Skip to main content
Normal View

Dáil Éireann debate -
Wednesday, 26 Jun 1957

Vol. 163 No. 1

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

Debate resumed on the following motion:—
That a sum not exceeding £6,064,600 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1958, for the Salaries and Expenses of the Offices of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain Services administered by that office, including Grants to Local Authorities and miscellaneous Grants.—(Minister for Health.)

Last night we were talking about the attitude which is beginning to be fostered, I think, in the country that we are spending rather too much money on hospital buildings and on health services generally, and that we have done so for the past few years. I very much hope that the Minister will not listen to those suggestions or be in any way influenced by them. It would be a very sad and unfortunate thing were the people to be frightened into cutting down on the Minister's policy or the Party's policy in relation to health services generally in the years gone by. I think it would be wrong if we allowed ourselves to be panicked into a sort of persecution mania or complex by the cost of health services.

The Minister's opening statement contained his best vindication—I think he recognised that himself—for the policy of the Department of Health over the past ten or 15 years or even longer. He gave the proposed expenditure in this Estimate on hospital services. Then he gave the very striking morbidity and mortality figures over the past few years. Since pre-war days the morbidity and mortality rates in respect of children and infants and the maternity and tuberculosis mortality rates have shown quite a remarkable fall. The Minister has every reason to be satisfied with the return which the public have received for the moneys laid out over the years. In his statement I think he conceded that fact.

Expenditure on health is not really any more extravagant than that in any of the other Departments of State. We cannot expect to run our health services at a profit. If we want to save lives, reduce disease rates and the disability associated with disease, then we have to pay for it. We have, as I have said, the additional considerable comfort from the taxpayers' and rate-payers' point of view that over the past 20 or 30 years they have been saved by the Hospitals Sweep Fund to the extent of about £30,000,000 which they would normally have to provide themselves. We would have had to seek it in the form of rates paid or in the form of taxation.

If we are coming to the stage at which it is considered necessary to call upon the taxpayer to start paying the full or a greater percentage of the costs of providing hospitals after almost 30 years of relief from such impositions, then I do not think the Government should be unduly concerned. The people generally—there is none I know of at any rate—have no regret at all for the moneys we have spent to create the present position of greatly reduced morbidity and mortality rates amongst all sections of our people.

Leaving aside the humanitarian point of view altogether, the existence of preventable disease is a very costly thing. The maintenance of our sanatoria or fever hospitals in the old days was an extremely costly business for the people both from the point of view of rates and taxation. I do not know what the present cost of sanatorium treatment is per patient but I suppose it is £8, £9 or £10 per week. That is because of the existence of preventable disease, a disease which, by the provision of proper diagnostic and treatment facilities, can be and I believe will be, in the very reasonably near future, practically totally eliminated.

From the hard-hearted actuarial point of view, that will be a very considerable saving to the community generally. When we proceed to reduce the cost of those institutions throughout the country, as they progressively become redundant, we will find less and less demand on central funds for their maintenance. Then we will be able to concentrate all the funds at our disposal on the provision of really first-class services for the diagnosis and treatment of unavoidable disease in well-staffed, well-equipped hospitals and institutions throughout the country.

Deputy O'Higgins was speculating on whether we had spent the money wisely or fruitfully or not, and the Minister also speculated in the same way. At this stage, we can only wonder whether we have expended the money to the best possible advantage over the past 30 years. I have read where we have been criticised by outsiders because of the number of hospitals we have built here and the number of beds which are available. I have equally read in a French hospital journal where we have received the highest praise indeed for the very intelligent way in which the money has been laid out in the past 30 years.

My attitude to both these opinions is that, while it is very pleasant to have these people take an interest, cursory or otherwise, in our affairs, we are the best judges of what we want for our people and what we intend to give them. Consequently, I feel we should not be in any way moved by either the praise or criticism of these people. In so far as we are close to the problem, we know the needs of our people; we know their attitudes of mind; we know the pattern of life of our people better than others. We know what we started from and what is required.

Deputy O'Higgins criticised the arrangement of the local government system which ordained that we should have only county hospitals or by which in one way or another, it worked out that we would have county hospitals. He questioned the desirability of the positioning of hospitals by the county. I myself have often wondered whether that was wise. At the same time, one has to remember that we were and we are at all times servants of public opinion in these things. We have to bear in mind the local pattern of life in each small area in our society. The attitude to the county boundaries has become too deeply ingrained in our people, I think, to override their wishes in that regard. If they want a hospital in their own county area, the Hospital Commission, the authority which in the past dealt with these matters, was wise, I think, in its decision to provide us with the county hospitals.

Ideally, if one were a dictator—I am not suggesting in the slightest that Deputy O'Higgins had any inclinations towards dictatorship—and if one had dictatorial powers, presumably one could work out an ideal pattern or plan or blueprint on paper, which would follow certain demographic patterns which would, according to different theories, suit the needs of the people.

I think it was wiser for the commission to accept the pattern of living of people in a county and to accept the necessity for a county hospital, leaving the county as the regional area. I agree that anomalies occurred in Athlone, which is a very unfortunate case. It is an exception where they have not got a hospital and which is an ideal centre, one would think, for a county hospital. Again, Wicklow is another area where it would be very difficult to find a suitable site for a county hospital, because of the mountains running down the centre, which divide the county into two separate areas from the point of view of transport and accessibility.

Transport and accessibility are important considerations in the positioning of hospitals. Where possible, there should be accessibility from the point of view of the patients, in the first instance, and visitors to the patients, in the second instance. That is, so I should imagine, a very important consideration in deciding or framing the general overall pattern for the distribution of hospitals in the country as a whole. The hospital service should be based on the district hospital, with the rather more difficult case going to the county hospital and then the complicated case, for the specialist care, going to the regional hospital. That is all based on the general practitioner, who should have at his disposal the county clinics, which would tour round at various intervals with the various specialists—the orthopaedic specialist, the ear, nose and throat specialist, the gynaecologist and the radiologist—so that the general practitioner would have these at his disposal in the county clinics as a first-class service which would decide what type of hospital care is required by his patient, either the county hospital at one level or the regional hospital service at another.

I think that was, broadly, the pattern they had in mind and which I am glad to say appears to be transpiring, in spite of the different vicissitudes of the Department of Health over the years. It seems that, broadly, there is this decentralisation of our medical services which was always, in my view, a very desirable thing indeed. At one stage, nearly all roads led to Dublin. Any worthwhile medicine available was to be found in Dublin. Broadly speaking, that was true. Galway and Cork had their centres, but there was too much centralisation in the Dublin area. Now that has been broken up, not without a certain amount of heart-searching on the part of the Dublin practitioners, no doubt. At the same time, from the point of view of the patient, there is now a greater availability of high level specialist, diagnostic and treatment service becoming available throughout the whole length and breadth of the country. That is a most desirable feature, which I hope the Minister will continue to develop in the years of his office.

Some references were made to the quality or, it was said, the unnecessarily high standard of the building which has gone on. I do not think the Minister should have any remorse or recrimination about the quality of building which we have indulged in during the years. We were all faced, when in office, with the problem as to whether we should cut our standards or build of the highest possible quality that money could buy. I know all about "cutting one's cloth according to one's measure," but there is a very practical consideration in building well. First of all one could depend upon the local authorities to raise the money for the maintenance of the buildings once they were provided in each area. Of course there is great reluctance to do that. There are other demands on the rates besides the maintenance of buildings already provided for the different areas.

In consequence, one of the important considerations is to provide buildings which will continue to give good service with the minimum possible maintenance. The result is that one does find a considerable amount of terrazzo and very high quality timbers with first quality steel in many local authority institutions. I am completely unrepentant in regard to any decisions for which I was responsible in that regard. If you give low quality buildings they will fall to pieces in a very short time.

In addition, I have seen the attempts of medical people, of nurses and others, to work in what 20 or 30 years ago were called temporary buildings. They go on being called temporary buildings long after attempts have been made to provide good satisfactory services in them. On a modern building which was provided during the period of office of a previous Minister, a unit which was the prototype of the big regional sanatorium, superlatively built and equipped, nothing but a negligible sum was spent on maintenance in the nine or ten years during which I have had knowledge of it. At the same time, other temporary buildings which I have known continue to be repaired and repainted in order to maintain something like reasonable conditions.

There is another side to this big bill for our hospitals. Remember that our hospitals are not being built for this year or next year. They are being built with an expectation of life of presumably 20 or 30 years or more. Consequently, one must take that into consideration in adding up the cost. The cost should be spread over a period of 20, 30 or 40 years which is, I think, the reasonable expectation of life of the average hospital, particularly the general hospital. The other types of hospital which Deputy T.F. O'Higgins mentioned, hospitals which are likely to become redundant after some few years, can be readapted in other directions. I doubt very much, when one looks at the overall picture of expenditure on hospitals and takes into consideration the expectation of life of these institutions, whether one could regard the initial expenditure on them as very unreasonable. I believe that the money should be spent in providing high quality institutions. Such expenditure would be, in my opinion, a first class investment.

There is only one point on which I have any doubt and that is in relation to sanatoria. If I had been responsible for the early planning of sanatoria I think I would not have accepted the pavilion system. I would have preferred to provide the multi-storey type of building on the assumption that sanatoria were meant to be closed, or ultimately to become redundant. I do not want to over-simplify the matter but buildings for the treatment of such diseases as tuberculosis should be provided with a view to becoming redundant and that these institutions would later be redirected towards some other aspects of one's health campaign.

However, the institutions that have been built are performing a very useful function and, as I have said, I think they will be needed for the best part of their expectation of life. I refer particularly to the national regional institutions. We have not yet completely overcome tuberculosis, though the end is in sight.

I should like to join with Deputy T. F. O'Higgins on the question of priority for the city hospitals. He referred to three—the Coombe, St. Laurence's, and St. Vincent's. He asked for priority for the Coombe Hospital. From what I can gather from people who know about these things, there is a tremendous need for the maternity type of hospital, and if it be possible at all for the Minister to provide such a hospital I hope he will come down on the side of trying to relieve the tremendous pressure on the Rotunda, the Coombe Hospital and the National Maternity Hospital.

It is a pity in many ways that in the very big building programme that has gone on we did not get round to providing a new voluntary general hospital in the city. I do not think the fault for that lies entirely with the Department of Health. There was a considerable amount of difficulty in coming to agreement on many matters among the authorities concerned. That, I believe, led to considerable delay. I, personally, was very glad to press ahead with the provision of what I had hoped would be a magnificent municipal hospital—St. Kevin's. With the expenditure of a considerable amount of money the Department has been able to bring it to a very high pitch of efficiency as a result of the alterations that have taken place over the last ten years or so.

May I bring in the name of Mr. Seamus Murphy in that regard? He has worked with great dedication over the years and, may I say, with a considerable amount of frustration. It was one of my main ambitions to see a first class, well-staffed, well-equipped municipal hospital in the city. I felt it would be good for the voluntary hospitals to find some competition, some pace-setter. The pace is being set by local authority hospitals. It is a great tribute to the whole principle of the local authority health services that in such a short time they have been able to exorcise the appalling reputation which the whole state of these institutions had up to a very short time ago.

It is a great tribute to the staff there, to the Department of Health, to Mr. Seamus Murphy and those others associated with him, that they have been able to create there a reputation for a very high standard of care and attention and of medicine. I have nothing to do with the hospital itself, but I understand, from talking to patients who go there, that the position now is that many people would prefer to go to St. Kevin's than to some of our voluntary hospitals. I do not get any great pleasure out of that, but I do think it is useful to have an example of a municipal hospital that can be competently run. That hospital is now available to the citizens of Dublin at St. Kevin's.

We have had to spend a fabulous amount of money, for a small country, I suppose, in the past two years on providing hospitals and health services. However, I do not think that anybody could suggest that there was any flagrant misuse of the money or any spending for spending's sake, or building up hospitals just for the fun of it. These hospitals, these institutions, these services were all provided and paid for, for the simple reason that they were very badly needed.

As regards the voluntary institutions, which no doubt worked as hard and as enthusiastically as they could out of the resources available to them, the amount of money we have had to pay in the past 20 years is a measure of their inability to meet the real need for hospital services. There is no reason in the world why the two services should not go on, one with the other. It is only right to remember, however, that the municipal health services generally do a vastly greater scope of work, taking all our services into consideration—mental hospitals, tuberculosis and fever hospitals, general hospitals and medical services. It is the State that provides the greater part of our health services in the community.

I am always surprised, therefore, when I hear the criticism from the proponents of the voluntary system of medicine who criticise what they call State intervention or State interference. If the State do not do it, nobody else will do it. The work has been there for 30, 40 and 50 years to be done and it has not been done. The State had no alternative, in my view, but to take the steps it has taken over the years to provide services which the voluntary organisations, who have done good work in this regard, could not do.

Consequently, I am surprised whenever I hear any criticism of the State coming to the aid of the voluntary institutions. Why should they resent this? Why should they not welcome this? If their main concern is the care of the sick and the aged, the nursing of the sick and the aged, the prevention of disease, the elimination of pain and the suffering associated with pain, why should they not welcome any agency, any interest, that chooses to relieve their burden? Why are they critical of services which are provided, and so excellently provided, on the whole, by the local authority?

As regards the quality of the building undertaken, one of the finest complaints I have ever listened to is that our sick are too well housed. That I had a tiny part in housing them in that way is a matter of great pleasure to me. It is about time that, in regard to something, our people should feel they are getting as good as, if not better than, what people get in similar conditions in other parts of the world.

Another point with which I wish to deal is the death rate and the moroidity rate in relation to tuberculosis. I only make the point in order to make a further point about extended health services generally. There is a feeling that if we had not spent money on one big thing or another, B.C.G., mass radiography, sanatoria, infectious diseases regulations and the magnificent Fianna Fáil 1947 Health Act, on the free, no means test treatment of tuberculosis under that Act, if we had not provided all those things over the years, the death rate and the morbidity rate would have fallen anyway. The suggestion has been put around that the death rate and the disease rate have fallen simply because new drugs and new medicines have become available.

It was put about in the beginning by people who merely wanted to denigrate the activities of the Department of Health in their drive to get rid of tuberculosis. That is unimportant, however, as long as people do not accept it as being true. There are no doubt magnificent drugs available which have revolutionised the treatment of tuberculosis and made it a relatively simple thing to treat the consumptive when he does fall sick and make him well again. The important thing is that we could not get these drugs, he could not be brought to treatment by these drugs, unless all these other ancillaries were there, unless there was a free diagnostic radiological service, unless there was a B.C.G. preventive vaccination service, unless there was a free treatment service in our sanatoria, unless there were infectious disease regulations for the dependents of people who went into sanatoria.

Unless these institutions had been built throughout the country the drugs could not be made available, the services of thoracic surgeons could not have been made available and these lives could not have been saved. Our disease statistics, our morbidity and mortality statistics to-day would be on a par with what they were prior to the 1947 Health Act, or on a par with what they are in many other countries in the world to-day, many undeveloped countries, countries subjected to exploitation and colonialism of one kind or another, such as Africa, Egypt, Sudan, Indo-China or the Philippines. There are many others I could mention in which the incidence of T.B. and the death rate from T.B. are still outrageously high.

I think, therefore, it would be wrong for people to go away with the idea or to suggest that all this would have happened anyway; we have the drugs and they kill the tubercle for us. I merely resent it from this point of view. I believe that the early diagnosis, the free, no means test idea incorporated in the 1947 Health Act—as far as I can recollect, it was the present Minister's Health Act or Deputy Dr. Ryan's Health Act—the infectious disease regulations, and all the other powers it gave to his successor to develop and expand health services in particular in relation to T.B., were more important factors in putting the Minister and so many of our people in a position to say to-day: "We have seen a remarkable and gratifying reduction in disease and death rates from T.B."

It is because I believe that the free, no means test principle has been the cause of this drop in disease and death rate figures that I earnestly advocate it and recommend it again to the Minister as being the ideal or the only principle under which it is possible to provide not only equitable health services but health services which will work effectively, and which will give results. The proof is here and that is why I make this point. All this nonsense about local authorities, health authorities and municipal authorities being unable to provide the health services is exploded. It is all finished. It was disproved years ago when the fever hospitals ended fever in this country. I hope it is now exploded for the second time. That aspect of health services through the free, no means test principle is the way in which the best possible service can be given to the people.

I was very glad to hear the Minister suggest, or hint rather in his speech, that he is concerned with mental diseases and with doing something for the mentally-diseased generally. With Deputy O'Higgins, I completely concur with this apparent decision of the Minister and I only hope that it is so. I was concerned with the mental hospitals and mental hospital services generally when I was in the Department and I had some experience of them. My own professional experience, of course, on this subject is nil and I am speaking merely as a layman now. My only mental unrest or discomfort came from the tour that I did at one time of many of our mental hospitals. I was left with the impression that a tremendous amount remains to be done in regard to them.

As far as the treatment of mental disease is concerned, it is lagging a little bit behind, say, T.B., but I think that at last a changed attitude to mental illness is becoming evident. We have moved away from the days of Bedlam when they locked them in, beat them and punished them, to the stage where there is a very much more understanding attitude of mind about the person whose mind is ill. At the same time, we are unfortunately left with the old barrack-like, prison-like buildings in which these people are housed. Equally, there is the rather appalling fact that the problem is a colossal one in relation to numbers. There are a large number of persons in our mental hospitals, so that I do not envy the Minister in any attempts he may make to deal with the question in a really effective way because it seems to me that to deal with it in such a way will cost a very considerable amount of money.

I think there are various aspects of mental health which could be looked into. First of all, there is the question of staffing. It is possible that by staff changes and by legislation some alteration could be effected which would improve the present position in our mental hospitals. The present medical superintendent of a mental institution seems to me to occupy a completely impossible position—that is, any that I have known anything about. They were all men, to my own knowledge, any that I have known, who were extremely conscientious and hardworking, but the work they have to do is so completely diversified and so completely varied in most cases, so completely remote from their profession, that it is difficult to believe that one is justified in making a doctor a medical superintendent of a mental hospital at all.

Would it not be worth while considering the appointment of a lay administrative head of a mental hospital and allowing the medical head of that hospital, the medical superintendent, to occupy himself entirely with the purely medical duties of the hospital? Certainly the men I knew had a certain amount of responsibility for the farm, for the medical side, for the domestic department, for the nursing side, together with the general overall administrative care of the institution itself. There is no man who could cope with all these duties competently or efficiently at one and the same time.

The pity of it is that a man becomes medical superintendent of such an institution only when he reaches his professional prime, having spent years of training and experience in subordinate positions. It is at that stage then that he becomes superintendent of a mental hospital, part farmer and part everything else. He is asked to look after a small village and he simply has not the time to use the knowledge and experience he has gained all through his professional life up to that stage for the benefit of those under his care. Would the Minister consider the desirability of arranging that the medical head of these institutions is left entirely free to concentrate on the purely medical work of the hospital?

Mental illness can sometimes be prevented from becoming either serious or chronic. The Act of 1945 marked an advance here in mental care. The idea of the voluntary patient was fostered. That was an important development and it would be an excellent development if it were likely to expand. If one wants to encourage patients to enter hospitals for voluntary treatment, one will have to make sure that, when they enter, they are not frightened out of it again or driven out of it because of the substandard conditions prevailing, the poor sanitary accommodation, the poor dining facilities, the unsatisfactory kitchen arrangements.

I have seen these things in some of our mental hospitals. I concede that they do not exist in all of them. There are some excellent hospitals in which the standard of care, equipment and accommodation is very high indeed. That is particularly so in the case of the newer hospitals. In the older ones, possibly through nobody's fault, there is the appalling atmosphere of incarceration, the horribly drab surroundings, the drab clothes, the very primitive serving arrangements, the unsatisfactory kitchens, cooking facilities, dining halls and dormitories in which there is serious overcrowding.

If that position were changed, I am certain that more people would seek voluntary treatment. While such conditions persist, it is fruitless to expect patients to enter such hospitals voluntarily or to remain voluntarily in them. Where such conditions exist, the intentions of the 1945 Act are completely stultified and that Act was designed to encourage people to receive early treatment.

That is again the humanitarian approach. There is then the hardheaded actuarial consideration. If admission to a mental hospital is delayed, the treatment of the patient is delayed. If treatment is delayed, the patient progresses from subacute to acute and then to chronic. When he reaches the chronic stage, he enters the hospital and will remain in it for the rest of his life, a burden on the taxpayer and the ratepayer. If there is any hope at all of reducing the incidence of chronic mental illness by facilitating early and easy treatment, everything possible should be done to achieve that object. Some attempt should be made to ensure that patients will find it less difficult to avail of out-patient facilities wherever they may require them. There has been an extension in that direction, but there is still a certain lacuna in that regard.

Recently I read a report to the effect that a number of old people are dumped into mental hospitals, not because they are mentally sick but because their relations do not want to keep them at home any longer. They are not difficult. They are not dangerously sick mentally. They are slightly troublesome. The situation seems to me a very serious comment on our attitude towards our aged.

I have received serious complaints about overcrowding in Grangegorman. I shall be glad to let the Minister have the facts. There are too many beds in the wards and there is no room for lockers. Food has to be carried around or kept under pillows. There are inadequate seating facilities in the dayrooms. The nurses have to care for too many patients and they cannot therefore give the patients the best possible attention. I do not suppose there is a more difficult form of nursing than that of nursing the mentally ill. It calls for a high degree of tolerance, understanding and patience. It is indeed a great tribute to them that one hears so little complaint, remembering the difficult circumstances in which they find themselves. At the same time, it would be well not to over-try them and to ensure that the number of patients under their care is reduced to the minimum.

The Minister referred to the case of the mental defective. There is no more pathetic or tragic illness than that of mental defectiveness. It is bad enough for the child. It is an appalling dilemma for the parent who is faced with the problem of deciding as between keeping the child at home, where it will be well treated, or consigning it to the care of strangers in some home or colony. The tragedy, of course, from the parents' point of view is that if they keep the child at home, if the child is a low-grade mental defective, it will remain a low-grade mental defective. If, on the other hand, they can trust the mental defective home or institution, it is possible that a low-grade mental defective can be educated into becoming a high-grade mental defective, closer to the normal mind, as a result of care and attention and education.

That is the dilemma of many unfortunate parents. They fear for the impatience which a stranger may visit on their children for one reason or another, these terribly difficult children to care for and to nurse and, consequently, they fear letting them go away and they keep them at home. In doing that, they do the children a terrible disservice because, of course, the time may come when the parent dies and the child then has to face going to an institution without any supervision at all.

In that regard I should like to pay a particular tribute to the Brothers of St. John of God. One of the greatest pleasures I had in the Department was in providing, as far as I could, any money for which the Brothers of St. John of God asked for the care of mental defectives. I do not think that there is any section of our society caring for the sick which does greater, finer or nobler work than do these men in the care of mentally defective children. I would urge on the Minister that, if he has any moneys at all at his disposal, he should do whatever he can to advance and further the opportunities for these men to expand and to continue to do the magnificent work which they are doing for children throughout the country at the present time. It is a most wonderful thing indeed to visit the houses of the Brothers of St. John of God and to witness the care and love which they give to the children and the dedicated way in which they do their work in these very trying circumstances.

I understand that in other countries, in Britain and elsewhere, it is accepted that the care of mental defectives is work which calls for men with a vocation, that very few lay people can tolerate mental defectives. Consequently, people like the Brothers of St. John of God are welcomed in any country to which they go and most health authorities in other countries are only too delighted to get them and give them every possible facility to do this work.

I hope the Minister will bear that point in mind and give them every possible opportunity to create the institutions, to run, organise and to maintain them and that he will give them every possible facility to do their work under the best possible circumstances, that is, to have the smallest possible number of patients to each brother and in that way relieve the minds of the parents and ensure that the highest possible number of low-grade mental defectives shall be given whatever opportunity medical science and care can give them to improve their chance in life and to become less burdened by the appalling cross of being mentally defective.

There is one other work which these brothers do which I wish the Minister would bear in mind, that is, the treatment of the difficult child. They have some clinics in the city here. I do not know very much about them, I am afraid, except what I have read in the papers but it seems to me that it is a very fine idea that they should be given facilities for the out-patient examination of the difficult or the recalcitrant child. A tremendous amount can be done for children such as these who are emotionally disturbed, who have a difficult home background or home circumstances, parents who do not understand the difficult emotional make-up of many children and who get into difficulties in rearing those children. A tremendous amount can be done by psychiatrists for these children in their early years.

I do not want to intrude something that possibly is not the Minister's concern but my whole case against the corporal punishment of children is that I feel the recalcitrant child is not a bad child but merely a child who is emotionally disturbed or who has some emotional disfunction in the background, in its home or in its own personal make-up, and that that should be treated, and treated by a medical person, and certainly not by beating or flogging. However, I do not want to deal with that point at this stage but I would ask the Minister to bear in mind the importance of having these clinics throughout the larger city centres so that parents who have difficult children—and there are such children—will be in a position to bring them to experts for examination and advice in order to try to overcome the difficulties with which they are presented and which they cannot overcome themselves.

I am a little disturbed to see the very small amount of money spent on the county homes. Would the Minister say whether very much has been done in relation to county homes over the last ten years? Again, this is a vast problem, a very costly problem, but, again, it is one which we have to face. It is a measure of our civilisation, a measure of our Christian attitude, our Christian way of life. How do we feel about the aged? How should they exist? How should they spend their last years? Are we content with the type of county home in which many of them at present find themselves?

I know that this comes back to the old idea that we must cut our cloth according to our measure but there are other expenses in which we indulge that we could cut down in order to meet what I consider are the primary needs of any civilised and Christian society, that is, in the first instance, the needs of the sick and then the needs of the aged. Should we not see that the places in which the aged live are places in which we ourselves would not be ashamed or afraid to spend our last years? The only criterion, the only standard, that I can understand, whether it be with regard to health, old age, education or anything else is what I would like for myself or my own children.

I know some of the homes for the aged are all right. There have been some very active local authorities and managers. There is one in Tipperary that is very good and one in Limerick that is very good also. There is a magnificent home in Mallow that is run by an order of nuns in which there are simply superb conditions for the aged. There is also the home run by the sisters in Kilmainham and a number of others. Generally speaking, the county homes, in my experience, leave a lot to be desired in relation to sanitary accommodation, service of food, cooking, buildings and the simple comforts of central heating or heating of some kind, club rooms, amenities for the winter months and the winter nights. At any rate, I found they were grievously lacking. They may have been improved since that time to the position that the Minister is now satisfied. I wonder, if he has time, would he consider going around, looking at these county homes and seeing if he is satisfied with the conditions in which the old people are living?

Another point in relation to county homes is the regulations, which struck me as being terribly primitive. One was the separation of husband and wife and the separation of children from the family when families were in there, which, fortunately, is very rare now. Does the separation of husband and wife go on still?

A further point was the type of clothes provided. I was struck by the dreadfully prison-like clothes which I remember seeing in St. Kevin's some years ago. I was slightly irate at the type of clothes until I was told that the combined purchasing section of the Department of Local Government made available a magnificent stock of clothes of all kinds for local authorities if they would care to call on them. There was no need for the prison-like clothes at all. It was merely a matter for the local health authority to call on the combined purchasing section of the Department of Local Government for this selection of clothes in order not to have our people in these county homes in uniform, as they seemed to me to be.

Another point I should like the Minister to bear in mind is to try to give these people more freedom to go out walking and to go into the local villages if they wish, not to treat them as if they were in a remand home. They are our old people, who have grown old in the service of the State and of the community. They have educated and brought up families. Surely they have the right to live as if they were at home? As far as I can gather, St. Kevin's has become a headline for other local authorities in that matter. Very considerable improvement has been made in relation to the provision of living conditions and comforts of one kind or another for the old people there. I wonder would the Minister bear that in mind in his years in the Department and not forget the county homes which, to a certain extent, are part of his responsibility?

A few words about deficits. The deficits of the voluntary hospitals are apparently quite a problem for the Minister. They have grown very considerably since before the war. In 1935, they were £73,000 and in 1955, about £1,000,000. They have risen even more than the cost of living. We cannot say it is all due to the cost of food and the cost of living. I wonder if the Minister has come to any decision at all about these voluntary hospitals? What will be their position in our future health services? As the Minister said himself, the pattern of our health services must change. Changing diseases will change the pattern of our health services, and the pattern of our voluntary hospitals' association with our health services, it seems to me at any rate, must be reviewed.

The position is that they have changed very fundamentally since Professor Cunningham, in the Seanad on one occasion, said that a voluntary hospital is one mainly run by voluntary subscription and in which the doctors operate on their patients without charge. If it ever were true, that has now changed very much. Is it not a fact now that, because of the expansion of our health services and because of the expenditure of the Hospitals Trust Fund, we are now paying our doctors, and voluntary subscriptions are negligible for the running of these institutions? We are paying our doctors, and I think quite rightly. It is about time we stopped the silly, snob notion of so called free treatment in these institutions. It is a heritage from the days of talking down to the poor and so on. I think it is a silly affectation. It is going out rapidly now, and it is a good thing that it should do so. If the labourer is worthy of his hire, so is the doctor. Pay him whatever he is worth and you are under no compliment to him. I think that is the correct attitude.

It seems to me, therefore, that we are no longer running our hospitals on voluntary subscription, with the exception of the Adelaide in this city. They are being run either from the Hospitals Fund or from central Exchequer taxation and rates, because of local authority payments. Are we to allow them go on that way, expending very considerable sums of public money without any detailed supervision on our part, and by "our" I mean the public?

The boards of these voluntary hospitals are not nominated nor, in the majority of cases, are they elected by any known democratic system. They do not represent any group or section of our society, any mass cross-section of our society. I do not know if they represent anybody at all. Is it not about time we reconsidered that position? Would the Minister consider extending the idea we introduced in the Meath Hospital Bill, through which some measure of democratic control over these institutions might be achieved? The question is not so much the democratic control of these institutions as the democratic control of the expenditure of very vast sums of public money in the form of taxes and rates paid.

Everybody is worried about the growth of the increase in the deficits. I believe it is due, on the whole, to the expansion of the services we have provided for the public, the improvement in many cases of equipment and the renewal of equipment after years of starvation in that regard. I think that the increase in wages of one kind or another and the increase in fees are all factors which have increased the postwar costs and are partly to blame for the increase in the deficits. But for those who are not satisfied that there is a justifiable and legitimate explanation for the increase, for those who are not satisfied that there has been reasonable, intelligent and careful spending of moneys in our voluntary hospitals, what do they propose to do about it? Will successive Ministers come back here year after year telling us: "That is the bill, pay it and smile" and at the same time leave us in the position that we cannot ask any questions or ask for any details?

Progress reported; Committee to sit again.
Business suspended at 1.30 p.m. and resumed at 3 p.m.