will cost the ratepayers of this city not more than 10d. in the £ and that covers the hospital cost for the additional classes at 18/- per day. It also covers the cost of the entire hospital pool for the old and new classes. It covers the cost of the addition in medical services for all classes. It covers the X-ray services for the additional classes only. It covers the specialist services for all classes, old and new.

Mr. Briscoe

What figure has the Minister got there? What is the total figure the Minister has for those?

Mr. O'Higgins

The total is £210,600.

Mr. Briscoe

How much is that on the rates?

Mr. O'Higgins

Half of that, £106,000, will be borne by the rates. That means 9.35 pence in the £.

Mr. Briscoe

Does that include the 15 per cent.?

Mr. O'Higgins

Yes.

Mr. Briscoe

It could not.

Mr. O'Higgins

May I make it clear again for Deputy Briscoe that less than 10d. in the £ covers everything that became necessary in order to provide these new services on March 31st? May I repeat that it covers the pool payment in relation to the old and new classes, it covers the increased payment for medical services for the old and new classes, the specialist service for the old and new classes? It covers every conceivable thing that might occur even to Deputy Briscoe.

Mr. Briscoe

Not at all. I gave you the figures last night.

Mr. O'Higgins

Perhaps, even with the Department of Health behind me, my figures are at fault. Maybe Deputy Briscoe has the proper figures and I have not.

Mr. Briscoe

The health charges in Dublin are going up by 2/9 in the £. Does the Minister dispute that?

Mr. O'Higgins

I have no doubt that is so.

Mr. Briscoe

How does it arise?

Mr. O'Higgins

Of that increase, 2/- is due to other circumstances—to factors which would have been apparent even if I did not bring these regulations into operation. The implementation of these services would mean an increase of less than 10d. in the £ in Dublin. I hope I have made that clear and, that having done so, the corporation of Dublin will recognise their responsibilities in this matter because they are statutory responsibilities. I hope they will make an effort to provide a good service under the new regulations. Deputy Briscoe said that I was providing payments for doctors and other people for services which were already there.

Mr. Briscoe

That is right.

Mr. O'Higgins

He did not make it clear what he had in mind, but I want to say that is not so.

Mr. Briscoe

Specialist fees. Are they not for a service already there?

Mr. O'Higgins

For what?

Mr. Briscoe

Payment of hospitals staff. Is that not for a service already there?

Mr. W. Murphy

Why did not you think of that when you put the Act before the House?

Mr. Briscoe

You are operating the Act now.

Mr. W. Murphy

An Act you brought in.

Mr. Briscoe

Who brought it in?

An Leas-Cheann Comhairle

If Deputies Briscoe and Murphy do not allow the Minister to make his concluding statement, I must ask them to leave the House.

Mr. W. Murphy

With all due respect to you my friend, there are things I can take and things I cannot take. I know what this has done to County Clare. We have a budget in County Clare——

An Leas-Cheann Comhairle

The Deputy unfortunately may not make a speech at this stage——

Mr. W. Murphy

——the latter part of which we have not yet seen.

An Leas-Cheann Comhairle

The Minister, concluding.

Mr. O'Higgins

I wanted to say in respect of the specialist clinics that out-patient services have been a very important part of the work of many hospitals. It is quite another thing to say that because these out-patient facilities are now being put into regular specialist clinics that is continuing a service already there. It is not. Not by any means. These new specialist clinics—and I would like people to appreciate what they mean— can be of considerable value not only to patients but also to general practitioners. If they are operated, as I believe they will be, every doctor who has an eligible patient—that is a patient with an income level of £600 and a valuation level of £50—be he a dispensary doctor or a private practitioner, will have available to him the full specialist facilities of every teaching hospital. If he requires to have pathology done, he can have the pathological services of the Dublin hospitals available to him.

Mr. Briscoe

Does not that exist at the moment?

Mr. O'Higgins

No, it does not.

Mr. Briscoe

Where does it not exist?

Mr. O'Higgins

Will the Deputy please listen to me? The specialist service clinics will be run on a reference system. The patient must be referred to the clinic by his own family doctor. That doctor will advise and direct—and this is in accordance with the regulations I have made—where the services of a specialist are necessary. There will be no question—I think Deputy Dr. Esmonde had this in mind—of a patient saying: "I insist on going to a specialist." That cannot happen. It is the patient's own medical adviser who will decide whether his condition is such that the services of a specialist are needed. This is an entirely new service. It has taken a considerable time to arrange for it to come into operation. I appreciate there will be quite a number of difficulties in getting the service going but I hope, when it does operate, that it will provide a very considerable improvement in the city.

I want now to give one bit of advice. Deputy Briscoe said yesterday that the possibility might be that the Dublin Corporation would refuse to strike a rate for these health services.

Mr. Briscoe

I did not say that at all.

Mr. Casey

Oh, yes, the Deputy did.

Mr. Briscoe

On a point of correction——

An Ceann Comhairle

Order!

Mr. Briscoe

I did not say anything of the kind. I said something quite different.

Mr. O'Higgins

If that is what the Deputy is working for, he will have to be very, very careful indeed.

Mr. Briscoe

Is it in order, when a Minister makes a statement like that, that he cannot be corrected? What I said was that we might refuse to strike a rate for the demand to meet these agreements that the Minister has made. That is what I said. That is a different thing from striking a health rate.

Mr. O'Higgins

I heard what the Deputy said.

Mr. Briscoe

I know what I said.

Mr. O'Higgins

I believe the Deputy has been manoeuvring to bring about a situation like that. I believe that he is endeavouring in all this——

Mr. Briscoe

To bring the Government down.

Mr. O'Higgins

——to cause further difficulties in relation to the provision of health services in this city.

Mr. Briscoe

Do not be talking nonsense.

Mr. O'Higgins

I tell him that is very dangerous ground to tread on.

Mr. Briscoe

The Minister always opposed them.

An Ceann Comhairle

The Minister should be allowed to speak. He is a member of the House, as well as being a Minister. He is entitled to the protection of the Chair and he must be allowed to speak.

Mr. Briscoe

As a member of the House, I am entitled to protection too.

An Ceann Comhairle

Deputy Briscoe has spoken. Surely the Minister is entitled to the same consideration.

Mr. O'Higgins

If Deputy Briscoe thinks it would be a wise or a prudent thing for him or the corporation to refuse to provide the money necessary to put these services into operation, then I suggest to him that he and his colleagues are flouting a statute of this House, a statute which the Deputy and some of his colleagues helped to put on the Statute Book. There is a statutory obligation on the Dublin Corporation to operate these services.

Mr. Briscoe

We have always operated them.

Mr. O'Higgins

It is a statutory obligation of the Dublin Corporation to operate these services in accordance with regulations made by me as Minister for Health. If there is any further political play-acting with regard to this matter, I am quite certain it will be necessary to remind the corporation of what its responsibilities are.

Mr. Briscoe

A sealed Order!

Mr. O'Higgins

A sealed Order, if necessary, if it will have the effect of providing health services for the people of this city.

Mr. Briscoe

The health services are there. We are providing them, and always have.

Mr. O'Higgins

Deputy Briscoe and other Deputies referred to the discussions which I have had over the last six or eight months with the medical profession. There was, and is, no secret with regard to them and I fail to understand why, in this House and elsewhere throughout the country, it has now become the fashionable thing for certain public representatives to attack the medical profession and to attack doctors. We have had too much of that. There are bad doctors, I have no doubt. There are bad lawyers, too, and there are bad Deputies also. But let us not have them making a fetish of attacks on a very honoured profession as a contribution towards providing health services for our people. The medical profession and the Irish doctor have won a place for themselves all over the world. The Irish family doctor is an institution we should value rather than belittle.

I do not believe that any health services could operate without the cooperation and agreement of that noble profession. It could not be contemplated that Civic Guards would provide the services. It could not be contemplated that it would be done by the Army. It has to be done by agreement with those who will have to operate it. In the last six months I have had these discussions with the medical profession, with the nursing profession and with other interested bodies. I have taken that responsibility on myself because it is contemplated under the Health Act that the Minister would have such discussions.

My predecessor, Deputy Dr. Ryan, did have some discussions with the Irish Medical Association in an effort, at that time, to seek agreement. He made certain suggestions to them, suggestions which were not acceptable, because there was perhaps too much heat in the air at that time. But any discussions Deputy Ryan had, or any discussions I had, were in pursuance of the responsibilities cast on the Minister for Health to seek agreement in order to have these services operated. Now the suggestion has been made by Deputy Briscoe, and others, that this was a hole-in-corner sort of performance. The suggestion has been made that I should have had consultations with all the elected members of health authorities. I do not know but that a suggestion like that would be more appropriately made inside some mental hospital. I cannot imagine myself, as Minister for Health, in the turbulent conditions then obtaining, leading a team of 600 county councillors and corporators to meet the Irish Medical Association.

Mr. Briscoe

That is a slight exaggeration.

Mr. O'Higgins

Of course, it is.

Mr. Briscoe

Like everything else the Minister says.

Mr. O'Higgins

In any event, if I was wrong in having these hole-in-corner discussions, I take full responsibility for that. I had many such discussions over quite a long period. For the last six months the responsible officials in my Department have given more in the way of thought, planning and discussion in relation to these conferences than I was, I think, entitled to expect from them; and I would certainly like here, as Minister, to pay my own officers the public tribute which I believe is due to them for the very successful discussions and negotiations in which they played so very large a part.

In any event, whatever actions I took in that matter were aimed at bringing about a peaceful situation, were aimed at making the Health Act a workable measure, and I have no apology whatsoever to make for having done what I did. I might say that it is rather unfair that Deputy Briscoe should charge me with making a bad bargain behind closed doors when he must appreciate that I was merely following the practice accepted by those who occupied my Ministry. These discussions traditionally have taken place between the Minister for Health and the representatives of the professions whose agreement he was anxious to secure.

Mr. Briscoe

Without even consulting the people who have to pay. That is my grievance.

Mr. O'Higgins

That may be a defect if you like, but it is the Health Act.

Mr. Briscoe

That is the grievance I have.

An Ceann Comhairle

Order!

Mr. O'Higgins

There is a statutory obligation on Dublin Corporation and all other health authorities to provide these services in accordance with the regulations made by the council. That is the Act. It is the law of this land and it is my job and the responsibility of this Government to see that that Act is obeyed, and obeyed it will be.

I should like now to deal with some matters of detail raised in the debate. I must apologise to Deputies if I do not cover every matter in detail, but all the points have been noted and I will arrange to have any information available conveyed to Deputies.

Deputy Barry spoke about the effect of cancer and its possible causation by smoking. He asked whether I was prepared to advise and warn young people with regard to its possible danger. I think the answer would be: "Yes, if necessary and when the matter is proved beyond doubt." A great deal has been written and said about this, but certainly, on the information available to me at the moment, it does not appear to have been established one way or the other. In any event, it is a matter that would be considered by the Cancer Association and certainly will be discussed by them.

Deputy Finlay referred to the possibility and desirability of extending the child guidance service outside Dublin. The Child Guidance Clinic at Orwell Road, as some Deputies may be aware, is a new service that was initiated and came into operation some months ago. It is an experiment in this country, although it is a service well known in England and other countries. The trouble about extending such a service is the trouble of staffing. The training involved in child guidance—training of psychiatrists, social workers and psychologists—is quite long; and, while we hope to extend the services, we can only do so when we have the necessary trained personnel available.

Deputy Childers referred to some matters. He referred to the need for improved accommodation for mentally defective children. The problem of our mental defectives is a very real one. It, perhaps, is becoming more and more appreciated now than in fact it has been in the past. It is estimated that, perhaps, around 6,000 children in the country require some form of care and treatment. It is not possible to hold out any hope of the provision of immediate accommodation for such a large number. We are going ahead quite steadily in providing new institutions, some of which I have mentioned in my opening statement, but we do depend very largely on the work of religious sisters and brothers who dedicate themselves to this kind of nursing. The Brothers of Saint John of God, the Brothers of Charity, and other similar orders of nursing brothers, have done considerable work in other countries and are doing it here. These orders are at the moment concentrating on training their own nurses and it is probable that, with the development of further training, it will be possible for them to take on additional institutions.

I have asked my Department to examine, in conjunction with some of these religious sisters and brothers, the possibility of running some form of day clinic or day school in the larger centres of population, such as Dublin or Cork, in which some of the high grade mentally defective children could receive some form of instructions and care during the daytime, and could go back to their own homes at night. It may be possible to get something of that kind under way.

Deputy Childers also mentioned the question of clinical records in hospitals. The position with regard to that is that the voluntary hospitals look after their own. As far as we are aware, their own records are adequate, and I am informed that the same applies to local authority institutions. The Deputy also mentioned the possibility of making the Central Pathological Service available to all voluntary hospitals. The pathological service in voluntary hospitals could only be integrated with the agreement of the hospitals themselves, and it is largely a matter for them. As far as the Dublin local authority is concerned, pathological services are now being centralised under the supervision of a new, highly-qualified pathologist.

Deputy Childers also referred to mental health services, and inquired whether mental hospitals were fully equipped. I think the Deputy can be assured that mental hospitals are fully equipped to carry out modern medicine and psychiatry, and their medical staffs keep in touch with scientific developments in this field. The question of the psychiatric clinic is one that has been engaging the attention of health authorities over a number of years. As I indicated in my opening statement, they have now reached a stage of real development. Psychiatric clinics operate in all parts of the country now, but there are difficulties in some places. Generally speaking, the medical staffs from the mental hospitals continue these psychiatric clinics. In addition, I may say that under the new arrangements I have made on the implementation of Sections 15 and 16 of the Health Act, a lot of the specialist out-patient clinics associated with the Dublin teaching hospitals and other hospitals will also have psychiatric sessions for eligible classes and they also should be of quite considerable value.

Deputy Dr. Ryan mentioned some matters to-day. He mentioned the question of colonies for old people. The problem of the care of the old, here as elsewhere, is a very difficult one. I am afraid that very little progress has been made in the provision of colonies such as he had in mind. The difficulties, frankly, are mainly financial, but very shortly something of that kind is contemplated for Ballymun by the Dublin Board of Assistance and the type of building that will be erected at Ballymun will be a small sort of separate house or chalet with four beds. It will be divided in half with two beds in each half, with sanitary and other facilities in between. It should be quite an interesting type of building. It is impossible to say when they will be completed at Ballymun, but it should not be too long.

Deputy Dr. Ryan also mentioned the question of securing nursing staff for mental defective nursing. I mentioned that and I hope that an improvement will take place. The Deputy also referred to the relaxation of conditions for the payment of disablement allowances and other Deputies also mentioned it. Frankly, there is nothing I can do with regard to that matter. The conditions for the payment of disablement allowances are statutory provisions, and, under the section of the Health Act, it is laid down that these allowances can be paid only to persons without any means and, in assessing means, the family income is the deciding factor, so that the room for relaxing conditions is very small. The statutory condition is that it can go only to a person without any means on a very stringent means examination. In fact, these allowances this year are costing over £600,000. Even nowadays, that is a very considerable sum which has to be footed both by health authorities and by the taxpayer.

Mr. W. Murphy

There was a sum of £10,000 put down for that last year and when the manager was striking the estimate in Clare, it finished up at £20,000.

Mr. O'Higgins

You are very generous in Clare. Deputy Desmond also referred to out-patient clinics under the Mental Treatment Act. I have already mentioned these. It is a developing service and I think it is working well. Deputy Desmond also mentioned the desirability of making people aware of what services will be available to them. That is a matter that we have under consideration at the moment and something will be done in the near future.

Deputy Brennan mentioned a difficulty with regard to mental patients. The position is that a mental patient is entitled to avail of Section 25 of the Health Act. That is the section which gives a choice of hospital or institution. He can avail of Section 25, if he does not want to go to his own local institution. The capitation rate must, however, be related to the cost of providing the services in the district mental hospitals, so that the rate of subvention will be much less than the sum in the general hospitals. The Deputy also suggested that, for disability allowances, there should be no means test. I have explained that that is a statutory condition and I cannot alter it.

Deputy Briscoe also referred to hospital deficits and suggested that payment of a particular sum should be made monthly, or under some arrangement of that kind. The position, in fact, is that two payments are made annually in the course of each year to each participating hospital.

The first is made about 1st April in respect of the first half of the year and the second about 1st October in respect of the second half of the year. These instalments are about three-quarters of the estimated deficit. The final adjustment, that is, correlating the estimated deficit with the actual deficit, takes place when the audited accounts are made available, so that, in fact, each hospital gets a payment twice a year, the total of both payments being about three-quarters of the estimated deficit. While there are always difficulties about the payment of these deficits, it is a matter which is constantly watched in the Department.

Deputy Tully raised the question of charges by doctors for treatment given by them in hospitals. The position there is that, where a health authority sends a patient to a public ward in a voluntary hospital, the payment by the health authority covers the cost of all medical attention, that is, with capitation payment. When the patient enters the hospital as a Section 25 patient, that is, when he exercises a choice and prefers to go to a voluntary hospital, rather than to his own local authority hospital, he is again exempt from any claim for medical treatment, if he is in a public ward.

Therefore, any patient who elects to go to a Dublin teaching hospital as against his own local authority hospital and goes into a public ward cannot be charged anything in respect of medical treatment. If, however, he goes into a private or semi-private ward, he has not any such protection and he has got to recognise that he can be charged whatever he can afford to pay.

Deputy Tully and Deputy Cunningham raised the question of certain medicines not being available at dispensaries when required for the treatment of a person holding a medical card. I am certainly surprised to learn from Deputy Cunningham and also from Deputy Tully that these cases are sufficiently numerous to be mentioned by them in this House and that the complaint they make is that these unfortunate people are compelled to pay for the medicines by having to provide them themselves. That should not be. Each health authority is bound to provide free of charge the medicines necessary for the treatment of the condition of any person who holds a medical card. I will have the matter looked at in my Department in relation to, I take it, the constituency of both Deputies.

A number of other Deputies—from Cork, of course—raised the question of the Cork Regional Hospital. I appreciate the views expressed by Deputy Barry, Deputy Manley and Deputy Corry with regard to the proposal, but I am afraid I cannot agree with them. I have examined this matter very carefully and very thoroughly. I have studied the full needs of the Cork region and in my view a new regional hospital is necessary in Cork and the work will proceed.

I am afraid I have not been able to cover all the matters raised by Deputies, but I shall endeavour to have them examined in my Department.

In conclusion, I should like to say just a word or two about the future. We have now reached the stage at which these new services under the Health Act will operate under conditions of goodwill, so necessary for their proper operation. As I have already made clear, I do not regard, and never have regarded, the Health Act as being the best way of meeting this problem, nor do I regard it in any way as the final phase in the provision of health services here. I think that, fundamentally, what is needed in the provision of health services is an effort by the State to supplement, and not supplant, individual effort. Where there is need, where there is poverty, where people are necessitous, then, of course, it must be the State's duty to come in and help completely in those circumstances. The State must provide without cost, whatever services are needed and whatever services can be provided for people in need.

To the extent that the Health Act aimed at providing for those in need either free or partially free health services, I declared that the Government and I were prepared to accept and implement it. That has now been done. However, outside the Health Act, there are those whose incomes exceed £600 per annum. There are farmers with a valuation of more than £50. There are thousands of citizens to whom the State owes a duty, but in respect of whom the State at the moment is giving no help or assistance whatsoever. I hope that in the near future it will be possible to help these people, but it will be done on the basis of helping them to help themselves. It will not be done by in any way interfering with their individual independence, their ordinary integrity as individuals. It will be done by helping them to the extent that they cannot provide for themselves. That, I believe, will be done by a system of voluntary health insurance, the details of the Report of the Advisory Body I hope to have in the near future. I think that will be a worthwhile development. It will mean that, under the Health Act, we will have provided for those who are unable to insure or who do not insure, but we will have, in addition to that, a national scheme whereby each person will be able to pay his own way according as he can afford it and look his neighbour straight in the eye, knowing that he is providing his own health services for himself.

Mr. MacCarthy

May I ask the Minister whether the question of the re-distribution of the dispensary areas in Cork is being considered?

Mr. O'Higgins

I intended to refer to that. My Department asked the local authority to submit their proposals on this matter and they have not done so yet. Actually, we are waiting.

Vote put and agreed to.